The SAGES Manual: Volume 1 Basic Laparoscopy and Endoscopy

Part 1

Basic Laparoscopy and Endoscopy: General Principles

Nathaniel J. Soper and Carol E.H. Scott-Conner (eds.)The SAGES Manual3rd ed. 2012Volume 1 Basic Laparoscopy and Endoscopy10.1007/978-1-4614-2344-7_1© Springer Science+Business Media, LLC 2012

1. Fundamentals of Laparoscopic Surgery (FLS) and of Endoscopic Surgery (FES)

Jeffrey M. Marks¹  

(1)

Department of General Surgery, Case Western Reserve Medical Center, University Hospitals of Cleveland, Cleveland, OH, USA

Jeffrey M. Marks

Email: jeffrey.marks@uhhospitals.org

Abstract

The Fundamentals of Laparoscopic Surgery (FLS) program was developed by surgeons, educators, and administrators, under the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The impetus to create this curriculum was born out of the need to safely introduce laparoscopic techniques into clinical practice and by the demand to demonstrate basic competence in the application of this new technology. Many of the same issues that prompted the development of FLS are apparent in the training of competent flexible endoscopists both in the fields of gastroenterology and gastrointestinal surgery. The importance of these skills for surgeons is rapidly increasing as we work toward the development of increasingly less invasive methods to treat gastrointestinal disease. In response to the need for an objective way to teach and assess the knowledge and skills required to perform basic flexible endoscopy, members of SAGES began to discuss the possibility of developing a flexible gastrointestinal endoscopy program, similar to FLS, that could serve as a benchmark for physicians of all specialties.

Keywords

FundamentalsLaparoscopic surgeryEndoscopic surgeryFLSTrainingSimulators

The Fundamentals of Laparoscopic surgery (FLS) is a validated ­program for the teaching and evaluation of the basic knowledge and skills required to perform laparoscopic surgery. The educational component includes didactic, Web-based material and a simple, affordable physical simulator with specific tasks and a recommended curriculum. FLS certification requires passing both a written multiple-choice examination and a proctored manual skills examination in the FLS simulator. The metrics for the FLS program has been rigorously validated to meet the highest educational standards and certification is now a requirement for the American Board of Surgery. This chapter summarizes the validation process and the FLS related research that has been done to date.

The FLS program was developed by surgeons, educators, and ­administrators, under the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The impetus to create this curriculum was born out of the need to safely introduce ­laparoscopic techniques into clinical practice and by the demand to ­demonstrate basic competence in the application of this new technology. In the early years of laparoscopy, some surgeons integrated these ­techniques into their practices after cursory weekend courses or animal labs. Unfortunately, an increase in bile duct injuries and other complications occurred during the early experience with laparoscopic cholecystectomies. This critical issue of patient safety was the initial driver for the FLS effort. Around the same time, the concept of simulation in medicine was also starting to gain popularity, especially in light of restricted resident work hours and limited operating room resources.

A. Program Description and Components

The FLS Program is not procedure or discipline-specific. It includes both teaching and assessment components.

1. Web-Based Study Guide

a.

Didactic modules (Fig. 1.1)

Fig. 1.1.

Web-based study guide for FLS.

i.

Preoperative considerations

ii.

Intraoperative considerations

iii.

Basic laparoscopic procedures

iv.

Postoperative care and complications

v.

Manual skills practice

b.

Patient scenarios

c.

Technical skills explanations

2. Assessment Tool

The assessment of this didactic material is done in the form of a 90-min multiple-choice examination of 75 questions. The computer-based test must be taken in a proctored setting at designated testing centers. It includes standard multiple-choice questions as well as case-based scenarios, and sometimes asks the examinee to interpret digital images.

3. Manual Skills (Fig. 1.2)

Fig. 1.2.

Manual skills tests for FLS.

a.

Five tasks performed in a box trainer with a built-in camera that is connected to a monitor (not included).

b.

The kit also contains a set of instruments and disposable supplies. FLS is modeled after the original program developed by Fried et al., and previously referred to as the McGill Inanimate System for the Training and Evaluation of Laparoscopic Skills (MISTELS).

c.

The tasks are scored for efficiency and precision, and each task has a predetermined cutoff time. The scores have been ­normalized and are equally weighted. A higher score indicates superior performance.

i.

