Laparoscopic Surgery: a Cut Abov

Laparoscopic surgery: A cut abov

24 OR Nurse 2013 September www.ORNurseJournal.com

While laparoscopy continues to be the surgical technique of choice, there are complications, some fatal, you should know more about.

By Ruth L. MacGregor, MBA, BSN, RN, RNFA, CNOR

Since the 1990s, laparoscopic surgery has been the surgical technique of choice. There are many benefits for patients who undergo laparoscopic surgery compared with open surgical procedures, but it’s important to understand the complications that may occur, Sas with any surgical procedure. The OR nurse must be knowledgeable regarding the advantages and dis- advantages of laparoscopic surgery to properly antici- pate unintended complications and ensure patient safety and quality of outcomes.

Definition of laparoscopy Laparoscopy is a surgical procedure that allows for visualization of the abdominal cavity through a small incision, typically through a trocar using a laparoscope that has a camera and a light source. The camera transmits the images via a computer system. The pic- ture is then displayed on one or more monitors for the surgeon, first assistant or resident, and OR staff to visualize.1 A trocar consists of a sheath or cannula and an obturator that has a three-sided pointed shaft that’s twisted to separate muscle to gain access to the surgical site. In laparoscopy, the trocar separates the muscle and fascia until it’s in the peritoneum. There’s an access port that allows the carbon dioxide to flow into the abdominal cavity, as well as the cannula portion that

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allows access for the instrument and disposable materials needle is typically inserted in the abdominal cavity (one-time use supplies) to enter the abdominal cavity. via the umbilicus. This is a blind technique. The sur- To allow for optimal conditions for the surgeon geon feels and/or listens for two punctures. The first to adequately visualize and expose the abdominal is when the needle goes through the skin/fascia and organs, a combination of approaches are used. The the second is when the needle penetrates the perito- gastrointestinal (GI) tract is decompressed once a neum. Once this is performed, the surgeon may patient is under general anesthesia. The patient confirm that he or she is in the abdominal cavity by is then placed in the Trendelenburg position. aspiration through a syringe filled with sterile water. Neuromuscular blocking drugs (NMBDs) are given, A drop test is done where the fluid (via gravity) goes and a pneumoperitoneum is created in the abdomi- into the abdominal cavity. If it fails to do so, then nal cavity. The GI tract can be decompressed prior the surgeon knows the needle isn’t in the proper to surgery if the surgeon has the patient perform a place or may have come across adhesions preventing bowel preparation. GI tract decompression may access to the peritoneum. Once the surgeon has continue during surgery if a nasogastric or orogastric confirmation that the needle is in the abdominal tube is inserted into the patient’s stomach immedi- cavity, pneumoperitoneum is initiated followed by ately after the induction of anesthesia. Lastly, the insertion of trocars.5 NMBDs are given to the patient during the induction Another method used to access the peritoneum of anesthesia to help relax the abdominal wall mus- is considered an open technique and involves the cles and facilitate the placement of the trocars and surgeon making an incision typically near or in the insufflation of the pneumoperitoneum.2 umbilicus. The tissue is dissected to the anterior The pneumoperitoneum is achieved by insufflat- abdominal fascia. The surgeon may or may not ing the abdomen with carbon dioxide to a pressure place sutures in the peritoneum. Next, the surgeon of 12 to 15 mm Hg.3 The normal abdominal incises the peritoneum under direct vision. Once pressure is 0 to 5 mm Hg.4 Clinically significant the surgeon confirms a safe access to the peritone- increases in abdominal pressure are considered to um, a wedge-shaped Hasson-type trocar is inserted be above 10 mm Hg; abdominal pressure above to form a seal. Pneumoperitoneum is initiated and 15 mm Hg can result in abdominal compartment maintained. At the end of the procedure, this syndrome, which can affect multiple organ sys- method requires the surgeon to repair the fascia tems.2 Carbon dioxide is the most suitable gas to via a suture.6 create the pneumoperitoneum and is clearly the gas of choice in laparoscopy.4 The ideal gas should Complications of laparoscopy be nontoxic, readily soluble in the blood, colorless, The incidence of complications occurring during a nonflammable, cost-effective, and expelled from laparoscopic procedure is 1% to 5%, with a mor- the body easily. Oxygen and air can result in an tality of approximately 0.05%.5 Complications can embolism, since they aren’t readily absorbable in be grouped into three categories depending on the the blood, and nitrous oxide doesn’t have a pre- phase of the procedure: complications of access, dictable absorption. Other gases such as helium are physiologic complications related to the pneumoperi- practically insoluble compared to carbon dioxide, toneum, and complications that occur during the and argon gas causes a more significant depressant operative procedure.7 effect on hemodynamics than carbon dioxide. It’s critical for the surgical team to understand all of Complications of access the physiologic effects that occur with a pneumo- Complications associated with the closed tech- peritoneum during a laparoscopic procedure for nique of using the Veress needle and trocar inser- optimal patient outcomes. tion for access include injuries to the bowel and major retroperitoneal vessels, which can result in Surgical techniques for abdominal access significant morbidity and mortality. Less serious There are a few surgical techniques that may be used complications of closed technique may include fas- to gain access to the abdominal cavity to establish cial dehiscence and herniation, abdominal wall pneumoperitoneum. The first method is considered hematoma, and wound infection. Complications a closed technique and uses a Veress needle. This for the open technique are often less severe.

