EndoWorld PRO 1-7-E/09-2011 TEO® – Transanal Endoscopic Operations Minimally Invasive Transanal Full Thickness Resection of Early Rectal Tumors TEO® – Transanal Endoscopic Operations The Method of Choice for Minimally Invasive Removal of Rectal Tumors Epidemiologic Background Incidence and age structure In Germany there are an estimated 60,000 new cases and 30,000 deaths each year due to colorectal carcinomas, of which 50% are in the rectal area. In spite of the comparatively good prognosis compared with other solid tumors, this figure can, nevertheless, be considerably improved. In the USA, for which comparative epidemiologic conditions can be assumed, there has been a 30% reduction in the mortality rate in the past few years. In addition to improvements in surgical techniques, (neo-) adjuvant therapies and the active treatment of tumor recurrences and metastases, this improvement in prognosis is due, above all, to the early recognition of colorectal tumors. Therefore, it is to be hoped that in Germany, early stage tumors will be treated more frequently in future. Indication 1. Assessing tumor status: In the treatment of rectal tumors, diagnostics and therapy are interrelated to an extent which is not seen in any other clinical area. This is due to the fact that there is practically a continuous spectrum of adenomatous tumors – from various stages of dysplasia through to invasive carcinomas. By definition, reference may only be made to an invasive carcinoma when the lamina muscularis mucosae has been infiltrated by the adenomatous process. This is a question, however, which can only be answered with absolute certainty following complete histopathologic preparation of the entire tumor. As such, the complete removal of the tumor as a “total biopsy” is necessary at both a diagnostic and therapeutic level. With this in mind, the endosonographic detection of the infiltration depth of a rectal tumor is of particular importance; although this process cannot directly predict the histologic tumor status, it is able to reliably predict the local resectability of a tumor. Additionally, the macroscopic assessment of tumor status by an experienced endoscopist and the clinical assessment based on rectal-digital examination (Mason clinical stage) remain reliable and proven criteria. 2. Staging: The indication and planning of local therapy on the rectum presents a particular challenge for preoperative diagnostics. Alongside the usual specification of the distance from the upper and lower tumor margins to the anal verge, it is also essential to give the distances to the dentate line (measured with rigid rectoscope), the circumferential extent of the tumor, the amount of the affected circumference, the stenosis stage and the endosonographic depth. A probe for rectal endosonography is available from numerous manufacturers of ultrasonic devices. Experienced examiners can achieve accuracy of well over 90% in the T-stage of rectal tumors, however the degree of distinction between the individual tumor stages varies. Differentiation between adenomas and T1 carcinomas is difficult, yet differentiation between T1 and T2 tumors is very good. In contrast, T2/T3 differentiation is considerably less precise. The endosonographic assessment of lymph nodes remains, in terms of methodology, an unsolved problem. The size of activated lymph nodes can be determined. In contrast, the differentiation of unspecific activated and tumor-infiltrated lymph nodes has proved almost impossible to date. About 50% of all fatal colorectal carcinomas are in the rectal area Complete removal of the tumor as a “total biopsy” is necessary at a diagnostic and therapeutic level. Diagnosis and differentiation of various rectal tumor stages 2 3 Minimally invasive transanal intervention and preservation of continence 