Open and Minimally Invasive Surgery

This is Unit Twenty-Five of Tech in Surgery Prep. Unit Twenty-Four ended with a wound class that changed during a case. This unit compares the two ways surgery reaches the body, through an open incision or through small ports with a camera. Carry one idea through this lecture. In a minimally invasive case, the most serious hazards, burns and fire, can start outside the camera's view, so preparation for the unseen is a large part of the work. That includes an open set kept ready, unopened, in case of conversion. A worked example near the end shows a case where the open set was never needed, and why it was still ready. By the end you will be able to explain open and laparoscopic surgery. To manage the camera, light and instruments, and a conversion. To describe endoscopy, arthroscopy and robotic surgery. And to prevent hidden energy burns.

Five entries on open and minimally invasive surgery, and on how a laparoscopic case is built.

Two approaches.

TSC 601 Open and Minimally Invasive

Surgery is done through an open incision or by minimally invasive techniques with small incisions and a camera. Minimally invasive surgery uses a scope and long instruments through small ports; open surgery uses a larger incision for direct access. Many minimally invasive cases can convert to open, so both sets may be needed.

The open incision.

TSC 602 Incisions and Exposure

In open surgery, the incision is placed and sized to give the exposure the operation needs. A laparotomy, for example, opens the abdominal wall through its layers, and retractors hold it open. Every layer opened is closed again, which is why the scrub person follows the layers on the way in.

Building a laparoscopic case.

TSC 603 Laparoscopy Basics

Laparoscopy is minimally invasive surgery in the abdomen. Working space is made by filling the abdomen with carbon dioxide, called insufflation. Ports, called trocars, go through small incisions. The laparoscope's camera and light show the inside on a monitor, and long graspers, scissors, dissectors and needle holders work through the other ports. At the end, ports come out, gas is released and the small incisions are closed. Gallbladder removal, hernia repair and appendectomy are common examples. The instruments' joints, lumens and insulation need careful handling, and an open set stays ready.

Making space with gas.

TSC 604 Insufflation

An insufflator fills the abdomen with carbon dioxide to create working space for ports and instruments. A Veress needle is one way to begin, and warmed insufflation gas helps keep patients warm. The insufflator and its gas supply are checked during setup.

The ports.

TSC 605 Trocars and Ports

Trocars are the ports through which laparoscopic instruments enter. Each has a cannula, a seal and an obturator, they come in several sizes, and they also serve to remove specimens. Ports and their parts are small items, counted or tracked as policy directs.

Four entries on the camera and light, laparoscopic instruments, and converting to open.

Seeing inside.

TSC 606 The Camera and Light

The camera, lens and light let the surgeon see inside. The handheld camera connects to the lens and has focus and white balance settings. Lenses come in several viewing angles and may need defogging. The light source sends light through a fiber-optic cable to the lens, and the image appears on monitors placed for the team. The cable carries intense light, and its tip can scorch drapes or burn skin. Connect it to the scope before switching on, switch off before disconnecting, and never lay a lit cable on the drapes; a scorched drape is a near miss for a fire.

A clear picture.

TSC 607 White Balance and Defogging

The camera is adjusted before use, and the lens is kept clear during the case. White balancing sets the colours correctly, and lenses that fog inside the warm body are defogged. A clear picture is a safety matter, because the surgeon cannot control what cannot be seen.

Long instruments.

TSC 608 Laparoscopic Instruments on the Field

Laparoscopic instruments are long, shafted versions of open instruments that grasp, retract, cut, cauterize and suture through ports. They are arranged for quick passing, with energy instruments' cords controlled. Their tips are fine and shafts insulated, so they are handled carefully and inspected.

When the case converts.

TSC 609 Converting to Open

A minimally invasive operation converts to open when the surgeon decides it cannot be finished safely through the ports. The surgeon announces it. The circulator opens the open set that was ready but unopened. The scrub person sets the open instruments, pads and suction, counting each new item in. Ports and laparoscopic instruments come out and are accounted for. The case continues open, and the final count covers both parts. Conversion is often urgent, which is when counts go wrong, so everything is counted in and out.

Five entries on endoscopy, arthroscopy, fluid, and robotic-assisted surgery.

Through a natural opening.

TSC 610 Endoscopy

Endoscopy examines internal structures with a scope passed through a natural opening or small incision, such as a bronchoscope in the airways or a cystoscope in the bladder, often with saline flow to make space. Endoscopes are reprocessed exactly as their manufacturers direct before the next patient.

Inside a joint.

