Dissection

Safe Dissection in Minimal Access Surgery

Remember that when operating laparoscopically, the image you are viewing is apparent and magnified
between approximately 2x to 8x. Your view is 2-dimensional leading to problems with depth perception as
well as physical and psychological fatigue. The view is also unnatural in a number of ways: the colour
rendition may be altered, the view distance is of the order of one tenth of that in open surgery, and there is
a loss of peripheral vision. All these aspects are important when it comes to dissecting in the MAS
environment.

Using long instruments with small jaws and with very little tactile feedback also means that dissection is
often one of the main challenges in a MAS procedure. The types of dissection are the same as used in
conventional surgery:

 Blunt
 Sharp
 Energised

Blunt Dissection

The most common instruments used for blunt dissection are the suction/ irrigation probe, atraumatic
graspers and the pledget or peanut swab. The non-dominant or assisting instrument is vitally important as
the counter-traction applied to the tissues will enable effective dissection to take place.

The picture shows a non-captive pledget in use.

Sharp Dissection

Scissors are useful instruments as both sharp and blunt dissectors. Remember that you should always see
both blades before cutting any structure and that the non-dominant hand is important in that it provides
counter-traction and tissue stability.

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Dissection

Common errors that have been noted in scissor dissection include ineffective use of non-dominant hand,
too much sharp and not enough blunt dissection, and also using scissors without clear view of field.
Applying monopolar of electrosurgery to scissors is useful but do remember that when used on open
scissors it has a tendency to blunt them.

Clip Application

Before proceeding to apply clips you must familiarize yourself with how to properly load the clip if using a
non-disposable applicator. Most applicators have their jaws angled relative to the shaft of the instrument
and so it is important to offer the jaws of the applicator to the clip at the correct angle. This normally
means that the shaft of the applicator will be slightly off the perpendicular relative to the clip.

Once the clip is loaded, the instrument should be carefully introduced into the abdomen taking care not to
dislodge it by accidentally squeezing the handle.

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Dissection

Once inside the abdomen, you must ensure that you visualize both jaws of the clip applicator before
proceeding. If necessary, turn the shaft of the instrument, alter the amount of distraction of the structure
with the non-dominant hand, or ask the camera operator to change the angle at which the scope is viewing
the structure (if using an angled scope).

Now, begin to close the jaws so that the tips of the clips approximate to form a ring but do not completely
close the clips at this point. You should then carefully place the clip in the desired position, check that you
have not trapped any tissue deep to the clip unintentionally, and only then completely close the clip
applying it transversely across the structure. Adequate pressure should be exerted to ensure the clip is
securely closed around the structure.

Common errors in clip application include:

 Ineffective use of non-dominant hand

 Incorrect clip placement
 Applying clip without clear view, and
 Accidental dislodgement of the clip.

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