3. Indication of local procedures: The fact that adenomatous rectal tumors (i.e. tumors without microvenous and/or lymphangic tumor infiltration) need to be completely removed for diagnostic-related reasons and to prevent a rectal carcinoma is undisputed. In the case of rectal carcinomas, all procedures must be measured against the oncologic standard of rectal resection or rectal extirpation with total mesorectal excision. It is known from large collections of tumor data (Erlangen Tumor Registry) that for low-risk carcinomas (i.e. tumors without microvenous or lymphatic tumor infiltration) the risk of the lymph nodes being affected in stage T1 is 3%. The operation mortality rate for anterior rectal resection is also around this level for the age group which is predominantly affected by rectal carcinomas. If a local radical R0 resection of a T1 low-risk carcinoma is technically possible, the probability of the patient suffering from lymphatic tumor recurrence is less than the mortality rate associated with a radical intervention. Additionally, patients also benefit from the minimally invasive nature of the transanal intervention and preservation of continence. A wealth of information is also available on the individual experiences of numerous patients with stage T2 and T3 tumors who, for various reasons, did not undergo a radical operation. It remains to be seen whether, in the future, the indication can be extended as a result of the combination with radiotherapy protocols. Transanal, endoscopic intervention using an operating rectoscope 4. Comparison of local procedures: There is a long history of local rectal resection procedures. Today, the lower extrarectal access routes, Mason anterolateral, or Kraske posterior approach, only have historical value. Various retractors (Parks etc.) are available for the transanal procedure which provide a sufficient view of the rectal wall, particularly in the lower third of the rectum. Since the 1980s the operating rectoscope developed by Gerhard Buess for transanal endoscopic microsurgery has been becoming increasingly popular. A corresponding telescope and endoscopic instruments can be inserted via a 40 mm rectoscope – enabling resections to be carried out extremely precisely on the entire rectum. Alongside mucous resections, full rectal wall resections with corresponding suture closure are possible in all areas of the entire rectum which can be reached with the rectoscope. The advantage of this procedure compared to other local procedures lies in the extreme precision of the resection – a requirement for ensuring long-term oncologic success. Indications for a transanal endoscopic intervention Advantages compared with open surgery Summary TEO® – Transanal Endoscopic Operations is indicated in the case of rectal tumors which • cannot be accessed for endoscopic mucous resection • do not infiltrate the lamina muscularis propria, and which show no signs of lymph node metastases • can be reached with the rectoscope, and which are at least 2 cm from the dentate line • are not bioptically identified as high-risk carcinomas Transanal Endoscopic Operations (TEO®) combines the minimal invasiveness of an intervention via a natural orifice (NOTES) with the precision of endoscopic microsurgical resection. • Available in lengths of 7.5 cm, 15 cm and 20 cm • The design of the channels has been adapted for the use of offset surgical instruments • Also suitable for staplers and ultrasonic scalpels (12 mm dia. of an instrument channel) 4 5 Autoclavable Hr 5 mm telescope with fiber optic light transmission and 30° angled eyepiece Excellent vision and simple orientation thanks to 30° direction of view as in laparoscopic surgery Irrigation channel positioned above telescope and lateral insufflation channel. Minimal gas loss during instrument