By now it should be news to no one that there is an obesity epidemic in the United States. For decades we have been warned to eat right and stay in shape by hundreds medical studies, alarmist investigative media reports, and a seemingly endless parade of diet and fitness programs. Evidently, few were listening. As new numbers come in every year, it has become abundantly clear that obesity is on the rise across the nation, especially in children.
Fortunately, as the problems (and our waistlines) continue to expand, steps are being taken to curb the epidemic. Nutrition and exercise are continuing to be stressed, and new guidelines for healthy eating are helping to educate the general public. People are becoming aware that fast-food isn’t necessarily the best food, and schools are beginning to take an active role in monitoring what children are eating by curtailing the availability of junk food and sugary soft drinks on campus. Nonetheless, we live in an age where Americans are simply coming in larger sizes. And, unfortunately, even in the event of an immediate nationwide health kick, the problem of obesity is one that will plague the nation for years to come.
The current generation of super-sized Americans has begun to cause some problems in a variety of settings, such as airplanes and movie theaters, where accommodating overweight and obese customers can be tricky given the slender efficiency of the seating. Perhaps the most difficult, and also the most critical, arena in which obesity has caused difficulty is in the surgical suite. Simply transporting and positioning obese patients can be a strain on the staff, but once in the operating room the surgeon can find himself confronted with numerous complications. Standard instruments and retractors have often proven ineffective in dealing larger patients.
While longer and stronger instruments address some of these concerns, the growing obesity epidemic is also opening up a whole new surgical specialty aimed directly at treating the special needs of the obese. Bariatric procedures are offering obese patients surgical options when conventional weight loss techniques have failed. This has prompted a number of medical device providers to redevelop existing instruments and invent new surgical devices to meet the unique requirements of the surgeons who perform these operations and treat obese patients. And fortunately they understand that sometimes just extending an instrument’s length isn’t enough to make it effective in bariatric surgery.
One such company is Cardinal Health in McGaw Park, IL, which has long offered the V. Mueller Full Circle Instrumentation product line. Rather than simply elongate the standard instrumentation, the V. Mueller open instrument patterns incorporate proprietary “double action” functionality, bringing the effectiveness and comfort of the standard instruments to longer bariatric instrumentation. This enables the working end of an 18-inch instrument to have the same physical characteristics as an 8-inch instrument, allowing the surgeon to use a longer tool without compromising his/her dexterity.
Also for open procedures, Cardinal offers its exclusive Multipurpose Abdominal Retractors System (MARS) to help facilitate procedures on just about any patient shape and contour.
Recently, Cardinal has acquired the Snowden Pencer® Diamond-Flex, Diamond-Touch and Diamond-Drive laparoscopic instruments. Diamond-Flex instruments are a unique line of articulating laparoscopic retractors, graspers and dissectors. The Diamond-Touch line is an “in-line” style laparoscopic instrument ideally suited for graspers and clamps in bariatric applications. The Diamond-Drive is a “pistol grip” style instrument most suitable for needle holders.
Diamond-Flex instruments can be articulated after being introduced into the abdominal cavity to form a large surface retractor (liver retraction) or an angled grasper/dissector, which is ideal for reaching behind structures that are difficult to access. Diamond-Touch instruments, with their in-line handle design, make it easy for the surgeon to work with the handle despite its often awkward position. The overall length and ergonomic design of these instruments make them ideal for long bariatric procedures and help surgeons avoid the fatigue that often accompanies using conventional instrumentation on larger patients.
For over 30 years, Automated Medical Products Corporation (Edison, NJ) has provided surgeons with high quality stainless steel instrument holders, retractors and accessories. In recent years they have expanded their product offerings to include innovative new instrumentation specifically designed to address the unique needs of bariatric surgery.
Among the newest offerings from Automated Medical is a novel instrument designed to accommodate the use of the LAP-BAND® System, a device that has come to be synonymous with the gastric banding bariatric surgical technique. The patent-pending Steinberg Introducer simplifies the introduction of the LAP-BAND® System into the abdomen and minimizes potential tissue damage. The Introducer’s guide is placed into a 10-mm port, and then the port is removed. The Introducer is placed onto the guide and slid into the abdomen. Once the Introducer enters the abdomen the guide is removed and LAP-BAND® is released. Then the surgeon can place the band around the esophageal junction with the stomach. As soon as the LAP-BAND® Adjustable Gastric Band is appropriately placed, the introducer is removed and the port is replaced.
Also available for use with the LAP-BAND® System is Automated Medical’s O’Brien Lap Band Set. This set of three instruments is specifically designed to simplify the procedure. The O’Brien Introducer introduces the device into the abdominal cavity. The O’Brien Placer is then used to assist in passing of the LAP-BAND® Adjustable Gastric Band behind the esophagus. (A flexible tip with a notch allows these two instruments to enter thorough a 5-mm trocar.) Finally, the 10-mm O’Brien Closer facilitates the closing of the LAP-BAND® Adjustable Gastric Band. All of the O’Brien instruments are designed with blunt, smooth ends to minimize the risk of perforating structures.
