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Transcript of LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH PARENCHYMAL CLAMP · 4 Laparoscopic Partial Nephrectomy with...
Eric HUYGHE Joe NOHRA
LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH
PARENCHYMAL CLAMP
®
LAPAROSCOPIC PARTIALNEPHRECTOMY WITH
PARENCHYMAL CLAMP
Dr. Eric HUYGHEDepartment of Urology and Andrology
Hôpital Rangueil Toulouse, France
Dr. Joe NOHRADepartment of Urology, Saint George Hospital,
University Medical Center, Ashrafi eh (Beirut), Lebanon
®
Laparoscopic Partial Nephrectomy with Parenchymal Clamp4
Please note:In cooperation with KARL STORZ MediaService, the authors issued a DVD ROM KS 704 with integrated Full HD video clips on Laparoscopic Partial Nephrectomy with Parenchymal Clamp
Laparoscopic Partial Nephrectomy with Parenchymal Clamp Dr. Eric HuygheDepartment of Urology and Andrology, Hôpital Rangueil Toulouse, FranceDr. Joe NohraDepartment of Urology, Saint George Hospital,University Medical Center, Ashrafi eh (Beirut), Lebanon
Correspondence address of the author: Dr. Eric HuygheDept. of Urology and AndrologyTSA 50032 Hôpital RangueilAvenue du Pr Jean PoulhèsFR-31403 Toulouse Cedex 9, FrancePhone: 05 61 32 25 33 (standard domestic dial-up) +33 (0)5 61 32 17 31Fax: +33 (0)5 61 32 22 85E-mail: [email protected]
All rights reserved.1st edition 2009© 2015 ® GmbHP.O. Box, 78503 Tuttlingen, GermanyPhone: +49 (0) 74 61/1 45 90Fax: +49 (0) 74 61/708-529E-mail: [email protected]
No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invent ed, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder.
Editions in languages other than English and German are in preparation. For up-to-date information, please contact ® GmbH at the address shown above.
Design and Composing:® GmbH, Germany
Printing and Binding:Straub Druck + Medien AGMax-Planck-Straße 17, 78713 Schramberg, Germany
05.15-0.3
ISBN 978-3-89756-325-4
Important notes:
Medical knowledge is ever changing. As new research and clinical experience broaden our knowledge, changes in treat ment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accept ed at the time of pu blication. However, in view of the possibili ty of human error by the authors, editors, or publisher, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this booklet, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this booklet is intended for use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature.
Some of the product names, patents, and re gistered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specifi c reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
The use of this booklet as well as any implementation of the information contained within explicitly takes place at the reader’s own risk. No liability shall be accepted and no guarantee is given for the work neither from the publisher or the editor nor from the author or any other party who has been involved in the preparation of this work. This particularly applies to the content, the timeliness, the correctness, the completeness as well as to the quality. Printing errors and omissions cannot be completely excluded. The publisher as well as the author or other copyright holders of this work disclaim any liability, particularly for any damages arising out of or associated with the use of the medical procedures mentioned within this booklet.
Any legal claims or claims for damages are excluded.
In case any references are made in this booklet to any 3rd party publication(s) or links to any 3rd party websites are mentioned, it is made clear that neither the publisher nor the author or other copyright holders of this booklet endorse in any way the content of said publication(s) and/or web sites referred to or linked from this booklet and do not assume any form of liability for any factual inaccuracies or breaches of law which may occur therein. Thus, no liability shall be accepted for content within the 3rd party publication(s) or 3rd party websites and no guarantee is given for any other work or any other websites at all.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 5
Table of Contents
1.0 Introduction and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.1 Main Epidemiological Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.2 Guidelines of the European Association of Urology (2009) . . . . . 6 1.3 Difference between the Open and Laparoscopic Techniques . . 6 1.4 Functional Objectives of the Laparoscopic Parenchymal Clamp . . . 6
2.0 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.1 The Laparoscopic Parenchymal Clamp . . . . . . . . . . . . . . . . . . . . . 7 2.2 Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.0 Operating Room Setup and Patient Positioning . . . . . . . . . . . . . . . . . . 8
4.0 Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.0 Dissection of the Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6.0 Usage of the Parenchymal Clamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 6.1 Positioning of the Clamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 6.2 Tumorectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6.3 Haemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6.4 Opening of the Parenchymal Clamp . . . . . . . . . . . . . . . . . . . . . . . . 10 6.5 Frozen Section Analysis for Tumor Margin Assessment . . . . . . . 10
7.0 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Instrument Set for Laparoscopic Partial Nephrectomywith Parenchymal Clamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Laparoscopic Partial Nephrectomy with Parenchymal Clamp6
1.0 Introduction and Epidemiology
1.1 Main Epidemiological DataRenal cell carcinoma (RCC) is the third most common urological cancer and its incidence has been strongly increasing over the last decades. The current worldwide annual increase in incidence is approximately 2%.Each year, approximately 40,000 new patients are diagnosed with kidney cancer in the European Union as well as in the U.S., a growing proportion of them being diagnosed at an early stage (Chart 1).Actually today, due to advancements in imaging technology, more than 50% of RCCs are detected incidentally.The analysis of data collected by the American National Cancer Database demonstrates that the mean tumor size has decreased over the past decade(Chart 2).The total number of T1 tumors has almost doubled during the same period (Chart 3).In terms of treatment, patients affl icted with a solitary tumor of less than 4 cm maximum diameter, nephron-sparing surgery provides recurrent-free and long-term survival rates similar to those observed after a radical surgical procedure. To date, the open approach remains the fi rst-line treatment for partial nephrectomy.
