A clearly defined setup for all laparoscopic colorectal procedures is recommended. Because laparoscopic surgery requires complex equipment, it is advisable to organize the operating room to facilitate each step of the procedure, increase efficiency, and shorten anesthesia time. A laparoscopic surgical procedure should be initiated only if all equipment is functional and has been calibrated immediately before the scheduled operation. There should also always be backup instruments to replace a broken or dysfunctional component. Successful troubleshooting with rapid replacement of components if the equipment mal functions must be possible during every laparoscopic procedure. It is also advisable to have a trained member of the team available during the operation who can troubleshoot during the operation.
The general setup of the operating room for laparoscopic colorectal surgery involves three major steps:
• Assembling the basic instrumentation
• Preparing the patient in the operating room
• Positioning the personnel and laparoscopic equipment
These basic instruments (see Chapter 2) should be available on the sterile equipment table for the preliminary evaluation, which may be done for diagnosis or to determine if the planned laparoscopic procedure will be possible:
• Scalpel handle equipped with no. 15 blade
• Scalpel handle equipped with no. 10 or no. 20 blade
• Fine long curved hemostats (e.g., tonsil clamps)
• Kocher grasping hemostats
• Electrosurgical unit
• Veress needle (or equivalent) if blind entry into the peritoneal cavity is considered
• Initial cannula for laparoscope (5 or 10 mm)
• Laparoscope with camera and light cable and carbon dioxide
• Insufflation tube
All surgical equipment necessary to perform a rapid laparotomy, if required, should be available.
If laparoscopic surgery appears to be feasible after the initial evaluation, the following laparoscopic instruments should be available on the equipment table to begin the procedure:
• Endoscopic dissecting device (for cutting and coagulation)
• All necessary cannulae and body wall anchoring devices
• Endoscopic scissor
• Endoscopic dissector
• Endoscopic graspers
• Finally, we believe that a colonoscope should be available at all times in the operating room if any clarification of the site of the target lesion becomes necessary. Cardon dioxide (CO2) should be considered as the insufflating gas, to avoid bowel distension during the procedure.
To initially position the patient, we have found that a modified lithotomy position works well for most laparoscopic colorectal surgical procedures. A moldable "bean bag" or a specialized body-length gel pad is placed under the patient's body on the table. The bean bag primarily is placed under the torso, and shoulder braces do not need to
be used. Such a setup helps to keep the body from sliding during the steep head-down and side-to-side positions often called for in laparo-scopic surgery.
The patient must be positioned so that the pelvis is just above the break at the lower end of the operating table - this position gives the surgeon free access to the perineum for intraoperative endoscopy, pelvic manipulation, or transanal anastomosis. The legs are placed in padded, adjustable stirrups (we prefer OR Direct Stirrups, Acton, MA) so that the surgeon can stand between the legs when necessary (Figure 4.1).
We initially wrap each calf or entire leg with pneumatic compression stockings. The use of intermittent pneumatic compression systems is highly recommended to prevent deep vein thrombosis. The legs are positioned in a 20° to 25° abducted position with the thighs only minimally elevated above the abdomen because higher thigh elevation may not allow the surgeon to freely move the instruments. We usually attempt to elevate the heel of each leg slightly above the knee to maximize venous outflow from the legs and minimize the risk of intraoperative venous stasis. After induction of anesthesia, an orogastric or a nasogastric tube should always be placed to empty the stomach of air and secretions. To empty the bladder and decrease the risk of inadvertent injury during the first phase of laparoscopy, a Foley urinary catheter should be placed.
In all procedures involving the left colon or rectum, rectal irrigation is performed just before skin preparation and draping. If laparoscopic surgery is to be performed to resect a colon or rectal tumor, endoscopy should be done preoperatively, and the bowel wall should be marked 2 cm below the distal tumor margin using India ink and a sclerotherapy needle passed endoscopically. In case of a tumor of the colon, either pre- or intraoperative colonoscopy or preoperative barium enema may be necessary to confirm the tumor location.
Positioning the Personnel and Laparoscopic Equipment
The positions of the personnel are determined by the location of the pathology. The surgeon generally stands on the side opposite the site of pathology, but between the legs when mobilizing either colonic flexure. When possible, standing to the patient's right side is usually preferred when performing pelvic surgery because sigmoid mobilization will be easier. The first assistant should stand opposite the surgeon or on the side opposite of the pathology when the surgeon stands between the legs. The second assistant (camera person) should stand next to the surgeon when the surgeon stands alongside the patient or next to the first assistant so that the operating team views the monitors from the same vantage point, which will facilitate guidance of the laparoscope (Figure 4.2).
The nurse should stand so that both the instrumentation table and the operative field are easily accessible. This is usually near the knee or foot of the patient usually on the left side. This position not only facilitates instrument passage but also enables the nurse to help the surgeon by performing such tasks as stabilizing the cannula while the surgeon exchanges instruments.
Depending on the area available in the operating room and the size of the equipment and instruments, the laparoscopic team should design a single setup that can easily be adapted for the most common procedures; having one setup will allow the equipment to be more quickly arranged. In addition, a backup set of equipment components must be available to avoid delay or termination of the procedure if a component fails. Because such failure is unpredictable, a plan should be developed that all team members understand so that components can be rapidly replaced. To increase efficiency, all members of the surgical team should learn the specified setup for each operation and be trained according to this setup.
The number of carts for the laparoscopic equipment should be kept to a minimum. In general, laparoscopic colorectal surgery calls for two mobile carts: they should either have wheels or be mounted on booms suspended from the ceiling. On one cart, a video monitor, light source, video system, and insufflator are placed on the patient side that is opposite to the first assistant so that the insufflator display can be seen during the entire procedure - high intraabdominal pressure, low gas flow, or an empty gas tank can thus be detected quickly. The second cart is positioned on the patient side opposite to the surgeon, and the irrigation suction unit, a video monitor, and the electrosurgical unit are placed on it.
The instrument table should be placed toward the lower end of the patient so that the nurse can easily work from it and assist the surgeon during all phases of the procedure.
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