1. Camera Holding Skills and the Role of the ASP
Jane P Bradley Hendricks
Laparoscopic Nurse Practitioner
Colchester General Hospital.

2. In The Beginning Early endoscopic surgery performed without cameras.
Surgeon used his eyes to visualize
Development of instrumentation
Necessity for assistant to visualise to interact appropriately.
Explosion of technology and technology
Early endoscopic surgeons were somewhat handicapped by the lack of instrummentation for even routine and elementary operative procedures. It was also very tedious and tiring for the surgeon to peer down the laparoscope without the interaction of an assistant who could visualize and thus effectively participate in the surgery and anticipate the manoevures necessary to optimize the results with a minimum of complications. The development of the chip video camera broke down a great many barriers, not the least of which was the ability of others to assist in the endoscopic surgery. Suddenly it became obvious that a much wider range of surgery and of increasing complexity could be performed. This encouraged the development of specialized instruments to enhance the scope of procedures available.
The unprecedented influx of new technology resulted in a such a phenomenal growth and development of surgical technique in this field that it rapidly overwhelmed the ability of academic training programmes to equip individuals with the skills required. There was a period when the traditional academic centres refrained from embarking on endoscopic surgery as it was viewed as a dangerous gimmick.

3. Role of the Theatre Person
“Today's operating theatre nurse is a highly trained, skilled person whose role is complex and difficult to define. With the advent of minimal access surgery it has to combine the technical knowledge and expertise associated with the sophisticated instruments, techniques and drugs in current use, and the basic nursing skills acquired through training and experience that are vital to the care of the patient.”
CARRINGTON A.C. (1991). Theatre Nursing as a Profession. Brit Jour Th Nurs. 1: 6-7.

4. Surgical Skills Learning curve. Loss of depth of perception
Loss 3D view
Elongated instruments and loss of tactile sensation
Degree of tension
Developing endoscopic surgical skills takes time and patience. A learning curve is to be expected when making the transition to minimal access surgery. The ASP/SCP must develop a conscious awareness of the loss of depth perception and three dimensional views and compensate accordingly. The handling of elongated instruments and the loss of tactile sensation brings a new feel which is very different to that of open surgery. You need to judge the degree od tension being applied to tissues and this can take some time to acquire. Care must be taken to avoid overly aggressive tissue manipulation in order to reduce the i8ncidence of tissue laceration.

5. Placement of Instruments
Under direct visualization only
Beware of tissue under traction out of view of laparoscope.
Telescopes: 0o, 30o and many others.
5mm,10mm and there are now 3/2mm available, although fragile.
The camera operator is a unique surgical team member. The role is crucial to the success of the procedure as the surgeon relies on the camera to visualize the surgical field. The ASP/SCP should carefullt intorduce the insteruments under direct visualization at all times. This will allow correct placement of instruments in order to avoid undue injury. Tissue should only be cut, coagulated or otherwise manipulated whilst under direct vision. There may be tissues under traction outside of the cameras field of view.
Beware when using 30 deg scope of orientation water going up hill,

6. Orientation

7. Understand Your Equipment

8. Equipment Necessary for MAS
Camera
Light Source
Insufflator
TV Monitor
Telescopes
Light Guide Cable
Apart from the insufflator the system will work better if all the components are from the same company as one piece talks to another

9. CAMERA These can be single chip or 3 chip.
CHIP: this is also called a charged coupled device in short, CCD.
These are flat silicone wafers with a matrix, a grid of minute image sensors called pixels.
White balance and sometimes black balance
Sleeve it don’t soak it!!!

10. Light Source
Halogen or Xenon, cold light but beware can still burn holes in drapes esp. disposable and burn patient’s skin if left on the abdomen.
Brightest to darkest measured in units of decibels.
Automatic illumination, does it talk to the camera and are the necessary leads plugged in.
Lamp life meter, look at it. Is it nearly out? EBME keep the spares and they change it.
White balance by making sure white is correct then all the colours through the spectrum are correct.

11. Telescopes Come in varying sizes, laparoscopes usually 5mm or 10mm.
Diagnostic 3mm scope available but not in general use in this hospital.
Made up of a rod and lens system.
Bundles of fibres, incoherent carry light and coherent carry image.
Wide range of angles available 0 and 30 degree are fairly standard.
All laparoscopes are autoclavable and can go thru steris, no ultrasonic bath.

