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AORN Journal; 3/1/2005



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.

6. Illuminated endoscopic light cords should not be allowed to remain in contact with drapes, patients' skin, personnel's skin, or any flammable material. The heat from light cords or endoscopes may cause drapes to burn. Turning off light sources when they are not in use and holding cords away from drapes or placing them on a moist towel helps prevent burns and fire. (11) Complete all cable connections before activating the source. Place the source on standby when disconnecting cables. Drape the patient only when all flammable prep solutions have fully dried. (12)

7. In practice settings where technology for sterilization of endoscopes is not available, endoscopes and other heat-sensitive items should receive high-level disinfection immediately before each use. Refer to AORN's "Recommended practices for cleaning and processing endoscopes and endoscope accessories" for appropriate protocols. (10) The availability and use of disinfectants in the health care field is dynamic, and manufacturers' recommendations should be followed. As newer disinfectants become available, selection should be guided by information in the scientific literature.

RECOMMENDED PRACTICE II

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

1. The perioperative nurse should demonstrate competence in C[O.sub.2] insufflation and management of its risks.

* Carbon dioxide is the most commonly used insufflation gas because it is readily absorbed by the body and excreted by the lungs, does not support combustion, and is commonly available. (13)

* Carbon dioxide insufflators should be filtered with a single-use hydrophobic filter that is compatible with the insufflator and impervious to fluids. A hydrophobic filter helps prevent gas cylinder contaminants from flowing through the insufflator into the surgical cavity, prevents backflow of abdominal fluids and particulates that could contaminate the insufflator, and prevents cross contamination. When the filter is compatible with the insufflator, it does not interfere with flow rate. The flow of contaminants occurs more readily when the volume of remaining gas in the cylinder is low. Replacing the primary cylinder before the gas level is low helps prevent contamination of the sterile field by particulate matter. (13) Cylinders with nonferrous internal surfaces and surfaces incapable of creating residual material that could escape during the gaseous phase of delivery may be helpful in preventing the transfer of particulate matter.

* The cylinder should be checked to verify that the gas is C[O.sub.2]). Only medical grade C[O.sub.2] should be used.

* The C[O.sub.2] cylinder should be replaced as needed. A second C[O.sub.2]. cylinder should be readily available for each procedure. Methods of monitoring the level of remaining gas in the cylinder include

** observing the insufflator gas cylinder gauge level,

** monitoring the refill history, and tracking cylinder use.

* The insufflator should be elevated above the level of the surgical cavity. Insufflator pressures should be monitored throughout the procedure, and the insufflator tubing should be disconnected from the trocar cannula before personnel deactivate the insufflator. When the pressure on the patient side is higher than at the insufflator connecting point, body fluid or gas is allowed to flow up the trocar cannula through the insufflation tubing and into the insufflator. This may result in cross contamination or damage to the insufflating device. (13)

* The insufflator and insufflation tubing should be flushed with gas before personnel connect the tubing to the cannula (eg, Verres needle). Flushing removes residual air from tubing, reducing the risk of air embolism. It also determines whether residues are present inside the insufflator. (13)

2. The perioperative nurse should demonstrate competence in fluid insufflation and management of its risks.

* Resectoscopes have been used for urologic procedures for many years. Since the 1950s, glycine 1.5% has been used as a cavity-distention medium for urologic procedures, primarily transurethral resection of the prostate (TURP), in which the resectoscope is used. (14) A complication sometimes observed with the use of glycine is TURP syndrome, which is caused by excessive absorption of the irrigating solution. Exposed blood vessels from tissue removal and elevated pressure being applied to the distention fluid enables intravasation (ie, distention fluid flows into the vascular system). (14,15) Physiological outcomes that can result from excessive fluid absorption include

** cardiac overload,

** cerebral edema,

** dilutional hyponatremia, and

** water intoxication. (14,16)

Comparable symptoms can occur in women undergoing hysteroscopic surgery with distention fluids.

