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Fundamentals of Operating Room Setup and Surgical Instrumentation

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Abstract

The focus of this chapter will be to introduce the general principles of how operating rooms are designed in order to provide surgical interventions that improve patients’ lives. Although the basic operating room design was first heralded in the nineteenth century, today’s advances have introduced complex surgical equipment that necessitates integration in a fixed space. Moreover, in order to be able to effectively and efficiently carry out a surgical procedure, a highly reliable interdisciplinary and integrated team is necessary. This chapter will provide the reader with a basic overview of the operating room, the key players that work in this environment, and the commonly utilized equipment and instruments.

Keywords

  • Introduction to the operating room
  • Operating room fundamentals
  • Surgical instruments

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Fig. 2.1
Fig. 2.2

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Correspondence to Karen A. Chojnacki .

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Appendices

OR Instrument Appendix:OR Instruments for Open Surgery

2.1.1 Scalpels (Fig. 2.3)

The scalpel is one of the synonymous instruments that is associated with surgery. Perhaps the most important decision to make prior to using the scalpel is the decision for where the incision will be placed. This should be a deliberate decision with the goal of the operation in mind. Essentially, the location of the incision should allow you to perform the operation safely and should provide you with adequate exposure. In general, reusable scalpels include a handle and blade. First, the blade. It comes in different sizes, with the most common sizes used in surgery being the 10, 11, 15, and rarely the 20 blade. The belly of the blade should be in contact with the surface that is being cut. As a general rule, when making an incision, one always cuts away from oneself or from the non-dominant to the dominant side. The handle which safely holds the blade also comes in different sizes. The size of the handle used is dependent on the location where the incision will be made. Of note, some surgeons sometimes use the scalpel for sharp dissection which necessitates the use of a longer handle (as in abdominal cases).

Fig. 2.3
figure 3

(a) Left to right, different varieties of knife handles: A, Bard-Parker knife handle #3; B, Bard-Parker knife handle #4; C, Bard-Parker knife handle #7. (b) Left to right, different varieties of blade numbers: A, number 10 blade; B, number 11 blade; C, number 15 blade; D, number 20 blade

2.1.2 Scissors (Figs. 2.4 and 2.5)

Scissors come in multiple varieties, and depending on the type, they are used in various settings. They have a bias for right-handed individuals. When using a scissor, place only about a half of the distal phalanx of your thumb and ring finger, and attempt to use your dominant hand if possible. Scissors used for dissection include the Metzenbaum scissor, which can be used for sharp dissection as in lysis of adhesions. Potts scissors are generally used in vascular surgery to extend the arteriotomy or venotomy. In contract, scissors, such as the straight and curved Mayo, are used for cutting suture or bowel during gastrointestinal anastomoses. One should avoid the use of finer instruments, such as the Metzenbaum scissor, to cut suture as it will dull the instrument.

Fig. 2.4
figure 4

Left to right, (a) Mayo scissor , straight; (b) Mayo scissor, curved; (c) Metzenbaum dissecting scissor, straight; (d) Metzenbaum dissecting scissor, curved; (e) Potts scissor; (f) tenotomy scissor; (g) Iris scissor

Fig. 2.5
figure 5

Left to right, (a) straight versus curved Mayo scissor; (b) straight versus curved Metzenbaum scissor; (c) Potts scissor , open

2.1.3 Forceps (Figs. 2.6 and 2.7)

The general principle for how forceps work is by grasping tissue in between two opposing surfaces. Deciding on which forceps to use depends on the task at hand. In general, forceps come in two varieties, smooth and toothed. Forceps that are smooth cause crushing tissue trauma, and in instances as such, the use of toothed forceps is preferable. An example is when handling skin, toothed Adson forceps are preferred so as to minimize tissue trauma.

