The SAGES Manual Volume 1 Basic Laparoscopy and Endoscopy PDF

The SAGES Manual The SAGES Manual Volume 1 Basic Laparoscopy and Endoscopy Third Edition Nathaniel J. Soper, MD Northwestern University Feinberg School of Medicine, Chicago, IL, USA and Carol E.H. Scott-Conner, MD, PhD University of Iowa Hospitals and Clinics, Iowa City, IA, USA Editors Editors Nathaniel J. Soper Carol E.H. Scott-Conner Department of Surgery Department of Surgery Northwestern University Feinberg University of Iowa Hospitals School of Medicine and Clinics Chicago, IL, USA Iowa City, IA, USA ISBN 978-1-4614-2343-0 e-ISBN 978-1-4614-2344-7 DOI 10.1007/978-1-4614-2344-7 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2012932411 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword As the Society of American Gastrointestinal and Endoscopic Surgeons completes its 30th year, our commitment to education burns as brightly as ever. The first SAGES manual was published in 1998. Since then, it has continued to be a well-organized, clear, and to the point reference in minimally invasive surgery written by experts in the field and aimed at the surgical resident. That said, it will also be useful to students and attending surgeons alike. This third addition of the SAGES manual reflects the best of what has been a leading reference in minimally invasive surgery yet at the same time incorporating many new concepts that have evolved since the second addition. This is mirrored by the tireless efforts of Carol E.H. Scott Connor, MD who has overseen this project since its inception and the addition of Ninh T. Nguyen, MD and Nathanial (Nat) Soper, MD as editors of the third edition. Together, this team has organized this brilliant reference in the field of minimally invasive surgery. Surgical residents and practicing surgeons will find this addition completely reorganized as the field of minimally invasive surgery continues to grow. Dividing the manual into two volumes allows for a convenient method of keeping it handy as well as reorganizing this book into basic (volume 1) and advanced procedures (volume 2). Students of history, who recall that SAGES’ roots grew out of flexible endoscopy, will also no doubt notice the increasing prominence of flexible endoscopy in this manual. This reflects the rise in interest of surgeon performed endoscopy as a therapeutic tool complementing other MIS techniques. Surgical residents interested in a career in gastrointestinal surgery should pay close attention to the increasing role that the endoscope will play in their future. While the first two chapters of this edition of the SAGES manual highlight the roles of the Fundamentals of Laparoscopic Surgery (FLS) and Maintenance of Certification (MOC) in the educational process, future editions will clearly also include information on the Fundamentals of Endoscopic Surgery (FES) and other key offerings as well. v vi Foreword Even as this book comes to press, controversies concerning optimal treatment strategies continue to swirl as issues of endoluminal therapies, surgical robotics, and natural orifice translumenal endoscopic surgery (NOTES) are debated around the world. Even the issue concerning the optimal number and size(s) of trocars in our bread and butter commodity procedure such as laparoscopic cholecystectomy remains unsettled. Clearly we should get working on the fourth edition. I have recently been asked if medical texts are destined for the same desolate fate as ice boxes, typewriters, and mimeographs in the annals of history, all supplanted by newer technologies. Clearly, the organization of medical information is evolving rapidly with so much information now available at our fingertips in digital form. The available “infostream” is coming at us like water spouting wildly from a fire hose, but amidst all that data, where do we find truly useful information concisely organized? I suspect it will be in places such as the SAGES Manual, and yes, this reference too will be available in a digital format for those who wish to abandon paper altogether. Whether on paper or in a digital format, I am sure that you will enjoy using this reference (at least until the next edition comes out). Steven D. Schwaitzberg, MD SAGES President 2011–2012 Cambridge, MA, USA Preface In creating this third edition of The SAGES Manual, we have completely restructured, reorganized, and revised the entire manual. Rather than put the manual on a diet, we have separated it into two volumes for better portability. Volume 1 covers the fundamentals and procedures performed during surgical residency. We anticipate that Volume 1 will be the first volume used by students, residents, and allied health-care professional trainees, do not be deceived, however; we have added material to these fundamentals and procedures that should also be of interest to experienced surgeons. Volume 2 covers more advanced procedures, generally taught during fellowship. If you own an old, dog-eared copy of the second edition, you will find much that is new in both volumes. All of the sections have been reorganized with a critical eye to the needs of the modern minimal access surgeon. Two new editors have been added. Although many chapters have new authors, many stalwart authors have continued to contribute. We have also added color photographs. As before, the manual strives to strike a balance between completeness and conciseness. Significant additional information, including videos, is available from the SAGES Web site (see Appendix, at the end of Volume 1). But, as always, we want you to think of this manual as a way to take SAGES experts along with you throughout your surgical journey. Nathaniel J. Soper Saint Louis, MO, USA Ninh T. Nguyen Orange, CA, USA Carol E.H. Scott-Conner Iowa City, IA, USA vii Contents Foreword.......................................................................................... v Preface.............................................................................................. vii Contributors..................................................................................... xv Part I Basic Laparoscopy and Endoscopy: General Principles 1 Fundamentals of Laparoscopic Surgery (FLS) and of Endoscopic Surgery (FES)............................................ 3 Jeffrey M. Marks 2 Maintenance of Certification.................................................... 15 Jo Buyske 3 Equipment Setup and Troubleshooting.................................... 21 Mohan C. Airan 4 Ergonomics in Operating Room Design.................................. 45 Erica R.H. Sutton and Adrian Park 5 Access to Abdomen................................................................. 61 Nathaniel J. Soper 6 Generation of Working Space: Extraperitoneal Approaches.............................................................................. 79 David M. Brams and Amila Husic 7 Single-Site Access Surgery...................................................... 87 James A. Dickerson II, Chan W. Park, and Aurora D. Pryor 8 Hand-Assisted Laparoscopic Surgery...................................... 99 Carol E.H. Scott-Conner 9 Laparoscopic Hemostasis: Energy Sources............................. 105 James G. Bittner IV, Michael M. Awad, and J. Esteban Varela ix x Contents 10 Laparoscopic Hemostasis: Hemostatic Products and Adjuncts............................................................................ 121 Thadeus L. Trus 11 Principles of Tissue Approximation........................................ 129 William C. Beck and Michael D. Holzman 12 Other Devices for Tissue Approximation................................ 143 Byron F. Santos and Eric S. Hungness 13 Documentation......................................................................... 163 Minh B. Luu and Daniel J. Deziel 14 Laparoscopy During Pregnancy............................................... 173 Carmen L. Mueller and Allan Okrainec 15 Previous Abdominal Surgery................................................... 183 Eric S. Hungness 16 Robotics in Laparoscopic and Thoracoscopic Surgery............ 191 W. Scott Melvin and Andreas Kirakopolous Part II Diagnostic Laparoscopy and Biopsy 17 Emergency Laparoscopy.......................................................... 207 Brian T. Valerian and Steven C. Stain 18 Elective Diagnostic Laparoscopy and Cancer Staging............ 215 Michael D. Honaker and Frederick L. Greene 19 Lymph Node Biopsy, Dissection, and Staging Laparoscopy............................................................................. 231 Lee L. Swanstrom Part III Laparoscopic Cholecystectomy and Common Duct Exploration 20 Laparoscopic Cholecystectomy............................................... 255 Pradeep Pallati and Dmitry Oleynikov 21 Laparoscopic Cholecystectomy: Avoiding Complications...... 265 Jessemae Welsh and Joseph J. Cullen 22 Cholangiography...................................................................... 273 Rahul Gupta, Daniel B. Jones, and Mark P. Callery Contents xi 23 Laparoscopic Ultrasound of the Biliary Tree........................... 291 Michael Lalla and Maurice E. Arregui 24 Laparoscopic Common Bile Duct Exploration: Transcystic Duct Approach...................................................... 311 Joseph B. Petelin and Timothy Mayfield 25 Laparoscopic Common Bile Duct Exploration via Choledochotomy................................................................ 