13.1. Spinal Access Operating Room Setup and Patient Positioning
Namir Katkhouda, M.D., F.A.C.S.
Sharan Manhas, M.D.
A. Equipment
1. Laparoscope, camera, and imaging equipment
a. Advanced laparoscopic surgery cannot be performed without excellent instrumentation. This procedure is best performed with a three-chip digitally enhanced camera.
b. The angle at which spinal surgery is performed is not usually straightforward, and therefore a 30° (or even 45°) scope is required to allow adequate visualization.
c. Imaging equipment
i. Fluoroscopic C-arm and fluoroscopy monitor
ii. Radiolucent table (this is required for fluoroscopic guidance during cage implantation)
iii. Two video monitors
2. Instrumentation: specific laparoscopic equipment required for spinal surgery
a. Atraumatic graspers (in particular, a needle-nose grasper with an atraumatic tip is recommended)
b. A 10-mm rotating right-angled dissector with an atraumatic blunt tip
c. Laparoscopic Kittner dissectors d. Sharp scissors
e. Medium and large clips f. Vessel retractor g. Vessel loops
h. Atraumatic retractor (e.g., five-finger fan retractor)
i. We recommend 5-mm ultrasonically activated shears because they limit lateral thermal damage
j. A total of five ports i. Three 10-mm ports ii. One 5-mm port
iii. One 15- to 18-mm port (for introduction of spinal instruments)
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B. Preoperative Preparation
1. Mechanical bowel preparation to decrease bowel distension is optional 2. Foley catheter
3. Orogastric tube
C. Patient Positioning and Operating Room Setup
1. The patient is placed supine on a radiolucent operating table when operating on the L4–L5 or L5–S1 disk spaces (Figure 13.1.1). The modified lithotomy position can be used when performing higher-level spine cases such as L3–L4 or higher (Figure 13.1.2).
a. The patient is either placed on a beanbag or is sufficiently padded to avoid any pressure injuries.
b. The arms must be placed across the anterior chest to avoid inter- ference with fluoroscopic imaging of the lumbar spine. The upper arms remain beside the torso, but the elbows are flexed, and the forearms are padded and laid transversely across the anterior chest. A foam pad can be placed between the arms and the chest as well as between the arms and the tape. It is important that the tape does not impede chest excursion and that the xiphoid process remain exposed.
c. A roll is placed transversely under the patient’s lumbar area.
d. Steep Trendelenburg positioning must be used to facilitate ex- posure of the lumbosacral spine by displacing small bowel from the pelvis. The bean bag, stirrups, or tape are helpful in prevent- ing the patient from sliding. If shoulder pads or shoulder table braces are used, great care must be used to avoid brachial plexus injury.
e. The patient’s head should be placed on a foam ring or pad and be strapped to avoid hyperextension of the neck.
f. The patient must be positioned in such a way that the fluoroscopic C-arm can rotate around the patient to allow anteroposterior and lateral X-rays to be taken by the spine surgeon. Specifically, the patient must be placed on the table so that the lumbar spine is not overlying the post of the bed. This part of the bed must be free above and below for passage of the C-arm.
2. The laparoscopic surgeon stands on the right side of the patient facing the video monitor positioned at the foot of the operating table when performing L4–L5 or L5–S1 cases.
3. For higher-level spine cases, when the patient is in the modified litho- tomy position, the laparoscopic surgeon stands between the legs and views the monitor to the left of the head of the table. Alternatively, if the patient is in the supine position for cases higher on the spine, the surgeon should stand on the patient’s right side looking at the left cephalad monitor.
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128 N Katkhouda and S Manhas
Figure 13.1.1. Supine patient position for spinal fusion.
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Figure 13.1.2. Modified lithotomy position for spinal fusion.
4. The spine surgeon stands on the patient’s right side (if right handed) by the patient’s legs and faces the video monitor and fluoroscopy machine placed behind the patient’s left shoulder.
5. The assistant (who runs the camera) stands on the patient’s left side and views the video monitor placed at the foot of the operating table.
The assistant drives the camera and, in rare cases, may work through an optional port to retract the small bowel if exposure is difficult.
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