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Four quadrants Nine regions 1 - right upper quadrant 1 - epigastric region (RUQ) 2 - umbilical region 415 2 - right lower quadrant 3 - hypogastric or 1 3 (RLQ) suprapubic region 3 - left upper quadrant 4 - right hypochondriac (LUQ) 627 region 4 - left lower quadrant 5 - left hypochondriac 2 4 (LLQ) region 839 6 - right lumbar region 7 - left lumbar region 8 - right inguinal region 9 - left inguinal region

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins; 2010: 985.

Studies have shown major vascular and bowel present in the large bowel. The most frequent injury injuries to be quite rare, with less frequent wound to the rectosigmoid colon occurs when there is pel- complications associated with the open technique vic adhesiolysis during the cul-de-sac dissection, compared to the closed technique.7 resection of pelvic masses, or treatment of pelvic Bowel injuries. Bowel injuries along with major adhesions. In this situation, the patient typically pres- vessel injuries represent the most serious complica- ents 3 to 4 days post-op with fever, lower abdominal tions that occur with laparoscopic surgery. When pain, epigastric pain, nausea, and anorexia. The considering laparoscopic surgery, it’s important to symptoms worsen along with an elevated WBC remember that the intestines are located in all quad- count 5 to 6 days post-op. Treatment to correct this rants of the abdominal cavity; some portions are injury is the same as for a small bowel injury.7 extra peritoneal, and some are intraperitoneal (see Vascular injuries. The most fatal complication Division of the abdomen into four quadrants or nine associated with laparoscopic surgery is a vascular regions).8 Injuries to the intestines may occur via a injury. Identification of vascular structures within the perforation, since long pointed instruments are used surgical area and avoidance of these vessels are the in laparoscopic procedures, or they may occur from best methods to prevent vascular injuries. Recognizing the initial trocar or Veress needle insertion. Injuries a vascular injury, keeping calm, and promptly control- may also occur via sharp dissection, thermal injury, ling the hemorrhage either laparoscopically or through or traction from tissues or serrated graspers. The open conversion are keys to a successful repair of a patient may need to undergo additional surgical pro- vascular complication.10 Proximal and distal control cedures to correct the problem.8 of the hemorrhage via direct pressure allows for the Small bowel injuries not identified intraoperatively surgeon to either repair the injury or allow time to become apparent 2 to 4 days post-op. Symptoms prepare for an open exploratory laparotomy to con- present as nausea, fever, pain, and lower abdominal trol the hemorrhage.10 pain. If still not recognized by 5 to 6 days post-op, One concern is if the injury is retroperitoneal. the patient presents with an elevated white blood When this occurs, it may be difficult for the surgeon cell (WBC) count and worsening symptoms. An to detect a vascular injury. These injuries, as with exploratory laparotomy, performed by a general or bowel injuries, are caused by either the trocar insertion colorectal surgeon, is required to correct the injury.7 from the laparoscopic instrument or tearing adherent Large bowel injuries can cause an abscess or infec- tissue.10 The reasons for this type of injury are the close tion due to the nature of higher bacterial counts proximity of the retroperitoneal vascular structures, www.ORNurseJournal.com September OR Nurse 2013 27

