Publication history, Reflections & comments
As laparoscopic surgery becomes more common, junior medical and nursing staff are asked to be camera operators and assistants more often. This is more likely in private and country hospitals where a second surgeon is not available, and as procedures become more complex and need an extra assistant.
All surgeons know the benefits of having a good assistant. The adverse effects of poor camera work have not been measured or discussed but are well known to operators, This is a great opportunity for research.
The role of the assistant
This varies with the procedure being performed. It might mean just holding an instrument or two in relatively fixed positions to expose the surgical anatomy. It may be more active, moving structures to one side or the other to put tension on the line of tissue being dissected. With experience, the assistant knows what the surgeon will do next and position instruments to help this..
An inexperienced assistant has to have their instruments put in place by the surgeon for each new step in the operation. This means the surgeon has to let go of their own instruments each time, which slows down the operation. Becoming an expert assistant needs practice and understanding of what the surgeon is aiming to do, helped if the surgeon can explain this properly.
Helping at lap surgery is harder than helping at open surgery. There is no direct view and you have to look at the screen and learn new co-ordination of the hand and eyes. Because the instrument passes through the port which is fixed in position, is acts as a lever with "paradoxical motion". When the handle of an instrument is moved, the working end of the instrument ( jaws, retractor, camera lens) moves in the opposite direction, and this is confusing at first.
Instruments used in laparoscopic surgery are more dangerous than those in open surgery because of their smaller size and the limited view of the operation.
For instance, fan-like retractors are useful for retraction but if they are turned sideways instead of pressing flat, their thin edges can lacerate organs like the liver. Tips of instruments can perforate viscera if used blindly or forcefully, especially as sense of touch is partly lost by friction of instruments moved in or out through a port. Grasping instruments placed on bowel or stomach, having small jaws, can avulse chunks of the wall leading to a perforation if not used with appropriately gentle force. Practicing in a surgical skills lab or a workshop increases the skill and confidence of assistants and surgeons alike.
Role of camera operator
The camera operator is often the only assistant. As with instruments (described above) there is paradoxical movement. When the camera operators hand is moved one way, the lens and the viewing area move the opposite way. The area of view is also restricted
There are several principles of good camera control. These are:
There are other ways of improving the view, for example by rotating the camera slightly or moving the view off centre away from glaring structures such as omentum when it is close to the light source. New developments such as binocular lenses to give better depth perception still have a way to go before they are routine, though it is simple now to have a second light in the abdomen to give more useful shadowing. A lot depends on the leadership given by the operator
The main points are shown in the accompanying chart, with some extra details.
INSTRUCTIONS FOR THE LAP SURGERY ASSISTANT
[These can be printed out]
1. Centre the camera view
If the point of dissection or suturing is at the edge of the screen, or even out of view. "Centre please" should fix this.
2. Rotate the image the right way up
The post [connected to the optical lead] on the scope can point down for a Zero degree scope when the weight of the cable makes it easier to hold a steady position.
For an angled scope (e.g. 30 or 45 degrees) the post must point UP, or the view is incorrectly orientated for most dissections.
3. In / out
Too small a view makes structures hard to find. Too big a view reduces perspective.
It is essential to keep the camera steady. Significant movement can distract (and irritate) the operator. Significant movement can occur if the camera operator is unaware of the problem, loses concentration and is particularly prevalent during conversation. The problem of excessive movement is obvious on video replays..
Some extra instructions
for the more experienced assistant
5. Reduce glare
Glare from omentum or instruments usually needs only a slight tilt away or a slight withdrawal of the scope for it to disappear.
6. Move slightly up / down / left /right / in / out
A better view saves wasting movements. In-out movement can be jerky if the scope sticks inside the cannula and may be affected by the valve. It helps to steady the hand or forearm.
7. Rotate clockwise / anticlockwise
With an angled scope this allows a view of the side of a structure .
8. Comfortable posture
A seat is a good idea, and so is alternate sitting and standing in longer operations, or alternating the roles of assistant and camera operator if feasible. If care to arrange them is not taken.The assistant and operator may clash forearms or instruments
Awkward postures of both assistant and surgeon can be improved by improving the positions of port sites.and sometimes by lowering the table or standing on a platform. (The platform may need a rim to stop foot controls slipping off).
Why bother with this
It is up to the surgeon to ensure the camera operator knows what is needed, and is comfortably positioned to do this.
Bad camera work slows the operator and increases the dangers of the procedure. The operator must see tissues, tools and materials clearly.
An experienced and skilful assistant who can follow the dissection without needing to be told what to do is very valuable.