2. Requirements

A. Surgical Team

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*.

B. Operating Room Setup

The operating room setup is relatively simple and efficient.

C. Apparatus

Indispensable for a successful C*I*S*H* is the following equipment:
  1. CO2electronic high flow insufflator with gas pre-warmer
  2. 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)
  3. Light source with camera and audiovisual system, printer
  4. Irrigation and suction system
  5. Warm solutions for irrigation

D. Instrumentation

"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:
  • Veress insufflationa needle
  • Injection needle for probing/sounding test
  • Conical trocars, 5 mm (4)
  • Conical trocars, 10 mm (3)
  • Conical trocar, 15 mm (1)
  • Conical trocar, 20 mm (1)
  • Biopsy forceps, 5 mm (3)
  • Hook scissors, 5 mm (1)
  • Peritoneal scissors, 5mm (1)
  • Dilatation set, from 5 to 10 mm with reducer (1)
  • Dilatation set, from 5 to 15 mm with reducer (1)
  • Dilatation set, from 5 to 20 mm with reducer (1)
  • Sponge holder, 10 mm (1)
  • Crocodile forceps (1) and point coagulator (1)
  • Applicators for suture and ligature material (4)
  • Needle holder, 3 mm (1)
  • Needle holders, 5 mm (2)
  • Pitressin application set (1)
  • Large emergency needle for hemostatic suture ligation of the abdominal wall
  • S.E.M.M.-sets: 10,15,20 mm diameter (Serrated Edge MacroMorcellator), a device to grasp and morcellate fingerlike portions of tissue out of the closed abdominal cavity.
  • C*U*R*T*-sets: 15,20,24 mm diameter (Calibrated Uterine Resection Tool), a device to core out a cervical tissue cylinder.
  • WISAP® Moto-Drive (1). Can be attached to both the S.E.M.M. and the C*U*R*T*. More comfortable for the surgeon, safer for the patient, and shortens the time of the operation.
  • Vaginal speculum and Hegar dilators
  • Single-tooth tenacula (2)
  • Ring forceps (1)
  • Syringes: 10 and 35 cc
  • Injection needle, 22 gauge
  • Sugicel (Johnson and Johnson Medical Inc., Arlington,TX)
  • Skin clips and Band-Aids
  • Pitressin solution (5 units in 100 ml NaCl)
  • ROEDER loops: 0 PDS and 0 catgut, plain and chromic
  • Ligatures and sutures for extracorporeal knottying: 0 Vicryl
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    P.F. Vietz, M.D.
    Westminster, Md. 21157 (USA)

    September 1997