TSC 611 Arthroscopy

Arthroscopy places a scope into a joint to diagnose and treat joint, ligament and tendon problems. Saline circulates through the joint to make working space, so large volumes are used. Heavy fluid use means wet floors and impervious shoe covers, so slips and spills are managed throughout.

Robotic arms.

TSC 612 Robotic-Assisted Surgery

In robotic-assisted surgery, the surgeon controls robotic arms that hold the instruments, usually laparoscopically. The surgeon sits at a console with a three-dimensional view. The arms hold the camera and instruments, with articulating heads for a wide range of motion. The bedside team changes instruments on request and shares the video. The scrub person prepares and drapes the system and manages instruments at the patient's side. The surgeon may be across the room, so communication must be clear and spoken, and the bedside team watches the patient directly while the surgeon watches the screen.

The scrub person beside the robot.

TSC 613 The Scrub Role in Robotic Cases

In robotic cases, the bedside surgical technician changes the robot's instruments as the surgeon requests. The bedside team also covers the arms with sterile drapes, manages the ports and passes supplies while the surgeon works from the console. Follow the robot's own procedures, which the facility trains on before you scrub a robotic case.

Fluid in, fluid tracked.

TSC 614 Fluid Management in Scopes

Arthroscopy, cystoscopy and similar procedures circulate fluid, usually saline, to make space and keep the view clear. The amount used is tracked, warmed fluid helps prevent hypothermia, and spills are cleaned promptly. Wet floors are a common cause of slips.

Four entries on hazards hidden from the camera, processing scopes and removing specimens, then two worked examples. The opening idea is paid off at the first.

Current without contact.

TSC 615 Capacitive Coupling in Laparoscopy

In laparoscopy, current can pass from an insulated instrument into nearby metal or tissue without touching it, called capacitive coupling. The lowest effective setting, no activation in open air, and no mixed metal and plastic ports reduce the risk. These burns may happen out of the camera's view, so prevention matters.

Hard to clean.

TSC 616 Cleaning Scopes

Scopes and laparoscopic instruments are among the hardest devices to clean, because of their channels, joints and insulation. Scopes entering sterile tissue should ideally be sterilized, and every channel is processed with the right connectors as the manufacturer directs. Residue hides in joints and lumens, so cleaning starts at the field.

Insulation that keeps current at the tip.

TSC 617 Insulated Laparoscopic Instruments

Laparoscopic energy instruments are insulated to keep current at the tip. A break in insulation lets current escape and burn tissue away from the camera's view, so insulation is inspected. An instrument with damaged insulation is removed from use and reported.

Specimens through a port.

TSC 618 Removing Specimens Through Ports

In laparoscopy, specimens come out through a port site, sometimes after enlarging the incision. Trocars serve as working ports and as removal routes, and the specimen is then handled and labelled like any other, still one at a time.

A gallbladder, laparoscopically.

TSC 619 A Laparoscopic Gallbladder

A worked example, constructed for this course, pays off the opening idea. Casey sets up the laparoscopic instruments, camera, light cable, insufflation tubing and trocars, with an open set in the room, unopened. Casey white-balances the camera and checks the lens and cable. After the time out, insufflation starts and the ports go in. Casey passes graspers, a dissector and a clip applier, keeps the light cable off the drapes and the energy instrument holstered, and defogs the lens when it fogs. The gallbladder comes out through a port into a labelled container, the ports are counted out, and the small incisions are closed. The open set was never needed, but it was ready, because preparing for the unseen is the work.

Converting mid-case.

TSC 620 A Conversion Mid-Case

A worked example, constructed for this course, follows a laparoscopic gallbladder removal with unclear anatomy and steady bleeding. The surgeon converts to open. Casey asks for the open set and pads, already in the room, and counts them in with the circulator before use. Each laparoscopic instrument and port comes out and is accounted for. Through an open incision, retractors, suction and pads go in, and the bleeding is controlled with clamps and ties. At closing, everything from both parts is counted, and it is correct. The conversion is recorded so the procedure performed is confirmed. Extending the count, rather than restarting it, kept one unbroken record of everything that entered the patient.

Look at what you can now do. You can compare open and minimally invasive surgery, and explain insufflation, trocars and the stages of a laparoscopic case. You can manage the camera, lens and light cable safely, arrange laparoscopic instruments, and count everything in and out when a case converts. You can describe endoscopy, arthroscopy and fluid management, and the bedside role in robotic-assisted surgery. And you can prevent burns out of the camera's view, start cleaning at the field, and remove specimens through ports with the same labelling. Unit Twenty-Six turns to closure, dressings and devices at the end of the case.