Operating Room Setup and Workflow
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Operating Room Setup and Workflow The organization of the operating room has undergone a dramatic evolution since the early history of our discipline. The Neurosurgical Atlas by Aaron Cohen-Gadol, M.D.
Transcript of Operating Room Setup and Workflow
OperatingRoomSetupandWorkflow
Theorganizationoftheoperatingroomhasundergoneadramaticevolutionsincetheearlyhistoryofourdiscipline.
TheNeurosurgicalAtlas byAaronCohen-Gadol,M.D.
Figure1:TheyoungHarveyCushingandhisoperatingroomatJohnsHopkins,circa~1908(upperimage).Atthepeakofhiscareer,inAugust1929,Cushingperformedanoperationfor
visitingProfessorI.P.Pavlov(lowerimage)(photoscourtesyoftheCushingBrainTumorRegistryatYaleUniversity).
Thesurgeonis“thecaptainoftheship”andresponsibleforalltheactionsoftheindividualsandtheworkflowintheoperatingroom.Thisresponsibilitydemandsaleaderwholeadsbyexample.Thefactorthatdistinguishesgreatfromaveragesurgeonsistheabilityoftheformertosucceedinthefaceofadversity,technicaldifficulty,orcrisiswhileunifyingtheteamtosecureanexcellentoutcome.
Effectiveplanningtodealwithunexpectedeventsanddisasteristhecenterpieceofasuccessfuloperativestrategy.Anticipationoftechnicaldifficultyandcogentpreparationisthefirststep.Thesurgeon’sdecision-makingprocessmustbeflexiblesothatalternativeoptionstohandlingthepathologybasedonmomentousintraoperativefindingscanbeaccommodatediftheinitialplanisdeemedunfit.Thepathology,ratherthanthesurgeon,mustdictatetheplan.Forcingtheoperator’sagendawithoutpursuitofflexiblealternativestrategiesoftenleadstodisappointingresults.
Thesurgeonneedstoperiodicallystepbackandinvestigatetheflowoftheoperationandtheexpectedversusanticipatedfindings.Surgeryunderhighmagnificationcanalso“magnifymyerrors”andIoftenstepbacksothatIdonotto“misstheforestforthetrees.”
Surgicalintuitionshouldnotbedismissed,butscrutinized.Surgicalintelligenceisdifficulttodefine,butitistheabilitytomonitorone'sownoperativemaneuvers,todiscriminatebetweendifferentoperativestrategiesforefficienthandlingofthelesion,andtouseimportantintraoperativefindingstoguidetheoverallplan.
OperatingRoomSetup
Itisanintegralresponsibilityoftheoperatortobeintimatelyfamiliar
withthenuancesoftheoperatingroomarrangementandorganization.Anefficientuseofthespaceisimportantforpracticalworkflow.
Figure2:Amodernoperatingroomsetupmustaccommodatethelocationandarrangementofitscomponentsinrelationtothepatient.Thesecomponentsincludetheoperatingandanesthesiateams,theancillarystaff,andavarietyofequipment.
Figure3:Thestrategicpositionofthepatientdefinesthelocationofallothercomponentsintheroom.Theanesthesiologistshouldbeabletoeasilyreachthepatient’sairwayandvascularaccess.Thesurgeonandsurgicaltechnician(nurse)arepositionedacrossthepatienttofacilitateseamlessexchangeofinstruments.Multiplemonitorsintheroomallowtheassistantstoviewtheoperativefieldandfollowtheworkflowofmicrosurgery.Theexperiencedsurgicaltechnician’santicipationoftheoperator’snextmaneuversignificantlyimprovestheefficiencyoftheoperation.Thislevelofinvaluableteamworkisonlypossibleifthesamesupporting
staffoperatewiththesamesurgeonconsistently.
Inselectcases,theanesthesiologistmaybepositionedatthefootofthetableifadditionalroomisrequiredfortheoperatingteam.Isitduringmicrosurgerybecausesittingoffersnumerousadvantages.Standingmayleadtoarmandhandfatigue,whereasasittingpositionallowstheuseofanarmrestandpromotesrelaxedandsteadyhands.Acomfortableandergonomicpositionalsofacilitatesmyabilitytoimprovemysurgicaltechniquebysharpeningmyfocustoeliminatenondeliberateandunintentionaldissectionmaneuvers.
