POIE 4033 SURGICAL INSTRUMENTATION AND EQUIPMENT LAPAROSCOPIC SURGERY INSTRUMENT SITI ZAIRINI AHMAD ILKKM KUBANG KERIAN
LEARNING OUTCOMES At the end of this learning session, the student will be able to 1. Explain care of fiberoptic scopes 2. Demonstrate handling of fiberoptic scopes 3. Care and handling of laparoscopic instrument and equipment 4. Discuss nursing responsibilities in laparoscopic surgery in perioperative phase • Pre - operative • intra - operative • post – operative
INTRODUCTION ▪ Laparoscopy or sometimes known as Endoscopy are currently the evolution of some widely used surgical modalities. ▪ Is a Minimal Invasive Surgery (MIS) ▪ It is necessary to have a knowledge of basic procedures, limitations and indications
INTRODUCTION Any surgical procedure , whether open or laparoscopic , requires two basic step: 1. Access and exposure of the part to be operated 2. The actual operation itself Laparoscopic surgery in the method of access, the incisions used are small holes, and a special telescopes is used to illuminate and see the operative field
INTRODUCTION For exposure, is by insufflating the area with a gas to create space for operative manipulation which is known as pneumoperitoneum Base on these two requirements laparoscopic surgical equipment can be classified into two broad categories i. Equipment for access and exposure ii. Hands instruments for actual operative procedure
DIFFERENCES / SIMILARITIES Laparoscopy Endoscopy ▪ Inserted through small incisions ▪ Diagnostic and operative ▪ Allows a surgeon to view and perform surgery on organs and tissue ▪ Minimally Invasive Surgery (MIS) ▪ Working through the trocars / port ▪ Inserted into a natural body orifice ▪ Diagnostic and operative ▪ Allows a surgeon to view and perform surgery on organs and tissue ▪ Minimally Invasive Surgery (MIS) ▪ Flexible and rigid
DIFFERENCES / SIMILARITIES
DIFFERENCES / SIMILARITIES
Preoperative management ❑ Patient preparation - Physical care - Psychological care - Equipments for the procedure Intraoperative management Postoperative management NURSING MANAGEMENT
EQUIPMENTS FOR ACCESS AND EXPOSURE i. Telescopes / laparoscopes - Telescopes / laparoscopes of various sizes and various visualization capabilities - 5 mm / 10mm of diameter flat 0° lens / 30° lens - 0 ̊lens, flat lens does not alter the angle of vision when rotating. - Having both degrees is prudent / variability in surgeon preference - Angled lenses; provide additional optical versatility and allows ability to view with an angle up to 30° / 45° by rotating the scopes EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE ii. Laparoscopic camera - Very important instruments and should be of good quality - Focusing of laparoscopic camera need to be focus before inserting inside the abdominal cavity - At time of focusing it should be placed at a distance of approximately 5 cm away from the target - Prior to attachment, ensure that the camera lens are clean / smog free EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE iii. Monitor - High resolution “medical” monitors display colours more accurately EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE iv. Light source - For obtaining a virtually micro - surgical view - Quality of image obtained very much depend on the quantity of light available at each step of optical and electronic system - A typical light sources consist of ; • a lamp • a heat filter • condensing lens and • manual or automatic intensity control circuit EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE v. Lamp / Bulb - Most important part of the light source - Quality of light depends on the lamp used - Commonly used lamps are Xenon and halogen. - Recent types of lamp used ; a. Quart halogen bulbs b. Xenon bulbs c. Incandescent bulbs – seldom use d. Metal halide vapor arch lamp EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE a. Quart halogen bulbs • Provides a highly efficient, produces yellow light and more heat • Made tungsten electrodes the only metal with sufficiently high melting temperature and sufficient vapor pressure at elevated temperatures • Low voltage • Cheap • Withstand 300 – 400hrs EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE b. Xenon bulbs • Tungsten bulb • For ultimate image quality. • Produce white light and less heat • Withstand 1000 hours EQUIPMENT FOR THE PROCEDURE
Bulbs
