Mastering Precise and Accurate Laparoscopic Surgery with the All “IN” One Forceps

Noriyuki Inaki, M.D., Ph.D., FACS Senior Associate Professor, Digestive and General Surgery

Juntendo University Urayasu Hospital

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Mastering Precise and Accurate Laparoscopic Surgery with the All “IN” One Forceps

A wide variety of forceps has been developed for use in endoscopic surgeries in the field of gastroenterological surgery. Even under such circumstances, however, it is truly difficult to encounter an excellent device which can maximally reproduce the fine motions that surgeons picture in their minds.

In laparoscopy-assisted resection of gastric cancer that I routinely perform, a surgeon and an assistant manipulate a total of 4 forceps, holding them bimanually. Out of the many types of forceps I have used so far, the CLICKLINE “MN” became my favorite, which is used as a grasping forceps for the surgeon’s left hand. In addition, due to its fine dissection and maneuverability properties, the NOSHIRO forceps are also among my favorites. CLICKLINE “MN”; thanks to its atraumatic properties and precise grasping force, even the thinnest membrane can be grasped. Combined with other “fine“ devices such as the NOSHIRO forceps, I believe it is possible to achieve “meticulous“ surgery.

An optimal grasping forceps should possess not only accuracy in grasping the “ultimate point“ but also the ability to respond to a wide variety of procedures, while allowing continuous use in one hand, for dissection and reconstruction without having to switch. I have consistently used the “MN” type forceps in my left hand for all of my dissections and reconstruction procedures. Meanwhile, I have envisioned the development of an ultimate all-in-one left hand forceps with accurate grasping for many kinds of tissues such as fatty tissue, mucosal tissue, serosa and lymph nodes, which also allows fine control of needles and sutures as an auxiliary forceps in reconstruction procedures.

1997 Graduated from School of Medicine, Kanazawa University Resident, Department of Surgery (1), Kanazawa University Hospital

2003 Ph.D. Degree, Graduate School of Medical Science at Kanazawa University2004 Guest Surgeon, Section for Minimally Invasive Surgery,

Department of Surgery, Tuebingen University2006 Assistant Professor, Department of Telesurgery and

Geomedicine, Graduate School of Medical Science, Kanazawa University

2007 Chief Surgeon, Department of Digestive Surgery, Ishikawa Prefectural Central Hospital

2014 Consultant Surgeon, Department of Digestive Surgery, Ishikawa Prefectural Central Hospital

2016 Visiting Lecturer, Department of General and Digestive Surgery, Kanazawa Medical University

2017 Associate Professor, Department of General, Thoracic and Cardiovascular Surgery, Kanazawa University

2018 Senior Associate Professor, Digestive and General Surgery, Juntendo University Urayasu Hospital

Noriyuki Inaki, M.D., Ph.D., FACS

Senior Associate Professor, Digestive and General Surgery

Juntendo University Urayasu Hospital

Introduction

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The concept behind the development of the INAKI forceps.

In the search for an all-in-one grasping forceps with improved atraumatic properties, delicacy and tissue visibility to improve the conventional CLICKLINE “MN” with additional features of tissue and suture handling, the INAKI grasping forceps (“IN”) was born. To meet the demands for atraumatic and fine grasping, especially in nerve branches, the straight and square shape of the MN was enhanced by maximizing the thinness and flatness of the frame with a round and curved tip. These features reflect the souls of the fine craftsmen at the KARL STORZ factory.

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Experience from real surgical cases using the INAKI forceps.

Scenario 1: Grasping of the gastric wallDuring exposure of the organ, the gastric wall needs to be grasped and retracted. Obviously the gastric wall needs to be grasped away from the site of the tumor, avoiding injuries to the serosa and preserving the conduit. With the INAKI forceps, you can grasp the gastric wall protectively, and tissue slippage is less likely to occur. (Figure 2)

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Figure 1: INAKI grasping forcepsThe rounded and curved forceps tip minimizes the trauma to the tissue. The thin frame assures no hindrance to the visual field.

Figure 2: Grasping of the gastric wallSlippage of the grasped tissue is less likely to occur, even when the gastric wall is lifted.

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Scenario 2: Grasping of membranesThe INAKI forceps facilitates grasping soft and nerve tissues as if pinching them with the tips of the fingernails, instead of the fingertips, as with conventional grasping forceps, while maintaining the best visibility. In gastric cancer surgery, the ventral tissues are dissected along the inferior border of the pancreas while grasping the membrane of the anterior lobe of the transverse mesocolon. (Figure 3, left). In esophageal cancer surgery, it is possible to grasp the pleura as if pinching it with the fingernails of the left hand during dissection of the intrathoracic adhesesion (Figure 3, right).

Figure 5: Good visibilityThe frame type with the curved tip provides good visibility during manipulation.

Figure 3: Grasping of membranesAccurate grasping to test a membrane (left). Grasping the pleura as if pinching it with the fingernails (right).

