Minimally Invasive Surgery By Mary Morain, RN Objectives: At the completion of this course, the learner will be able to: 1. Identify the benefits of MIS to the patient. 2. Identify disadvantages of performing a surgery in a minimally invasive manner. 3. Recognize attributes of robot-assisted surgery and natural orifice transluminal endoscopic surgery (NOTES). 4. Discuss common nursing interventions for the patient who is having a minimally invasive surgery. Endoscopy Endoscopy involves exploration using a long tube called an endoscope. It can be performed via any tract that can be entered by a natural orifice or through a small surgical opening into body cavities such as the chest, abdomen, pelvis, and joints. The endoscope has a channel through which a light and camera are threaded, and another lumen for instruments, such as forceps, a cutter, or a snare. The first human thoracoscopy was performed in 1910 and laparoscopy in 1912. In the 1930s technology caught up, providing lenses and insufflation methods that gave doctors the tools they needed to use the endoscopy via a laparotomy (incision in the abdomen) to diagnose gallbladder and liver disease. Skills progressed and in 1944 doctors were performing gynecological laparoscopy. At this point, doctors began to develop ways of performing procedures and surgery via the endoscope instead of just using it to diagnose. The first colon polyp was removed in 1969. By 1980 laparoscopic tubal ligations were routine and in 1984 a laparoscopic cholecystectomy was successfully performed. The science took off, and many surgeries were challenged to see if they could be done using an endoscope in a minimally invasive way. Minimally Invasive Surgery (MIS) Minimally invasive surgery using endoscopy has revolutionized the field of surgery. There are many surgical and medical centers all across the country, in Canada and in Europe offering a large number of MIS procedures. For example, some of the MIS procedures now offered at the Mayo Clinic include: 1 1 Mayo Clinic, Minimally Invasive Surgical Procedures, Retrieved November 9, 2007: http://mayoclinic.org/minimally-invasive-surgery/
Heart surgery: septal defect repair, valve procedures, coronary artery bypass Neurosurgery: carotid angioplasty, resection of brain tumors, aneurysm treatment, herniated cervical and lumbar disk repair Thoracic Surgery: Laparoscopic fundoplication for GERD, large hiatal hernia repair, lung surgery. Gastroenterologic and General Surgery: adrenalectomy, appendectomy, bariatric surgery, distal pancreatectomy, esophagectomy, hernia repairs, splenectomy Gynecological Surgery: Hysterectomies, fibroid removal, cyst removal, vaginal fistula repair Urological Surgery: Nephrectomy, pyeloplasty Colon and Rectal Surgery: Treatment of colon cancer, dysmotility, Crohn's disease, diverticular disease, polyps, inflammatory bowel disease, and rectal prolapse. Orthopedic Surgery: Carpal tunnel release, spine surgery, pelvic fracture repair, hip and knee replacement, release of joint contractures, rotator cuff repair, early arthritis treatment MIS is not as widespread as it was hoped, since there is no formal method of training in endoscopic surgery. Perhaps this will be solved by including it in formal surgical residency programs. This should occur if MIS becomes the preferred surgical method by patients, with improved outcomes over conventional open incision surgery. Benefits of minimally invasive surgery (MIS) to the patient include: Shorter hospital stays, outpatient procedures in many cases Less tissue trauma Less blood loss Less adhesions Lower risk of infection Smaller incisions with less scaring Less pain Able to cough and deep breathe and ambulate sooner Fewer life-threatening complications Shorter recovery, faster return to work and usual activities MIS may be more appropriate for pediatric, high-risk and elderly patients Robots and computers can be utilized for steadiness, precision, and for operating from a distance. Disadvantages of performing a surgery in a minimally invasive manner include: Limited vision of the operative area and surroundings Using instruments that need to be retracted and reintroduced through the endoscopic lumen repeatedly Minimal space within which the surgeon has to perform the surgery The requirement for excellent hand-eye coordination
