Supplement II: The Video Encyclopedia of Endoscopic Surgery/ Medical Video Productions^TM
Laparosonic Coagulating Shears (LCS)
New and Evolving Laparoscopic Technologies

Introduction:
The laparoscopic approach has been rapidly replacing open surgery in gynecology. Because effective hemostasis is so crucial during dissection, surgeons have spent a great deal of time in mastering the use of thermal energy sources such as electrosurgery and lasers. However, there have been numerous reports in the literature of adverse effects as a result of stray current, capacitive coupling, direct coupling, insulation breakdown and fire. Introduced in 1994, the LCS offers a new mechanical laparoscopic energy source.
The LCS offers multiple advantages over existing energy sources for laparoscopic use. These include reduced thermal damage to tissue, minim al production of smoke and char, facilitated dissection within tissue planes, improved wound healing and no risk of stray electrical current or capacitive coupling. It has become a widely used technique for cost-effective and safe laparoscopic hysterectomy.

Illuminated Infrared Ureteral Catheters
One of the greatest risks of gynecologic and pelvic surgery is the risk of ureteral injury. Physicians in both residency and fellowship programs are routinely instructed on good surgical technique in order to minimize ureteral injury. With open laparotomy, the surgeon has the advantage of being able to palpate and feel the location of the pelvic ureter during surgical dissection. However, with the rise in popularity of laparoscopic procedures, this hands-on tactile ability is lost.
In 1994, a new development using the infrared spectrum and a specially designed infrared-sensitive laparoscopic video camera was released, and this improved technology has significantly improved the ability of the surgeon to clearly visualize the ureter(s) through several centimeters of tissue. Surgical evaluations of this new infrared catheter system have demonstrated the enhanced ability to perform laparoscopic gynecologic procedures with clear identification of the ureters at all times. In addition, the need to routinely dissect ureters prior to beginning surgery has been significantly reduced.

Pneumo-occluder & Colpotomizer for Laparoscopic Hysterectomy
With the increase in popularity of laparoscopic hysterectomy (LH), most gynecologists have noted that their field of vision, lighting and surgical access is vastly superior from the laparoscopic route as compared to the vaginal approach. Accordingly, the greater the amount of dissection which can be performed laparoscopically, the shorter the operating room times, reduced blood loss, and better overall visualization occurs. Limitations to performing a true Laparoscopic Hysterectomy (LH) have been a rapid loss of pneumoperitoneum once the colpotomy incision is made (unless gasless laparoscopy technique is being used), increased risks of ureteral injury, and difficulty in seeing the reflection of the vagina and cervix. These issues have been addressed by the recent introduction of the Koh Colpotomizer and vaginal occlusion device which is combined with a RUMITM uterine manipulator. This device is in the final phase of FDA trials and should be available for general use in late 1996
*(Dr. Galen is one of the FDA investigators.)

Radially Dilating Abdominal Access Cannulas
Historically, laparoscopic surgery has necessitated the use of sharp trocars to allow access to the abdominal cavity. Most trocar designs rely upon a sharp pyramidal or linear metal blade to cut through the layers of the abdominal wall. This sharp blade is either automatically covered by a plastic sleeve (safety trocars), or uncovered (non-safety design). Despite the surgeon's careful placement, trocar-related complications have, and continue to be a serious, and sometimes life-threatening problem.
In 1994, a new "trocar" design became available. This laparoscopic access system incorporates a patented expandable sleeve and blunt dilator and cannula. This StepTM system dilates (splits) rather than cuts through, the tract created by the insufflation needle.

Gasless Laparoscopy
Present techniques for laparoscopic surgery involve the establishment of a pneumperitoneum using carbon dioxide (CO₂) insufflation. This insufflation is necessary to provide a working cavity by displacing the anterior abdominal wall. Although the pneumoperitoneum allows surgeons to perform endoscopic surgery, it has certain disadvantages.
An improved, and more refined device (Laparoliftª) was introduced in 1993 in the United States. This device uses an expandable fan or soft balloon to elevate the abdominal wall at the umbilicus via a table-mounted, electrically powered multidirectional arm.

New and Safer Applications for Unipolar Electrical Energy - ABC Electrosurgery has been an accepted partner in surgical procedures since the 1920's.
Traditionally, laparoscopic dessication methods all involve direct tissue contact to transfer their energy. As the electrode is removed from the tissue, it tends to stick to the tissue and/or eschar. This frequently results in the unanticipated removal of eschar, which may require reapplication of energy because of recurrent bleeding
Argon Beam Coagulation (ABC) A newer, safer, and more rapid method for delivering electrocoagulation has been available for laparoscopic use since 19925. This device allows a jet of argon gas to carry electrons from a unipolar electrode through space, to impact on tissue which is grounded. This energy is delivered via a non-touch technique through a plume of argon gas, which prevents smoke from being produced.

Laparoscopic Bipolar Coagulation of Leiomyoma (myolysis)
Of the 650,000 hysterectomies performed annually in the United States, leiomyomata are an indication in about 25%. Traditionally, the treatment of choice for women who do not desire a future pregnancy and who have symptomatic fibroids, has been a hysterectomy. In addition, approximately 18,000 abdominal myomectomies are also performed annually to conservatively treat symptomatic myomata uteri1. Complications of traditional myomectomy, however, include excessive blood loss, infection, a high risk of transfusion, and a significant (340%) incidence of postoperative adhesion formation. An alternative surgical technique laparoscopic myoma coagulation (myolysis) was initially developed in Europe during the late 1980's4,5. This technique of treating uterine fibroids differs from an open or laparoscopic myomectomy in that no surgical uterine incision is made, and thus the risk of bleeding is dramatically reduced.

Endometrial Ablation using a Thermal Balloon
Endometrial ablation has been a viable treatment option for women with abnormal uterine bleeding (from benign causes) since 1981. There are, however, also risks in performing conventional roller-ball endometrial ablation. These include uterine perforation and bowel burns, as well as fluid overload from dilutional hyponatremia. Current nonconductive solutions used for endometrial ablation include glycine, sorbitol, mannitol and high molecular weight dextran 70. To overcome these potential risks and complications, thermal balloon systems have recently been developed for endometrial ablation. Early results from both European and Canadian studies revealed that the balloon ablation therapy has success rates comparable to other ablation techniques. In clinical trials of over 250 patients, there have been no reported complications to date.

Micro-Laparoscopy Under Local Anesthesia/Conscious Sedation
*(BAFGMG one of few in California performing)
The first laparoscopy in humans was performed by Jacobaeus in 1910. Since that time, dramatic advances have been made by surgeons utilizing this technique. The high cost of performing conventional laparoscopy under general anesthesia, however, has become prohibitive for many health care providers and managed care organizations. Physician interest in office laparoscopy under local anesthesia has thus enjoyed a recent boost. In several studies, the cost of office laparoscopy was found to be more than 80% lower than with traditional laparoscopy.

Topics discussed here will appear in full form in the Video Journal of Obstetrics and Gynecology^TM, produced jointly by the American Association of Gynecologic Laparoscopists (AAGL) and Medical Video Productions^TM.
MVP^TM may be reached by phone at: 1-800-822-3100, or fax at 314-991-4575.
email MVP at mvp@medvideo.com

Copyright 2000-2005 Donald I. Galen, M.D. 
Physician partner in the Reproductive Science Centerª of the San Francisco Bay Area
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