Fig. 2.6
figure 6

Left to right, commonly used tissue forceps or pickups: (a) Bonney tissue forceps; (b) Russian tissue forceps; (c) DeBakey forceps; (d) Gerald tissue forceps; (e) Adson tissue forceps with teeth; (f) Adson tissue forceps without teeth; (g) Adson-Brown tissue forceps

Fig. 2.7
figure 7

Left to right, (a) Bonney tissue forceps; (b) Russian tissue forceps; (c) DeBakey tissue forceps; (d) Adson tissue forceps

2.1.4 Needle Holders (Fig. 2.8)

The type, size, and weight of the needle holder are determined by the needle and suture. For example, larger and heavier needle holders are required for large needles, such as the ones used for fascial closure. Conversely, small needles that are used for vascular anastomoses require finer and lighter needle drivers, such as the Castroviejo. When loading the needle on to the needle holder, it is important to remember that a circular motion requires pronation and supination of the surgeon’s wrist. This is necessary in order to prevent tissue trauma at the site of the needle point’s entry.

Fig. 2.8
figure 8

Left to right, (a and b) Mayo-Hegar needle driver, two different sizes; (c) Ryder needle driver; (d) Castroviejo needle driver

2.1.5 Retractors (Figs. 2.9 and 2.10)

Much like other instruments, retractors come in different varieties, and their use is determined by the task at hand. They can be handheld or self-retaining retractors. An example of commonly utilized handheld retractors that are utilized in general surgery include the Army-Navy and Richardson retractors. Similarly, self-retaining retractors, such as the Bookwalter and Balfour, are commonly utilized during large abdominal procedures. There are also smaller self-retaining retractors, such as the Weitlaner, which are used during open procedures, such as an inguinal hernia repair.

Fig. 2.9
figure 9

Left to right, different varieties of handheld retractors. (a) Harrington or Sweetheart retractor , (b) Deaver, (c) Kelly retractor, (d) Eastman, (e) Richardson retractor, (f) Richardson-Eastman retractor, (g) S-retractor, (h) Cushing vein retractor, (i) Senn retractor, (j) Rake retractor, (k) Army-Navy

Fig. 2.10
figure 10

Left to right, (a and b) Balfour self-retraining retractor, (c) Weitlaner self-retaining retractor, (d) Gelpi

2.1.6 Suction (Fig. 2.11)

Visualization of the operative field is important, which is accomplished through the use of suction devices. Sizes of the suction tip depend on the area and type of tissue being worked on. The commonly used Yankauer aspirates through the tip end and is either disposable plastic or reusable metal. A Poole sucker has multiple ports all along the side and is used to quickly aspirate a large volume of fluid, such as after irrigating the abdominal cavity with liters of saline. Smaller tips include the Andrews or Frazier, usually used in pediatric or vascular cases. Suction on Frazier tips are controlled by a small hole on the handle.

Fig. 2.11
figure 11

Left to right, (a) Yankauer suction; (b) Andrews suction; (c) Poole suction; (d) Frazier suction; (e) Poole suction broken down into its components

2.1.7 Clamps (Figs. 2.12, 2.13, 2.14, 2.15, 2.16, and 2.17)

Clamps are used to hold objects in place and/or to maintain control of tissue, such as cutting off blood flow to an area of interest. They can be either straight or curved, perforating or non-perforating, fine-tipped for more precise clamping or broad for thicker or more generalized areas, and with or without teeth depending on the power of the grip desired. Tissue type and desired outcome are some of the factors that determine clamp choice. Babcocks are used to grasp bowel firmly while causing the least amount of damage, whereas a Kocher has multiple serrations that allow for strong grasping of fascia.