changeover due to automatically sealing valves Adaptor for fiber optic light cable Mount for fastening to a holding arm and connector for vapor evacuation LUER-Lock connectors for cleaning telescopes and CO2 insufflation Operating Rectoscope for TEO® – Transanal Endoscopic Operations Transanal Endoscopic Operations (TEO®) combines the minimal invasiveness of an intervention via a natural orifice (NOTES) with the precision of endoscopic microsurgical resection. A wide lumen rectoscope enables precise guidance of surgical instruments under visual control. Special Features: l Autoclavable H® Telescope with fiber optic light transmission and oblique view l Excellent view and simple orientation due to 30° angle view, as in laparoscopic surgery l Automatically sealing valves ensure minimal gas loss during instrument changes l The new design of the channels has been designed for using offset operating instruments l Also suitable for stapler with a diameter of 12 mm (large instrument channel) l Available in lengths of 7.5 cm, 15 cm and 20 cm l Connectors for insufflation and vapor evacuation l Compatible with all standard laparoscopic camera systems 6 7 Operating Rectoscope n for TEO® – Transanal Endoscopic Operations – Working length 7.5 cm 24941 BA 24942 TK 24942 AK 24942 OK TEO® Operating Rectoscope 24941 BA H® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable, fiber optic light transmission incorporated, color code: red Working length 7.5 cm: 24942 TKTEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 7.5 cm, with handle for holding system, LUER-Lock connector for vapor evacuation 24942 OK TEO® Obturator, for use with Operating Rectoscope Tube 24942 TK 24942 AK TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 TK Operating Rectoscope n for TEO® – Transanal Endoscopic Operations – Working length 15 cm 24941 BA 24942 T 24942 A 24942 O TEO® Operating Rectoscope 24941 BA H® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable, fiber optic light transmission incorporated, color code: red Working length 15 cm: 24942 T 24942 O 24942 A TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 15 cm, with handle for holding system, LUER-Lock connector for vapor evacuation TEO® Obturator, for use with Operating Rectoscope Tube 24942 T TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 T 8 9 Operating Rectoscope n for TEO® – Transanal Endoscopic Operations – Working length 20 cm 24941 BAL 24942 TL 24942 AL 24942 OL TEO® Operating Rectoscope 24941 BAL H® Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 28 cm, autoclavable, fiber optic light transmission incorporated, color code: red Working length 20 cm: 24942 TL 24942 OL 24942 AL TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 20 cm, with handle for holding system, LUER-Lock connector for vapor evacuation TEO® Obturator, for use with Operating Rectoscope Tube 24942 TL TEO® Working Attachment, with attachment for H® Telescope 24941 BAL, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock adaptor for insufflation, for use with Operating Rectoscope Tube 24942 TL Accessories and Replacement Parts for Operating Rectoscope for TEO® – Transanal Endoscopic Operations 24960 B 24941 F 24941 I 24941 SP 24941 SPF 24941 AKF Accessories: 24941 F Sealing Cap, fenestrated, with holder for Fiber Optic Light Carrier 24960 B 24960 B Fiber Optic Light Carrier, with connector pin for fiber optic light cable, with sealing ring n 24941 I Insertion Aid, for placement of inner silicone leaflet valves 24941 AKF TEO® Working Attachment, for use with 10 mm H® telescopes, 2 channels for instruments up to size 14 mm and 1 channel for instruments up to size 10 mm, automatic sealing with silicone leaflet valve, for use with TEO® Operating Rectoscope Tube 24941 T/TK and 24942 T/TK Replacement parts: 24941 SP Sealing