–The table should be close enough for the surgeon to be able to reach out for instruments.

–Ideally, the nurse is also able to view the surgery through the microscope.

•Anesthesia machine: None of the tubes must be stretched in order to reach to the patient.

•Infusion-bottle holder44: Should be fixed to the operating table, not stand on the floor.

•Monitor: It should be wall-mounted and be positioned so that the surgeon (and the nurse) can easily view it.45

One possible blueprint of the OR is shown on Fig. 16.8. As mentioned before,

the arrangement has implications, among others, for the use of tools connected to the vitrectomy machine. If, for instance, the cable of the light pipe46 is too close to the surgeon, it can easily get into contact with a non-sterile object or snake into view – it needs to be secured (see Fig. 16.6).

16.13 The Captain in the OR

Especially if paired with an experienced nurse, the inexperienced young fellow tends to accept whatever the nurse is suggesting, even when he knows he should “stand up for his rights” (see Chap. 6). Avoiding a conflict this way brings early benefits but can be detrimental long term: it will be much more difficult to make the OR personnel change their habits and behavior later. Optimally, the surgeon knows what he wants and firmly but politely conveys to the OR personnel that he has a reason for what he is asking and that he expects everybody to oblige.47

Q&A

Q Who should have the final word if there is conflict in the OR?

AThe surgeon. He is the captain of the ship, and he will be held accountable for anything, and everything, that goes wrong during the operation. With that responsibility, certain rights also come.

44May carry the BSS bottle as well as that used by the anesthesiologist but, preferably, the two are on separate poles. If they hang from the same pole, both the anesthesiology and VR personnel must be keenly aware which is which.

45This is crucial for video recording; see Sect. 12.4.

46A rather rigid structure.

47I remember performing live surgery at a foreign institution. The pedals were placed opposite to my preference (see Sect. 16.3). The chief nurse was a strong-willed individual, who had been bossing everybody, including the local VR surgeon, around. When I asked her to switch the pedals around, she refused, telling me in an icy voice that “this is how it’s always been in this OR.” I replied, in a calm but firm voice, that I understand, and as long as it is somebody else operating, it is his business. But now it will be me operating; therefore, the pedals have to be placed the way I prefer it. She obliged and never argued again. (To note, once the local surgeon started operating, her bossing attitude returned.) In that OR, the nurse was the captain.

AM

I

OT

MI

NBT

AC

NT

MW

VM

SC

Fig. 16.8 Schematic representation of one possible OR blueprint. The surgeon is right-handed; the microscope is floor-mounted. Both the assistant and the nurse are able to view the operation through the microscope. Note that the microscope’s two arms form an angle. See the text for further details. AM anesthesiology machine, I infusion stand, OT operating table, MI operating microscope, NBT nurse’s backup table, NC nurse’s chair, AC assistant’s chair, MW monitor on wall, NT nurse’s table, SC surgeon’s chair, VM vitrectomy machine

It requires delicate political balancing from the surgeon to not alienate the nurse yet insist on his own ideas if he is convinced that his is the better option. Conversely, a surgeon who rejects any idea just because it is coming from “only a nurse” is a fool. He not only deprives himself of a useful advice (and prevents any that may have come in the future) but also alienates someone who should be his best friend (see Chap. 6).

16.14The Fundamental Technical Rules of Performing Intravitreal Surgery

The surgeon is now ready to start the operation. Without providing more details, which are either unnecessary because the rule speaks for itself, or are provided in various chapters in this book, a brief summary of the most basic technical rules is provided in Table 16.6.

Table 16.6 A brief summary of the most fundamental technical rules in VR surgery

aE.g., tearing or even detaching the retina.

bThis strict rule may be loosened with time as the surgeon’s experience grows, but if he does look up, he needs to keep the instruments absolutely secured. His hands/fingers must remain in a fixed position and not make even the slightest move. Remember, even if the tip of the tool is kept truly in the center of the vitreous cavity, it is still only some 10 mm from the retina.

cUnless it is electrically controlled, and even then only after some precautions (see above).

dSuch as delivering 1,200 laser spots after the truly difficult part of the surgery has been successfully completed.

Q&A

QDoes the VR surgeon have to go through all the steps listed in this chapter every time he operates?

ASome always (e.g., adjusting his posture or the head of the operating table), others only if something has been changed (e.g., the previously set brightness or temperature of the OR was altered). The important thing is to carefully consider all the items listed and make conscious decisions about them as the actual situation requires.