By Don Sadler
Recent advances in endoscopic and minimally invasive surgery (MIS) are truly remarkable, bringing new approaches to both in-patient and out-patient surgeries. Today’s physicians and surgeons are looking to new technological advances in endoscopic surgery and MIS to help provide better patient care and improved surgical outcomes.
“Endoscopic and minimally invasive surgery is the wave of the future,” says Julian J. Hamlet, RN, BSN, CNOR, OR service leader at INOVA Fairfax Medical Campus in Falls Church, Virginia. “Advances in this area are helping patients tremendously.”
Benefits of Endoscopic Surgery and MIS
Patients and health care facilities are enjoying a wide range of benefits from the widespread use of endoscopic surgery and MIS, says Paula Cruz MSN, RN, CNOR, staff nurse, department of surgery at the Colorectal and Pelvic Malformation Center in Boston.
“These include reduced OR time compared to open cases, less risk of bleeding, faster recovery times, shorter inpatient stays and reduced infection risk,” says Cruz.
Smaller and fewer incisions, decreased incision site trauma, better ergonomics for surgeons and more flexibility in terms of where the system docks are located are other benefits, adds Hamlet.
“The main benefits of using endoscopic surgery and MIS technologies are enjoyed by the patients,” says Raymond Dunia, LSA, CSA, AACS, senior surgical first assistant at INOVA Fairfax Medical Campus. “With less post-op discomfort, patients experience less pain and can resume their usual activities sooner.”
Dunia acknowledges that adopting new technology like endoscopic and minimally invasive surgery takes time and training.
“The investment may increase the cost of surgery initially,” he says. “But when used by skillful surgeons, robotic technologies reduce the amount of blood loss and post-surgical infections and help protect nerves and vessels, all of which sharply decrease costs in the long run.”
Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN), says that more cardiothoracic procedures are now being performed through a minimally invasive approach.
“Procedures that previously required opening the chest are now done by threading thin catheters and wires endovascularly through vessels to replace valves in the heart or using video-assisted robotic technology to visualize and remove tumors in the lungs,” says Wright. “This allows patients to return to their lives sooner after these minimally invasive life-saving procedures.”
Using a minimally invasive approach for cardiothoracic procedures combats the challenges and complications associated with an open approach, Wright adds.
“These include the extended recovery, discomfort and physical restrictions suffered by patients that result from going through the sternum or ribs,” she says. “The minimally invasive approach translates to less discomfort, a shorter hospital stay, faster recovery and ultimately reduced overall costs.”
Lots of Specialties Covered
Dunia believes that minimally invasive technology is a vast subject that covers many different specialties in surgery today including spine surgery, stereotactic brain biopsy and more.
“In endoscopic surgery, abdominal laparoscopic made a big advance mainly with the use of the da Vinci robotics,” says Dunia. “The XI and Single Port (SP) robots are the latest technologies on the market. With 3D and magnified vision, the agility of the instrument’s rotations improved safety and precision along with more skills ability than regular laparoscopy.”
Meanwhile, Intuitive Surgical has dominated the robotic surgery market for many years, notes Hamlet, creating what he calls “an excellent platform for surgeons to operate on.” Other companies have also launched or are making their way to the market, bringing exciting new features, he adds.
One of these is haptic feedback. “This gives the surgeon a sensing of pressure through alerts, while a pivot point potentially helps with minimizing incision site trauma and pain,” says Hamlet. “Also, eye-tracking software allows camera control when the system senses the surgeon’s eye activity.”
Hamlet says he had open abdominal surgery 29 years ago and was hospitalized for over a month. “Patients today with the same surgery can go home within days or in some cases even the day after surgery,” he says. “Advances in MIS are allowing patients to return to their regular lives and routines much sooner.”
Amanda Heitman, BSN, RN, CNOR, education resource specialist/surgical services at WakeMed Cary Hospital in Cary, North Carolina, says her hospital has recently added robotic-assisted orthopedic and spine procedures where patients receive a CT scan prior to surgery.
“This allows the surgeon to have more precise measurements during the surgery based on the scans, using the robotic technology to guide surgeons to exactly what they need,” Heitman explains. “Patients are able to have the ideal post-operative experience because the procedure was specific to them.”
WakeMed Cary Hospital also uses endoscopic ultrasonography (EUS) to assess for GI and lung disease.
“This procedure offers specific information for diagnostic findings to help treat patients efficiently,” says Heitman. “And we also offer ESG (endoscopic sleeve gastroplasty) to help patients in need of a less-invasive weight loss procedure or help with bariatric revisions.”
Heitman says that laparoscopic and robotic laparoscopic surgeries have been around for a while but there have been vast improvements in the technology. “These improvements include HD cameras and different supporting devices for effective hemostasis and insufflation.”
“Robotic procedures are optimal for patients and surgeons because they permit the 3D/360-degree approach for enhanced visualization and dissection,” Heitman adds. “All of these advancements can allow for a better surgical and post-operative experience.”