Set, for TEO® Working Attachments 24941 A/AK and 24942 A/AK/AL 24941 SPF Sealing Set, for TEO® Working Attachment 24941 AKF 10 11 Operating Instruments for TEO® – Transanal Endoscopic Operations c Dissecting and Grasping Forceps, rotating, dismantling, with and without connector pin for unipolar coagulation Size 5 mm Handle Working Length 33151 33152 n 33121 33122 n 33161 33132 n 36 cm 43 cm Single-action jaws offset downwards Insert No. Catalog number for the complete instrument 25310 ME 25351 ME 25352 ME 25321 ME 25322 ME 25361 ME 25332 ME 25410 ME 25451 ME 25452 ME 25421 ME 25422 ME 25461 ME 25432 ME |____ 14 ____| c Dissecting and Grasping Forceps, jaws offset downwards, multiple teeth, atraumatic, width of jaws 4.8 mm 25310 DF 25351 DF 25352 DF 25321 DF 25322 DF 25361 DF 25332 DF 25410 DF 25451 DF 25452 DF 25421 DF 25422 DF 25461 DF 25432 DF |____ 18 ____| c Universal Grasping Forceps, atraumatic, jaws offset downwards 25310 MG 25351 MG 25352 MG 25321 MG 25322 MG 25361 MG 25332 MG 25410 MG 25451 MG 25452 MG 25421 MG 25422 MG 25461 MG 25432 MG |____ 14 ____| c Dissecting and Grasping Forceps, jaws offset downwards, 2 x 4 teeth 25310 PMR 25351 PMR 25352 PMR 25321 PMR 25322 PMR 25361 PMR 25332 PMR 25410 PMR 25451 PMR 25452 PMR 25421 PMR 25422 PMR 25461 PMR 25432 PMR |____ 14 ____| c Universal Grasping Forceps PARROT-JAW®, jaws offset downwards, curved right 25310 PML 25351 PML 25352 PML 25321 PML 25322 PML 25361 PML 25332 PML 25410 PML 25451 PML 25452 PML 25421 PML 25422 PML 25461 PML 25432 PML |____ 14 ____| c Universal Grasping Forceps PARROT-JAW®, jaws offset downwards, curved left 25310 ML 25351 ML 25352 ML 25321 ML 25322 ML 25361 ML 25332 ML 25410 ML 25451 ML 25452 ML 25421 ML 25422 ML 25461 ML 25432 ML |_____ 22 _____| c KELLY Universal Grasping Forceps, long, jaws offset downwards Operating Instruments for TEO® – Transanal Endoscopic Operations c Dissecting and Grasping Forceps, rotating, dismantling, with and without connector pin for unipolar coagulation Size 5 mm Handle Working Length 33151 33152 n 33121 33122 n 33161 33132 n 36 cm 43 cm Single-action jaws straight Insert No. Catalog number for the complete instrument 33310 ME 33351 ME 33352 ME 33321 ME 33322 ME 33361 ME 33332 ME 33410 ME 33451 ME 33452 ME 33421 ME 33422 ME 33461 ME 33432 ME |____ 14 ____| c MANHES Grasping Forceps, multiple teeth, atraumatic, width of jaws 4.8 mm 33310 MG 33351 MG 33352 MG 33321 MG 33322 MG 33361 MG 33332 MG 33410 MG 33451 MG 33452 MG 33421 MG 33422 MG 33461 MG 33432 MG |____ 14 ____| c MANHES Grasping Forceps, 2 × 4 teeth Double-action jaws 33310 UL 33351 UL 33352 UL 33321 UL 33322 UL 33361 UL 33332 UL 33410 UL 33451 UL 33452 UL 33421 UL 33422 UL 33461 UL 33432 UL |____ 13 ____| c REDDICK-OLSEN Dissecting and Grasping Forceps, strong Please note: For c instruments only the individual component parts are numbered. The catalog number for the complete instrument is not on the instrument. Instruments with insulated handles with connector pin for unipolar coagulation, are shown against the red background, instruments with handles without connector pin for unipolar coagulation are shown against the blue background. The colour green indicates the inserts. 12 13 Operating Instruments for TEO® – Transanal Endoscopic Operations c Scissors, rotating, dismantling, with and without connector pin for unipolar coagulation Size 5 mm Handle Working Length 33121 33151 33125 33127 33161 n n 36 cm 43 cm Single-action jaws offset downwards Insert No. Catalog number for the complete instrument 25310 MT 25351 MT 25321 MT 25325 MT 25327 MT 25361 MT 25410 MT 25451 MT 25421 MT 25425 MT 25427 MT 25461 MT |____ 16 ____| c Scissors, jaws offset downwards, serrated 25310 MAR 25351 MAR 25321 MAR 25325 MAR 25327 MAR 25361 MAR 25410 MAR 25451 MAR 25421 MAR 25425 MAR 25427 MAR 25461 MAR |____ 22 ____| c Scissors, jaws offset downwards, curved right 25310 MAL 25351 MAL 25321 MAL 25325 MAL 25327 MAL 25361 MAL 25410 MAL 25451 MAL 25421 MAL 25425 MAL 25427 MAL 25461 MAL |____ 22 ____| c Scissors, jaws offset downwards, curved left Please note: For c instruments only the individual component parts are numbered. The catalog number for the complete instrument is not on the instrument. Instruments with insulated handles with connector pin for unipolar coagulation, are shown against the red background, instruments with handles without connector pin for unipolar coagulation are shown against the blue background. The colour green indicates the inserts. Operating Instruments for TEO® – Transanal Endoscopic Operations c Scissors, rotating, dismantling, with and without connector pin for unipolar coagulation Size 5 mm Handle Working Length 33121 33151 33125 33127 n 33161 n 36 cm 43 cm Single-action jaws straight Insert No. Catalog number for the complete instrument 34310 MT 34351 MT 34321 MT 34325 MT 34327 MT 34361 MT 34410 MT 34451 MT 34421 MT 34425 MT 34427 MT 34461 MT |____ 15 ____| c Scissors, serrated 34310 S 34351 S 34321 S 34325 S 34327 S 34361 S 34410 S 34451 S 34421 S 34425 S 34427 S 34461 S 7 c Micro Dissecting Scissors Double-action jaws 34310 MW 34351 MW 34321 MW 34325 MW 34327 MW 34361 MW 34410 MW 34451 MW 34421 MW 34425 MW 34427 MW 34461 MW |____ 15 ____| c Scissors, serrated, curved, conical 34310 MA 34351 MA 34321 MA 34325 MA 34327 MA 34361 MA 34410 MA 34451 MA 34421 MA 34425 MA 34427 MA 34461 MA |____ 20 ____| c Scissors, with serrated jaws, curved, spoon blades 34310 EK 34351 EK 34321 EK 34325 EK 34327 EK 34361 EK 34410 EK 34451 EK 34421 EK 34425 EK 34427 EK 34461 EK c Hook Scissors, jaws not crossing 9 14 15 Operating Instruments for TEO® – Transanal Endoscopic Operations Coagulating Suction Tubes Size 5 mm Instrument Working Length 33 cm Distal End Instrument 25370 DM Coagulating Suction Tube, proximally and distally bent downwards, needle-shaped 25370 SC Coagulating Suction Tube, proximally and distally bent downwards Working Length Instrument 36 cm 43 cm Distal End Instrument 37370 DL 37470 DL 37370 DB 37470 DB 30804 Coagulating and Dissecting Electrode, with suction channel, L-shaped Coagulating and Dissecting Electrode, with suction channel, blunt, spatula-shaped Handle with Trumpet Valve, for suction or irrigation, autoclavable, for use with 5 mm coagulating suction tubes and 5 mm suction and irrigation tubes Operating Instruments for TEO® – Transanal Endoscopic Operations Dissecting Hook Electrode, Dissecting Electrodes, Diathermy Loop Size 5 mm Instrument Working Length 33 cm Distal End Instrument 25370 KG 25370 KGG Working Length Dissecting Hook Electrode, proximally and distally bent downward, needle-shaped Dissection Hook Electrode, distally bent downwards, needle-shaped Instrument 36 cm 43 cm Distal End Instrument 26775 UF 26778 UF 26775 UE 26778 UE 26775 S 26778 S 26775 UM 26778 UM Coagulating and Dissecting Electrode, L-shaped Coagulating and Dissecting Electrode, spatula-shaped, blunt Coagulating and Dissecting Electrode, knife-shaped MOTSON Diathermy Loop 16 17 Operating Instruments for TEO® – Transanal Endoscopic Operations Suction and Irrigation Tubes, Injection Needles Size 5 mm Working Length Instrument 36 cm 43 cm Instrument Distal End 37360 LH 37460 LH 37360 SC 37460 SC 30805 Working Length Suction and Irrigation Tube, with lateral holes Suction and Irrigation Tube Handle with Two-Way Stopcock, for suction and irrigation, autoclavable, for use with suction and irrigation tubes size 5 mm Instrument 36 cm 43 cm Distal End Instrument 26175 P 26178 P Injection Needle, LUER-Lock, diameter 1.2 mm Operating Instruments for TEO® – Transanal Endoscopic Operations KOH Macro Needle Holders Size 5 mm Instrument Working Length 33 cm 43 