**2. The components of the orchestra**

There are four main components to the whole scenario. If we liken it to a Musical Concert, then the place where the whole operation takes place is the Operating Room (OR) while the main Conductor of the event is the Chief Surgeon. The surgical (musical) instruments are what are essential for the surgery to take place and finally the musical score is the patient upon which this whole event is dependent upon to be successful.

#### **2.1 The operating room**

The theatre where the drama takes place is the operating room. The environment in this room is critical to the success of the surgery. The conductor or Master of the OR is the surgeon and the environment should be tailored to his or her preference.

Microsurgery requires a steady hand and practiced skill. It takes hours to complete a replantation or undertake a coronary artery by-pass graft while demanding full concentration to the task at hand. Mundane issues must be sorted out for any discomfort may prolong the surgery and even render it unsuccessful.

#### *2.1.1 Temperature and lighting*

The temperature of the OR is of course controlled within specified limits of regulatory standards, but the main surgeon must be comfortable throughout the duration of the surgery.

The lighting, similarly, has to be of superb quality to visualise the most intricate detail. The aim is to have a well-illuminated field without shadows. The operating microscope achieves this by housing an incandescent or halogen bulb in the floor stand and transmitting the light via a built-in fibre optic cable to the operating field. The general surgical field, however, is wider and once the surgeon looks out to this area, it will appear dark, thus the periphery also has to be well-lit with good OR lights.

#### *2.1.2 Theatre equipment*

Surgical equipment such as the Operating microscope, the x-ray machine, the coagulation (diathermy) unit, the heart-lung bypass machine and the anaesthetic machines all need to be co-ordinated and well-spaced out (**Figure 1**). In a centre routinely performing these surgeries, there are fixed protocols: they are there for a reason. Surgeons in different centres will do it differently depending on how (and where) they have been trained; therefore, these protocols are to be tailored to the surgeon or institution.

The surgeon's stool (**Figure 1**: inset) is obviously of extreme importance and depending upon their preference should be comfortable and of perfect (adjustable) height with rollers to allow the surgeon to move seamlessly. Different sub-specialties have slightly varying adjustments such back support, arm support (or none) a ring

#### **Figure 1.**

*Operation theatre set-up. The X-ray machine (mini C-arm), operating microscope and diathermy machine should all be away from the main surgeon and not touching the operating table. The surgical stool is shown in the inset.*

**145**

**Figure 2.**

*Tips and Tricks in Microvascular Anastomoses DOI: http://dx.doi.org/10.5772/intechopen.92903*

should be made to accommodate them.

**2.2 The surgeon**

deep breaths.

**2.3 The equipment**

*2.3.1 The operating microscope/loupes*

all with the push of a button.

does not even have to look down at the field (**Figure 2**)!

*surgeon can operate seeing up, not down, reducing neck strain.*

with the rollers of the operating surgeon's stool.

below to rest the foot and so on. These are personal preferences and every attempt

The Diathermy cable should be tucked well out of the way and the foot pedal next to the surgeon's dominant foot. If the microscope has foot control, then it could be placed at the assistant's preferred foot or elsewhere. The wire should not interfere

The surgeon performing an operation must be well rested, energised, reasonably hydrated and abreast of the task at hand. It is important to note that any heavy activity (swinging heavy objects, manual activity) should be avoided in the 24 hours prior to microsurgery. If one wants to test this out, try playing table tennis after a round of tennis. Using the larger muscle groups will compromise the fine motor control (in millimetres and micrometres) required in microsurgery. Caffeine intake should be the amount the surgeon is used to: not more and not less. For obvious reasons the use of sedatives prior to surgery is not advised as are medications that may cause drowsiness. During emergency cases, if progress is not being made, a 10–20-minute break is advised; it usually allows a fresh take on the stumbling block. If it is a technically difficult step, take a breather before starting it, better insight is gained with a few

