- Email: [email protected]
Operating Room Setup
CHAPTER
2
Operating Room Setup
This chapter covers the general organization of the operating room, anesthesia, patient positioning, as well as equipment and instruments.
CLINICAL DATA It is helpful to have a copy of the patient’s record in the operating room. This allows the surgeon to compare the examination under anesthesia with the examination documented in the office. For patients with glenohumeral instability, the surgeon can compare the patient’s report of which activities or motions produce pain to the amount of translation observed during examination under anesthesia. The patient record also includes a summary of the pertinent findings on magnetic resonance imaging, ultrasonography, and computed tomography, allowing the surgeon to assess these to the findings at arthroscopy. The pertinent imaging studies are also placed in plain view for review if needed (Figs. 2.1–2.3). With the advent of electronic medical records, this goal may be achieved by having a computer or laptop in the room displaying the pertinent data.
on the floor. The foot pedals that control the power instruments and cautery are placed for easy access (Figs. 2.5–2.9). The shoulder preparation table contains the skin razor and adhesive tape for removing hair. We use an iodine-based product (Duraprep); for individuals with iodine allergy, a chlorhexidine gluconate (Hibiclens) scrub is followed by an isopropyl alcohol solution. We prefer to have the patient’s hair shaved from the area that will be covered by the bandage. It is not necessary to shave the axilla. Only those instruments required for the operation are placed on the Mayo stand. The back table contains rarely used instruments and the postoperative dressing (Fig. 2.10). Text continued on page 42.
SETUP AND PREPARATION The operating room layout is shown in Fig. 2.4. There must be adequate space to maneuver between the head of the table and the anesthetist. The cart with the arthroscopy equipment is angled toward the surgeon so all of the settings can be seen if needed. Similarly, the arthroscopic pump and fluid bags should be visible so the surgeon can see the pressure and flow at any time. The surgeon should also ask the anesthetist to rotate the blood pressure monitor so that he can check it during the procedure without disturbing his or her concentration. An absorbent mat to collect fluid is placed
38
FIGURE 2.1 Patient record in the operating room.
CHAPTER 2
n
Abstract
Keywords
To perform shoulder arthroscopy, the surgeon must be familiar with the basic setup. This involves knowledge of patient preparation and positioning, the equipment and instruments used in the operating room, and the roles of staff in the operating room. Fundamentals of proper patient care include identification of the surgical site, application of anesthesia, and positioning the patient to protect them while under anesthesia. The operating room equipment includes video technology and fluid management technology. The instruments are the fine tools that allow the surgeon to manipulate and repair target tissues. All of these are reviewed in this chapter.
arthroscopic instruments operating room setup beach chair arthroscopic equipment
Operating Room Setup
38.e1
CHAPTER 2
n
Operating Room Setup
No history of prior similar shoulder problem Previous treatment consisted of selective rest and activity modification Allergies: Patient has no known drug allergies Current Medication: None Social History: Patient denies the use of any tobacco products; patient occasionally drinks socially Clinical Examination: Dominant Hand: Right Right Shoulder Examination: Tenderness — Shoulder: Present at the bicipital groove and biceps muscle Swelling: None Ecchymosis: None Crepitus: None Deformity: None present Atrophy: None present Skin: No incisions, lacerations, or abrasions noted Effusion: Absent Passive Range of Motion: elevation = 120 degrees external rotation (shoulder adducted) = 85 degrees internal rotation to the lumbar level 1-2 Strength: Strength was normal when the patient was tested for resisted elevation, external rotation, internal rotation and subscapularis push-off Muscle Pain Tests (resisted): Resisted internal rotation — not painful Elevation — no pain External rotation — no pain Abduction — no pain Belly-press test — no pain Subscapularis push-off — no pain Stability: Stability was normal when the patient was tested for sulcus, Rowe, abduction/external rotation and posterior translation Neurovascular Examination: Normal Office Radiographs: RIGHT Anterior-posterior radiographic findings: AP normal
FIGURE 2.2 Close-up of patient record.
39
40
SECTION I
n
The Basics
FIGURE 2.3 Magnetic resonance imaging study in the operating room.
CHAPTER 2
Back table
Technician
n
Operating Room Setup
Absorbent mat Assistant
Anesthesia equipment
Surgeon
Mayo stand
Operating table
Anesthesia
FIGURE 2.5 Foot pedals and absorbent mat.
Camera power monitor video recorder
Fluid/pump electrogenerator
FIGURE 2.4 Operating room setup.
FIGURE 2.6 Instrument cart and fluid management equipment.
FIGURE 2.7 Fluid management system.
FIGURE 2.8 Final setup example.
FIGURE 2.9 Mayo stand.
41
42
SECTION I
n
The Basics
FIGURE 2.10 Back table.
FIGURE 2.12 Laryngeal mask air tube secured in place with tape.
FIGURE 2.11 Laryngeal mask air tube.
ANESTHESIA We routinely perform an interscalene block in the preoperative holding area, but this is surgeon preference. The patient is then moved to the operating room, where general anesthesia is started. Because many patients find remaining motionless in the seated position uncomfortable, and we find patient movement and conversation distracting, we prefer to use general anesthesia rather than operating under regional block alone. The interscalene block has no direct effect on blood pressure. With sensory input blocked, there is no sympathetic response to the otherwise painful stimuli, and catecholamine release is avoided. The beta-antagonistic effects (vasodilation and bradycardia) of the general anesthetic agents are then more pronounced, without the pain response to offset them. This causes relative bradycardia and hypotension. The result is improved visualization. Because the operated area is anesthetized, only light general anesthesia is necessary, minimizing postoperative nausea. Some anesthesiologists prefer a laryngeal mask airway, which eliminates the need for endotracheal intubation. Immediate postoperative pain is well controlled (Figs. 2.11 and 2.12). To avoid “wrong site” surgery, always confirm with the patient which shoulder is to be operated on. This is done in the preoperative holding area before the patient receives any sedation. The anesthesiologist uses
FIGURE 2.13 Skin marking.
a surgical marking pen to write “yes” on that shoulder prior to administering the block. The surgeon also asks the patient to confirm the correct site and writes his or her initials and a “yes” on the correct shoulder (Fig. 2.13).
PATIENT POSITIONING Successful shoulder arthroscopy is the result of planning and organization. Many seemingly minor details can have a profound effect on the procedure, and we encourage all surgeons to invest the necessary time to adequately prepare the operating room and the surgical staff. Patients are positioned in either the lateral decubitus or the sitting (beach-chair) orientation. Each position has its advantages and disadvantages, and surgeon preference should dictate the choice. Both diagnostic and reconstructive shoulder arthroscopy can be performed successfully in either position. We generally
CHAPTER 2
use the beach-chair position. Patient positioning is critical as this aids in portal placement and facilitates the procedure. Incorrect positioning adds complexity to an already difficult procedure.
