Tips for Basic Shoulder Arthroscopy- Part1 Theatre Set Up and Equipment
My name is Gavin Jennings. I am a Shoulder Surgeon based in Bath, UK.
This talk is the first in a series discussing the basics of shoulder arthroscopy and focuses on the theatre equipment and set up needed for performing this type of surgery.
There are some general principles which if adhered to will make shoulder arthroscopy easier and safer. Firstly it is important to know what equipment is essential for undertaking arthroscopic assessment and surgery and it is the surgeons responsibility to make sure that what is required is available.
It is also important to know and understand the set up of each of the pieces of equipment.
Finally, good communication with the anaesthetist is vital to ensure a safe procedure where risks to the patient are minimised.
Considering equipment, the essential requirements include an image management system, light source, monitor, a pump which controls inflow and outflow of fluid and shaver and ablation systems.
For all basic and most advanced shoulder arthroscopy, a 30 degree scope is employed. For many procedures, a 90 degree ablation tool and shaver system are needed
There are many interchangeable shaver types, but a bone burr is frequently used and a soft tissue shaver often desirable.
The pump and stack should be positioned on the opposite side of the table close enough to the operating table to ensure there is plenty of slack in all cables and tubing.
Other desirable pieces of equipment include a dedicated shoulder arthroscopy table attachment to allow easy access to the back of the shoulder and, for some more advanced procedures, an arm holder is often useful.
Fluid management pumps are not widely used outside of shoulder arthroscopy and as such , it is worthwhile having a good understanding of the set up and operation of this piece of equipment, particularly if the theatre staff are not experienced in using this type of equipment.
Good communication and understanding with the anaesthetist is important for a number of reasons. Firstly, positioning the patient can be hazardous and care must be taken to protect the airway, head and neck. Care should be taken when positioning in beach chair with the older patient in particular. They may not have adequate autonomic drive to maintain blood pressure and cerebral blood flow if sat up too rapidly whilst anaesthetised. During the procedure it is often helpful to have slightly hypotensive, or at least normotensive anaesthesia to help minimise bleeding in the joint.
It is also important to ensure that set up allows the anaesthetist easy access to manage the airway throughout.
Whichever patient position you choose for operating, the patient should be pre-marked in a site that wont be obscured by the drapes. Intermittent calf compression pumps should also be employed for the duration of the procedure.
The two options for patient positioning are the beach chair and lateral decubitus. Both have their advantages.
Beach chair may allow better visualisation of structures in their “anatomical position”.
Airway access and management is easier in this position.
It’s easier to move the arm and to convert to an open procedure if necessary. It’s easy to operate with an awake patient under inter scalene block in beach chair. Also traction is not needed.
Disadvantages of beach chair compared to lateral decubitus include the fact that hypotensive anaesthesia is less safe, distraction of the joint is more difficult and posterior labral repairs, at least when starting out, are more of a challenge, partly because of an inability to distract, but also because of the need to get used to the orientation of the joint when viewing from the front. This is less of an issue in lateral as the joint is parallel to the floor and thus orientation is similar both front and back.
Thanks for listening.
Part 2 of this series will look at the diagnostic routine in shoulder arthroscopy.