* Some gynecological procedures resect or ablate abnormal tissue using cutting or coagulating monopolar current. Procedures might include

** endometrial ablation,

** evaluation of infertility,

** intrauterine assessment,

** removal of intrauterine fibroids, and

** removal of polyps.

Cavity distention, often with irrigating fluids, provides a broader visual field. Irrigation fluids help clear the field of blood and debris. (17) Only electrically inert (ie, nonconductive), near-isotonic solutions should be used for uterine irrigation when monopolar electrosurgical current is used. Instead of energy being focused on the tissue, conductive solutions diffuse the energy, resulting in decreased tissue effect.

* Perioperative nurses should implement safety measures to minimize fluid-related patient complications during hysteroscopy procedures.

** SELECTION OF DISTENTION FLUID. When electrosurgical energy is to be used, only non-conductive, salt-free solutions should be used. (11) Media for cavity distention include

*** C[O.sub.2] gas;

*** dextran 70;

*** glycine;

*** isotonic electrolytic solution (eg, normal saline, Ringer's lactate);

*** mannitol;

*** sorbitol; and water.

** FLUID DEFICIT MONITORING. Fluid deficit is the difference between the volume of fluid infused and the volume recovered. (18) This deficit should be monitored to determine how much fluid is being absorbed by the patient (ie, fluid intravasation). Dilutional hyponatremia is associated with intravasation. Rapid influx of hypotonic fluid increases circulation of free water and reduces the extracellular sodium concentration. (19) As a general rule, serum sodium falls 10 millimoles per L for every liter of hypotonic fluid absorbed. (19) The critical volume of intravasation before symptoms are exhibited is not predictable. (20) The American Association of Gynecological Laparoscopists suggests that 750 mL of fluid absorption implies impending excessive intravasation and completion of the procedure should be planned. (21) Fluid deficit amount should be reported to the anesthesia care provider and surgeon at regular intervals during the procedure.

** FLUID PRESSURE MONITORING AND CONTROL. The ideal pressure at which fluid is delivered to the cavity is believed to be at or below the patient's mean arterial pressure. (18) There are four basic types of fluid delivery/monitoring systems.

*** Gravity-fed systems deliver fluid at a rate and pressure dependent on the difference between height of the bag and the OR bed, the inner bore of the tubing, how tightly the endoscope sheath fits into the cavity, and the aperture of the outflow valve. (17)

*** Automated gravitational systems maintain pressure and outflow control.

*** Automated pressure systems deliver fluid at a constant pressure and release return flow when the internal pressure reaches a specified level.

*** Automated roller pump systems measure fluid inflow by counting rotations on a pump roller or deliver fluid at a constant, pressure-regulated flow rate maintained by a pressure transducer. Fluid is extracted by a self-contained vacuum system. Fluid deficit is calculated on weight of the fluid infused versus the weight of the fluid returned. (18)

** PROCEDURE LENGTH. Fluid absorption increases with increased length of the procedure. Safe completion of procedures in an expedient manner (ie, one hour or less) can help limit complications from fluid absorption. Complications from fluid overload are less likely to occur and postoperative recovery time may be decreased with shorter anesthetic and procedure time. (18)

RECOMMENDED PRACTICE III

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

1. Perioperative team members should continuously monitor the functioning of equipment and the integrity of endoscopic instruments to ensure that hazards are minimized. Electrosurgical injuries are caused by insulation failure, direct coupling of current, and capacitive coupling. Equipment should be used according to manufacturers' written instructions. Perioperative team members should continuously monitor the functioning of equipment and the integrity of endoscopic instruments to ensure that hazards are minimized.

* Insulation failure of the laparoscopic active electrode can be caused by trauma during reprocessing and provides an alternate pathway for the current to leave the electrode. Current leaves the electrode at the point of insulation failure as opposed to the tip of the electrode as intended. This can cause significant tissue damage and serious patient injury, particularly when the injury is internal and not immediately recognized. Routine visual inspection may reveal small cracks or mechanical damage. Use of disposable devices will not guarantee elimination of insulation failure because the quality of the insulation material may be less than that of a reusable item. (22)

* Direct coupling is caused by touching the active electrode to an anatomic structure other than the one intended. Three potential problems arise from direct coupling.