1.2 Guidelines of the European Association of Urology (2009)The 2009 EAU Guidelines state, that in experienced hands, laparoscopic partial nephrectomy might be an alternative to open nephron-sparing surgery for selected patients. Although the oncological outcome following laparoscopic partial nephrectomy is supposed to be equivalent to that of nephron-sparing techniques by ways of open surgery. The reported sequelas of the laparoscopic approach are a longer warm ischemia time when compared with open surgery.
1.3 Difference between the Open and Laparoscopic Techniques One difference between the open and laparoscopic techniques of partial nephrec tomy is the availability of parenchymal clamps for open surgery, whereas, so far, pedicle clamping is necessary to perform laparoscopic partial nephrectomy.Renovascular occlusion necessitates dissection of the renal pedicle, which is technically challenging, time-consuming and potentially dangerous. Furthermore, renovascular occlusion and its subsequent warm renal ischemia increases the risk of postoperative renal failure. A recently published original article reported on predictive factors correlated with renal functional outcome after partial nephrectomy and concluded, that “ischemia is the strongest modifi able surgical risk factor accounting for decreased renal function after partial nephrectomy” and, accordingly, suggested that “efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy” (lane et al. 2008, J Urol).
1.4 Functional Objectives of the Laparoscopic Parenchymal ClampThe rationale underlying the development of this new surgical instrument was the need for reducing the risk of warm ischemia and facilitating partial nephrectomy.The laparoscopic renal parenchymal clamp has been designed with the aim of facilitating laparoscopic partial nephrectomy while eliminating the need for pedicle clamping.This booklet is to describe the technique for laparoscopic partial nephrectomy with selective parenchymal clamping, using a new specially designed parenchymal clamp.
Incidence rate of new cases of early-stage kidney cancer in the U.S. over a 12-year-observation period.(J Urol, 2006, 176).
C1
According to a review of data provided by the American National Cancer Database, the mean tumor size has decreased over the past decade (J Urol, 2008, 179).
C2
Epidemiological chart showing the annual increase in the incidence rate of renal cell carcinoma in the U.S. The total number ofT1 tumours has almost doubled during the same period (see paragraph 1.1).(J.Urol, 2008, 179).
C3
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 7
2.0 InstrumentsIn conjunction with the parenchymal clamp, we routinely use a set of laparoscopic instruments including the following key components: 0°/30°-laparoscopes connected to a video camera system and a set of laparoscopic instruments as detailed below.One disposable balloon trocar, one 11 mm trocar and two 6 mm trocars on the left side. The third trocar, required for liver retraction, is placed on the right side underneath the xiphoid process. One of the advantages of the parenchymal clamp is that it can be inserted via an 11 mm trocar. In our experience, the instrument can generally be used without modifi cation of the standard trocar placement. However, in particular circumstances, depending on the course of the operation, the surgeon may decide to reintroduce a second 11 mm-trocar that permits placement of the clamp in a position that facilitates the partial nephrectomy procedure. Two platform or KELLY forceps, 1 METZENBAUM scissors for unipolar coagulation and 1 bipolar forceps.Two KOH needle holders with disengagable ratchet for suture of the renal parenchyma.Furthermore, 5 mm Hemolock clips are also used for the suture. They allow to apply tension to the thread without causing damage to the parenchyma. The clip applicator can be introduced via a 6 mm trocar.
2.1 The Laparoscopic Parenchymal ClampDimensions and WeightThe clamp is 10 mm in diameter, with a shaft of 29.5 cm in length. Therefore, it can be used without diffi culty, regardless of the size and weight of the patient (Fig. 1).HandlingThe handle has been particularly designed to permit bimanual control (Fig. 2). It is lightweight so as not to create leverage, which could damage the kidney.The ratchet permits smooth, gradual increase of the pressure applied to the kidney, and allows to maintain optimal pressure throughout the tumorectomy stage(Fig. 3). A simple ninety-degree turn of the handle suffi ces to release the pressure.Snare PressureThe distal part includes a snare of 120 mm in length, with a 5 mm wide Nitinol blade. The latter component has been specifi cally designed for effi cient clamping of the kidney without causing iatrogenic parenchymal trauma (Fig. 4).DisassemblingFor sterilization purposes, the clamp can be dismantled into three components(Fig. 5) by pulling out the snare beyond the maximum position until release (Fig. 6).