EQUIPMENTS FOR ACCESS AND EXPOSURE vi. White Balancing - A proper white balancing before start of the operation is a very good practices for obtaining a natural color. - A white light is composed of equal proportion of Red, Blue, and Green Color. - At the time of white balancing the camera sets its digital coding for these primary colors to equal proportion assuming that the target is white - providing of white background EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE vii. Fibre Optic Cable - Flexible, fiber optic bundles - Connecting the light source to the telescope - Two types ; - Fiber optic - Liquid crystal gel cable - Should always be aware that the light cords have limited life span - When a significant decrease in light noted ie: the field is dark promptly identify the intactness and functions of the fiber optic EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE vii. Fibre Optic Cable - Maintenance - Handle them care fully - Avoid twisting the cable - After the operation has completed , the cable SHOULD be disconnected from the telescope/endoscope & then connected to the light source ( plug for holding cables) until it cools down. EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE vii. Fibre Optic Cable – Prevention of Injury - Turn off the light cord when it is not plugged into the laparoscope / telescope - The light at the tip of the cord produces heat that can ignite a fire and causes harm to patient and operating room staff. - High intensity of the light causes retinal damage. - Avoid light fall directly on the eye when it is lighted. EQUIPMENT FOR THE PROCEDURE
LIGHT SOURCE AND CABLE
EQUIPMENTS FOR ACCESS AND EXPOSURE Attachment of Light Source / DIC Interface - DIC Attachment Conventional has at right angle connection for light source and camera - The benefit is to : - Maintain upright orientation regardless of angle of viewing, using auto rotation system - provides single handed control of the entire endoscope camera system EQUIPMENT FOR THE PROCEDURE
Connection
EQUIPMENTS FOR ACCESS AND EXPOSURE viii. Insufflators - Required to create a working space Pneumoperitoneum with the aid of Veress Needle - CO2 pump should be a high flow insufflation pump with both low flow and high flow settings - Normal flow rate = 8 – 10 Lit / min - Intraabdominal pressure sett at 12 – 15 mmHg - Alarm sound or pressure release valves when pressure limit is exceeded EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE viii. Insufflators - Contemporary insufflators electronically monitor, maintain, and control the intra-abdominal pressure at the level by the surgeon. - Insufflator and tubing are capable of delivering a high gas flow insufflation of 24L/min – limited by trocar or needle which is attached EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE viii. Insufflators – Veress Needle - Used for creating initial pneumoperitoneum to ensure the trocar enter safely - To increase the abdominal wall from the abdominal viscera - Prior to usage, Veress needle, it should be checked for its potency and spring action. - Available in three length - 80 mm - 100 mm - 120 mm EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE ix. Cylinder of Gases - Full tank and functioning well - Types of gases used; - Carbon Dioxide (C02 ) - Nitrous Oxide (N20) - Helium (He) - Neon (Ne) - Argon (Ar) EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE Carbon Dioxide (CO2 ) Commonly used EQUIPMENT FOR THE PROCEDURE Disadvantage • Hypercarbia • Peritoneal / abdominal discomfort when used in LA Advantage • Safe – does not support combustion or explosion • Rapidly absorbed • Rapidly soluble – decrease risk of gas embolism
EQUIPMENTS FOR ACCESS AND EXPOSURE Nitrous Oxide (N2O) EQUIPMENT FOR THE PROCEDURE Disadvantage • Support combustion • Absorbed slower than C02 Advantage • Readily available • Better analgesia • Physiologically inert • Non explosive • Decreased intra-op entitle C02 and minute ventilation required to maintained homeostasis
EQUIPMENTS FOR ACCESS AND EXPOSURE x. Gas Filter - CO2 gas filter should be used between the pump and trocar - A filter is typically incorporated into the insufflation tubing - Some insufflators are now equipped with C02 , tubing warmer, thus the delivered C02 is warm ( body temperature) which will theoretically decrease operative time. EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE xi. Insufflator Tubing - Contains a filter that prevent bacterial and viral contamination from possible backflow of surgical smoke thus protecting both equipment and operating room - Equipped with hydrophobic membranes that provide complete backflow protection - Has a virus Filtration Efficiency ( VFE) of 99.999% for viruses to 0.02 microns EQUIPMENT FOR THE PROCEDURE
