Laparoscopic Surgery Flashcards
1
Q
Laparoscopy basic setup
A
- Video Tower is either behind you or end of bed or head of bed – look for it
- Video Tower contains:
- Monitor for viewing
- Light source for connecting light cable
- Camera source for connecting camera cable
- Insufflator source for connecting gas tubing (puts gas into the abdomen to create space for doing the surgery)
- Printer for photos taken during the surgery
- Accessory Monitor (slave)
- opposite the video tower for viewing by the assistant surgeon
2
Q
Insufflator source
A
- The machine has a preset flow rate and preset pressure
- Preset pressure is 15mm/Hg – never higher than 20mm
- Flow rate is initially set at 3mm (low flow) and then set to 40mm
- The machine constantly measures the flow rate and pressure
- A millimeter of mercury is a manometric unit of pressure
- WILL NOT BE TESTED ON THIS OR SETTING THESE MACHINES (don’t need to know the numbers)
3
Q
insufflation tubing
A
- After the patient is draped
- The assistant will secure the insufflation tubing to the drape with a non-penetrating towel clamp or velcro on drapes
- The assistant will hand off the other end (with the filter) of tubing to the nurse for connection to the INSUFFLATION SOURCE
- BE CAREFUL THAT YOU DON’T HAND OFF
- THE WRONG END
4
Q
light and camera cord
A
- Next the assistant will secure the light cord to the drape or pocket and pass off the other end of the cord to the nurse to be connected to the mounted light source
- Lastly, the camera cord is secured to the drape or in a pocket and the cord is passed off to the nurse to be connected into the camera box
- BE CAREFUL OF HANDING THE NURSE THE CORRECT END!
5
Q
setting up the camera scope
A
- The assistant will ask the scrub tech for a scope (the tech will most likely know what scope to start with)
- The first scope size is determined by the size of the port incision – if the surgeon makes a very small incision and uses a 5mm port, then you would choose a 5mm scope to start
- Choices of scope:
- 10mm 0 degree
- 10mm 30 degree
- 5mm 0 degree
- 10mm 30 degree
- Once the camera is connected to the scope, the light cable is connected to the scope
- When the light cable is connected – the assistant will ask the nurse to turn on the light source
- Make sure that the light is never touching the drapes or aimed at someone’s eyes –
- It is up to the camera holder (the assistant) to safeguard all aspects of the camera
6
Q
white balance the camera
A
- Once the camera light source is turned on – the assistant will white balance the camera by aiming the scope at a white lap sponge or raytex and pushing the “w” button on the camera head
- You will see on the monitor in front of you, “white balance complete”
- White balance can NOT be done when the light source is on “stand by” – always look at the display on the light source first before initiating white balance
7
Q
pneumoperitoneum
A
- The surgeon will make a small incision above the umbilicus – because there is a lot of important anatomy below the umbilicus
- The surgeon will then introduce a veress needle into the patient’s abdomen – there are many varieties –
- 10cc of saline in a syringe is twisted on to veress needle to check placement
- The surgeon will aspirate first – to check that the needle is not in a vessel and then inject saline – to check that the flow is laminar – proving that youre not in an organ and not in a vessel
- The syringe is removed and the assistant places the insufflation tubing onto the veress needle
- A Veress needle is a spring-loaded needle used to create pneumoperitoneum for laparoscopic surgery. Of the three general approaches to laparoscopic access, the Veress needle technique is the oldest and most traditional.
- Pneumoperitoneum- air or other gas in the peritoneal cavity, a potential space within the abdominal cavity.
- Co2 is used to inflate the abdomen:
- Inexpensive
- Non-combustible
- Very soluble and reduces risk of gas embolism - Gas embolism: blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system.
8
Q
“gas on”
A
- Once the insufflation tubing is attached to the veress needle, the surgeon will state “gas on.”
- The nurse will turn on the insufflator and the surgeon and assistant must watch the initial pressure – too high indicates that it is not deep enough or into an organ – pull back and see if the pressure drops
- The veress needle only allows low flow (3)so can ask for high flow (40)
9
Q
Insufflation pressure
A
- If the pressure is above the preset number – the patient is “tight”
- If the pressure drops, the causes are:
- Tubing not engaged properly
- Ran out of CO2
- Port is leaking or open
10
Q
port/trocar placement
A
- When the patient’s abdomen is inflating to the preset pressure (15), the veress needle is pulled out and a trocar is inserted
- If the incision is small, a 5mm port with trocar will be placed
- Otherwise, a 10 or 12mm port with trocar is placed
- When the trocar is removed from the port, the assistant will clean the camera scope (to reduce condensation) and insert into port
- Focus can be adjusted with the dial on the camera head
- This now is the assistant’s camera port
- This is all surgeon dependent. Don’t get too fixated on the sizes
11
Q
first thing to look at
A
- When the assistant takes the camera, the surgeon will continue the placement of additional ports
- The assistant will “watch” the trocar as it is placed through the abdominal wall
- The surgeon will need to see the tip always!
12
Q
“driving” the camera
A
- Camera head is up
- Light cable is pointing up (for 0 degree)
- If a 30 degree camera is used – the camera head never moves, only the light cord –
- direction the light cord is pointing is the direction of view
- “pretend” you are the surgeon and focus on what he or she is looking at
- The operating field or his/her instruments should be square in the middle of screen
13
Q
Keeping the scope from fogging up
A
- To clear up the “foggy” view, take out the camera and either wipe the scope on the FRED sponge or dip it in the FRED solution. The best way is hot water (in a thermos) if available; followed by tapping the excess off
- Wipe the scope clean with lab sponge before dipping in FRED
- Clean scope by briefly touching liver (never the intestines) – some surgeons don’t like this method
- FRED stands for Fog Reduction Endoscopic Device
14
Q
“driving” tips
A
- Keep your hand steady –
- Holding the scope from the top allow you to use the focus dial with one hand
- The scope should be looking between the 2 ports that the surgeon is using
- Keep the surgeon’s instrument in the middle of the screen
- Make slow movements – fast movements will make the surgeon sick
- Your monitor should be at eye level and turned towards you – ask nurse to move it if you can’t see properly
- Never take your eyes off the monitor, unless…
- If you get lost, briefly look at where the light is shining through the abdomen and aim it where you want to be looking
- If a vessel is hit, keep your eye on the vessel – not anything else –
- If blood hits your scope – do nothing UNLESS the surgeon asks you to clean the scope -
- Constantly reorient yourself to the important landmarks
- Always be looking at where the surgeon is working
- Move in close if the surgeon is trying to look at a vessel or suture or cut – can you see it?
- Move out if the surgeon is making sweeping moves with his instruments
15
Q
if you constantly hear:
A
- “TURN YOUR WRIST” – you are drifting off of the horizon – pay attention to keeping it flat and the organs anatomical
- “I’M OVER HERE” – you are not looking at the operating field – pay attention to where the surgeon’s instrument is at all times
- “I’M GETTING NAUSEATED” – you are moving too fast or you are not keeping up with the surgeon’s movements
- “I CAN’T SEE ANYTHING” – clean the scope – always ask first
- “FOCUS” – it’s not the scope focus, it is you – pay attention!
