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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_986_Библиотеки_им_академика_М_И_Перельмана
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Operation Theatre Layout Handbook of Laparoscopy Instruments 19
https://t.me/medicina_free
trolley, and the laparoscopic procedure to be performed are all important factors.
It is critical to enter in the operating room early enough to ensure proper setup and
that all instruments are available andin good working order. One must allow
sufficient time for an appropriate set of equipment and operating table.
Establishing the Orientation and Appropriate Position of the Operating
Table
If the room is spacious enough, the standard operating table position will suffice
for laparoscopy.
In a small operating room, the operating table must be placed diagonally, and the
laparoscopic accessory tools must be arranged appropriately around the operating
table.
Optimal Position and Orientation of the Surgical Team
Establish the best position and orientation for the surgical team based on the
Laparoscopic procedure. In conventional operation, it is only left or right for the
operating surgeon. Unlike traditional laparoscopic surgery, the following factors
must be considered (Figs. 3.1 and 3.2):
Surgeon's position.a.
Number of assistants (1 or 2).b.
Staff nurse.c.
Monitors - video images must be in line with the ports and the surgeon.d.
Equipment trolley etc.e.
Robotic System and Its Effect on Operating Theatre Space
The use of da Vinci robot requires a lot of space
o Surgeon console
o Slave cathode ray tube monitor screen for operating theatre team viewing
o Robotic arm cart.
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Fig. (3.1). Basic Laparoscopic Theatre Setup. Source - Soper NJ, Scott-Conner CE, editors. The SAGES
Manual: Volume 1 Basic Laparoscopy and Endoscopy. Springer Science & Business Media; 2012 Jun 2 [2].
Operation Theatre Layout Handbook of Laparoscopy Instruments 21
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Fig. (3.2). Laparoscopic cholecystectomy set up in a small Operating theatre. Source - Soper NJ, ScottConner CE, editors. The SAGES Manual: Volume 1 Basic Laparoscopy and Endoscopy. Springer Science &
Business Media; 2012 Jun 2 [2].
22 Handbook of Laparoscopy Instruments Ramteke et al.
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Checklist for Equipments [3, 4]
A checklist for equipment ensures that all the necessary tools are readily
available, and it minimises the time delay in the operating theatre after the patient
has been taken inside it. Following is the list of equipment and instruments that
are required for operative laparoscopy:
Anaesthesia cart with monitors and equipment.a.
Advanced Electric operating table.b.
2 Video displays.c.
Irrigators with suction.d.
Electrocautery unit with a current monitoring system and earthing pad.e.
Ultrasonic scissors, scalpel, or other advanced units, if required.f.
Carton wheels help transfer laparoscopic equipment to different positions.g.
1. Source of light
2. The insufflator
3. Video recorder
4. Printer
5. The camera control unit (CCU).
h. X-ray unit with the facility of C-arm & remote monitor (if cholangiography
required)
i. Mayo tray/table with the laparoscopic instruments listed below:
Scalpel blades and handles (#11,#15)1.
Towel-sheet clips2.
Hasson cannula / Veress needle3.
CO2 gas insufflating tubes.4.
A fibre-optic cable is used to connect the laparoscope to the light source.5.
Instead of soaking in cidex solution, the video camera and cord should be6.
wrapped in sterile polythene or fabric sleeves.
Electric cord for an instrument with various adaptors.7.
2 Curved Kocher’s artery forceps (6 inches).8.
Small-sized retractors (Army-Navy retractors or S-retractors).9.
Trocars and cannulas vary in size and quantity depending on the planned10.
procedure.
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j. Laparoscopic Hand instruments.
❍
Atraumatic Grasper
❍
Locking Jaw toothed grasper
❍
Needle holders
-Straight, curved and right-angled dissector
❍
Intestinal grasping forceps
❍
Babcock’s forceps
❍
Metzenbaum scissors, Hook scissors, micro-tip scissors
❍
Fan retractors (10mm, 5mm)
-Advanced retractors (curved endoscopic retractors)
❍
Forceps for taking a biopsy
❍
Tru cut/ Core biopsy needle.
k. Dissection tools with a mono-polar cautery
❍
L shape hook
❍
Spatula shape tip dissector/coagulator
❍
Coagulator with ball tip
l. Ultrasound scalpel (Optional)
●
Scalpel
●
Hook dissector
●
Scissor dissector /coagulator Ball-tipped coagulator
m. Probe for Endocoagulation (Optional)
n. Devices for port closure.
o. Additional basket containing -Clip appliers
●
Endoscopic staplers
●
Endoscopic suture materials
●
Additional trocars
●
Pretied suture ligatures, endoloop etc.