Lateral Decubitus Position The lateral decubitus position offers excellent access to the glenohumeral joint and allows arm suspension (and distraction, as necessary) without the need for an assistant. The surgeon can choose to terminate the arthroscopic procedure and can easily perform an open operation in the subacromial space. Disadvantages include the need to lift and turn the patient, the possibility of excessive distraction across the glenohumeral joint and potential nerve injury, limited access to the anterior shoulder in the subacromial space, and the need to reposition the patient if an open anterior glenohumeral reconstruction is required. Another potential disadvantage is the tendency for the suspension apparatus to place the arm in internal rotation. This is important in glenohumeral reconstruction because repair of the glenohumeral ligaments or rotator interval with the arm in internal rotation may result in permanent loss of external rotation. The surgeon can overcome all these difficulties with appropriate care. Before the patient is brought to the operating room, a vacuum beanbag is placed on the operating table and smoothed (Table 2.1). The patient is assisted onto the table and centered on the beanbag. The cephalad edge of the beanbag should be level with the patient’s upper thorax, but not high enough to protrude into the axilla. After general endotracheal anesthesia has been established, the tube is secured on the side of the mouth away from the surgical site. Both shoulders are examined for range of motion and translation. The patient is then turned over on the unaffected side, with the pelvis and shoulders perpendicular to the table. The beanbag is gathered up around the patient and deflated so that it is firm. The operating table is tilted 20 to 30 degrees posteriorly so that the glenoid is parallel to the floor. Considerable attention is given to protecting the neurovascular structures, soft tissues,
TABLE 2.1 Table Positioning Aids—Decubitus U-shaped Vacupak beanbag, 3 feet long Axillary roll Kidney rest supports for operating table (2) Contoured foam head and neck support Arm board Pillows (2) Foam pads for ankles, knees, and arms Three-inch–wide cloth adhesive tape
n
Operating Room Setup
43
and bony prominences. A soft sheet is rolled into a cylinder approximately 6 inches in diameter and placed under the upper thorax to raise the patient’s chest off the table and thereby minimize pressure on the neurovascular structures within the axilla. The roll should not be placed in the axilla. A 1-L fluid bag wrapped in a towel also works nicely. The downside hip and knee are slightly flexed to stabilize the patient. Pillows are placed between the legs to protect the ankles, knees, and peroneal nerves, and the breasts are carefully padded. Kidney rests are useful to support the beanbag, and broad adhesive tape may be used to further stabilize the patient. The cervical spine must be supported to prevent any hyperextension or lateral angulation during the procedure. An electrosurgical grounding pad is placed over the muscular area of the lateral thigh. The surgeon should inspect the patient’s position carefully and check each pressure area to make sure it is adequately padded. The circulating nurse prepares the entire shoulder, arm, and hand. An assistant grasps the patient’s wrist with a sterile towel, and the surgeon and scrub nurse place the lower U-drape over the patient. The forearm and hand are then placed in the traction device. The wrist is carefully padded to avoid pressure on the sensory branch of the radial nerve. The arm is placed on the lower drape, the upper drape is put into position, and the fluid collection pouch is applied. The arm is attached to the suspension device. Usually 10 pounds of weight is sufficient, but the weight may be increased slightly for larger individuals. The surgeon should think of the suspension device as a stabilizing mechanism rather than a method of producing traction. The shoulder is positioned in 60 degrees of abduction and 10 degrees of flexion.
Sitting Position We prefer the term sitting position rather than the older beach-chair position because the patient’s thorax must be placed 70 to 80 degrees relative to the floor. This upright position is necessary to place the acromion parallel to the floor and allow access to the posterior shoulder. A more recumbent position forces the surgeon to “work uphill” and makes entry into the inferior– posterior shoulder difficult if such a portal is required for glenohumeral reconstruction. One advantage of the sitting position is that it is similar to that used during traditional open operations, so conversion from an arthroscopic to an open rotator cuff repair or glenohumeral reconstruction does not require a change in patient position. Also, the anterior shoulder is more approachable than in the lateral decubitus position; the surgeon need not lean over the patient to gain anterior access. In this position, the arthroscopic
44
SECTION I
n
The Basics
orientation seems more familiar to surgeons, with the vertical orientation of the glenoid similar to that seen during physical examination or radiographic review. Shoulder distraction is not continuous, which minimizes the chance of neurologic injury; the assistant can provide a distraction force during the brief periods when this is needed. A mechanical arm holder can maintain the shoulder in external rotation during glenohumeral reconstruction and in elevation during rotator cuff repair. A special bed needs to be used in which the corner around the shoulder is either absent or removable to allow access to the upper quadrant of the extremity. A regular bed can be used with the patient pulled over to the operative side partially off of the bed, but access to the shoulder and the security of cervical spine stabilization is compromised. This special bed and the arm-holding device are helpful, but not essential, and they do add a fixed cost to the procedure that is not present in lateral decubitus positioning (Table 2.2). Once the patient is assisted onto the operating table, general anesthesia is induced. The head of the table supporting the patient torso is then raised, a small amount of Trendelenburg is applied, and the legs are lowered. The position is adjusted until the patient’s acromion is nearly parallel to the floor. The head and neck are positioned for patient comfort and secured. Pillows are placed under the knees, and a foam pad protects the contralateral elbow. Check to make sure that no pads or drapes interfere with access to the anterior or posterior shoulder. The shoulder, arm, and hand are prepared, and an assistant grasps the wrist while the scrub nurse positions the bottom drape. The hand–wrist support is attached, and the forearm is placed on the patient’s lap. The upper drape is applied, and the suction drainage bag is affixed around the shoulder. The applicable surface anatomy is drawn, and the surgery begins (Figs. 2.14–2.26).
but that is surgeon preference as it can sometimes facilitate visualization of the subscapularis or anterior structures from the posterior portal. An alternative would be to move the arthroscope to an anterior–superior portal to improve visualization of these structures.
FIGURE 2.14 Positioning the patient.
FIGURE 2.15 Patient in the sitting position.
EQUIPMENT Arthroscope A standard 4-mm arthroscope with a 30-degree angled lens is used for all shoulder arthroscopy. We do not generally find it necessary to use a 70-degree arthroscope,
TABLE 2.2 Table Positioning Aids—Sitting Specialized patient table/positioner to expose shoulder blade Specialized arm holder Foam pads for ankles, knees, and arms
FIGURE 2.16 Check the relationship of the acromion to the floor.