331 Richard A. Alexander, Karla Russek, and Morris E. Franklin Part IV Basic Laparoscopic Gastric Surgery 26 Laparoscopic Gastrostomy....................................................... 345 Sajida Ahad and John D. Mellinger 27 Laparoscopic Plication of Perforated Ulcer............................. 353 I. Bulent Cetindag and John D. Mellinger Part V Basic Laparoscopic Procedures of the Small Intestine, Appendix, Colon 28 Small Bowel Resection, Enterolysis, and Enteroenterostomy............................................................ 361 Bruce David Schirmer 29 Laparoscopic Placement of Jejunostomy Tube........................ 379 Bruce David Schirmer 30 Laparoscopic Appendectomy................................................... 389 Jessica K. Smith 31 Laparoscopic Colostomy......................................................... 403 John Byrn Part VI Hernia Repair 32 Laparoscopic Inguinal Hernia Repair: Transabdominal Preperitoneal and Totally Extraperitoneal Approaches........... 413 Nathaniel Stoikes and L. Michael Brunt 33 Laparoscopic Repair of Ventral Hernia.................................... 431 Michael J. Rosen xii Contents Part VII Pediatric Laparoscopy and Endoscopy 34 Pediatric Minimally Invasive Surgery: General Considerations.......................................................................... 443 John J. Meehan 35 Pediatric Minimally Invasive Surgery: Specific Surgical Procedures................................................................................ 449 John J. Meehan 36 Complications in Pediatric MIS............................................... 479 John J. Meehan Part VIII Flexible Endoscopy: General Principles 37 Flexible Endoscopes: Characteristics, Troubleshooting, and Equipment Care................................................................. 497 Gary C. Vitale and Brian R. Davis 38 Endoscopy Handling................................................................ 509 Kevin El-Hayek, John Rodriguez, and Bipan Chand 39 Monitoring, Sedation, and Recovery....................................... 525 Jennifer Hrabe and Joseph J. Cullen 40 Flexible Endoscopy: Principles of Documentation.................. 531 Raphael Sun and Joseph J. Cullen Part IX Flexible Endoscopy: Basic Upper Gastrointestinal Endoscopy 41 Diagnostic Upper Gastrointestinal Endoscopy........................ 539 Jarrod Wall and John D. Mellinger 42 Percutaneous Endoscopic Feeding Tube Placement................ 557 Melissa S. Phillips, Bipan Chand, and Jeffrey L. Ponsky 43 Capsule Enteroscopy................................................................ 571 Jeremy A. Warren and Bruce V. MacFadyen Jr. Contents xiii Part X Flexible Endoscopy: Basic Lower Gastrointestinal Endoscopy 44 Flexible Sigmoidoscopy........................................................... 581 John A. Coller 45 Diagnostic Colonoscopy.......................................................... 597 Aman Banerjee, Melissa S. Phillips, and Jeffrey M. Marks 46 Therapeutic Colonoscopy and Its Complications.................... 611 Aaron S. Fink Appendix.......................................................................................... 627 Index................................................................................................ 631 Contributors Sajida Ahad, MD Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA Mohan C. Airan, MD, FACS Advocate Good Samaritan Hospital, Lombard, IL, USA Richard A. Alexander Jr., MD Department of General Surgery, South East Baptist Hospital, San Antonio, TX, USA Maurice E. Arregui, MD Department of General Surgery, St. Vincent’s Hospital and Healthcare Center, Indianapolis, IN, USA Michael M. Awad, MD, PhD, FACS Section of Minimally Invasive Surgery, Division of General Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA Aman Banerjee, MD Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA William C. Beck, MD Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA James G. Bittner IV, MD Department of Surgery, Medical College of Georgia School of Medicine, Augusta, GA, USA David M. Brams, MD Department of Surgery, Lahey Clinic, Burlington, MA, USA xv xvi Contributors L. Michael Brunt, MD Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA Jo Buyske, MD American Board of Surgery, Philadelphia, PA, USA John Byrn, MD Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Mark P. Callery, MD Department of Surgery, Division of General Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA I. Bulent Cetindag, MD Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA Bipan Chand, MD, FACS Department of Bariatric and Metabolic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA John A. Coller, MD Department of Colon & Rectal Surgery, Lahey Clinic, Burlington, MA, USA Joseph J. Cullen, MD, FACS Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Brian R. Davis, MD Department of Surgery, Paul L. Foster School of Medicine, Texas Tech University, El Paso, TX, USA Daniel J. Deziel, MD Department of General Surgery, Rush University Medical Center, Chicago, IL, USA James A. Dickerson II, MD Department of Surgery, Duke University Medical Center, San Antonio, TX, USA Kevin El-Hayek, MD Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA Contributors xvii Aaron S. Fink, MD VA Medical Center Atlanta, Emory University School of Medicine, Decatur, GA, USA Morris E. Franklin Jr., MD, FACS Texas Endosurgery Institute, San Antonio, TX, USA Frederick L. Greene, MD, FACS Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA Rahul Gupta, MBBS, MS, DNB Division of General Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA Michael D. Holzman, MD, MPH Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA Michael D. Honaker, MD Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA Jennifer Hrabe, MD Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Eric S. Hungness, MD, FACS Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA Amila Husic, MD Department of General Surgery, Lahey Clinic, Burlington, MA, USA Daniel B. Jones, MD, MS Department of Surgery, Division of General Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA Andreas Kirakopolous, MD Department of Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA Michael Lalla, MD Department of Surgery, St. Vincent’s Hospital, Indianapolis, IN, USA Minh B. Luu, MD Department of General Surgery, Rush University Medical Center, Chicago, IL, USA xviii Contributors Bruce V. MacFadyen Jr., MD, FACS Department of Surgery, Medical College of Georgia, Augusta, GA, USA Jeffrey M. Marks, MD, FACS Department of General Surgery, Case Western Reserve Medical Center, University Hospitals of Cleveland, Cleveland, OH, USA Timothy Mayfield, MD Surgix Minimally Invasive Surgery Institute, Shawnee Mission Medical Center, Shawnee Mission, KS, USA John J. Meehan, MD Robotic Surgery Center, Seattle Children’s Hospital, Seattle, WA, USA John D. Mellinger, MD, FACS Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA W. Scott Melvin, MD, FACS Department of Surgery, The Ohio State University, Columbus, OH, USA Carmen L. Mueller, BSc, MD Division of General Surgery, University of Toronto, Toronto, ON, Canada Allan Okrainec, MD, MHPE, FRCSC, FACS Department of Surgery, University of Toronto, Toronto, ON, Canada Dmitry Oleynikov, MD Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA Pradeep Pallati, MBBS Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA Adrian Park, MD, FRCSE, FACS, FCS (ECSA) Department of Surgery, Anne Arundel Health System, Annapolis, MD, USA Chan W. Park, MD Department of Surgery, Duke University Medical Center, Durham, NC, USA Contributors xix Joseph B. Petelin, MD, FACS Department of Surgery, University of Kansas School of Medicine, Shawnee Mission, KS, USA Melissa S. Phillips, MD Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA Jeffrey L. Ponsky, MD, FACS Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA Aurora D. Pryor, MD Department of Surgery, Duke University Medical Center, Durham, NC, USA John Rodriguez, MD Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA Michael J. Rosen, MD Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA Karla Russek, MD Texas Endosurgery Institute, San Antonio, TX, USA Byron F. Santos, MD Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA Bruce David Schirmer, MD, FACS Department of Surgery, University of Virginia, Charlottesville, VA, USA Carol E.H. Scott-Conner, MD, PhD Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Jessica K. Smith, MD Department of Surgery, Iowa City VA Medical Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Nathaniel J. Soper, MD Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA xx Contributors Steven C. Stain, MD Department of Surgery, Albany Medical School, Albany, NY, USA Nathaniel Stoikes, MD Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA Raphael Sun, MD Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Erica R.H. Sutton, MD University of Louisville School of Medicine, Louisville, KY, USA Lee L. Swanstrom, MD, FACS Department of Surgery, Oregon Health Sciences University, Portland, OR, USA Thadeus L. Trus, MD Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Brian T. Valerian, MD Department of Surgery, Albany Medical School, Albany, NY, USA J. Esteban Varela, MD, MPH, FACS Division of General Surgery, Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA Gary C. Vitale, MD Department of Surgery, University of Louisville, Louisville, KY, USA Jarrod