2.2 UnitsThe procedure is performed using a complete laparoscopic column with a video monitor, a camera system, a xenon 300 cold light source and an insuffl ator. The pneumoperitoneum is usually established with a maximum intraabdominal pressure of 12 mmHg. For coagulation, we routinely use the AUTOCON® II 400 system, which can be operated alternately in both the unipolar and bipolar modes. The system can be easily switched from one operating mode to the other by use of programmable keys.
Macroscopic view of the parenchymal clamp.
1
Handle of the parenchymal clamp.
2
Ratchet of the parenchymal clamp.
3
Distal part of the parenchymal clamp with fully unfolded opening of the snare.
4
Handle of the parenchymal clamp.
5
Hook connecting the snare with the shaft.
6
Laparoscopic Partial Nephrectomy with Parenchymal Clamp8
3.0 Operating Room Setup and Patient PositioningLaparoscopic partial nephrectomy with a parenchymal clamp is performed under general anesthesia with the patient in the lateral supine position using the same room setup and patient positioning as for transperitoneal laparoscopic radical nephrectomy (Fig. 7). Draping of the surgical area is defi ned by the following boundaries: the posterior axillary line at the back, the mammillary line at the front, the iliac crest at the base and, at the front, the navel, which is left visible as a landmark.Two bags are placed at the patient’s back that will be used at the beginning of the procedure, i.e., the camera, bipolar forceps, unipolar scissors, suction and irrigation system, grasping forceps, suction cannula and the high- frequency knife electrode. On the instrument table, we prepare the trocars needed for the procedure, namely: two 11 mm-trocars and two 6 mm-trocars, as well as a braided 2.0 suture, which is crimped lengthwise with a Farabeuf retractor loaded with a Surgicel bolster for the suture.
Patient positioning for left laparoscopic partial nephrectomy.
7
The skin markings show the standard ports used for left partial nephrectomy.
8
4.0 Trocar PlacementThe primary trocar for the laparoscope is placed periumbilically, with one 6 mm-trocar positioned directly below the costal margin, three fi ngerwidths above and externally from the camera trocar, an 11 mm-trocar for the clamp which is advanced parallel to the longitudinal axis of the laparoscope, further in the caudal direction. Particular care must be taken to make sure that the ports are placed at suffi cient distance to each other to facilitate dissection and suturing. The fourth 6 mm-trocar is positioned more laterally, in the majority of cases, on the anterior axillary line (Fig. 8). If the tumor is located on the upper pole of the kidney, the 11 mm-port is placed quite low. In the presence of a lower-pole tumor, the trocar should be placed more cranially.For tumors located on the right side, a fi fth 6 mm-trocar can be placed to allow for liver retraction and to facilitate access to the upper renal pole. On the left side, four trocars are often enough.At our institution, the primary port is usually established using an open technique. Next, a disposable balloon trocar is inserted, which – owing to its ring-shaped valve assembly – provides a perfectly sealed port. Once the pneumoperitoneum has been established, the other trocars are placed under continuous visual control.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 9
5.0 Dissection of the KidneyAfter the incision of the parietal peritoneum in the paracolic gutter, we begin dissection of the kidney by establishing contact with it. If tumor location necessitates mobilization of the kidney for good exposure, the kidney is freed. If tumor invasion involves one pole, one should consider limiting dissection to one half of the kidney. Anyway, with parenchymal clamp, dissection of the medial side of the pedicle must be minimal.
Positioning of the parenchymal snare for right partial nephrectomy.
9
The snare of the parenchymal clamp has been gradually pulled tight until the upper pole of the kidney presents a bluish discoloration.
10
6.0 Usage of the Parenchymal Clamp
6.1 Positioning of the ClampA suction probe or atraumatic forceps is used to apply counterpressure and guide the kidney into the snare (Fig. 9). When positioning of the clamp seems to be optimal, the snare of the parenchymal clamp is pulled tight gradually until the upper pole of the kidney presents a bluish discoloration (Fig. 10).We systematically check for proper exposure of the tumor prior to starting tumorectomy.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp10
6.2 TumorectomyFor the duration of the partial nephrectomy, we advise the anesthesiologist that arterial pressure be maintained quite low in order to limit bleeding, with a systolic pressure of 100–110 mmHg.The tumorectomy stage begins with the incision of the capsule using scissors. Once a short incision has been made, we usually check if the pressure exerted on the parenchyma is suffi cient or needs to be increased by a notch or two (Fig. 11). The parenchymal clamp can be used to facilitate exposure and to perform tumorec tomy under visual control in favorable operating conditions. If adequate pressure is applied, the section slice is bloodless and haemostasis can be accomplished without undue stress.
