8 Operating Room Setup Abstract This chapter reviews the general concept of operating room layout, equipment, equipment setup, radiation safety, monitoring, and patient positioning pertinent to MISS in order to ensure smooth workflow and increase operational efficiency. Keywords: operating room, endoscopy, minimally invasive, spine, surgery, setup Minimally invasive spine surgery (MISS) has experienced an incredible advancement over the last decade and is being adopted by an increasing number of spine surgeons.1,2 One important aspect of learning and mastering the minimally invasive techniques is to gain a solid understanding of the basic concept of the operating room (OR) setup, as well as to be familiar with various imaging tools and navigation systems available for MISS. Although the OR setup for MISS is similar to traditional open approaches in many ways, additional equipment such as microscope, endoscope, video monitor towers, C-arm, and O-arm require additional space and must be positioned in such a way that the workflow of the operation is optimized. Hence, the importance of standardization of the setup and of the OR conditions cannot be overemphasized to optimize the ergonomics of the workflow during MISS. This chapter reviews the general concept of OR layout, equipment setup, and patient positioning pertinent to MISS in order to ensure smooth workflow and increase operational efficiency. First and foremost, the OR used for minimally invasive spinal procedures should be of sufficient size to accommodate the fluoroscopy machine (and/or O-arm), microscope or endoscope, and various video monitors, in addition to the usual OR equipment such as the operating table, Mayo stand, anesthesia setup, and neuromonitoring personnel. It is important to have enough space to maneuver the C-arm or O-arm intraoperatively. The setup of the entire equipment within the OR should be standardized to facilitate maximum performance by the surgeon and the entire team. In general, the anesthesia setup is at the head of the patient, the surgeon is at the side of the spinal pathology, the endoscope monitor or operating microscope base positioned at the opposite side of the surgeon, the C-arm is either cranial or caudal to the area of operation, and the fluoroscopy monitor is either at the feet of the patient or on the opposite side of the surgeon for easy visualization ( Position of the surgical microscope is critically important too. If the arms are long enough, positioning the microscope behind the surgeon enables easy handling. The joints of the lever arms of the microscope should be bent in such a way that the optical unit is midline squared toward the patient, so that the surgeon and the assistant have a comfortable working position, especially regarding their head and neck posture. Essentially, all the equipment has to be placed in such a way that the surgeon has maximum flexibility and is as comfortable during the procedure as possible. It is useful to place the video monitor in such a way that the scrub nurse also has full view of the screen to follow the procedure. An example of OR setup for minimally invasive microdiscectomy is demonstrated in In addition to the usual OR setup, various additional equipment may be required for MISS depending on the specific procedure in question. In general, a radiolucent bed is required for localization with fluoroscopy or O-arm navigation. We prefer a Jackson table that allows for the free movement of image guidance or fluoroscopic unit into and away from the surgical field. This is especially crucial when performing percutaneous instrumentation placement as it allows for unencumbered view of the spinal anatomy ( Various tubular retractors are available ranging from 14-mm tubes to X-tube (25 mm expandable to 40 mm) for larger exposures. Minimally invasive instruments are also available from various vendors. For intraoperative visualization, endoscope, microscope, or loupes can be used depending on the pathology and intended procedure. The endoscope should be properly set up and white-balanced to optimize intraoperative visualization ( A list of typical equipment needed for various MISS procedures is: • Radiolucent bed (Wilson frame, Jackson bed). • Tubular dilator system or spine access system ( • Minimally invasive instruments. • Fluoroscopy (C-arm) or O-arm ( • Microscope. • Endoscope and video tower. Correct patient positioning for MISS is critical and is often similar to open approaches. For decompressive procedures such as discectomy or laminectomy, using the Wilson frame may help to widen the interlaminar space to allow easier decompression ( For lateral transpsoas procedures, the patient should be positioned in such a way that the iliac crest is at the break of the table. The adjustable surgical table is flexed so as to increase the iliac crest–rib cage distance. The disc in question is localized with lateral fluoroscopy, and marked directly lateral to the disc space. The importance of doing X-rays and ensuring the visualization anticipated during the surgery cannot be overemphasized. The patient should be properly secured with belts and cloth tape (
8.1 Introduction
8.2 Equipment
8.2.1 Placement
Fig. 8.1).
Fig. 8.2.
8.2.2 Essential Equipment
Fig. 8.3).
Fig. 8.4).
Fig. 8.5).
Fig. 8.6).
8.3 Patient Positioning
Fig. 8.7). For fusion procedures, a Jackson table allows the abdomen to hang free with gravity and allows the spine to fall into its natural contour and is preferable.
Fig. 8.8).
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