Operative Suite Prerequisites for Successful Outcomes



Operative Suite Prerequisites for Successful Outcomes


Guy I. Benrubi



INTRODUCTION

In the United States, if not worldwide, a cesarean delivery is the most commonly performed abdominal operation and except for cataract surgery, the most commonly performed procedure in medicine.1 The estimates are that in 2018 there will be approximately 1,300,000 cesarean deliveries in the United States and 30 million worldwide. To put these numbers in perspective, the current estimate is that there is one cesarean section performed every second somewhere in the world.2 There are two aspects of this procedure, which lead to a somewhat cavalier attitude toward the potential complications which may arise. As in the concept that “familiarity often breeds contempt,”such a frequently performed operation is all too often taken for granted as being routine. The other influencing issue is that the procedure in its basic form is not complicated. In some ways, it is not an operation at all, but essentially an open and close process. In the standard case, it is a matter of entering several layers—skin, subcutaneous fat, fascia, peritoneum, uterus—removing an infant without requiring any surgical maneuvers, and then closing all the layers in proper sequence. It does not require any operative manipulations, such as removing a gall bladder or an appendix or a uterus, once the layers are open.

In the operative suite, the instrumentation required is minimal, and all too frequently, the C-section tray is significantly sparser than a hysterectomy tray in the same hospital. Many, if not most, hospitals have a hysterectomy tray readily available in Labor and Delivery, but this does not hold true for all obstetric operative suites around the country.

The most important prerequisite for the safe and efficacious performance of any surgical procedure or intervention is proper preparation. Obvious components include an understanding of the indications for the procedure, the goals of therapy, the potential pitfalls and complications which may be encountered during the procedure, and the immediate postprocedure and long-term consequences.3 Inherent in preparation is having the proper tools to accomplish the tasks, which also implies the knowledge and training with the use of such tools. Expanding on the old adage, “if your only tool is a hammer, everything appears like a nail” we can say, “if the only tool with which you are comfortable using is a hammer, then everything to you will look like a nail.”



OPERATING ROOM FACILITY

The single most important approach in adequately preparing the operating suite for the difficult cesarean section is to first and foremost realize that the team is not dealing with the standard open-and-close cesarean section, but a pelvic and an abdominal operation which could potentially be as complex as a pelvic exenteration or an abdominal/perineal resection. Whatever mental and resource preparations are required for those complex surgical operations, the same preparation is required for the difficult cesarean delivery.

The operating room space should be adequate space to accommodate the multimember team. If an accreta is known beforehand, the procedure should probably be scheduled in a main OR suite. The operating tables should be adequate to accommodate possibly multiple “scrubbed” surgeons and technicians, and patients with a high body mass index (BMI). Lighting is critical, and personal head lamps may be necessary. Communication systems with potential intraoperative consultants should be in working order. The anesthesia team should be comfortable with management of rapid fluid changes, possible requirement of massive transfusion therapy, the management of central monitoring, and prolonged anesthesia times, as a minimum.


INSTRUMENTS AND EQUIPMENT

Below is a list of equipment and instruments required in a cesarean tray. This standard cesarean tray is more than adequate to enable the obstetrician to perform the procedure safely and expeditiously. In most cesarean delivery procedures, most of these instruments would be superfluous. However, in a difficult case, this list would be inadequate and needs expansion to include other instruments and equipment as described below (Figure 13-1).






FIGURE 13-1 A standard C-section tray may not have sufficient instruments for complicated cesarean delivery.



To the above list, the following must be added with description of when and why they are needed. The first components would be essentially the same as those found in a standard hysterectomy tray (Figure 13-2).








FIGURE 13-2 Instrument tray typically used in oncologic gynecologic surgery. These instruments are very frequently necessary in difficult cesarean sections. Radical hysterectomy tray has additional instruments which may be necessary for complicated cesarean deliveries.


Types of Retractors

For exposure there are two major types of retractors. There are fixed retractors and nonfixed retractors.


Fixed Retractors

The fixed retractors are the Bookwalter and the Omni (Figure 13-3). Both have a fixed arm, which attaches to the operating table. This allows for excellent exposure without operator or assistant fatigue. The Bookwalter has a ring to which various types of retractor blades can be attached. The Omni does not have a fixed ring and thus may be of additional help in obese patients, as the extent of lateral retraction is not limited by the width of the ring as with the Bookwalter.


Nonfixed Retractors

The nonfixed retractors include the Balfour and the O’Connor-O’Sullivan (Figure 13-4). They are easy to use and easily deployed, and most gynecologists are familiar with these as they are frequently used for open hysterectomies in nonobese patients. As the fixed retractors require some facility with their deployment, but well worth the extra time at the beginning of the case, surgeons attempting the difficult cesarean delivery, such as with an accreta, or an obese patient should be comfortable with the use of fixed retractors.


Additional Instruments Needed From the Gynecology/Oncology Tray

In addition to the hysterectomy tray and the retractors, the surgeon performing a difficult cesarean, such as with known accreta, obese patient, or in a case of a fourth-repeated (four-peat) or higher procedure, should have the following instruments which are normally found in a gynecology/oncology tray. The obstetrician should be comfortable using these instruments or have ready access to a surgeon who is. In
obese patients, as in deep pelvic procedures such as with percreta attachments to deep structures, long instruments are essential.






FIGURE 13-3 Operative exposure. The Omni-Tract or similar self-retaining retractor system permits the wide exposure of the operative field necessary. Omni retractor showing ability to get maximum exposure. (With permission from Darling RC, Ozaki CK. Master Techniques in Surgery; Vascular Surgery: Arterial Procedures. © Lippincott Williams & Wilkins/Wolters Kluwer; 2015 [Figure 20-3].)

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Apr 13, 2020 | Posted by in GYNECOLOGY | Comments Off on Operative Suite Prerequisites for Successful Outcomes

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