Advances In Surgery Channel

This video reflects the current status of the nursing procedures that are required for an operating theatre setup to perform a Cecil Approach.

This is a list of the devices required:

• Two CO2 insufflation system (standard and continuously insufflation system)
• Two laparoscopy system
• Two electric scalpel devices
• Two aspirators
• Two boxes of the basic instruments required for placement of trocars, removal of the specimen, and anastomosis
• Two optical devices (10mm or 5 mm, 30º or 0º, and 3D)
• Two tables for laparoscopy instruments
• Two Mayo tables for basic instruments
• Two Allen hydraulic stirrups
• One special self-designed table for the transanal stage

Transabdominal Field (instruments, materials, and sutures):

• One optical device 10mm. 30º or 0º
• One CO2 tube
• One thermos to heat the optical device with 70ºC distilled water
• One kidney dish with physiological serum and povidone in 1% concentration
• Ten large gauzes
• Ten small gauzes (Gauzes are counted)
• One aspiration tube with a Yankauer aspiration tip
• One electric scalpel

Sutures:

• One 2/0 triangular nonabsorbable polyfilament suture to fix the drain
• One polyfilament absorbable suture with hook needle to close the fascia of 12 mm trocar
• Four polyfilament absorbable suture 3/0 cylindrical needle for the ileostomy

One box of inventoried laparoscopy instruments including:

• Two 5mm short grasper
• One 5mm medium grasper
• One 5mm long blade grasper
• One 5mm scissors
• One 5mm needle holder
• One 5mm bipolar
• One 5mm hook that adapts to the manual electric scalpel

Fungible laparoscopy materials:

• One 5mm grasper  (Clinch type)
• One 5mm aspirator
• One 5mm energy sealing device
• One Veress needle
• One 12mm trocar
• Three 5mm trocars

Transanal Field (instruments, materials, and sutures):

• One 3D visualization system
• One CO2 tube (continuously insufflation system)
• One thermus to heat the optical device with 70º distilled water
• One kidney dish with physiological serum and povidone in 1% concentration
• One small kidney dish with a diluted solution of 100 ml physiological serum and 1mg adrenalin
• One small kidney dish with lubricating gel
• Ten large gauzes
• Twenty small gauzes (Gauzes are counted)
• Two large surgical patties
• One aspiration tube with a Yankauer suction tip
• One electric scalpel
• One Lone star retractor
• One set of EEA 25 – 31 mm calibrators
• 2 mini Deaver retractors

Sutures:

• One 0 nonabsorbable polyfilament triangular needle to fix the anal device
• One 0 nonabsorbable monofilament suture with cylindrical needle for pursestring suture to close the rectal lumen
• One 0 nonabsorbable monofilament suture tapercut needle for pursestring suture in the distal rectum
• One 3/0 absorbable polyfilament cylindrical needle if any hemostasis stitch is required in the anastomosis
• One 2/0 nonabsorbable polyfilament triangular needle to fix the drain

Inventoried laparoscopy instruments:

• Two 5mm short grasper
• One 5mm medium grasper
• One 5mm needle holder
• One 5mm bipolar
• One hook that adapts to the manual electric scalpel

Fungible laparoscopy materials:

• One special trocar (continuous insufflation system) that adapts to the CO2 tube of the same brand
• One transanal access platform (with removable cap)
• One 5 mm energy sealing device
• One EEA 33mm-4.8mm short circular endostapler (if mechanical anastomosis will be performed)
• One short linear endostapler (not always) with different sizes of cartridges depending on the type of anastomosis (End-to-Side, Colonic J Pouch)

Three nurses are required for the Cecil Approach. Two provide the the instruments (one for the abdominal field and one for the transanal field). The third nurse serves as a circulating nurse for both fields. Because at the start the circulating nurse has plenty of work, the setup of the tables for both fields is performed by one of the nurses providing the instruments, while the other nurse is in charge of placing the patient, the pneumatic stockings, and the scalpel plates, preparing the table for rectal washing, etc.

Meanwhile, the circulating nurse provides the instrument nurse who is preparing the tables with all that is required for the surgery. The tables are set up in such a way that the Instrument Nurse is placed to the right of the surgeon in each field.

SETUP OF TABLES FOR THE TRANSABDOMINAL FIELD:

The basic instruments and sutures are placed on the small table.

The laparoscopy pincers, the kidney dish with a diluted iodine solution, the gauzes, and the thermos are placed. Two panniers are placed right at the angle of the large table. They contain the bipolar pincers, the Yankauer and the laparoscopy aspirators, the energy device, and the manual hook. In this way, everything is placed near the surgical field. Also in this angle we have placed a velcro strip to fix all the cables and control them to avoid contamination. This angle has also been reinforced by means of an adhesive stem so that if any instrument pierces the pannier, it will not be contaminated.

SETUP OF  TABLES FOR THE TRANSANAL FIELD:

The basic instruments, sutures, retractors, EEA calibrators, and the 2 surgical patties are placed on the small table.