6.3 HaemostasisThe use of thrombin glue or suture placement for maintaining adequate haemostasis and closure of the defect is largely determined by the tumor and the individual preferences of the surgeon. Following homogeneous delivery of thrombin glue, we usually open the clamp one notch to let the hemostatic matrix fi ll the defect and promote platelet aggregation. Next, we close the clamp again. After removing the clamp, we decide to perform a thread suture and temporarily reinstall the clamp on the kidney. This can be done without diffi culty.The suture is made with single stitches using a braided absorbable 2-0 thread. The stitches are fi xed with a Hemolock clip. Once the clamp is released, we decide to add an additional stitch. This can be performed without problems using the clamp.
6.4 Opening of the Parenchymal ClampThe parenchymal clamp is gradually opened by a simple ninety-degree turn of the handle which normally suffi ces to release the pressure.Once adequate haemostasis has been secured, the clamp can be easily removed, whatever means have been used, sutures, clips or Surgicel bolsters.
6.5 Frozen Section Analysis for Tumor Margin AssessmentIf a frozen section analysis is required, due to the absence of pedicle clamping, the parenchymal clamp can be left in place on the kidney for the time necessary for tumor extraction and analysis. In the case of positive margins, the clamp can be repositioned to perform complementary resection.
The tumorectomy stage begins with the incision of the capsule using scissors.
11
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 11
7.0 ConclusionIn conclusion, this new renal parenchymal clamp allows to perform laparoscopic partial nephrectomy without pedicle clamping in the majority of tumors, excluding mid-renal tumors. It enables optimal nephron-sparing surgery while minimizing warm ischemia times, which had previously put limitations on the development of the procedure. It negates the need for dissection of the pedicle at the risk of causing vascular trauma, offers improved exposure of the tumor and enables the performance of tests in which the clamp is partially released, which enable the surgeon to verify the quality of the hemostasis.
Recommended Reading
1. GILL IS, MATIN SF, DESAI MM, KAOUK JH, STEINBERG A, MASCHA E,THORNTON J, SHERIEF MH, STRZEMPKOWSKI B, NOVICK AC: Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in200 patients. J Urol. 2003 Jul;170(1):64–8
2. HUYGHE E, NOHRA J, LEOBON B, EL KHOURY E, KHEDIS M, SOULIE M, PLANTE P: Open partial nephrectomy with selective renal parenchymal control: a new reliable clamp. Urology. 2006 Sep;68(3):658–6.
3. LANE BR, NOVICK AC, BABINEAU D, FERGANY AF, KAOUK JH, GILL IS: Comparison of laparoscopic and open partial nephrectomy for tumor in a solitary kidney. J Urol. 2008 Mar;179(3):847–51
4. PATARD JJ, SHVARTS O, LAM JS, PANTUCK AJ, KIM HL, FICARRA V,CINDOLO L, HAN KR, DE LA TAILLE A, TOSTAIN J, ARTIBANI W, ABBOU CC, LOBEL B, CHOPIN DK, FIGLIN RA, MULDERS PF, BELLDEGRUN AS: Safety and effi cacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol. 2004 Jun;171(6 Pt 1):2181–5
5. SIMMONS MN, SCHREIBER MJ, GILL IS: Surgical renal ischemia: a contemporary overview. J Urol. 2008 Jul;180(1):19–30
6. SONG C, BANG JK, PARK HK, AHN H: Factors infl uencing renal functionreduction after partial nephrectomy. J Urol. 2009 Jan;181(1):48–53
7. THOMPSON RH, BOORJIAN SA, LOHSE CM, LEIBOVICH BC, KWON ED, CHEVILLE JC, BLUTE ML: Radical nephrectomy for pT1a renal masses may beassociated with decreased overall survival compared with partial nephrectomy.J Urol. 2008 Feb;179(2):468–71
Laparoscopic Partial Nephrectomy with Parenchymal Clamp12
Instrument Set for Laparoscopic Partial Nephrectomy with Parenchymal Clamp
27710 NK 1 Kidney Clamp, for clamping the kidney and limiting blood supply, size 10 mm, length 29 cm,
including: Handle, with ratchet
Outer Sheath Snare
26003 AA 1 HOPKINS® Straight Forward Telescope 0°, enlarged view, diameter 10 mm, length 31 cm, autoclavable, fiber optic light transmission incorporated, color code: green
26003 BA 1 HOPKINS® Forward-Oblique Telescope 30°, enlarged view, diameter 10 mm, length 31 cm, autoclavable, fiber optic light transmission incorporated, color code: red
30103 MP 2 Trocar, with pyramidal tip, with insufflation stopcock, size 11 cm, working length 10.5 cm, color code: green,
including: Cannula, without valve
Trocar only Multifunctional Valve
30103 AO 1 Trocar, size 11 mm, color code: green, including: Trocar only, with blunt tip
Cannula, with 2 flanges for fixation of sutures, adjustable cone, with insufflation stopcock, working length 13 cm Automatic Valve Cone
30120 TQX 3 Trocar, with pyramidal tip, with insufflation stopcock, size 6 mm, working length 10.5 cm, color code: black,
including: Cannula, with thread
Trocar only SiliconeLeafletValve
