Guidelines for setting a laparoscopic unit

I – GUIDELINES OF LAPAROSCOPIC SURGICAL EQUIPMENT[edit | edit source]

The laparoscope has become basic equipment that a surgeon has to use for the diagnosis and treatment of his patients. It has become mandatory today to perform certain procedures like cholecystectomy using laparoscopy. Hence every hospital where general surgery is being performed needs to set up a laparoscopic unit. These are some important points to be considered for selection of equipment and setting up of the operation theatre.

Camera[edit | edit source]

Laparoscopic surgery is today performed using video imaging. The camera, which transmits the image from the telescope to the monitor, is called a C.C.D. (Charge-Coupled Device) Camera. This could be either an analogue or (preferably) a digital camera. They come either as one-chip or three-chip cameras, the latter uses separate chips to identify and analyse the three basic colours (red, blue and green) individually. Hence the colour definition of the image is better in a three-chip camera. The other points to be noted while selecting the camera are:

a. Resolution: the image is divided into small squares called pixels and each of these squares are defined separately by the C.C.D. camera. The greater the resolution (the number of pixels), the better is the image definition. Most cameras provide more than 250,000 to 380,000 pixels of resolution.

b. Minimum illumination: This is a factor, which defines the minimum light that is required for the camera to pick up images. The lesser the value the better it is. This becomes more pertinent while operating in bloody field or in the extra-peritoneal region, where light is not reflected back by the glistening surface of the peritoneum.

c. White balancing: This is a feature that is a must in all the CCD cameras being used in laparoscopic surgery. The colour of the light being used (e.g. The yellow colour of a halogen light or the blue colour of the xenon light source) is subtracted from the image when a white object is being focussed upon and the white balance switch is pressed.

d. Automatic adjustments and controls: There may be additional features in various permutations and combinations in different cameras, such as automatic gain control (helps in brightening dark images), digital zoom, corrections of individual colours, recording facility, various output signals, etc.

Monitor[edit | edit source]

The camera is attached to the monitor and ultimately the resolution of the picture displayed is dependent on the resolution of the monitor as well as that of the camera. Most consumer-grade monitors or televisions have 350 lines of horizontal resolution. As far as laparoscopy is concerned, monitors that gives more than 700 horizontal lines are preferred.

Gas insuflator[edit | edit source]

The basic function of the gas insufflator is to maintain the pressure in the abdomen at the set pressure by insufflating gas into the abdomen. There are two kinds of gas insufflators - manual and electronic (high flow). The manual insufflator gives a flow rate of 1 Litre/min. and a high flow of 3 Litres/min. The internal drum in the machine needs to be filled up manually every time it is empty. An electronic insufflator gives a much higher flow rate of upto 30Litres/minute and is much more convenient to use in major surgeries and in instances where suction is frequently used. The gas either flows interruptedly or continuously based on the technology used in that particular make of the insufflator.

Certain special features that may be included in the electronic gas insufflators are:

Automatic desufflation: When the intra-abdominal pressure rises beyond the set pressure, the gas in the abdomen is automatically desufflated.

Incubated gas: The gas is heated and delivered at a set temperature through the tubing to the abdominal cavity. This helps in preventing fogging of lens during the surgery and also in avoiding hypothermia in cases where lot of gas is used.

Sterilized gas: This may be beneficial where medical grade gases are not available.

Light source[edit | edit source]

The three different cold light sources that are used in laparoscopy comprise of halogen, halide and xenon. Each of these lights have their inherent colour temperatures and hence do not have an identical brightness. The Xenon light is light blue in colour and is the brightest of all. The halide is a white light and the halogen light is yellow in colour. Besides it has the lowest brightness of the three, but is commonly used, as it is the most cost-effective option.

Telescope[edit | edit source]

The rigid telescope used for laparoscopy has a combination of a set of central rod lens and a peripheral rim of fibreoptic light bundles. This may be of 10 or 5 mm diameter. The angle of viewing may be 0 or 30 degrees for most standard procedures. Special features that may be found in different telescopes include wide angle, correction of peripheral distortion and option of autoclaving.

II - GUIDELINES FOR OPERATING ROOM SETUP[edit | edit source]

The introduction of the laparoscope into the surgeon's basic armamentarium has resulted in the need for more sophistication and greater planning to set up a laparoscopic operating suite. Proper designing ensures greater ease of personnel movement, decreases clutter, improves ergonomics, maintains the sterile field, and facilitates the use of advanced imaging and display devices (4). This also ensures that the basic components are in place and functioning (3). Enlisted herein are some basic guidelines in setting up a laparoscopic operating suite.

