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, thoracoscopic procedures should be scheduled early in the day because of challenges with anesthesia, such as one‐lung ventilation, as well as the increased potential for complications. Clean laparoscopic procedures are often scheduled after thoracic procedures, and clean‐contaminated procedures that lead to contamination of instrumentation should be scheduled last [75–79].
Fully Equipped Minimally Invasive Surgery Suite: Hybrid Rooms
The combination of endoscopy and fluoroscopy has led to the establishment of interventional endoscopy and radiology. In recent years, the concept has been adopted by the veterinary field. Multipurpose MIS rooms integrating interventional endoscopy and interventional radiology furthered the concept of hybrid rooms (Figure 3.13a).
The above require fluoroscopy equipment (C‐arm), either a floor‐wheeled unit or ceiling boom suspended unit. Radiation protection is required. Endo‐ultrasonography is also a modality commonly available in human medical hybrid settings, though rarely incorporated into veterinary medicine [80–84]. In human hospitals, complex hybrid rooms also comprise interventional computed tomography or interventional magnetic resonance units for intraoperative imaging, navigation, planning, and reconstruction, often mounted on suspended racks [65, 86].
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