Fig. 16.6 At the start of the vitrectomy. The probe is in the surgeon’s dominant right hand. Both wrists are supported by the “U” of the operating table (draped over, thus not visible here). The vitrectomy machine is to the right of the surgeon; therefore, the cable of the light pipe, held in the surgeon’s left hand, is looped under his wrist (this keeps the rather rigid cable from curling into the field of view and reduces the risk that it touches a non-sterile surface). At the onset, the surgeon places the light pipe first and the probe second to reduce the chance that the tubings get entangled (the light pipe remains in the left hand during most if not all the operation; the instrument in the right hand may be replaced several times. If the tools are switched, the probe will be taken first). The light pipe is held by three fingers (thumb, index, middle), and in addition to the support under the wrist, the hand’s position is further secured by resting three fingers (middle, ring, little) on the patient’s forehead (the same is true for the right hand, not visible here). The BIOM is not swung in place yet; the nurse’s table is seen on the left

16.7.3 Staring into the Microscope

Performing PPV requires unrelenting, maximal concentration from the surgeon (see Sect. 3.7). When someone is so concentrated on nonstop visualization of the actions of his hand movements, the normal blinking frequency (15–17/min while resting) can drop to 0–1/min. The ocular surface dries fast, exacerbated by the dry air in the OR. The surgeon should force himself to blink often.

16.8Music in the OR

Most patients prefer it,33 but some surgeons find it distracting. Decide for yourself whether you like to hear the noise of the various machines in the OR instead.

33 Just think about yourself being in the dentist’s chair. You keep staring at the ceiling for extended periods, with nothing to occupy your mind. A patient may well spend even more time on your operating table, also with nothing to do – but also nothing to look at. The music helps in putting him at ease. Try to select a type of music that has no “rough edges” (baroque, smooth jazz, easy listening ─ not hard rock) and do not make it loud.

16.9The Brightness in the OR

Some surgeons prefer working in total darkness, and in principle it indeed helps being completely adapted. However, the nurse’s table needs to be illuminated so that she can find the instruments you ask for. You must work out a compromise between these two antagonistic needs.

16.10 The Quality of the Air in the OR

The air has two qualities that must be kept in mind to increase comfort for patient and personnel.

•The humidity in the OR is low: the air is about as dry as it is in an airplane.34

–This issue is more important for the surgeon than for the patient.35

–Reduced humidity can easily lead to dehydration.

–The air cannot be humidified, and air conditioning is often used, making the air even drier.

Pearl

The surgeon should make it a habit to drink after each operation, even if not feeling thirsty. Going to the bathroom often is preferred to developing headaches or kidney stones.

•The temperature in the OR should be set around 18 °C (64 °F).36

–Feeling cold is more important for the patient than for the surgeon; the latter wears two layers of clothing and produces extra heat due to his activities37 and to his own anxiety.

16.11 The Nurse’s Table38

There are two locations for the nurse to store the sterile instruments and materials that are (likely) to be used during PPV (see Fig. 16.7).39 The most commonly used tools should be readily available on the mobile table; the less frequently required ones are kept on a fixed table/shelf nearby.

34If air conditioning is not used, humidity in most homes is 35–60%, depending on the outside environment. In the OR, the air is usually less than 20% humid.

35Who spends less time there than the surgeon.

36While this temperature may be ideal for the surgeon, who prefers a colder environment due to his activity than those around him, the patient may feel extremely cold (see above, Sect. 16.6).

37I remember operating in ORs without air conditioning. On hot summer days, the circulator had to, every few minutes, wipe sweat off my forehead. Dripping sweat is a potential source of endophthalmitis.

38See also Chap. 6.

39Equipment, instruments, spare parts etc., which are very infrequently used, may be stored in cabinets along the wall, even outside the OR. The key is for the circulator to always be available;

c

Fig. 16.7 The nurse’s table. (a) The minimalistic option. Only the most frequently used tools and materials are kept on a mobile table in front on the nurse. The accessories of the VR machine are found on the machine’s own pullout tray on the right of the picture. (b) The maximalist option. Virtually any instrument and material that may become necessary are in front of the nurse, some on the “lower floor,” and underneath a drape. (c) The reserve table, where less commonly used tools/materials are kept. One factor determining whether the minimalistic or maximalist option is chosen is the distance between the nurse’s chair and this reserve table

Pearl

Clutter on the nurse’s table is highly undesirable. Even if the nurse places all instruments onto the table in some kind of logical arrangement, “in the heat of the battle” this order will not be kept, and from then on, it will take time for the tools to be located. Each delay increases the surgeon’s frustration, which in turn increases the risk of iatrogenic complications.

Ideally, the nurse finds the right compromise between having too many vs too few instruments on her table.40 If the surgeon is dissatisfied with that compromise, he should voice his feelings (see Sect. 16.13) and the two have to work out a solution.

both she and the nurse must know where that piece of equipment is stored and what its packaging looks like to shorten the time locating it (see above, Sect. 16.1).

40 Different nurses, of course, define that compromise differently.

Q&A

QShould the surgeon take tools off the nurse’s table himself or always ask for them?

AIt occasionally speeds up surgery if the surgeon simply takes the instrument himself. However, some nurses hate this; in addition, there is an inherent danger. The surgeon may take a syringe with the wrong fluid or wrong concentration or a sharp tool when the nurse also wants to handle it – and somebody gets stuck. In general, it is thus preferable for the surgeon to ask for the instruments from the nurse and wait patiently until it is placed in his hand.

16.12 The Blueprint of the OR

How the entire OR is arranged is an important part of the surgical setup. Just as all other issues related to PPV require a conscious decision, this arrangement should also be carefully considered, not simply accepted as a given fact – just because “it’s always been like this.”41 The arrangement has many implications, including how the surgeon handles the tools connected to the vitrectomy machine (light pipe, probe). The following components must find their (permanent) location.

•Microscope.

–If ceiling-mounted, it determines how far the operating table can be placed from it.42

–If floor-mounted, the surgeon has a lot more leeway, but the arrangement should be such that the microscope does not require movement between surgeries. The length of the two mobile arms of the microscope determines how far the microscope can be from the operating table, but the two arms should never form a straight line. They should be at an angle to allow, should it become necessary, manual intraoperative adjustment of the microscope’s head.

•Operating table: sufficient space must be left, preferably on both sides, for other equipment to be placed and for the OR personal to get to the patient.

•Vitrectomy and other machines.

–The nurse and the circulator must have easy access to them (for re-/program- ming, draining the collected fluid etc.).

–The surgeon must be able to see the display intraoperatively.43

•The nurse and her table.

–The nurse should be seated behind her table, not forced to stand. She should be close enough to the surgeon for the instrument handover not to require stretching from either of them.

41Of course, other surgeons are likely to work with the same nurses in the same OR, which may require a discussion to find a solution everybody can live with.

42Before the microscope is fixed to the ceiling, its location must be very carefully evaluated.

43Having the display behind the surgeon is suboptimal.