The pause, or time-out has just been done and the incision has been made.
For a lap appy this is no time to chart and rest on your laurels. Or on your phone, if you’re that type. We all know them.
Everything may be hooked up and ready to go but you, as the circulator, has to be prepared to dim the lights, turn on the camera light, and turn on the gas.
During a lap appy, carbon dioxide or CO2, fills the abdomen and expands the open area between the abdominal wall and musculature and the internal organs. Doing this allows the surgeon to direct the camera in different directions and see different things. The surgeon has be mindful of the angles in placing his trocars. The trocars are the working channels for the instruments. Basically a tube with a sharp end that is introduced through the skin and muscles into the abdominal cavity. There is an art to placing the trocars in. There has to be enough force to go through the muscle layer, but not enough force to damage the organs. It is a fine balance, especially on a skinny person. What most of the surgeons that I’ve worked with do is place the largest trocar at the belly button, take a peek with the camera to make sure they are through the muscle, and call for CO2. This will begin to expand the cavity and make the other smaller trocars easier to place.
I have a story here. In my first hospital in CA, when laparoscopic surgery was first beginning, a surgeon who had been through classes with pigs was putting in the opening trocar. He was unsure of how much resistance the abdominal wall would give so he took this bladed trocar and shoved it in as hard as he could because that was what he understood. You know what is immediately underneath the belly button? All along the back of the peritoneal cavity, underneath the colon and small bowel?
The vena cava.
This is the largest vein the body. It carries all the blood from the periphery back to the heart where it can be re-oxygenated and pumped back out to the body. Yeah. The surgeon knew enough not to pull the trocar back out, and luckily a vascular surgeon was nearby to open and cross-clamp the vena cava so the patient wouldn’t bleed to death. That lap case turned into an open case real quick. But that was years and years ago.
But for this lap appy and patient A, the large 12 mm trocar was introduced without issue. A quick visual was obtained and the surgeon called for CO2. Me being who I am, was standing next to the tower and turned on the flow of CO2. The machine can be tricky, sometimes you have to hit it twice because the first time only turns on the potential for airflow. A pro tip is to wait for the numbers to begin to go up. These numbers refer to the amount of CO2 given. If the numbers are not going up, the trocar is not in the abdomen and must be withdrawn and the cut down began again. Depending on the size of the patient, and the fluffiness of their subq this can happen.
Finally the CO2 numbers are ticking up. This is a good time to do two things at once. Ask the surgeon if the screen is in a good position and check how many bars the CO2 has on the machine. This indicates how much CO2 is in the tank.
If the screen is in a good place, leave it be.
If there are more than 2 bars on the machine, you are probably in a good position. If there is 1 bar, be prepared to change it. This should be part of your pre-case setup but everyone does things a bit different. I always check the bars when I am turning on the video tower, others do not. There should be a spare, unopened tank on the tower. If you have a suspicion that you will run out of CO2, make sure you have a spare and a tank key to switch them out.
You’ve started gas and the abdomen is filling nicely. The next thing that needs to be turned on is the light cord for the camera. Otherwise it is going to be mighty dark in the abdomen. I will discuss the make-up of the light cord at a different time. It is fascinating.
For laparoscopic cases you need lights, camera plugged in, and action by the surgeon.
Sorry, couldn’t resist.
By now the 5 mm working trocars that the laparoscopic instruments can fit down have been inserted. Depending on what kind of case this is there can be 2-3 5mm trocars. Most surgeons use 2.
Take this opportunity to turn off the room lights. This refers to the overhead lights and are controlled by switches by the door.
And dim the spots, or surgical lights as they are very bright.
One can be turned off completely and the other can be dimmed so that the scrub tech has a small amount of light over their back table.
This is now the time to ensure that the auxiliary monitor that the scrub tech uses is in a good position and they can see what the surgeon sees.
With luck the appendix is sitting in plain view on top of the small bowel coils. Otherwise the surgeon might have to go fishing.