Recommended practices for endoscopic minimally invasive surgery

AORN Journal,  March, 2005  

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The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comment to members and others. These recommended practices are effective Jan 1, 2005.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended to provide guidance for various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

PURPOSE. Endoscopic minimally invasive surgery (MIS) has evolved from a diagnostic modality to a widespread surgical technique. This evolution occurred in response to the reported benefits of endoscopic surgery compared to the benefits of conventional surgical procedures for patients. These recommended practices provide guidance to help perioperative personnel reduce risks to patients during endoscopic surgery. Benefits to the patient include reduced pain, faster healing, decreased length of hospital stay, and quicker return to normal life. The primary benefit to the hospital is financial, resulting from the decreased length of stay.

The perioperative nursing vocabulary is a clinically relevant and empirically validated standardized language. This standardized language consists of the Perioperative Nursing Data Set (PNDS) and includes perioperative nursing diagnoses, interventions, and outcomes. The expected outcomes of primary import to these recommended practices fall into two categories: freedom from injury during the perioperative period and maintenance/ improvement of baseline physiological status. Specifics will be found in the documentation section.

RECOMMENDED PRACTICE I

Potential patient injuries and complications associated with endoscopic MIS should be identified, and practices that reduce the risk of injuries and complications should be established.

1. The perioperative nurse should understand the goals and objectives of endoscopic MIS. Nursing knowledge, technological skills, and a thorough preoperative patient assessment provide the basis for establishing an appropriate plan of care for a patient undergoing endoscopic surgery. (1)

2. Patient monitoring during laparoscopic procedures should include measurement of the patient's

* electrocardiogram,

* end tidal carbon dioxide (C[O.sub.2]),

* noninvasive blood pressure,

* oxygen saturation, and

* temperature.

Although endoscopic procedures are minimally invasive, using C[O.sub.2] for insufflation increases the risk of hypercarbia, subcutaneous emphysema, pulmonary embolism, pneumoscrotum, and hypothermia. End tidal C[O.sub.2] is closely monitored to detect the onset of hypercarbia, and the patient is observed for subcutaneous emphysema. (2) Carbon dioxide insufflation is one cause of hypothermia and is one contributing factor to thermal loss, along with irrigation, room temperature, exposed body surface, procedure length, and patient age and medical condition. The higher the flow of the C[O.sub.2], the lower the temperature of the gas, (3) but the incidence of hypothermia during endoscopic surgery has been reported to be similar to that of open surgery. (4,5) Additionally, endoscopic surgery presents a risk of limited visibility, which may result in undetected and uncontrolled bleeding. (6)

3. Specific positioning devices should be provided to secure the patient and provide safety in accordance with AORN's "Recommended practices for positioning the surgical patient." (7) Exaggerated positioning may be used during endoscopic surgery to displace intracavity organs or enhance visibility for the surgical team. Positioning devices should be readily available before the patient is moved onto the OR bed.

4. Patients undergoing endoscopic procedures should be prepped and draped for an open procedure when applicable. It may be necessary to convert to an open procedure at any time. Prior preparation reduces anesthesia time and increases OR efficiency. (8) Prior preparation will facilitate conversion to an open procedure should that become necessary. (8) Instruments and supplies for an open procedure should be readily available. When it is necessary to convert to an open procedure, the conversion should be accomplished efficaciously.

5. Instruments that enter sterile body cavities are classified as critical items and should be sterile when used. (9) Endoscopes and endoscopic instruments (eg, biopsy forceps, graspers) used for endoscopic surgery should be processed according to AORN's "Recommended practices for cleaning and processing endoscopes and endoscope accessories." (10) Endoscopes and accessories to be sterilized should be packaged before sterilization or be processed immediately before use.