Grand Rounds: Advances in laparoscopic tools for gynecologic surgery

December 1, 2005

As gynecologic surgeons have honed their laparoscopic skills, the tools used for minimally invasive gynecologic surgery have followed suit. Better specimen removal and vessel ligation devices, improved trocars, and automatic morcellators are among the reasons this approach has become easier—and safer.

Laparoscopic surgery has come a long way over the past three decades. In the early 1970s, operative laparoscopy in gynecology was limited chiefly to female sterilization, lysis of pelvic adhesions, and fulguration of endometriosis. Laparoscopic tools were pretty basic, consisting of a laparoscope with an eyepiece and simple grasping, suturing, and cutting instruments. Monopolar electrocautery was the original energy source for laparoscopic surgery.1

Now 30 years later, the field has advanced tremendously. Intricate procedures that were once thought to be the exclusive domain of open laparotomy can now be performed by minimally invasive gynecologic surgeons.2-5 As gynecologic surgeons have honed their laparoscopic skills, the need to create innovative laparoscopic equipment to facilitate minimally invasive surgery has become increasingly important.

Although video laparoscopy and better insufflation devices have greatly helped to improve the safety of laparoscopy, we'll focus mainly here on advancements in trocars, vessel ligation devices, specimen retrieval bags, and automatic morcellators.

Trocar-related injuries and complications are one of the main causes of morbidity in laparoscopic gynecologic surgery. Vascular injuries at the port site or in the pelvic area or abdomen are a major concern for gynecologic surgeons.6

The VersaStep Plus Access System (Auto Suture, Inc., Norwalk, Conn.) uses radial dilation of the fascial fibers to secure trocars safely in place. First, a needle with an expandable sleeve is inserted. After the needle is removed, the surgeon inserts the desired VersaStep trocar through the sleeve, radially expanding tissue, which minimizes tissue injury while the trocar is secured in the peritoneal cavity.

Key among this product's many benefits is its ability to stretch, rather than cut, abdominal tissues. This helps prevent blood vessels from being severed upon insertion, and also tamponades other blood vessels at the port site. Moreover, the VersaStep Plus Access System anchors the cannula in place while enabling access ports to expand to larger sizes. When the trocars are removed, the remaining fascial opening is small and slit-like enough to actually obviate the need for fascial closure in certain cases.

A newly developed tool is a dilating trocar device that divides fascial fibers using an asymmetric bladeless tip (ADAPt, Taut, Inc., Geneva, Ill.). This bladeless laparoscopic access port features a unique curved tip designed to dilate through fascial layers, creating a nonlinear tract, which separates muscle fibers instead of cutting them. In addition, one specific model of the ADAPt access port features a latex-free balloon that is fully inflated with 10 mL of saline to secure intraperitoneal placement and to tamponade port site bleeding, as necessary.

Instead of a flapper valve, this device features a rotary valve, which completely opens the lumen of the trocar. This, in turn, facilitates specimen removal and drain placement, and permits irregularly-contoured instruments and curved needles to pass through with minimal damage to the trocar. Like the VersaStep Plus, the ADAPt access port leaves a small defect that re-approximates after the port is removed, theoretically reducing the possibility of postoperative hernia. Bladeless technology such as this minimizes sharp cutting trocar injuries. The asymmetric dilation of fascial fibers enables you to maintain tension in the different layers of fascia to hold the port securely in place.

Vessel ligature devices

Of the various ways to perform laparoscopic ligation, three of the most common techniques involve electrothermal bipolar vessel sealers, laparoscopic clips, and laparoscopic stapling.7