such as the distal aorta and right reduction in tissue perfusion, common iliac artery to the reduced exchanges of gases, abdominal wall. respiratory acidosis from the Other vessels that may be absorption of carbon dioxide, injured are the inferior vena and a decrease in cardiac out- cava, iliac vessels, and epigastric put up to 30% related to a vessels, especially the inferior decrease in stroke volume.7 epigastric vessel. The repair of Systemically, a pneumoperito- this type of injury can be accom- neum causes respiratory acido- plished in a variety of methods sis and transient hypercapnia.4 depending on the size and loca- The longer the patient has a tion of the injury. Small injuries pneumoperitoneum, the more The incidence of complica- may be controlled using a vessel likely the patient will experience tions occurring during a sealing device and/or electrosur- hypercapnia and acidosis. laparoscopic procedure is gery. Larger injuries may require Oliguria may occur, as there is 1% to 5%, with a mortality assistance from a vascular sur- reduced renal perfusion. It acti- of approximately 0.05%. geon in addition to surgical clips vates the renin-angiotensin- or sutures.11 aldosterone system resulting Hernia and weeping peritoneum. Herniation in renal cortical vasoconstriction, which when can occur at the trocar site especially if either a decreased, causes medullar renal flow and glomeru- Hasson technique is used to access the peritoneum lar filtration to decrease as well. or a 10 mm or larger diameter trocar is inserted and Lastly, adhesion formation may occur from the used. This type of injury may occur at either the pneumoperitoneum. This occurs from mesothelium umbilicus or at an extra umbilical site if it’s not closed desiccation damage and underlying connective tissue properly. The surgeon must be cognizant to close the drying in as little as 30 seconds. Preventive tech- fascia to prevent herniation from occurring.7,8 niques such as low carbon dioxide flow rates, low IAP, short duration of pneumoperitoneum, minimal Complications from pneumoperitoneum damage to abdominal structures, minimal blood loss, The carbon dioxide used to create the pneumoperi- and preventing hypothermia should be encouraged.4 toneum can cause irritation to the peritoneum and, although rare, a weeping peritoneum or pyrexia. Complications from the surgery Patients who experience this type of injury report Infection. The most frequent complication in laparo- symptoms of vomiting, abdominal cramps, and ele- scopic surgery is infection. It’s not associated with the vated heart rate. If left untreated, severe peritonitis laparoscopic technique itself but is mainly associated may occur.2,5 with proper maintenance of aseptic technique and Pneumoperitoneum. The next category of sterilization of the OR equipment and instruments. In complications involves physiologic complications addition, adequately disinfecting the OR environment, related to pneumoperitoneum (see Pneumoperitoneum including floors and walls, and minimizing traffic established for a female patient undergoing a laparoscopy). and dust can lower the risk of infection.5 Superficial Carbon dioxide is pumped into the abdominal cavity incisional surgical site infections (SSIs) tend to occur via a trocar to create the pneumoperitoneum needed within the first 30 days after the procedure and for visualization of structures. It also allows the sur- involve only the skin and subcutaneous tissue. Deep geon to use instruments within the abdominal cavity incisional SSIs involve the deeper fascia or muscle and avoid internal structures. layers and also occur within the first 30 days after There are several local and systematic effects asso- the procedures. If an implant was inserted in the ciated with pneumoperitoneum, including increased patient or if the infection involved an organ that was heart rate, intra-abdominal pressure (IAP), mean arte- manipulated or opened during the procedure, the rial pressure, systemic pulmonary vasculature and infection could appear up to the first year after the systemic vascular resistance, and a decrease in cardiac procedure.12 If the SSI involved an organ, the criteria output and venous return.4 This, in turn, causes a to classify it as an SSI would be purulent drainage, an