Wall, MB, BCh, PhD Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA Jeremy A. Warren, MD Department of Surgery, Georgia Health Sciences University, Augusta, GA, USA Jessemae Welsh, MD Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Part I Basic Laparoscopy and Endoscopy: General Principles 1. Fundamentals of Laparoscopic Surgery (FLS) and of Endoscopic Surgery (FES) Jeffrey M. Marks, M.D., F.A.C.S. The Fundamentals of Laparoscopic surgery (FLS) is a validated program for the teaching and evaluation of the basic knowledge and skills required to perform laparoscopic surgery. The educational component includes didactic, Web-based material and a simple, affordable physical simulator with specific tasks and a recommended curriculum. FLS certification requires passing both a written multiple-choice examination and a proctored manual skills examination in the FLS simulator. The metrics for the FLS program has been rigorously validated to meet the highest educational standards and certification is now a requirement for the American Board of Surgery. This chapter summarizes the validation process and the FLS related research that has been done to date. The FLS program was developed by surgeons, educators, and administrators, under the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The impetus to create this curriculum was born out of the need to safely introduce laparoscopic techniques into clinical practice and by the demand to demonstrate basic competence in the application of this new technology. In the early years of laparoscopy, some surgeons integrated these techniques into their practices after cursory weekend courses or animal labs. Unfortunately, an increase in bile duct injuries and other complications occurred during the early experience with laparoscopic cholecys- tectomies. This critical issue of patient safety was the initial driver for the FLS effort. Around the same time, the concept of simulation in medicine was also starting to gain popularity, especially in light of restricted resident work hours and limited operating room resources. N.J. Soper and C.E.H. Scott-Conner (eds.), The SAGES Manual: Volume 1 3 Basic Laparoscopy and Endoscopy, DOI 10.1007/978-1-4614-2344-7_1, © Springer Science+Business Media, LLC 2012 4 J.M. Marks A. Program Description and Components The FLS Program is not procedure or discipline-specific. It includes both teaching and assessment components. 1. Web-Based Study Guide a. Didactic modules (Fig. 1.1) i. Preoperative considerations ii. Intraoperative considerations iii. Basic laparoscopic procedures iv. Postoperative care and complications v. Manual skills practice b. Patient scenarios c. Technical skills explanations Fig. 1.1. Web-based study guide for FLS. 1. Fundamentals of Laparoscopic Surgery (FLS)… 5 2. Assessment Tool The assessment of this didactic material is done in the form of a 90-min multiple-choice examination of 75 questions. The computer-based test must be taken in a proctored setting at designated testing centers. It includes standard multiple-choice questions as well as case-based scenarios, and sometimes asks the examinee to interpret digital images. 3. Manual Skills (Fig. 1.2) a. Five tasks performed in a box trainer with a built-in camera that is connected to a monitor (not included). b. The kit also contains a set of instruments and disposable sup- plies. FLS is modeled after the original program developed by Fried et al., and previously referred to as the McGill Inanimate System for the Training and Evaluation of Laparoscopic Skills (MISTELS). Fig. 1.2. Manual skills tests for FLS. 6 J.M. Marks c. The tasks are scored for efficiency and precision, and each task has a predetermined cutoff time. The scores have been normalized and are equally weighted. A higher score indicates superior performance. i. Peg transfer ii. Precision cutting iii. Placement of a ligating loop iv. Suturing using extracorporeal knot tying v. Suturing using intracorporeal knot tying 4. Global Operative Assessment of Laparoscopic Skills (GOALS) The Global Operative Assessment of Laparoscopic Skills (GOALS) is a validated measure of intraoperative laparoscopic skill, and a high positive correlation exists between FLS manual skill performance and GOALS scores in the operating room during dissection of the gallblad- der from the liver bed. B. FLS Simulator Practice Improves Operating Room Performance The true test regarding the effectiveness of the FLS manual skills program as a training program is whether or not the skills acquired and measured in the simulator transfer to the operating room. Sroka et al. recently conducted a randomized controlled trial examining the effects of training using the FLS proficiency based curriculum described by Ritter and Scott on operating room performance as measured by GOALS. The FLS-trained group achieved the proficiency goals and improved significantly (increased by 6.1 ± 1.3, p < 0.01) in the operating room compared to the control group whose GOALS scores remained unchanged (increased by 1.8 ± 2.1, p = 0.47). After 2.5 h of supervised practice, and 5 h of individual deliberate practice, the simulator group, composed of first and second year residents performed at the level of third and fourth year residents in a previous study. They acquired skills in the simulator in 7.5 h that they may have otherwise acquired during 1 or 2 years of residency training! 1. Fundamentals of Laparoscopic Surgery (FLS)… 7 C. Fundamentals of Endoscopic Surgery (GOALS) Many of the same issues that prompted the development of FLS are apparent in the training of competent flexible endoscopists both in the fields of gastroenterology and gastrointestinal surgery. The importance of these skills for surgeons is rapidly increasing as we work toward the development of increasingly less invasive methods to treat gastrointestinal disease. In response to the need for an objective way to teach and assess the knowledge and skills required to perform basic flexible endoscopy, members of SAGES began to discuss the possibility of developing a flexible gastrointestinal endoscopy teaching and evaluation program, similar to FLS, that could serve as a benchmark for physicians of all specialties. Through this discussion, Fundamentals of Endoscopic Surgery (FES) was born. At the time of preparation of this chapter, the program is still being developed and validated, with the intention to launch the program by Fall 2011. Similar to FLS, the FES Program is not procedure or discipline- specific and includes teaching and assessment components. 1. Web-Based Study Guide a. Didactic modules (Figs. 1.3 and 1.4) i. Technology ii. Patient preparation iii. Sedation and analgesia iv. Upper gastrointestinal endoscopy v. Lower gastrointestinal endoscopy vi. Performing lower GI procedures vii. Lower GI anatomy, pathology, and complications viii. Didactic Endoscopic Retrograde Cholangiopancreato- graphy (ERCP) ix. Hemostasis x. Tissue removal xi. Enteral access xii. Endoscopic therapies 8 J.M. Marks Fig. 1.3. Web-based study guide pages for FES. Fig. 1.4. Web-based study guide pages for FES. 1. Fundamentals of Laparoscopic Surgery (FLS)… 9 2. Assessment Tool The assessment of this didactic material is done in the form of a 90-min multiple-choice examination of 75 questions. The computer-based test must be taken in a proctored setting at designated testing centers. It includes standard multiple-choice questions as well as case-based scenarios, and sometimes asks the examinee to interpret digital images. 3. Manual Skills a. It consists of five separate modules administered on the Simbionix GI Mentor II platform (Fig. 1.5). b. Because of the cost of this platform, it is envisioned that the test will initially be given at regional testing centers around the world. Eventually, the goal is to develop a desktop testing Fig. 1.5. Simbionix GI Mentor II for FES hands on skills (GI Mentor, Simbionix, USA). 10 J.M. Marks platform, which could be more easily distributed to individual training programs. i. Module 1—Navigation (traversal, tip deflection, and torque) (Fig. 1.6a) ii. Module 2—Loop reduction iii. Module 3—Retroflexion (Fig. 1.6b) iv. Module 4—Mucosal evaluation (Fig. 1.6c) v. Module 5—Targeting (Fig. 1.6d) 4. Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) was developed by expert endoscopists and educators. The fundamental skills required for flexible endoscopy were identified and Fig. 1.6. Manual skills tests for FES. (a) Navigation (traversal, tip deflection, and torque); (b) Retroflexion; (c) Mucosal evaluation; (d) Targeting (GI Mentor, Simbionix, USA). Fig. 1.6. (continued) 12 J.M. Marks Fig. 1.6. (continued) then distilled into two global assessments: GAGES Upper Endoscopy (GAGES-UE) and GAGES Colonoscopy (GAGES-C). The assessments were modeled after the Objective Structured Assessment of Technical Skills (OSATS) for open surgery and the GOALS for laparoscopic surgery and consist of itemized skills rated on a 5-point Likert scale with anchors at 1, 3, and 5. D. Conclusion The concept that merits reiteration is the notion that passing FLS, and eventually FES, does not indicate that an individual is a competent surgeon or endoscopist, but that they have demonstrated competence in the basic knowledge and technical skills required to safely perform these procedures. Just as one would expect that a trainee learn the differences 1. Fundamentals of Laparoscopic Surgery (FLS)… 13 between needle drivers and suture materials and how to suture and tie knots outside of the operating room, these programs attempt to assure a basic level of knowledge and skill before entering the clinical arena. Overall, the goal is to optimize patient safety and the utilization of operating room resources while improving the efficiency and quality of surgical education. Selected References Clarke JR. Making surgery safer. J Am Coll Surg. 2005;200:229. Derossis AM, Antoniuk M, Fried GM. Evaluation of laparoscopic skills: a 2-year follow- up during residency training. Can J Surg. 1999;42:293. Fried GM, Feldman LS, Vassiliou MC, et al. Proving the value of simulation in laparoscopic surgery. Ann Surg. 2004;240:518–25. discussion 525–8. McCluney AL, Vassiliou MC, Kaneva PA, et al. FLS simulator performance predicts intraoperative laparoscopic skill. Surg Endosc. 