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]

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05.15-0.3

ISBN 978-3-89756-325-4

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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.

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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


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


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


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.


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.


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


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


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


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.


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


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


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


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


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Side-by-side view: Parallel display of standard image and Visualization mode

Intelligent icons

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## Forward and backward compatibility with video endoscopes and FULL HD camera heads

## Sustainable investment## Compatible with all light sources

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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

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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


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


Weight

Specifications:

TC 200EN

TC 300

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.


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


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


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


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


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


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


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


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


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


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


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.


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.


Notes:

with the compliments of

KARL STORZ — ENDOSKOPE

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH PARENCHYMAL CLAMP · 4 Laparoscopic Partial Nephrectomy with...

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