CHAPTER 2
n
Operating Room Setup
45
FIGURE 2.17 Secure the breathing tube.
FIGURE 2.18 Position the cervical spine.
FIGURE 2.19 Secure the cervical spine with a chin strap.
FIGURE 2.20 Check the cervical spine alignment from the front.
FIGURE 2.21 Pad the legs and contralateral arm.
FIGURE 2.22 Base of the arm holder.
46
SECTION I
n
The Basics
FIGURE 2.25 Access to the anterior shoulder.
FIGURE 2.23 Recheck the position of the acromion.
FIGURE 2.26 Access to the posterior shoulder.
FIGURE 2.27 Body of needle-passing device.
Suture Passers
FIGURE 2.24 Position the shoulder with arm holder.
Sutures are passed through soft tissue either directly or indirectly. There are three types of direct methods briefly described in Chapter 1. In the first method, a device passes a needle loaded with a braided suture directly through the soft tissue (Figs. 2.27–2.30). We use a needle-passing device to pass sutures through the rotator cuff during repair. The second involves piercing the soft tissue with an instrument and then grabbing the suture and pulling it back through the soft tissue
CHAPTER 2
n
Operating Room Setup
47
FIGURE 2.31 Body of arthroscopic tissue penetrator. FIGURE 2.28 Close-up of mouth of needle-passing device.
FIGURE 2.32 Tip of arthroscopic tissue penetrator.
FIGURE 2.29 Body of different needle-passing device. FIGURE 2.33 Handle of straight eyelet direct suture passer.
FIGURE 2.30 Close-up of needle-passing device with the needle deployed.
FIGURE 2.34 Tips of straight eyelet direct suture passer.
(Figs. 2.31 and 2.32). This is used if the target tendon or structure is thick and fibrotic, and it is difficult or impossible to pass a suture through it using the needlepassing device or for side-to-side rotator cuff repairs. In the third method, an instrument passes the suture
through the tendon or ligament using a standard needle with an eyelet to hold the suture (Figs. 2.33–2.38). This can also be used for side-to-side rotator cuff repairs. The indirect method involves placing a passing suture through the soft tissue and using this transport suture
48
SECTION I
n
The Basics
FIGURE 2.39 Handle of disposable cannulated shuttle suture passer. FIGURE 2.35 Handles of left curved eyelet direct suture passers.
FIGURE 2.36 Tips of left curved eyelet direct suture passers.
FIGURE 2.40 Tips of cannulated shuttle suture passer.
FIGURE 2.37 Handles of right curved eyelet direct suture passers.
FIGURE 2.41 Tips of cannulated shuttle suture passer. FIGURE 2.38 Tips of right curved eyelet direct suture passers.
to pull the repair suture through the soft tissue (Figs. 2.39–2.41). A standard 2-0 nylon can be used as a loop or as two free ends with a loop on the other end (Figs. 2.42 and 2.43). The looped end will transfer the repair suture. We often use this method for instability repairs.
Soft Tissue Management A soft tissue grasper is used to test the tension of the glenohumeral ligaments before instability repair and to evaluate the excursion and reparability of a torn rotator cuff. Regular and locking graspers are helpful.
CHAPTER 2
n
Operating Room Setup
49
FIGURE 2.44 Nonaggressive soft tissue grasper.
FIGURE 2.42 Clinical photo of cannulated shuttle suture passer with looped ends. FIGURE 2.45 Close-up of nonaggressive soft tissue grasper.
FIGURE 2.46 More aggressive soft tissue grasper. FIGURE 2.43 Clinical photo of cannulated shuttle suture passer with free ends.
A grasper with less aggressive teeth allows one to pull on sutures without shredding them. A blunt probe is useful to evaluate for the presence of a subtle Bankart or a superior labrum anterior to posterior (SLAP) lesion. When a Bankart lesion has healed with a fibrous union, the lesion may not be apparent, and a sharp chisel dissector can peel the labrum off the anterior glenoid. To ensure that the capsule is not adherent to the subscapularis, a blunt soft tissue instrument can be used to dissect between the two structures. A large soft tissue punch is useful to excise portions of a contracted capsule during contracture release. We have found the capsular punches designed by Harryman to be the most effective for capsular release in patients with shoulder
stiffness. Two of the instruments were modified so that they bend downward rather than upward, which gives a more comfortable angle of approach to the capsular tissue. A blunt-ended probe is used for dissection around nerves or blood vessels. The markings on the end of the probe are useful for measuring distances and the size of lesions (Figs. 2.44–2.62).
Suture Management A crochet hook is used to retrieve sutures from within the subacromial space or glenohumeral joint. If a suture gets caught in the tendon or labrum, a fine-toothed crochet hook is less likely to damage the suture or the articular cartilage. A looped suture grasper is used to ensure that Text continued on page 52.
50
SECTION I
n
The Basics
FIGURE 2.48 Suture grasper with locking handle.
FIGURE 2.47 Close-up of more aggressive soft tissue grasper.
FIGURE 2.50 Chisel dissector.
FIGURE 2.52 Blunt dissector.
FIGURE 2.49 Close-up of suture grasper. FIGURE 2.53 Close-up view of blunt dissector.
FIGURE 2.51 Chisel dissector.
FIGURE 2.54 Close-up view of blunt dissector.
CHAPTER 2
n
Operating Room Setup
51
FIGURE 2.55 Rasp.
FIGURE 2.56 Close-up view of two-sided rasp.
FIGURE 2.57 Straight capsular resection punch.
FIGURE 2.58 Close-up of capsular resection punch.
FIGURE 2.59 Close-up of capsular resection punch.
FIGURE 2.60 Modified angled capsular punch.
FIGURE 2.61 Close-up view of modified angled capsular punch.
FIGURE 2.62 Blunt probe with measuring guide markings.
52
SECTION I
n
The Basics
there are no suture tangles within the working cannula before tying each suture. A larger instrument is useful during rotator cuff repairs, and a smaller one is easier to maneuver within the glenohumeral joint. There are a number of knot-tying instruments available, but a single-lumen knot pusher suffices, which can double as a knot pusher and puller. Arthroscopic scissors are needed to cut suture and soft tissue. End-cutting scissors are used when the knot is not visualized well during a rotator interval repair, or simply to cut the suture in the cannula containing the suture (Figs. 2.63–2.75).
FIGURE 2.63 Close-up of crochet hook.
FIGURE 2.68 Small loop grasper.