1. The usual requirements for a good operation theatre are necessary and not elaborated in this article.
2. Operating Room Size has to be adequate for easy placement of equipment and  to  make  necessary  changes according to surgeon's requirements. It should also facilitate free movement of OT personnel.
3. In a large room the operating table is  to  be  positioned  normally  and  in  a smaller room the operating table can be placed diagonally.
4. Doors and Windows should be opacified to prevent unwanted light.
5. Cables  should  run  the  shortest  possible  distance, not to be left dangling and hinder movement of OT personnel.
6. Multiple electrical points should be available on the equipment trolley. Multiple         plug points are to be provided around the room so that when the trolley is moved around, the electric cable from the trolley to the wall is maintained at the shortest distance. It is preferable to isolate the electrosurgical unit from other equipment to avoid electrical disturbances.
7. Proper earthing has to be provided and there  should  be  an  uninterrupted power supply with adequate  power  back up. It  is  also  necessary  to  use voltage    stabilizer    and   surge   supressor   to avoid inadvertent tosensitive electronic equipment.
8. Laparoscopic   equipment   is   generally   housed   in   a  cart on wheels to facilitate   its   movement  around the operation table. Optimal height of the equipment trolley is 5 feet.  The equipment is ideally arranged as shown in the figure.
9. Two full Co2 Cylinders one of which will be standby.
10. The   operating   team   may   be more comfortable standing on footstools, to compensate for the increased  height  due to usage of long instruments. These footstools have to be broad to  accommodate  the surgeon and foot peddles.
11. Use footboard and extra safety straps for large patients
12. A dedicated   team   is   the   primary   requirement   and  it ensures bettercoordination,  decreases   operating   time,   improves   patient   care,  and decreases cost to the patient and institution (7)
13. Preparation   for   conversion  to open surgery is necessary for every case being taken up for laparoscopy.(15)
14. Surgeon   should   preferably   come   to  OT  sufficiently  early to facilitate  correct   placement  of  equipment  and  to  ascertain  that  all  instruments  necessary are available and functioning.
15. A checklist is mandatory to ensure availability and proper functioning of all  equipment  and instruments at the beginning of the day and also before. It  also prevents unnecessary delays during surgery and anesthesia.

An example for standard check-list for any surgery is as follows:

1. Anesthesia Equipment – Check for gases and anaesthetic agents.
2. Electrically / Manually controlled operating table –Check the table lift and tilt mechanism
3. Video monitor/s – properly connected to camera / recorder
4. Camera – functioning checked on monitor
5. Recorder – VCR connected properly. Video tape is in place for documentation
6. Gas Insufflator – Cylinders full, no leakage and settings are proper
7. Light source – Both bulbs illuminating
8. Suction irrigator - Full volume of irrigation fluid in the container
9. Electrosurgical unit with grounding pad equipped with current monitoring system – functioning properly and settings checked
10. Ultrasonically activated scissors or other energy sources – functioning properly and settings checked
11. C. Arm x-ray unit for specialized procedures.
12. Instruments placed on the instrument trolley:
13. No 11 & No 15 scalpel blade with BP Handle
14. Verres Needle and Hassan's cannula
15. Tubings and Cables (Gas Insuffalator tube, Fiberoptic cable,  
    1. diathermy and other energy sources' cables, irrigation and suction tubings).
16. Laparoscopic instruments needed for the particular surgery.
17. A set curved hemostats.
18. Small Langenbachs / Catspaw retractors
19. Trocars & Cannulas
20. A complete laparotomy set
21. A set of vascular clamps, needles holders and fine suture materials.
22. Patient is shifted to theater after all equipment are positioned optimally.
23. Monitor to be positioned at eye level
24. Precise set up to be altered as per requirements of the particular  operative procedure.

Principles include[edit | edit source]

a. Laparoscope to point at the site of operation b. Surgeon stands opposite the pathology and looks at the monitor. Surgeon, camera, organ being operated upon and monitor to be in a straight line.

Design For Equipment Stand[edit | edit source]

The future

1. The development of ergonomically adequate handle designs and efficient methods  of handle to tip force transmission remains an interesting quest (16)
2. The advent of the robotic arm will abolish the need for assistance and provide greater ability of view, less inadvertent smearing of the lens, and the absence of fatigue.(17)  Further robots may perform surgeries in the future
3. We would take the laparoscope out of the operation theater as a informative diagnostic tool.(20)
4. The informative age is bringing in digitization of all equipment and hence imaging, documentation and handling equipment and instrumentation is going to radically change.
5. "Image guided surgery" may transform the way we operate on our patients.

References[edit | edit source]

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