Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR...

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Sarah L. Cohen, MD MPH Brigham and Women’s Hospital 2016 Collaborative Symposium on Minimally Invasive Gynecologic Surgery Operating Room Set Up and Instrumentation: Making the OR Work for You

Transcript of Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR...

Page 1: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

SarahL.Cohen,MDMPHBrighamandWomen’sHospital

2016CollaborativeSymposiumonMinimallyInvasiveGynecologicSurgery

OperatingRoomSetUpandInstrumentation:MakingtheORWorkforYou

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Disclosures

� IhaveservedasaconsultantforOlympusSurgical

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ObjectivesImprovesafetyandefficiencyintheORby:

1.Optimalroomset-up

2.Thoughtfulinstrumentchoices

3.Team-basedapproach

4.Surgeonpreparation

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“Inallthingssuccessdependsonpreviouspreparation,andwithoutsuchpreviouspreparationthereissuretobefailure.”

-Confucius

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Troubleshooting

�Gettoroomearly!

�Ensurecriticalequipmentpresent,working�Optimizesetupforbestsurgeonergonomics

�Setuprecording�Helppositionpatient

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GoldilocksPhenomenon

TOOLOW!

TOOHIGH!JUSTRIGHT

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AUDIENCERESPONSE:Afteralongdayintheoperatingroomdoinglaparoscopiccases,whathurtsthemost?

A) Neck/ShouldersB) Arms/HandsC) LowBackD) Legs/Feet

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OptimalTableHeight

� Goal=minimizestrainfatigue

� Instrumenthandlesatelbowleveltominimizeupperarmandshoulderwork

� Adjustbed,utilizestepstoattaindesiredheight

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� 21surgeons,2handedcirclecuttingtaskatvaryinginstrumentheights� Measuredsurgeondiscomfort,taskdifficulty� EMGreadingsatdeltoid,trapezius

SurgEndosc 2002

Discomfort

Table Height, ref elbow

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OneMonitor TwoMonitors

VideoScreens

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Recommendations

� Monitorstraightahead� Inlinewiththeforearm– instrumentmotoraxis� Avoidaxialrotationofthespine� Positionedlowerthaneyeleveltoavoidneckextension

�Optimumangleis15degreesdownward

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MonitorPositioning

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Surgeonstance� Feetflat

� Canuserubberpadstostandon,placeonefootuponstep� Hipslevel

�Avoidtilting/cockingorleaning� Shouldersdownandrelaxed� Armsbysides,elbows90degres� Spinestraightahead,facingmonitor� Neckneutral,notpushedforward� Gazeslightlydown

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Anotheroption…fromEthosTMSurgical

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PatientPositioning� Anti-skiddevices� Pads,foam,beanbag� PreventpatientslippingduringsteepT-berg

� Avoidshoulderbracesorchestwallstrapping

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PatientPositioning� Neurologicallyneutrallowlithotomy�Yellow-finstirrups

� Candycanes:littlesupport,allowuncontrolledhipabduction&rotation

� Bootstirrups:adjustable,minimizepressureonlateralandposteriorcalf

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PatientPositioning� Tuckingarmsmilitarystylewithpadding

� Sleighs,toboggans,sheettuck� Providesunrestrictedmobilityforsurgeon

� Preventssurgeonfrom“sitting”onthepatient’sarm� Preventsarmfrombeingdislodgedfromarmboard�Avoidulnarnerveinjury,protecthands

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Neutral,paddedpositioning;Knee,umbilicusandcontralateralshoulderin-line

Optimalpatientpositioning

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Considercost- limitdisposableinstruments

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AUDIENCERESPONSE:Whatisyourpreferredenergysourceforlaparoscopicsurgery?A) MonopolarB) Advancedbipolar(Ligasure,Enseal,PK)C) Ultrasonic(Harmonic,Thunderbeat,Sonocision)D) Laser

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EnergySources

� Monopolar� Advancedbipolar� Ultrasonic� Laser

ALLdevicescarrypotentialforelectrosurgicalinjury,knowyourdeviceandit’slimitations!