FIGURE 2.69 Close-up of small loop grasper with jaws open.
FIGURE 2.64 Close-up of fine-toothed crochet hook.
FIGURE 2.70 Knot pusher.
FIGURE 2.65 Large loop grasper.
FIGURE 2.66 Close-up of large loop grasper.
FIGURE 2.67 Loop grasper with the jaws open.
FIGURE 2.71 Close-up of knot pusher.
CHAPTER 2
n
Operating Room Setup
53
FIGURE 2.76 Shaver. FIGURE 2.72 Scissors.
Sutures
FIGURE 2.73 Close-up of scissors.
Several different sutures are used during shoulder arthroscopy. Most repairs are done with one of the many No. 2 braided high-tensile strength sutures on the market that often depend on the anchor that is used. A 2-0 nylon is a good transfer suture to bring the braided sutures through the rotator cuff or glenoid labrum. Prolene and PDS were often used in the past, but are now rarely used. 3-0 Monocryl or nylon can be used for the skin closure of portal incisions.
Power Instruments
FIGURE 2.74 End-cutting scissors.
Relatively few power instruments are needed. Shavers range in size from 3.5 to 5 mm; and burs may range from a 4-mm round bur to a 5.5-mm acromionizer bur. A 4.5-mm acromionizer bur can be used during abrasion arthroplasty for arthritis, or for coracoid preparation during an arthroscopic Latarjet procedure. The 3.5- or 4-mm shaver and 4-mm round bur are used within the glenohumeral joint for glenohumeral instability and SLAP repair, and a power drill is used to predrill the bone anchor holes for these repairs. A larger shaver is used to remove bursal tissue during arthroscopic subacromial decompression, and an acromionizer is used for acromioplasty. A round or oval bur can be used within the subacromial space to prepare the rotator cuff repair site. Cautery or ablation instruments are very helpful to remove soft tissue and maintain hemostasis. Some instruments come as a hybrid of a shaver and cautery, and can be useful as well (Figs. 2.76–2.87).
Cannulas FIGURE 2.75 Close-up of end-cutting scissors.
A metal cannula is used for the arthroscope and may have ports for inflow, outflow, and pressure. In addition
54
SECTION I
n
The Basics
FIGURE 2.78 Electroblade.
FIGURE 2.77 Close-up of shaver. FIGURE 2.80 Round bur.
FIGURE 2.79 Close-up of Electroblade. FIGURE 2.82 Close-up of round bur.
FIGURE 2.84 Close-up of acromionizer bur.
FIGURE 2.81 Close-up of round bur.
FIGURE 2.83 Acromionizer bur.
FIGURE 2.85 Close-up of acromionizer bur.
CHAPTER 2
n
Operating Room Setup
FIGURE 2.86 Less aggressive oval bur. FIGURE 2.88 Cannula (8 mm).
FIGURE 2.89 Cannula (5.5 mm). FIGURE 2.87 Close-up of oval bur.
to the metal cannula and blunt trocar for the arthroscope, plastic, translucent cannulae are very helpful when performing arthroscopic reconstructive shoulder surgery. During anchor insertion or knot tying, using a cannula can prevent adjacent soft tissue from interfering with the insertion. Because the cannula is translucent, anchors can be inserted and knots can be tied even with the cannula covering the involved area. An 8-mm cannula is large enough to accommodate the power tools and the large suturing instruments; larger cannulas (8.5 and 10 mm) are also available. A 5.5-mm cannula is used if smaller instruments will be passed (Figs. 2.88 and 2.89).
FIGURE 2.90 Electrocautery.
Thermal Instruments Two types of thermal instruments can be used during shoulder arthroscopy. The first instrument can cauterize or ablate tissue (Figs. 2.90–2.92). This is helpful during arthroscopic subacromial decompression to remove soft tissue from the undersurface of the acromion; and the coagulation setting can be used to control bleeding from branches of the coracoacromial artery or from vascularized bursal tissue. A probe that has
FIGURE 2.91 Close-up of electrocautery.
55
56
SECTION I
n
The Basics
FIGURE 2.92 Close-up of electrocautery. FIGURE 2.93 Switching stick.
suction attached to it is helpful so that the bubbles produced during ablation or coagulation are removed from the operative field. The second instrument is the combination shaver and cautery (see Figs. 2.78 and 2.79).
Fluid Management An arthroscopic pump system for delivering fluid to the shoulder is a valuable asset. A pump system eliminates the need to hang bags of irrigating fluid high above the floor and allows the surgeon to increase pump pressure and flow rate when bleeding is encountered. We use lactated Ringer’s solution without epinephrine. If a surgeon considers epinephrine helpful, it is advisable to add it to every other bag of Ringer’s solution to minimize any potential cardiotoxic effects.
FIGURE 2.94 Tip of switching stick.
for cyst formation. We rarely use biocomposite because of cost issues as well.
Transfer Rods Surgeons who prefer to create portals with the inside-out technique will find the Wissinger rod useful (described in Chapter 3). Switching rods are blunt on both ends and are used to maintain the cannula position when the arthroscope is moved from one position to another (Figs. 2.93 and 2.94).
Anchors The number of anchor types on the market is too cumbersome to discuss in detail. In general, we prefer PEEK 4.5 to 5.5 mm for primary rotator cuff repairs and smaller 2.5- to 3.0-mm PEEK anchors for labral repair. We only use metal anchors for revision rotator cuff repairs in patients with poor bone stock and multiple previously placed anchors. We virtually never use bioabsorbable anchors due to cost and the potential
Photography and Video Recording It is extremely helpful to take intraoperative photographs. They record the lesions found during the operation more precisely than the description in the operative notes. They have the added advantage of documenting normal findings that surgeons commonly omit from the operative record. Most arthroscopy systems have the ability to take photographs during surgery with the use of a foot switch or a control button on the camera. The photographs can be printed directly or stored on recordable media or a computer hard drive. Video recordings of the operations also can be helpful if hard drive space is available, and if the surgeon has the time to review it with the patient. We often use video to capture interesting pathology, but do not use it on a regular basis as it can be cumbersome to review it with patients.
CHAPTER 2
n
Operating Room Setup
DEDICATED TEAM We cannot emphasize enough the advantages of having a trained, dedicated, operating room team (Fig. 2.95). Reconstructive shoulder arthroscopy is complicated, and it is helpful when the scrub nurse, assistant, and circulating nurse can perform their jobs without instruction from the surgeon. The surgical nurse can load the instruments so they are ready for the next step; can clean the shavers and burs so they function appropriately; and can have the next instrument ready so the operation will run smoothly. FIGURE 2.95 World’s best operating room team.
