Almost on a daily basis, it seems, gastrointestinal, gynecologic, urologic and even cardiac surgeons find another use for laparoscopy, pioneering new techniques that allow them to do through keyhole incisions what they once could accomplish only through large, traumatic wounds. Some believe that all abdominal surgeries may one day be done via laparoscopy. At the same time, insurers are increasing the fees they pay for many of these procedures. The fee for laparoscopic hernia repair done in an ASC, for example, is slated to more than double when the new ambulatory payment classification scheme goes into effect.

If you are thinking of expanding the services you offer, and you don't currently offer laparoscopy, you should give it a good hard look. Here are some tips on how you can find capable surgeons and staff and design a facility to handle these cutting-edge procedures.Screen your surgeons Many facilities struggle with how to credential laparoscopic surgeons, since the discipline is only about a decade old. "The vast majority of surgeons in practice have not undergone standard laparoscopic training," says Adrian Park, MD, a laparoscopic surgeon at the University of Kentucky Medical Center. The most experienced surgeons, says Dr. Park, have undergone one or two-year laparoscopic fellowships; however, only about four dozen of these formal training programs are offered every year.

Screen your surgeons
Many facilities struggle with how to credential laparoscopic surgeons, since the discipline is only about a decade old. "The vast majority of surgeons in practice have not undergone standard laparoscopic training," says Adrian Park, MD, a laparoscopic surgeon at the University of Kentucky Medical Center. The most experienced surgeons, says Dr. Park, have undergone one or two-year laparoscopic fellowships; however, only about four dozen of these formal training programs are offered every year.

It's important to ensure that your surgeons have an adequate level of experience without creating too much of a burden to prove their skills. At the bare minimum, you should document what kinds of cases they've competed and how many, what their complication rates were, and what laparoscopic training they've undergone, recommends Michael Mastran-gelo, MD, a laparoscopic surgeon who also practices at the University of Kentucky. Less experienced surgeons should be proctored.

Some facilities require surgeons to be credentialed in categories of procedures (e.g. diagnostic laparoscopy, upper GI tract, and lower GI tract). This ensures that they don't have to be credentialed for each procedure, but prevents them from being inadvertently credentialed for advanced procedures that they aren't qualified to do without supervision.

Overhead booms, multiple monitors, and an electrically powered table will help make your OR "laparoscopy friendly"

Design a laparoscopy suite
An ideal laparoscopy suite has the equipment and setup to allow the surgeons and staff to move around easily, see the surgical site, and position the patient. If you have the option, it may be a good idea to designate one OR as a laparoscopy suite-the same room can be used for gastrointestinal and gynecological laparoscopy procedures, arthroscopies, and even sinus surgeries. Here are some features and equipment you may want to consider for this OR:

Overhead booms: Mounting key equipment, such as monitors, cameras, lights, insufflators, and anesthesia towers, on hydraulically powered ceiling booms accomplishes three things: It keeps the floor around the table from getting cluttered, it reduces the damage that may result from transporting equipment on carts, and, most importantly, it aids in the precise positioning of the equipment around the surgical site, which is critical for laparoscopic procedures.

High quality, easy-to-position monitor(s): To a laparoscopic surgeon, the video monitor is essentially the surgical site; therefore, it needs to offer the highest resolution possible and be able to be positioned exactly right. It's in the ideal position, says Dr. Mastrangelo, if you can draw a straight line from the surgeon's eye through the trocar port to the monitor. "If the monitor is positioned off that axis by more than 90 degrees," he says, "the surgeon starts to see movements on the screen that do not correspond intuitively to what he is doing inside the patient."

Keeping the monitor on a boom will greatly facilitate positioning, which should ideally be about 15 degrees below eye level. It may even pay to have multiple monitors to enable assisting surgeons and nurses to get a clear view of the procedure.

Many companies have been working on how to get the monitor closer to the operative field, according to Dr. Park. Products they've developed include drapable monitors and even disposable monitors. However, "the quality of the image in these products is not where it needs to be," says Dr. Park. "And no surgeon will want to do anything to sacrifice quality and resolution of the image in order to bring the monitor closer to the surgical site."

