Chapter 3
Safe setup and positioning
Dafydd Loughran
Aims
By the end of the chapter you will be able to:
• Recognise the importance of, and key factors relating to, patient selection and optimisation to minimise peri-operative complications
• Appreciate the safety considerations applicable to a range of instruments and technologies used during laparoscopy
• Develop an appropriate plan for patient positioning with appropriate supports to allow optimal surgical exposure and ensure patient safety
Introduction
Patient safety is the most important factor to be considered in laparoscopic surgery. This must be at the forefront of your mind in setting up and conducting your procedure. This chapter discusses factors related to the setup and positioning of kit, patient and staff in order to ensure optimise safety and efficiency.
Pre-operative planning
A key determinant of operative outcomes, both laparoscopic and open, is appropriate patient selection, so the first thing to consider is whether this patient is an appropriate candidate for a laparoscopic operation. In most circumstances a laparoscopic approach is preferred over open surgery due to shorter recovery times and fewer wound complications, but there are patients in whom the nature of laparoscopic surgery makes it a less favourable option. Examples include patients with significant previous abdominal operations, which may be associated with significant intra-abdominal adhesions, or those with respiratory complications in whom the pressure effects of a pneumoperitoneum may increase the risk of significant peri-operative complications.
Medical optimisation can range from simple interventions, such as withholding anticoagulants, administering corticosteroids, peri-operative glucose control, to longer term interventions prior to surgery, such as smoking cessation, nutritional optimisation, or excess weight loss, all of which may reduce the risk of medical complications and surgical site infections.
As with any surgical procedure, informed consent must be obtained ensuring that the patient has been provided with all the relevant information about the operation, the risks and benefits, and what to expect during their recovery. If there is a laterality, left or right, to the operation site, then this side should be checked and clearly marked with a skin marker at a site visible within the operative field.
Some laparoscopic procedures may benefit from bowel preparation and the benefit should be balanced against the possibility of causing electrolyte abnormalities. Thromboembolic prophylaxis should also be considered, considering both local guidelines and patient factors.
Theatre Preparation
As the first part of the World Health Organisation (WHO) Checklist
1, a team brief should be performed prior to the commencement of the operating list to ensure that th