30141 DB 1 Reducer, 11/5 mm
26120 J 1 VERESS Pneumoperitoneum Needle, with spring-loaded blunt inner cannula, LUER-Lock, autoclavable, diameter 2.1 mm, length 10 cm
34325 MS 1 CLICKLINE METZENBAUM Scissors, rotating, dismantling, with connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, curved, length of jaws, 15 mm, size 5 mm, length 36 cm,
including: Metal Handle, insulated, without ratchet
Metal Outer Sheath, insulated Scissors Insert
33332 ON 1 CLICKLINE Grasping Forceps, rotating, dismantling, without connection for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, single action jaws, with especially fine atraumatic serration, fenestrated, size 5 mm, length 36 cm,
including: Metal Handle, with MANHES style ratchet
Metal Outer Sheath, insulated Forceps Insert
33331 ML 1 CLICKLINE KELLY Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, long, size 5 mm, length 36 cm,
including: Metal Handle, without ratchet Metal Outer Sheath, insulated Forceps Insert
33331 R 1 CLICKLINE Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, right angled, size 5 mm, length 36 cm,
including: Metal Handle, without ratchet Outer Sheath, insulated Forceps Insert
38651 ON 1 RoBi® Grasping Forceps, CLERMONT- FERRAND model, rotating, dismantling, with connector pin for bipolar coagulation, with especially fine atraumatic serration, fenestrated jaws, double action jaws, size 5 mm, length 36 cm, color code: light blue,
including: RoBi® Plastic Handle, without ratchet
RoBi® Metal Outer Sheath RoBi® Forceps Insert
38651 ML 1 RoBi® KELLY Grasping Forceps, CLERMONT-FERRAND model, rotating, dismantling, with connector pin for bipolar coagulation, double action jaws, especially suitable for dissection, size 5 mm, length 36 cm, color code: light blue,
including: RoBi® Plastic Handle, without ratchet
Outer Sheath Forceps Insert
26173 KAF 2 KOH Macro Needle Holder, with tungsten carbide insert, ergonomic straight handle with disengageable ratchet, ratchet position right, jaws straight, size 5 mm, length 33 cm, for use with suture material size 0/0 to 7/0 and needle sizes BV, SH or CT-1
26173 BN 1 Suction and Irrigation Tube, with lateral holes, with two-way stopcock for single-hand control, size 5 mm, length 36 cm
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 13
Kidney Clamp
27710 NK
27710 NK Kidney Clamp, for clamping the kidney and limiting blood supply, size 10 mm, length 29 cm,
including: Handle, with ratchet
Outer Sheath Snare
HOPKINS® Telescopesdiameter 10 mm, length 31 cm
26003 AA
26003 AA HOPKINS® Straight Forward Telescope 0°, enlarged view, diameter 10 mm, length 31 cm, autoclavable, fiber optic light transmission incorporated, color code: green
26003 BA HOPKINS® Forward-Oblique Telescope 30°, enlarged view, diameter 10 mm, length 31 cm, autoclavable, fiber optic light transmission incorporated, color code: red
It is recommended to check the suitability of the product for the intended procedure prior to use.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp14
Trocarssize 6 and 11 cm, length 10.5 and 13 cm
30103 MP Trocar, with pyramidal tip, with insufflation stopcock, size 11 cm, working length 10.5 cm, color code: green,
including: Cannula, without valve
Trocar only Multifunctional Valve
30103 AO Trocar, size 11 mm, color code: green,
including: Trocar only, with blunt tip
Cannula, with 2 flanges for fixation of sutures, adjustable cone, with insufflation stopcock, working length 13 cm Automatic Valve Cone
30120 TQX Trocar, with pyramidal tip, with insufflation stopcock, size 6 mm, working length 10.5 cm, color code: black,
including: Cannula, with thread
Trocar only SiliconeLeafletValve
30141 DB Reducer, 11/5 mm
VERESS Pneumoperitoneum Needle
26120 J VERESS Pneumoperitoneum Needle, with spring-loaded blunt inner cannula, LUER-Lock, autoclavable, diameter 2.1 mm, length 10 cm
26120 J
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 15
CLICKLINE Scissors, Dissecting and Grasping Forceps
33332 ON
33332 ON CLICKLINE Grasping Forceps, rotating, dismantling, without connection for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, single action jaws, with especially fine atraumatic serration, fenestrated, size 5 mm, length 36 cm,
including: Metal Handle, with MANHES style ratchet Metal Outer Sheath, insulated Forceps Insert
33331 ML
33331 ML CLICKLINE KELLY Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, long, size 5 mm, length 36 cm,
including: Metal Handle, without ratchet Metal Outer Sheath, insulated Forceps Insert
unipolar
34325 MS CLICKLINE METZENBAUM Scissors, rotating, dismantling, with connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, curved, length of jaws, 15 mm, size 5 mm, length 36 cm,
including: Metal Handle, insulated, without ratchet
Metal Outer Sheath, insulated Scissors Insert
34325 MS