** Metal-to-metal sparking can cause necrosis of underlying tissue.

** Metal-to-metal sparking can cause frequency demodulation. The demodulated current results in lower frequency, which can result in neuromuscular stimulation noted by muscular twitching.

** Metal-to-metal sparking may cause current flow to unintended sites. The density of the current determines the amount of tissue damage. A large point of contact will have low current density, and no tissue damage would be expected. A small point of contact will have high current density, and significant tissue damage is possible. (23)

* Capacitive-coupling is caused by stray currents being transferred from one conductor to another with no insulation break. This occurs when magnetic fields are produced around the current-carrying, active electrode. When radio-frequency currents flow through an electrode, the flow may initiate stray currents onto other nearby conductors even though the insulation on the electrode and its wires are intact. Three common equipment arrangements may lead to significant amounts of stray current causing capacitive coupling.

** Active electrodes are placed through metal cannulae.

** Active electrodes are housed through operative laparoscopes.

** Active electrodes are used through metal suction irrigators. (24)

Capacitive-coupled, radio-frequency currents may cause undetected burns to nearby structures outside the endoscope's viewing area. Alternative-site burns can be severe and may damage tissue. These burns are particularly dangerous to hollow organs and may lead to undetected perforation with subsequent infection and possible death. (25) Use of active electrode monitoring devices minimizes the risk of undetected insulation failure, direct coupling, and capacitive coupling.

2. Electrical cords and plugs should be handled in a manner that minimizes the potential for damage and subsequent patient injuries. Equipment should be placed near the sterile field, with cords reaching the wall or column outlet without stress on a cord or blocking a traffic path. Stress on cords may cause damage to the cord, posing an electrical hazard. Cords should be free of kinks, knots, and bends that could damage the cord or cause leakage, current accumulation, and overheating of the cord's insulation. The internal parts of the connectors should be inspected for the appearance of shiny metal. If the presence of char debris is noted, the cord should be removed from use. Cords should be kept away from fluids. Fluids dripping onto the cord or connections cause electrical hazards.

RECOMMENDED PRACTICE IV

Reusable endoscopic instruments should be processed according to AORN's recommended practices using methods that reduce the risk of personnel injury.

1. Perioperative personnel involved with endoscopic procedures should practice according to AORN's "Recommended practices for standard and transmission-based precautions in the perioperative practice setting." (26) Endoscopic surgery is referred to as minimally invasive. This terminology may lead to a false sense of security when considering potential hazards. This false sense of security may result in a less diligent use of standard precautions. Those performing the procedure and those who clean and process instruments and accessory equipment should wear personal protective equipment (PPE). (27)

2. Endoscopic surgery should be performed in a manner that minimizes perioperative personnel's exposure to blood and body fluids, droplets, noxious fumes, gases, or smoke. Smoke and laser plume should be evacuated throughout the procedure with appropriate smoke evacuation equipment. The release of gas, electrosurgical smoke, and laser plume during endoscopic surgery may expose surgical team members to blood products, fluid, and cellular debris. Smoke evacuation systems provide protection and reduce the risk of exposure to potentially infectious or toxic agents. Spontaneous sparking may result if electrosurgical smoke is allowed to accumulate in large amounts. AORN's "Recommended practices for electrosurgery" (28) and "Recommended practices for laser safety" (29) should be used when selecting a smoke evacuation system.

3. Cleaning methods should minimize splashing, spraying, splattering, and droplet generation to minimize risk of exposure to blood or body fluids. Using standard precautions (eg, wearing gowns, gloves, goggles or face shields) helps protect employees. Standard precautions should include use of protective barriers or PPE, such as

* eye protection (eg, face shields, goggles, glasses with side shields);

* gowns; and

* intact gloves.

Leg coverings, shoe covers, and other PPE may be used when indicated. Exposure to potentially infectious material is reduced by use of these products.