Peg transfer

ii.

Precision cutting

iii.

Placement of a ligating loop

iv.

Suturing using extracorporeal knot tying

v.

Suturing using intracorporeal knot tying

4. Global Operative Assessment of Laparoscopic Skills (GOALS)

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a validated measure of intraoperative laparoscopic skill, and a high positive correlation exists between FLS manual skill performance and GOALS scores in the operating room during dissection of the gallbladder from the liver bed.

B. FLS Simulator Practice Improves Operating Room Performance

The true test regarding the effectiveness of the FLS manual skills program as a training program is whether or not the skills acquired and measured in the simulator transfer to the operating room. Sroka et al. recently conducted a randomized controlled trial examining the effects of training using the FLS proficiency based curriculum described by Ritter and Scott on operating room performance as measured by GOALS. The FLS-trained group achieved the proficiency goals and improved ­significantly (increased by 6.1 ± 1.3, p < 0.01) in the operating room compared to the control group whose GOALS scores remained unchanged (increased by 1.8 ± 2.1, p = 0.47). After 2.5 h of supervised practice, and 5 h of individual deliberate practice, the simulator group, composed of first and second year residents performed at the level of third and fourth year residents in a previous study. They acquired skills in the simulator in 7.5 h that they may have otherwise acquired during 1 or 2 years of residency training!

C. Fundamentals of Endoscopic Surgery (GOALS)

Many of the same issues that prompted the development of FLS are apparent in the training of competent flexible endoscopists both in the fields of gastroenterology and gastrointestinal surgery. The importance of these skills for surgeons is rapidly increasing as we work toward the development of increasingly less invasive methods to treat gastrointestinal disease. In response to the need for an objective way to teach and assess the knowledge and skills required to perform basic flexible ­endoscopy, members of SAGES began to discuss the possibility of ­developing a flexible gastrointestinal endoscopy teaching and evaluation program, similar to FLS, that could serve as a benchmark for physicians of all specialties. Through this discussion, Fundamentals of Endoscopic Surgery (FES) was born. At the time of preparation of this chapter, the program is still being developed and validated, with the intention to launch the program by Fall 2011.

Similar to FLS, the FES Program is not procedure or discipline-­specific and includes teaching and assessment components.

1. Web-Based Study Guide

a.

Didactic modules (Figs. 1.3 and 1.4)

Fig. 1.3.

Web-based study guide pages for FES.

Fig. 1.4.

Web-based study guide pages for FES.

i.

Technology

ii.

Patient preparation

iii.

Sedation and analgesia

iv.

Upper gastrointestinal endoscopy

v.

Lower gastrointestinal endoscopy

vi.

Performing lower GI procedures

vii.

Lower GI anatomy, pathology, and complications

viii.

Didactic Endoscopic Retrograde Cholangiopancreato­graphy (ERCP)

ix.

Hemostasis

x.

Tissue removal

xi.

Enteral access

xii.

Endoscopic therapies

2. Assessment Tool

The assessment of this didactic material is done in the form of a 90-min multiple-choice examination of 75 questions. The computer-based test must be taken in a proctored setting at designated testing centers. It includes standard multiple-choice questions as well as case-based scenarios, and sometimes asks the examinee to interpret digital images.

3. Manual Skills

a.

It consists of five separate modules administered on the Simbionix GI Mentor II platform (Fig. 1.5).

Fig. 1.5.

Simbionix GI Mentor II for FES hands on skills (GI Mentor, Simbionix, USA).

b.

Because of the cost of this platform, it is envisioned that the test will initially be given at regional testing centers around the world. Eventually, the goal is to develop a desktop testing ­platform, which could be more easily distributed to individual training programs.

i.

Module 1—Navigation (traversal, tip deflection, and torque) (Fig. 1.6a)

Fig. 1.6.

Manual skills tests for FES. (a) Navigation (traversal, tip deflection, and torque); (b) Retroflexion; (c) Mucosal evaluation; (d) Targeting (GI Mentor, Simbionix, USA).

ii.

Module 2—Loop reduction

iii.

Module 3—Retroflexion (Fig. 1.6b)

iv.

Module 4—Mucosal evaluation (Fig. 1.6c)

v.