Automated Medical also offers a variety of instruments to assist in retracting the liver in bariatric and other upper abdominal surgeries. The Dbaly retractors can be introduced through a 5-mm hole, left of the xiphoid process, and placed at the visceral area of the liver. Nathanson Hook Liver Retractors are designed specifically to retract the liver during laparoscopic surgery, and can hold the liver out of the way for the entire duration of the surgery. Both the Dbaly and Nathanson retractors can be used in conjunction with Automated Medical’s Iron Intern Automatic Retractor Holders for steady and consistent retraction.
Thomas Medical of Alpharetta, GA offers a line of Gynecology instruments that are 12 inches and 14 inches long. Instrument configurations include scissors, hysterectomy clamps, uterine curettes, cervical curettes, and vaginal speculums that have six- to seven-inch long blades. These long-bladed speculums allow the doctor to open the vaginal vault without having the walls of the vagina close in on his/her view of the cervix.
The extended length of these Gynecology instruments allow surgeons to perform a variety of procedures on large and obese patients without having to struggle with short standard instruments that can not reach the deeper surgical sites. Thomas Medical continues to offer more and more instruments in longer lengths and is planning to add even longer 16-inch instruments to the product line in the future.
Headquartered in San Jose, CA, Stryker Endoscopy offers a full line of bariatric laparoscopic instruments in 5-mm and 10-mm diameters and 33-cm and 45-cm working lengths. Designed for every type of bariatric procedure currently being performed, the 10-mm instruments provide increased rigidity while the longer 5-mm instruments and longer scopes make procedures easier and more comfortable for the surgeon. In addition to the laparoscopic instruments, the company also offers a 40 Liter High Flow insufflator and a high definition camera to provide a crystal clear picture. The camera is lightweight and ergonomically designed, which is important in long bariatric procedures.
Olympus (Orangeburg, NY) provides a complete line of rigid telescopes, videoscopes, hand instruments, trocars, ultrasonic cutting and coagulation equipment, energy products, and gastroscopes for bariatric surgery. Among the newest Olympus products for the bariatric field is the HD EndoEYE videolaparoscope. With a 10-mm outside diameter and a working length of 390 mm, this autoclavable device can accommodate even the largest patients. Offering a 30 degree and 45 degree direction of view, the HD EndoEYE utilizes proprietary distal tip technology to provide optimal image quality with increased durability compared to traditional rod lens systems that transfer the image through multiple interfaces. The distal chip provides focus free convenience with reduced fogging and produces 1080 lines of resolution for a crisp, clear image with vibrant color reproduction.
The HiQ+ line of hand instruments also complements Olympus’s bariatric offerings. These instruments are available in standard, monopolar, and bipolar configurations, and provide an ergonomic design for maximum comfort and reduced surgeon fatigue. The HiQ+ line employs two different joint mechanisms: The CAM joint allows maximum force transmission during grasping for strong precise control with minimal effort, while the SL joint enables maximum force transmission during dissection, providing strong and precise tissue separation. Designed with a generous 430-mm working length, the instruments are easy to assemble and disassemble, allowing for easy cleaning and sterilization.
Islandia, NY-based Mediflex Surgical Products has collaborated with world-renowned surgeons to design and manufacture a number of advanced surgical devices for the bariatric procedures and other specialties. The Mediflex product line currently consists of three categories of instrumentation: The Bookler Table Mounted Retractor Systems for open surgery, including specific systems for bariatrics; the Flex Arm and StrongArm brands of Universal Holders and Positioners; and Mediflex brand laparoscopic instruments.
To assist in liver retraction in laparoscopic bariatric surgery, Mediflex offers the Nathanson Hook Liver Retractor System, which combines the basic Nathanson design with the StrongArm holding and positioning device. The Mediflex Nathanson Hook is equipped with a special “Quick Disconnect” hex-fitting that allows it to be accepted by a similar fitting available on the StrongArm devices. This coupling virtually eliminates any axial movement of the retractor and ensures that the liver is kept out of the surgical field throughout the duration of the procedure.
All of these new and innovative medical devices and surgical instruments have come together to help surgeons more efficiently and effectively treat obese patients. While bariatric and weight loss surgeries do not address the root of the obesity epidemic, they do provide extremely valuable and, in some cases, lifesaving options for those suffering from excessive weight. Bringing obesity under control is going to be long, hard road and will require a shift in values and an incredible strength of will on the part of the general public. For now, though, it’s comforting to know that there are surgical options open for those in dire need of help…and there are effective tools to help the surgeon do the job.