2007;21:1991–5. Sroka G, Feldman LS, Vassiliou MC, et al. Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial. Am J Surg. 2010;199(1):115–20. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101. 2. Maintenance of Certification Jo Buyske, M.D. A. Introduction 1. Definition of Maintenance of Certification Maintenance of Certification (MOC) is the documentation of a personal program of continuous learning and improvement. MOC is required for ongoing certification by the American Board of Surgery and starts immediately upon initial certification or recertification. MOC crosses all specialties. It was established in 2002 by the American Board of Medical Specialties, a federation of 24 member boards. It is the logical continued growth of the process of board certification and also answers the public demand for demonstration of quality and ongoing acquisition of knowledge. 2. History of Board Certification Board certification in the USA has evolved since its inception in 1917. The American Board of Ophthalmology was the first board formed, inspired by a 1908 speech to the American Academy of Ophthalmology and Otolaryngology by Derrick Vail, an ophthalmologist. He stated: I hope to see the time when ophthalmology will be taught in this country as it should be taught. That day will come when we demand… that a certain amount of preliminary education and training be enforced before a man may be licensed to practice ophthalmology. After a sufficiently long term of service in an ophthalmic institution … he should be permitted to appear before a proper examining board for examination… and if he is found competent let him then be permitted and licensed to practice ophthalmology. N.J. Soper and C.E.H. Scott-Conner (eds.), The SAGES Manual: Volume 1 15 Basic Laparoscopy and Endoscopy, DOI 10.1007/978-1-4614-2344-7_2, © Springer Science+Business Media, LLC 2012 16 J. Buyske That speech inspired the formation of the American Board of Ophthalmology in 1917, and in 1937 the American Board of Surgery was formed. The original mission statement of the ABS notes that the Board is formed to “protect the public and improve the specialty” which was to be accomplished by the establishment of a comprehen- sive, standardized certification process, including periodic assessment of individual hospitals as appropriate places of training, the requirement of 5 years of training beyond internship, and the development of an examination process designed to assess both knowledge and judgment. 3. Background of MOC From 1937 until 1976 certification was lifelong: once certified, noth- ing further was required for the duration of one’s surgical career. In 1976, the American Board of Surgery formally recognized that surgery is a field that requires ongoing active engagement in learning and that this should be supported by requiring recertification. Recertification requirements included: submission of a case log, assessment of knowledge by a broad-based multiple choice exam with a passing score, proof of active license and hospital privileges, and testimonials from hospital officials including the chief of surgery. The decision to implement intermittent reassessment for recertification was supported by the outcome. The results of those first recertification exams confirmed that the body of knowledge of surgeons 20 or 30 years out of training was not the same as that of surgeons within 10 years of their training; the former group failed the exam in high numbers. A confluence of events at the turn of the century caused the specialty boards to revisit the duration of certification yet again. Increased public scrutiny of patient safety, the issuance of the IOM report “To Err is Human” in 1999, and the highly successful safety campaign by the air- line industry all drove focus towards more oversight of knowledge and training. In addition, surgery underwent a series of rapid changes, including the widespread adoption of laparoscopy, the development of endo- vascular surgery, the introduction of sentinel node technology, the discovery of Helicobacter pylori, the penetration of interventional endoscopy, and the increased use of noninvasive management of blunt trauma. All these things combined to make it clear that surgical training and practice were dynamic arenas that required ongoing attention and self- education. 2. Maintenance of Certification 17 B. Defining MOC MOC is a result of that reassessment. MOC changes the emphasis from a burst of studying every 10 years to that of an ongoing process of learning and assessment. It is broken into four categories, based upon the ABMS/ACGME Six Competencies, adopted in 1999. The Six Competencies are a rubric for resident education and assessment across all specialties. Programs are required to demonstrate that their curriculum addresses these arenas. The competencies are as follows: Patient Care and Procedural Skills: Provide care that is com- passionate, appropriate and effective treatment for health problems and to promote health. Medical Knowledge: Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care. Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound, uses effective listening skills with nonverbal and verbal communication; working as both a team member and at times as a leader). Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations. Systems-Based Practice: Demonstrate awareness of and responsibility to larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g., coordinating care across sites or serving as the primary case manager when care involves multiple specialties, profes- sions or sites). Practice-Based Learning and Improvement: Able to investi- gate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their practice of medicine. 18 J. Buyske C. Components of MOC 1. Categories/Components of MOC for Surgeons MOC combines the Six Competencies and condenses them into four categories. The components of MOC are as follows: Part 1—Professional standing through maintenance of an unrestricted medical license, hospital privileges and satisfactory references. Part 2—Lifelong learning and self-assessment through continuing education and periodic self-assessment. Part 3—Cognitive expertise based on performance on a secure examination. Part 4—Evaluation of performance in practice through tools such as outcome measures and quality improvement programs, and the evaluation of behaviors such as communication and professionalism. 2. Fulfilling the MOC Requirements for Surgery As is true of the field of surgery, MOC is an evolving field. Parts I and 3 are straightforward. Part 1 includes submission of documentation of an unrestricted license, and hospital privileges, as well as a testimonial form filled out by the chief of surgery and chair of the credentials committee. This is to be submitted once every 3 years. Part 3 is the familiar “recertification” examination, which still must be taken once every 10 years. Admissibility to that exam will include timely fulfillment of all other MOC requirements, as well as a case log. Parts 2 and 4 have a lot of promise, and are both more complicated and more interesting. Part 2 is self-assessment. In surgery, this will be fulfilled by CME I credits, especially those that require self-assessment. 30 credits will be required each year, 20 of which must be self-assessment. Standards for satisfactory self-assessment are under development by the ABS. Standards currently include CME 1 products that include a self test, which must be passed with a minimum 75% correct. Live activities, enduring materials, journal-based reading, and skills training are all offerings eligible for self-assessment. SAGES offers vehicles for self-assessment, both at the annual meeting and via the online SAGES University (http://www.sages.org/education/university.php). 