Module 5—Targeting (Fig. 1.6d)

4. Global Assessment of Gastrointestinal Endoscopic Skills (GAGES)

The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) was developed by expert endoscopists and educators. The ­fundamental skills required for flexible endoscopy were identified and then distilled into two global assessments: GAGES Upper Endoscopy (GAGES-UE) and GAGES Colonoscopy (GAGES-C). The assessments were modeled after the Objective Structured Assessment of Technical Skills (OSATS) for open surgery and the GOALS for laparoscopic surgery and consist of itemized skills rated on a 5-point Likert scale with anchors at 1, 3, and 5.

D. Conclusion

The concept that merits reiteration is the notion that passing FLS, and eventually FES, does not indicate that an individual is a competent surgeon or endoscopist, but that they have demonstrated competence in the basic knowledge and technical skills required to safely perform these procedures. Just as one would expect that a trainee learn the differences between needle drivers and suture materials and how to suture and tie knots outside of the operating room, these programs attempt to assure a basic level of knowledge and skill before entering the clinical arena. Overall, the goal is to optimize patient safety and the utilization of ­operating room resources while improving the efficiency and quality of surgical education.

Selected References

Clarke JR. Making surgery safer. J Am Coll Surg. 2005;200:229.PubMedCrossRef

Derossis AM, Antoniuk M, Fried GM. Evaluation of laparoscopic skills: a 2-year follow-up during residency training. Can J Surg. 1999;42:293.PubMed

Fried GM, Feldman LS, Vassiliou MC, et al. Proving the value of simulation in laparoscopic surgery. Ann Surg. 2004;240:518–25. discussion 525–8.PubMedCrossRef

McCluney AL, Vassiliou MC, Kaneva PA, et al. FLS simulator performance predicts ­intraoperative laparoscopic skill. Surg Endosc. 2007;21:1991–5.PubMedCrossRef

Sroka G, Feldman LS, Vassiliou MC, et al. Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial. Am J Surg. 2010;199(1):115–20.PubMedCrossRef

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during ­laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101.PubMed

Nathaniel J. Soper and Carol E.H. Scott-Conner (eds.)The SAGES Manual3rd ed. 2012Volume 1 Basic Laparoscopy and Endoscopy10.1007/978-1-4614-2344-7_2© Springer Science+Business Media, LLC 2012

2. Maintenance of Certification

Jo Buyske¹  

(1)

American Board of Surgery, Philadelphia, PA, USA

Jo Buyske

Email: jbuyske@zmail.absurgery.org

Abstract

Maintenance of Certification (MOC) is now required of all newly certified and recertified surgeons. It is a program of continuous professional development that includes continuing education, self-assessment, and evaluation of performance in practice. MOC is divided into four components: Part 1 Professional Standing, Part 2 Lifelong Learning and Self-Assessment, Part 3 Cognitive Expertise, and Part 4 Evaluation of Performance in Practice. Documentation must be provided to the American Board of Surgery in 3-year cycles, and will include proof of CME, CME self-assessment, professional testimonials, and documentation of participation in a database. The ABS Recertification Examination is now required for Part 3, and, as before, must be taken once every 10 years to fulfill MOC requirements and thus allow for continuing ABS certification. The American Board of Surgery Web site provides clear instructions on MOC requirements and how to document and fulfill them. SAGES, through the annual meeting and SAGES University, can help fulfill MOC requirements.

Keywords

Maintenance of CertificationSelf-assessmentSelf-assessment CMEAmerican Board of SurgerySAGES UniversitySAGES Journal ClubSAGES OSAPSAGES Online Self-Assessment ProgramMOC Part 2MOC Part 4

A. Introduction

1. Definition of Maintenance of Certification

Maintenance of Certification (MOC) is the documentation of a personal program of continuous learning and improvement. MOC is required for ongoing certification by the American Board of Surgery and starts immediately upon initial certification or recertification. MOC crosses all specialties. It was established in 2002 by the American Board of Medical Specialties, a federation of 24 member boards. It is the logical continued growth of the process of board certification and also answers the public demand for demonstration of quality and ongoing acquisition of knowledge.