cm Instrument Distal End 26173 KAF 26178 KAF 26173 KAL 26178 KAL 26173 KAR 26178 KAR KOH Macro Needle Holder, with tungsten carbide insert, ergonomic straight handle with disengageable ratchet, ratchet position right, jaws straight KOH Macro Needle Holder, with tungsten carbide insert, ergonomic straight handle with disengageable ratchet, ratchet position right, jaws curved to left KOH Macro Needle Holder, with tungsten carbide insert, ergonomic straight handle with disengageable ratchet, ratchet position left, jaws curved to right Instrument Working Length 33 cm 43 cm Distal End Instrument 26173 KPF 26178 KPF 26173 KPL 26178 KPL 26173 KPR 26178 KPR KOH Macro Needle Holder, with tungsten carbide insert, ergonomic pistol handle with disengageable ratchet, ratchet position left, jaws straight KOH Macro Needle Holder, with tungsten carbide insert, ergonomic pistol handle with disengageable ratchet, ratchet position left, jaws curved to left KOH Macro Needle Holder, with tungsten carbide insert, ergonomic pistol handle with disengageable ratchet, ratchet position right, jaws curved to right 18 19 KOH Macro Needle Holder n dismantling KOH Macro Needle Holder, size 5 mm, dismantling, including: ## Handle ## Outer Sheath ## Working Insert Cleaning and sterilization are gaining increasing importance for KARL STORZ as a manufacturer of surgical instruments. Similar to all our surgical instruments, the cleaning and hygiene of our needle holders also play an important role. Our KOH macro needle holders feature consistent effectiveness and precision, with significantly improved cleaning results achieved by dismantling the instrument. The handle, outer sheath and inner part can be cleaned and sterilized separately for perfect results. This unique reusable three-piece design offers the user the following benefits: ## Can be disassembled into three separate components ## Fully autoclavable ## Cleaning adaptor ## Choice of six different handles and three different working inserts ## With tungsten carbide inserts correct: In the event of damage, only the component with the defect needs to be replaced ## User-friendly and ergonomic handling ## Environmentally Handles and Outer Sheaths n KOH Macro Needle Holders, dismantling Handles, axial and pistol, grip with disengageable ratchet Handle, axial, with disengageable ratchet, ratchet release on top Handle, axial, with disengageable ratchet, ratchet release on the right side 30173 AL Handle, axial, with disengageable ratchet, ratchet release on the left side 30173 AO 30173 PR Handle, pistol grip, with disengageable ratchet, ratchet release on the right side 30173 PL Handle, pistol grip, with disengageable ratchet, ratchet release on the left side 30173 PO Handle, pistol grip, with disengageable ratchet, ratchet release on top 30173 AR Metal Outer Sheath Size 5 mm 30173 A with LUER-Lock connector for cleaning Length 30173 A 33 cm 30178 A 43 cm 20 21 KOH Macro Needle Holder n dismantling Size 5 mm Working Length Handle 30173 AR 30173 AL 30173 AO 33 cm 43 cm Single-action jaws Complete Instrument Insert No. 30173 R 30173 RAR 30173 RAL 30173 RAO 30178 R 30178 RAR 30178 RAL 30178 RAO KOH Macro Needle Holder, dismantling, jaws curved to right, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 30173 L 30173 LAR 30173 LAL 30173 LAO 30178 L 30178 LAR 30178 LAL 30178 LAO KOH Macro Needle Holder, dismantling, jaws curved to left, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 30173 F 30173 FAR 30173 FAL 30173 FAO 30178 F 30178 FAR 30178 FAL 30178 FAO KOH Macro Needle Holder, dismantling, straight jaws, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 KOH Macro Needle Holder n dismantling Size 5 mm Working Length Handle 30173 PR 30173 PL 30173 PO 33 cm 43 cm Single-action jaws Insert No. Complete Instrument 30173 R 30173 RPR 