Laparoscopic Partial Nephrectomy with Parenchymal Clamp16
33331 R
33331 R CLICKLINE Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with LUER-Lock irrigation connector for cleaning, double action jaws, right angled, size 5 mm, length 36 cm,
including: Metal Handle, without ratchet
Outer Sheath, insulated Forceps Insert
CLICKLINE Dissecting and Grasping Forceps
unipolar
38651 ML RoBi® KELLY Grasping Forceps, CLERMONT-FERRAND model, rotating, dismantling, with connector pin for bipolar coagulation, double action jaws, especially suitable for dissection, size 5 mm, length 36 cm, color code: light blue,
including: RoBi® Plastic Handle, without ratchet Outer Sheath
Forceps Insert
38651 ON
38651 ON RoBi® Grasping Forceps, CLERMONT-FERRAND model, rotating, dismantling, with connector pin for bipolar coagulation, with especially fine atraumatic serration, fenestrated jaws, double action jaws, size 5 mm, length 36 cm, color code: light blue,
including: RoBi® Plastic Handle, without ratchet RoBi® Metal Outer Sheath
RoBi® Forceps Insert
RoBi® Grasping Forceps
bipolar
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 17
26173 KAF
26173 KAF KOH Macro Needle Holder, with tungsten carbide insert, ergonomic straight handle with disengageable ratchet, ratchet position right, jaws straight, size 5 mm, length 33 cm, for use with suture material size 0/0 to 7/0 and needle sizes BV, SH or CT-1
Please note: Using the needle holder with a needle larger than recommended
may result in a mechanical damage to the instrument.
KOH Macro Needle Holder
26173 BN Suction and Irrigation Tube, with lateral holes, with two-way stopcock for single-hand control, size 5 mm, length 36 cm
Suction and Irrigation Tube
26173 BN
Laparoscopic Partial Nephrectomy with Parenchymal Clamp18
Innovative Design## Dashboard: Complete overview with intuitive menu guidance
## Live menu: User-friendly and customizable## Intelligent icons: Graphic representation changes when settings of connected devices or the entire system are adjusted
## Automatic light source control## Side-by-side view: Parallel display of standard image and the Visualization mode
## Multiple source control: IMAGE1 S allows the simultaneous display, processing and documentation of image information from two connected image sources, e.g., for hybrid operations
Dashboard Live menu
Side-by-side view: Parallel display of standard image and Visualization mode
Intelligent icons
Economical and future-proof## Modularconceptforflexible,rigidand 3D endoscopy as well as new technologies
## Forward and backward compatibility with video endoscopes and FULL HD camera heads
## Sustainable investment## Compatible with all light sources
IMAGE1 S Camera System n
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 19
Brillant Imaging## Clear and razor-sharp endoscopic images in FULL HD
## Natural color rendition
## Reflectionisminimized## Multiple IMAGE1 S technologies for homogeneous illumination, contrast enhancement and color shifting
FULL HD image CHROMA
FULL HD image SPECTRA A *
FULL HD image
FULL HD image CLARA
SPECTRA B **
* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.
IMAGE1 S Camera System n
Laparoscopic Partial Nephrectomy with Parenchymal Clamp20
TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU
Specifications:
HD video outputs
Format signal outputs
LINK video inputs
USB interface SCB interface
- 2x DVI-D - 1x 3G-SDI
1920 x 1080p, 50/60 Hz
3x
4x USB, (2x front, 2x rear) 2x 6-pin mini-DIN
100 – 120 VAC/200 – 240 VAC
50/60 Hz
I, CF-Defib
305 x 54 x 320 mm
2.1 kg
Power supply
Power frequency
Protection class
Dimensions w x h x d
Weight
TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200ENincluding:Mains Cord, length 300 cm
Link Cable, length 20 cm
For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN
IMAGE1 S Camera System n
TC 300 (H3-Link)
TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) 22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3, 22 2200 54-3, 22 2200 85-3 (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)
1x
100 – 120 VAC/200 – 240 VAC
50/60 Hz
I, CF-Defib
305 x 54 x 320 mm
1.86 kg
Camera System
Supported camera heads/video endoscopes
LINK video outputs
Power supply
Power frequency
Protection class
Dimensions w x h x d
Weight
Specifications:
TC 200EN
TC 300
* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 21
TH 104
TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD
IMAGE1 FULL HD Camera Heads
Product no.
Image sensor
Dimensions w x h x d
Weight
Optical interface
Min. sensitivity
Grip mechanism
Cable
Cable length
IMAGE1 S H3-ZA
TH 104
3x 1/3" CCD chip
39 x 49 x 100 mm
299 g
integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)
F 1.4/1.17 Lux
standard eyepiece adaptor
non-detachable
300 cm
Specifications:
TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD
IMAGE1 FULL HD Camera Heads
Product no.
