State of the Art Atlas of Endoscopic Surgery in Infertility and Gynecology Nutan Jain
INDEX
×
Chapter Notes

Save Clear


1General
  1. OR Set-up and Basic Instrumentation for Gynecological Endoscopy
  2. Laparoscopic Retroperitoneal Anatomy
  3. Laparoscopic Access
  4. Laparoscopic Cutting and Hemostasis
  5. Laparoscopic Suturing
  6. Laparoscopic Tissue Retrieval
  7. Laparoscopic Adhesion Prevention
  8. Correlation of Endosonography and Endoscopic Surgery
  9. Anesthesia for Gynecologic Laparoscopic Surgery
    2

OR Set-up and Basic Instrumentation for Gynecological Endoscopy1

Radha Syed
 
INTRODUCTION
An organized and well-equipped operating room is essential for successful laparoscopy and hysteroscopy procedures. The surgical team and the operating team staff should be familiar with each and every instrumentation and have familiar places in the operating room. The surgeon is ultimately responsible for the proper functioning of not only all the instrumentation and the equipment but also the positioning in the operating room for optimal efficiency and safety. Remember, consistency saves lives and inconsistency kills! It is imperative that the instruments and equipment be checked periodically for deficiencies to prevent inadvertent accidents.
The equipment positioning varies according to the surgeon's preference, the number of monitors in the operating room and the ease of the movement and flow. In general, most operating rooms have one or two monitors and for gynecological surgeons the placement of the monitors is most often between the patient's lower extremities for laparoscopy and near the patient's head for hysteroscopy.
Most laparoscopic trolleys have the insufflator, light, camera and sometimes the lavage aspiration system stacked on it. The screen is generally at the top of this stack. The patient is connected to the trolley by the sort of umbilical cord, which includes: The CO2 cable, the light cable, the camera cable and sometimes a lavage and an aspiration cable. Usually this cord comes from the trolley which supports the surgeons' screen. However, the length of the cord is limited by the length of the optics cable, which should be as short as possible to avoid loss of light. These cables are usually around two meters long.
The following pictures illustrate the OR set-up for laparoscopy and hysteroscopy. The captions are descriptive.
The room is partially set up prior to the patient's being brought into the room. The patient is positioned in a semi-lithotomy position with sequential stockings and arm pads, pressure point pads and adduction of the arms to her sides. The table should have the capabilities for Trendelenburg and reverse Trendelenburg in an automated fashion. Modern stirrups are optimally padded and have gel inserts to minimize injury during surgery due to pressure. The stirrups additionally have the capability for altering positions of the lower extremities during the procedure with the compression of a lever at the bottom of the stirrup handle (OR Direct makes the best stirrups, in my opinion). A Bear-hugger or similar warming device should be used for maintaining body warmth. A new device called INSUFLOWTM delivers filtered, heated and humidified air during laparoscopy. This device reduces inadvertent injuries to intra-abdominal organs due to cold air, reduces dew-point condensation on the lens and maintains euthermia during prolonged laparoscopic procedures. A general endotracheal anesthesia is essential to maintaining proper oxygenation and relaxation during the procedure. A Foley catheter placement is routine. A laparoscopic and hysteroscopic drape is commonly used, especially with a disposable pouch for collecting fluid output at the bottom of the perineum. Usually the first assistant stands opposite the surgeon who stands to the left of the patient. A second assistant stands between the legs of the patient and the scrub tech stands behind the surgeon with her Mayo stand with immediate use instruments just between the surgeon and herself. To the left of the scrub tech a large cart with basic and advanced laparoscopic instrumentation is placed. The height of the patient should be below the waist of the surgeon for maximal efficiency. For short surgeons, 4such as myself, the use of stepping stools in the OR is extremely valuable. It's a well known fact that to prevent trocar related injuries, placing the patient below the height of the surgeon's waist precludes the use of excess force. In my armamentarium today, I find that apart from basic laparoscopic instruments I am comfortable with a laparosonic coagulative shears 5 mm and a bipolar disposable Kleppinger forceps 5 mm for coagulation. Where large-sized specimen removal is required, I use a Gynecare disposable morcellator called Xtract or a Karl Storz reusable 12 mm morcellator.
zoom view
Fig. 1.1: OR layout
zoom view
Fig. 1.2: OR set-up
zoom view
Fig. 1.3: Computerized digital OR recording
zoom view
Fig. 1.4: Laparoscopy team in OR
zoom view
Fig. 1.5: OR team position in laparoscopy
zoom view
Fig. 1.6: Position for combined hysteroscopy and laparoscopy
zoom view
Fig. 1.7: Position of monitor for hysteroscopy
5
zoom view
Fig. 1.8: Scissors and graspers
zoom view
Fig. 1.9: Probes and needles and cautery
zoom view
Fig. 1.10: Laparoscopy grasper tips
zoom view
Fig. 1.11: Laparoscopy table layout
zoom view
Fig. 1.12: Laparoscopic instruments set up
zoom view
Fig. 1.13: Uterine manipulator, laparoscopic graspers
6
zoom view
Fig. 1.14: Hysteroscopic monitor position
zoom view
Fig. 1.15: Hysteroscopic positioning
zoom view
Fig. 1.16: Gynecare versascope
zoom view
Fig. 1.17: Hysteroscopy and chromopertubation
zoom view
Fig. 1.18: Kesa Bettochi
zoom view
Fig. 1.19: Kesa Bettochi hysteroscope
7
zoom view
Fig. 1.20: ACMI hysteroscope
zoom view
Fig. 1.21: Array-2 hysteroscopy
zoom view
Fig. 1.22: Thermachoice
zoom view
Fig. 1.23: TVT
zoom view
Fig. 1.24: Xtract (morcellator)
zoom view
Fig. 1.25: Veristatnurse
8
zoom view
Fig. 1.26: Versascope
zoom view
Fig. 1.27: View of myoma from the OS
zoom view
Fig. 1.28: VP generator
zoom view
Fig. 1.29: VP scope and the electrodes
zoom view
Fig. 1.30: VP system
9
zoom view
Fig. 1.31: Interceed
zoom view
Fig. 1.32: Intergel
zoom view
Fig. 1.33: Harmonic scalpel
zoom view
Fig. 1.34: Davol fluid management system
10
For hysteroscopy, I routinely use Gynecare Versascope a—1.6 mm microhysteroscope with a disposable sheath containing a coaxial channel for instrumentation and an in-flow and out-flow ports. This microhysteroscope is readily assembled and efficiently used with a minimum loss of time in any OR, as there are no “parts” to it. However, for clarity of vision and excellent picture quality I find the Karl Storz Bettochi microhysteroscope 2.9 mm with its unique “tip” for ease of entry into the endocervix (even without a tenaculum) and an instrument channel, unbeatable. For most resections of small intrauterine pathology and diagnostic work, the Bettochi hysteroscope is extremely valuable. In the following pages the basic instrumentation most routinely used during the majority of procedures will be depicted with captions detailing the situations.
 