57
2
Operating Room Setup
This chapter covers the general organization of the operating room, anesthesia, patient positioning, as well as equipment and instruments.
CLINICAL DATA It is helpful to have a copy of the patient’s record in the operating room. This allows the surgeon to compare the examination under anesthesia with the examination documented in the office. For patients with glenohumeral instability, the surgeon can compare the patient’s report of which activities or motions produce pain to the amount of translation observed during examination under anesthesia. The patient record also includes a summary of the pertinent findings on magnetic resonance imaging, ultrasonography, and computed tomography, allowing the surgeon to assess these to the findings at arthroscopy. The pertinent imaging studies are also placed in plain view for review if needed (Figs. 2.1–2.3). With the advent of electronic medical records, this goal may be achieved by having a computer or laptop in the room displaying the pertinent data.
on the floor. The foot pedals that control the power instruments and cautery are placed for easy access (Figs. 2.5–2.9). The shoulder preparation table contains the skin razor and adhesive tape for removing hair. We use an iodine-based product (Duraprep); for individuals with iodine allergy, a chlorhexidine gluconate (Hibiclens) scrub is followed by an isopropyl alcohol solution. We prefer to have the patient’s hair shaved from the area that will be covered by the bandage. It is not necessary to shave the axilla. Only those instruments required for the operation are placed on the Mayo stand. The back table contains rarely used instruments and the postoperative dressing (Fig. 2.10). Text continued on page 42.
SETUP AND PREPARATION The operating room layout is shown in Fig. 2.4. There must be adequate space to maneuver between the head of the table and the anesthetist. The cart with the arthroscopy equipment is angled toward the surgeon so all of the settings can be seen if needed. Similarly, the arthroscopic pump and fluid bags should be visible so the surgeon can see the pressure and flow at any time. The surgeon should also ask the anesthetist to rotate the blood pressure monitor so that he can check it during the procedure without disturbing his or her concentration. An absorbent mat to collect fluid is placed
38
FIGURE 2.1 Patient record in the operating room.
CHAPTER 2
n
Abstract
Keywords
To perform shoulder arthroscopy, the surgeon must be familiar with the basic setup. This involves knowledge of patient preparation and positioning, the equipment and instruments used in the operating room, and the roles of staff in the operating room. Fundamentals of proper patient care include identification of the surgical site, application of anesthesia, and positioning the patient to protect them while under anesthesia. The operating room equipment includes video technology and fluid management technology. The instruments are the fine tools that allow the surgeon to manipulate and repair target tissues. All of these are reviewed in this chapter.
arthroscopic instruments operating room setup beach chair arthroscopic equipment
Operating Room Setup
38.e1
CHAPTER 2
n
Operating Room Setup
No history of prior similar shoulder problem Previous treatment consisted of selective rest and activity modification Allergies: Patient has no known drug allergies Current Medication: None Social History: Patient denies the use of any tobacco products; patient occasionally drinks socially Clinical Examination: Dominant Hand: Right Right Shoulder Examination: Tenderness — Shoulder: Present at the bicipital groove and biceps muscle Swelling: None Ecchymosis: None Crepitus: None Deformity: None present Atrophy: None present Skin: No incisions, lacerations, or abrasions noted Effusion: Absent Passive Range of Motion: elevation = 120 degrees external rotation (shoulder adducted) = 85 degrees internal rotation to the lumbar level 1-2 Strength: Strength was normal when the patient was tested for resisted elevation, external rotation, internal rotation and subscapularis push-off Muscle Pain Tests (resisted): Resisted internal rotation — not painful Elevation — no pain External rotation — no pain Abduction — no pain Belly-press test — no pain Subscapularis push-off — no pain Stability: Stability was normal when the patient was tested for sulcus, Rowe, abduction/external rotation and posterior translation Neurovascular Examination: Normal Office Radiographs: RIGHT Anterior-posterior radiographic findings: AP normal
FIGURE 2.2 Close-up of patient record.
39
40
SECTION I
n
The Basics
FIGURE 2.3 Magnetic resonance imaging study in the operating room.
CHAPTER 2
Back table
Technician
n
Operating Room Setup
Absorbent mat Assistant
Anesthesia equipment
Surgeon
Mayo stand
Operating table
Anesthesia
FIGURE 2.5 Foot pedals and absorbent mat.
Camera power monitor video recorder
Fluid/pump electrogenerator
FIGURE 2.4 Operating room setup.
FIGURE 2.6 Instrument cart and fluid management equipment.
FIGURE 2.7 Fluid management system.
FIGURE 2.8 Final setup example.
FIGURE 2.9 Mayo stand.
41
42
SECTION I
n
The Basics
FIGURE 2.10 Back table.
FIGURE 2.12 Laryngeal mask air tube secured in place with tape.
FIGURE 2.11 Laryngeal mask air tube.
ANESTHESIA We routinely perform an interscalene block in the preoperative holding area, but this is surgeon preference. The patient is then moved to the operating room, where general anesthesia is started. Because many patients find remaining motionless in the seated position uncomfortable, and we find patient movement and conversation distracting, we prefer to use general anesthesia rather than operating under regional block alone. The interscalene block has no direct effect on blood pressure. With sensory input blocked, there is no sympathetic response to the otherwise painful stimuli, and catecholamine release is avoided. The beta-antagonistic effects (vasodilation and bradycardia) of the general anesthetic agents are then more pronounced, without the pain response to offset them. This causes relative bradycardia and hypotension. The result is improved visualization. Because the operated area is anesthetized, only light general anesthesia is necessary, minimizing postoperative nausea. Some anesthesiologists prefer a laryngeal mask airway, which eliminates the need for endotracheal intubation. Immediate postoperative pain is well controlled (Figs. 2.11 and 2.12). To avoid “wrong site” surgery, always confirm with the patient which shoulder is to be operated on. This is done in the preoperative holding area before the patient receives any sedation. The anesthesiologist uses
FIGURE 2.13 Skin marking.
a surgical marking pen to write “yes” on that shoulder prior to administering the block. The surgeon also asks the patient to confirm the correct site and writes his or her initials and a “yes” on the correct shoulder (Fig. 2.13).
PATIENT POSITIONING Successful shoulder arthroscopy is the result of planning and organization. Many seemingly minor details can have a profound effect on the procedure, and we encourage all surgeons to invest the necessary time to adequately prepare the operating room and the surgical staff. Patients are positioned in either the lateral decubitus or the sitting (beach-chair) orientation. Each position has its advantages and disadvantages, and surgeon preference should dictate the choice. Both diagnostic and reconstructive shoulder arthroscopy can be performed successfully in either position. We generally
CHAPTER 2
use the beach-chair position. Patient positioning is critical as this aids in portal placement and facilitates the procedure. Incorrect positioning adds complexity to an already difficult procedure.