The surgeon's inability to feel the consistency of tissues during surgery Longer operative times Complications such as bleeding or injury to other organs are harder to control Very expensive operative equipment Difficult and time-consuming training for surgeons that is not yet integrated into routine surgical training Endoscope Innovations Endoscopes have become more refined to meet the needs of MIS. Some are flexible and others are rigid. Hand control and manipulation of the various tools wielded through the endoscope are continually being improved. Optical fibers direct light from a source outside the body to the area being viewed. Cameras at the end take real time video and relay it to monitors. Various instruments, lasers, or probes are inserted through separate lumens depending on the procedure being performed. During a procedure two endoscopes can be inserted to get more than one view of the operative site, one getting a close-up and one getting the wide angle view. This helps the surgeon to not loose site of instruments. Previously, the end of the scope had to be moved in or out for different views. Capsule endoscopy, an innovation in which the patient swallows a 26.4 mm by 11mm capsule that contains a camera at each end is currently being explored. Peristalsis moves the capsule through the entire GI tract. The cameras take pictures every 2 seconds and send them to a recorder which the patient wears on a belt. The information from the recorder is then downloaded to a computer for interpretation. Capsule endoscopy detects tumors of the small intestine, an area not able to be examined by endoscopy, however it does not identify where the tumor is exactly. Endoscopes are not only helpful to the medical community. They have been used to look within machines or bombs, to perform covert surveillance, to look for victims in a disaster, and in the building and industry professions. Robot-Assisted Surgery Robotic devices have been designed in the attempt to improve MIS. In 1985 a robot assisted in a brain biopsy by using CT information to place a needle. AESOP (Automated Endoscopic System for Optimal Positioning), a robotic arm with voice control was devised to hold the endoscope to give the surgeon an extra hand. ORTHODOC and ROBODOC robots assist orthopedic surgeons in hip and knee replacements, NEUROMATE is used in neurological procedures, and SpineAssist is used for spinal surgeries. A new robot, Cranio-assist, is predicted for 2009. It will be able to guide instruments to the precise area for keyhole surgery within the brain. A camera robot is being developed that can be inserted into the abdomen and its position would be
controlled via a magnet on the outside of the body to give the surgeon any angle of vision he may need. In 2000, the FDA approved robotic surgical system-assisted surgery. Two systems used to assist the surgeon with MIS are called da Vinci and Zeus (da Vinci was named after Leonardo da Vinci who first designed a robot). Both da Vinci and Zeus operate via a bedside console with thin robotic arms that hold camera, light, and two instruments. Zeus incorporates AESOP to hold the camera and light. The surgeon sits at a distance from the patient at another console and either looks through two lenses (da Vinci) or wears special glasses (Zeus) to look into the console to view the surgical area. This view which is seen in 3-dimensions can be magnified up to 15 times. The da Vinci has foot pedals for camera control. The surgeon holds flexible wrist joysticks that translate hand and wrist movements to the robotic arms and the instruments within the body. The system filters the surgeon's movements by translating 1 inch of movement of the hands to ¼ in. of movement of the instrument and filters out all tremors so that the motion of the instruments is very precise and controlled. The robot is unable to initiate movement by itself. A separate monitor in the room allows the surgical staff to view the progress of the surgery and can even allow an assistant or mentor to draw on the monitor with a finger to show the surgeon what to do, since the drawing is conveyed to the surgeons viewing system. An assistant changes the instruments held by the robotic arms. The systems shut down slowly in case of power outages so that the surgeon can stay in control of the surgery and continue in the standard endoscopic manner or convert to open surgery if needed. Robotic-assisted surgery is costly up front, since the robotic systems cost about $1 million. The learning curve is long since the surgeon needs both surgical experience and robotic skills with excellent hand-eye coordination. The FDA requires the manufacturer to provide training which consists of practice using the robotic system to do simulated surgery. It takes about 12-18 repetitions of the same procedure for the surgeon to reach the speed of a standard MIS using hand held instruments. Training is also provided to nurses who set up the system, assist intraoperatively, and clean and maintain the system after surgeries. The FDA has to approve each separate procedure that the robots can assist with. Robotassisted surgeries in the US consist of cardiothoracic, gynecologic, urologic, and bariatric. Robot-assisted MIS costs about $2000 more than standard endoscopic MIS. The procedure takes longer as well. However, there are also advantages to this type of MIS. The surgeon sits and has ergonomic support, resulting in less fatigue. Magnification of the surgical area and lack of tremor makes it easier to operate on tiny blood vessels, nerves, and pediatric anatomy. Remote Telepresence Surgery Remote Telepresence Surgery using these robotic surgical systems now makes it possible for the surgeon to be far away from the patient. Sound impossible? The first trans-