Fig. 2.12
figure 12

Left to right, (a) curved Crile; (b) straight Crile; (c) mosquito

Fig. 2.13
figure 13

(a and c) Perforating towel clip; (b and d) non-perforating towel clip

Fig. 2.14
figure 14

(a and c) Straight Kelly clamp; (b and d) curved Kelly clamp

Fig. 2.15
figure 15

(a) Kocher clamp; (b and c) Kocher clamp details

Fig. 2.16
figure 16

(a) Right angle, two different sizes; (b) right angle details

Fig. 2.17
figure 17

Left to right, (a and c) Allis clamp; (b and d) Babcock clamp

Basics of Instrumentation and Equipment for Laparoscopic Surgery

Laparoscopic procedures require surgical skills that include dexterity, efficiency, and the ability to operate in a three-dimensional environment that is usually visualized in two dimensions. In addition to patient and surgeon positioning, one must be cognizant of equipment positioning in order to facilitate the expeditious progression of the operation. The equipment that is required to carry out a laparoscopic case, such as the components of the imaging system or insufflator, is oftentimes located on a laparoscopic tower (Fig. 2.18). For the remainder of this section, basic laparoscopic equipment and the fundamentals of proper use will be discussed. A more detailed overview of instruments used in laparoscopic surgery can be found in the appendix of this book.

Fig. 2.18
figure 18

Laparoscopic tower that includes the necessary hardware during a laparoscopic case. (a) Broad overview of components located on the tower. (b) Insufflator measures the pressure and the flow of gas that is provided during the case. The surgeon can vary the insufflation pressure by adjusting the preset pressure. (c) Transmitter that allows for signal to be sent to other monitors in the room. (d) Camera connection. (e) Light source connection

2.1.1 Imaging System

The imaging system consists of the laparoscope, camera, video monitor(s), and light source. In general, the sterile components of this system include the laparoscope, camera, and fiber-optic cord that connects the laparoscope to the light source.

Most modern laparoscopes utilize a rod-lens system that was initially discovered by Harold H. Hopkins in the late 1950s. This was coupled with fiber-optic transmission technology by Karl Storz in the 1960s. Since then, the rod-lens system has revolutionized laparoscopy [5, 6]. Significant advances have been made that allow for a number of laparoscope options, and therefore, not surprisingly, laparoscope selection is largely surgeon dependent. The ultimate goal when selecting a laparoscope is to maintain adequate visualization of the operative field. Laparoscopes can vary in a number of ways, as described below.

  • Size—The diameter (or size) of the laparoscope can vary from 0.88 mm to 12 mm. The larger the diameter of the laparoscope, the better the visualization. The most commonly utilized laparoscopes are 5 mm and 10 mm.

  • Angle—The angle of laparoscope can vary from 0 to 70°. A laparoscope that is 0° allows for a panoramic view, i.e., provides a view of the field that is directly ahead. In contrast, an angled laparoscope allows one to view a structure from different viewpoints without the necessity to change between ports. The most commonly utilized angles are 30° and 45°. An important tip to remember when using an angled laparoscope is to point the angle away and not toward the area of interest [7].

Significant advances in camera designs have occurred as laparoscopy has become more popular. Perhaps the most notable advance in enhanced imaging in laparoscopy has been the introduction of the charged-coupled device (CCD) chip camera and digital video imaging (i.e., high-definition imaging). In the future, improvements in three-dimensional imaging will address depth perception, which is lost with two-dimensional imaging. There are a number of features and controls that one must be familiar when it comes to the laparoscopic camera. Controls present on the camera are manufacturer specific but, in general, include:

  • White balance allows for the color that is produced by the camera to be adjusted to the color of the light source. It is important to white balance the camera against a white object, such as a lap sponge, prior to use.

  • Focus allows for a clear image to be viewed. Prior to inserting the camera into the abdominal cavity, the camera is held 5 cm away from a target object, and the camera is focused to the clearest image.

  • Illumination adjustments allow for the intensity of the light to be increased or decreased.

  • Optical zoom allows for closer viewing of the operative field without loss of resolution of the image.

Monitors come in a variety of sizes and resolutions. Using a high-resolution monitor with a camera with similar capabilities optimizes the quality of the image.