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Forceps

Operating laparoscope

Pneumoperitoneum

Uterine cannula

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins; 2010: 1412. abscess, or other evidence on direct exam that Electrosurgery injuries. Electrosurgery during showed an infection involving the organ.12 Although laparoscopic surgery is often used in minimally inva- laparoscopic surgery has a lower SSI rate than open sive abdominal procedures. The use of electrosur- surgery, it’s still a concern in laparoscopy. gery in open surgery has been shown to be safe in In 2005, The Surgical Care Improvement the past 50 years. In laparoscopic surgery, the energy Project protocol was initiated in an attempt to used must be passed through cannulas and have reduce surgical mortality and morbidity. Parts of insulated active electrodes. The first type of electro- this initiative included prophylactic antibiotics surgical energy injury is related to insulation failure. given within 1 hour of the surgical incision, proper This occurs from damage to the insulation surround- antibiotic selection, prophylactic antibiotics discon- ing the portion of the instrument meant to protect tinued within 24 hours after the completion of opposing structures from the current. This damage is the surgical procedure, proper hair removal with typically a break or hole in the insulation. This break clippers, normothermia, and proper glucose man- allows a pathway for the electrical current to leave agement. All of these therapies were collaboratively the device as it travels through the circuit to the initiated to improve surgical outcomes and reduce patient return electrode. An arc may occur, and tissue SSIs.13 not meant to be cauterized may be cauterized.14 www.ORNurseJournal.com September OR Nurse 2013 29

Another complication of elec- which can cause anemia.17 In trosurgery is direct coupling, patients with sickle cell disease, which occurs when the ener- who have pulmonary hyper- gized electrode, while activated, tension, pneumoperitoneum comes unintentionally in contact can be fatal, as the high pres- with another metal instrument sure in the arteries of the lung or object in the abdominal cavi- narrow and their walls thicken, ty. If this occurs, unintended tis- causing systemic vascular resis- sues may suffer damage due to tance and pulmonary vascula- the electrical current completing ture.18 The surgeon, anesthesi- its circuit through the metal ologist, and OR staff must col- instrument.14 laborate to assess the benefits Adequately disinfecting Vessel sealing device inju- of laparoscopy in this patient the OR environment, ries. Over the past few years, population and determine if including floors and bipolar energy devices have the benefit outweighs the walls, and minimizing been used successfully in lapa- risks associated with the pro- traffic and dust can roscopy.15 These devices use cedure.18 lower the risk vibrations or bipolar energy to Urologic injuries. During a of infection. seal or cauterize tissues. A laparoscopic procedure, the sur- grounding pad used in monopolar geon takes precautions to protect electrosurgery to complete the circuit isn’t needed the ureters, especially when there’s a concern of dis- when these devices are used. The alternating current torted anatomy. Some techniques to prevent this is distributed through the target tissue. One of the complication are the insertion of ureteral catheters benefits of this technology is the ability to use lower placed prior to the laparoscopic portion of the pro- voltages to achieve the same tissue effect with cedure to allow the surgeon to more readily visualize decreased thermal spread, reducing damage to sur- the ureters. If a ureteral injury occurs, it may be chal- rounding tissues.15 lenging to diagnose, as up to 50% of a unilateral Complications may occur if the intended cauter- injury is asymptomatic.19 A cystoscopy with indigo ized tissue isn’t properly sealed and bleeding occurs. carmine administration can be performed after the Damage can also occur when the instrument heats procedure to see if the ureters are functioning prop- up and inadvertently touches unintended tissues and erly via visualizing ureteral flow. For minor injuries, a organs. The surgeon and the OR staff should take stent may be inserted, but surgical repair may be care when using these technologies to prevent an needed for more severe injuries.10 unanticipated adverse event.15 Another urologic injury that may occur is a blad- Laser injuries. During laparoscopic laser surgery, der injury, particularly in women with severe endo- the primary complication that can occur is due to metriosis or with a previous cesarean section. In reflection to the patient’s abdominal structures while these patients, the bladder may become adherent using the laser through a trocar. Other injuries include to the abdominal wall during laparoscopic hysterec- accidental activation of the laser prior to use or tomy or laparoscopically assisted vaginal hysterecto- material within the surgical field that may ignite. my, causing an unintended injury to occur. This Overall, laparoscopic laser surgery is safe and effec- type of injury can be identified intraoperatively via tive, but having an individual designated to run the air in the urinary catheter, hematuria, or drainage laser is a precaution that should always be taken to of urine into the abdominal cavity. Most of these prevent risk or injury.16 types of injuries require prompt surgical interven- Sickle cell disease. It’s important for patients tion by a urologist.19 with sickle cell disease, a disorder of the blood Complications associated with anesthesia. caused by inherited abnormal or distorted (sickled) For optimal patient outcomes, OR staff should hemoglobin, to have a thorough workup prior to monitor pathophysiologic changes associated with any laparoscopic surgery. In sickle cell disease, the general anesthesia in laparoscopic surgery patients. abnormal cells are fragile and prone to hemolysis, Hemodynamic effects such as increased heart rate,