2. History of Board Certification

Board certification in the USA has evolved since its inception in 1917. The American Board of Ophthalmology was the first board formed, inspired by a 1908 speech to the American Academy of Ophthalmology and Otolaryngology by Derrick Vail, an ophthalmologist. He stated:

I hope to see the time when ophthalmology will be taught in this country as it should be taught. That day will come when we demand… that a ­certain amount of preliminary education and training be enforced before a man may be licensed to practice ophthalmology. After a sufficiently long term of service in an ophthalmic institution … he should be permitted to appear before a proper examining board for examination… and if he is found competent let him then be permitted and licensed to practice ­ophthalmology.

That speech inspired the formation of the American Board of Ophthalmology in 1917, and in 1937 the American Board of Surgery was formed. The original mission statement of the ABS notes that the Board is formed to protect the public and improve the specialty which was to be accomplished by the establishment of a comprehensive, standardized certification process, including periodic assessment of individual hospitals as appropriate places of training, the requirement of 5 years of training beyond internship, and the development of an examination process designed to assess both knowledge and judgment.

3. Background of MOC

From 1937 until 1976 certification was lifelong: once certified, nothing further was required for the duration of one’s surgical career. In 1976, the American Board of Surgery formally recognized that surgery is a field that requires ongoing active engagement in learning and that this should be supported by requiring recertification. Recertification requirements included: submission of a case log, assessment of knowledge by a broad-based multiple choice exam with a passing score, proof of active license and hospital privileges, and testimonials from hospital officials including the chief of surgery. The decision to implement intermittent reassessment for recertification was supported by the outcome. The results of those first recertification exams confirmed that the body of knowledge of surgeons 20 or 30 years out of training was not the same as that of surgeons within 10 years of their training; the former group failed the exam in high numbers.

A confluence of events at the turn of the century caused the specialty boards to revisit the duration of certification yet again. Increased public scrutiny of patient safety, the issuance of the IOM report To Err is Human in 1999, and the highly successful safety campaign by the airline industry all drove focus towards more oversight of knowledge and training. In addition, surgery underwent a series of rapid changes, including the widespread adoption of laparoscopy, the development of endovascular surgery, the introduction of sentinel node technology, the discovery of Helicobacter pylori, the penetration of interventional endoscopy, and the increased use of noninvasive management of blunt trauma. All these things combined to make it clear that surgical training and practice were dynamic arenas that required ongoing attention and self-education.

B. Defining MOC

MOC is a result of that reassessment. MOC changes the emphasis from a burst of studying every 10 years to that of an ongoing process of learning and assessment. It is broken into four categories, based upon the ABMS/ACGME Six Competencies, adopted in 1999. The Six Competencies are a rubric for resident education and assessment across all specialties. Programs are required to demonstrate that their curriculum addresses these arenas.

The competencies are as follows:

Patient Care and Procedural Skills: Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health.

Medical Knowledge: Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care.

Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound, uses effective listening skills with nonverbal and verbal communication; working as both a team member and at times as a leader).

Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

Systems-Based Practice: Demonstrate awareness of and responsibility to larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g., coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

Practice-Based Learning and Improvement: Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their practice of medicine.

C. Components of MOC

1. Categories/Components of MOC for Surgeons

MOC combines the Six Competencies and condenses them into four categories. The components of MOC are as follows:

Part 1—Professional standing through maintenance of an unrestricted medical license, hospital privileges and satisfactory references.

Part 2—Lifelong learning and self-assessment through continuing education and periodic self-assessment.

Part 3—Cognitive expertise based on performance on a secure examination.

Part 4—Evaluation of performance in practice through tools such as outcome measures and quality improvement programs, and the evaluation of behaviors such as communication and professionalism.

2. Fulfilling the MOC Requirements for Surgery

As is true of the field of surgery, MOC is an evolving field. Parts I and 3 are straightforward. Part 1 includes submission of documentation of an unrestricted license, and hospital privileges, as well as a testimonial form filled out by the chief of surgery and chair of the credentials committee. This is to be submitted once every 3 years.

Part 3 is the familiar recertification examination, which still must be taken once every 10 years. Admissibility to that exam will include timely fulfillment of all other MOC requirements, as well as a case log.