The light source can vary by type and voltage. The current industry standard is a Xenon lamp with an output of 300 W. The laparoscope is connected to the light source through a fiber-optic cable. Any breakage in the fiber-optic cable results in decreased light transfer from the light source to the laparoscope, which results in decreased light being transferred to the operative field. Always be mindful of the fiber-optic cable once the illumination is turned on, regardless of whether or not it is connected to the laparoscope. It generates a significant amount of heat that has been known to start fires or burn holes through the sterile drapes and can lead to patient injury.

Other necessary equipment for laparoscopic surgery includes:

  • Insufflator—The insufflator is necessary to obtain pneumoperitoneum that allows for a successful laparoscopic case to be carried out. Several options are available for the type of gas used to insufflate, the most common being carbon dioxide. Carbon dioxide is preferentially used since it is nonflammable, colorless, and odorless. And, in general, it is safely absorbed and excreted. Insufflator tubing connects the insufflator to the instrument (i.e., trocar or Veress needle) that will facilitate the delivery of the gas into the abdominal cavity.

  • Trocars or ports are used to pierce the abdominal wall and serve as a conduit that allows for the entry of laparoscopic instruments into the abdominal cavity. They can vary in size and be either cutting or blunt. Trocars can have additional features, such as a side port, which allows for pneumoperitoneum to be maintained if the insufflator tubing is changed between ports [7].

2.1.2 Instrumentation for Obtaining Access to the Abdominal Cavity

When initially planning the location for initial access for an abdominal laparoscopic procedure , first, survey the abdomen for scars from prior surgery or for any masses. Second, keep the planned operation and the operative field in mind. The most common site for initial entry and trocar placement is the umbilicus. The amount of soft tissue between the skin and the fascia is less compared to other areas in the abdomen in this location. It is also possible to hide a scar in an existing skin crease for improved cosmesis. Another common entry location is in the left upper quadrant in a location known as Palmer’s point, which is located 3 cm below the left subcostal border in the midclavicular line [8]. Instruments commonly used to obtain access for laparoscopic surgery will be briefly described next. For more specific details, refer to Chap. 14Fundamentals of Laparoscopic Surgery.

First described by Dr. Harrith M. Hasson in the 1970s, the open technique for laparoscopic access is preferred by some as it is believed to minimize complications such as gas embolism, major vessel or visceral injury, or insufflation of the preperitoneal space [9]. The cannula itself is usually fitted with a cone-shaped sleeve and an outer secondary sleeve that allows for stay sutures to be placed to secure the port. It is primed with a blunt obturator to prevent injury to underlying structures. The Hasson cannula is inserted into the abdomen with the blunt obturator in place, and stay sutures secure the cannula to the fascia on either side to seal the opening in the abdominal wall and to prevent gas leak during the procedure [10].

The Veress is used to obtain access to the abdominal cavity during laparoscopic surgery with the closed technique. The Veress needle was first discovered in the 1930s by Janos Veres, and it was Raoul Palmer who introduced the use of the Veress needle in laparoscopic surgery to establish pneumoperitoneum in the 1940s [8, 11]. It is a spring-loaded needle that is 12–15 cm long with an external diameter of 2 mm. It consists of a two-cannula system. The outer cannula has a beveled needle that is sharp to cut through the abdominal wall. The inner cannula is nested within the outer cannula and has a spring-loaded stylet with a dull tip. When the Veress needle is passed through tissue, direct pressure on the tip of the needle pushes the dull stylet into the outer cannula. Once the needle tip enters a space, such as the peritoneal cavity, the dull inner stylet springs forward and protects any underlying tissue.

Optical trocars are a relatively new technique that utilizes the conventional trocar and cannula push-through design. These units are designed in such a way that the trocar is hollow and allows for a 0° laparoscope to be inserted and locked along with the trocar. It can then be used to visualize entry into the abdominal cavity as the trocar pierces sequential abdominal wall layers. This system is generally used after the abdominal cavity has been insufflated [10, 12].