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. increased intra-abdominal pressure, and decreased results. This occurs mostly during the initial inser- cardiac output during a laparoscopy are primarily tion of the Veress needle but may occur at any due to the pneumoperitoneum. Healthy patients tol- point during the surgical procedure. Treatment erate this procedure better than those with comor- consists of placing the patient in a left lateral head bidities. Patients with cardiac disease are at increased down position and hyperventilation.20 A central risk for further complications, as the carbon dioxide line is inserted to aspirate the gas. CPR and hyper- gas used to create the pneumoperitoneum depresses baric oxygen may also be required.2 the patient hemodynamically.2 Rare complications. One rare complication is The Trendelenburg position can also cause hemo- necrotizing fasciitis and carries a high associated dynamic effects, such as decreased venous return mortality. In this situation, an aggressive bacterial and cardiac output, increased intracranial and intra- infection invades the soft tissue with rapid necrosis of ocular pressure, and venous stagnation, which may the fascia and subcutaneous fat. Only a few reported cause cyanosis and edema in the face and neck, cases of necrotizing fasciitis have been reported after especially during a prolonged period of time. laparoscopic surgery. Early diagnosis and aggressive Dysrhythmias may occur in these patients during surgical intervention are critical to survival.21 the insertion of the ports or during the pneumo- Other common complications. Pneumonia, peritoneum from the insufflation of carbon dioxide, bronchitis, thromboembolism, adhesion formation, causing a profound increase in vagal tone; therefore, and abdominal wall ecchymosis may commonly occur slow insufflation is recommended during this proce- from either the effects of carbon dioxide administra- dure.2 Pulmonary effects due to an increase in pres- tion for the pneumoperitoneum, entrance of the sure on the diaphragm and reduced expansion or abdominal cavity with a foreign body, or local vascular compression of the lungs may also occur. Atelectasis hemorrhage from a port entry required to perform a can result from a decreased end-expiratory lung vol- laparoscopy.5 Surgeons and perioperative staff should ume that’s insufficient to maintain alveoli patency. be aware of these common complications and imple- Morbidly obese patients have greater peak airway ment best practices to prevent injuries from occurring. pressures and may not be able to tolerate a prolonged Trendelenburg position.2 Contraindication for laparoscopy Other pulmonary effects include subcutaneous Laparoscopic surgery is contraindicated for patients emphysema, endobronchial intubation within a bron- with severe heart failure, respiratory insufficiency, chus, pneumothorax, and gas embolism. The most uncorrectable coagulation defect, diffuse peritonitis, common respiratory complication is subcutaneous and distended bowel.5 In addition, a patient who has emphysema. It’s caused by extra peritoneal insuffla- had previous abdominal surgery may not be the best tion of carbon dioxide. An endobronchial intubation candidate for this surgical technique, as there may be is caused by the elevation of the diaphragm by the extensive adhesions.5 Older adults are at greater risk pneumoperitoneum, resulting in only one lung being for laparoscopic complications along with the mor- ventilated. The anesthesia team should watch for bidly obese. These patients have a decreased reserve, decreased oxygen saturation and pulmonary compli- often have poorer health, and decreased pulmonary ance to recognize this.2 and cardiovascular function.2,5 Serious complications include pneumothorax and gas embolism. When a pneumothorax occurs, Nursing considerations the surgical procedure should be terminated, Preoperative preparation for patients undergoing lap- release of the pneumoperitoneum initiated, and a aroscopy should include a medical history and physi- chest tube inserted. A gas embolism, which can cal exam, complete blood count with differential, occur during pneumoperitoneum and has a mortali- serum electrolytes, urinalysis, prothrombin time, par- ty of 30%, is rare and can be fatal if not treated tial thromboplastin time, bleeding time, and imaging immediately.2 Signs of a carbon dioxide embolism as indicated.5 In addition, depending on the surgeon’s include cyanosis, profound hypotension, hypercapnia preference and the surgical procedure, a bowel prep- and hypocapnia, dysrhythmias, and asystole. This aration may be completed prior to surgery.2,19 If this occurs due to a “gas lock” in either the vena cave is required, patients should be encouraged to have a or right ventricle and an interruption in circulation clear liquid diet the day prior to surgery. www.ORNurseJournal.com September OR Nurse 2013 31