2. Maintenance of Certification 19 SAGES University is available free to SAGES members and includes SAGES Journal Club, Online Self-Assessment Program (OSAP), and my CME/MY MOC Web page. A partial list of other self-assessment vehicles are listed on the ABS Web page (http://home.absurgery.org/ default.jsp?exam-moccme). Part II MOC reporting to the ABS will be required each 3-year cycle, along with Parts 1 and 4. Future plans for Part 2 MOC include linking the CME subject areas to case logs and practice, as well as using this venue for continuing education in ethics, professionalism, and perhaps systems-based practice. Ideally, Part 2 requirements will eventually link to requirements of other certifying and licensing groups, such as state licensing boards, hospital credential committees, the Joint Commission, and others. Professional societies including SAGES are providing multiple pathways to achieve those self-assessments credits that are meaningful to an individual’s learning and pertinent to his or her practice. Part 4 is the evaluation of performance in practice. To fulfill Part IV, the ABS currently requires participation in an outcomes database. At present a wide variety of databases fulfills this requirement, including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the American College of Surgeons Case Log, Mastery of Breast Surgery (The American Society of Breast Surgeons), participation in the United Network for Organ Sharing (UNOS), participation in bariatric surgery databases offered either by the American College of Surgeons or the American Society of Metabolic and Bariatric Surgery, and many others (for a partial list see http://home.absurgery.org/ default.jsp?exam-mocpa). Currently, participation alone is adequate to fulfill requirements; practice data does not need to be provided. Although the ABS recognizes that actual analysis of one’s own practice and outcomes compared those of one’s peers is ideal, at present no one perfect database exists that allows for such a requirement. Therefore, for now, participation alone is adequate, on the theory that the process of recording one’s own practices is valuable in and of itself. Future plans for Part 4 MOC include a single, unified database for ABS use that is currently under development by the American College of Surgeons. In addition, a requirement of assessment of communication skills based upon patient surveys will likely be included in Part IV as well (Table 2.1). MOC, when mature, will provide both a vehicle and a requirement for surgeons to structure their learning and measure their practices and outcomes. In practice, the ABS Web site will guide practitioners through the existing requirements, as well as updates as high-quality vehicles for Parts 2 and 4 continue to emerge. 20 J. Buyske Table 2.1. ABS MOC requirements timeline. MOC year MOC requirement 0 Year of certification or recertification 1 Yearly CME (30 h Category I, 50 overall) 2 Yearly CME 3 Yearly CME → Diplomate submits information through the ABS Web site regarding medical license, hospital privileges, references, CME and practice assessment participation 4 Same as Year 1 5 Same as Year 2 6 Same as Year 3 7 Same as Year 1 8 Same as Year 2 9 Same as Year 3 8–10 Secure examination (application and 12-month operative log required) MOC Year July 1 to June 30, starting July 1 following certification or recertification Used with permission of the American Board of Surgery Selected References ACGME Outcomes Project. http://www.acgme.org/outcome/comp/GeneralCompetencies Standards21307.pdf. Accessed 6 July 2011. Maintenance of Certification. http://home.absurgery.org/default.jsp?exam-moc. Accessed 6 July 2011. SAGES ACCME Compliance. http://www.sages.org/education/university.php. Accessed 6 July 2011. To Err is Human: 1999 Reports Brief. http://www.iom.edu/~/media/Files/Report%20 Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20 report%20brief.pdf. Accessed 6 July 2011. 3. Equipment Setup and Troubleshooting Mohan C. Airan, M.D., F.A.C.S. A. Room Layout and Equipment Position 1. General considerations include the size of the operating room, location of doors, outlets for electrical and anesthetic equipment, and the procedure to be performed. The time required to position the equipment and operating table is well spent. Arrive at the operating room sufficiently early to assure proper setup and to ascertain that all instruments are available and in good working order. This is particularly important when a procedure is being done in an operating room not normally used for laparoscopic operations, or when the operating room personnel are unfamiliar with the equipment (e.g., an operation performed after hours). 2. Determine the optimum position and orientation for the operating table. If the room is large, the normal position for the operating table will work well for laparoscopy. 3. Small operating rooms will require diagonal placement of the operating table and proper positioning of the laparoscopic accessory instruments around the operating table. 4. Robotic systems and their effect on operating room space. If used, the da Vinci® robot requires significant space for surgeon console, slave CRT screens for operating room team view- ing, as well as the surgical arm cart. 5. An equipment checklist helps to ensure that all items are available and minimizes delays once the patient has arrived in the operating room. The following is an example of such a checklist. Most of the equipment and instruments listed here will be needed for operative laparoscopy. Additional equipment N.J. Soper and C.E.H. Scott-Conner (eds.), The SAGES Manual: Volume 1 21 Basic Laparoscopy and Endoscopy, DOI 10.1007/978-1-4614-2344-7_3, © Springer Science+Business Media, LLC 2012 22 M.C. Airan may be needed for advanced procedures. This is discussed in subsequent sections. a. Anesthesia equipment b. Electric operating table with remote control if available c. Two video monitors d. Suction irrigator e. Electrosurgical unit, with grounding pad equipped with current monitoring system f. Ultrasonically activated scissors, scalpel, or other specialized unit if needed g. Laparoscopic equipment, generally housed in a cart on wheels: i. Light source ii. Insufflator iii. Videocassette recorder (VCR), other recording system, tapes iv. Color printer (optional) v. Monitor on articulating arm vi. Camera-processor unit h. C-arm X-ray unit (if cholangiography is planned) with remote monitor i. Mayo stand or table with the following instruments: i. #11, #15 scalpel blades and handles ii. Towel clips iii. Veress needle or Hasson cannula iv. Gas insufflation tubes with micropore filter v. Fiber-optic cable to connect laparoscope with light source vi. Video camera with cord vii. Cords to connect laparoscopic instruments to the electrosurgical unit and other energy sources viii. 6-in. curved hemostatic forceps ix. Small retractors (Army-Navy or S-retractors) x. Trocar cannulae (size and numbers depend on the planned operation, with extras available in case of accidental contamination) xi. Laparoscopic instruments Atraumatic graspers Locking toothed jawed graspers Needle holders 3. Equipment Setup and Troubleshooting 23 Dissectors: curved, straight, right angled Bowel grasping forceps Babcock clamp Scissors: Metzenbaum, hook, microtip Fan retractors: 10 mm, 5 mm Specialized retractors, such as endoscopic curved retractors Biopsy forceps Tru-Cut biopsy-core needle xii. Port site closure devices xiii. Monopolar electrocautery dissection tools L-shaped hook Spatula tip dissector/coagulator xiv. Ultrasonically activated scalpel (optional) Scalpel Ball coagulator Hook dissector Scissors dissector/coagulator/transector xv. Endocoagulator probe (optional) xvi. Basket containing: Clip appliers Endoscopic stapling devices Pretied suture ligatures—endoloops, etc. Endoscopic suture materials Extra trocars j. Robot holder if available B. Room and Equipment Setup 1. With the operating table positioned, and all equipment in the room, reassess the configuration. Once the patient is anesthe- tized and draped, it is difficult to reposition equipment. Consider the room size (as previously discussed), location of doors (particularly if a C-arm is to be used), and the quadrant of the abdomen in which the procedure will be performed. Figure 3.1 shows a typical setup for a laparoscopic cholecystectomy or other procedure in the upper abdomen. Figure 3.2 illustrates a typical setup in a small operating room. 24 M.C. Airan Fig. 3.1. Basic room setup. This is the typical setup for laparoscopic cholecystectomy. The room must be sufficiently large to accommodate all of the equipment (see Fig. 3.2 for setup for smaller room). A similar setup can be used for hiatus hernia repair or other upper abdominal surgery. In these cases, one 21-in. or larger monitor can be used in the center where the anesthesiologist usually sits, with the anesthesiologist positioned to the side. The position of the surgeon (S), camera holder (C), and the assistant (A) depends on the procedure that is planned. The best position for the monitor is opposite the surgeon in his line of sight. A C-arm, if used, should be placed perpendicular to the operating table. A clear pathway to the door facilitates placement of the C-arm, and should be planned when the room is set up. 3. Equipment Setup and Troubleshooting 25 Fig. 3.2. Laparoscopic cholecystectomy, small operating room. The monitors, anesthesia machine, and relative position of surgeon and first assistant have been adapted to the diagonal operating table placement. 