Maternal-Fetal Surgical Advances
Wright points to advances in minimally invasive fetal surgery that allow babies to be treated in-utero for conditions like twin-to-twin transfusion syndrome and congenital diaphragmatic hernia before they are even born.
“Maternal-fetal surgery reduces the risk of infant mortality before, during and after birth by improving conditions for development,” says Wright. “For example, it re-establishes healthy blood flow as in the case of twin-to-twin transfusion or inserting a balloon to encourage lung growth to counteract the effects of a congenital diaphragmatic hernia.”
Meanwhile, collaboration among clinicians, the FDA, the Centers for Disease Control and Prevention (CDC) and manufacturers has led to the introduction of single-use endoscopes to replace reusable scopes that have been associated with infectious outbreaks, such as duodenoscopes and bronchoscopes.
“This eliminates the risk of disease transmission from an ineffectively processed reusable endoscope,” says Wright. “It also eliminates the time needed for turnover between cases and may ultimately reduce costs by eliminating the need to pay for maintenance, reprocessing or repair.”
“Additionally, advances in fetoscopic surgery have improved the prognosis for conditions that previously had unfavorable outcomes,” Wright adds.
The Perioperative Nurse’s Role
Perioperative nurses play a critical role in managing these technologies inside the OR and ASC and ensuring that they are used most effectively and efficiently and in ways that prevent patient injury.
“A wide range of safety issues can be related to the use of MIS technology,” says Dunia, who lists fire hazards, patient positioning issues and CO2 insufflations among his main safety concerns.
“The use of electricity to operate the machines and cautery devices always makes fire hazards a concern, but this can be managed by using compatible cables,” says Dunia. “And patient positioning has been a struggle for surgical teams in order to protect patients from post-surgery injuries like muscle strains or nerve damage.”
Wright notes that some MIS approaches require the use of highly specialized equipment that requires specific training or involves placing the patient in extreme positions for an extended period of time that could increase the risk for injury.
“Considerations for patient positioning might include a pre-operative assessment of the patient (such as the patient’s nutritional status, body habitus, pre-existing injuries or range of motion limitations), the surgeon’s preference for position and/or positioning devices, the condition and availability of the positioning devices to be used and the operating room bed capabilities,” says Wright.
Also, when using robots to manipulate surgical arms, surgeons can accidentally hit the patient’s body in different places based on the surgery.
“It’s up to the OR team as circulators, scrubs and first assistants to position the patient in a safe way to protect sensitive areas like ulnar nerves, ankles and knees and adjust the robotic arms in a way that doesn’t cause harm to the patient,” says Dunia.
Safety Considerations for OR Nurses
Hamlet lists some of the main safety considerations OR nurses should consider when caring for patients during minimally invasive surgeries. The list includes:
- Reduce risk of injury associated with gas insufflation (such as carbon dioxide) by setting the insufflation flow rate as specified by the surgeon and in accordance with the manufacturer’s recommendations.
- Monitor the amount of fluid used and collected during the procedure, as well as the patient’s core temperature and potential fluid retention. He cites AORN Guidelines which state that while fluid distention-related complications occur in less than one percent of procedures, the risk increases with the length of the procedure and degree of dissection of the surrounding tissue.
- Look for any movements in the patient’s position whenever the OR bed is repositioned during the case. Notify the surgeon if the patient’s position is moved or anyone will be moving the patient during the surgery.
- Clean the system between each surgical procedure to reduce the risk of cross-contamination between patients and surgical site infections. Also inspect the instruments and equipment for any defects and remove defective items from service.
Cruz recommends that perioperative nurses help prepare for endoscopic and minimally invasive surgeries by making sure the appropriate instruments are available beforehand and positioning the robot in an optimal place depending on the procedure.
“OR nurses should also check the equipment pre-operatively to make sure it will be ready for the case,” she adds. “And during the case, OR nurses should be ready to not only care for the patients but also to assist with the robot as needed.”
In addition, Cruz stresses the importance of always knowing where the emergency key is to manually move the robot off the field as needed. “And organize the wires in the operating room to reduce the chances of any falls or trips,” she says.
As with any new technology, familiarity with the device or equipment and knowledge of the procedure are the main safety considerations, says Wright. “Engaging vendors in educating perioperative personnel is key to ensuring the instructions for use are followed so that medical devices are used as intended and in a manner that is safe for both patients and users,” she says.
“Training the end-users is essential to providing patients with the safest care and best outcomes,” adds Hamlet. “Everyone touching the system should be knowledgeable in how it operates, how to troubleshoot and what to do in an emergency.”
Heitman stresses that the main role of the perioperative nurse in managing endoscopic and MIS technologies is the same as it has always been – patient advocacy and safety.
“OR nurses are there to prepare the rooms for our patients’ specific needs and ensure proper positioning, prepping, sterility monitoring and trouble shooting any issues that may arise during the case,” says Heitman. “We are the front line for our patients, which means keeping them safe and providing the best outcome possible.”