Atlantic surgery, called Project Lindbergh, occurred in 2001. The surgeon was in New York and the patient was in Strasburg, France. A minimally invasive cholecystectomy was performed without complication. There was only 1/10th of a second of lag time in the translation of movement from the surgeon to the robot. It took 16 minutes to set up and 54 minutes to perform the operation. Since then, many surgeries have been performed by telepresence in Canada. In 2006, in Italy, an unmanned robot performed a heart surgery. NASA and the military are very interested in medical robotics and are working on robots that can evacuate, diagnose, and treat casualties using telepresence medicine. This technology could also improve medical care during natural or man-made disasters, and on future space missions. Natural Orifice Transluminal Endoscopic Surgery (NOTES) The newest method of MIS that is shaking up the endoscopic surgery world is NOTES. This method uses an endoscope which is inserted into any of the natural orifices, then guided through small holes in the stomach or the vagina or colon to whatever location the surgery will be. Prompted by the desire to lower the pain and discomfort that a patient feels from the small incisions made during standard endoscopic surgery, NOTES was only a concept until 2007 when a transgastric appendectomy, transgastric cholecystectomy, and transvaginal cholecystectomy were successfully performed on humans. NOTES comes with a new set of instrumental needs and procedural challenges being addressed currently. Visualization of the operative area is problematic and may require skin incisions to provide the best camera view of the area being operated on. There is a need to lengthen endoscopes so that they can reach remote targets. They need to be multiluminal and rigid in certain segments. Transluminal instruments are being adapted to manipulate tissues through a long distance lumen. The best method of opening a hole in the anterior of the stomach wall, vagina, or colon to permit passage of an endoscope is being sought. The control of infection and bleeding depend on finding a way to adequately close this entry port at the conclusion of the procedure. Physicians are trying various suturing and stapling techniques. Insufflation of the abdomen with CO 2, nitrous oxide, or room air is more problematic and may need to be provided by laparotomy during NOTES. The risk of bleeding, perforation, and organ injury means that the patient needs to be under general anesthetic so that immediate open incision surgery can commence if there is a need. The many problems inherent in this type of surgery have prompted US surgeons and gastroenterologists to form a working group to develop standards for NOTES. This group, the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR), will be a clearing house for reports of success and failure in NOTES done via the transgastric route. The New European Surgical Academy (NESA) has a working group that concentrates on female natural orifice surgery done via the transdouglas route through the pouch of Douglas between the uterus and the colon. These groups will help
to decrease errors that can be prevented by rapid dissemination of information and help guide this method as it emerges. NOTES may be especially helpful for the obese or other high risk patients since there will be no skin incision with pain, hernias, infections, or scarring. The immune system may be less affected as well. The benefits and advantages of using this method over conventional MIS remain to be demonstrated. Training is problematic again as it is with Endoscopic MIS and robot-assisted surgery. Nursing Care of the MIS Patient MIS nurses use the nursing process to evaluate each individual patient for problems or nursing diagnoses depending on their risk factors, disease states, and type of surgery chosen. Following standards of care and policies and procedures, interventions are developed that prevent or solve the problems and then evaluate the outcome, modifying where needed. This involves a tremendous learning burden to the nurse. There is a need to understand many procedures, done in different ways, and the individual risks and problems of each. There are many different pieces of equipment and machines to be sterilized, set up, checked, dismantled, and maintained. The MIS nurse must also need to know what to do if the machine fails during the surgery or if there are surgical complications. This type of education is provided by inservices or classes by the institution, the biomedical