SETUP OF THE OPERATING ROOM AND EQUIPMENT [3, 4]
Reassess the configuration with the operating table and all the operating rooma.
equipment in place.
Before bringing the patient to the operating theatre, set up all the requiredb.
equipment correctly. A systematic approach, beginning from the head of the
operating table, is advisable.
Adequate space should be available for the anesthesiologist to positioni.
anaesthesia equipment and work safely.
Then focus on the monitor's position and the path that connecting cablesii.
will occupy. “Fencing in” the surgeon and assistant by the connected
cables should be avoided at all costs. This is especially critical if the
24 Handbook of Laparoscopy Instruments Ramteke et al.
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surgeon and assistant need to relocate or change positions throughout the
procedure.
The exact configuration must be appropriate for the procedure beingiii.
performed. A good rule of thumb is that the laparoscope should be pointed
toward the quadrant of the abdomen with the pathology, and the surgeon
should be standing opposite the pathology and looking directly at the
primary monitor.
c. Inspect the equipment and confirm the following:
Two full CO2 cylinders should be in the room; one will be used for the surgery,
and the other will serve as a backup in case the pressure in the first cylinder drops
too low. Each type of gas cylinder has its own set of fittings, and if they don't fit
properly, it suggests that the cylinder is filled with a different kind of gas (e.g.
O2).
d. It is critical to pay close attention to the underlying details.
Assure that the table tilt mechanism is functioning correctly.i.
For obese patients, consider a footboard and an extra safety strap.ii.
Make sure the X-ray cassette plate is in the correct position.iii.
Notify the radiology technician.iv.
Ensure that Foley's catheter and Ryle's tube are available.v.
Double-check that all power sources are connected, and all functionalvi.
units are turned on.
Avoid overloading circuits by plugging several sockets or extensionvii.
cables into a single source.
Make sure the insufflator is working properly. Ascertain that theviii.
insufflator alarm is set correctly.
Make sure the irrigation fluid bottle is full.ix.
If documentation is required, ensure enough printer film and videotape.x.
Inspect the electrocautery unit; ensure that the machine's auditory alarm isxi.
operational and that the earthing pad is proper for the patient,
appropriately placed, and operational.
e. Before the surgery, connect the camera and light cord to the laparoscope. Focus
and white balance the laparoscope. Immerse the laparoscope in warm saline or an
electric warmer.
Operation Theatre Layout Handbook of Laparoscopy Instruments 25
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Double-check the following:
i. Check for good plunger/spring action on the veress needle and simple flushing
of saline through the stopcock and the needle channel.
ii. Ensure that all ports have closed stopcocks.
TROUBLESHOOTING [3, 5]
Laparoscopic surgeries are fundamentally intricate. Numerous things can go
wrong. If any difficulty arises, the surgeon must be familiar with the equipment's
troubleshooting, and it's the solution (Fig. 3.3).
OPERATING ROOM FIRES [4, 6]
It is advised to be cautious, especially related to the tip of the light cord, i.e.a.
the part that goes into the light generator, as its temperature is very high. As
per guidelines, the light cord is not removed from its source if any oxygen
source is present nearby, such as a nasal cannula, mask, oropharyngeal tube, or
endotracheal tube. During extubation, this hazard is fatal.
Bovie tips, hot ultrasound tips, and other devices can ignite the vapours fromb.
alcohol-based antiseptic preparation, like ChloraPrep.
26 Handbook of Laparoscopy Instruments Ramteke et al.
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Problem
Poor insufflation
1.
i.
Loss of pneumoperitoneum
Excessive pressure
2.
required for insufflation
(initial or subsequent)
Inadequate lighting
3.
(partial/complete loss)
Cause
tank empty
CO
2
Open accessory port stopcock (s)
Leak in sealing cap or stopcock
Excessive suctioning
Instrument cleaning channel screw
cap missing.
Loose connection of insufflator tubing
at source or at port
Loose Hasson stay sutures
Veress needle or cannula tip not in
free peritoneal cavity
Occlusion of tubing (kinking, table
wheel, inadequate size tubing etc).
Port stopcock turned opened
Inadequate muscle relaxation
Loose connection at source or at
scope
Light is on "manual minimum"
Bulb is burnt out
Fiberoptics are damaged
Automatic iris adjusting to bright
reflection from instrument
Monitor brightness turned down
Solution
Change tank
Inspect all accessory ports
-close stopcock (5)
Change cap or cannula
Allow abdomen to reinsufflate
Replace screw cap
Tighten connection
Replace or secure sutures
Reinsert needle or cannula.