Figure 4: Grasping of nervesNerves along the common hepatic artery can be delicately grasped and retracted.

Scenario 3: Grasping of nervesGrasping and retraction of nerves along the arteries are often meticulously performed in lymphadenectomies of gastric cancers. The INAKI forceps have proved themselves as the most appropriate for this purpose (Figure 4).

Scenario 4: Grasping and retracting of tissueThe INAKI forceps is efficient even in cases with high visceral fat deposition. With its moderate frictional force, vulnerable tissues can be grasped gently even with slightly applied pressure. The frame type with the curved tip provides an additional merit of good visibility of the grasped tissue behind (Figure 5).

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Scenario 5: Suture and ligatureThe multi-purpose INAKI forceps is suitable for grasping, not only during dissection but also in suturing and ligation without the surgeons having to switch between different types of forceps, for tasks such as grasping the intestine, holding the needles and suturing. The curved and finely tapered tip of the INAKI forceps provides greater maneuverability in intestinal and reconstructive surgery (Figure 6, left). Furthermore, the intestinal wall can be grasped gently and atraumatically (Figure 6, right).

Figure 6: Suture and ligatureJejuno-jejunal anastomosis in a Roux-en-Y reconstruction after distal gastrectomy.The curved and tapered tip design makes it easier to grasp the needle and provides good visibility (left).The consistency of the jejunal wall can be tested with gentle and trauma free grasping (right).

Conclusion

With the emergence of robotic-assisted surgery, a great deal of precise coordination between the hand and forceps is demanded from surgeons. However, robotic surgery is actually indicated for partial surgical procedures, and surgeons still perform many endoscopic surgeries using conventional instruments. This time, while I was developing the INAKI forceps, I focused on similar devices. With perseverance I realized more meticulous and finer surgical procedures could be pursued. Last but not least, I received enthusiastic feedback from doctors such as “I can grasp the gastric wall with no injuries”. “I can use this forceps not only for grasping but also for dissection procedures!”. “This forceps facilitates suturing!” and “I was longing to have such an ultimate forceps!”. These comments testify that the INAKI forceps is truly the all “IN” one forceps.

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Dissecting and Grasping Forceps

CLICKLINE – rotating, dismantling, insulated, with connector pin for unipolar coagulation

Size 5 mm

unipolar

LengthHandle

33151 33152 33153 33156 33121 33149

36 cm

Single action jaws

Working Insert Complete Instrument

33310 IN 33351 IN 33352 IN 33353 IN 33356 IN 33321 IN 33349 IN

27 mm

CLICKLINE INAKI Dissecting and Grasping Forceps, slender, atraumatic, fenestrated, curved

33310 CC 33351 CC 33352 CC 33353 CC 33356 CC 33321 CC 33349 CC

27 mm

CLICKLINE CROCE-OLMI Grasping Forceps, atraumatic, fenestrated, curved, single action jaws

33310 MN 33351 MN 33352 MN 33353 MN 33356 MN 33321 MN 33349 MN

26 mm

CLICKLINE MOURET Dissecting and Grasping Forceps, slender, atraumatic, fenestrated, single action jaws

Double action jaws

33310 NO 33351 NO 33352 NO 33353 NO 33356 NO 33321 NO 33349 NO

16 mm

CLICKLINE NOSHIRO Dissecting and Grasping Forceps, short, fine, for dissection

Operating instruments, length 36 cm, for use with trocars size 6 mm

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Dissecting and Grasping Forceps

CLICKLINE – rotating, dismantling, without connector pin for unipolar coagulation

Size 5 mm

LengthHandle

33161 33162 33163 33166 33131 33146 33147

36 cm

Single action jaws

Working Insert Complete Instrument

33310 IN 33361 IN 33362 IN 33363 IN 33366 IN 33331 IN 33346 IN 33347 IN

27 mm

CLICKLINE INAKI Dissecting and Grasping Forceps, slender, atraumatic, fenestrated, curved

33310 CC 33361 CC 33362 CC 33363 CC 33366 CC 33331 CC 33346 CC 33347 CC

27 mm

CLICKLINE CROCE-OLMI Grasping Forceps, atraumatic, fenestrated, curved

33310 MN 33361 MN 33362 MN 33363 MN 33366 MN 33331 MN 33346 MN 33347 MN

26 mm

CLICKLINE MOURET Dissecting and Grasping Forceps, slender, atraumatic, fenestrated

Double action jaws

33310 NO 33361 NO 33362 NO 33363 NO 33366 NO 33331 NO 33346 NO 33347 NO

16 mm

CLICKLINE NOSHIRO Dissecting and Grasping Forceps, short, fine, for dissection

Operating instruments, length 36 cm, for use with trocars size 6 mm

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17 mm

34310 MA-D CLICKLINE Scissors Insert with Outer Sheath, curved, double action jaws, spoon-shaped jaws, length of blades 17 mm, size 5 mm, length 36 cm, sterile, for single use, package of 10