2.1.3 Tips for “Driving” the Camera During Laparoscopic Surgery

All of the components of the imaging system are put together to allow the visualization of an image. Once access to the abdominal cavity is obtained, proper use of the imaging equipment to provide adequate visualization during the operation is of paramount importance. Here are a few pearls for proper handling of the camera and laparoscope and for effective “driving” of the camera:

  • Practice holding the camera. In general, the non-dominant hand should cradle the camera and laparoscope. The buttons of the camera should always point up.

  • The light cord is attached to the laparoscope, and in the neutral position, it points up. This is especially important to remember when using an angled laparoscope, since the direction of the light cord corresponds to the direction of the viewing angle.

  • When “driving” the camera, a good rule to keep in mind is the rule of opposites. To view an image to the right, the camera is moved to the left. Or to view an image that is up, the camera is pointed down. Moreover, the camera should be moved toward the object of interest to provide a closer view. Movement of the camera out (or into the trocar) will result in the ability to get a panoramic view of the field.

  • When using an angled laparoscope, movement of the light handle results in a change of the angle. Therefore, when the light handle is in the neutral position, i.e., pointing up, the viewing angle is down. When the light handle points up, the viewing angle points down.

  • The lens can fog once the laparoscope is inserted into the abdominal cavity. This occurs due to the temperature difference between the outside environment and the intra-abdominal cavity. This can be avoided by warming the lens tip in warm water or with the use of antifog solutions [12].

2.1.4 Basics of Instrumentation and Equipment for Endoscopy

Endoscopy in general surgery has many applications and can be used in abdominal or thoracic procedures. This section will provide a brief overview of the common components of endoscopes used for upper and lower endoscopy.

2.1.5 The Endoscope

The endoscope is comprised of three main parts:

The handpiece is used to control the direction the tip of the insertion tube is facing, which aids in visualization as well as maneuvering the scope as it traverses a lumen. A large and small wheel is used to either maneuver the tip up-down or left-right, respectively. Turning of the wheel leads to tip angulation in the opposite direction on the monitor. For example, turning the large wheel up causes the endoscopic tip to be directed downward and vice versa. The wheels can be locked in a desired position to aid in diagnostic or therapeutic maneuvers, such as obtaining a biopsy. Buttons on the handpiece control different capabilities. The blue button has two features: covering the port will insufflate air, while pushing the button infuses water. Pushing the red button provides suction. A biopsy port allows for the passage of biopsy forceps or other instruments through the insertion shaft. Camera buttons allow the operator to obtain pictures or videos.

The insertion tube is a flexible cord that is manually manipulated by the operator by pushing, pulling, and torqueing. The deflectable tip at the distal end of the cord has the capability of flexing side to side and up and down via controls on the handpiece. The tip also contains the port sites for multiple applications, including a water nozzle for irrigation, an air nozzle for insufflation, a suction channel, a light source, and objective lens.

The umbilical cord is a flexible tube that contains all of the channels (air/water, suction, and light source) that connect to the tower that houses the video processor and displays screen. The proximal end of this cord is directly inserted to the tower. A video processor cord connects the umbilical cord to the image processor. A water bottle and suction tubing are connected to the umbilical cord to allow for irrigation and aspiration.

2.1.6 The Endoscopy Tower

The endoscopy tower consists of an image processor and display screen, a light source and air insufflator, water irrigation, and energy source. Once all equipment is positioned and connected appropriately, check that the insufflation, irrigation, and suction are working properly before beginning the procedure [13].

OR Instruments Used in Laparoscopic Surgery

2.1.1 Laparoscopes (Fig. 2.19)

Laparoscopes come in many varieties, as discussed in the Fundamentals of operating room setup and surgical instrumentation chapter. Illustrated here are 10 mm laparoscopes, both at various angles.