Figure4:Theoperatingroomsetupforaleft-handedsurgeonin
thecaseofaretromastoidoperation.
Figure5:Theorganizationoftheoperatingroomforapercutaneoustrigeminalrhizotomy.
Theoperatingromteamincludesoneortwocirculatingnurses,asurgicaltechnicianornurse,ananesthesiateamthatincludesanattendinganesthesiologist,residentorfellow,acertifiedregisterednurseanesthetist(CRNA),andananesthesiatechnician.Thesurgicalteamiscomprisedoftheattendingneurosurgeonandaresident,fellow,ormedicalstudents.Otheraccessorypersonnelincludeneurophysiologicalmonitoringtechnicians,X-raytechnicians,andothervisitingphysicians.
Allmembersoftheteamshouldhavetheirowndedicatedspace.Thisarrangementenhancesworkflowandallowsunobstructedmovementsofthecirculatingstaffintheroom.Roamingofvisitingstaffintheroomcansignificantlycompromiseworkflowandincreasetheriskofinfection.
Figure6:Operatingroomsetupforanexpandedtransnasalendoscopicprocedure.Dedicatedmonitorsareavailableforthesurgeonandassistant.
PreparingforSurgeryandtheWorkflow:PersonalPerspectives
IarriveintheORafterthepatientisanesthetizedandproceedtopositionthepatientonthetableandmarktheincision.IthendiscussthenecessarystepsoftheoperationandanestheticneedswiththeentireORteamwhilethewoundisbeingpreparedanddraped.Alloftheteam’simportantquestionsarecordiallyansweredandthesatisfactionofeachteammemberisconfirmed.Thepreoperative
imagesandplanarealsoreviewedwiththeoperatingteam.
Ialsoalertthestaffregardingtheneedforspecialsurgicalsuppliesandequipment.Forexample,theneedofafemoralarterysheathforanarteriovenousmalformationoperationinexpectationofanintraoperativeangiographyshouldbediscussedwiththestaffbeforethepatiententerstheroom.Aspreviouslymentioned,itisbesttostandardizeandsimplifytheORsetupbecausethispracticewillimprovethesafetyandefficiencyofthesurgery.Inconsistentrequestsleadstooperatingroomstaffs’confusion.
Figure7:Aspartofpreparationforsurgery,Icheckthebalanceofthemicroscopeandensurethecorrectheightandconfigurationofthemouthswitch.ItisimportantthatthesurgeonisintimatelyinvolvedinORsetupandfamiliarwiththeequipment.
Figure8:Thesurgeonshouldreceivetheinstrumentsseamlesslywhilehisorherattentionandeyesremainontheoperativefield.Thenumberofinstrumentsandinterchangesusedshouldbekepttoaminimum,andeachinstrumentshouldbeusedformultiplepurposes.Therepertoireofinstrumentsshouldbestandardandlimited.
Figure9:Adedicatedcomfortablechairwitharmrestsis
mandatoryformicrosurgery.Anergonomicposturehelpstheoperatorimprovesurgicaltechniquebyeliminatingnondeliberateorunintentionaldissectionmaneuvers.
MarkingtheIncisionandDrapingtheOperativeField
Thefirststepoftheoperationshouldalwaysincludeathoroughreviewofthepreoperativeradiologicalstudiesandconfirmationofthesideofthelesiontodefinethelocationoftheoperatorandtherestoftheteaminrelationtothepatient.Theoperativeplanshouldbereviewedonceagain.
Afterthepatient’sheadisimmobilizedintheskullclampanditspositionfinalized,Iuseneuronavigationtoplantheincision.Ialwaysusesuperficialanatomiclandmarks(theear,zygoma,sagittalsuture,inion,orsuperiornuchalline)toverifytheapproximatelocationofthelesionrelativetotheincision.Errorsinnavigationcanleadtoirreversibleresults.
Itypicallyshaveastripofhairaroundtheincision,butavoidshavingtheentirehead;Idonotbelievetheriskofpostoperativeinfectionisdependentontheextentofhairremoval.Iuseclippers,notrazors,forthispurpose.