26 M.C. Airan 2. Set up the equipment before bringing the patient into the operating room. A systematic approach, starting at the head of the table, is useful. a. There should be sufficient space to allow the anesthesiologist to position the anesthesia equipment and work safely. b. Next, consider the position of the monitors and the paths that connecting cables will take. Try to avoid “fencing in” the surgeon and assistants. This is particularly important if surgeon and assistant need to change places or move (for example, during cholangiography). c. The precise setup must be appropriate to the planned procedure. The setup shown is for laparoscopic cholecystectomy or other upper abdominal procedures. Room and equipment setups for other laparoscopic operations are discussed with each individual procedure in the chapters that follow. A useful principle to remember is that the laparoscope must point toward the quadrant of the abdomen with the pathology, and the surgeon generally stands opposite the pathology and looks directly at the main monitor. d. If a C-arm or other equipment will need to be brought in during the procedure, plan the path from the door to the operating table in such a manner that the equipment can be positioned with minimal disruption. This will generally require that the cabinet containing the light source, VCR, insufflator, and other electronics be placed at the side of the patient farthest from the door. Consider bringing the C-arm into the room before the procedure begins. e. Additional tables should be available so that water, irrigat- ing solutions, and other items are not placed on any electrical units where spillage could cause short circuits, electrical burns, or fires. 3. Check the equipment and ascertain the following: a. If no piped-in lines are available, there should be two full carbon dioxide cylinders in the room. One is used for the procedure, and the second is a spare in case the pressure in the first cylinder becomes low. The cylinder should be hooked up to the insufflator and the valve turned on. The pressure gauge should indicate that there is adequate gas in the cylinder. If the cylinder does not appear to fit properly, do not force it. Each type of gas cylinder has a unique kind 3. Equipment Setup and Troubleshooting 27 of fitting, and failure to fit properly may indicate that the cylinder contains a different kind of gas (e.g., oxygen). The piped-in lines should be color coded and connected to appropriate intake valves. b. If the carbon dioxide cylinder needs to be changed during a procedure: i. Close the valve body with the proper handle to shut off the gas (old cylinder). ii. Unscrew the head fitting. iii. Replace the gasket in the head fitting with a new gasket, which is always provided with a new tank of gas. iv. Reattach the head fitting so that the two prongs of the fitting are seated in the two holes in the carbon dioxide gas tank valve body. v. Firmly align and tighten the head fitting with the inte- gral pointed screw fixture. vi. Open the carbon dioxide gas tank valve body, and pressure should be restored to the insufflator. c. Look inside the back of the cabinet housing the laparoscopic equipment. Check to be certain that the connections on the back of the units are tightly plugged in (Fig. 3.3). 4. Attention to detail is important. The following additional items need careful consideration, and can be checked as the patient is brought into the room and prepared for surgery: a. Assure table tilt mechanism is functional, and that the table and joints are level and the kidney rest down. b. Consider using a footboard and extra safety strap for large patients. c. Position patient and cassette properly on operating table for cholangiography. d. Notify the radiology technologist with time estimate. e. Assure proper mixing and dilution of cholangiogram con- trast solution for adequate image. f. Assure availability of Foley catheter and nasogastric tube, if desired. g. Assure all power sources are connected and appropriate units are switched on. Avoid using multiple sockets or extension cords plugged into a single source, as circuits may overload. h. Check the insufflator. Assure that insufflator alarm is set appropriately. 28 M.C. Airan Fig. 3.3. Connections on rear panel. The actual configuration of connections on the rear panels varies, but there are some general principles that will help when tracing the connections. The video signal is generated by the camera box. A cable plugs into the “video out” port of the camera box and takes the video signal to the VCR or monitor by plugging into a “video in” port. A common arrangement takes the signal first to the VCR, and then from the “video out” port of the VCR to the “video in” port of the monitor. (see Chap. 9, Documentation). Some cameras have split connectors that must be connected to the proper ports. Once connected, these should not be disturbed. The surgeon should be familiar with the instrumentation, as connections frequently are loose or disconnected. The last monitor plugged in should have an automatic termination of signal port to avoid deterioration of the picture quality. i.Assure full volume in the irrigation fluid container (recheck during case). j. Assure adequate printer film and video tape if documentation is desired. k. Check the electrosurgical unit; make sure the auditory alarm of the machine is functioning properly and the grounding pad is appropriate for the patient, properly placed, and functioning. l. The surgeon should specify the electrosurgical unit that he uses. m. Apply S.C.D.’s 3. Equipment Setup and Troubleshooting 29 5. Once you are gowned and gloved, connect the light cable and camera to the laparoscope. Focus the laparoscope and white balance it. Place the laparoscope in warmed saline or electrical warmer. Verify the following: a. Check Veress needle for proper plunger/spring action and assure easy flushing through stopcock and/or needle channel. b. Assure closed stopcocks on all ports. c. Check sealing caps for cracked rubber and stretched openings. d. Check to assure instrument cleaning channel screw caps are in place. e. Assure free movements of instrument handles and jaws. f. If Hasson cannula to be used, assure availability of stay sutures and retractors. C. Types of Equipment Available 1. Electrosurgical Units a. Simple E.S.U.—coagulation and cut features—use AEM technology overlay machine. b. Complex E.S.U.—ForceTriad™ energy platform comprises monopolar, bipolar, and proprietary functions utilizing LigaSure™ tissue fusion technology, the Force Triverse™ electrosurgical device, and Valleylab™ mode (Figs. 3.4–3.6). c. Ultrasonic machines. D. Troubleshooting 1. Laparoscopic procedures are inherently complex. Many things can go wrong. The surgeon must be sufficiently familiar with the equipment to troubleshoot and solve problems. Table 3.1 gives an outline of the common problems, their cause, and suggested solutions. 30 M.C. Airan Fig. 3.4. ForceTriad™ energy platform front panel. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices division of Covidien. The ForceTriad™ is an electrosurgical all in one unit. The bipolar device allows surgeons, urologists, gynecologists to perform in a saline environment. Tissue fusion technology permanently fuses vessels up to 7 mm, lymphatic and tissue bundles. The devices can divide the structures as soon as fusion is accomplished. Valleylab™ mode provides equal or superior hemostasis than standard valley lab E.S.U. The touch screens’ screen displays change based on instrument recognition technology. Each instrument has its own electronic signature recognized by the unit. Fig. 3.5. Force TriVerse™ electrosurgical device. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices division of Covidien. The surgeon can change the settings from the sterile field freeing up the circulating RN for other duties. 3. Equipment Setup and Troubleshooting 31 Fig. 3.6. LigaSure™ Impact instrument. ©2010 Covidien. All rights reserved. Image reprinted with permission from the Energy-based Devices division of Covidien. Used for open surgery to fuse and divide. The function is more economical than using vascular staplers for small vessels. 2. General Troubleshooting Guidelines—ForceTriad™ energy platform. If the Force Triad™ energy platform malfunctions, check for obvious conditions that may have caused the problem: a. Check the system for visible signs of physical damage. b. Make sure the fuse drawer is tightly closed. c. Verify that all cords are connected and attached properly. d. If an error code is displayed on the touch screens, note the code along with all information on the error screen, then turn the system off and turn it back on. 32 Table 3.1. Common problems, causes, and solutions. Problem Cause Solution 1. Poor insufflation/loss CO2 tank empty or volume low Change tank M.C. Airan of pneumoperitoneum Accessory port stopcock(s) open Inspect all accessory ports. Open/close stopcock(s) as needed Leak in sealing cap, reducer Change cap or stopcock cannula Excessive suctioning pressure Allow time to reinsufflate, lower suction Loose, disconnected, or kinked insufflation tubing Tighten connections or reconnect at source or at port, unkink tubing Hasson stay sutures loose Replace or secure sutures CO2 flow rate set too low Adjust flow rate Valve on CO2 tank not fully open Use valve wrench to open fully Leak at skin where port enters cavity Apply penetrating towel clip or suture around port 2. Excessive pressure Veress needle or cannula tip not in peritoneal space Reposition needle or cannula under visualization if required for insuffla- possible tion (initial or Occlusion of tubing (kinking, table joints, etc.) Inspect full length of tubing subsequent) CO2 port stopcock turned off Fully open stopcock Patient is “light” Communicate to anesthesia Morbidly obese patient Use longer Veress needle 3. Inadequate lighting Light is dim Increase gain. Check scope for adequate fiber-optics (partial/complete loss) Replace light