12. Light guide Cables Different diameters Fibre light cable
Buy auroclavable
Don’t bend to acutely as will break fibres.
Check when you plug them in are all the fibres are okay.
Condensers

13. Electrosurgery You should be aware of the following potential situations:
Insulation failure of the active electrode.
Direct coupling of current to other instrumentation by direct contact.
Capacitance which may be created by two electrical conductors separated by an insulator

14. Appropriate safety standards can be maintained if surgeons adhere to the following guidelines
Use a low voltage waveform (cut instead of coagulation) whenever possible.
Use the lowest possible power setting that will deliver the desired tissue effect.
Ensure that insulation on reusable and disposable instrumentation is intact and uncompromised before activating.
Do not activate the electrode in air space (open circuit activation). Activate the generator only when the active electrode is in direct contact with target tissue.
Do not activate electrode when in contact with other instruments.
Use bipolar electro surgery were appropriate, good for coag. But not for cutting tissue.

15. Introduction History of the first assistant
Role of advanced scrub practitioner formerly first assistant.
Surgeons assistant / surgical practitioner.
NATN NMC NAASP.
21/09/2018

16. How the Role Has Evolved in UK
NHS Plan 2000.
More power and information for patients
More hospitals and beds
More doctors and nurses
Shorter waiting times for serviced
Cleaner wards and better food and facilities in hospitals
Improved care for older patients
Tougher standards for for NHS organisations and rewards for best.

17. Changing Workforce Programme
Aim of the programme
Reducing Waits across all sectors
Reducing junior doctors hours
Recruiting to hard to fill posts
Improving access to services
Improving working lives of staff
Benefits
Improved patient care
Less faces
Maximised staff potential
Increased job satisfaction
Attractive jobs
Reduced vacancies and staff turnover.

18. Areas for Consideration
Legal issues
Bolam test
Accountability
Primary liability : individual liability
Negligence
GMC

19. GMC
“you may delegate medical care to nurses and other health care staff who are not registered medical practitioners if you believe it is best for the patient. But you must be sure that the person to whom you delegate is competent to undertake the tasks. You will still be responsible for managing the patient’s care. You must not enable anyone who is not registered with the GMC to carry out tasks that require the knowledge and skills of a doctor”
Assistants in surgical practice Sept.1999.

20. Within the Workplace Vicarious liability
Working within bounds job description
Dual rolling

22. Future.
Robotics
da Vinci: $1.2 million, FDA cleared for advanced surgical techniques.
ZEUS – assists only.
AESOP-
Telepresence surgery
Robot assisted surgery is the latest development in the larger movement of endoscopy. Robots represent a new computer assisted tool that provides another way for surgeons to work. With robotic surgical systems surgeons don’t move endoscopic instruments directly with their hands. Instead they sit at a console several feet or several thousand miles away from the operating table and use joysticks to perform surgical tasks in a process known as telemanipulation.
Robotic surgical systems can also im prove depth perception, giving surgeons three dimensional view compared with the normal 2 D, surgical field can also be magnified. Robots don’t have a tremor so image is steady at all times.

23. Future.
Training.
Haptic technology, science of touch: allows computers to interact with virtual worlds by feel.
MIST-VR; eval by Kothari et al.
Kothari et al (2002). Training in lap Suturing Skills using a Computer Based System. Jour laproendosc. & Adv Surg Tech. 12:3:
Haptics, the science of touch, lets computer users interact with virtual worlds by feel. Some commercial computer games already benefit from early haptic devices, like the force-feedback steering wheels that torque and vibrate on bumpy driving-game roads. But haptics isn't all fun and games. Scientists use computers to simulate not only the impact of a golf club hitting the ball, but also the springiness of a kidney under forceps.
Using Salisbury's haptic technology is like exploring the virtual world with a stick. If you run your stick along a cyberspace sidewalk, it vibrates lightly. If you push it into a virtual balloon, you feel the balloon push back. The computer communicates sensations through a haptic interface -- a stick, scalpel, racket or pen that is connected to force-exerting motors.
"By coordinating the forces that are exerted on your handle or your stick or your stylus or your fingertips, you can make it feel as though you're touching something," says Salisbury.
MIST-VR minimally invasive surgery trainer virtual reality evaluated by kothari et al in the Us compared it to traditional methods of training and found it to be equivalent.

24. Questions
Thank you for your time