Operating Room Positioning, Equipment, and Instrumentation for Laparoscopic Bariatric Surgery

Fig. 1.

Use of lateral transfer device to move patient on and off operating table.

During surgery, we use a supine position with legs together and arms abducted. The patient is positioned and secured at the waist with table straps. The patient is also secured at the legs with tape to keep the knees from flexing apart while in steep reverse Trendelenburg position. The patient’s weight should be evenly distributed on the table without parts of the torso or limbs hanging over the side. Side rail extensions can be used to augment the width of the table. Pneumatic compression devices that accommodate the super-obese patient are placed on the patient prior to induction of anesthesia [12].

After the induction of general anesthesia and endotracheal intubation, a urinary catheter is inserted (often requiring two staff members, one for retraction of skin folds and one for insertion), and a bovie grounding pad is placed usually on the anterior thigh. A foot board is placed on the table so the feet will have a secure base to rest when the patient is in extreme reverse Trendelenburg position.

The surgeon stands on the patient’s right side along with the scrub nurse; the first assistant and the camera operator are on the patient’s left side. The arms may be left out if adequate room is available or one or both may be tucked. Occasionally, when tucking an arm, a metal or plastic limb holder (sled) may be required to secure the arm at the side. This approach also serves to protect the arm.

The base of a stationary retractor-holding device may be attached to the table at this time. Care must be taken that it does not come in direct contact with the patient’s skin to avoid pressure injury or electrocautery conduction.

Prior to prepping and draping the patient, a “final check” is important to be sure that all pressure points are avoided, especially along the side, arms, hands, head, and feet. Sequential compression devices should be placed and turned on (Fig. 2a). Table attachments must be padded appropriately to avoid pressure or nerve injuries (Fig. 2b). Security of the patient on the table and neutrality of joint positioning of the extremities are also confirmed again (Fig. 2c). Of special note is to be certain there is no undue pressure on the gluteal area. A rare complication of rhabdomyolysis has been reported, especially with patients with a BMI 60 or greater. Consequences of rhabdomyolysis include renal failure and death [13, 14]. Heating blankets are helpful in preventing hypothermia related to heat loss from evaporation and continuous insufflation, particularly during operations of long duration.

Fig. 2.

Patient positioning and application of sequential compression device (a). Padded bed extensions should be used for larger patients (b). Inspect for areas of significant pressure, circulatory compromise, neutral positioning of extremities, and patient security to table prior to prepping and draping the abdomen (c).

After prepping and draping the abdomen, setting up the equipment on the field, and assembling the OR team, the working field will appear as depicted in Fig. 3. Some surgeons prefer the “French” or “between the legs” positioning in which the patient’s legs are abducted and the surgeon stands between them with assistants and OR technician flanking him/her. This is described in other chapters. A limitation with this approach is that there may be a little space between the legs due to the girth of the thighs or of the surgeon.

Fig. 3.

The operating team in their places. Primary surgeon is to the patient’s right. First assistant is across from the primary surgeon. Second assistant and scrub nurse are at the foot of the bed.

Laparoscopic Access

The Veress Needle Approach

We utilize a Veress needle to establish a pneumoperitoneum in the obese patient because it is technically very difficult to perform an open cutdown (Hasson) technique. A long-length Veress needle of 150 mm (Autosuture, Division of Tyco Healthcare) (Fig. 4a, b) is inserted using a subcostal incision in the left upper quadrant. The 2-mm needle has a spring-loaded blunt inner cannula that automatically extends beyond the needle point once the abdominal cavity has been entered. This blunt cannula has a side-hole to permit entry of CO₂ gas into the abdominal cavity. Correct position of the Veress needle after it has passed through the abdominal wall can be verified by methods such as the water drop test or by assessing CO₂ pressures and flow. In obese patients, opening intra-abdominal pressures may be high (up to 10–12 cm of H₂O).

Fig. 4.

Standard and long Veress needles.