Image sensor
Dimensions w x h x d
Weight
Optical interface
Min. sensitivity
Grip mechanism
Cable
Cable length
IMAGE1 S H3-Z
TH 100
3x 1/3" CCD chip
39 x 49 x 114 mm
270 g
integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)
F 1.4/1.17 Lux
standard eyepiece adaptor
non-detachable
300 cm
Specifications:
For use with IMAGE1 S Camera System IMAGE1 SCONNECTModuleTC200EN,IMAGE1SH3-LINKModuleTC300 and with all IMAGE 1 HUB™ HD Camera Control Units
IMAGE1 S Camera Heads n
TH 100
Laparoscopic Partial Nephrectomy with Parenchymal Clamp22
9826 NB
9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image fomat 16:9, power supply 100 – 240 VAC, 50/60 Hzincluding:External24VDCPowerSupplyMains Cord
9619 NB
9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply 100 – 240 VAC, 50/60 Hz, wall-mounted with VESA 100 adaption,including:
External24VDCPowerSupplyMains Cord
Monitors
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 23
Monitors
Optional accessories:9826 SF Pedestal, for monitor 9826 NB9626 SF Pedestal, for monitor 9619 NB
26"
9826 NB
l
–
l
l
l
l
l
–
l
–
l
l
l
l
l
l
19"
9619 NB
l
–
–
l
l
l
l
l
l
l
–
l
l
l
l
l
KARL STORZ HD and FULL HD Monitors
Wall-mounted with VESA 100 adaption
Inputs:
DVI-D
Fibre Optic
3G-SDI
RGBS (VGA)
S-Video
Composite/FBAS
Outputs:
DVI-D
S-Video
Composite/FBAS
RGBS (VGA)
3G-SDI
Signal Format Display:
4:3
5:4
16:9
Picture-in-Picture
PAL/NTSC compatible
19"
optional
9619 NB
200 cd/m2 (typ)
178° vertical
0.29 mm
5 ms
700:1
100 mm VESA
7.6 kg
28 W
0 – 40°C
-20 – 60°C
max. 85%
469.5 x 416 x 75.5 mm
100 – 240 VAC
EN 60601-1, protection class IPX0
Specifications:
KARL STORZ HD and FULL HD Monitors
Desktop with pedestal
Product no.
Brightness
Max. viewing angle
Pixel distance
Reaction time
Contrast ratio
Mount
Weight
Rated power
Operating conditions
Storage
Rel. humidity
Dimensions w x h x d
Power supply
Certified to
26"
optional
9826 NB
500 cd/m2 (typ)
178° vertical
0.3 mm
8 ms
1400:1
100 mm VESA
7.7 kg
72 W
5 – 35°C
-20 – 60°C
max. 85%
643 x 396 x 87 mm
100 – 240 VAC
EN 60601-1, UL 60601-1, MDD93/42/EEC, protection class IPX2
Laparoscopic Partial Nephrectomy with Parenchymal Clamp24
KARL STORZ Touch Screen
20 0904 02 19" KARL STORZ Touch Screen, wall or swivel-arm mounting, video inputs: VGA/SVGA/XGA/SXGA, max. screen resolution 1280 x 1024 (SXGA mode), power supply 100 – 240 VAC, 50/60 Hz, incl. 3 touch screen covers,
including: 19" Touch Screen, incl. RS 232 cable,
SVGA cable, mains cord, driver CD RS 232 Connecting Cable, length 600 cm SVGA Connecting Cable, length 600 cm Touch Pen, for KARL STORZ Touch Screens
Cold Light Fountain XENON 300 SCB
20 133101-1 Cold Light Fountain XENON 300 SCB
with built-in antifog air-pump, and integrated KARL STORZ Communication Bus System SCB power supply: 100 –125 VAC/220 –240 VAC, 50/60 Hz
including: Mains Cord SCB Connecting Cable, length 100 cm20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt20133028 XENON Spare Lamp, only,
300 watt, 15 volt
Fiber Optic Light Cable
495 NCS Fiber Optic Light Cable, with straight connector, extremely heat-resistant, diameter 4.8 mm, length 250 cm
495 NA Fiber Optic Light Cable, with straight connector, diameter 3.5 mm, length 230 cm
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 25
THERMOFLATOR® with KARL STORZ SCB withHighFlowInsufflation(30l/min.)
26 4320 08-1 THERMOFLATOR® SCB including: THERMOFLATOR® with KARL STORZ SCB
power supply 100 – 240 VAC, 50/60 Hz Mains Cord OPTITHERM® Heating Element, sterilizable Silicone Tubing Set, sterilizable Universal Wrench SCB Connecting Cable, length 100 cm * CO2/N2O Gas Filter, sterile,
for single use, package of 10
Subjecttothecustomer’sapplication-specific requirements additional accessories must be ordered separately.* This product is marketed by mtp.
