In recent years, laparoscopic and endoscopic technologies have stretched the limits of minimally-invasive surgery. In response to the demand, an ever-increasing number of facilities are building laparoscopy and/or "endo suites," which are ORs designed specifically for laparoscopy, arthroscopy and/or diagnostic procedures such as colonoscopy and ultrasound. We spoke with several experts who shared their insights on why it may be helpful to build such a suite and offered their suggestions on how to design and equip one.

Why build a Lap/Endo suite?
The key advantages to building a laparoscopy or endo suite can be summed up in two words: convenience and productivity.

Says Edwin Montell, MD, gastroenterologist and partner in Hilo Gastroenterology Associates, Hilo, Hawaii, "From a doctor and a facility's perspective, it's a much more efficient use of time and space to have a suite designed specially for our practice. There is no hospital around here that dedicates a room specifically for endoscopy. So, we would be dealing with a lot of unneeded equipment in the room and a layout that is probably not optimal for our procedures. At our ASC, we can go back and forth from our office to our endoscopy suite, rather than drive to

Adds Nancy Edwards, MSN, RN, CNAA, executive director of the River View Surgery Center, in Marion, Ind., "We are a multi-specialty AAASC-accredited center that built an endo suite in 1998. The suite quickly became a very important part of what we do at the surgicenter. We did 2,011 cases in there last year, 1,380 of which were performed by our two gastroenterologists. The remainder were divided among six general surgeons who do assorted endoscopic procedures. Most commonly, however, we do colonoscopies, gastroscopies, bronchoscopies, and flexible cysts. It made sense from an efficiency and quality of care standpoint to confine the procedures to a single area. We assign staff, all of whom are ACLS certified, specifically to the endoscopy area. Also, we are able to consistently have sterile endoscopes available ahead of the next case, as the suite is conveniently located to our reprocessing area and we turn the scopes around quickly."

Dr. Montell reports that his facility's endo suite cost about $600,000 to build and equip. He adds, however, "We are going to be making further modifications to it, because we've outgrown the room already with the volume of cases that we bring in there. So the total cost of the suite will end up being higher."

Alan Katz, president of VTS, Inc., says that the physical layout of a laparoscopy or endo suite is critical, and that it is the usage of space that is the primary difference from doing the same cases in a standard OR. "Obviously, the equipment you use will play a major part in how well you do the cases. But you can still have those same pieces of equipment in a regular OR. If you can't lay out the room to maximize the floor space you have available or if the surgical team has to go all around the room to control the equipment, you've defeated the purpose of creating the suite, which is to have an efficient workspace for doing the cases."

Design and key features
There will be differences in what you will need to equip the suite, depending on whether you are doing laparoscopy-which will require you to set up for surgery-or diagnostic endoscopy, such as colonoscopy. The demands are greater for laparoscopy. In general, if the suite is set up to do laparoscopy, you could also set up the room to do diagnostic endoscopy cases. If you are only doing the "clean" non-surgical procedures, for example, you don't need an operating table and lights are not a major issue, whereas they are relevant concerns to those doing laparascopic surgery.

One option to explore when you are building a laparoscopy or endo suite is to contract with a single manufacturer for all of the equipment. It can also be equipped a little bit at a time. For example, existing medical grade monitors can be used and then replaced at a later time. You may also want to look into the option of buying well-conditioned used or refurbished equipment. Reports Miss Edwards, "When we were building our endo suite, we equipped the entire suite through one manufacturer, which brought down the cost significantly per each piece of equipment. Also, when we first opened, we were ableto save money on the endoscopes themselves by purchasing used scopes from the hospital. Since then, we have tried to add one or two new scopes each year."

Central Design: Mr. Katz says that you will have to look at making the suite as interactive as possible to make the best use of the suite's workspace. In his opinion, the idealsuite has a single panel on the wall from which the lights and video system can be controlled. "You will have to look at your lights, your cameras, your video output and your data input. You will find that you get optimal interactivity from the equipment-and save yourself both space and money-if you can suspend the video and lighting equipment from a single mounting hub positioned over the table. This can support the surgical lights, the video monitors, your cameras, your anesthestic gases, and your smoke evacuation. If can avoid it, you don't want to have to wheel in the equipment on a bunch of carts because that will take away from the work space. Whether you can do that depends on the size of the room. A room about 18 feet by 18 feet or even 16 by 16 is fine if you've got the floorspace freed up. The ceiling also needs to be sufficiently high enough to be able to suspend the booms and be able to position equipment where you need it."

In a laparoscopy suite, it's also important to incorporate your anesthetic gas delivery system into the design of the suite. Says Garry Oldham, MD, a Boston, Mass.-based gynecolic surgeon, "You can run into the problem of what to do with the tanks you need for insufflation in laparoscopy. A lot of ambulatory surgery facilities do not have a place to keep the tanks outside the OR, so they end up taking up space inside the OR."