CONCLUSION
It is obvious that the preceding information is less than exhaustive. Even as I write, newer and better instruments are being invented and manufactured for use in endoscopy. However, it is necessary to have a basic armamentarium of tools which one would always utilize and be completely familiar with them. In my experience majority of cases would require these basic tools with an occasional necessity for specialized tools. As in laparotomy, in the final count, the surgeon is better than any instrument at accomplishing a specified procedure though the need for technology weighs heavier on the side of endoscopy.
The evolution of modern diagnostic and operative laparoscopy has been reviewed by Semm, Cushieri and Buess, Murphy, Gomel and Nezhat and colleagues. These authors discussed essential instruments, the utility of multiple puncture sites, insufflation equipment, light sources, endoscopic photography and the use of video monitors in endoscopic procedures. To improve proficiency in complex endoscopic procedures, it is imperative that one learns from masters in the field. There are many courses held worldwide which employ the format of didactics, live operating room sessions and hands-on lab sessions with Pelvic Trainers and animate models to enhance this process. Learning videolaparoscopy and maintaining these skills requires continual exposure to procedures ranging from simple to difficult. The frequency with which these are repeated, the manual dexterity, patience, motivation, dedication and clinical acumen of the surgeon serve greatly to influence the process of learning.
zoom view
Fig. 1.35: Hanging out in OR
 
ACKNOWLEDGMENT
I would like to acknowledge with grateful thanks the technological assistance and advice for accumulating the digital images in the operating room given by Dr Kishore Agrawal, General Surgeon, Staten Island University Hospital, Staten Island, New York. I am grateful to Karl Storz Endoscopy America, Gynecare and Ethicon for generously providing me with photographs of endoscopic instrumentation and lending me certain instruments to obtain digital quality images. I would also like to acknowledge the operating room staff of Staten Island University Hospital, Staten Island, New York and my patients who have been essential in development and maintenance of the endoscopic equipment and procedures. I would like to thank my office manager, Ms. Liza Pearson for her assistance in compiling this chapter.
Lastly, there can be no knowledge without a Guru. I would like to express my undying gratitude to Dr Camran Nezhat, Stanford University Hospital, Palo Alto, California, whose work and teachings continue to inspire me and light up this dark world of endoscopy.11
REFERENCES
  1. Pro Luca Mencaglia. Manual of Gynecological Laparoscopic Surgery: Florence Center for Outpatient Surgery and Infertility, Florence, Italy. Arnaud Wattiez, Department of Obstetrics and Gynecology, University of Clermont-Ferrand, Clermont-Ferrand, France. Published by Endo-Press,  Tuttlingen  1998.
  1. Camran Nezhat, Farr R Nezhat, Anthony A Luciano, Alvin M Siegler et al. Operative Gynecologic Laparoscopy Principles and Techniques. McGraw-Hill Inc,  1995.
  1. Semm K. Operative Manual: Endoscopic Abdominal Surgery. Year Book Publishers,  Chicago:  1987.
  1. Cusheiri A, Buess G. Introduction and historical aspects. In: Cusheiri A, Buess G, Perissat J (Eds): Operative Manual of Endoscopic Surgery. Springer-Verlag:  Berlin:  1992.
  1. Murphy AA. Diagnostic and Operative Laparoscopy. In: Thompson JD, Rock JA (Eds): TeLinde's Operative Gynecology (7th edn). JB Lippincott,  Philadelphia:  1992.
  1. Gomel V. Operative Laparoscopy: Time for Acceptance. Fertil Steril 1989;52:1–11.
  1. Nezhat C, Nezhat F, Nezhat C. Operative Laparoscopy (minimally invasive surgery): state-of-the-art. J Gynecol Surg 1992;8:111–41.