The operating team at laparotomy usually consists of the surgeon, his assistant, the anesthesiologist, the scrub nurse, and the circulating nurse.
Many laparoscopic procedures can be performed without skilled assistance. This does not apply to C*I*S*H. The lack of skilled surgical assistance significantly increases the operating time. We have been taught that "the endoscopic abdominal surgeon will strive to perform all endoscopic procedures in accordance with the rules and techniques established for laparotomy".
C*I*S*H* requires two equally skilled and trained surgeons working as one person. The operating steps follow a protocol, enabling the trained scrub nurse to place and change instruments through the trocar sleeves without the surgeon having to ask for them. The anesthesiologist helps with the positioning of the patient and the illumination of the operating field as required. The circulating nurse attends to the apparatus and ancillary equipment as usual.
A well trained, well rehearsed team is indispensable for a safe, smooth, efficient C*I*S*H*.
The operating room setup is relatively simple and efficient.
- The patient is placed in modified lithotomy position with her thighs as flat as possible. With C*I*S*H* there is no need to change the patient's position intraoperatively.
- The left arm is tucked in, the right arm is positioned on an arm board with an IV line and other attachments.
- A metal bridge crosses the patient's chest for the surgeon and the assistant to lean on.
- The surgeon stands to the left of the patient with the apparatus cart on the side. The assistant surgeon stands opposite, cephalad to the arm board. The scrub nurse stands next to the assistant surgeon with a small instrument table in front and the ancillary equipment beside him or her.
- A Mayo stand with continuously used instruments is placed between the patients's thighs, as is the television monitor and other video equipment.
- A small tray with instruments for the vaginal part of the C*I*S*H* is ready, placed away from the table.
Indispensable for a successful C*I*S*H* is the following equipment:
- CO2electronic high flow insufflator with gas pre-warmer
- Endocoagulator for hemostasis(monopolar or bipolar current, lasers, harmonic scalpel, clips, or staples may be used at the discretion of the surgeon but does not contribute to enhanced patient safety or cost containment)
- Light source with camera and audiovisual system, printer
- Irrigation and suction system
- Warm solutions for irrigation
"Easy access to multiple instruments will facilitate and accelerate the operative procedure".
About 100 instruments must be at the disposal of the gynecologic surgeon for a laparotomy. Similarly, the same complement of instruments must be available for endoscopic surgery. Reusable, stainless steel instruments are preferable, especially in an effort to contain cost. All trocars have a conical tip with beveled sleeves. The instrumentation for C*I*S*H* includes the following:
P.F. Vietz, M.D.
Westminster, Md. 21157 (USA)