Laporoscopic to Open cases

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    I am curious as to how many ORs have a general major kit set up, counted and ready to
    use during major laparoscopic cases such as, Lap Choles, bowels, Nissens,
    gastrectomies etc...

    We have recently gone to setting up only minimal instruments such
    as 2 snaps, 4 kellys, 2 tooth forceps a metz and suture scissors. The
    times I have been involved when the case has converted to an "open"
    procedure, I have found the MDs don't want to wait the 10 mins for us to
    open a major, set-up and count. I'd appreciate hearing from others as to
    their thoughts and how it is done elsewhere. Thanks.
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  3. 9 Comments so far...

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    We do not open anything that is not necessary for the laparoscopic procedure.
    We do always have available an "open cart". This contains all the basic supplies for a smooth conversion to an open case. Any specialized stuff like vascular clamps, bowel staplers, sutures etc. would then be collected from the core or ordered to be sent up from case carts.
    Seems to me that the surgeon that can't wait for at least a major tray and a pack of laps to be opened and counted doesn't have the patience for and shouldn't be doing laparoscopic procedures. Sounds like they want you to waste lots of YOUR money and YOUR time having both open and lap cases ready to go for a laparoscopic procedure. Perhapse the MDs in question should have those costs deducted from of their reimbursement for the case. Ask them if they would be interested in fronting you the cash in advance for the reduction in possible wait time if they should have to open. If they have to open, they get a refund. I bet you don't get any takers.
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    Two facilities I worked at had a very nice setup for lap to open cases. Called a Lap choly set, it had a more than what you stated (also included 2 clip appliers, 2 army-navy, 2 harringtons, long lahey, 2 kockers) Basically, you could do an open with it and all you would have to add would be a self-retaining retractor if requested.

    K. Lynn
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    In our OR we set up for the lap with the laproscopic instruments, and a basic tray which includes, hemostat's, kellys, mayo's, army navy, scissors, needle holders. When it becomes open we have a tray on the side that is a chole tray that has all your long instruments, balfour. Only takes a minute to open that tray, everything else is already open and on the table.
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    I agree with kathrynlynn, we have a Lap Chole Inst set that includes: scope, lite cord, all graspers, kellys, kockers, s-retractors, USAs, NHs, KHs and scissors.We have everything in the room to do an open procedure and only takes a few minutes to setup. I don't care if the surgeon is in a hurry I just tell them to go get a cup of coffee and it will be ready when they get back.I tend to slooow down when pushed to hard.Luckily 90% of all our Lap Choles stay that way. We use alot of disposables and that makes me more mad to open them and waste them versus doing a open procedure. Mike
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    In our OR, we have a lap chole cart, bowel cart, etc...It is in the room for whatever it is that we are doing. On it is what we need for the laperscopic version, as well as a box containing what is needed to open. It is a very smooth transition really. Our usual lap chole drum has a few things in it too, like suction, kochers, kellys, snaps, just oa few of each... and we always have a #20 blade loaded, ready to go. A surgeon is happiest when cutting, after all. We, of course do a full count to start with, and a small at the end if we have not opened. It takes no time to do a full count. Just opening everything, and then doing an x-ray does not sound like very good technique.
    Last edit by mud on Feb 14, '02
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    when we go from lap to open we do not do a full count. We continue to count everything but instruments. Then we x-ray at the end. It makes the transition to open much quicker and smoother.
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    Where I used to work during a Lap Chole the bovie was always set up and along with the Lap Chole Tray there was a Minor Tray and a #10 blade available so they could open in 2 seconds if they needed to. Which was the case once when the umbilical trocar hit the liver. 5 laps were soaked in seconds once they were open!! As far as anything for a gyne laparoscopy if the case was scheduled as an "operative laparascopy" or "possible open" we just opened a laparotomy tray and had the retractor tray on the side unopened. Plus supplies like blades, bovie and suction were in a little bag "just in case". We were able to open, if need be, in just a few minutes.

    Where I work now, the back table used for open cases is taller than the back table for scopes so an entire new pack has to be opened and four trays counted for a laparotomy. I think this is such a waste of time.
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    Where I work we set up a Lap case with the intention we might have to open. The only thing we may not open is suture for a open case. We set up and count everything just in case we have to open. A good tech should know that anything booked lap might lead to open so you should be ready to keep the case moving along smooth. We have a mini lap insrument pan but most people never use it.
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    We have worked diligently with our physicians to promote efficient yet effective use of resources, including number of instruments opened for cases. To get to that point, we established "constituency" teams of physicians, key OR staff, representative from adminitration, materials management, infection control, and even post-op units to discuss optimal clinical pathways for patients. Costs and time studies are shared with physicians to get their input and most importantly buy-in. We selected key docs from various groups to be sure and include everyone. Not getting their buy-in and then trying to argue costs with them won't get you anywhere. They will tell you they don't care what it costs, and that the hospital is making money...sound familiar?! Arguably any laparoscopy case could end up as an open case and staff should have equipment/supplies readily available to handle that situation. It is not only very costly but very inefficient timewise to open up things "just in case" for procedures that 95% of the time are not going to open. Get em on your team and ask them for advice on how best to handle the issue. They love feeling important! The best OR nurses have figured out how to use that surgeon arrogance to their advantage in getting the desired result! Come on! We know who really runs the ORs! WE DO- Carrie


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