34310 MS-D CLICKLINE METZENBAUM Scissors Insert, with outer sheath, curved, length of blades 12 mm, double action jaws, size 5 mm, length 36 cm, sterile, for single use, package of 10

12 mm

For use with reusable handles in the CLICKLINE series

unipolar

Single-Use Scissors

CLICKLINE – rotating, dismantling, insulated, with connector pin for unipolar coagulation

Size 5 mm, length 36 cm, sterile, for single use

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KOH Macro Needle Holder Handles and Outer Sheaths

dismantling, size 5 mm

Handles, axial and pistol-shaped, with disengageable ratchet

30173 AR Handle, axial, with disengageable ratchet, ratchet position right

30173 AL Handle, axial, with disengageable ratchet, ratchet position left

30173 AO Handle, axial, with disengageable ratchet, ratchet position on top

30173 PR Handle, pistol-shaped, with disengageable ratchet, ratchet position right

30173 PL Handle, pistol-shaped, with disengageable ratchet, ratchet position left

30173 PO Handle, pistol-shaped, with disengageable ratchet, ratchet position on top

Metal Outer Sheath Size 5 mm

30173 A Metal Outer Sheath, with LUER-Lock connector for cleaning, size 5 mm, length 33 cm

30178 A Same, length 43 cm

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KOH Macro Needle Holder

dismantling, size 5 mm

Operating instruments, lengths 33 and 43 cm, with axial handle for use with trocars size 6 mm

LengthHandle

30173 AR 30173 AL 30173 AO

33 cm

43 cm

Single action jaws

Working Insert Complete Instrument

30173 R 30173 RAR 30173 RAL 30173 RAO

30178 R 30178 RAR 30178 RAL 30178 RAO

KOH Macro Needle Holder, jaws curved to right, with tungsten carbide inserts

30173 L 30173 LAR 30173 LAL 30173 LAO

30178 L 30178 LAR 30178 LAL 30178 LAO

KOH Macro Needle Holder, jaws curved to left, with tungsten carbide inserts

30173 F 30173 FAR 30173 FAL 30173 FAO

30178 F 30178 FAR 30178 FAL 30178 FAO

KOH Macro Needle Holder, straight jaws, with tungsten carbide inserts

30173 G 30173 GAR 30173 GAL 30173 GAO

KOH Macro Assistant Needle Holder, straight jaws

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KOH Macro Needle Holder

dismantling, size 5 mm

Operating instruments, lengths 33 and 43 cm, with pistol grip handle, for use with trocars size 6 mm

LengthHandle

30173 PR 30173 PL 30173 PO

33 cm

43 cm

Single action jaws

Working Insert Complete Instrument

30173 R 30173 RPR 30173 RPL 30173 RPO

30178 R 30178 RPR 30178 RPL 30178 RPO

KOH Macro Needle Holder, jaws curved to right, with tungsten carbide inserts

30173 L 30173 LPR 30173 LPL 30173 LPO

30178 L 30178 LPR 30178 LPL 30178 LPO

KOH Macro Needle Holder, jaws curved to left, with tungsten carbide inserts

30173 F 30173 FPR 30173 FPL 30173 FPO

30178 F 30178 FPR 30178 FPL 30178 FPO

KOH Macro Needle Holder, straight jaws, with tungsten carbide inserts

30173 G 30173 GPR 30173 GPL 30173 GPO

KOH Macro Assistant Needle Holder, straight jaws

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26173 HA Needle Holder, with needle raising function, ergonomic axial handle with ratchet, ratchet-release on the right side, straight jaws, with tungsten carbide insert, diameter 5 mm, length 33 cm

Needle Holder with Righting Function

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Coagulation and Dissection Electrode

37370 GC GORDTS and CAMPO Coagulation Suction and Irrigation Tube, bipolar, diameter 5 mm, length 36 cm, for use with suction and irrigation handles

37113 A Handle, pistol grip, with clamping valve, for suction and irrigation, autoclavable, including Cleaning Adaptor 8236091, for use with 3, 3.5, 5 and 10 mm suction and irrigation tubes

37370 DL Coagulation and Dissection Electrode, with suction channel, insulated sheath, with connector pin for unipolar coagulation, L-shaped, size 5 mm, length 36 cm

30803 Handle, without irrigation and suction connector, autoclavable, for use with 5 mm coagulating and dissecting electrodes with suction channel

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Notes

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It is recommended to check the suitability of the product for the intended procedure prior to use.

Notes

KARL STORZ SE & Co. KG Dr.-Karl-Storz-Straße 34, 78532 Tuttlingen/Germany Postbox 230, 78503 Tuttlingen/Germany Phone: +49 (0)7461 708-0 Fax: +49 (0)7461 708-105 E-Mail: info@karlstorz.com

www.karlstorz.com

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