Fig. 2.19
figure 19

Top to bottom, (a and c) 0° laparoscope, (b and d) 30° laparoscope

2.1.2 Laparoscopic Graspers (Figs. 2.20 and 2.21)

Most laparoscopic instruments have a 360° rotating knob to turn the tip of the instrument in order to maintain the wrist in the most ergonomically neutral position. Electrocautery sources can be plugged into the metal port on the handle, which are usually controlled via a foot pedal. The atraumatic bowel grasper is used to handle more delicate tissue, such as when running the bowel. One should use the majority of the jaw to grasp the anti-mesenteric side to minimize damage. Using just the tip of the grasper can cause more damage secondary to the increased pressure exerted by the smaller surface area. A hand-to-hand or hand-over-hand technique can be utilized to accomplish this task. Clinch graspers are usually toothed and ratcheted, with a locking mechanism. This could be used to grasp and retract thicker or heavier tissue, such as omentum. The Maryland dissector that has a pointed tip can be utilized to dissect through more fine tissues and is commonly used when dissecting around the cystic duct and artery during a laparoscopic cholecystectomy.

Fig. 2.20
figure 20

Top to bottom, laparoscopic graspers; (a) bowel grasper; (b) Clinch grasper; (c) Maryland dissector

Fig. 2.21
figure 21

Top to bottom, (a) Cinch grasper; (b) atraumatic bowel grasper; (c) Maryland dissector

2.1.3 Suction Devices and Cautery (Fig. 2.22)

There are a variety of instruments that exist that allow for the utilization of electrocautery during laparoscopic procedures. Illustrated here is the spatula, in which the metal shaft is insulated so as to protect the surrounding tissue. Suction cannulae come in variety of sizes. The tip doubles as a suction and irrigator when connected to the appropriate adaptor and tubing. This adaptor usually has two buttons: red for suction and blue for irrigation. The combination of suction and the blunt tip can also be utilized to dissect tissue.

Fig. 2.22
figure 22

Top to bottom, (a) insulated spatula cautery with suction cannula; (b) insulated spatula cautery with suction cannula separated in individual components; (c) laparoscopic suction cannula in two different sizes

2.1.4 Trocars and Obturator (Fig. 2.23)

Once inserted through the abdominal wall, trocars (commonly referred to as ports) are left in place to allow for the passage of laparoscopic instruments. Once this first port is placed, either through open or Veress technique, the laparoscope can be introduced intra-abdominally to help visualize the placement of subsequent ports. To place a port, a twisting motion along with constant, steady pressure is applied to the trocar with the obturator insert. This allows the pointed obturator tip to dissect through the abdominal wall layers. The tip should be visualized with the laparoscope as it enters into the abdominal cavity so as to avoid injury to organs, such as the bowel, liver, or spleen. The obturator is removed once the trocar is in place, and a laparoscopic instrument can then be introduced. Ideally, the trocar should be able to freely move in any direction so as to allow for an optimal operative field.

Fig. 2.23
figure 23

Top to bottom, laparoscopic trocars; (a) 12 mm trocar with obturator; (b) 5 mm trocar with obturator; (c) 5 mm trocar and obturator

2.1.5 Port Closure Device (Fig. 2.24)

Large port sites, particularly 10 mm or greater, usually require that the fascia be closed after port removal. Port closure devices are particularly useful when it would be difficult to close the fascial defect by hand, such as in an obese patient. The Carter-Thomason system uses a cone-shaped obturator that is placed into the port site. A free suture is grasped by the tip of the suture passer and then introduced into one of the two holes in the cone. The laparoscope is used to visualize the sharp suture passer as it pierces one side of the fascial defect. Once the sharp tip is in the abdomen, the suture is released, and the suture passer is removed and then placed into the opposite hole in the cone. Again, the sharp tip is visualized as it pierces the opposite side of the defect and grabs the free suture to pull it back out so the free ends of the suture can be tied down to close the fascial defect.

Fig. 2.24
figure 24

Carter-Thomason laparoscopic port closure device with cone-shaped guides in two different sizes

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Dukleska, K., Aka, A.A., Johnson, A.P., Chojnacki, K.A. (2018). Fundamentals of Operating Room Setup and Surgical Instrumentation. In: Palazzo, F. (eds) Fundamentals of General Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-75656-1_2

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