Mr. Katz says that one way to work around the problem is to run the gas lines up through the ceiling and deliver the anesthetic aerially. "Consider the CO2 delivery lines part of the same hub as the lights. Especially if you end up with the tank inside the OR, it's important not to have the lines getting in everyone's way."

If you are building a diagnostic endo suite, says Dr. Montell, this is a non-issue.

Lightweight, high-resolution monitors: In both laparoscopic surgery and endoscopy, the quality of the monitor is vital to the physician. It's crucial that the screen provides a crystal clear image; moreover, they need to be lightweight in order to be incorporated into the design of the OR.

Says Mr. Katz, "Big, heavy CRT monitors often can't be suspended from ceiling booms. And even if they can, they are more or less rooted to the spot. In a laparoscopy OR, you have to be able to move the monitors to a wide variety of positions, depending on the specific procedure. The lighter the weight of the video monitor, the wider degrees of maneuverability you will have. If possible, you may want to invest in the newer flat-panel monitors, which are ultra-lightweight. But they aren't absolutely necessary. From a surgical field perspective, it is the digital display video technology that you will want."

Be advised, however, that flat-panelled monitors still tend to be expensive. Says Dr. Montell, "We'd love to be able to get flat-panelled monitors, but they would cost us about $5,000 each, and in our opinion, the money is better spent elsewhere right now. Our monitors are digital-quality, but they are heavy. We have them on carts and station one on each side of the room."

Keep in mind that in many procedures you will be doing in the suite, it is preferable to have two video monitors in use; one for the surgeon and one for his assistants. Says Dr. Montell, "You don't absolutely need a second monitor in there, but it makes things run smoother and enhances communications. You are being pennywise and pound foolish not to have a second monitor in the room. In the long run, the efficiency of putting in the extra monitor more than makes up the cost."

OR table: As with lights, there are no special requirements in an endo suite for the table on which you perform the procedure. However, with laparoscopy, there are very specific needs. Maneuverability is the key word to remember when it comes to tables. Explains Dr. Oldham, "The laparoscopic operating field is higher than the usual field. What I mean by that is the patient is actually positioned higher, so the table has to be lowered by a proportional amount. This is especially true for laparoscopic surgeons doing pelvic surgery, because the Trendelenburg position raises the operating field even higher. The laparoscopic operating table needs to be around eight inches lower than traditional tables. If you don't have a table designed specifically for laparoscopy, there's still a way around it. The surgeon can stand on a small platform. The platform has to be wide enough for the surgeon to stand comfortably on and still reach any pedals that he has to operate."

Finally, in laparoscopy, the organs have moved aside by gravity, which is done by tilting the table. This movement must therefore be easy to perform, to increase access to the internal organs. The optimum solution is an electric table. Says Dr. Oldham, "An electric table saves immeasurable time and makes moving the patient safer, provided there is sufficient padding, than if the team has to physically move him."

Lighting: According to Miss Edwards, this is one of the major differences between an endo suite and a suite that is suitable for laparoscopy. "In endoscopy, the room is basically kept dark. So our endo suite is dimly lit."

Conversely, during laparoscopy, the area needs to be well-lit and the nature of the procedures present some unique lighting requirements. You need to make sure that your surgical lights can do the job.

Says Dr. Oldham, "In laparoscopy, adequate lighting of the surgical theater is essential for monitoring the unconscious patient. Monitoring the skin is one of the first signs of circulatory and respiratory problems, which can occur during these operations. Furthermore, working without opening the stomach sometimes imposes certain conditions where delicate movements are being performed outside of the abdomen, for example, when you are suturing. Detecting these movements necessitate fairly bright lighting of the operating area. Although the surgeon is looking at the screen the whole time, the nurses need to be able to observe the patient directly. As opposed to conventional techniques, the space needs for the positioning of the laparoscopic operating team is a little larger, so the lights have to do the job over a larger-than-normal area. For example, when operating on the colon, the best position for the surgeon will be on the left for the left colon, on the right for the right colon and between the legs for the transverse."

Adds Ms. Edwards, "In the endoscopy suite, there are monitors that measure the patient's heart rate, blood pressure and oxygen level. But since we're not doing actual surgery, we don't have the same requirements for direct observation of the patient."

Mr. Katz opines that it may not be necessary to go purchase all new surgical lights for a laparoscopy OR. "Nine times out of ten, if you alreadyhave OR lights that are reasonably new-let's say, about five years old-they should be bright enough to be sufficient for laparoscopic use without creating unwanted shadows that will hinder the procedure."