Clinical procedure

Theatre organization

Arthroscopic surgery of the shoulder is a highly technical and demanding form of surgery. It requires special instrumentation and a highly skilled team consisting of surgeon, anaesthet­ist, scrub nurse and circulating nurse. Diagnos­tic arthroscopy of the shoulder, on the other hand, requires little more than an arthroscope, light source and hook probe, as well as a large helping of enthusiasm and determination on the part of the surgeon, and tolerance from the anaesthetist and the nursing team. Initially even diagnostic arthroscopy takes time, and the goodwill of the operating team is increased if they can all follow events on a television monitor.

Since shoulder arthroscopy is a very special­ized form of surgery, it is best performed in a dedicated day-case arthroscopy suite. Failing this, a good-sized general or orthopaedic theatre, with nurses trained in arthroscopic techniques of the knee, is the next best situation. To perform this type of surgery in a general surgical theatre with untrained staff needs an extremely optimistic outlook from the surgeon!

The surgeon should have a good training in arthroscopic surgery of the knee before under­taking arthroscopy of the shoulder, and this must be combined with an extensive know ledge of shoulder anatomy, pathology, and an ability to undertake open surgery of the shoul­der in an experienced and competent fashion. The surgeon should then attend a shoulder arthroscopy course, and practise on shoulder models before attempting any form of arthro­scopic procedure on the shoulder of a patient. The surgeon may wish to practise on cadaver shoulders but, unless very fresh cadavers are used, the shoulder soon shrinks and becomes difficult to move, and the whole process becomes rather sordid. It is far better to practise on models and to gain experience by assisting a surgeon who is competent in this technique.

A good theatre layout is shown in Figure 4.1 and is based on the dedicated suite of Dr L Johnson's unit, at Ingham Medical Center, Lansing, Michigan. The patient lies in the lateral decubitus position with the surgeon directly behind his/her shoulder. A Mayo stand with the principal arthroscopic equipment required for the procedure is placed directly opposite the surgeon, and the scrub nurse stands alongside the Mayo stand ready to hand instruments to the surgeon when needed. Directly beyond the instruments is the television stand on which are placed the television monitor, camera equip­ment, light source, shaver system and video recorder. The arm of the patient is supported by a shoulder holder. An extra Mayo stand with accessory instruments is placed to the right of the surgeon and the first assistant stands to the surgeon's left.

Figure 4.1 Suggested theatre setup for shoulder arthroscopy. An, Anaesthetist; N, Nurse; S, Surgeon; A, Assistant; M and M2, Mayo stands; TV, Television monitor; CSV, Camera, Shaver, Video.