Parts 2 and 4 have a lot of promise, and are both more complicated and more interesting. Part 2 is self-assessment. In surgery, this will be fulfilled by CME I credits, especially those that require self-assessment. 30 credits will be required each year, 20 of which must be self-assessment. Standards for satisfactory self-assessment are under development by the ABS. Standards currently include CME 1 products that include a self test, which must be passed with a minimum 75% correct. Live ­activities, enduring materials, journal-based reading, and skills training are all offerings ­eligible for self-assessment. SAGES offers ­vehicles for self-assessment, both at the annual meeting and via the online SAGES University (http://www.sages.org/education/university.php). SAGES University is ­available free to SAGES members and includes SAGES Journal Club, Online Self-Assessment Program (OSAP), and my CME/MY MOC Web page. A partial list of other self-assessment vehicles are listed on the ABS Web page (http://home.absurgery.org/default.jsp?exam-moccme). Part II MOC reporting to the ABS will be required each 3-year cycle, along with Parts 1 and 4. Future plans for Part 2 MOC include linking the CME subject areas to case logs and practice, as well as using this venue for continuing education in ethics, professionalism, and perhaps systems-based practice. Ideally, Part 2 requirements will eventually link to requirements of other certifying and licensing groups, such as state licensing boards, hospital credential committees, the Joint Commission, and others. Professional societies including SAGES are providing multiple pathways to achieve those self-­assessments credits that are meaningful to an individual’s learning and pertinent to his or her practice.

Part 4 is the evaluation of performance in practice. To fulfill Part IV, the ABS currently requires participation in an outcomes database. At present a wide variety of databases fulfills this requirement, including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the American College of Surgeons Case Log, Mastery of Breast Surgery (The American Society of Breast Surgeons), participation in the United Network for Organ Sharing (UNOS), participation in bariatric surgery databases offered either by the American College of Surgeons or the American Society of Metabolic and Bariatric Surgery, and many others (for a partial list see http://home.absurgery.org/default.jsp?exam-mocpa). Currently, participation alone is adequate to fulfill requirements; practice data does not need to be provided. Although the ABS recognizes that actual analysis of one’s own practice and outcomes compared those of one’s peers is ideal, at present no one perfect database exists that allows for such a requirement. Therefore, for now, participation alone is adequate, on the theory that the process of recording one’s own practices is valuable in and of itself. Future plans for Part 4 MOC include a single, unified database for ABS use that is currently under development by the American College of Surgeons. In addition, a requirement of assessment of communication skills based upon patient surveys will likely be included in Part IV as well (Table 2.1).

Table 2.1.

ABS MOC requirements timeline.

MOC Year July 1 to June 30, starting July 1 following certification or recertification

Used with permission of the American Board of Surgery

MOC, when mature, will provide both a vehicle and a requirement for surgeons to structure their learning and measure their practices and outcomes. In practice, the ABS Web site will guide practitioners through the existing requirements, as well as updates as high-quality vehicles for Parts 2 and 4 continue to emerge.

Selected References

ACGME Outcomes Project. http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf. Accessed 6 July 2011.

Maintenance of Certification. http://home.absurgery.org/default.jsp?exam-moc. Accessed 6 July 2011.

SAGES ACCME Compliance. http://www.sages.org/education/university.php. Accessed 6 July 2011.

To Err is Human: 1999 Reports Brief. http://www.iom.edu/∼/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf. Accessed 6 July 2011.

Nathaniel J. Soper and Carol E.H. Scott-Conner (eds.)The SAGES Manual3rd ed. 2012Volume 1 Basic Laparoscopy and Endoscopy10.1007/978-1-4614-2344-7_3© Springer Science+Business Media, LLC 2012

3. Equipment Setup and Troubleshooting

Mohan C. Airan¹  

(1)

Advocate Good Samaritan Hospital, Lombard, IL, USA

Mohan C. Airan

Email: airanm2340@msn.com

Abstract

This chapter describes key elements essential for safe and facile performance of laparoscopic procedures. Checklists are provided to assist the surgeon in preoperative preparation. The example of a common laparoscopic procedure, laparoscopic cholecystectomy, is used to illustrate general principles. Troubleshooting is emphasized, and this chapter includes tips for troubleshooting new energy modality platforms such as the LigaSure™ and ForceTriad™. Issues that are specific to particular procedures (for example, laparoscopic adrenalectomy or laparoscopic bariatric surgery) are described in the chapters that follow.

