There is no more dependent surgeon on the earth than the one who has two eyes fixed on the TV, one hand holding the scope, the other hand holding the instrument, one foot on a cautery pedal and one foot bearing his or her entire weight.
For any surgeon, surgical theater and its interior design is very important.
For doing endoscopy surgery it is something extra important as it includes not only the surgical table but sophisticated gazettes around it because without those basic armamentarium, surgeons cannot perform any surgery. Success of any endoscopy surgery depends on properly designed and well equipped operative theater, competent surgical team and skill of the surgeon. Efficient placement of equipments, streamlined instruments handling, well trained and dedicated staff can contribute not only to the theater efficiency but also to the time and cost saving
Surgical theater arrangement for endoscopy surgery is quite important. To plan a new theater especially for endoscopy is not necessary. If an extra space is available it is well and good otherwise little modification in present OT will serve the purpose.
A good area of 15/15 feet will be adequate. Excellent trolleys are available which occupies minimum space and have maximum instrumentations. A good electric supply behind the trolly with minimum 8 to 10 sockets will be enough and it will reduce the complex bunch of wiring and cables. Keep light source, Camera equipment, electro pneumo peritoneum, cautery.3
Extra sources, one monitor and formalin chambers having instruments in it. Other monitor can be placed on opposite direction for assistant to watch.
Position of surgeon should be on the left side of the patient and little bit higher with one leg on stool have good co-ordination with camera men, otherwise hands of both assistant and surgeon will touch each other.
On that stool there is placement of cautery peddel both monopolar as well as bipolar and foot pedal of suction machine.
Anesthetist has to take his position at level of head end of patient with his all tubing and oxygen line or concentrator and pulse oxymeter and if he is co-operative may take job of recording with remote control in hand
Camera man's position is between anesthetist and surgeon.
Second assistance is in between the legs, of patient, with instrument like leach Wilkinson's cannula attached with 20 cc syringe filled with methylene blue.
One freeman has to do so many jobs like side rhythm instrumentalist, he has to make all instrument on and off like CO2 insufflator when needed, white balance of camera before starting of surgery on trolley with white cotton.
Patient Position
The operation table should have the facility of having good Trendelenburg position. The leg of the patient should be kept in modified lithotomy position, so that the thighs are in straight line with the abdomen and this position 4will allow the surgeon to have finer surgical movements. Modified lithotomy position give easy maneuver of instrument from second trocar. Patients buttocks should be at the edge of table for movement of instrument from vagina like uterine manipulator and cannula for chromopertubation. Surgeon's hip, elbow and operation table should be at the same level so all the movement of surgeon can be from the elbow joint and not from the shoulder joint.
The left hand of patient is kept on the side and covered with towel. Right hand is used for all medications and for anesthetic drugs.
Cautery pad should be under the buttocks as this area is near the pelvis and make sure that whole plate is in the contact with the patients.
Endoscopy Theater Includes
- Proper design of an operation theater.
- Proper OT table for head low and lithotomy position of patient.
- Instruments arranged in assessable manner.
- Properly placed wire (cable) and tubing.
- Easily assessed equipment.
- Proper place of laparoscopy trolley and TV monitor.
- Anesthetic corner and well equipped anesthetist trolley.
- Space for two surgical and two moving assistance.
- Better electrical supply.
- Good air condition to keep everyone cool.
- Cleaning of instruments after surgery.
INSTRUMENT FOR ENDOSCOPY SURGERY
This can be divided in three parts:
- Instrument on endoscopy trolley.
- Instruments on surgical trolley.
- Instruments for open surgery.
Instrument on Endoscopy Trolley
- Video recorder with remote control or/and computer.
- Flat TV or monitor.
- Light source.
- CO2 insufflators.
- Endovision camera.
- Electrosurgical unit (cautery) bipolar and monopolar.
- Continuous voltage stabilizer.
- Emergency invertor or generator compatible for all instruments.
- Optional instruments like morcellator, endomet, second TV.