4. Disposable, reusable, and reposable instruments should be used according to manufacturers' recommendations. To ensure that the device is assembled correctly and will perform as intended after processing and reassembly, manufacturers' recommendations should include clear, understandable instructions for processing that include guidelines for

* assembly and disassembly,

* cleaning,

* routine user testing, and

* sterilization.

Products should not be purchased or used unless such information is provided.

Manufacturers are required by the US Food and Drug Administration to supply detailed instructions for processing reusables. Reposable instruments have a reusable component and a single-use or limited-use component. Adhering to AORN's "Recommended practices for cleaning and caring for surgical instruments and powered equipment" (30) and "Recommended practices for care and cleaning of endoscopes" (10) will minimize the risk of personnel injury associated with cleaning endoscopes and related equipment.

5. Sharps should be handled, processed, and stored in a manner that reduces the risk of injury to employees. Transporting reusable sharp instruments in containers that allow instrument handles to be immediately accessible to staff members minimizes risk of injury. Disposing of singe-use sharp instruments as regulated medical waste complies with state and federal guidelines. (27)

RECOMMENDED PRACTICE V

Endoscopic instruments and equipment should meet performance and safety criteria established by the practice setting.

1. Written information regarding safety, testing methods, warranties, maintenance, and inspections for all endoscopic equipment should be obtained from the manufacturer. Endoscopic equipment manuals provide guidelines for developing operating, safety, and maintenance practices. Proper inspection, testing, use, and processing of equipment reduces the risk of adverse outcomes or damage to equipment. (27)

2. Each piece of endoscopic equipment (eg, camera system, monitor; insufflator) should be assigned an identification number. Identification numbers allow for inspections and tracking equipment problems.

3. Monitors should be positioned for good visibility for surgical team members and secured to carts or ceiling mounts. Good visibility is essential for patient care. Securing the monitors prevents injury to patients and personnel as well as equipment damage. (11)

4. All endoscopic equipment, including cameras, light sources, and videocassette recorders (VCRs) should be checked before use. Correct control settings should be labeled on equipment and on a quick reference chart attached to the equipment. When practical, equipment should be standardized so that systems are interchangeable. (11) Standardization of equipment allows for interchangeability in the event of equipment malfunction. To promote patient safety without delays during surgical procedures, all equipment should function correctly.

5. Endoscopic trocars should meet safety criteria established for the practice setting. The most frequent catastrophic patient injury involves trocars. Organ and vessel trauma may occur from excessive use of pressure during trocar insertion. When an all metal system is used, capacitive current is safely dispersed through the metal anchor and the greater surface area provided by the chest or abdominal wall, thereby reducing current concentration. Metal cannula systems are best for the(electrosurgical instrument port. (31) An all plastic system is another alternative. Using this system, the capacitor is the patient, which minimizes the risk of concentrated capacitive-coupled current. (31) A risk of direct coupling injuries, however, remains. Hybrid trocars (ie, metal trocars with plastic anchors) are not recommended due to the unsafe dispersion of electrical energy. (31,32) Each trocar and cannula can act as an electrical conductor, inducing an electrical current from one to the other. This could result in capacitive-coupling injuries.

6. Fiberoptic light cords or cables should be long enough to reach from the surgical field to the equipment without undue stress. The cord should be inspected for broken light bundles before use. Broken light bundles will diminish the transmission of light and decrease visibility. A backup cord should be available. Tension increases the risk that the cords and fiberoptic cables will become disconnected or break, thereby creating a safety hazard for patients and personnel. Having sterile backup cords readily available decreases surgical delays. (11)

7. Robotic devices may be used to hold and manipulate the laparoscope under the physician's guidance. The movement is voice activated or is managed by hand-held controls or a foot pedal. The robotic arm maintains the laparoscope in proper orientation, maximizing visualization and providing stable images. The laparoscope attaches to the robotic positioning arm with a magnetic coupling device. A sterile drape covers the arm to maintain a sterile field. The control system allows the operator to move the arm for exact positioning of the laparoscope. (33) All robotic equipment should be checked before use. Problematic issues identified with robotics include, but are not limited to,

* insufficient white balancing, which can cause the robot to misread the marker;

* limitation of the surgeon's movement due to positioning of the robotic arm; and

* a potential for conversion to an open procedure or need for a human camera assistant. (33)

RECOMMENDED PRACTICE VI

Personnel should demonstrate competency in the use of endoscopic surgical equipment in the practice setting.

