Core Laparoscopic Skills

Chapter 3

Safe setup and positioning

Patient safety is the most important factor to be considered in laparoscopic surgery. This must be at the forefront of your mind in setting up and conducting your procedure. This chapter discusses factors related to the setup and positioning of kit, patient and staff in order to ensure optimise safety and efficiency.

A key determinant of operative outcomes, both laparoscopic and open, is appropriate patient selection, so the first thing to consider is whether this patient is an appropriate candidate for a laparoscopic operation. In most circumstances a laparoscopic approach is preferred over open surgery due to shorter recovery times and fewer wound complications, but there are patients in whom the nature of laparoscopic surgery makes it a less favourable option. Examples include patients with significant previous abdominal operations, which may be associated with significant intra-abdominal adhesions, or those with respiratory complications in whom the pressure effects of a pneumoperitoneum may increase the risk of significant peri-operative complications.

Medical optimisation can range from simple interventions, such as withholding anticoagulants, administering corticosteroids, peri-operative glucose control, to longer term interventions prior to surgery, such as smoking cessation, nutritional optimisation, or excess weight loss, all of which may reduce the risk of medical complications and surgical site infections.

As with any surgical procedure, informed consent must be obtained ensuring that the patient has been provided with all the relevant information about the operation, the risks and benefits, and what to expect during their recovery. If there is a laterality, left or right, to the operation site, then this side should be checked and clearly marked with a skin marker at a site visible within the operative field.

Some laparoscopic procedures may benefit from bowel preparation and the benefit should be balanced against the possibility of causing electrolyte abnormalities. Thromboembolic prophylaxis should also be considered, considering both local guidelines and patient factors.

As the first part of the World Health Organisation (WHO) Checklist1, a team brief should be performed prior to the commencement of the operating list to ensure that there are no errors on the theatre list and that all members of the team know each other to minimise any barriers to effective communication or raising concerns. The checklist should then cover the patients’ details, operation details, and any concerns either from an anaesthetic or surgical perspective. Especially pertinent to laparoscopic work should be a discussion of possible complications and a ‘plan B, plan C’ approach. Here an understanding of the limitations of a laparoscopic approach should be shown and a discussion should be held regarding what instruments may be required in certain circumstances or open conversion, as well as whether these instruments should be available from the start of the case.

All other equipment should then be checked, ideally by the operating surgeon who has overall responsibility, including the light source, light cable, camera, and monitor to ensure that there are no delays once the patient is in the operating room. The camera system must also be ‘white balanced’ against a known white reference point- usually a white swab. This ensures that there are no unrealistic colour casts and that the colours seen on screen are an accurate representation, therefore minimising the risk of incorrectly identifying anatomical structures. The ‘white balance’ process must be undertaken for each case as the levels depend on each component of the system as well as the ambient light, not solely the camera lens.

Carbon dioxide is used as the insufflation gas for laparoscopic surgery due to the low risk of gas embolisation, low toxicity, rapid reabsorption, low cost, and that it inhibits combustion2. Gas flow to maintain the pneumoperitoneum is regulated automatically to maintain a pressure of usually between 12-15mmHg by providing a variable flow rate. Higher pressures are usually avoided if possible due to the risk of hypercarbia, acidosis, and adverse haemodynamic and pulmonary effects2. Before commencing each case the remaining volume of carbon dioxide should be checked to be sufficient and the availability of additional reserves confirmed, as well as expertise and tools for changing the tank.

Energised dissection technology, such as diathermy and ultrasonic devices, is used during laparoscopy to produce heat for cutting and coagulation purposes3. The diathermy unit should be checked and the settings confirmed to be appropriate prior to any procedure. Energising devices are covered in detail in chapter 8 of this book.

Many different patient positions are used for laparoscopic surgery, dependant on various factors and we will look at each in turn. The physiological effects of patient positioning are discussed in chapter 4 of this book.

As a rule of thumb, arm boards should be placed at no more than a 90o angle to the body, with the hands in a supinated position, to minimise the risk of brachial plexus injury. Patient flexibility should also be considered pre-operatively with any fixed flexion or other deformities of the shoulders, hips or other joints taken into account when planning patient positioning. In addition, security straps should be used where possible on any operating table, and should only be applied by personnel trained to do so. A patient falling from the table is entirely preventable and constitutes a ‘never event’, which sadly happens with surprising frequency.

The supine position describes the patient lying on their back on a flat table. If there are no indications for a different position, then a supine position is used as it is the most straightforward for patient transfer, the patient has little gravitational tendency to roll and so extensive securing is not usually needed, and all joints can be at a natural angle.

The Trendelenburg position describes a tilted operating table, such that the patient’s head is lower than their pelvis. This is used for pelvic surgery as gravity encourages the small bowel to drop into the upper abdomen, increasing pelvic exposure. Of note, a decrease in functional residual capacity (FRC) may be encountered with the Trendelenburg position due to the pressure effect of the abdominal contents on diaphragm movements.

The reverse Trendelenburg position describes a tilt in the table, such that the patient’s head is higher than the pelvis. This is often used in upper gastrointestinal surgery since abdominal contents are encouraged to drop into the lower abdomen and pelvis. This position is associated with increased venous stasis of the lower extremities so anti-embolism stockings and active calf compression devices should be considered. When Trendelenburg or reverse Trendelenburg positions are used, and a steep table incline is required, a non-sliding mattress with gel pads should be used. Shoulder supports are discouraged when using the Trendelenburg position, owing to the risk of brachial plexus injuries6.

A small amount of lateral tilt may be possible with no additional supports but with operations such as a laparoscopic splenectomy or nephrectomy, where a 45o tilt may be required, the patient can be supported with pads, a suction beanbag, or tape, depending on surgeon preference. For these operations in the region of the flank the table will often be ‘broken’, meaning that both the head and feet are dropped below the pelvis, to increase flank exposure.

The lithotomy position is commonly used for urological and gynaecological procedures and can also be used in laparoscopic and open pelvic colorectal operations. The legs are raised and abducted into stirrups to allow access to the perineal and perianal area. Important considerations include the increase in cardiac pre-load caused due to blood shift from the lower limbs to the thorax, and also the calf muscles should be supported evenly to minimise the risk of venous stasis. Given the position of the hips and legs there is a risk of neuropathy and care should be taken to ensure alignment of the shoulder, hip, leg, and foot. An extension of just 10-15% of a peripheral nerve can temporarily or permanently affect sensation and function so this should be at the forefront of your thoughts whilst positioning patients.

With the advent of robotic surgery particular care should be taken to ensure none of the robotic arms are leaning on the patient as these can easily go unnoticed and cause significant pressure...