OR Setup for a Laparoscopic Cholecystectomy (South College, Knoxville, TN)

CHAPTER 1

Hi guys. My name is Madison Campbell. I'm full-time faculty here at South College in Knoxville, and I also work PRN at a hospital here in Knoxville as well. Today I'm gonna talk to you about a setup for a laparoscopic cholecystectomy.

CHAPTER 2

So over here I have my basin full of all my supplies. My table's already double draped. That's really important because we don't wanna puncture holes in our table, and it protects our patient even more. My Mayo stand is also already draped out and ready to go. It is also already double draped. At this point, I'm gonna go ahead and start organizing my stuff. So over here will be my working end, where I will have my irrigation, my medicines, my sharps. In the middle here, I'll have my trays, and over here on my non-working end will be drapes, gowns, gloves, et cetera. So to start organizing my drapes and everything, I'm gonna put my towels here. My patient drape is gonna go over here on the corner. This is just a magnet pad. This is kind of surgeon's preference on if they wanna use it or not. Around here we use four sticky towels instead of regular towels, but that's also surgeon's preference, depending on what area you're in. I have another drape just for extra reinforcement. My sticky towels will go there and my surgeon's gloves and my assist's gloves. I put my indicator glove inside of their outer glove, and I just go ahead and stack 'em in the correct order. After that, I'll go ahead and put these on top of my patient drape. Here I have some laparoscopic disposable scissors and my laparoscopic clip applier. I'm gonna go ahead and move those to my Mayo since I know I'm gonna be using them. And then here is my laparoscopic specimen bag. Typically, this bag is tucked inside of this tube here, but for demonstration purposes, the bag is out.

CHAPTER 3

So with my basin to make my efficiency of movement better, I just like to go ahead and get everything out. So this is a sticky pad that we use here in Knoxville. We use that as a no pass zone for our sharps. I also like to go ahead and get my suture laid out and ready, that's visible. And then in my basin, I will leave my Bovie tip with the Bovie, my light handle, my insufflation tubing, as well as my suction tubing.

CHAPTER 4

At this point, I'm ready to grab my instruments. I'm checking my indicator, making sure that the pan is good. Once I get that okay from my circulator, I can put my tray down. I also need to grab my laparoscopic instrumentation. So same thing there. My circulator will check my indicator at the bottom of the pan to make sure there's no moisture. I am also grabbing my light cord, my camera cord, my laparoscopic Bovie cord, and my lenses. Typically, your lenses will come in their own separate container, and you have zero-degree or 30-degree lenses, as well as five-millimeter or 10-millimeter lenses. Your surgeon's preference will be on their preference card. For this demonstration, I have two five-millimeter zero-degree scopes. So now I'm gonna go ahead and make my roll towel for my instruments. Get them set out and ready to go. I'll also organize the rest of my instruments, so my retractors, I'll make them visible for my circulator for when I start counting. My towel clips, I'll sit out here to the side just so that they're visible. And then I'll also grab out my knife handles and set them in my no-pass zone and then organize my pickups with my atraumatic on my working end and my traumatic on my non-working end. I do that just in case of emergency. If we run into bowel or something, you always wanna grab an atraumatic forcep, so that your surgeon doesn't penetrate any bowel. At this point, I'm ready to count with my circulator, and I'm gonna go ahead and move my extra cords over here to my bucket, since I know they're gonna be thrown off.

CHAPTER 5

So anytime you are ready to count, you will count your softs first. And you don't wanna break your band on your softs until you're ready to count. So Laps, I have 1, 2, 3, 4, 5. Ray-Tecs. I have 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. For my sharps, I have 1, 2, 3 suture needles. Blades, I have one. And just to elaborate on your blade, for laparoscopic procedures, your surgeons might wanna use an 11 blade or a 15 blade. So just be aware of your preference card when you're looking at it. Hypo, I also have one. Bovie tips, I have one and two. Trocar pieces are counted sometimes at facilities as well. So you need to make sure that you have this plastic piece taken off because it's not x-ray detectable. If it falls in the patient, you're gonna have a hard time trying to find it. So I always like to put mine in my kidney basin or in a trash bag or wherever it can go. So your trocar pieces, they do come apart, and you have the potential for it to fall into your patient if you go open. So some facilities count their pieces. So this would technically be three pieces where I'm at, but some facilities might count it different. So I'm gonna go ahead and take my plastic pieces off and get that ready. I also like to make sure that my trocars are in order after I count them. So I've counted my softs and my sharps. At this point, I need to count my instruments with my circulator. I don't unstring my instruments until after I've counted. Mosquitoes, I have 1, 2, 3, 4. Criles or snaps. I have 1, 2, 3, 4, 5, 6, 7, 8. Kelly, 1, 2, 3, 4, 5, 6, 7. Kochers, I have 1, 2. Allis, 1, 2, 3, 4. Babcock, 1, 2, 3, 4. Tonsil Schnidt, I have one, two. Right angle, I have one. Foerster sponge stick, one, two. Clip applier, one, two. Needle holders, 1, 2, 3, 4. Metzenbaums, I have one. Curved Mayo, one. Straight Mayo, one. For my retractors, Army-Navy, one, two. S-shapes, one, two. Weitlaner, I have one. I also have a Yankauer suction tip that is two pieces. For my pickups, I have one smooth dressing forcep. DeBakey, I have one. Adson with teeth, I have one. And rat-tooth, I have one. For my knife handles, I have one, two. Towel clips. Altogether I have 1, 2, 3, 4, and 5. I also need to count my laparoscopic instruments. So depending on where you're at, your facility might count it by number as in 1, 2, 3, 4, or they might have you say the name out loud. I'm gonna demonstrate the names. So for my laparoscopic instruments, I have a suction irrigator, a laparoscopic Bovie tip, Metzenbaum scissors, a Lahey, atraumatic graspers, I have one, two. Maryland, I have one. And then also in this tray I had a Bovie tip come up.

