Transcript 8-Principles of Endoscopy an endoscope, light source, and irrigating fluid • irrigation fluids include sterile water, glycine, or normal saline.

8-Principles of Endoscopy
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an endoscope, light source, and irrigating fluid •
irrigation fluids include sterile water, glycine, or
normal saline. If electrocautery use is
anticipated, a solution free
of electrolytes should be used •
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Video-endoscopic units, comprising a light
source, camera for the endoscope, image
processor and recorder, and monitor, are
usually arranged on a mobile tower, are
transmitted to the image processor by a
camera attached to the eyepiece and displayed
on a viewing monitor
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Cystourethroscopy is used to directly visualize the anterior urethra,
posterior urethra, and
the bladder. •
of the most common
indications for cystourethroscopy is the evaluation of microscopic
and gross hematuria. Other indications for cystourethroscopy
include evaluation of voiding symptoms, surveillance of urothelial
carcinoma, foreign body removal, and assisting in difficult placement
of a catheter. •
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Endoscope sizes are expressed using the French (Fr)
scale and refer to the outer circumference in millimeters.
Pediatric endoscopes are generally 8 to 12 Fr whereas
adult scopes range from 16 to 25 Fr.
The size of the endoscope selected will depend on the specific
procedure performed,
the need for additional working instruments,
and the degree of irrigant flow that will be required, but
in general the smallest diameter endoscope that will
accomplish the goals of the procedure is selected to minimize
genitourinary tract trauma.
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UPPER URINARY TRACT ENDOSCOPY •
Indications •
Ureteroscopy is a standard urologic technique that •
provides
direct visualization of the upper urinary tract, facilitating
both diagnostic and therapeutic interventions
Ureteroscopy is most •
commonly used for the treatment of nephrolithiasis •
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Ancillary Equipment
Wires. Guidewires used during retrograde instrumentation
serve to provide access to a particular area of the urinary tract and
serve as a guide to pass catheters, stents, and sheaths .
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Guidewire properties vary with
respect to length, diameter, composition, tip design, surface
coating, and shaft rigidity. Guidewire diameters and lengths range
from 0.018 to 0.038 inch and 145 to 280 cm, respectively.
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The
ideal guidewire should have a flexible lubricous tip allowing for
easy atraumatic passage through a tortuous, obstructed ureter
while providing sufficient rigidity of the shaft for the passage of
catheters and instruments.
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Care should be taken to use only as much irrigation needed to
provide a clear visual field.
Utilizing the minimum amount of irrigation necessary to
provide a clear view during ureteroscopy minimizes stone
migration, bleeding from hydrodistention, and
pyelolymphatic
or pyelovenous backflow.
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l The holmium:YAG laser is the gold standard for ureteroscopic
intracorporeal lithotripsy.
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Complications of ureteroscopic
basketing range widely in severity and include
ureteral
avulsion, intussusception, abrasion,
perforation, postoperative
stricture formation, and basket breakage or
entrapment
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PREPARATION FOR SURGERY
Patient Factors That Increase the Risk of •
Infection
Advanced age •
Anatomic anomalies •
Poor nutritional status •
Smoking •
Chronic corticosteroid use •
Immunodeficiency •
Chronic indwelling hardware •
Infected endogenous/exogenous material •
Distant coexistent infection •
Prolonged hospitalization •
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Skin Preparation
Sterile skin preparation is fundamental in the prevention of SSI for any procedure.
Currently, the most commonly used skin antiseptics are alcohol, povidone-iodine, or
chlorhexidine based.
Whichever antiseptic is chosen, the solution should be applied in concentric circles from
the center of the surgical site and be allowed to dry before incision.
A recent review from the did not find sufficient evidence to recommend one skin
preparation over another .
Furthermore, although the CDC clearly recommends preoperative showering/bathing to
reduce SSI, there is no evidence that bathing with an antiseptic solution reduces the
rate of
infection.
Regarding hair removal, the CDC recommends that if hair removal is performed, it should
be performed immediately before the surgical procedure and performed with clippers
(rather than shaving .
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PATIENT ENVIRONMENT
Patient Temperature •
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There are two primary reasons for hypothermia to develop in the
operating room.
Anesthetic agents induce peripheral vasodilation redistributing heat from
the core (trunk, head) with resultant drop in immediate core
temperature after induction.
Throughout the rest of the procedure, radiation and conductive heat loss
account for most of the heat loss during a surgical procedure.
Normothermia is defined as core temperature between
36° C and 38° C, and even hypothermia of 1° C to 2° C results in adverse
effect.
mild hypothermia (decrease of 1°C) resulted in a 16% increase in
estimated blood loss and 22% increase in transfusion requirements
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The increased bleeding risk is thought to result from a
hypothermia-associated decrease in clotting cascade
enzymatic function and platelet aggregation.
Even more significant is the increase in the risk of surgical
site infections (SSI) associated with mild hypothermia (34° C
to 36° C).
Hypothermia was associated with a three times increased risk
of wound infection and a 2.6-day increase in hospitalization.
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Strategies to improvement maintenance of
normothermia including:
regular use of warming blankets,
warmed intravenous fluids,
warmed irrigation fluids (especially during
TURP and other prolonged endoscopic
procedures),
warmed/humidified CO gas during laparoscopy,
and increase in ambient operating room
temperature.
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Skin Preparation
Sterile skin preparation is fundamental in the prevention of SSI for any procedure.
Currently, the most commonly used skin antiseptics are alcohol, povidone-iodine, or chlorhexidine
based.
Whichever antiseptic is chosen, the solution should be applied in
concentric circles from the center of the surgical site and be
allowed to dry before incision.
A recent review from the Cochrane database did not find sufficient evidence to recommend one skin
preparation over another .
there is no evidence that bathing with an antiseptic solution reduces the rate of
infection.
Regarding hair removal, the CDC recommends that if hair removal is performed, it should
be performed immediately before the surgical procedure and performed
with clippers (rather than shaving) (Mangram et al, 1999)
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Patient Safety
Three causes of immediately preventable injuries are :
retractor-associated injuries, thermal injuries
and patient position–related injuries.
1-increased rate of neuropathy (especially femoral nerve) following
laparotomy with self-retaining retractors versus without selfretaining retractors .
Careful attention to be certain that the lateral blades do
not directly compress the psoas muscle and only cradle the rectus
abdominal muscles will ensure avoidance of femoral neuropathy
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2-In both endoscopic and laparoscopic surgery,
high-wattage light sources are used to
illuminate the operative field.
While illuminated, the ends of the light cords
can result in burns when in direct contact with
the patient (even through draping).
These light sources should be turned off at all
times when not in use.
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