ovariectomy or gastropexy, and they can be used to help stabilize organs during tissue dissection or ligation.
Figure 4.7 Endoscopic scissors (from top to bottom): straight scissors; curved Metzenbaum scissors; serrated Manhes scissors; scissors with curved, conical, serrated blades; scissors with spoon‐shaped blades; Manhes micro scissors; straight microdissecting scissors; curved microdissecting scissors; and hook scissors.
Source: © 2014 Photo courtesy of KARL STORZ GmbH & Co. KG.
Several different kinds of retractors are available for human MIS. Of these, only the fan retractor is regularly used in veterinary surgery (Figure 4.8b). The fan retractor consists of a straight shaft with a series of flat blades at the end that distend in the shape of a paper fan when the outer sheath of the shaft is rotated. The completely opened retractor is sturdy and is used to retract organs with large surface areas, such as the liver or intestines. It is often used for advanced procedures such as laparoscopic cholecystectomy or adrenalectomy. Fan retractors are available in both 5‐ and 10 mm diameter sizes.
Figure 4.8 (A). Palpation probe with centimeter markings. Inset shows detail of the instrument tip. (B). Fan retractor. Inset shows detail of the collapsible fan blades at the working end.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Figure 4.9 Retractors used in human minimally invasive surgery (from top to bottom): Cuschieri retractor with end deployed (A); retractor for gastric banding, with close‐up of working end (inset) (B); Leroy H‐retractor, with close‐up of working end (inset) (C); and Leroy T‐retractor with end deployed, with inset showing the closed end (D).
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Other types of retractors that are widely used in human laparoscopic surgery include the Cuschieri retractor, gastric banding retractors, and Leroy retractors (Figure 4.9). The Cuschieri retractor was designed as safe retractor of the liver for extended periods of time during laparoscopic surgeries. When activated, the distal end roughly resembles a hexagon, allowing for support of a larger surface area. When closed, the retractor can also be used to move and retract other abdominal structures, such as the intestinal tract. A similar principle is used and advanced upon in newer designs based on the Cushieri articulating retractor. A variety of retractor shapes are available, including curved, triangular, circular, and pretzel shapes. Gastric banding retractors have a flat, angled distal end that is used to bluntly retract the stomach and intestines. A fenestration at the end of the instrument is used to secure a gastric band for passage around the esophagus. Leroy retractors come in a variety of configurations and are used in human colorectal surgery. These retractors may become more widely used as surgeons begin to perform more advanced procedures.
Ovariectomy hooks are used during laparoscopic ovariectomy and ovariohysterectomy to suspend the ovary against the body wall to facilitate ligation and transection of the ovarian pedicle (Figure 4.10). Ovariectomy hooks are placed percutaneously to capture the ovary and proper ligament within the curve of the hook. They have a heavy, T‐shaped handle to facilitate retraction and to prevent rotation of the hook after being placed. The heavy handle allows positioning of the instrument without an assistant, and the small puncture that is created does not need to be closed. Both small and large ovariectomy hooks are available to accommodate patient size. A straight‐handled hook may be used in some clinics but is no longer manufactured. When ovariectomy hooks are not available, a large diameter suture on a large needle (i.e., 0 polypropylene on a CT‐26 or CT‐40 swaged needle) can be used to capture and retract the ovary in the same manner.
Figure 4.10 An ovariectomy hook with a T‐shaped handle.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Needle Holders and Suturing Devices
Different methods of suturing for advanced laparoscopic and thoracoscopic procedures include extracorporeal knot tying, intracorporeal knot tying, and intracorporeal suturing. A variety of needle holders and suture assist devices are available for this purpose. The most common diameter needle holders used are 5 mm, although 3 mm diameter instruments are available for smaller patients. Endoscopic needle holders most commonly come with straight handles (Figure 4.11) rather than ring handles to provide a more ergonomic motion while manipulating suture and needle. The handles lock via a ratchet mechanism.
Figure 4.11 KOH macro‐endoscopic needle driver with straight handle. Used with a wide range of suture and needle sizes; from 0/0 to 7/0.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Figure 4.12 Endoscopic needle holders (from top to bottom): straight jaws, jaws curved to the left, jaws curved to the right, Szabo‐Berci needle holder (“Parrot Jaw”), and Szabo‐Berci assistant needle holder (“Flamingo Jaw”).
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
The traditional endoscopic needle holder (see Figure 4.11) has straight jaws with tungsten carbide inserts to prevent needle slippage. It is used in combination with grasping forceps to pass the needle from one side of an incision to the other and to tie knots. Needle holders