cable and/or camera Light is on standby Take light off standby Loose connection at source or at scope Adjust connection Light is on “manual-minimum” Go to “automatic” Fiber-optics is damaged Replace light cable Problem Cause Solution Automatic iris adjusting to bright reflection from Reposition instruments, or switch to “manual” instruments Monitor brightness turned down Readjust brightness setting, adjust gain Room brightness floods monitors Dim room lights Bulb is burned out Replace bulb Scope dark Check white balance 4. Lighting too bright Light is on “manual-maximum” “Boost” on light source activated Monitor brightness turned up Go to “automatic,” deactivate “boost,” readjust setting 5. No picture on Camera control or other components (VCR, printer, Make sure all power sources are plugged in and monitor(s) light source, monitor) “not on” turned on Cable connector between camera control unit and/or Cable should run from “video out” on camera control monitors not attached properly unit to “video in” on primary monitor. Use compatible cables for camera unit and light source Cable between monitors not connected Cable should run from “video out” on primary monitor to “video in” on secondary monitor Input selection button on monitor doesn’t match Assure matching selection “video in” choice Input selection button on monitor or video peripher- Adjust input selection als (e.g., VCR, digital capture, printer) not selected 6. Poor-quality picture Flickering electrical interference, poor cable Replace cautery cables, switch camera head, make shielding sure cables don’t cross, use different plug points Color problems White balance camera, monitor chrome on monitor, check printer, VCR, digital capture cables 3. Equipment Setup and Troubleshooting Glare not caused by lighting Check for loose cables not plugged in (continued) 33 34 M.C. Airan Table 3.1. (continued) Problem Cause Solution a. Fogging, haze Condensation on lens from cold scope entering Use antifog solution or warm water, wipe lens warm abdomen externally Condensation on scope eyepiece, camera lens Detach camera from scope (or camera from coupler); inspect, and clean lens as needed b. Flickering, Moisture in camera cable connecting plug Use suction or compressed air to dry out moisture electrical (don’t use cotton-tip applicators on multipronged interference plug) Poor cable shielding Move electrosurgical unit to different circuit or away from video equipment, make sure cables don’t cross, switch camera head; replace cables as necessary Insecure connection of video cable between Reattach video cable at each monitor monitors c. Blurring, Incorrect focus Adjust camera focus ring distortion Cracked lens, internal moisture Inspect scope/camera, replace if needed Too grainy Adjust enhancement and/or grain setting for units with this option Problem Cause Solution 7. Inadequate suction/ Occlusion of tubing (kinking, blood clot, etc.) Inspect full length of tubing. If necessary, detach from irrigation instrument and flush tubing with sterile saline Occlusion of valves in suction/irrigator device Detach tubing, flush device with sterile saline Not attached to wall suction Inspect and secure suction and wall source connector Irrigation fluid container not pressurized Inspect pressure bag or compressed gas source, connector, pressure dial setting 8. Absent or “weak” Patient not grounded properly Assure adequate grounding pad contact cauterization Connection between electrosurgical unit and Inspect both connecting points instrument loose Foot pedal or hand-switch not connected to Make connection electrosurgical unit Wrong output selected Correct output choice Connected to the wrong socket on the Check that cable is attached to endoscopic socket electrosurgical unit Instrument insulations failure outside of the Use new instrument and inspect insulation surgeon’s view Reprinted with permission from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 3. Equipment Setup and Troubleshooting 35 36 M.C. Airan e. If a solution is not readily apparent, refer to Table 3.2, Correcting Malfunctions, to help identify and correct specific malfunctions. After the malfunction is corrected, verify that the system completes a prescribed self-test. If the malfunction persists, the system may require service. Contact the institution’s biomedical engineering department. 3. REM Alarms. If the ForceTriad™ energy platform does not sense the correct impedance for the connected REM patient return electrode, monopolar energy will be disabled, the REM symbol will illuminate red and enlarge on both the center and left touch- screen displays, and an alarm tone will sound twice. The REM symbol will return to its smaller size but will remain red, and RF energy will remain disabled until the REM alarm is corrected. When the REM alarm is corrected, the system is enabled and the REM alarm indication illuminates green. Valleylab recommends the use of Valleylab REM patient return electrodes. Return electrodes from other manufacturers may not provide proper impedance to work correctly with the ForceTriad™ energy platform. To correct a REM alarm condition, follow these steps: a. Inspect the return electrode plug and cord. If there is evidence of cracks, breaks, or other visible damage, replace the return electrode and/or the cord. b. Verify that the patient return electrode cord is correctly connected to the energy platform. c. Verify that the return electrode is in good contact with the patient. Follow the instructions for use provided with the Valleylab REM patient return electrode. d. If the REM alarm persists it may be necessary to use more than one patient return electrode. Refer to the troubleshooting flow chart in the Valleylab REM patient return electrode instructions for use. E. Patient Safety Issues—Thermal Injury 1. The surgeon must be aware of the possibility of thermal injury when utilizing any of these devices. 2. Unintended radiofrequency burns—Visceral burns may occur by inadvertent direct coupling, capacitative coupling, and/or insulation failures. This can happen during da Vinci® robotic surgery, single port surgery, or NOTES surgery. Table 3.2. Correcting malfunctions. Situation Possible causes Solution Abnormal neuromus- Metal-to-metal sparking Check all connections to the energy platform, patient cular stimulation return electrode, and active electrodes (stop surgery Can occur during coagulation Use a lower power setting for the Fulgurate and Spray Immediately) modes Abnormal 50–60 Hz leakage currents Contact your biomedical engineering department or a Valleylab technical service representative for assistance Energy platform does Disconnected power cord or faulty wall outlet Check power cord connections (energy platform and not respond when wall outlet). Connect the power cord to a functional turned on outlet Faulty power cord Replace the power cord Fuse drawer is open or fuses are blown Replace the blown fuses(s). Close the fuse drawer Refer to the ForceTriadEnergy Platform Manual Internal component malfunction Use a backup energy platform. Contact your biomedical Engineering department or a Valleylab technical service representative for assistance System is on, but did not Software malfunction Turn off, then turn on the system complete the self-test Internal component malfunction Note the code along with all information on the error screen Note the number and refer to System Alarms in the User’s manual Use a backup energy platform. Contact your biomedi- 3. Equipment Setup and Troubleshooting cal Engineering department or a Valleylab technical service representative for assistance (continued) 37 38 Table 3.2. (continued) Situation Possible causes Solution M.C. Airan Energy platform is on Malfunctioning footswitch or handswitching Turn off the energy platform. Check and correct all and instrument is instrument instrument connections activated but system Turn on the energy platform. Replace the instrument does not deliver if it continues to malfunction output Power is set too low Increase the power setting An alarm conditions exists Note the code along with all information on the error screen. Note the number and refer to System Alarms in the User’s manual In case of a REM alarm, refer to Correcting a REM Alarm Condition in the User’s manual Internal component malfunction Contact your biomedical engineering department or a Valleylab technical service representative for assistance System does not detect tissue fusion instrument Firmly insert the LigaSmart connector into the appropriate receptacle on the energy platform front panel. Ensure the vessel fusion touch screen indicates that it has detected the instrument System does not detect monopolar instrument Firmly insert the Smart connector into the appropriate receptacle on the energy platform front panel. Ensure the monopolar touch screen indicates that it has detected the instrument Situation Possible causes Solution System does not detect bipolar instrument Firmly insert the connector into the appropriate receptacle on the energy platform front panel. Ensure the bipolar touch screen indicates that it has detected the instrument CHECK INSTRUMENT Excessive tissue/eschar on electrode tips or jaws Clean electrode tips and jaws with a wet gauze pad screen appears, a Electrodes have come loose from the instrument Reinsert the electrode into the instrument jaws six-pulsed tone jaws making sure that all the electrode