The Working Environment |
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Fig. 1.5 Conventional setup for left colectomy and low anterior resection. S surgeon; FA first assistant; CA camera assistant. Arrow indicates movement of monitor
Laparoscopy is performed in a closed abdominal cavity where space is limited. Tilting the operating table so that gravity provides natural retraction by pulling the intraabdominal organs to the lower side can increase available space significantly. It should be possible to position the patient in Trendelenburg or reverse Trendelenburg with either the right side or left side up depending on the procedure, and it is therefore important to use an appropriate table to allow such maneuvers. Some old tables are obsolete and it is worthwhile investing in a modern electrical operative table if one is to embrace advanced laparoscopic surgery.
Laparoscopic surgery demands great concentration. It is therefore important for the operating room to be quiet when the surgeon is performing laparoscopic surgery, especially in advanced cases involving knot tying.
The abdomen is a closed unit and the working space is a virtual one that has to be created and maintained (Fig. 1.6a–c). The working space can be increased by means of various maneuvers such as tilting the patient – head up or head down, right side up or left side down – where gravity is used to displace adjacent organs from the operating site.
In upper abdominal operations the working space is created by positioning the patient head up to allow the stomach,the colon,and the omental fat to drop down.For hernia repair the patient is placed in a steep Trendelenburg position, so that the small bowel is similarly moved up to free the pelvic area. For colon surgery and appendectomies working space can be created in the same manner, with the addition of lateral tilting of the table to move the
The Working
Environment
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Chapter 1 General Concepts |
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b
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Fig. 1.6 (a–c) The “working space” concept. (a) Inadequate working space, (b) ideal |
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working space, and (c) safe entry site of the laparoscope in the case of small bowel |
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obstruction |
small bowel away from the operative site. The splenectomy technique also involves creation of working space, with the patient being positioned head up, left side up allowing the stomach and the colon to fall to the right side, giving access to the left hypochondrium.
During a laparoscopic procedure for small bowel obstruction, the same effect can be achieved by tilting the patient to the side opposite the presumed site of the obstruction as indicated by the preoperative physical examination and abdominal plain films.
The working space concept is especially important upon inserting the laparoscope. If the working space is severely limited, as, for example, with small bowel obstruction, it is easy to injure the bowel with placement of the first trocar. For this reason, flexibility in the choice of trocar insertion sites is recommended, following the simple principle of triangulation that governs all trocar insertions.
If the maximum pressure of 15 mmHg is reached with a flow of less than 2 L of CO2 upon insertion of the first trocar, one should convert to an open procedure as this indicates that there will not be adequate working space due to the distended bowel.