For additional information, please apply to: mtp medical technical promotion gmbh, Take-Off Gewerbepark 46, D-78579 Neuhausen ob Eck, Germany
HAMOU® ENDOMAT® with KARL STORZ SCBSuction and Irrigation System
26 3311 01-1 HAMOU® ENDOMAT® SCB, power supply 100 – 240 VAC, 50/60 Hz
including: Mains Cord 5x HYST Tubing Set*, for single use 5x LAP Tubing Set*, for single use SCB Connecting Cable, length 100 cm VACUsafe Promotion Pack Suction*, 2 l
Subjecttothecustomer’sapplication-specific requirements additional accessories must be ordered separately.
* This product is marketed by mtp. For additional information, please apply to:
mtp medical technical promotion gmbh, Take-Off Gewerbepark 46, D-78579 Neuhausen ob Eck, Germany
AUTOCON® II400SCB20 5352 01-125 AUTOCON®II400HighEnd,SetSCB
power supply 220 - 240 VAC, 50/60 Hz, HF connecting sockets: Bipolar combination, Multifunction, Unipolar 3-pin + Erbe Neutral electrode combination 6.3 mm, jack and 2-pin, System requirements: SCB R-UI Software Release 20090001-43 or higher
including: AUTOCON®II400,with KARL STORZ SCB Mains Cord SCB Connecting Cable, length 100 cm
Laparoscopic Partial Nephrectomy with Parenchymal Clamp26
UG 540 Monitor Swifel Arm, height and side adjustable, can be turned to the left or the right side, swivel range 180°, overhang 780 mm, overhang from centre 1170 mm, load capacity max. 15 kg, with monitor fixation VESA 5/100, for usage with equipment carts UG xxx
UG 540
Equipment Cart
UG 220
UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistributors with 12 sockets, holder for power supplies, potential earth connectors and cable winding on the outside,
Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d), caster diameter: 150 mm
inluding: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 27
Recommended Accessories for Equipment Cart
UG 310 Isolation Transformer, 200 V – 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d), for usage with equipment carts UG xxx
UG 310
UG 410 Earth Leakage Monitor, 200 V – 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d), for usage with isolation transformer UG 310
UG 410
UG 510 Monitor Holding Arm, height adjustable, inclinable, mountable on left or right, turning radius approx. 320°, overhang 530 mm, load capacity max. 15 kg, monitor fixation VESA 75/100, for usage with equipment carts UG xxx
UG 510
Laparoscopic Partial Nephrectomy with Parenchymal Clamp28
Data Management and DocumentationKARL STORZ AIDA®–Exceptionaldocumentation
The name AIDA stands for the comprehensive implementation of all documentation requirements arising in surgical procedures: A tailored solution that flexibly adapts to the needs of every specialty and thereby allows for the greatest degree of customization.
This customization is achieved in accordance with existing clinical standards to guarantee a reliable and safe solution. Proven functionalities merge with the latest trends and developments in medicine to create a fully new documentation experience – AIDA.
AIDA seamlessly integrates into existing infrastructures and exchanges data with other systems using common standard interfaces.
WD 200-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, power supply 100-240 VAC, 50/60 Hz
including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm
WD 250-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, including SMARTSCREEN®(touch screen), power supply 100-240 VAC, 50/60 Hz
including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm
*XX Please indicate the relevant country code (DE, EN, ES, FR, IT, PT, RU) when placing your order.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp 29
Workflow-orienteduse
Patient
Entering patient data has never been this easy. AIDA seamlessly integrates into the existing infrastructure such as HIS and PACS. Data can be entered manually or via a DICOM worklist. ll important patient information is just a click away.
Checklist
Central administration and documentation of time-out. The checklist simplifies the documentation of all critical steps in accordance with clinical standards. All checklists can be adapted to individual needs for sustainably increasing patient safety.
Record
High-quality documentation, with still images and videos being recorded in FULL HD and 3D. The Dual Capture function allows for the parallel (synchronous or independent) recording of two sources. All recorded media can be marked for further processing with just one click.
Edit
With the Edit module, simple adjustments to recorded still images and videos can be very rapidly completed. Recordings can be quickly optimized and then directly placed in the report. In addition, freeze frames can be cut out of videos and edited and saved. Existing markings from the Record module can be used for quick selection.
Complete
Completing a procedure has never been easier. AIDA offers a large selection of storage locations. The data exported to each storage location can be defined. The Intelligent Export Manager (IEM) then carries out the export in the background. To prevent data loss, the system keeps the data until they have been successfully exported.
Reference
All important patient information is always available and easy to access. Completed procedures including all information, still images, videos, and the checklist report can be easily retrieved from the Reference module.
Laparoscopic Partial Nephrectomy with Parenchymal Clamp30
Notes:
with the compliments of
KARL STORZ — ENDOSKOPE