EQUIPMENTS FOR ACCESS AND EXPOSURE xi. Ancillary Equipment - Diathermy machine ( Complete & function) - Suction Machine ( Complete & function) - Drip stand with warm Normal Saline Pump ( Pressure Bag) - Brushes to clean the equipment - Telescope anti - fog solution xii. Positioning of patient EQUIPMENT FOR THE PROCEDURE
HANDS INSTRUMENT FOR ACTUAL OPERATIVE PROCEDURE • The first requirement is to decide “what the equipment is going to be used for” ? • Typically, equipment is used for commonly laparoscopic surgery; • Laparoscopic cholecystectomy • Laparoscopic appendicectomy • Laparoscopic gynaecology • Diagnostic laparoscopy EQUIPMENT FOR THE PROCEDURE
HANDS INSTRUMENT FOR ACTUAL OPERATIVE PROCEDURE • Trocars and cannulas • 2 x 10 / 11 mm • 2 x 5 / 5.5 mm • 1 x 11 / 5.5 mm reducer • 11 – 7mm reducer • Veress Needle • 2 x non traumatic Graspers • 1 x toothed Grasper • 1 x curved dissector EQUIPMENT FOR THE PROCEDURE
TROCAR AND CANNULAS
HANDS INSTRUMENT FOR ACTUAL OPERATIVE PROCEDURE • 1 pair Scissors • Tissue • Suture • 1 pair of hook scissors ( optional) • 1 x cautery spatula • 1 x gallstone retrieving forceps • 1 x Needle holder • Needles and retractors ( Fan retractor) • Knot pusher – optional EQUIPMENT FOR THE PROCEDURE
Actively and skillful anticipation throughout the procedure • Assist. • Anticipate. • Alert. • Action INTRAOPERATIVE MANAGEMENT
Actively and skillful anticipation throughout the procedure • Cleaning of instrument • Cleaning of lens • Topping of normal saline • Solving crop up trouble shooting • Observing patients condition INTRAOPERATIVE MANAGEMENT
• Patient care • Instrument care POSTOPERATIVE MANAGEMENT
COMPLICATION Pneumoperitoneal ▪ C02 embolism ▪ Hypercarbia ▪ Respiratory acidosis ▪ Subcutaneous emphysema ▪ Renal failure ▪ Venous thrombosis ▪ Pneumothorax Inserted related ▪ Major vascular injury (0.25%) ▪ GI injury ( 0.14%) ▪ Bladder injury ▪ CO2 embolism ▪ Abdominal wall hemorrhages Post insertional • GI perforations (acute or delayed) • Laceration and bleeding from solid organs • Abdominal wall hernia
CONTRAINDICATION Absolute • Uncorrectable coagulopathy • Intestinal Obstruction with massive abdominal distention • Hemorrhagic shock • Severe cardiac dysfunction (Class IV) • Concomitant disease requiring laparotomy Relative • Inability to tolerate GA • Abdominal sepsis / peritonitis • Multiple previous abdominal operations • Severe COPD • Pregnancy • Diaphragmatic hernia • Morbid obesity
⦿ Cleaning ⦿ Sterilization ⦿ Storage CARE OF FIBRE OPTIC SCOPE
Before Procedures • Prepare clean and dry reusable soaking container with tightly fitting lid • Prepare appropriate sterile container/basin for rinsing of sterile instruments THE APPROPRIATE METHOD HANDLING OF FIBEROPTIC SCOPES
Preparation of Disinfectants 1. Wear PPE 2. Check expiry date of solution 3. Activate solution according to manufacturer recommendation 4. Label date of activation and expiry 5. Close lid of container THE APPROPRIATE METHOD HANDLING OF FIBEROPTIC SCOPES
1. Check instruments, dry and clean 2. Open all rachet of biopsy forceps 3. Arrange instruments accordingly, place light cable then follow by the telescope last 4. Ensure all surface areas of items including lumens are completely immersed 5. Close lid of container 6. Note time of immersion 7. Soak according to the recommended time given by the manufacturer instruction PREPARATION AND IMMERSION OF FIBEROPTIC SCOPE/RIGID ENDOSCOPE AND ITS ACCESSORIES
After Procedures • Personnel perform hand scrub, gowned and gloved • Remove telescope and accessories from soaking container (High Level Disinfection) • Rinse telescope and accessories thoroughly with sterile water • Dry telescope and accessories, then assemble the parts layout the instruments on a sterile trolley ready to be use • Avoid contamination during preparation THE APPROPRIATE METHOD HANDLING OF FIBEROPTIC SCOPES
After Procedures, Decontamination is Carried Out • Wipe the scope with a disinfectant wipe from the proximal to the distal end to remove all blood, mucous, faeces and debris along the external endoscope tube and accessories. • Clean water (mixed with detergent) should be suctioned through the suction channel and flushed through the water channel until clear • Disconnect the endoscope from light source and remove camera head. THE APPROPRIATE METHOD HANDLING OF FIBEROPTIC SCOPES
1. Detached all removable channel valves and caps should be detached before leakage testing. 2. Attached the endoscope to the leak tester and turned it on before immersion and during the enzymatic cleaning process. If bubbling occur during leakage test that means scope leaking, immediately sent for repair 3. During leakage test, observe for the presence of bubbles. 4. Sent fiberoptic scope for repair immediately PERFORM LEAKAGE TEST