Lateral Decubitus Position The lateral decubitus position offers excellent access to the glenohumeral joint and allows arm suspension (and distraction, as necessary) without the need for an assistant. The surgeon can choose to terminate the arthroscopic procedure and can easily perform an open operation in the subacromial space. Disadvantages include the need to lift and turn the patient, the possibility of excessive distraction across the glenohumeral joint and potential nerve injury, limited access to the anterior shoulder in the subacromial space, and the need to reposition the patient if an open anterior glenohumeral reconstruction is required. Another potential disadvantage is the tendency for the suspension apparatus to place the arm in internal rotation. This is important in glenohumeral reconstruction because repair of the glenohumeral ligaments or rotator interval with the arm in internal rotation may result in permanent loss of external rotation. The surgeon can overcome all these difficulties with appropriate care. Before the patient is brought to the operating room, a vacuum beanbag is placed on the operating table and smoothed (Table 2.1). The patient is assisted onto the table and centered on the beanbag. The cephalad edge of the beanbag should be level with the patient’s upper thorax, but not high enough to protrude into the axilla. After general endotracheal anesthesia has been established, the tube is secured on the side of the mouth away from the surgical site. Both shoulders are examined for range of motion and translation. The patient is then turned over on the unaffected side, with the pelvis and shoulders perpendicular to the table. The beanbag is gathered up around the patient and deflated so that it is firm. The operating table is tilted 20 to 30 degrees posteriorly so that the glenoid is parallel to the floor. Considerable attention is given to protecting the neurovascular structures, soft tissues,
TABLE 2.1 Table Positioning Aids—Decubitus U-shaped Vacupak beanbag, 3 feet long Axillary roll Kidney rest supports for operating table (2) Contoured foam head and neck support Arm board Pillows (2) Foam pads for ankles, knees, and arms Three-inch–wide cloth adhesive tape
n
Operating Room Setup
43
and bony prominences. A soft sheet is rolled into a cylinder approximately 6 inches in diameter and placed under the upper thorax to raise the patient’s chest off the table and thereby minimize pressure on the neurovascular structures within the axilla. The roll should not be placed in the axilla. A 1-L fluid bag wrapped in a towel also works nicely. The downside hip and knee are slightly flexed to stabilize the patient. Pillows are placed between the legs to protect the ankles, knees, and peroneal nerves, and the breasts are carefully padded. Kidney rests are useful to support the beanbag, and broad adhesive tape may be used to further stabilize the patient. The cervical spine must be supported to prevent any hyperextension or lateral angulation during the procedure. An electrosurgical grounding pad is placed over the muscular area of the lateral thigh. The surgeon should inspect the patient’s position carefully and check each pressure area to make sure it is adequately padded. The circulating nurse prepares the entire shoulder, arm, and hand. An assistant grasps the patient’s wrist with a sterile towel, and the surgeon and scrub nurse place the lower U-drape over the patient. The forearm and hand are then placed in the traction device. The wrist is carefully padded to avoid pressure on the sensory branch of the radial nerve. The arm is placed on the lower drape, the upper drape is put into position, and the fluid collection pouch is applied. The arm is attached to the suspension device. Usually 10 pounds of weight is sufficient, but the weight may be increased slightly for larger individuals. The surgeon should think of the suspension device as a stabilizing mechanism rather than a method of producing traction. The shoulder is positioned in 60 degrees of abduction and 10 degrees of flexion.
Sitting Position We prefer the term sitting position rather than the older beach-chair position because the patient’s thorax must be placed 70 to 80 degrees relative to the floor. This upright position is necessary to place the acromion parallel to the floor and allow access to the posterior shoulder. A more recumbent position forces the surgeon to “work uphill” and makes entry into the inferior– posterior shoulder difficult if such a portal is required for glenohumeral reconstruction. One advantage of the sitting position is that it is similar to that used during traditional open operations, so conversion from an arthroscopic to an open rotator cuff repair or glenohumeral reconstruction does not require a change in patient position. Also, the anterior shoulder is more approachable than in the lateral decubitus position; the surgeon need not lean over the patient to gain anterior access. In this position, the arthroscopic
44
SECTION I
n
The Basics
orientation seems more familiar to surgeons, with the vertical orientation of the glenoid similar to that seen during physical examination or radiographic review. Shoulder distraction is not continuous, which minimizes the chance of neurologic injury; the assistant can provide a distraction force during the brief periods when this is needed. A mechanical arm holder can maintain the shoulder in external rotation during glenohumeral reconstruction and in elevation during rotator cuff repair. A special bed needs to be used in which the corner around the shoulder is either absent or removable to allow access to the upper quadrant of the extremity. A regular bed can be used with the patient pulled over to the operative side partially off of the bed, but access to the shoulder and the security of cervical spine stabilization is compromised. This special bed and the arm-holding device are helpful, but not essential, and they do add a fixed cost to the procedure that is not present in lateral decubitus positioning (Table 2.2). Once the patient is assisted onto the operating table, general anesthesia is induced. The head of the table supporting the patient torso is then raised, a small amount of Trendelenburg is applied, and the legs are lowered. The position is adjusted until the patient’s acromion is nearly parallel to the floor. The head and neck are positioned for patient comfort and secured. Pillows are placed under the knees, and a foam pad protects the contralateral elbow. Check to make sure that no pads or drapes interfere with access to the anterior or posterior shoulder. The shoulder, arm, and hand are prepared, and an assistant grasps the wrist while the scrub nurse positions the bottom drape. The hand–wrist support is attached, and the forearm is placed on the patient’s lap. The upper drape is applied, and the suction drainage bag is affixed around the shoulder. The applicable surface anatomy is drawn, and the surgery begins (Figs. 2.14–2.26).
but that is surgeon preference as it can sometimes facilitate visualization of the subscapularis or anterior structures from the posterior portal. An alternative would be to move the arthroscope to an anterior–superior portal to improve visualization of these structures.
FIGURE 2.14 Positioning the patient.
FIGURE 2.15 Patient in the sitting position.
EQUIPMENT Arthroscope A standard 4-mm arthroscope with a 30-degree angled lens is used for all shoulder arthroscopy. We do not generally find it necessary to use a 70-degree arthroscope,
TABLE 2.2 Table Positioning Aids—Sitting Specialized patient table/positioner to expose shoulder blade Specialized arm holder Foam pads for ankles, knees, and arms
FIGURE 2.16 Check the relationship of the acromion to the floor.