Investing in flat screen monitors may be worth the cost, according to Gerald Fried, MD, a laparoscopic surgeon at McGill University in Monteal. They are less cumbersome and may decrease the overhead clutter on the ceiling boom.

Centralized gas delivery: Dr. Fried recommends having a large capacity insufflation source, perhaps located in a tank room outside the OR (the large "H" tanks are at least five times the size of the smaller "E" tanks normally located inside ORs). The tanks deliver CO2 through a system that regulates the pressure and sends the gas through a line that goes up into the ceiling, down a column hanging from the ceiling, and then into the insufflator. If you think you will do a lot of procedures, having a tank room may ensure that you never have to switch tanks during a procedure and guarantee that you have enough gas for at least a month.

Equipment to facilitate patient positioning: In open procedures, surgeons can use retractors to move and position skin and organs and manipulate the surgical site. In laparoscopic procedures, the patient must be tilted and positioned in such a way that gravity does the work of the retractors. To facilitate this, it's crucial to have surgical tables that allow for the broadest range of positioning. An electric or powered operating room table is a definite asset, since it allows the surgeon to easily change patient positioning during the procedure, which is often particularly difficult since the room is usually dark. You may also want to buy a table that is C-arm compatible.

It's important to cushion the patient with adequate padding to prevent nerve injuries due to awkward positioning. Dr. Fried's facility uses a "surgical bean bag" that conforms to the patient's body, holds the patient in place on the table, and ensures that the arms, legs, and back are properly padded.

A high-flow insufflator: Hugo Ribot, MD, an Atlanta-based gynecologic laparoscopic surgeon, recommends that every laparoscopic OR suite have a high-flow insufflator that can deliver gas at a rate of 15-20 liters per minute to maintain a constant intra-abdominal pressure between 12 and 18 mm Hg. You may also want to consider an insufflator that warms and humidifies the gas before it enters the abdomen. This may cause less CO2 absorption, keep the abdominal tissues moist, and reduce the risk of hypothermia, particularly in longer procedures.

A gas scavenging system: A scavenging system may help remove potentially contaminated insufflation gas more completely. This may not always be necessary, says Dr. Fried, but installing one may be a good idea if you are doing many procedures.

A variety of trocars: Provide a variety of disposable and reusable trocar sizes; the insufflator, for example, should ideally be connected to a larger trocar to provide minimal resistance to gas flow, says Dr. Fried. He feels that reusable trocars are just as good as disposables, as long as the valves are in good shape and the trocars are sharp.

Train your staff
Laparoscopy requires several special measures not required in other procedures, so make sure your anesthesiologists and staff are well-trained before beginning.

As far as anesthesia goes, it's necessary to avoid anesthetics with nitrous oxide, since it can accumulate in the bowel and interfere with visualization, says Dr. Fried. It's also important to use short-acting, nausea-inhibiting anesthetics, such as propofol, as well as anti-emetics, since these patients usually are prone to PONV. Finally, your anesthesiologists should be experienced in administering the right amount of anesthetic to keep the patient's abdomen relaxed during the procedure, since inadequate paralysis could cause fluctuations in intra-abdominal pressure.

Your surgical staff also needs training in how to set up the room and how to handle patients.

Dr. Ribot has nurses trained specifically in laparoscopy procedures, including a circulating nurse who stays in the room at all times, to help set up the suite and make sure all the correct instruments are available.

PACU nurses also need to be familiar with laparoscopic patients' special needs. Often, patients assume that because they will be having "minimally invasive" surgery, they will feel fine immediately afterward. This is usually not the case-patients will often be nauseous from the insufflation gas combined with the effects of the anesthesia, plus they may feel slight pain around their incisions. They may also feel referred pain in their shoulders caused by residual insufflation gas putting pressure on the diaphragm. Your nurses need to educate patients about these potential side effects and manage them, says Dr. Mastrangelo. Make sure they help patients out bed as soon as possible post-op; light exercise is critical to help the lungs expand and decrease the risk of deep vein thrombosis.

Laparoscopy is one of the fastest-growing surgical technologies. It may require a substantial investment to make your facility "laparoscopy friendly," but it may be well worth your while.