department, and manufacturers of the medical device. Nurses also seek out information on the internet or in medical libraries to further their education. A period of orientation and mentorship is needed as it is for other critical care areas. Let's look at nursing interventions that are common to MIS patients. Pre-operative care: MIS is sometimes done on an outpatient basis or with a shortened hospital stay. Education of the patient and family or care-giver is crucial for a good outcome. Day surgical clinics, hospital outpatient surgical departments, and specialist's offices often schedule a pre-op visit. During this visit the patient may discuss his case and the proposed surgery with the doctor, reviewing the risks to the particular procedure. Pre-op surgical release from primary physicians is arranged if needed. Labs and other diagnostic procedures are also done or scheduled. The patient is often given a video to watch that outlines the procedure and pre and post op care in laymen's terms. It is best if the nurse watches the video with the patient and the family. They can ask questions as they develop during the movie. Otherwise they may not remember which parts were unclear, or may be hesitant to ask questions. Pre-op instructions should be given verbally, with a written copy of the same instructions given to the patient to take home. Remember to tailor this information to the culture and level of understanding of the patient. People will absorb information at different rates
and times and in different ways. If possible, a call to the patient a day or two before the procedure can answer questions and help convey caring. Post-op instructions are handled in the same way during the same visit. It should include the measures that will be used to control any pain, nausea, or vomiting. Activity, diet, and wound care should also be discussed. With orthopedic or other procedures that are done on an inpatient basis, augment the post-op teaching as needed with information about coughing and deep breathing, physical therapy exercises, and any other information pertinent to the procedure. Anxiety about the procedure may not be helped by telling the patient that "we have done this procedure X amount of times on many patients like you with no problems". Patients aren't concerned about others. This is THEIR surgery and they want to feel like their individual problems are taken into consideration, not that they will get cookie-cutter treatment by nurses with a nonchalant attitude. Development of a therapeutic relationship and the assurance of patient advocacy are crucial to the successful outcome of any procedure. Intra-operative care: Always follow procedure to double or triple check the location of the surgery on the body and the type of procedure being done with the surgical team prior to the surgery. Verify any autologous blood to be used according to procedure. Nurses need to monitor the progress of the surgery and maintain communications within the OR suite. Be ready to trouble-shoot equipment problems. Set up robots or other equipment, check and maintain operations during the surgery. Monitor the method of insufflation used and the connections. Check tanks and that there are back-up tanks available. Keeping insufflation pressure within the abdomen less than 15mm/ Hg prevents impairment of venous return. Watch for subcutaneous emphysema. Assist anesthesia to maintain proper positioning of the patient and thermoregulation. Provide the correct irrigation fluids for the procedure and maintain the temperature as ordered to prevent hypothermia. Monitor for fluid overload by monitoring fluid amounts in and out and reporting any deficit. Precautions and procedures for the use of cautery must be followed and documented to prevent electrosurgery complications. Keep light cords away from flammable surfaces and the patient's skin. Instruments that would be needed to convert the procedure to standard endoscopy or open incision must be present in the room for all MIS procedures. Be aware that doctors who use robot systems are not scrubbed in and another physician may be present who is scrubbed in case of problems.
Procedures and documentation should follow current AORN standards and facility policies and procedures. If a patient or healthcare worker is harmed during surgery, the equipment used must be handled according to the Safe Medical Devices Act. When in doubt, ASK! Post-operative Care: Monitor the patient for pain, nausea, vomiting, and effects of anesthesia. Monitor vital signs and the operative area for signs of hemorrhage. Monitor any incisions and cover per hospital policy and procedure. If the patient is to go home, verify that criteria of mental status, activity, fluid or food intake, vital sign stability and any other pertinent conditions are met. Discuss post-op care with the patient and caregiver or family and give written