Figure10:Oncetheincisionismarked,Iscrubtheskin,firstwithalcoholandthenwithChloraPrepskinantiseptic,arapid-acting
andpersistentpreoperativeskinpreparation,tofurthercleantheskin.Next,Igenerouslyinjectthesubcutaneousspaceoftheincisionlinewithlidocainehydrochlorideandepinephrinesolutiontominimizebleedingduringtheincision.IthenrepreptheoperativefieldwithChloraPrepandwaituntiltheskiniscompletelydry.Alocalanestheticmayalsoamelioratepostoperativepainthroughpreconditioningmechanisms.
Figure11:Theincisionisthendrapedinthestandardfashion.Ifaventriculostomyoranotherformofdrainagesystemiscontemplated,adjacentareasoftheskinarepreppedfortunnelingthedrainagecatheter.
IntraoperativeWorkflow
Theexposure/craniotomyportionofthesurgeryshouldproceedexpeditiouslysotheoperatorcandedicatemostofhisorherenergyandfocustothecriticalintraduralportionoftheoperation.
Theintraoperativeworkflowisverydependentonthespecificsofthecase.Itisadvantageoustothinkaheadateverystepofeachsurgicalmaneuverandaskfortheinstrumentbeforeyouarereadytoexchangesothatitisreadyforyou.Suchmeasuresimproveefficiencytremendously.
Ifanintraoperativeangiogramiscontemplated,theoperatingroom
setupshouldaccommodatethespacerequiredforfluoroscopy.Idonotusuallyusetheradiolucentheadholderandhavenothadanysignificantdifficultyacquiringtheappropriateimageswhileworkingaroundtheregularskullclamp.
Theuseofamouthswitchisparamountforimprovedvisualizationandoperativeefficiency.Formoredetails,pleaserefertothechapterontheSurgeon'sPhilosophyandOperatingPosition.Duringsurgery,thereasoningbehindeachoperativemaneuveristhoroughlydescribedtotheresidents,fellows,andvisitingsurgeons.
AdditionalConsiderations
Irecordallofmysurgerieswiththemicroscope-integratedcameraforlatercriticalreviewandadvancementofthesafetyandefficiencyofmyoperativemaneuversinthefutureoperations.
Theoperativeplanshouldbecarefullyre-revieweddaysbeforethesurgery.Ioftensolicitmycolleagues’opinionsaboutmyoperativeplansforcomplexoperations,andIhaveneverbeendisappointedindoingso.Ialsodiscusstheplanofactionwithmyfellowsandresidentsthenightbeforesurgery.
PearlsandPitfalls
Theoperatingroomsetupiscrucialforadvancingthesafetyandefficiencyofoperativeorganization,workflow,andteamwork.
Thesurgeonis“thecaptainoftheship”andshouldpaycloseattentiontoalldetailsofoperatingroomevents,includingORsetup.
Operatingroomsetupshouldbesimplifiedandstandardizedsothatcomplexityandinconsistencyarenotleadingto
confusionanderror.
Foradditionalillustrationsofcranialnervemonitoring,pleaserefertotheJacklerAtlasbyclickingontheimagebelow:
DOI:http://dx.doi.org/10.18791/nsatlas.v1.ch05
RelatedVideosOperatingRoomSet-up:IncreasingSurgicalEfficiencyandOperator'sComfort
NavigatingtheORTable
PlacementofthePins(SkullClamp)
PatientPositioningandMyocutaneousFlapforRetromastoidCraniotomy
AcousticNeuroma:TheSittingPosition
Parasagittal/ParafalcineMeningioma:AvoidingIschemia
MedialSphenoidWingMeningioma:OrbitozygomaticOsteotomy
GrandRounds-PatientPositioningforIntracranialSurgery:AGuideforResidentsandFellows
TheIntroductiontotheUseofORMicroscope:Interview
PreoperativeMicroscopeSetup
NuancesofTechniqueforOptimalMicroscopeImage
NuancesofMaintainingMicroscopeBalance
MouthswitchandFootpedal:Advantages
MaximizingtheMicroscope'sPotential:ORErgonomics
LightfieldAdjustmenttoMinimizeTissueInjury
AdjustmentofOculars
