Practical Endoscopy: Tips by Experts Sunita R Tandulwadkar, Nirzari Mangeshikar
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1Basic Endoscopy2

How to Set-up an Ideal Endoscopic Operation TheaterChapter 1

PG Paul,
Sunita R Tandulwadkar,
Renuka Borisa,
P Biju,
Kannan K,
Fiadjoe P
  • Well-equipped, well-organized and well-spaced operating room is essential for successful laparohysteroscopic procedures.
  • The arrangement of instruments and equipment is important for safety and efficiency.
  • Ceiling mounted instrument carts avoid gas tubing and electrical wires on the floor.
  • Electrosurgical generator and suction irrigation device are kept on a separate trolley for avoiding spill of irrigation fluid on other equipment.
  • Ideally operation theater should be square in shape with minimum measurement of 20 × 20 square foot and should be large enough to accommodate all the equipment (Fig. 1.1).
  • The OT table should have capability for Trendelenberg and reverse Trendelenberg positions with right and left tilt. The table should have adjustment to go as below as 2 feet so that one can operate comfortably even with very obese patients. The height of the table should be below the waist of the surgeon for maximum efficacy. For short surgeons, use of stepping platforms is extremely valuable.
  • To avoid fatigue and further consequences of the shoulder joint, surgeons should take precautions to see that his/her patient's position is in such a way that he/she does not have to abduct the upper extremity beyond 45° angle unless he/she is using contralateral port.
  • A well-equipped Boyle's apparatus for general endotracheal anesthesia is essential to maintain proper oxygenation and relaxation during the procedure along with an ET CO2 and pulse oximeter monitoring.
  • The surgeon stands by the patients left side at an angle facing the patient's contralateral foot. Usually, the first assistant stands opposite the surgeon, i.e. on the right side of the patient, while a second assistant sits between the legs of the patient and helps in uterine manipulation. Rarely in cases of advanced surgery, where even first assistant is using two ipsilateral ports, one more assistant is needed to hold the camera, who can stand at the head end, next to the anesthetist.
  • The nurse and the instrument table are positioned on the left side of the surgeon for easy accessibility.
  • Second trolley is arranged on the foot end of the patient, easily accessible to the left hand of the sister and the right hand of the second assistant.
  • Endoscopic equipment cart (Fig. 1.2) should carry:
    • Main video monitor
    • Endovision camera
    • Recording system
    • Light source
    • The CO2 insufflator to allow continuous monitoring of inflation rate and intra-abdominal pressure
    • Electrosurgical generators/harmonic/other energy sources
    • Endomat/hysteromat
    • Morcellator.
    One can also have hanging unit which can carry monitor, camera, recording system, light source and CO2 insufflator.
    If its mobile cart ensure that wheels are good for easy mobility of the unit.
  • For laparoscopic surgery this cart with monitor should be placed at the foot end of the table, usually at the patients right foot while for hysteroscopic surgery, the monitor is placed toward the patient's right shoulder.
  • Another monitor should be placed at the head end of the patient, which benefits the second assistant and the nurse/technician.
  • It is not only the surgeon but assistants, nursing staffs and even ward boys who should be familiar with the functioning of all the equipment for better outcome.
  • The place of each and every equipment and instrument should be fixed and everyone should be aware of their placement.
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    Figs. 1.1A and B: OT layout
  • Sterilization system for the instrument could be either autoclaving, gassing of individual instrument or formalin sterilization by keeping in formalin chambers. It depends on individual's choice as long as it gives 100% assurance of sterility.
  • One of the video monitors should have facility to record in multisystem form. One of the most important aspects in endoscopy setup is the facility of proper documentation. The DVD recording is the most easiest and simplest installable modality. Many computer softwares are available to record the live surgery as well as for the data base maintenance, which helps in quick analysis of the total patient information.
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Fig. 1.2: Mobile cart