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Monopolar� Scissor,dissector,L-hook,paddle

� Cuttingmode� Lowvoltage,lessthermalspread

� Coagulationmode� Highervoltage,morefulguration

� Simpleandcheap,easytouse� Smoke,thermalspread,hottips

� Beawareofcouplinginjury,insulationfailure

� MUSTHAVEGROUNDINGPAD

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AdvancedBipolarDevices

� Limitstraycurrenteffectseenwithmonopolar� Lowervoltage,lessthermalspread� Electrosurgicalgeneratorswithfeedbackcontrol

� Stillatriskforinsulationfailure,injury� Feweroptionsfortissueeffect(sealsanddivides)

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AdvancedBipolarDevices

LigaSureTM (Covidien)� Sealsvesselsupto7mm� Minimalsticking/charring� 2mmthermalspread� Varietyoftips,deviceoptions

� LigaSureAdvanceTM hasmonopolartip

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AdvancedBipolarDevices� GyrusPlasmaKinetic(Olympus)

� Pulsedbipolarenergy,allowsintermittentcooling� Limitedthermalspread/sticking� Seals5-6mmvessels,3mmthermalspread� Limitedcomparativedata,butmayhavemorevariablesealingresults

� EnSeal®(Ethicon)� Compressionandbipolar� Sealsvesselsupto7mm� 1mmthermalspread� Longestvesselsealtime

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UltrasonicDevices� Convertultrasonicenergyintomechanicalenergy,heatsproteins,separatestissue� Versatiledissection,lesssmoke� 1mmthermalspread� Onlysealsvesselsupto5mm� Surgeondependent– beawareoftissuetension

Harmonic®(Ethicon)Thunderbeat– includesbipolaroption(Olympus)Sonocision- cordless(Covidien)

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Laser

� Preciseapplicationofenergy,controloftargetdepth� Verylimitedthermalspread

� Lasermediums:CO2,argon,KTP,NdYAG

� Limitedbyequipmentcost,training

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LawandLyons.ComparativeStudiesofEnergySourcesinGynecologicLaparoscopy.JMIG2013.

LimitedadequatelypoweredcomparativestudiesManyindustrysponsoredHardtocompareinvivo,exvivo

Advancedbipolarcanseallargervesselshavehighersealburstpressures

Ultrasonicandmonopolarwithbestdissection

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BUT….Whichenergydeviceisbest?!?

NONE arewithoutrisk

ALL cancausethermalorelectrosurgicalinjury

Page 31: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

Uterinemanipulators� Yoursecondmostimportantassistant

� Choiceofmanipulatordependsonnatureandcomplexityofcase

� Maindifferencebetweenmanipulatorsisthedegreeofante- andretro-version

Hulka

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RUMI®(Cooper) V-Care®(ConMed)Excellentretro/anteversionOptionalpneumooccluderballoonRigidcupdelineatesfornicesMoredifficulttoassembleLimitedwithnullip/smallpelvicoutletPartiallyreusable

GooduterinemobilityBuiltinpneumooccluderVeryeasytoinsertOptionwithoutcupFullydisposable

Page 33: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

SutureOptions/AssistDevices� Laparoscopicneedledrivers

�Non-barbedSuture� BarbedSuture

� Automatedsuturingdevices� EndostitchTM (Covidien)

� LapraTy®(Ethicon)

Page 34: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

Theintangibleyetinvaluableaspects…

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AUDIENCERESPONSE:DoyouhaveadedicatedORteamforyourprocedures?A) Yes– coregroupofstaffB) No– differentpeopledependingontheday

Page 36: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

Teamwork:Learnfromaviation,crewresourcemanagement

� Highlyfunctioningteamiskeytopatientsafety

�Decreasewrongsitesurgery,surgicalsiteinfection

� Efficiency

� Specifictocertainprocedures,techniques� ie robotics

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TeamApproach

� Whattodoifyoudon’thaveateam?

� Seekoutinterestednurses,staff� Providetraining,inservices� Discusswithadministration– hardtoarguewithsafety,efficiencydata

� Howtooptimizeyourteam?

