Basic operating room setup

TTTS. Basic operating room setup

The operating room setup is the basic operative fetoscopy arrangement originally described by us.14 Basically, the setup involves the use of ultrasound imaging, endoscopic imaging, and a laser equipment. In the United States, the ultrasound machine is placed to the right of the patient, as most sonographers are accustomed to scanning with their right hand, facing the patient. 

An endoscopic tower is also placed on the right side of the patient, more distally, to allow viewing of the surgery across the patient from the left side. An additional monitor is placed on the left side of the patient (slave monitor). 

Additional slave monitors may be used to allow viewing of the procedure from any angle of the operating room, as well as a dedicated monitor for the patient. The laser machine is placed on the left side of the patient. The patient is typically placed in decubitus. Occasionally, the dorsolithotomy position is used for patients with difficult access to an anterior placenta. 

Ultrasound machine 

A high-resolution ultrasound machine is used during laser surgery. A 2D 3.5 MHz transducer is preferred, as it provides adequate image quality and weighs less than the 3D counterparts. Draping of the ultrasound transducer is done first with a CIVCO cover (CIVCO Medical Instruments, Kalona, IO), followed by a standard laparoscopy camera drape (Advanced Medical Designs, Marietta, GA). The sonographer is gowned and gloved and has contact with the transducer with her right hand on the patient. The left hand of the sonographer is placed on the controls of the machine and never reaches the operating field. Sterile covers for the keyboard of the ultrasound machine have proven cumbersome and unnecessary. 

Endoscopy 

Endoscopic viewing is provided by a three-chip digital endoscopic camera, a 300 Watt Xenon light source, and a high-resolution monitor with Super VHS and DVD connection. The camera and light cord can be sterilized and brought across the operating field. Non-sterile cameras can be draped with a special sterile laparoscopy sheath and coupler. We normally use two cameras, one for the diagnostic endoscope and one for the operating endoscope. This arrangement cuts down on the operating time and helps maintain sterility. 

Videomixing 

The combination of endoscopy and ultrasound is best done with the help of a videomixer. This machine allows two or more imaging inputs, and can display them on a monitor separately or in combination (picture-in-picture). The mixer is placed within the endoscopic tower in one of the available shelves. 

Laser machine 

The laser machine is placed on the left side of the patient, next to the left endoscopy tower. The machine is operated by a laser-certified nurse. The laser fiber is passed from the operating field to the laser machine and is prevented from unwinding by attaching it to the light cord and camera cable with plastic clips. The laser fiber can be fed through the operating endoscope prior to entering the amniotic cavity to save on operating time. 

Activation of the laser energy is done via a pedal placed at the foot of the operator. The delivery is normally set to continuous mode, where the laser energy is transmitted via the fiber as long as the pedal is pressed. The machine is typically set at 15–20 watts, which may be increased up to 40 watts, depending on vessel size.