17.1. Laparoscopic Ultrasonography:
Patient Positioning and Operating Room Setup
Maurice E. Arregui, M.D., F.A.C.S.
Matthew S. French, M.D.
A. Introduction
There are indications and applications for laparoscopic ultrasound during numerous laparoscopic procedures. These situations include evaluation of the biliary tree during laparoscopic cholecystectomy, evaluation of the pancreas and surrounding vasculature during staging of pancreatic cancer, and evaluation of the liver for diagnosis and the ablative treatment of malignant lesions. Other indications include characterization of adrenal tumors, localizing colorectal tumors and retroperitoneal masses, and finding pancreatic islet cell tumors. With increasing experience, the indications for laparoscopic ultrasound continue to expand. This section discusses patient positioning and operating room (OR) setup requirements in patients undergoing laparoscopic ultrasound evaluation.
B. Positioning Patient on the Operating Room Table
Generally, laparoscopic ultrasound is performed in addition to other proce- dures and therefore positioning the patient is specific to the primary surgical pro- cedure. For this reason, patient positioning is rarely a major issue. With articulating probes, little difficulty is encountered even when the patient must be positioned in the lateral decubitus position for laparoscopic adrenalectomy or splenectomy. The ultrasound equipment can be adapted accordingly. Port place- ment is more important to successful completion of the examination and is dis- cussed in the next chapter.
C. Equipment
High-quality, up-to-date equipment is essential for performing precise laparoscopic ultrasound evaluations. Numerous companies are now producing equipment dedicated to intraoperative open and laparoscopic use. Most ultra-
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sound units are large with a monitor at eye level for viewing, a keyboard and control panel for manipulating the image, recording equipment for VHS, SVHS, or digital recording, and a printer for making hard copies of an image. Most also have the ability for storing images in the hard drive of the computer for later viewing. Although they are portable, the machines were designed for use in dedicated radiology suites rather than operating rooms. The limited space in the operating room and the relative immobility of most ultrasound units makes them awkward to position. The controls are also designed for manipulation in a radi- ology suite or office setting, and modifications for use in a sterile environment are lacking. Some of the newer ultrasound units are more compact, and attempts have been made to develop remote hand controls for use by the surgeon under sterile conditions. Currently, for the operating surgeon to control the unit a trans- parent sterile plastic drape must be placed on top of the controls. This method works reasonably well, but I have found it difficult to position the ultrasound probe and manipulate the controls at the same time. It is more efficient to have the circulating nurse manage the ultrasound unit under the surgeon’s direction.
The transducers themselves have been designed for intraoperative open and laparoscopic uses. Most transducers can be sterilized; however, some cannot and must be placed in plastic covers to be used in the operating field. Laparoscopic transducers, in general, are specific to each unit or to the line of units made by each company and thus they are not interchangeable. They are typically made to fit through a 10-mm trocar and are either rigid or made with articulating tips.
The tip may articulate in two directions, although newer designs will articulate in four directions. The transducer generally provides a linear ultrasound array at a frequency of 5–10 MHz. This is a higher frequency than that used for trans- abdominal ultrasound (3.5–5.0 MHz) and results in a more detailed image. The higher frequency is possible due to the close approximation of the probe tip to the structures being evaluated. Guides to assist with biopsy under ultrasound are not easy to find and in general are not helpful. Freehand technique is therefore used for biopsies and placement of radiofrequency probes.
D. Room Setup
Proper positioning of equipment in the operating room is crucial to suc- cessful performance of laparoscopic ultrasound. The average OR becomes clut- tered during these procedures. The ultrasound machine itself is large and must be positioned in addition to the anesthesia cart, laparoscopic tower, and scrub table. It must also be close enough to allow good visualization. The most effec- tive arrangement is shown in Figure 17.1.1.
