Placement of Operative Team and Equipment

Proper positioning of equipment and personnel is essential for the smooth performance of most laparoscopic procedures.

The monitor, insufflator, light source should be preferably placed on a ceiling-mounted boom. The monitors (preferably two) should be diagonally opposite to the primary surgeon and the assistant surgeon at the direct eye-level. The insufflator and light source should also be within the surgeon's field of view to keep a constant monitoring of the intra-abdominal pressure.

For upper tract laparoscopic surgery, the surgeon and first assistant (camera person) usually stands opposite the area of surgical interest and the second assistant stands on the contralateral side of the table. During pelvic laparoscopic procedures, the surgeon and second assistant stand on the left side of the patient and the first assistant on the right side of the patient. Incoming lines from insufflator, suction/irrigation, and electrosurgical devices are properly secured to a part of the surgical drape so that they do not entangle with each other and do not interfere with the free flow of laparoscopic instrument exchange. Optional technology (e.g., harmonic scalpel, argon beam coagu-lator) must be arranged in an orderly fashion using either preexisting or improvised pockets of the surgical drape. Additional technology (e.g., high-speed electrical tissue morcellator, laparoscopic ultrasound probe) may be moved to the operating table depending on the surgeon's needs and the availability of space.

Modern laparoscopic operating room systems now integrate all equipment (optics, insufflant) that can be centrally controlled by a touch screen or by voice activation and make operating room logistics smoother. These systems also integrate digital image and video capture and additional technology such as electrocautery, ultrasound energy, etc. Moreover, they involve the use of high-resolution flat screen liquid crystal display monitors that are ergonomically superior.

A checklist ensuring that all essential equipments are present and operational should be completed just before initiating the pneumoperitoneum. Specifically, this list should include (i) light cable on the table, connected to the light source and operational; (ii) laparoscope connected to the light cable and to the camera, with an image that is white balanced and focused on a gauze sponge; (iii) operational suction and irrigation functions of the irrigator/aspirator; (iv) insufflator tubing connected to the insufflator, which is turned on to allow the surgeon to see that there is proper flow of CO2 through the tubing as kinking of the tubing would result in an immediate increase in the pressure recorded by the insufflator, with concomitant cessation of CO2 flow; (v) an extra tank of CO2 in the room; and (vi) a Veress needle, checked to ensure that its tip retracts properly and that, when it is connected to the insufflator tubing, the pressure recorded with 2-L/min CO2 flow through the needle is less than 2 mmHg.

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