Page 38: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

TeamApproach

� Simulation

� Enhancecommunication�Updatepreferencecards,alerttospecificcaseneeds� Timeouts/debriefs� Safetychecklists

Page 39: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

AUDIENCERESPONSE:What,ifany,personalpreparationdoyoudobeforeacase?A) None.Doescoffeecount?B) ReviewthepatienthistoryC) DiscussthecasewithcolleaguesD) ReviewvideosE) Mentalimageryexercise

Page 40: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

SurgeonPreparationBorrowedfromtheworldofsportspsychology

Page 41: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

SurgeonPreparation� Mentalimagery:“thesymbolicrehearsalofaphysicalactivityintheabsenceofanygrossmuscularmovements”

� Producescognitiveblueprintsformovementpatterns

� Mentalrehearsaloftheseblueprintsallowsmovementstobecomeautomatic

RichardsonA.Mentalpractice:areviewanddiscussion,partI.ResQ1967;38:95-107.

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SurgeonPreparation� 66residentswithlimitedexperienceincystoscopy

� Imagerygrouphad<20minuteguidedsessiontoenvisiontheprocedure

� Controlgroupreadtextbookchapter

� Surgeryassessmentscores15.9%higher inimagerygroup

AJOG,2009

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SurgeonPreparation

Alsofromthesportsworld:�Recordyourcases,reviewyourperformance

Makeuseofyourcolleagues�Brainstormaboutdifficult/uniquecases�Neverhesitatetoaskforhelp

Surgeryisateamsport!

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FinalTips

� Gettotheroomearly� Setthingsupthesamewayeverytime� Beawareofyourstance� Knowallequipmentbetterthananyone�Repsavailable ifneeded

� Knowwheresuppliesarekept

Page 45: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

FinalTips

� Optimizeyourteam� Updatepreferencecards� Recordcasesoften� Considermentalimageryexercises� Observeotherhigh-performingsurgeons

Page 46: Operating Room Set Up and Instrumentation: Making … Room Set Up and Instrumentation: Making the OR Work for You Disclosures I have served as a consultant for Olympus Surgical Objectives

References� Berquer R,SmithWD,DavisS. Anergonomicstudyoftheoptimumoperatingtableheightforlaparoscopicsurgery. Surg

Endosc.2002Mar;16(3):416-21.� MaternU.Ergonomicdeficienciesintheoperatingroom:examplesfromminimallyinvasivesurgery.Work.

2009;33(2):165-8.Review.� SariV,Nieboer TE,Vierhout ME,Stegeman DF,Kluivers KBTheoperationroomasahostileenvironmentforsurgeons:

physicalcomplaintsduringandafterlaparoscopy.MinimInvasiveTher AlliedTechnol.2010Apr;19(2):105-9� vanDetMJ,MeijerinkWJ,HoffC,Totté ER,Pierie JP.Optimalergonomicsforlaparoscopicsurgeryinminimallyinvasive

surgerysuites:areviewandguidelines.Surg Endosc.2009Jun;23(6):1279-85.Epub 2008Oct2.� SankaranarayananG, etal.Commonuses and cited complications of energy in surgery.Surg Endosc. 2013

Sep;27(9):3056-72.� LawKS, AbbottJA, LyonsSD.Energysourcesforgynecologic laparoscopic surgery:areviewoftheliterature.Obstet

Gynecol Surv. 2014Dec;69(12):763-76.� LawandLyons.ComparativeStudiesofEnergySourcesinGynecologicLaparoscopy.JMIG2013� PowersKA,Rehrig ST,Irias N,AlbanoHA,MalinowA,JonesSB,MoormanDW,Pawlowski JB,JonesDB. Simulated

laparoscopicoperatingroomcrisis:Anapproachtoenhancethesurgicalteamperformance. Surg Endosc.2008Apr;22(4):885-900.

� RichardsonA.Mentalpractice:areviewanddiscussion,partI.ResQ1967;38:95-107.� Komesu Y,Urwitz-LaneR,Ozel B,Lukban J,KahnM,MuirT,Fenner D,RogersR. Doesmentalimagerypriortocystoscopy

makeadifference?Arandomizedcontrolledtrial. AmJObstet Gynecol.2009Aug;201(2):218.e1-9.


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