Extra Television/Monitor (Fig. 1.1)
Flat television or monitor can be used with endovision camera for better visualization of all the internal structures of abdominal cavity. Success of all surgical procedures depends on better visualization of the sharp images on TV screen.
Endoscopy Camera (Fig. 1.2)
This is a single factor which has whole focus in endoscopy.
All routine surgery can be nicely performed by single chip camera. Three chip useful more in microendoscopy surgery like tubal recanalization where tissue magnification is must for finer work.
Camera should be of light weight, picture should be good at low lux (1 lux= illumination of one candle light) and not be ground glass, good white balance, no reflection or glare on object like ovary.
Light Source (Fig. 1.3)
This again has so many options like, xenon, mercury and halogen.
Minimum 250 watts cold light fountain will serve the purpose. Xenon light source is very good but very expensive as a unit and recurring loss of bulb after 500 hours.
Halogen light of more than 200 watts is also sufficient to do the routine surgery as it will give yellow light always ask for proper white balancing before start of surgery.
Light Cables (Fig. 1.4)
Fiberoptic cables are used for surgeries and it should be cared very much as fiber can break with rough handling. This light cable is always kept in the larger circular pattern to avoid breakage of inner fibers
CO2 Insufflators (Figs 1.5A and B)
At present wide variety of choices are available for purchasing CO2 insufflators. Point to be kept in mind is good quality constant flow (9 to 20 lit), PSI adjusted valve long tubing Flow per minute indicator, intra-abdominal pressure indicator, Warning sign for emptying of CO29
cylinder and also equipped with in built air insufflator for emergency.
Optional thermoflator with high flow is useful in long endoscopic surgery to prevent peritoneal irritation by cold gas and prevent fogging of scope during surgery.
Medical grade CO2 can also be used.
As a first step simple CO2 insufflator which can give sufficient lift of abdominal wall by which we can carry small procedure like diagnosis, PCOD drilling, adhesiolysis, lap. Tubal ligation, cyst aspiration and removal, ectopic pregnancy removal is sufficient.10
We must keep our eye on flow and total usage of CO2, as in beginning one may take long time in surgery so always keep extra CO2 cylinder ready.
Electrosurgical Units (Figs 1.6A and B)
Solid state electrosurgical unit with both bipolar and monopolar facility with separate foot switches is necessary.
In endoscopy both sharp incisions with scissors and coagulation of specific vessel by bipolar current is required.11
Both foot switches of monopolar and bipolar paddle should be customized as the need of surgeon and must be perfect to avoid accidental injuries. Electrical current should be varied depends on the type of surgery and on structure, e.g. in tubal pathology 60 watts and for hysterectomy it should be in the range of 100 watts and should be minimal in PCOD drilling.
Generator and/or Invertors
This is very much of important in KHS. In OAS one can have light source by torch but in endoscopy we are handicapped without electricity and its alternative like generator or invertors are necessary. No instrument run without it and all our competence and expertise will be lost if there is electricity failure.
Video Recorder
Used for recording silent features of surgical procedure and viewing the recording afterwards. It helps for the patients benefits in future.
Cassette
For video recording
Computer (Fig. 1.7)
It is very useful in present day surgery as it records the procedure in hard disk. An excellent softwear program helps in editing and printing the important images. The monitor of computer can also used as extra TV.12
Instruments on Surgical Trolley
Telescope (Fig. 1.8)
Telescope varies from 2 to 12 mm in diameter and angle varies from 0 to 70°. Most commonly used telescope is 0° 10 mm and 30° 10 mm.
0° 10 mm telescope is used in almost all cases of diagnostic laparoscopy. 0° 5 mm is very useful in specimen removal from 10 mm trocar.
Verres' Needle (Fig. 1.9)
They are reusable and disposable. Latest Verres' needle has got so many safety features but they are costly. Normal length and reusable Verres' needle is prefered.
Trocar (Fig. 1.10)
Primary trocar: Reusable or disposable with combination of metal and plastic. Different type of valves are there like flap, trumpet and with magnet. This valve prevents leakage of gas and easy access of instrument in it into the abdomen. These are available with different type tip like pyramidal and spilled pyramidal with safety feature.