30173 RPL 30173 RPO 30178 R 30178 RPR 30178 RPL 30178 RPO KOH Macro Needle Holder, dismantling, jaws curved to right, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 30173 L 30173 LPR 30173 LPL 30173 LPO 30178 L 30178 LPR 30178 LPL 30178 LPO KOH Macro Needle Holder, dismantling, jaws curved to left, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 30173 F 30173 FPR 30173 FPL 30173 FPO 30178 F 30178 FPR 30178 FPL 30178 FPO KOH Macro Needle Holder, dismantling, straight jaws, with tungsten carbide inserts, for use with suture material size 0/0 – 7/0 22 23 Operating Instruments for TEO® – Transanal Endoscopic Operations Knot Tier, Clip-Applicator, Titanium Clips 26596 SK 26596 SK KOECKERLING Knot Tier, for extracorporeal knotting, size 5 mm, length 36 cm Size 10 mm 30444 GA 30444 GA 30460 AP Original size Clip Applicator, dismantling, rotating, size 10 mm, length 36 cm, for PILLING-WECK Titanium Clips 30460 AP (medium), with ratchet to lock the jaw holding the clip, including: Metal Handle, with ratchet Metal Outer Sheath Insert PILLING-WECK Titanium Clip, medium, box with 10 sterile cartridges, 25 clips each, for use with Clip Applicators 30444 GA, 30443 GA and 26060 GA Caution: The use of clips other than those indicated can lead to damage of the jaws. Holding System U-shaped Special Features: fast and accurate positioning ## New, reinforced versions of various articulated stands ## Five joint functions enable a large number of different positions ## All five joint functions and instruments can be fixed by means of the mechanical central clamp KSLOCK ## Variable height adjustment by using the socket ## Additional angle adjustment by using the socket 28172 HR ## Simple, ## Socket for use with European and United States standard rails ## Ergonomical positioning at the operating table ## Instruments and telescopes are clamped securely ## Steady imaging of the operation field ## Modular composition using individual elements ## Maintenance-free solid construction ## Autoclavable 28172 HR 28272 HD 24 25 Holding System U-shaped Articulated stand 28172 HK 28272 HD A D E Socket C 28172 HR B A 25 cm B 31 cm C 10 cm D 20 cm E 17 cm Catalog number of the entire holding system 28272 KLD 28272 RLD Recommended Configuration for TEO® – Transanal Endoscopic Operations Telescope for Operating Rectoscope, working length 7.5 cm and 15 cm 24941 BA HOPKINS® II Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 21 cm, autoclavable, fiber optic light transmission incorporated, color code: red n Operating Rectoscope, working length 7.5 cm 24942 TK 24942 OK 24942 AK TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 7.5 cm, with handle for holding system, LUER-Lock connector for vapor evacuation TEO® Obturator, for use with Operating Rectoscope Tube 24942 TK TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 TK n Operating Rectoscope, working length 15 cm 24942 T 24942 O 24942 A TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 15 cm, with handle for holding system, LUER-Lock connector for vapor evacuation TEO® Obturator, for use with Operating Rectoscope Tube 24942 T TEO® Working Attachment, with attachment for Telescope 24941 BA, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock connector for insufflation, for use with 24942 T n Telescope for Operating Rectoscope, working length 20 cm 24941 BAL HOPKINS® II Forward-Oblique Telescope 30°, angled eyepiece, diameter 5 mm, length 28 cm, autoclavable, fiber optic light transmission incorporated, color code: red n Operating Rectoscope, working length 20 cm 24942 TL 24942 OL 24942 AL TEO® Operating Rectoscope Tube, outer diameter 40 mm, working length 20 cm, with handle for holding system, LUER-Lock connector for vapor evacuation TEO® Obturator, for use with Operating Rectoscope Tube 24942 TL TEO® Working Attachment, with