Patients may also be required to take a shower during the insertion of the trocar. In thin patients, the the evening prior to surgery with an antiseptic soap. force required to insert the trocar may be less than Nurses should instruct their patient to clean their anticipated because of a thin fascia. During all trocar umbilicus using a cotton swab, as the abdominal insertions, the practitioner must be cognizant of the access is often through the umbilicus. The patient force required to insert the trocar without injuring should also be instructed to not eat or drink any- abdominal structures.16 Once the trocar is inserted, thing either after midnight prior to surgery, or 6 to carbon dioxide should be infused slowly and set at a 8 hours before the procedure. Nurses should pressure of 15 mm or less.2 review medications (prescription, over-the-counter, Nursing considerations for the immediate post-op supplements, vitamins, and herbal medicines) the phase are to assess the patient for pain and provide patient should take on the day of surgery and the appropriate amount of pain medication pre- which ones may need to be stopped a few days scribed by the surgeon following the patient’s pain prior to the day of surgery.5 rating results. The pain seen in laparoscopy is less The patient’s position during the surgical proce- severe when compared to open surgical procedures, dure must be considered. Patients should have but it can still be considerable. Monitoring of vital proper body alignment maintained. If in a lithotomy organ function is accomplished via continuous mon- position, the patient’s legs should be placed in itoring of peripheral oxygen saturation, BP measure- padded stirrups, avoiding hyperflexion of the legs. ment, respiratory rate, and electrocardiography Hyperflexion can cause compression of the femoral monitoring.23 Lastly, antiemetics should be adminis- nerve of the peroneal nerve. The patient’s buttocks tered if the patient experiences nausea and vomiting should only extend beyond the end of the OR after surgery.23 table by a few centimeters to allow for either uter- Postoperatively, patients should be monitored for ine manipulation or insertion of a stapling device.22 pain, fever, chills, elevated WBC count, herniation, Body habitus must be considered for all patients and infection. (See Signs and symptoms of laparoscopy regardless of weight. Trocars are inserted almost complications.) If the patient is discharged from the vertically. The distance between the trocar tip and hospital shortly after the surgical procedure, the the sacral promontory is relatively small.22 Care nurse should educate the patient to recognize the should be taken, as major vessels can be injured signs and symptoms of complications and quickly contact their physician if they have any concerns. Signs and symptoms of Patients should also be encouraged to move and laparoscopy complications5 walk as much as tolerated to minimize the risk of postoperative complications. Notify the surgeon if the patient develops any of the following signs and symptoms that may indicate an injury related to the laparoscopic Summary procedure. Laparoscopic surgery has many benefits to patients when compared to open surgery. Even so, it’s • Fever • Chills important for nurses to properly communicate to • Nausea patients that all surgery has the potential for com- • Vomiting plications. Knowing the signs of laparoscopic com- • Lower abdominal pain plications, accurately diagnosing, and expeditiously • Abdominal tenderness correcting unintended injuries before they’re fatal • Abdominal distension are crucial to optimal patient outcomes following • Epigastric pain laparoscopic surgery. OR • Bleeding or increased redness at the surgical site • Abscess REFERENCES • Decreased urine output 1. ehealthMD. What is laparoscopy? http://ehealthmd.com/content/ • Tachycardia what-laparoscopy#axzz2ZEL7xBd1. • Hypotension 2. Nguyen JH, Tanaka PP. Anesthesia for laparoscopic surgery. http:// laparoscopy.blogs.com/prevention_management_3/2010/10/anesthesia- • Cardiac dysrhythmias for-laparoscopic-surgery.html. • Tachypnea 3. Smith CE. Gastrointestinal surgery. In: Rothrock JC. Alexander’s Care of the Patient in Surgery. 14th ed. Elsevier Mosby; 2011:317-320.

