Curved Instruments

The possibility of reaching optimal working conditions is restricted by the use of straight instruments. We started in 1980 to develop instruments for endorec-tal surgery, and we noticed that curves and bayonet-formed angulations brought significant advantages in the maneuverability of the instruments (see below). The use of optimal curves in instrument design allows, for example, an optimal placement of a needle and modification of the direction of the needle [4].

A needle holder and suture grasper design has been developed by the Wolf Company [5], which gives an ideal advantage in directing the position of the needle in the needle holder. Figure 12.1 shows the suture of the fundic wrap. The round needle holder allows optimal positioning of the needle, and the golden tip of the suture grasper always gives the best view to the tip of the needle and provides the best possible conditions to manipulate the needle (Fig. 12.2).

Instruments with larger curves have to be introduced through a flexible trocar. Figure 12.3 shows the curved window grasper and the flexible trocar. Figure 12.4 shows the introduction of the curved window grasper through the flexible trocar. The intra-abdomi-nal situation of the curved instrument is demonstrated in Figure 12.5: The curved instrument has a number of advantages during surgical manipulation. The most important advantage is better ergonomic position, which

Fig. 12.1 Suture of the fundic wrap. The needle holder on the right side is driving the needle; the suture grasper with the golden tip is holding the tip of the needle. The curve of the suture grasper gives optimal view of the needle and a good hold in all different positions

Fig. 12.5 Curved window grasper introduced through the flexible trocar and simulation of the abdominal wall

Fig. 12.2 Needle holder (upper half of the image) and suture grasper (lower half of the image). The needle holder gives a firm hold on the needle in different positions. The tip of the needle holder has an atraumatic area for grasping the suture. The suture grasper has a uniform profile, so that the needle can be held strongly enough, and the suture material is not destroyed by the surface

Fig. 12.5 Curved window grasper introduced through the flexible trocar and simulation of the abdominal wall

Fig. 12.2 Needle holder (upper half of the image) and suture grasper (lower half of the image). The needle holder gives a firm hold on the needle in different positions. The tip of the needle holder has an atraumatic area for grasping the suture. The suture grasper has a uniform profile, so that the needle can be held strongly enough, and the suture material is not destroyed by the surface

Fig. 12.3 Curved window grasper (upper half) and a flexible trocar

Fig. 12.6 Ergonomical working position for the surgeon by the use of a curved instrument. Both working instruments of the surgeon are on the right side of optic, so that there is no conflict with the camera assistant

Fig. 12.3 Curved window grasper (upper half) and a flexible trocar

Fig. 12.4 Introduction of the instrument through the flexible trocar

Fig. 12.7 Demonstration of retraction by the use of the back of the curved instrument. The curve is less traumatic when compared with the tip of a straight instrument

Fig. 12.8 Demonstration of the angle between the curved and the straight instrument. Although the two instruments are close together and in parallel position, there is an optimal working angle between them

is demonstrated in Figure 12.6: The curved instrument allows an assistant guiding the camera at the side of the surgeon. The instruments of the surgeon are in a parallel position because of the advantage of the angulation of the instrument tip.

Better retraction is possible by the use of the curve of the instrument shown in Figure 12.7. The angle between the two working instruments due to the angulation is demonstrated in Figure 12.8. Only this condition affords the surgeon a convenient ergonomic parallel working position of the hands and an optimal working angle between the instruments themselves.

An additional advantage of the curves is the possibility to encircle structures, for example the esophagus in fundoplication [6]. In case of mechanical conflict between instruments, only the rotation of the curved instrument has to be changed to allow again free handling of the endoscopic instrumentation.

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