Keywords

Room layoutErgonomicsLaparoscopic instrumentsSurgeon positionAEM®—EncisionElectrosurgical unitLigaSure™Troubleshooting guide

A. Room Layout and Equipment Position

1.

General considerations include the size of the operating room, location of doors, outlets for electrical and anesthetic equipment, and the procedure to be performed. The time required to position the equipment and operating table is well spent. Arrive at the operating room sufficiently early to assure proper setup and to ascertain that all instruments are available and in good working order. This is particularly important when a procedure is being done in an operating room not normally used for laparoscopic operations, or when the operating room personnel are unfamiliar with the equipment (e.g., an operation performed after hours).

2.

Determine the optimum position and orientation for the operating table. If the room is large, the normal position for the operating table will work well for laparoscopy.

3.

Small operating rooms will require diagonal placement of the operating table and proper positioning of the laparoscopic accessory instruments around the operating table.

4.

Robotic systems and their effect on operating room space. If used, the da Vinci ® robot requires significant space for surgeon console, slave CRT screens for operating room team viewing, as well as the surgical arm cart.

5.

An equipment checklist helps to ensure that all items are available and minimizes delays once the patient has arrived in the operating room. The following is an example of such a checklist. Most of the equipment and instruments listed here will be needed for operative laparoscopy. Additional equipment may be needed for advanced procedures. This is discussed in subsequent sections.

a.

Anesthesia equipment

b.

Electric operating table with remote control if available

c.

Two video monitors

d.

Suction irrigator

e.

Electrosurgical unit, with grounding pad equipped with current monitoring system

f.

Ultrasonically activated scissors, scalpel, or other specialized unit if needed

g.

Laparoscopic equipment, generally housed in a cart on wheels:

i.

Light source

ii.

Insufflator

iii.

Videocassette recorder (VCR), other recording system, tapes

iv.

Color printer (optional)

v.

Monitor on articulating arm

vi.

Camera-processor unit

h.

C-arm X-ray unit (if cholangiography is planned) with remote monitor

i.

Mayo stand or table with the following instruments:

i.

#11, #15 scalpel blades and handles

ii.

Towel clips

iii.

Veress needle or Hasson cannula

iv.

Gas insufflation tubes with micropore filter

v.

Fiber-optic cable to connect laparoscope with light source

vi.

Video camera with cord

vii.

Cords to connect laparoscopic instruments to the electrosurgical unit and other energy sources

viii.

6-in. curved hemostatic forceps

ix.

Small retractors (Army-Navy or S-retractors)

x.

Trocar cannulae (size and numbers depend on the planned operation, with extras available in case of accidental contamination)

xi.

Laparoscopic instruments

Atraumatic graspers

Locking toothed jawed graspers

Needle holders

Dissectors: curved, straight, right angled

Bowel grasping forceps

Babcock clamp

Scissors: Metzenbaum, hook, microtip

Fan retractors: 10 mm, 5 mm

Specialized retractors, such as endoscopic curved retractors

Biopsy forceps

Tru-Cut biopsy-core needle

xii.

Port site closure devices

xiii.

Monopolar electrocautery dissection tools

L-shaped hook

Spatula tip dissector/coagulator

xiv.

Ultrasonically activated scalpel (optional)

Scalpel

Ball coagulator

Hook dissector

Scissors dissector/coagulator/transector

xv.

Endocoagulator probe (optional)

xvi.

Basket containing:

Clip appliers

Endoscopic stapling devices

Pretied suture ligatures—endoloops, etc.

Endoscopic suture materials

Extra trocars

j.

Robot holder if available

B. Room and Equipment Setup

1.

With the operating table positioned, and all equipment in the room, reassess the configuration. Once the patient is anesthetized and draped, it is difficult to reposition equipment. Consider the room size (as previously discussed), location of doors (particularly if a C-arm is to be used), and the quadrant of the abdomen in which the procedure will be performed. Figure 3.1 shows a typical setup for a laparoscopic cholecystectomy or other procedure in the upper abdomen. Figure 3.2 illustrates a typical setup in a small operating room.

Fig. 3.1.

