General 1
Concepts
Before commencing any laparoscopic procedure it is of paramount importance to go through a checklist to ensure the working environment is as comfortable as possible. Working from monitors creates an unnatural and abstract environment that requires manual skill, concentration, and coordination of hands and brain; hence it is crucial that the surgeon be comfortable to allow optimum technical performance.
The Checklist
Approach
The Team
A successful laparoscopic program is dependent on harmonious interaction within the surgical team.Whenever possible the nursing staff should be dedicated to the laparoscopic surgical program. Only then they will be able to excel in all aspects of the procedure, both technical and medical. The circulating nurse should work in harmony with the scrub technician and both should observe procedures carefully to allow them to anticipate problems and preempt the surgeon’s requests. This also requires knowledge of the instruments, their functions, and construction in order to replace or repair instruments when necessary.
It is also important that both the scrub technician and the circulating nurse have a basic knowledge of video imaging to be able to connect and disconnect TV monitors and video recorders, and to assist if problems arise with the imaging system. In the ideally staffed operating theater, a third dedicated technical support person is responsible for maintenance of the sophisticated electronic equipment.
The team is created by selecting committed individuals from the surgical staff, teaching them the basic principles of laparoscopic procedures, and providing access to the laboratory for familiarization with procedures and their technical considerations. It is usually too late to begin the teaching process when an advanced procedure is about to begin; the whole surgical scenario should have been rehearsed earlier.
N. Katkhouda, Advanced Laparoscopic Surgery,
DOI: 10.1007/978-3-540-74843-4_1, © Springer-Verlag Berlin Heidelberg 2011
2 Chapter 1 General Concepts
After completion of basic training in laparoscopic surgery, it is beneficial for nursing staff to attend focused courses. In educational terms, courses intended for nurses and those offered for surgeons can be equally useful.
Following training, it is important to have checklists in the operating room, preferably fixed to the TV monitor, to which nursing staff can refer before and during preparation of the patient. Members of the nursing team should work in harmony, providing understanding and support for each other. The circulating nurse should never leave the operating room without the knowledge and approval of the scrub technician, or more importantly, the surgeon.The surgeon is dependent on the environment,and should an operative problem occur in the absence of the circulating nurse, the smooth rhythm of the operation is threatened.
More than one nursing team should receive appropriate training so that a back up team is always available.
The surgical assistants should also have appropriate training and the above remarks apply equally to this group. They should clearly understand the different steps of the procedure to facilitate a flawless operative process. They should also be taught about potential incidents and complications and be briefed as to what course of action to take.
An advanced surgical procedure will proceed smoothly only if the surgical environment is right. It is the surgeon’s responsibility, as team leader, to ensure that all team members have been adequately trained and prepared.
The Instruments
The instruments, the camera, and the video imaging system should all be checked prior to beginning an operation, to ensure that all wiring is connected correctly and all instruments are ready for use. This should be completed preferably half an hour prior to bringing the patient back to the operating room.
Surgeons involved in laparoscopy will each have their preferred list of instruments. This may vary from the standard laparoscopic set which comes in basic and advanced versions:
The minimum basic set usually consists of trocars, a Veress needle, one rightangle hook, one spatula, one 5 mm dissector, one electrical scissors, one 10 mm Babcock clamp, one cholangiogram clamp, two atraumatic 5 mm graspers, one rightangle dissector, one ratchet grasper, one clip applier, and 0 and 30° 5 or 10 mm laparoscopes.
The advanced set should include more trocars,two needle holders,two 10 mm Babcock clamps, one 10 mm right-angle dissector, microscissors, sharp scissors, two or three atraumatic graspers, clip appliers (medium and large), laparotie absorbable clips, one needle nose grasper, and harmonic shears.
The basic and advanced trays can naturally be tailored to suit the team’s preference, but sets should be standardized to avoid confusion and to make instrument selection and preparation as cost effective as possible. Other specific items needed for a particular procedure should be considered in advance, such as a bag for retrieval of large organs like the spleen. Zeroand 30° 5 and 10 mm laparoscopes should always be available, and an extra camera should be kept in the operating room in case of a technical problem with the original.