Figure 3.12 Mobile cart equipped with NIR/ICG imaging system for laparoscopic and thoracoscopic procedures.
Source: © KARL STORZ SE & Co. KG, Germany.
Integrated and Intelligent Operating Rooms
As the number of devices has increased in MIS, access to each piece of equipment has become a challenge, risking excessive circulation near or within the sterile area. This challenge led to the development of integrative software and hardware platforms, or the integrated room. The integrated OR concept is based on a single‐post control station near the border of the sterile area (Figure 3.13b), which allows a single operator to coordinate, manipulate, manage, and access all information by a network and integration software displayed on one or multiple screens [52].
These integrative platforms optimize the space in the OR while establishing capabilities for teleconferencing and teaching. The internal connection with hospital data management programs and other imaging platforms such as PACS (Picture Archiving and Communication System) also permits surgeons inside the OR to access other diagnostic images simultaneously for navigation or decision‐making during procedures. Although costly, the ease of accessing and producing medical reports, data exchange, and storage can be advantageous in hospitals with large caseloads [53].
Operating Room Setup
The optimal design of an OR has been widely discussed, and standards for OR construction have been published by the American College of Surgeons on the Operating Room Environment and the American Institute of Architects Committee on Architecture for Health. In veterinary medicine, no specific guidelines exist, so common sense and translations from human surgery are used. Several solutions are commonly proposed to reduce equipment crowding and cables or lines crossing the floor in the OR [54–56].
Preparation for Open Surgery
All instrumentation for open surgery should be available in case conversion becomes necessary. The entire surgical team should be prepared for a smooth and expedient transition [9,57–64].
Considerations for a Minimally Invasive Theater or Suite
With the advent of minimally invasive, image‐guided laparoscopic procedures and other enhanced visualization and guidance systems, PACS and electronic medical records, the demands and needs for different qualities, types and intensities of light, as well as variations of brightness and focus in the different zones around the room have become primary functional and design challenges and concerns. Lighting systems today must provide flexibility in terms of intensity in the level and movement of light in the space, so that the system can adapt to the different requirements of open surgery, MIS, or image‐guided procedures. The need for different lighting in different zones within the OR to support the specialized functions during the procedure, and the complexity of the integrated OR control systems has added an additional level of complexity beyond what was seen even in the recent past.
The room must accommodate at least two equipment towers (endoscopy and anesthesia), and space must allow for their free movement to either end of the surgical table. Also, adequate clearance from the patient is required to avoid breaks in sterile technique. Ideally, two to three monitors are positioned either on booms, the equipment towers, or separate wheeled carts [55–58].
Figure 3.13 (A). State‐of‐the‐art integrated operating room with simultaneous multiimaging systems for veterinary image‐guided procedures – pictured ceiling rack mounted fluoroscopy and endoscopy systems. (B). The integrated OR single‐post control station near the border of the sterile area, which allows a single operator to coordinate, manipulate, manage, and access all information by a network and integration software displayed on one or multiple screens.
Source: Photo courtesy of Dr. Allyson Berent – AMC‐NY, USA.
Ergonomic Considerations
Endoscopic surgery challenges the surgeon's natural view of the operating field. One basic ergonomic consideration—the correct position of the video display relative to the user's eyes—is often ignored in veterinary endoscopy. It has been shown that the preferred viewing angle for video displays is between 10 and 25° below the line of sight. Excessive height of monitors may cause neck and back pain for the surgeon. Ceiling booms and mobile stands allow the surgeon to place the monitor at the ideal position [54, 65, 66].
Laparoscopic and thoracoscopic instruments require four to six times more force than open surgery instruments to complete the same task. It is therefore not surprising that surgeons report increased fatigue after endoscopic surgery. Furthermore, endoscopic surgery has changed the surgeon's posture to a more upright axial skeletal posture during laparoscopy compared to open surgery. This upright posture, however, seems to be accompanied by substantially less body movement and weight shifting than during open procedures. Increased static postural fatigue may occur during MIS. With incorrect movements and incorrect postures, surgeons significantly increase the physical load on the shoulder, neck, and arm musculature [56, 66, 67].
As with the monitor positioning, awareness of some basic ergonomic rules that affect the surgeon's posture, such as lowering the height of the OR table to accommodate the increased length of rigid instruments, is lacking in veterinary medicine. The choice of the surgical table is of utmost importance in addressing these ergonomic challenges. Electrically adjustable hydraulic tables allowing Trendelenburg to reverse‐Trendelenburg positioning and lateral side tilt are ideal. V‐top tables are also beneficial because they permit smooth tilting of the patient from one side to the other, facilitating access to different organs during surgery [67–70].
Planning Coordination and Efficiency
The entire surgical team is involved in planning for MIS procedures. A surgical checklist may facilitate preparation. Adequate function and availability of equipment need to be confirmed by the surgeon before anesthesia.
A sample checklist of MIS room assessment is:
Confirm light source working properly and check bulb life (expended hours).
Turn insufflator on and check for gas availability and spare tank.
Check image capture devices for appropriate functioning and storage capacity.
Turn on electrosurgical unit and check for proper function.
Check suction and irrigation equipment and confirm for sterile containers and parts.
Confirm availability of additional hemostasis aids, Gelfoam, etc.
Confirm availability of other disposables necessary (e.g., staplers, graspers, trocars, and surgical loops).
Confirm availability of trays and instrumentation needed for MIS and conventional surgery [56, 58,71–74].
In general,