Insertion of Trocars

In addition to being safe and reliable, trocars and cannulas for laparoscopic bariatric surgery should minimize air leaks, secure readily to the abdominal wall, allow rapid exchange of instruments of various diameters, and be of sufficient length to reach the peritoneal cavity without causing excessive disruption of the abdominal fascia. We currently use a 5-mm optical viewing trocar (Xcel, Ethicon Endosurgery, Cincinnati, OH) for initial access to the peritoneal cavity. The 5-mm scope is placed into the trocar after the camera is white balanced. The focus is adjusted on the end of the clear trocar tip. The trocar is placed through a 5-mm incision and the fatty, fascial, and muscular layers of the abdominal wall are directly visualized as the trocar passes through them (Fig. 5a). After the tip of the trocar passes through the preperitoneal fat and the peritoneum, the camera and obturator are removed, and the insufflations tubing is attached. Once adequate pneumoperitoneum is established, the remaining trocars are placed under direct laparoscopic vision. Trocars with 100-mm shafts are usually sufficient, but occasionally, extra-long trocars (150 mm) are required for the patient with an excessively thick abdominal wall (Fig. 5b).

Fig. 5.

(a) A 5-mm optical viewing trocar can be used to obtain direct access to the peritoneal cavity without pneumoperitoneum. The distinct layers of subcutaneous fat, fascia, muscle, preperitoneal fat, and the peritoneum are identified as the trocar passes through them (Endopath Xcel, Ethicon Endosurgery, Cincinnati, OH). (b) 5- and 12-mm trocars (100 and 150 cm lengths) (Endopath Xcel, Ethicon Endosurgery, Cincinnati, OH). These clear-tipped bladeless trocars can also be used for optical entry into the peritoneal cavity.

After the insertion of the first trocar, a standard 25-gauge spinal needle can be helpful in locating the precise intra-abdominal location for the placement of additional trocars and providing preemptive analgesia with injection of local anesthetic (Fig. 6).

Fig. 6.

Spinal needle placed through abdominal wall to help with port positioning. Local anesthetic is injected into the preperitoneal space under laparoscopic visualization prior to port placement.

Insufflator

In laparoscopic surgery, exposure depends upon insufflation of the peritoneal cavity with CO₂ to create a pneumoperitoneum. The insufflator monitors the current intra-abdominal pressure and regulates the flow of CO₂ from a pressurized reservoir. A desired intra-abdominal pressure is selected and the flow of gas is automatically regulated. The front LCD screen on the insufflator displays the current intra-abdominal pressure, the preset desired pressure, the current rate of CO₂ insufflation, the volume of gas infused, and the residual volume in the CO₂ tank. Alarms signal high intra-abdominal pressures, excessive gas leak, and low gas level in the CO₂ tank. The rate of insufflation can be adjusted from 1 up to 40 L/min and higher flows are typically used. Our standard preset intra-abdominal pressure is 15-mmHg, but we will intermittently use higher pressure (16–18-mmHg) when better exposure is needed or a lower pressure when instrument length is insufficient or the patient isn’t physiologically tolerating higher pressures.

Gas leakage can be very troublesome during laparoscopic bariatric procedures especially if a circular stapling technique is in use. A high flow insufflator (40 L/min) is highly recommended to accommodate for gas leakage from small air leaks at port sites, instrument exchanges, and during intra-abdominal suctioning (Fig. 7).

Fig. 7.

High flow insufflator. Stryker.

Visualization

Technology which provides the surgeon with a clear view of the operating field has been critical to the development of advanced laparoscopic procedures. Safely and effective performance of a laparoscopic procedure is dependent upon the quality of visualization. Since the surgeon is not able to touch and palpate, a clear crisp bright image is mandatory at all times. There are no “blind” maneuvers in laparoscopy. Components that create and maintain the image have steadily improved.

There are several conditions specific to laparoscopic bariatric surgery that make obtaining an adequate image challenging. In the morbidly obese patient, the voluminous abdominal cavity expanded by the pneumoperitoneum requires more light for visualization than that required for the non-obese patient. Copious adipose tissue covering mesentery, omentum, and viscera may crowd the view and obscure the landmarks of interest. Instrumentation that will allow viewing around or over or under such objects is necessary. Additional instruments are needed to enable adequate exposure.

Laparoscope

The laparoscope uses the Hopkins rod lens system which consists of a series of quartz rod lenses and a fiber bundle surrounding the rod lens for transmission of light [5, 6]. The eyepiece of the laparoscope is connected to the camera by means of a coupler adapter.

Standard laparoscopes have a length of approximately 32 cm and have diameters that range from 2 to 10 mm. Scopes are angled to various degrees, most commonly from a 0° to 45° orientation. Angled scopes provide more flexibility in viewing internal structures and provide access to areas that would be “blind” to 0° scopes. However, they require some additional skill to operate and the angling decreases light transmission slightly.