CHAPTER 6

So at this point, now I can go and start setting up my Mayo. I know for sure I'll need suture scissors so that when we're closing, I have my suture scissors ready to go. Sometimes surgeons will also tie in their trocars to help keep it in place. I also know that I might need some Metzenbaums just in case we run into some tissue. I know for sure I'll need a needle driver for the very end, and I also need it to load my blade. A lot of surgeons like to use Kochers to grab onto the fascia to pull up on it before you insufflate. And then some surgeons also like to use a couple of Kellys, so I like to have everything ready to go. I also know that I will need a DeBakey forcep as well as an Adson with teeth, so that I'll have an atraumatic and a traumatic forcep up on my Mayo. Before I go over to my Mayo, I'm gonna go ahead and load my knife handle. And put it in my no-pass zone. The rest of my instrumentation, I'm gonna go ahead and bring over here. I like to leave my pickups close to me so they're easily accessible. My scissors, I like to keep kind of far. And then my Kocher and my Kellys, I like to keep close to me because those are the things we're gonna use first. I also need to put my lenses up there. Because that's how we're gonna get in.

CHAPTER 7

So when you're doing a laparoscopic cholecystectomy, you'll have four to five incisions. Your surgeon will make an incision at the umbilicus area, and they can use several different methods. They can use an Optiview, which is using a trocar with the lens inside of it as you dissect down with the trocar. You can also use a bladed trocar. There's also Hassons, or you can use a Veress needle. That's all surgeon's preference, and it'll be on your preference card. You also will have two or four other incisions, two subcostal, and then potentially two on your lower abdominal area. Once you get in with your initial trocar, you'll visualize the anatomy, and then your surgeon will use an atraumatic locking grasper to grab onto the gallbladder, which is located beneath the liver. They'll grab onto the gallbladder, push it up to the abdominal wall, and then the assist will grab onto this grasper and your surgeon will start using both hands. They will be using both hands with the laparoscopic Bovie and a Maryland grasper or a dolphin nose grasper. Once they've dissected down and have found the cystic duct and the cystic artery, they will use a clip applier or a PDS EndoLoop. This will clamp off the cystic duct and cystic artery and allow for your surgeon to cut in between your clips or cut the cystic duct and cystic artery away from the EndoLoop. At this point, your surgeon will peel the gallbladder off of the liver bed and check for any kind of bleeding. Once that gallbladder is detached from the liver bed, they'll insert the specimen bag. Once the specimen bag is inserted, the gallbladder will go into the bag. We'll pull this green handle, take the string off of the hook, and pull the gallbladder out through the incision site. After that, your gallbladder's in the bag, it should be in your specimen cup on your back table. At this point, your surgeon will be checking for any kind of bleeding. They might use a hemostatic agent of some sort, or you might be done with your procedure. At that point, your surgeon will start closing the incision sites, and you will help get dressings ready and start counting your instruments for the end of the case. There's also the potential that your surgeon could do a cholangiogram. This is where we use x-ray to make sure that there are no stones left in any kind of duct so your patient doesn't stay sick. At this point, you need to make sure that your medications are labeled accurately. You don't wanna confuse contrast with local or saline. You also wanna make sure that you don't have any bubbles in your contrast because bubbles can look like stones on x-ray. As you're doing your procedure as well, we use what's called an igloo sometimes. This is a scope warmer, or you can use a FRED, which is a fog reduction elimination device. We also will use a suction irrigator to irrigate everything out if there's a lot of bleeding or if we puncture the gallbladder and bile came out. This is your Bovie tip that you'll use, a Maryland grasper, and then, as I said, your locking atraumatic grasper. Your circulator will also give you contrast dye, and you can label that in one cup, your local solution in another cup, and then in your basin or your pitcher, you can have your irrigation. Your irrigation will be used at the end, and all of those solutions need to be labeled accurately. At this point, I'm ready to gown and glove my surgeon and drape my patient. Thank you for watching.