CHAPTER 2
n
Operating Room Setup
45
FIGURE 2.17 Secure the breathing tube.
FIGURE 2.18 Position the cervical spine.
FIGURE 2.19 Secure the cervical spine with a chin strap.
FIGURE 2.20 Check the cervical spine alignment from the front.
FIGURE 2.21 Pad the legs and contralateral arm.
FIGURE 2.22 Base of the arm holder.
46
SECTION I
n
The Basics
FIGURE 2.25 Access to the anterior shoulder.
FIGURE 2.23 Recheck the position of the acromion.
FIGURE 2.26 Access to the posterior shoulder.
FIGURE 2.27 Body of needle-passing device.
Suture Passers
FIGURE 2.24 Position the shoulder with arm holder.
Sutures are passed through soft tissue either directly or indirectly. There are three types of direct methods briefly described in Chapter 1. In the first method, a device passes a needle loaded with a braided suture directly through the soft tissue (Figs. 2.27–2.30). We use a needle-passing device to pass sutures through the rotator cuff during repair. The second involves piercing the soft tissue with an instrument and then grabbing the suture and pulling it back through the soft tissue
CHAPTER 2
n
Operating Room Setup
47
FIGURE 2.31 Body of arthroscopic tissue penetrator. FIGURE 2.28 Close-up of mouth of needle-passing device.
FIGURE 2.32 Tip of arthroscopic tissue penetrator.
FIGURE 2.29 Body of different needle-passing device. FIGURE 2.33 Handle of straight eyelet direct suture passer.
FIGURE 2.30 Close-up of needle-passing device with the needle deployed.
FIGURE 2.34 Tips of straight eyelet direct suture passer.
(Figs. 2.31 and 2.32). This is used if the target tendon or structure is thick and fibrotic, and it is difficult or impossible to pass a suture through it using the needlepassing device or for side-to-side rotator cuff repairs. In the third method, an instrument passes the suture
through the tendon or ligament using a standard needle with an eyelet to hold the suture (Figs. 2.33–2.38). This can also be used for side-to-side rotator cuff repairs. The indirect method involves placing a passing suture through the soft tissue and using this transport suture
48
SECTION I
n
The Basics
FIGURE 2.39 Handle of disposable cannulated shuttle suture passer. FIGURE 2.35 Handles of left curved eyelet direct suture passers.
FIGURE 2.36 Tips of left curved eyelet direct suture passers.
FIGURE 2.40 Tips of cannulated shuttle suture passer.
FIGURE 2.37 Handles of right curved eyelet direct suture passers.
FIGURE 2.41 Tips of cannulated shuttle suture passer. FIGURE 2.38 Tips of right curved eyelet direct suture passers.
to pull the repair suture through the soft tissue (Figs. 2.39–2.41). A standard 2-0 nylon can be used as a loop or as two free ends with a loop on the other end (Figs. 2.42 and 2.43). The looped end will transfer the repair suture. We often use this method for instability repairs.
Soft Tissue Management A soft tissue grasper is used to test the tension of the glenohumeral ligaments before instability repair and to evaluate the excursion and reparability of a torn rotator cuff. Regular and locking graspers are helpful.
CHAPTER 2
n
Operating Room Setup
49
FIGURE 2.44 Nonaggressive soft tissue grasper.
FIGURE 2.42 Clinical photo of cannulated shuttle suture passer with looped ends. FIGURE 2.45 Close-up of nonaggressive soft tissue grasper.
FIGURE 2.46 More aggressive soft tissue grasper. FIGURE 2.43 Clinical photo of cannulated shuttle suture passer with free ends.
A grasper with less aggressive teeth allows one to pull on sutures without shredding them. A blunt probe is useful to evaluate for the presence of a subtle Bankart or a superior labrum anterior to posterior (SLAP) lesion. When a Bankart lesion has healed with a fibrous union, the lesion may not be apparent, and a sharp chisel dissector can peel the labrum off the anterior glenoid. To ensure that the capsule is not adherent to the subscapularis, a blunt soft tissue instrument can be used to dissect between the two structures. A large soft tissue punch is useful to excise portions of a contracted capsule during contracture release. We have found the capsular punches designed by Harryman to be the most effective for capsular release in patients with shoulder
stiffness. Two of the instruments were modified so that they bend downward rather than upward, which gives a more comfortable angle of approach to the capsular tissue. A blunt-ended probe is used for dissection around nerves or blood vessels. The markings on the end of the probe are useful for measuring distances and the size of lesions (Figs. 2.44–2.62).
Suture Management A crochet hook is used to retrieve sutures from within the subacromial space or glenohumeral joint. If a suture gets caught in the tendon or labrum, a fine-toothed crochet hook is less likely to damage the suture or the articular cartilage. A looped suture grasper is used to ensure that Text continued on page 52.
50
SECTION I
n
The Basics
FIGURE 2.48 Suture grasper with locking handle.
FIGURE 2.47 Close-up of more aggressive soft tissue grasper.
FIGURE 2.50 Chisel dissector.
FIGURE 2.52 Blunt dissector.
FIGURE 2.49 Close-up of suture grasper. FIGURE 2.53 Close-up view of blunt dissector.
FIGURE 2.51 Chisel dissector.
FIGURE 2.54 Close-up view of blunt dissector.
CHAPTER 2
n
Operating Room Setup
51
FIGURE 2.55 Rasp.
FIGURE 2.56 Close-up view of two-sided rasp.
FIGURE 2.57 Straight capsular resection punch.
FIGURE 2.58 Close-up of capsular resection punch.
FIGURE 2.59 Close-up of capsular resection punch.
FIGURE 2.60 Modified angled capsular punch.
FIGURE 2.61 Close-up view of modified angled capsular punch.
FIGURE 2.62 Blunt probe with measuring guide markings.
52
SECTION I
n
The Basics
there are no suture tangles within the working cannula before tying each suture. A larger instrument is useful during rotator cuff repairs, and a smaller one is easier to maneuver within the glenohumeral joint. There are a number of knot-tying instruments available, but a single-lumen knot pusher suffices, which can double as a knot pusher and puller. Arthroscopic scissors are needed to cut suture and soft tissue. End-cutting scissors are used when the knot is not visualized well during a rotator interval repair, or simply to cut the suture in the cannula containing the suture (Figs. 2.63–2.75).
FIGURE 2.63 Close-up of crochet hook.
FIGURE 2.68 Small loop grasper.
FIGURE 2.69 Close-up of small loop grasper with jaws open.