For our bariatric procedures, we have a variety of laparoscopes available: 30° and 45° with 5 and 10 mm diameters (Fig. 8a, b) (Stryker Endoscopy). Typically we use a 5-mm 45° scope, initially at the 5-mm entrance site, to visualize the other port placements. A 10-mm diameter, 45° angled laparoscope is used for the rest of the procedure as we have found that it provides the best field of view especially in extremely obese patients. An extra-long laparoscope (45–50 cm) is sometimes necessary and very helpful in super-obese patients. Excessive abdominal wall thickness, together with a large expanded abdominal cavity, does not allow for a close-up view of distant sites (e.g., the esophagogastric junction) using the standard-size scopes. Extra-long scopes are also helpful during the use of any type of scope-holding instrument or robot which takes up functional scope length in establishing the connection.

Fig. 8.

Laparoscopes: angled 45° (inset) and 30°, 5 and 10 mm diameters and standard and long lengths.

An important scope accessory is a stainless steel scope warmer canister filled with hot sterile water for cleaning the scope and preventing lens fogging (Applied Medical) (Fig. 9).

Fig. 9.

Laparoscope warmer decreases fogging (Applied Medical). The laparoscope warmer should be attached to the surgical drapes for easy access.

Video Camera

Miniature lightweight cameras, weighing as little as 40 g, are now in use providing excellent resolution and color rendition which are essential for laparoscopic bariatric surgery. The miniature camera uses an LCD chip containing approximately 300,000 light-sensitive pixels on the chip surface measuring only about ½ inch on the diagonal. Three-chip cameras have become the industry standard; each chip provides one of the three primary colors: red, green, and blue. There are a number of options for this type of equipment including the Stryker Endoscopy^® 3-chip camera (Fig. 10), which has 1920 × 1080p resolution.

Fig. 10.

Three-chip video camera (Stryker).

A C-mount endoscopic coupler permits rapid attachment of the camera to whichever scope is in use. The coupler also has a focusing knob. The camera head control buttons enable the user to adjust gain, digital zoom, and printer modalities. The camera is connected to the power supply and electronic control by cable. The system is further enhanced using voice activation technology to control adjustments of white balance, gain, shutter, and digital enhancement.

Light Source and Light Cable

Laparoscopy requires a high intensity light source for an adequate video image of the operative field. A xenon or metal halide bulb with a life span of about 250 h is typically used because these provide the desirable color temperature in the range of daylight (5,500 k). An automatic adjustment as well as a manual override is available (to over- or under-illuminate if needed). Interaction between the camera and the light source allows automatic adjustment of the illumination intensity with changes in light level at the camera CCD surface. This will greatly reduce annoying glare. The light is transmitted from the bulb to the scope through a fiber optic light cable which should be replaced if more than 15 % broken fibers are noted. A full benefit of the light source depends on proper connection of the cable to the light source and the telescope. The light cables should not be autoclaved and must be sterilized in either ethylene-oxide or glutaraldehyde.

Video Monitor

The video monitor providing the laparoscopic image should be of the highest quality. There are many configurations and products available. We currently utilize a flat panel digital design mounted on an overhead boom. The boom facing the operating surgeon (right side) has two screens so that endoscopic and laparoscopic images can be simultaneously displayed (Fig. 11).

Fig. 11.

Dual monitors facing the operation surgeon allow for simultaneous laparoscopic and endoscopic images which is particularly useful when performing an intraoperative leak test.

Operating Tables

The operating table must provide maximum tilt and rotation and allow gravity to shift abdominal structures to allow full visualization. For bariatric procedures, the operating table must have the capacity to support super-obese patients up to the maximum weight with which the surgeon is comfortable. Many standard general purpose OR tables have weight limits of about 227 kg which are adequate for 95 % or more of the cases in most bariatric practices. It is advisable to check with the manufacturer regarding the specific weight limitations of the specific operating table model and vintage available to you. Bariatric practices which include patients with weights greater than 227 kg require access to an operating room table that can accommodate them safely. Many general purpose tables have been modified to accommodate the greater weight with some loss in the angle of tilt and Trendelenburg/reverse Trendelenburg in the interest of assuring stability. This trade-off has become less necessary due to improving weight ratings and articulation in recent operating table technology. Important bed accessories include side extenders, footboards, straps, and padding to safely secure the patient to the bed and prevent injuries.

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