There are various options for the room setup. This choice depends on the procedure, positioning of the patient, and additional equipment that may be nec- essary such as a fluoroscopic unit in the case of laparoscopic common bile duct exploration or for performing radiofrequency tumor ablation. For laparoscopic ultrasound during laparoscopic cholecystectomy, our preferred setup is to have the laparoscopic monitor at the head of the bed (if a flat screen monitor is avail- able) or off the right shoulder of the patient (Figure 17.1.2). The ultrasound unit is located on the right side of the patient adjacent to the armboard. When it is WHE17 6/16/2005 2:21 PM Page 213
time to perform the ultrasound, the surgeon goes to the right side of the patient.
The surgeon then directs the circulating nurse to adjust the settings in the ultra- sound unit. Although this is somewhat cumbersome for the surgeon, we have found that it is easiest for the surgeon to direct the nurse or resident with the ultrasound unit in proximity so that they can more easily show where the correct Figure 17.1.1. Operating room setup for laparoscopic ultrasound of upper abdomen (liver, bile ducts, pancreas, stomach, etc.). If a standard CRT monitor is to be used, then it is placed off the patient’s right shoulder; if a flat screen monitor or a boom is available, then it is ideally placed at the head of the bed.
The ultrasound machine is positioned on the patient’s right side. The surgeon stands on the patient’s right side and operates the camera and ultrasound probe.
This room setup can also be used for radiofrequency ablation (RFA); in this case, the RFA machine is best positioned on the patient’s right side.
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knobs are located. If the unit is on the other side of the table, the surgeon can more easily see the monitor in a more comfortable manner but has more diffi- culty seeing the ultrasound console to direct the circulating nurse for the proper adjustments.
We have also tried using picture-in-picture on the monitor at the head of the bed. The image quality is degraded and the same difficulty applies to directing the nurse with the ultrasound console. The same setup, as seen in Figure 17.1.1, is used for laparoscopic staging of pancreatic cancer and for evaluation of the liver during radiofrequency tumor ablation. In the latter procedure, during place- ment of the radiofrequency needle, the surgeon stands on the patient’s left side while the assistant surgeon holds the ultrasound probe in position to monitor the placement of the radiofrequency needle. The room lights should be turned down
Figure 17.1.2. Alternate OR set up for laparoscopic cholecystectomy or other upper abdominal ultrasound examinations.
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or off for accurate viewing and the screen turned toward the surgeon. OR staff trained in the operation of the ultrasound console are invaluable but rare.
The recommended OR setup for the performance of pelvic ultrasonography is shown in Figure 17.1.3. Finally, the room setup for ultrasonography with the patient in the left lateral decubitus position is shown in Figure 17.1.4.
E. Discussion
Laparoscopic ultrasound has become very useful during surgery and its indications are increasing. Currently, we use this modality for evaluation of the biliary tree for choledocholithiasis and to confirm normal anatomy before Figure 17.1.3. Operating room setup for use of ultrasound in the pelvis (legs can also be placed in modified lithotomy position).
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transection of the cystic duct. Anatomic information of the surrounding struc- tures, including the vascular structures, can be very useful when operating on inflamed gallbladders. In our hands, this has effectively replaced intraoperative digital fluorocholangiography. Ultrasound also adds important staging informa- tion for intraabdominal malignancies, especially in pancreatic cancer. With the recent interest and increasing use of radiofrequency tumor ablation of hepatic lesions, ultrasound is a requirement. Currently, intraoperative ultrasound has the highest sensitivity for identifying and characterizing hepatic malignancies. It is more sensitive than computerized tomography (CT) scans and magnetic reso- nance imaging (MRI) scans. We often find many additional lesions intraopera- Figure 17.1.4. Operating room setup for use of ultrasound with patient in right lateral patient position (example, left adrenalectomy).
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tively when performing radiofrequency tumor ablation. Because of this, intra- operative ultrasound offers the patient the best hope for identification and erad- ication of all hepatic lesions. The success of radiofrequency ablation, cryosurgery, or resective surgery depends on high-quality ultrasound imaging.
F. Selected References
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