One of my best pieces of advice for laparoscopic and robotic surgeons is to take the time at the beginning of a procedure to set yourself up for success. One of my mentors used to say, “If you can work in a field, why would you choose to work in a hole?” In other words, if the intestines are in your way, you should take the time to carefully mobilize them. Many surgeons, particularly those who don’t specialize in bowel surgery, are reluctant to perform this manipulation out of fear of injuring these structures. I would argue that this manipulation is the best way to prevent injury. Bowel injuries are most likely to occur when your focus is on something else. In addition, the extra time spent creating a “field” is often recaptured by easing the remainder of the procedure.
Dependable insufflation is also high on my list for maintaining excellent surgical exposure. I use the AirSeal® System for all of my surgeries. It eliminates any fluctuations of pressure or abdominal distention, with the added benefit of the best smoke evacuation on the market. In addition, I can use a much lower pressure, thereby minimizing pain and other risks following the surgery.
Here is a short list of tips for surgical exposure:
- Careful patient positioning
- Adequate table angle (but not extreme)
- Good insufflation management
- Good smoke evacuation
- Minimize cauterization
- Control bleeding along the way
- Early and extended bowel mobilization
- Ensure good ergonomics for the entire surgical team
In surgery, seeing is everything.