Basic room setup. This is the typical setup for laparoscopic cholecystectomy. The room must be sufficiently large to accommodate all of the equipment (see Fig. 3.2 for setup for smaller room). A similar setup can be used for hiatus hernia repair or other upper abdominal surgery. In these cases, one 21-in. or larger monitor can be used in the center where the anesthesiologist usually sits, with the anesthesiologist positioned to the side. The position of the surgeon (S), camera holder (C), and the assistant (A) depends on the procedure that is planned. The best position for the monitor is opposite the surgeon in his line of sight. A C-arm, if used, should be placed perpendicular to the operating table. A clear pathway to the door facilitates placement of the C-arm, and should be planned when the room is set up.

Fig. 3.2.

Laparoscopic cholecystectomy, small operating room. The monitors, anesthesia machine, and relative position of surgeon and first assistant have been adapted to the diagonal operating table placement.

2.

Set up the equipment before bringing the patient into the ­operating room. A systematic approach, starting at the head of the table, is useful.

a.

There should be sufficient space to allow the anesthesiologist to position the anesthesia equipment and work safely.

b.

Next, consider the position of the monitors and the paths that connecting cables will take. Try to avoid fencing in the surgeon and assistants. This is particularly important if surgeon and assistant need to change places or move (for example, during cholangiography).

c.

The precise setup must be appropriate to the planned procedure. The setup shown is for laparoscopic cholecystectomy or other upper abdominal procedures. Room and equipment setups for other laparoscopic operations are discussed with each individual procedure in the chapters that follow. A useful principle to remember is that the laparoscope must point toward the quadrant of the abdomen with the pathology, and the surgeon generally stands opposite the pathology and looks directly at the main monitor.

d.

If a C-arm or other equipment will need to be brought in during the procedure, plan the path from the door to the operating table in such a manner that the equipment can be positioned with minimal disruption. This will generally require that the cabinet containing the light source, VCR, insufflator, and other electronics be placed at the side of the patient farthest from the door. Consider bringing the C-arm into the room before the procedure begins.

e.

Additional tables should be available so that water, irrigating solutions, and other items are not placed on any electrical units where spillage could cause short circuits, electrical burns, or fires.

3.

Check the equipment and ascertain the following:

a.

If no piped-in lines are available, there should be two full carbon dioxide cylinders in the room. One is used for the procedure, and the second is a spare in case the pressure in the first cylinder becomes low. The cylinder should be hooked up to the insufflator and the valve turned on. The pressure gauge should indicate that there is adequate gas in the cylinder. If the cylinder does not appear to fit properly, do not force it. Each type of gas cylinder has a unique kind of fitting, and failure to fit properly may indicate that the cylinder contains a different kind of gas (e.g., oxygen).

The piped-in lines should be color coded and connected to appropriate intake valves.

b.

If the carbon dioxide cylinder needs to be changed during a procedure:

i.

Close the valve body with the proper handle to shut off the gas (old cylinder).

ii.

Unscrew the head fitting.

iii.

Replace the gasket in the head fitting with a new gasket, which is always provided with a new tank of gas.

iv.

Reattach the head fitting so that the two prongs of the fitting are seated in the two holes in the carbon dioxide gas tank valve body.

v.

Firmly align and tighten the head fitting with the integral pointed screw fixture.

vi.

Open the carbon dioxide gas tank valve body, and pressure should be restored to the insufflator.

c.

Look inside the back of the cabinet housing the laparoscopic equipment. Check to be certain that the connections on the back of the units are tightly plugged in (Fig. 3.3).

Fig. 3.3.

Connections on rear panel. The actual configuration of connections on the rear panels varies, but there are some general principles that will help when tracing the connections. The video signal is generated by the camera box. A cable plugs into the video out port of the camera box and takes the video signal to the VCR or monitor by plugging into a video in port. A common arrangement takes the signal first to the VCR, and then from the video out port of the VCR to the video in port of the monitor. (see Chap. 9, Documentation). Some cameras have split connectors that must be connected to the proper ports. Once connected, these should not be disturbed. The surgeon should be familiar with the instrumentation, as connections frequently are loose or disconnected. The last monitor plugged in should have an automatic termination of signal port to avoid deterioration of the picture quality.

4.