copies. Ensure that the patient goes home with someone and will not be alone. Call the patient later and in a day or two to check on progress of recovery and to answer any questions. When the patient remains in the hospital for a few days, monitor vital signs and for complications of hemorrhage, infection, effects of anesthesia, and incisions and treat pain, nausea, vomiting as ordered. Encourage coughing and deep breathing and movement and exercise as ordered. Provide verbal and written instructions for home care at the time of discharge. Evolving Medicine It's inevitable that humans will always tinker with the current state of the surgical art in the effort to do it better, faster, and cheaper. Health care costs require that medical research be done to fine tune procedures to have the highest benefit with the lowest cost possible. Many truly amazing accomplishments have been and are continuing to be made. But the center of attention is always on the patient to provide the safest procedure that provides the fastest relief, the best outcome, with the least pain. As nursing adapts to new and evolving equipment and procedures we will play our part by applying the nursing process to help solve the patient's problems to the best of our ability. Because that's what nurses do. Keep abreast of changes in MIS by monitoring these sites: PubMed lists many articles published in 2007 describing new MIS procedures, equipment, complications, and innovations that are currently being investigated: http://www.ncbi.nlm.nih.gov/sites/entrez?db=pmc NOSCAR.org provides updates in the development of NOTES: http://www.noscar.org/index.html
ClinicalTrials.gov has a long list of studies concerning different types of MIS studies that are recruiting: http://clinicaltrials.gov/ The FDA Site issues articles and news releases about medical devices used for MIS: http://www.fda.gov/default.htm AORN provides updated Standards and Recommended Practices and Position Statements that can be obtained via their website: http://www.aorn.org/ References AORN. Recommended practices for endoscopic minimally invasive surgery. AORN Journal. March, 2005. Retrieved November 8, 2007: http://findarticles.com/p/articles/mi_m0fsl/is_3_81/ai_n13471136 Bragg K, VanBalen N, Cook N. Future trends in minimally invasive surgery. AORN Journal, Dec, 2005, Retrieved November 8, 2007: http://findarticles.com/p/articles/mi_m0fsl/is_6_82/ai_n16100880 Francis P, Winfield HN. Medical Robotics: The Impact on Perioperative Nursing Practice. Urol Nurs. 2006;26(2):99-108. Retrieved November 9, 2007: http://www.medscape.com/viewarticle/531748_print Hatzinger M, Badawi K, Langbein S, Hacker A. The Seminal Contribution of Georg Kelling to Laparoscopy. Journal of Endourology. 2005, 19(10): 1154-1156. Retrieved November 8, 2007: http://www.liebertonline.com/doi/abs/10.1089/end.2005.19.1154?cookieset=1&journalc ode=end Intuitive Surgical Inc. da Vinci Surgery. Retrieved November 8, 2007: http://davincisurgery.com/surgery/index.aspx Gurudu SR, Leighton JA. Obscure Gastrointestinal Bleeding-The Role of Endoscopy. MedGenMed. 2006; 8(2): 38. Retrieved November 9, 2007: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1785185 Mayo Clinic, Minimally Invasive Surgical Procedures, Retrieved November 9, 2007: http://mayoclinic.org/minimally-invasive-surgery/ Meadows M. Robots Lend a Helping Hand to Surgeons. FDA Consumer Magazine. May- June 2002. Retrieved November 10, 2007: http://www.fda.gov/fdac/features/2002/302_bots.html
Medical News Today. 01 Oct 2007. Israeli Team Develops GPS Accuracy for Keyhole Neurosurgery Using Mini-Robot. Retrieved November 8, 2007: http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=84152 Mundus. Future VTOL Applications. Retrieved November 8, 2007: http://www.mundusgroupinc.com/future_vtol.htm NOSCAR.ORG. White Paper. Editorial:Transgastric surgery in the abdomen: the dawn of a new era?.retrieved November 8, 2007: http://www.noscar.org/index.html Rentschler, M. E., Oleynikov, D., "Will In-vivo Robotics be the Future of Minimally Invasive Surgery?" Med Tech Business Review, March 2007. Retrieved November 9, 2007: http://64.233.167.104/search?q=cache:wdux8to8etij:www.noscar.org/documents/not ES_White_Paper_Feb06.pdf+%22White+paper%22+%22ASGE/SAGES%22&hl=en&ct =clnk&cd=1&gl=us University of California, San Diego Medical Center: NOTES-Natural Orifice Surgery. Retrieved November 8, 2007: http://health.ucsd.edu/specialties/surgery/mis/notes.htm Wagh, MS, Thonpson CC. Surgery Insight: Natural Orifice Transluminal Endoscopic Surgery-An Analysis of Work to Date. Nat Clin Pract Gastroenterol Hepatol. 2007. 4(7): 386-392.Retrieved November 8, 2007: http://www.medscape.com/viewprogram/7320_pnt Wikipedia.org. Endoscopy, Robotic surgery, Minimally invasive procedure, Natural orifice transluminal endoscopic surgery. Retrieved November 8, 2007: http://en.wikipedia.org/wiki/main_page