Helping at Lap Surgery

Surgery

As laparoscopic surgery becomes more common, junior medical and nursing staff are asked to be camera operators and assistants more often. This is more likely in private and country hospitals where a second surgeon is not available, and as procedures become more complex and need an extra assistant.

All surgeons know the benefits of having a good assistant. The adverse effects of poor camera work have not been measured or discussed but are well known to operators, This is a great opportunity for research.

The role of the assistant

This varies with the procedure being performed. It might mean just holding an instrument or two in relatively fixed positions to expose the surgical anatomy. It may be more active, moving structures to one side or the other to put tension on the line of tissue being dissected. With experience, the assistant knows what the surgeon will do next and position instruments to help this..

An inexperienced assistant has to have their instruments put in place by the surgeon for each new step in the operation. This means the surgeon has to let go of their own instruments each time, which slows down the operation. Becoming an expert assistant needs practice and understanding of what the surgeon is aiming to do, helped if the surgeon can explain this properly.

Helping at lap surgery is harder than helping at open surgery. There is no direct view and you have to look at the screen and learn new co-ordination of the hand and eyes. Because the instrument passes through the port which is fixed in position, is acts as a lever with "paradoxical motion". When the handle of an instrument is moved, the working end of the instrument ( jaws, retractor, camera lens) moves in the opposite direction, and this is confusing at first.

Instruments used in laparoscopic surgery are more dangerous than those in open surgery because of their smaller size and the limited view of the operation.

For instance, fan-like retractors are useful for retraction but if they are turned sideways instead of pressing flat, their thin edges can lacerate organs like the liver. Tips of instruments can perforate viscera if used blindly or forcefully, especially as sense of touch is partly lost by friction of instruments moved in or out through a port. Grasping instruments placed on bowel or stomach, having small jaws, can avulse chunks of the wall leading to a perforation if not used with appropriately gentle force. Practicing in a surgical skills lab or a workshop increases the skill and confidence of assistants and surgeons alike.

Role of camera operator

The camera operator is often the only assistant. As with instruments (described above) there is paradoxical movement. When the camera operators hand is moved one way, the lens and the viewing area move the opposite way. The area of view is also restricted

There are several principles of good camera control. These are:

Keep instruments in the field of view as they are brought into the abdomen. As instruments are introduced through a port the camera should view the tip of the instrument and follow the instrument to its site of action. Depending on the habits and skill of the operator, this should be done each time instruments are introduced into the abdomen.
The site of the operation should be kept in the centre of view. This is important for safety as well as efficiency as it lets the surgeon to see better what he or she is trying to do. It also helps to eliminate light flare which can occur when another organ sited at a different distance from the camera occupies most of the visible area. The camera's automatic aperture will then adjust to that organ, rather than the operative field.
The lens of the laparoscope scope must be the right distance from the site of operation. If the field is too large and the camera too far away, there is not enough detail for the operator to see accurately what they are doing. If the camera is too close, the field is over-magnified, and shows too small an area, making movements appear too large and losing landmarks and perspective outside the view. Getting the right balance is difficult and a real test of the camera operator's skill.
Fogging of the camera lens can be a serious problem, which seems to occur with some surgeons more than others for no obvious reason.. It can occur because the camera is cooler than the temperature inside the abdomen so that moisture condenses on the lens.. The remedy for this is to wipe the end of the scope against a clean surface or an organ such as the liver, or to wipe the scope with a gauze swab moistened in warm saline. Products such as Murdoch lens cleaner (Cook Australia) also help reduce fogging. Condensation can also occur in the junction between the camera lens and the laparoscope lens if these are separate units and have not been properly dried before connecting them.
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f the camera operator is standing awkwardly and gets tired, the camera view will not be steady. It is up to the surgeon, as captain of the operating team, to ensure this is not a problem, perhaps by organizing a seat or arm support or re-arranging where people stand.

There are other ways of improving the view, for example by rotating the camera slightly or moving the view off centre away from glaring structures such as omentum when it is close to the light source. New developments such as binocular lenses to give better depth perception still have a way to go before they are routine, though it is simple now to have a second light in the abdomen to give more useful shadowing. A lot depends on the leadership given by the operator

The main points are shown in the accompanying chart, with some extra details.

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INSTRUCTIONS FOR THE LAP SURGERY ASSISTANT

[These can be printed out]

1. Centre the camera view

If the point of dissection or suturing is at the edge of the screen, or even out of view. "Centre please" should fix this.

2. Rotate the image the right way up

The post [connected to the optical lead] on the scope can point down for a Zero degree scope when the weight of the cable makes it easier to hold a steady position.
For an angled scope (e.g. 30 or 45 degrees) the post must point UP, or the view is incorrectly orientated for most dissections.

3. In / out

Too small a view makes structures hard to find. Too big a view reduces perspective.

4. Steady

It is essential to keep the camera steady. Significant movement can distract (and irritate) the operator. Significant movement can occur if the camera operator is unaware of the problem, loses concentration and is particularly prevalent during conversation. The problem of excessive movement is obvious on video replays..

Some extra instructions
for the more experienced assistant

5. Reduce glare

Glare from omentum or instruments usually needs only a slight tilt away or a slight withdrawal of the scope for it to disappear.

6. Move slightly up / down / left /right / in / out

A better view saves wasting movements. In-out movement can be jerky if the scope sticks inside the cannula and may be affected by the valve. It helps to steady the hand or forearm.

7. Rotate clockwise / anticlockwise

With an angled scope this allows a view of the side of a structure .

8. Comfortable posture

A seat is a good idea, and so is alternate sitting and standing in longer operations, or alternating the roles of assistant and camera operator if feasible. If care to arrange them is not taken.The assistant and operator may clash forearms or instruments

Awkward postures of both assistant and surgeon can be improved by improving the positions of port sites.and sometimes by lowering the table or standing on a platform. (The platform may need a rim to stop foot controls slipping off).

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This text has not been published before except in course notes for workshops on advanced laparoscopic surgery for OR nurses.

Why bother with this

It is up to the surgeon to ensure the camera operator knows what is needed, and is comfortably positioned to do this.

Bad camera work slows the operator and increases the dangers of the procedure. The operator must see tissues, tools and materials clearly.

An experienced and skilful assistant who can follow the dissection without needing to be told what to do is very valuable.

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