Attention to detail is important. The following additional items need careful consideration, and can be checked as the patient is brought into the room and prepared for surgery:

a.

Assure table tilt mechanism is functional, and that the table and joints are level and the kidney rest down.

b.

Consider using a footboard and extra safety strap for large patients.

c.

Position patient and cassette properly on operating table for cholangiography.

d.

Notify the radiology technologist with time estimate.

e.

Assure proper mixing and dilution of cholangiogram contrast solution for adequate image.

f.

Assure availability of Foley catheter and nasogastric tube, if desired.

g.

Assure all power sources are connected and appropriate units are switched on. Avoid using multiple sockets or extension cords plugged into a single source, as circuits may overload.

h.

Check the insufflator. Assure that insufflator alarm is set appropriately.

i.

Assure full volume in the irrigation fluid container (recheck during case).

j.

Assure adequate printer film and video tape if documentation is desired.

k.

Check the electrosurgical unit; make sure the auditory alarm of the machine is functioning properly and the grounding pad is appropriate for the patient, properly placed, and functioning.

l.

The surgeon should specify the electrosurgical unit that he uses.

m.

Apply S.C.D.’s

5.

Once you are gowned and gloved, connect the light cable and camera to the laparoscope. Focus the laparoscope and white balance it. Place the laparoscope in warmed saline or electrical warmer. Verify the following:

a.

Check Veress needle for proper plunger/spring action and assure easy flushing through stopcock and/or needle channel.

b.

Assure closed stopcocks on all ports.

c.

Check sealing caps for cracked rubber and stretched openings.

d.

Check to assure instrument cleaning channel screw caps are in place.

e.

Assure free movements of instrument handles and jaws.

f.

If Hasson cannula to be used, assure availability of stay sutures and retractors.

C. Types of Equipment Available

1. Electrosurgical Units

a.

Simple E.S.U.—coagulation and cut features—use AEM technology overlay machine.

b.

Complex E.S.U.—ForceTriad™ energy platform comprises monopolar, bipolar, and proprietary functions utilizing LigaSure™ tissue fusion technology, the Force Triverse™ ­electrosurgical device, and Valleylab™ mode (Figs. 3.4–3.6).

Fig. 3.4.

ForceTriad™ energy platform front panel. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices division of Covidien. The ForceTriad™ is an electrosurgical all in one unit. The bipolar device allows surgeons, urologists, gynecologists to perform in a saline environment. Tissue fusion technology permanently fuses vessels up to 7 mm, lymphatic and tissue bundles. The devices can divide the structures as soon as fusion is accomplished. Valleylab™ mode provides equal or superior hemostasis than standard valley lab E.S.U. The touch screens’ screen displays change based on instrument recognition technology. Each instrument has its own electronic signature recognized by the unit.

Fig. 3.5.

Force TriVerse™ electrosurgical device. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices ­division of Covidien. The surgeon can change the settings from the sterile field freeing up the circulating RN for other duties.

Fig. 3.6.

LigaSure™ Impact instrument. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices division of Covidien. Used for open surgery to fuse and divide. The function is more ­economical than using vascular staplers for small vessels.

c.

Ultrasonic machines.

D. Troubleshooting

1.

Laparoscopic procedures are inherently complex. Many things can go wrong. The surgeon must be sufficiently familiar with the equipment to troubleshoot and solve problems. Table 3.1 gives an outline of the common problems, their cause, and suggested solutions.

Table 3.1.

Common problems, causes, and solutions.

Reprinted with permission from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

2.

General Troubleshooting Guidelines—ForceTriad™ energy platform. If the Force Triad™ energy platform malfunctions, check for obvious conditions that may have caused the problem:

a.

Check the system for visible signs of physical damage.

b.

Make sure the fuse drawer is tightly closed.

c.

Verify that all cords are connected and attached properly.

d.

If an error code is displayed on the touch screens, note the code along with all information on the error screen, then turn the system off and turn it back on.

e.

If a solution is not readily apparent, refer to Table 3.2, Correcting Malfunctions, to help identify and correct specific malfunctions. After the malfunction is corrected, verify that the system completes a prescribed self-test. If the malfunction persists, the system may require service. Contact the institution’s biomedical engineering department.

Table 3.2.

Correcting malfunctions.