attachment for HOPKINS® II Telescope 24941 BAL, 2 channels for instrument size 5 mm and 1 channel for instruments up to size 12 mm, automatic sealing with silicone leaflet valve, LUER-Lock adaptor for insufflation, for use with Operating Rectoscope Tube 24942 TL Operating Instruments 25332 ME 25333 MG 25351 PMR 25361 ML 25351 MAR 25370 SC 25370 DM 2x 30804 37370 SC 30805 30173 RAL 30173 LAR 26596 SK 30444 GA 30460 AP 28272 RLD c Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with irrigation connection for cleaning, single action jaws, width of jaws 4.8 mm, jaws offset downwards, multiple teeth, atraumatic, size 5 mm, length 36 cm c Dissecting and Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, with irrigation connection for cleaning, single action jaws, jaws offset downwards, 2 x 4 teeth, size 5 mm, length 36 cm c Universal Grasping Forceps “PARROT-JAW®”, rotating, dismantling, with connector pin for unipolar coagulation, single action jaws, jaws offset downward, curved to the right, size 5 mm, length 36 cm c KELLY Universal Grasping Forceps, rotating, dismantling, without connector pin for unipolar coagulation, single action jaws, jaws offset downward, long, size 5 mm, length 36 cm c Scissors, rotating, dismantling, with connector pin for unipolar coagulation, single action jaws, jaws offset downward, curved to the right, size 5 mm, length 36 cm Coagulating Suction Tube, insulated sheath, proximally and distally bent downwards, punctual, size 5 mm, length 33 cm Coagulating Suction Tube, insulated sheath, proximally and distally bent downwards, needle-shaped, size 5 mm, length 33 cm Handle with Trumpet Valve, for suction or irrigation, autoclavable, for use with 5 mm coagulating suction tubes and 5 mm suction and irrigation tubes Coagulating and Dissecting Electrode, with suction channel, insulated sheath, with connector pin for unipolar coagulation, size 5 mm, length 36 cm, for use with trocars size 6 mm Handle with Two-Way Stopcock, for suction and irrigation, autoclavable, for use with suction and irrigation tubes size 5 mm KOH Macro Needle Holder, dismantling, with LUER-Lock connection for cleaning, single action jaws, jaws curved to right, with tungsten carbide inserts, with ergonomic handle, axial, disengageable ratchet, ratchet position left, size 5 mm, length 33 cm KOH Macro Needle Holder, dismantling, with LUER-Lock connection for cleaning, single action jaws, jaws curved to left, with tungsten carbide inserts, with ergonomic handle, axial, disengageable ratchet, ratchet position right, size 5 mm, length 33 cm KOECKERLING Knot Tier, for extracorporeal knotting, size 5 mm, length 36 cm Clip Applicator, dismantling, rotating, size 10 mm, length 36 cm, for PILLING-WECK Titanium Clips 30460 AP (medium), with ratchet to lock the jaw holding the clip PILLING-WECK Titanium Clip, medium, box with 10 sterile cartridges, 25 clips each, for use with Clip Applicators 30444 GA, 30443 GA and 26060 GA Holding System, for use with Operating Rectoscope Tubes 26 27 Notes EndoWorld® www.karlstorz.com Dr. med. Georg F. B. A. Kähler, M.D., Director of the Department for Endoscopy and Sonography Chirurgische Universitätsklinik Mannheim Fakultät für klinische Medizin der Universität Heidelberg Theodor-Kutzer-Ufer 1 – 3 68167 Mannheim KARL STORZ GmbH & Co. KG Mittelstraße 8, 78532 Tuttlingen, Germany Postfach 230, 78503 Tuttlingen, Germany Phone: +49 (0)74 61 708-0 Fax: +49 (0)74 61 70 8-105 E-Mail: [email protected] www.karlstorz.com +49 (0)621 3832647 +49 (0)621 3833825 [email protected] KARL STORZ Endoscopy-America, Inc. 2151 East Grand Avenue El Segundo, CA 90245-5017, USA Phone: +1 424 218-8100, +1 800 421-0837 Fax: +1 424 218-8526 E-Mail: [email protected] EW PRO 1-7-E/09-2011 Phone: Fax: E-Mail:
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