Many of the latest advancements in general surgery involve scaling down: less invasive techniques, smaller (and fewer) incisions, thinner scopes and instruments. But ask anyone who's recently outfitted a brand-new minimally invasive surgery suite and they'll tell you there's nothing small about the investment, time and manpower required for such a project. In the past 5 years, we've renovated 2 ORs for minimally invasive surgery at our Harrisburg, Pa., campus and are working on upgrading 2 more. Here are some of the lessons we've learned along the way.

$2.5 million per room
Whether you're building a brand-new facility or renovating an existing space, outfitting a minimally invasive suite will likely entail extensive planning, building and engineering to accommodate your new, state-of-the-art visualization equipment, laparoscopic devices and booms to house everything comfortably. If all of that sounds expensive, that's because it is. We spent about $2.5 million per room, including renovations and equipment purchases, for each of our 2 newer minimally invasive suites.

The actual construction phase at our facility lasted about 6 to 9 months per room, but we started long before that, as a project of this size and scope requires months of planning and forethought. You may need to knock down walls and build new ones, install steel reinforcements overhead to support ceiling-mounted booms and do extensive re-wiring to accommodate high-def technology and integrated OR controls. Start by sketching out, in high-level detail, exactly what you want the room to be and what you want to accomplish with it (for example, what types of procedures will be hosted there?). Plan every last detail down to the placement of the electrical outlets in the room.

Include as many experts and stakeholders as possible in the planning process: architects, electrical engineers, telecommunications staff, equipment vendors, OR management, surgeons, anesthesia providers and frontline staff. Bring all these people together for regular coordination meetings during the planning, building and equipping stages of the project to ensure that no detail gets overlooked. Continuing to hold these regular meetings was a challenge during our project, but we found that letting them lapse would inevitably leave us scurrying to fix problems that could have been easily avoided with better communication.

Basic equipment needs
Here are the basics in capital equipment for a new laparoscopy suite.

• High-definition laparoscopes. High-def video is becoming the gold standard in minimally invasive surgery, and we certainly wanted our equipment to be high def. As laparoscopes are typically magnifying the image of the surgical site, getting the best resolution possible on those images is helpful when your surgeons are operating around structures that can be as small as 4 to 5 millimeters in diameter. Laparoscopes are very delicate, and we've had issues with equipment breakage in the past, so we were careful to choose scopes that were durable as well. Other features that our surgeons and staff looked for in new scopes were flexible tips to allow for better visualization and an all-in-one cord for the scope's light source and camera to improve efficiency and ease of use during cases.

We had our surgeons who do a lot of laparoscopic procedures trial several scopes, and they agreed upon 1 vendor that they considered the best. "We love the consistency of the scope from case to case," says surgeon Harold Yang, MD, PhD, who notes that newer models have the CCD chip embedded in the tip, where it's protected from damage. "The tip of the scope is flexible, so you can see around corners and around structures that you previously could not see. That makes it a lot nicer and gives you a lot more confidence when you're operating."

• High-definition monitors. To give both surgeons and staff a clear, sharp view of the surgical site during minimally invasive procedures, we recommend you purchase all HD monitors for your new suite, not just the one the surgeon will use. We went with 1 52-inch wall-mounted monitor and 2 to 3 smaller panels situated on booms for optimal visualization.
• LED lighting. Brighter, cooler and more energy-efficient than traditional incandescent bulbs, LED lights keep the surgical field from heating up over the course of a long case. While more expensive initially, they end up saving money in energy costs over time. And because the overhead lights are often dimmed during minimally invasive cases to prevent glare on the video monitors, we installed a track of lights with green sleeves over them. These lights bathe the room in a green glow to help support staff see what they're doing without interfering with the surgeon's view of the screen.
• Equipment booms. In addition to the scopes and video equipment, you'll need insufflation and electrosurgery units, light sources, recording and printing equipment if you opt for those capabilities, and of course anesthesia equipment and monitors. In the old days, we'd house all these devices, with their attendant tangle of wires, on movable carts that could be wheeled in and out of rooms — not the safest or most efficient mode of transport for such delicate items. Equipment booms, which hang from the ceiling or from floor-mounted pillars, help reduce clutter on your floors and make it much easier for staff to set up, access and manipulate the various devices needed for laparoscopic procedures.

Choose a boom that fits the needs of your OR. For example, we wanted booms with 4 shelves (some have only 3) to house all our equipment, leaving nothing on the floors. Also consider the cost of renovations to ensure your ceilings will support heavy booms; some have minimum ceiling height requirements, too. If you're an older facility, you might consider floor-mounted booms instead.

Finding the right boom can be a challenge, since they can't be installed temporarily for a trial run. Instead, you'll need to visit facilities in your area that use different types of booms from different manufacturers (there are several) and talk to the people who use them to find out what they like and don't like about the units. You can also trial booms on the show floor at medical meetings or at the vendor's facility, where they'll let you move the arms around and get a feel for how they work.

Depending on your case mix and surgeons' preferences, you may also outfit your minimally invasive suite with these newer technological innovations.

• OR integration. It can be a challenge to operate so many different pieces of equipment in a single room. Some manufacturers have made it easier by designing centralized control systems. From a single station, the circulating nurse can use a computer console to do just about anything — choose which images will appear on which monitors, dim or brighten the lights, call up lab reports or diagnostic images from the PACS, or even dial out of the OR to facilitate the surgeon's consultation with an outside physician, pathologist or radiologist.
• Recording and broadcasting capabilities. If you're an academic institution, or if some of your minimally invasive surgeons like to record their surgeries for teaching purposes, consider equipment that can capture and record high-def surgical images.
• Single-incision surgery. Dr. Yang performs many single-incision laparoscopic procedures once a week in our new ORs. The technique lets the surgeon insert multiple trocars and instruments through a single access port in the patient's abdomen, leaving the patient with just 1 scar, which can be hidden around the belly button. Several companies have developed single-incision laparoscopy systems, each of which requires a slightly different technique. The solution you choose will largely depend on your surgeons' preferences. You'll also need articulating instruments for grasping, cutting and sealing tissue.

Consider the users
It was worth spending $2.5 million on the renovations and equipment needed to bring our suites into the 21st century. Just be sure you involve the end-users in the decision-making process and buy equipment that meets — or even better, exceeds — their needs.