pins are firmly sounds, and RF Electrode pins may have been compromised seated output is disabled or bent during assembly to the instrument and may need to be replaced Metal or other foreign object is grasped Avoid grasping objects, such as staples, clips, or within jaws encapsulated sutures in the jaws of the instrument Tissue grasped within jaws is too thin Open the jaws and confirm that a sufficient amount of tissue is inside the jaws. If necessary, increase the amount of tissue and repeat the procedure Pooled fluids around instrument tip Minimize or remove excess fluids REACTIVATE screen The seal cycle was interrupted before completion. Reactivate the seal cycle without removing or appears, a four-pulsed The handswitch or footswitch was released repositioning the instrument tone sounds, and RF before the end tone activated output is disabled Additional time and energy are needed to complete the fusion cycle Continuous monitor Malfunctioning monitor Replace the monitor (continued) 3. Equipment Setup and Troubleshooting 39 40 M.C. Airan Table 3.2. (continued) Situation Possible causes Solution Interference Faulty chassis-to-ground connections Check and correct the chassis ground connections for the monitor and for the energy platform Check other electrical equipment in the room for defective grounds Electrical equipment is grounded to different Plug all electrical equipment into line power at the objects rather than a common ground. The same location. Contact your biomedical engineer- energy platform may respond to the resulting ing department or a Valleylab representative for voltage differences between grounded objects assistance Interference with other Metal-to-metal sparking Check all connections to the energy platform, patient devices only when return electrode, and instruments instrument the energy platform is High settings used for fulguration Use lower power settings for fulguration activated Electrically inconsistent ground wires in the Verify that all ground wires are as short as possible operating room and go to the same grounded metal If interference continues when the energy platform Some manufacturers offer RF choke filters for use in is activated, the monitor is responding to radiated monitor leads. The filters reduce interference when frequencies the energy platform is activated and minimize the potential for an electrosurgical burn at the site of the monitor electrode Situation Possible causes Solution Pacemaker interference Intermittent connections or metal-to-metal Check the active and patient return electrode cord sparking connections It may be necessary to reprogram the pacemaker Current traveling from active to return electrode Consult the pacemaker manufacturer or hospital during monopolar electrosurgery is passing too cardiology department for further information when close to pacemaker use of electrosurgical appliances is planned in patients with cardiac pacemakers Use bipolar instruments, if possible If you must use a monopolar instrument, place the patient return electrode as close as possible to the surgical site. Make sure the current path from the surgical site to the patient return electrode does not pass through the vicinity of the heart or the site where the pacemaker is implanted Always monitor patients with pacemakers during surgery and keep a defibrillator available Internal Cardiac ICD is activated by energy platform Stop the procedure and contact the ICD manufacturer Defibrillator (ICD) for instructions activation Copyright ©2010 Covidien. All rights reserved. Reprinted with the permission of the Energy-based Devices division of Covidien. 3. Equipment Setup and Troubleshooting 41 42 M.C. Airan Fig. 3.7. Encision® active electrode monitoring unit. ©2010 Encision. All rights reserved. Image reprinted with permission from Encision, Inc. 3. These injuries can be avoided by use of bipolar RF, harmon- ics, or laser or use of active electrode monitoring system such as Encision® (Fig. 3.7). a. Monopolar devices—Thermal injuries can occur at the tip of monopolar instruments. b. Bipolar devices—Bipolar instruments usually do not have an extensive spread around the operating tip if the current used is brief. c. Valleylab ForceTriad™ energy platform—LigaSure™ platform also limits the thermal spread at the operating tip. d. Ultrasonic scalpels can also have thermal spread at the operating tip. 4. Operating room fires. a. Be aware that the light cord tip can become very hot, i.e., the end that goes into the light generator. Do not disconnect hot light cord from light generator if it is close to an oxygen source, i.e., nasal cannula, masks, oropharyngeal tube, endotracheal tubes. This hazard is deadly during extuba- tion. Many patients have been burned. b. Chlora-Prep has alcohol base. The vapors from the preparation can be ignited by Bovie tips, hot ultrasonic tips, etc. 3. Equipment Setup and Troubleshooting 43 Acknowledgments Berdelle, Susan. Office Manager, Mohan C Airan, MD SC. Riechert, John Brian. Energy Based Sales Representative. Covidien. Selected References Podnos Y, Williams R. Fires in the operating room. American College of Surgeons, Committee on Perioperative Care. http://www.facs.org/about/committees/cpc/ oper0897.html. Accessed 28 Mar 2011. Encision Inc. Developer and manufacturer of the patented AEM technology. http://www. encision.com. Accessed 19 Jan 2011. Energy Based Division, Covidien. User’s Guide ForceTriad™ energy platform. Boulder, CO; 2008. ForceTriad Web site. http://www.forcetriad.com. Accessed 19 Jan 2011. SAGES Continuing Education Committee. Laparoscopy Troubleshooting Guide. SAGES, Santa Monica, CA; 2006. http://www.sages.org/publications/troubleshooting/. Accessed 4 Mar 2011. Sony Corporation. Rear panel diagram for Trinitron color video monitor. 1995. 4. Ergonomics in Operating Room Design Erica R.H. Sutton, M.D. Adrian Park, M.D., F.R.C.S.E., F.A.C.S., F.C.S. (ECSA) A. The Human–Machine Interface The operating room (OR) is a complex working environment reliant on high-stakes decision-making that increasingly must take into account interfaces between humans and machines. With the opportunities for error frequent and the consequences potentially grave, the gathering of full, accurate, applicable knowledge regarding these interfaces must be considered of utmost importance. As nearly three decades of minimally invasive surgical advancements have indicated, the cost of conditions ergonomically unfavorable to the surgeon cannot safely be disregarded, for the resulting consequences are surely borne by doctor and patient alike. Achievement of optimal human–machine interfaces in the OR depends on the systematic discovery and implementation of ergonomically sound principles in this challenging workspace. B. Ergonomics Defined The objective of the applied science of ergonomics is ensuring that efficient and safe interaction is possible between things and persons. Ergonomics seeks—as suggested by its Greek roots translatable as “the natural laws of work”—to establish and define people’s relationship to work, which may at once be both physical and cognitive. Ergonomics as applied to OR design is still taking shape as an infor- mative, evidence-based field of research. A good number of mechanical ergonomics studies have appeared that take as their focus the optimal N.J. Soper and C.E.H. Scott-Conner (eds.), The SAGES Manual: Volume 1 45 Basic Laparoscopy and Endoscopy, DOI 10.1007/978-1-4614-2344-7_4, © Springer Science+Business Media, LLC 2012 46 E.R.H. Sutton and A. Park physical and technological working conditions of the OR—monitor placement and display characteristics, table height, instrument design and capability, surgical workflow. Standard ergonomic research into OR design and equipment has elucidated many shortcomings of the working environment, thus far with particular regard to open surgery performance. The research to date, however, primarily offers only suggestions as to what a prototype might do or how it and its end user should interface. Ergonomics, theoretical and applied, has not yet determined what consti- tutes an ideal OR suite or even the most advantageous prototypes needed for efficacious research. Similarly, while staples of our evidence-based literature, the metrics by which we assess cognitive ergonomics—subjective reports of well-being or psychological stress, gaze and attention disruptions, heart-rate variability, or complex indices of mental workload—are not well or often defined in relation to one another and even more rarely in terms of consequence to surgeon or surgical outcome. Correlations to professional longevity and patient safety are often suggested but infre- quently measured. While the definitions of mechanical ergonomics and cognitive ergonomics have gained consensus, their component metrics are at present subjective and substantially lacking validation in the field of medicine. C. Influence of Nonsurgical Ergonomics Given the reality of the significant consideration that must be accorded to the human–machine interface, the introduction of ergonomics as a primary consideration in the design of the OR suite has been in many ways as unsystematic as was the introduction of MIS itself. Prior to its recent acceptance of the potentials to be gained by obtaining and applying ergonomic data gathered in its environments and from its staffs, the medic

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