Minimally Invasive Surgery (MIS) Module 12 - RPN2023 PDF

MODULE 12: Minimally Invasive Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 199-219. Tighe (2015) Instrumentation for the Operating Room Chapter 6-8...

MODULE 12: Minimally Invasive Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 199-219. Tighe (2015) Instrumentation for the Operating Room Chapter 6-8 ORNAC Standards 2023 p. 3-134 – 3-138 Learning Outcomes Define the term endoscopic surgery. Describe the function and usage of common endoscopic instrumentation. Understand pneumoperitoneum and potential complications. Discuss the process for converting from an MIS case to an open case. Minimally Invasive Surgeries Defined as any surgical procedure that is performed using technology, such as a laparoscope and camera, eliminating the need for a large incision. Endoscopic surgery, laparoscopic surgery, and minimally invasive surgeries are used interchangeably. Terminology and Acronyms MAS/MIS – Minimal access surgery / Minimally invasive surgery SPA – Single puncture access SPS - Single post-surgery SILS - Single incision laparoscopic surgery OPUS - One port umbilical surgery NOTES - Natural orifice transluminal endoscopic surgery Advantages of Minimally-Invasive Surgery (MIS) Patient Benefits Ambulatory or shortened length of stay in hospital. Short post-operative recuperation Decreased post-operative pain Module 12: MIS  Earlier return to work and/or activities Less surgical complications such as wound infections, large visible scarring, adhesions. Hospital Benefits Decreased costs due to shorter hospital stays Lower wound infection rates and costs associated Disadvantages of Minimally-Invasive Surgery Hospitals weigh the costs of the equipment and supplies in MIS. These items are costly, but the advantage to patient recovery is also taken into consideration. These procedures are highly technical and require the scrub and circulating nurse to have in-depth understanding of the function, workability, safety and assembly of MIS instruments, equipment, and environment. The nursing team MUST always prepare to convert from a MIS case to an open procedure with all necessary instrumentation. Endoscopic Instrumentation Several laparoscopic instruments have the same names and tips as instruments used in open procedures, such as babcock, scissors, allis, etc. The endoscopic instruments will simply have a different shape with a long shaft. Endoscopes - An endoscope is an instrument that is inserted into a natural orifice or through a tiny incision. The purpose is to access internal organs or structures and provide visualization into the designated cavity. Trocar System – Consists of an obturator and a sleeve (cannula). The trocar system allows the endoscopes and endoscopic instruments to be inserted or removed from the body. The obturator and sleeve are inserted to access the operative site. When port of entry has been made, the obturator is removed, and the sleeve is left in place. There are disposable and non-disposable trocar systems available. The most commonly non-disposable trocar in MIS surgery is the Hasson trocar. Disposable Trocar Re-Usable Trocar (Hassan Trocar) The Hassan Trocar is processed in MDRD disassembled. The scrub nurse will require assembling prior to use. Disposable trocars do not require assembly. Module 12: MIS Clip Appliers – Commonly used in MIS to replace ligating or suturing a vessel. Endoscopic clip appliers are available in disposable and non-disposable methods. The non-disposable instruments require manual loading of the clips, similar to loading clip appliers for open procedures. The disposable clip appliers are pre-loaded with a designated number of clips, and do not require loading. Suturing and Retrieval - During endoscopic surgery, sutures are often referred to as Loop ligatures, Extracorpeal and Intracorpeal sutures. Endocatch Instrument – A plastic net used to retrieve specimens that are potentially contaminated or dirty through the port sites ie. ruptured gall bladder. Camera – A non-sterile device that connects to the endoscope. The camera must be draped with a sterile camera sleeve by the scrub nurse. Note: The nursing team is required to prepare open instrumentation for all MIS surgeries in the event of converting to open procedure. This can be an urgent event, such as an uncontrollable bleed and will require timely instrumentation. Pneumoperitoneum Air or gas present in the abdominal peritoneum using an insufflator. A pneumoperitoneum is deliberately created by the surgical team in order to perform endoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide. Pneumoperitoneum may be achieved with the closed method using the verres needle, or the open method with the Hassan Trocar. Characteristics of Pneumoperitoneum Carbon dioxide (CO2) is the gas of choice to create a pneumoperitoneum CO2 is the safest gas to use - It is rapidly absorbed into the bloodstream. We cannot use simple room air as the oxygen is combustible and would cause a fire in the presence of the electrocautery. We cannot use nitrogen even though it is a very inert gas. Nitrogen could enter the patient's bloodstream and cause nitrogen poisoning. The first step in creating a pneumoperitoneum is insufflation. Insufflation Inserting CO2 gas into the surgical area separates all the organs from each other, thereby reducing the risk of perforation of non-operative tissue when the trocars are introduced. An insufflator, smoke evacuator and insufflation tubing are required for all MIS procedures. Insufflator control panel indicates the rate of flow, volume delivered and intra-abdominal pressure. Module 12: MIS Rate of Flow (per minute) - Can deliver up to 15 – 20 Litres per minute. Volume Delivered - 2.5 to 4 Litres is the normal amount delivered. This will vary depending on the size of the patient. Laparoscopic surgery is done on children as well as obese patients and the amount needed for pneumoperitoneum to occur that supports the surgery is heavily dependent on the size of the patient. Intra-abdominal pressure - The pressure pneumoperitoneum exerts in the abdominal cavity. Administering an insufficient amount of CO2 could cause piercing of the bowel or other vital organs upon insertion of the trocars. 14 to 16 mm hg is the desired pressure for laparoscopic procedures. A higher pressure may cause a gas embolus. Systems are equipped with an alarm that will sound if the pressure exceeds a certain threshold. Safety Considerations Intra-Abdominal Pressure Too much pressure and the CO2 will diffuse into the blood, resulting in hypercarbia and respiratory acidosis. The end tidal CO2 monitoring will detect increased CO2 absorption. Factors that cause the intra-abdominal pressure to increase are: Leaning on the patient’s abdomen Adding additional sources of gas such as the argon beam coagulator or the use of the CO2 laser with a purge gas system. Increased pressure increases diaphragmatic pressure → gastric regurgitation and aspiration of stomach products (hence a ETT tube is normally used). Increased pressure could reduce intrathoracic space resulting in decrease respiratory effort and cardiac output. The phrenic nerve is responsible for some motor activity of diaphragmatic respiration. Irritation to this nerve with ↑ pressure causes postoperative pain the shoulder and neck area. Care is taken at the end of laparoscopic cases to ensure as much CO2 is removed from the abdomen. Carbon Dioxide and Hypothermia CO2 is delivered in a liquid state as it expands it is delivered as a gas state. During conversion form a liquid to a gas, energy is lost and thus the gas becomes “cold.” The ↑ flow rate the colder the gas is. This can cause a ↓in the patient’s temperature. Using cold solutions, exposing the patient to cold OR atmosphere, length of procedure all contribute to hyperthermia and intervention is required. Module 12: MIS