The Operating microscope is used in many different surgical specialities and has been adapted for their particular needs. The Ophthalmic one for example is angled at 45° while the neuro one is used while in standing position. The Plastic and Hand Surgeons use the same one in a sitting position and new the latest ones by Zeiss (Pentero and Kinevo) have 3D images and screens that are facing the surgeon so he

The Neuro Microscopes show arterial and venous flow – they also have infrared technology that allows intra-operative visual assessment of blood flow and patency,

*Operating microscopes. The classic Zeiss microscope came on the S88 floor stand. Now Zeiss has the modern Pentero and Kinevo which can do fluoroscan view as well as show the screen up front (on the right), so the* 

#### *Tips and Tricks in Microvascular Anastomoses DOI: http://dx.doi.org/10.5772/intechopen.92903*

below to rest the foot and so on. These are personal preferences and every attempt should be made to accommodate them.

The Diathermy cable should be tucked well out of the way and the foot pedal next to the surgeon's dominant foot. If the microscope has foot control, then it could be placed at the assistant's preferred foot or elsewhere. The wire should not interfere with the rollers of the operating surgeon's stool.

### **2.2 The surgeon**

*The Current Perspectives on Coronary Artery Bypass Grafting*

The theatre where the drama takes place is the operating room. The environment in this room is critical to the success of the surgery. The conductor or Master of the OR is the surgeon and the environment should be tailored to his or her preference. Microsurgery requires a steady hand and practiced skill. It takes hours to complete a replantation or undertake a coronary artery by-pass graft while demanding full concentration to the task at hand. Mundane issues must be sorted out for any

The temperature of the OR is of course controlled within specified limits of regulatory standards, but the main surgeon must be comfortable throughout the

The lighting, similarly, has to be of superb quality to visualise the most intricate detail. The aim is to have a well-illuminated field without shadows. The operating microscope achieves this by housing an incandescent or halogen bulb in the floor stand and transmitting the light via a built-in fibre optic cable to the operating field. The general surgical field, however, is wider and once the surgeon looks out to this area, it will appear dark, thus the periphery also has to be well-lit with good OR lights.

Surgical equipment such as the Operating microscope, the x-ray machine, the coagulation (diathermy) unit, the heart-lung bypass machine and the anaesthetic machines all need to be co-ordinated and well-spaced out (**Figure 1**). In a centre routinely performing these surgeries, there are fixed protocols: they are there for a reason. Surgeons in different centres will do it differently depending on how (and where) they have been trained; therefore, these protocols are to be tailored to the

The surgeon's stool (**Figure 1**: inset) is obviously of extreme importance and depending upon their preference should be comfortable and of perfect (adjustable) height with rollers to allow the surgeon to move seamlessly. Different sub-specialties have slightly varying adjustments such back support, arm support (or none) a ring

*Operation theatre set-up. The X-ray machine (mini C-arm), operating microscope and diathermy machine should all be away from the main surgeon and not touching the operating table. The surgical stool is shown in* 

discomfort may prolong the surgery and even render it unsuccessful.

**2.1 The operating room**

*2.1.1 Temperature and lighting*

duration of the surgery.

*2.1.2 Theatre equipment*

surgeon or institution.

**144**

**Figure 1.**

*the inset.*

The surgeon performing an operation must be well rested, energised, reasonably hydrated and abreast of the task at hand. It is important to note that any heavy activity (swinging heavy objects, manual activity) should be avoided in the 24 hours prior to microsurgery. If one wants to test this out, try playing table tennis after a round of tennis. Using the larger muscle groups will compromise the fine motor control (in millimetres and micrometres) required in microsurgery. Caffeine intake should be the amount the surgeon is used to: not more and not less. For obvious reasons the use of sedatives prior to surgery is not advised as are medications that may cause drowsiness.

During emergency cases, if progress is not being made, a 10–20-minute break is advised; it usually allows a fresh take on the stumbling block. If it is a technically difficult step, take a breather before starting it, better insight is gained with a few deep breaths.