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 4. Ott DE. The pneumoperitoneum. http://laparoscopy.blogs.com/ 15. Nezhat C, Lewis M, King LP. Laparoscopic vessel sealing devices. prevention_management_3/2010/11/the-pneumoperitoneum.html. http://laparoscopy.blogs.com/prevention_management_3/2010/10/ 5. World Laparoscopy Hospital. Complications of laparoscopic surgery. laparoscopic-vessel-sealing-devices.html. http://www.laparoscopyhospital.com/complication-of-laparoscopic- 16. Kim AH, Adamson GD. Laparoscopic laser injury. http://laparoscopy. surgery.html. blogs.com/prevention_management/chapter_04_laser_injury. 6. World Laparoscopy Hospital. Laparoscopic port closure technique. 17. National Institutes of Health. National Heart, Lung, and Blood http://www.laparoscopyhospital.com/laparoscopic_port_closure_ Institute. What is sickle cell anemia? http://www.nhlbi.nih.gov/health/ technique.htm. health-topics/topics/sca/. 7. Perugini RA, Callery MP. Complications of laparoscopic surgery. In: 18. Youssef MA, Al Mulhim A. Physiologic effects of pneumoperito- Holzheimer RG, Mannick JA, eds. Surgical Treatment: Evidence-Based and neum in adults with sickle cell disease undergoing laparoscopic chole- Problem-Oriented. Munich: Zuckschwerdt; 2001. cystectomy (a case control study). Surg Endosc. 2008;22(6):1513-1518. 8. Geis WP, Stratoulias C. Minimally invasive bowel surgery. http:// 19. Nezhat F, Nezhat C, Nezhat C. Averting complications of laparos- laparoscopy.blogs.com/prevention_management/chapter_11_bowel_surgery. copy: pearls from 5 patients. J Fam Pract. 2007;19(8). 9. Berker B, Taskin S, Taskin EA. Complications of laparoscopic 20. Smith HJ. Carbon dioxide embolism during pneumoperitoneum for gynecologic surgery. http://laparoscopy.blogs.com/prevention_ laparoscopic surgery: a case report. AANA J. 2011;79(5):371-373. management_3/2010/07/complications-of-laparoscopic-gynecologic- http://www.aana.com/newsandjournal/Documents/co2embolism_1011_ surgery.html. p371-373.pdf. 10. Lanzafame RJ. Prevention and management of intraabdominal 21. Mohammadhosseini B, Vaji MB. Necrotizing soft tissue infection and pelvic catastrophes. http://laparoscopy.blogs.com/prevention_ after laparoscopic surgery. Surg Pract. 2008;12(4):129-132. management_3/2010/08/prevention-and-management-of- 22. Nezhat C, Nezhat C, Nezhat F, Ferland R, Lewis M, King LP. intraabdominal-and-pelvic-catastrophes.html. Laparoscopic access. http://laparoscopy.blogs.com/prevention_manage- 11. Suarez C. Vascular complications in laparoscopy. http://laparoscopy. ment_3/2011/04/laparoscopic-access.html. blogs.com/prevention_management/chapter_12_vascular_surgery/. 23. American Society of PeriAnesthesia Nurses (ASPAN). 2012-2014 12. Dorian H, Gruber B. Pathogenesis of surgical site infection. http:// Perianesthesia Nursing: Standards, Practice, Recommendation, and Interpretive laparoscopy.blogs.com/prevention_management_3/2010/07/pathogenesis- Statements. Cherry Hill, NJ: ASPAN; 2012. of-surgical-site-infection-ssi.html. Ruth L. MacGregor is a surgical assistant at Virtua Memorial Hospital in 13. Medscape General Surgery. Surgical care improvement project Mt. Holly, N.J. (SCIP): module1: infection prevention. 2006. http://www.medscape. org/viewarticle/531895. The author and planner have disclosed that they have no financial relationships related to this article. 14. Rohlf S. Laparoscopic electrosurgery. http://laparoscopy.blogs.com/ prevention_management/chapter_02_electrosurgery. DOI-10.1097/01.ORN.0000433525.56540.65

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