Basic Setup and Equipment for Laparoscopic Surgery

Cynthia Arvizo

M. Jean Uy-Kroh

Operating Room Setup

The operating room (OR) should be set up to allow mobility of members of the surgical team throughout the room, quick access to instruments, patient safety, and comfortable surgeon positioning. The OR table should be electric to allow for easy positioning of the patient during the case. Overhead lighting should be placed over the surgical field. The light source, monitor, and insufflator may be located on one mobile boom or suspended from the ceiling. A monitor should be placed directly in front of each surgeon to facilitate ergonomic operating. If only one monitor is available, the monitor should be placed between the patient’s legs. Two separate sterile surgical fields are set for abdominal and vaginal instruments. Ideally, the scrub nurse is positioned between the patient’s legs, or as close to the surgical field as feasible.

The Image

The imaging chain consists of seven devices: light source, light cable, laparoscope, camera head, camera control unit, digital cable, and the monitor. Malfunction of any of these components will lead to suboptimal image quality and disruption of the surgical case.

Troubleshooting during a surgical case is inevitable but sound knowledge of the imaging chain saves time.

Light Source and Light Cable

Good image quality is dependent on good lighting. The most widely available light sources use xenon, metal halide, or LED bulbs. LED bulbs are touted as more eco-friendly because they emit less heat and last longer than xenon bulbs. Light is transmitted from the light source through a light-guide cable. Two types of cables are available—fiber optic and liquid cables. Most ORs are equipped with fiber optic cables.

Laparoscope

Several laparoscope designs are available on the market. The two most common types of laparoscopes are a hollow rod with a series of lens connected to a video camera (rod–lens system) or digital systems with a charge-coupled device (CCD) at the end of the laparoscope. The digital laparoscope unites the video and light cable. A variety of scope diameters are available. Scope diameters as small as 1 mm exist, but most operative gynecologic surgery is performed with 5- or 10-mm zero-degree laparoscopes. Flexible and angled laparoscopes can significantly aid visualization, particularly when dealing with a bulky and enlarged uterus.

Camera, Camera Control Unit, and Monitor

The laparoscope attaches to the camera head, which is connected to the camera control unit (CCU) via the digital cable. Cameras are provided as one-chip or three-chip devices. Three-chip cameras are most commonly used today as they provide higher resolution than one-chip devices. An image passes through the lens on the camera head. A prism within the camera head splits light into three primary colors (red, blue, and green) each with a corresponding CCD. The CCD converts the image to an electric signal that is transmitted to the CCU. The CCU can then send the image as either analog or digital video outputs or signals for viewing and recording.

Insufflator

Surgery cannot be safely performed without adequate insufflation. An insufflator delivers carbon dioxide into the peritoneal cavity and maintains a set pressure and an inflow rate. Intracavitary pressure of 12 to 15 mm Hg produces sufficient pneumoperitoneum for most laparoscopic cases. Various insufflating systems offer additional features such as warmed, humidified carbon dioxide, concomitant smoke evacuation, and filtration. Leaky gaskets, cracked, poorly connected, or kinked tubing, and empty gas tanks are common causes of poor or absent insufflation.

Instruments and Equipment

Proper, well-functioning instruments allow for a smooth surgical case. In gynecologic laparoscopy, two sets of instruments are routinely utilized—vaginal and laparoscopic.

Vaginal Instruments

In general, the vaginal instruments aid in placing the uterine manipulator. The most basic set should include an open-sided speculum or Auvard weighted speculum, Sims vaginal retractor, single-toothed tenaculum, ring forceps, uterine sound, Hulka tenaculum, and cervical dilators.

There are several uterine manipulators available. The preferred manipulator is a cost-effective device that adequately manipulates and serves the needs for the particular surgery. The most basic manipulator is a reusable Hulka tenaculum. Other manipulators may provide additional functions such as a chromopertubation port, custom-sized colpotomy cup, built-in vaginal occluder, ante/retroflexion capabilities, and an angled curvature and sliding mechanisms to facilitate cervical insertion. Certain devices may be preferred for their durability with heavy specimens or they may work as accessories to surgical positioning units.