Inspect full length of tubing, replace
with proper size as necessary
Assure stopcock is off
More muscle relaxant
Adjust connection
Go to "automatic"
Replace bulb
Replace light cable
Reposition instruments,
or switch to "manual
Readjust setting
4. Lighting too bright
5. No picture on monitor.
Light is on "manual maximum"
"Boost" on light source activated
Monitor brightness turned up
Camera control unit or other
components (VCR, printer, light
source, monitor) not on
Cable connector between camera
control unit and/or monitors not
attached properly
Go to "automatic"
Deactivate "boost"
Readjust setting.
Make sure all power sources are
plugged in and turned on
Cable should run from "video out"
on camera control unit to "video in"
on primary monitor, use compatible
cables for camera unit and light
source.
(Fig. ) contd .....
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Cable should run from video out" on
primary monitor to "video in"
on secondary monitor
6. Poor-quality picture
i. Fogging, haze
ii. Flickering electrical
interference
iii. Blurring, distortion
Condensation on lens of cold scope
entering warm abdomen
Condensation on scope eyepiece,
camera lens, coupler lens.
Moisture in camera cable connecting
plug
Poor cable shielding
Insecure between monitors
connection of video cable
Incorrect focus, cracked lens,
internal moisture
Clean the lens tip with warm water or
gently wipe lens on viscera; use
anti-fog solution or warm water it is
preferred not to wipe the lens on the
viscera or the end of telescope may
get hot; gently wiping on liver or
uterine surface is preferable
Detach camera from scope (or
camera from coupler), inspect and
clean lens as needed
Use compressed air to dry out
moisture (don't use cotton - tip
applicators on multiprong plug)
Replace video cable between
monitors
Reattach video cable at
each monitor
Adjust camera focus ring inspect
scope and camera, replace as needed
7. Inadequate suction/irrigation
8. Absent/inadequate
cauterization.
Occlusion of tubing (kinking, bloodt
clot, etc)
Occlusion of valves in suction/irrigator
device
Not attached to wall suction
Irrigation fluid container
not pressurized
Patient not grounded properly
Connection between electrosurgical
unit and pencil not secure.
Foot pedal or hand-switch not
connected to electrosurgical unit.
Inspect full length of tubing; if
necessary, detach from instrument
and flush tubing with sterile saline
Detach tubing, flush device with
sterile saline
Inspect and secure canister
connectors, wall source connector
Inspect compressed gas source,
connector, pressure dial setting
Assure adequate patient grounding
pad contact, and pad cable
electrosurgical unit connection
Inspect both connecting points.
Make connection
Fig. (3.3). Troubleshoot guidelines Source- Palanivelu C. Art of Laparoscopic Surgery: Textbook and Atlas.
Jaypee Brothers Medical Publishers; 2005 [4].
28 Handbook of Laparoscopy Instruments Ramteke et al.
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CONCLUSION
Operating theatre planning has been studied. A two-step approach has been
defined to solve it. First, the patient interventions are assigned to operating rooms
on a medium-term horizon. Second, the patient interventions are rescheduled
daily to integrate more characteristics (recovery room cleaning operations, etc..)
for human and material resource synchronisation. A primal-dual heuristic has
been proposed to solve the weekly assignment problem. On further more
integrates, release and due date constraints and, on the other hand, limited
capacity constraints. It optimises the operating theatre overload as well as the
patient waiting time. The obtained results are pretty good and inspire confidence
for other integration, such as a surgeon or anaesthesiologist agendas (physician
working gaps) which require scheduling each intervention of physicians such that
two interventions of the same physician do not take place at the same time. This
decision tool could also integrate bed availability, which can define a bottleneck
resource when interventions are postponed.
REFERENCES
[1] Göras C, Nilsson U, Ekstedt M, Unbeck M, Ehrenberg A. Managing complexity in the operating
room: a group interview study. BMC Health Serv Res 2020; 20(1): 440.
[http://dx.doi.org/10.1186/s12913-020-05192-8] [PMID: 32430074]
[2] Sutton ER, Park A. 4 Ergonomics in operating room design. The SAGES Manual 2012; pp. 45-59.
[3] Palanivelu C. Palanivelu’s textbook of surgical laparoscopy.
[4] Airan MC. Equipment Setup and Troubleshooting. The SAGES Manual. New York, NY: Springer
2012; pp. 21-43.
[5] Paz-Partlow M. Basic Instrumentation and Troubleshooting. Operative Strategies in Laparoscopic
Surgery. Berlin, Heidelberg: Springer 1995; pp. 3-9.
[6] Podnos YD, Williams RA. Fires in the operating room. Bull Am Coll Surg 1997; 82(8): 14-7.
[PMID: 10169956]
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