Technical problems during laparoscopy: a systematic method of troubleshooting for surgeons

Introduction

The core equipment in laparoscopic surgery has largely remained unchanged since the 1990s and this includes the scope, the laparoscopic tower or stack and the connection cables [1]. However, as the laparoscopic procedures undergo new innovations and become more complex, equipment continue to evolve to keep up with the latest surgical techniques as well as technological advancement [2]. With this, the maintenance and troubleshooting of laparoscopic equipment in the event of technical problems also become challenging. To optimise patient safety, theatre staff including surgeons need to have a basic understanding and knowledge of laparoscopic equipment [3, 4]. Currently, many surgical training programmes do not seem to have dedicated curricula addressing this issue among surgical trainees. Furthermore, different companies that manufacture the same type of surgical equipment may have a wide variety of modifications [5].

Current status

Laparoscopy as a technique is common in general surgery, with aspiring trainees being exposed to the various aspects of laparoscopy even before they enter training. So, what is the current understanding and skill set of trainees regarding the troubleshooting of laparoscopic equipment, including the laparoscopic tower? Many of these surgical trainees are competent in basic laparoscopic skills before application for training. In fact, it is a requirement in many countries for prospective applicants to training programme to have that basic knowledge of laparoscopy [6]. This implies that prospective and current surgical trainees have good understanding of the principles of basic laparoscopy. However, the question remains: does this translate to good understanding and troubleshooting technique among trainees?

There are various laparoscopic skill courses that are conducted by training bodies. The Royal Australian College of Surgeons (RACS) conducts Australian and New Zealand Surgical Skills Education and Training (ASSET), where trainees are taught the basics of laparoscopic skills [7, 8]. This is equivalent to the Basic Surgical Skills Course (BSS) in England and the Fundamentals of Laparoscopic Skills (FLS) in the United States. These courses are conducted over 2–3 days. The half-day session that addresses laparoscopy on this course is entitled “Principles and Practice of Rigid Endoscopy”. The objective, as stated in its curriculum, is to ensure that the candidate “displays competency in a variety of basic practical skills relating to different endoscopic environments and the mechanics of instrumentation”. During this course, candidates are introduced to various elements of laparoscopy, such as camera, scope, fibre optic cable, light source, gas connection and operations of the basic mechanics, and connections and operations of these elements. Candidates are then guided toward performing a number of simple laparoscopic tasks and practicing them. However, they are not taught methods regarding troubleshooting if any issues arise, except for checking connections and attempting to obtain a clearer image by adjusting settings on the camera head itself. In addition, the FLS course covers elements such as operating room setup, ergonomics, general use of laparoscopic instruments and equipment, safety consideration using the laparoscopic stack, laparoscopic training box and virtual reality trainers [9]. The breadth and depth of the curriculum required to teach laparoscopic equipment troubleshooting techniques are limited by time constraints.

Approach to troubleshooting

The commonest source of problems when having trouble with laparoscopy equipment seem to be the scope, camera head, light cable, light source, insufflation tube and gas insufflator [10]. There are a number of ways that problems could be addressed. A large proportion of the problems are due to user error. Different companies producing slightly different types of laparoscopic equipment, which is continuously evolving, adds another element of difficulty to the process of troubleshooting [5].

Verdaasdonk et al. [11] suggested that any approach to troubleshooting laparoscopic equipment challenges should be systematic and standardised and incorporate a form of checklist. They showed a 53% decrease in the adverse incidents while using such a systematic approach. The usage of checklist taking into account the fact that there are different types of laparoscopic stack and adjuncts has its own challenges, and one may need different checklists for different manufacturers.

Mees et al. [10] from Adelaide proposed an approach represented in the form of a flow diagram and followed a series of checklists. Their approach was to start with the monitor and work the way toward various leads and connections and then to the camera head and scope itself. Their study, however, specifically addressed poor image quality and how to solve those issues. It did not address issues related to gas insufflation.

Tichansky et al. [12] suggested a method where the whole laparoscopic equipment and its various adjuncts were divided into three groups, and problems associated with each group were addressed individually. They were (a) the laparoscopic stack that included the monitor, image enhancement system, gas insufflator (thermoflator) and light source; (b) leads that included fibre optic cable for light transmission, camera lead connected to the camera head, and the gas insufflation tube; and (c) the laparoscope itself. The image enhancement system is in turn connected to the monitor (up to two monitors could be connected), image link modules (up to three), light source, and documentation system (keyboard, printer and screen). The image enhancement system is connected to the monitor with visual interface cables. The most commonly used interface cables (digital) are digital visual interface (DVI) and/or serial digital interface (SDI).

It seems logical to group the equipment into categories and try to address the issues separately from each component. However, all these groups of equipment are interconnected and they work in unison and harmony to produce a clear picture. At times the issue may lie with part of the laparoscopic equipment that belongs to two different groups and so cannot be dealt with in isolation. Furthermore, the issue may lie with the patient and the effect of anaesthetic agents on the patient.

We suggest a method of troubleshooting laparoscopic tower problems by categorising them into either image quality problems or insufflation problems. The rationale behind this approach is that, when an issue arises, a surgeon relates that to an outcome that he can visualise. Image and lighting are intricately related, so we consider them a single entity for the purposes of problem solving. We have developed a chart we recommend to be used as a problem-solving chart in operating theatres (Tables 1 and 2).

Conclusion

Laparoscopy as a surgical technique has continued to grow. However, surgeons, trainees and aspiring junior doctors have a varying degree technical knowledge of how the laparoscopy stack works. The current surgical training curriculum lacks specific components to address this knowledge gap. As this can potentially cause patient harm, we recommend the adoption of a uniform, logical and practical method that addresses this potential lack of knowledge and aid troubleshooting in a timely manner within the operating theatre.