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Laparoscopic Surgery: a Cut Abov Laparoscopic surgery: A cut abov 24 OR Nurse 2013 September www.ORNurseJournal.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. ve the rest? 2.5 ANCC CONTACT HOURS 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 com- pared with open surgical procedures, but it’s impor- tant 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 visu- alize.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 www.ORNurseJournal.com September OR Nurse 2013 25 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Laparoscopic surgery: A cut above the rest? 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. 26 OR Nurse 2013 September www.ORNurseJournal.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Division of the abdomen into four quadrants or nine regions 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
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