The Ternamian trocar sheath is very safe trocar sheath. As turn by turn you have to see through scope and have to enter in abdomen.14
When we are able to see bluish or white glistening peritoneum it insure safe entry into peritoneal cavity.
Most commonly useful 10 mm metal trocar with valve which you are used to with side channel for CO2 is work as primary trocar.
Safety trocar 10 mm with spring mechanism are also available in market as its tip is sharp and with spring as it approaches intra-abdominal its recede inside sheath to prevent injury into viscera and vessels.
Secondary Trocar (Fig. 1.11)
Five mm with different valve like flap and flower type are used. An endoscopic surgeon who doesn't require suturing much will opt for flap valve. Trocar with thread is also available for easy entry of thread and can be screwed making them immobile while suturing.
Forceps/Graspers (Fig 1.12)
These all are of 5 mm size and its functions are to cut, coagulate, grasp, dissect and suture. So they are either atraumatic or traumatic.
Maryland Dissector
It is most commonly used hand instrument in all procedure and it resemblance like curved hemostat in OIS. It is useful in grasping the tissue as well as in dissection and very useful in fimbrial dilatation of fallopian tube in case of fimbrial block. It is also useful in dissection of omental adhesion over abdominal wall and uterus with cautery attachment for cut and coagulation as adhesiolysis.
Grasper
It should be with rounded tip and jaws with serration for easy grasp of tissue. Different varieties of graspers are available in market and as they are commonly used so 16wear and tear in common. It is used as probe when jaw closed and as dissector with open one.
Fine Forcep
It is useful in fine dissection as in fimbrioplasty and ovariolysis.
Allis type serrated forcep—It is used to hold cyst wall, myoma wall.
Babcock's Forceps (Fig. 1.13)
This is very important instrument in tube testing as it resemblance like Babcock in OAS it gives minimal trauma to the tube while chromopertubation.
Scissors (Fig. 1.14)
Different types are available like straight, curved, hooked, single blade with cut, for suture cutting, with cautery attachment for cut with coagulation simultaneously.
Its looses sharpness easily with use and especially when it combine with cautery. Special designer scissor is also available for surgery like Burch colposuspension.
Four in One Hand Instrument
These are design with one attachment with screw by witch you can have suction and irrigation, aspiration needle, hook and spatula.
Suction and Irrigation Channel
It is useful in all procedure of KHS. One can aspirate from POD and give irrigation to burnt ovary of PCOD by normal saline and again suction it. While doing cauterization you can also put suction cannula near by as it suction fumes and gases and hold the structure away from cautery area. Suction cannula is the only hard instrument in the trolley in KHS and we have to use it for water dissection (aqua dissection) and blunt dissection. Bigger size suction cannula 10 mm with different hole size are also useful particularly in ectopic pregnancy where large amount of blood clots have to be removed.
Hook
Hook is very beautiful instrument for dissection in cases of adhesiolysis, separation of bladder from uterus in case of LAVH.18
Spatula
Spatula is useful for cutting in case of myoma and to open POD for removal of specimen from abdomen.
Monopolar Puncture Needle (Fig. 1.15)
Important instrument in case of PCOD for drilling and gives excellent result in decrease in circulating LH and concivement in infertility.
It can be used in puncturing the cyst wall and fine incision for salpingostomy in case of ectopic pregnancy.
They are used for coagulation of blood vessel, fulguration of endometriotic patches, coagulation of pedical in hysterectomy, Removal of tube in ectopic pregnancy, tube coagulation and cut in case of tubal sterilization operation and for separation of adhesion of omentum over uterus and abdominal wall.19
Instruments for Open Surgery (Fig. 1.18)
To keep ready for any emergency laparotomy.
Specialized Instrument List
- Needle holder.
- Myoma screw.
- Clip applicator.
- Tissue morcellator.
- 10 mm grasper and forcep.
- CCL (Colpochirurgie Lausane) for removal of specimen from POD.
- Specimen removal bags.
- Fan-shaped retractors.
- Injection needle.
- Port closure needle.