The two panniers are placed on the duly protected angle of the larger table. The Yankauer aspirator, the bipolar pincers, the manual hook, and the energy device if required are also placed by means of the velcro. As there are two empty compartments left in the pannier, one of the two pairs of grasper pincers is kept in one of them and the needle holder is placed in the other one. In this way, more space is left on the table. The large kidney dish with the diluted iodine solution, the small kidney dish with the lubricating gel, the gauzes, the thermos, the transanal device, and the 8 mm trocar are placed on this table.

In addition, a special table is prepared where the instruments required to introduce a catheter  are placed. It is later used by the transanal team to place the camera or any other instrument required.

PATIENT POSITIONING & PREPARATION

The patient’s position is crucial for a suitable transanal approach without causing lesions to the patient’s peripheral nerves through compression. The patient is placed in the Lloyd-Davies position with Allen hydraulic stirrups. These stirrups allow for easy and sterile intraoperative repositioning. Pneumatic anti-embolism stockings are placed to encourage venous return, thus preventing thromboembolism.

The arms are placed parallel to the body and protected by foam to avoid compression. The thorax is fixed to prevent the patient from slipping in the Trendelenburg position.  One scalpel plate is placed on each anterior thigh. In this way, they are near the surgical field, thus shortening the electrical feedback of the neutral plate with the electric scalpel. Two plates are placed because there are two surgical fields.

The assistant surgeon washes the rectum. A physiological serum solution with iodised povidone in a 1% concentration, a 50 ml wide cone syringe, a 28 rectal probe, lubricating gel, a shaving razor, and a 2/0 silk straight needle have been prepared in case the scrotum must be suspended to leave the anal area free.

In this stage, the assistant surgeon also performs a rectal examination. When performing the rectal washing, it must be ensured that the same amount of solution that enters the body also comes out, so that when the transanal surgery starts no biological substances come out that might contaminate the surgical field.

While the assistant surgeon performs the rectal washing, the nurse who is preparing the patient proceeds to place the laparoscopy tower, electric scalpels, monitors, lamps, and aspirators in the correct position and places the stirrups in the low position, almost parallel to the patient’s body.  After these procedures, the assistant surgeon withdraws to wash his or her hand surgically.

At this point, the second instrument nurse also washes to take his or her position, either in the abdominal or in the rectal field. Nurses usually take turns in each field and circulating. In this way nurses are always ready to work in any position.

The assistant surgeon is helped to put on the gloves, and then proceeds to wash both areas with the iodised soap solution, starting by the abdominal area and ending in the perineum area. Drying is then performed in the same way. Nurses ensure at all times that the scalpel plates are not wet and that no areas are contaminated.  The areas are disinfected twice using an iodised solution. The abdominal field is dried and then the rectal field is dried. It should be pointed out that if the patient is female the vagina is also disinfected, as a an intraoperation vaginal examination must be performed.  

The surgeon is then given a stem to be placed under the patient’s backside and his or her gloves are removed. Then the surgeon is helped to put on the gown and gloves to set up the surgical field.  The surgical field is arranged while the stirrups are in the low position so that the fitting is not broken when the stirrups are moved.

The instrument nurses and their respective instrument tables take their positions and each one starts to place the relevant instruments on the field. The abdominal field is similar to the conventional field for a laparoscopy. First the leg sleeves, then the two side stems, then the upper sheet which also serves as a cover, and the lower sheet is replaced by an adhesive stem so as not to hinder the lower team.

The instrument nurse stands to the right of the patient, next to the patient’s knee. Because tables are moved to that side, an adhesive stem is placed as a cover in order to isolate the field. Velcro strips are placed on areas crossed by both optical devices as well as two panniers, one for the optical device and the other one for the hook and the energy device. All the cables are handed over to the circulating nurse for connection.

The instrument nurse in the rectal field places adhesive strips to fix the stirrup covers and performs the vesical catheterisation. This catheterisation is performed at this time and not before the area is disinfected because the catheter and the diuresis bag must be in the surgical field in case the area should be moved. Preparation of the field is completed and all the cables are handed over for the circulating nurse to connect them. One metre is left as it suffices for the small rectal field.    

The circulating nurse connects the cables on the basis of the priorities in the procedures, as many cables, pedals, monitors, optical devices, CO2, hot water for the optical devices, etc. must be connected by order of use.

The circulating nurse goes over the checklist following the hospital template.

The pneumo settings are:

• 15 mmHg (continuous insufflation system) or 9 mmHg (standard insufflation system)  
• 12-13 mmHg for the transabdominal insufflator

And the settings for the energy devices are:

• TRANSANAL FIELD: 30 cut, 30 coagulation, 30 bipolar
• TRANSABDOMINAL FIELD: 45 cut, 45 coagulation, 35 bipolar

Finally, the operating theatre is set up as follows:

• Two surgeons in the transanal field, Three surgeons in the transabdominal field
• One nurse for every surgical field and one circulating nurse
• The transanal team watches the work in both fields through screens placed at the patient’s head and the transabdominal team watches it through screens placed to the left of the patient