FIGURE 2.64 Close-up of fine-toothed crochet hook.
FIGURE 2.70 Knot pusher.
FIGURE 2.65 Large loop grasper.
FIGURE 2.66 Close-up of large loop grasper.
FIGURE 2.67 Loop grasper with the jaws open.
FIGURE 2.71 Close-up of knot pusher.
CHAPTER 2
n
Operating Room Setup
53
FIGURE 2.76 Shaver. FIGURE 2.72 Scissors.
Sutures
FIGURE 2.73 Close-up of scissors.
Several different sutures are used during shoulder arthroscopy. Most repairs are done with one of the many No. 2 braided high-tensile strength sutures on the market that often depend on the anchor that is used. A 2-0 nylon is a good transfer suture to bring the braided sutures through the rotator cuff or glenoid labrum. Prolene and PDS were often used in the past, but are now rarely used. 3-0 Monocryl or nylon can be used for the skin closure of portal incisions.
Power Instruments
FIGURE 2.74 End-cutting scissors.
Relatively few power instruments are needed. Shavers range in size from 3.5 to 5 mm; and burs may range from a 4-mm round bur to a 5.5-mm acromionizer bur. A 4.5-mm acromionizer bur can be used during abrasion arthroplasty for arthritis, or for coracoid preparation during an arthroscopic Latarjet procedure. The 3.5- or 4-mm shaver and 4-mm round bur are used within the glenohumeral joint for glenohumeral instability and SLAP repair, and a power drill is used to predrill the bone anchor holes for these repairs. A larger shaver is used to remove bursal tissue during arthroscopic subacromial decompression, and an acromionizer is used for acromioplasty. A round or oval bur can be used within the subacromial space to prepare the rotator cuff repair site. Cautery or ablation instruments are very helpful to remove soft tissue and maintain hemostasis. Some instruments come as a hybrid of a shaver and cautery, and can be useful as well (Figs. 2.76–2.87).
Cannulas FIGURE 2.75 Close-up of end-cutting scissors.
A metal cannula is used for the arthroscope and may have ports for inflow, outflow, and pressure. In addition
54
SECTION I
n
The Basics
FIGURE 2.78 Electroblade.
FIGURE 2.77 Close-up of shaver. FIGURE 2.80 Round bur.
FIGURE 2.79 Close-up of Electroblade. FIGURE 2.82 Close-up of round bur.
FIGURE 2.84 Close-up of acromionizer bur.
FIGURE 2.81 Close-up of round bur.
FIGURE 2.83 Acromionizer bur.
FIGURE 2.85 Close-up of acromionizer bur.
CHAPTER 2
n
Operating Room Setup
FIGURE 2.86 Less aggressive oval bur. FIGURE 2.88 Cannula (8 mm).
FIGURE 2.89 Cannula (5.5 mm). FIGURE 2.87 Close-up of oval bur.
to the metal cannula and blunt trocar for the arthroscope, plastic, translucent cannulae are very helpful when performing arthroscopic reconstructive shoulder surgery. During anchor insertion or knot tying, using a cannula can prevent adjacent soft tissue from interfering with the insertion. Because the cannula is translucent, anchors can be inserted and knots can be tied even with the cannula covering the involved area. An 8-mm cannula is large enough to accommodate the power tools and the large suturing instruments; larger cannulas (8.5 and 10 mm) are also available. A 5.5-mm cannula is used if smaller instruments will be passed (Figs. 2.88 and 2.89).
FIGURE 2.90 Electrocautery.
Thermal Instruments Two types of thermal instruments can be used during shoulder arthroscopy. The first instrument can cauterize or ablate tissue (Figs. 2.90–2.92). This is helpful during arthroscopic subacromial decompression to remove soft tissue from the undersurface of the acromion; and the coagulation setting can be used to control bleeding from branches of the coracoacromial artery or from vascularized bursal tissue. A probe that has
FIGURE 2.91 Close-up of electrocautery.
55
56
SECTION I
n
The Basics
FIGURE 2.92 Close-up of electrocautery. FIGURE 2.93 Switching stick.
suction attached to it is helpful so that the bubbles produced during ablation or coagulation are removed from the operative field. The second instrument is the combination shaver and cautery (see Figs. 2.78 and 2.79).
Fluid Management An arthroscopic pump system for delivering fluid to the shoulder is a valuable asset. A pump system eliminates the need to hang bags of irrigating fluid high above the floor and allows the surgeon to increase pump pressure and flow rate when bleeding is encountered. We use lactated Ringer’s solution without epinephrine. If a surgeon considers epinephrine helpful, it is advisable to add it to every other bag of Ringer’s solution to minimize any potential cardiotoxic effects.
FIGURE 2.94 Tip of switching stick.
for cyst formation. We rarely use biocomposite because of cost issues as well.
Transfer Rods Surgeons who prefer to create portals with the inside-out technique will find the Wissinger rod useful (described in Chapter 3). Switching rods are blunt on both ends and are used to maintain the cannula position when the arthroscope is moved from one position to another (Figs. 2.93 and 2.94).
Anchors The number of anchor types on the market is too cumbersome to discuss in detail. In general, we prefer PEEK 4.5 to 5.5 mm for primary rotator cuff repairs and smaller 2.5- to 3.0-mm PEEK anchors for labral repair. We only use metal anchors for revision rotator cuff repairs in patients with poor bone stock and multiple previously placed anchors. We virtually never use bioabsorbable anchors due to cost and the potential
Photography and Video Recording It is extremely helpful to take intraoperative photographs. They record the lesions found during the operation more precisely than the description in the operative notes. They have the added advantage of documenting normal findings that surgeons commonly omit from the operative record. Most arthroscopy systems have the ability to take photographs during surgery with the use of a foot switch or a control button on the camera. The photographs can be printed directly or stored on recordable media or a computer hard drive. Video recordings of the operations also can be helpful if hard drive space is available, and if the surgeon has the time to review it with the patient. We often use video to capture interesting pathology, but do not use it on a regular basis as it can be cumbersome to review it with patients.
CHAPTER 2
n
Operating Room Setup
DEDICATED TEAM We cannot emphasize enough the advantages of having a trained, dedicated, operating room team (Fig. 2.95). Reconstructive shoulder arthroscopy is complicated, and it is helpful when the scrub nurse, assistant, and circulating nurse can perform their jobs without instruction from the surgeon. The surgical nurse can load the instruments so they are ready for the next step; can clean the shavers and burs so they function appropriately; and can have the next instrument ready so the operation will run smoothly. FIGURE 2.95 World’s best operating room team.
57