1. Perioperative personnel should demonstrate competence in the use of endoscopic surgical equipment before use. Instruction and return demonstration in proper usage minimizes the risk of injury and extends the life of the equipment.

2. Perioperative practitioners should be knowledgeable about advancing instrumentation, dissection and hemostasis, computer-assisted technologies (eg, voice recognition software, robotics), and camera technologies that simplify endoscopic MIS and expand its application (Table 1). Technology is continually evolving. Ongoing advances will need to be monitored and competencies, including skills validation, updated to reflect those advances.

3. Perioperative practitioners should be knowledgeable about procedural advances that simplify endoscopic MIS and that can expand its application (Table 2).

RECOMMENDED PRACTICE VII

Perioperative nursing care for patients experiencing endoscopic MIS should be documented in the patient's record.

1. Documentation should be consistent with AORN's "Recommended practices for documentation of perioperative nursing care." (34)

2. The PNDS (35) should be used when documenting perioperative nursing care. Use of standardized nomenclature will facilitate data capture and analysis for safe, quality patient care. Documentation should include safety parameters implemented during MIS. The following PNDS outcomes are expected to be met with this recommended practice.

* O2--The patient is free from signs and symptoms of injury caused by extraneous objects. (35)(p85-90)

* O4--The patient is free from signs and symptoms of electrical injury. (35)(p94-95)

* O10--The patient is free from signs and symptoms of infection. (35)(p105-117)

* O13--The patient's fluid, electrolyte, and acid-base balances are consistent with or improved from baseline levels established preoperatively. (35)(p123-127)

The PNDS should be referred to for identification of specific nursing diagnoses and nursing interventions. (35)

3. information about adverse patient outcomes related to endoscopic MIS should be collected and analyzed as part of a facility-wide quality management program. To monitor the quality of patient care and formulate recommendations for changes, it is necessary to maintain a system of evaluation. Quality improvement standards for perioperative nurses that can be used for evaluating endoscopic surgery have been published. (36)

RECOMMENDED PRACTICE VIII

Policies and procedures for endoscopic surgery should be developed, reviewed periodically, and readily available in the practice setting.

1. These policies and procedure should include but not be limited to:

* documentation of identification numbers, settings used, and volume of gas;

* equipment maintenance programs;

* guidelines for equipment processing; and

* staff member competency requirements.

2. These recommended practices should be used as guidelines for developing policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. An introduction to reviewing the policies and procedures should be included in orientation and ongoing educational sessions to help personnel develop the appropriate knowledge, skills, and attitudes that affect patient care. Policies and procedures also assist in developing quality assurance and improvement activities.

3. Policies and procedures for equipment must be in compliance with the Safe Medical Devices Act (SMDA) of 1990, as well as facility-specific policies and procedures. (37) If patient or personnel injuries or equipment failures occur, the laparoscopic equipment and associated attachments must be handled in accordance with the SMDA. Device identification, maintenance and service information, and adverse event information should be included in the report from the practice setting. (38)

4. Policies and procedures must comply with the Standards of Privacy and Security of the Health Insurance Portability and Accountability Act of 1996 for the protection of health information. In addition, these policies and procedures should take into account applicable state laws, as well as applicable national and professional standards. These policies and procedures should cover not only the disclosure of information but also access to and use of databases, including, but not limited to, digital pictures and patient information. Policies and procedures should be revised as needed to account for any changes, or amendments to applicable laws, rules, and standards. (39)

GLOSSARY

CAPACITIVE COUPLING: Transfer of electrical current from the active electrode through intact insulation to adjacent conductive items (eg, tissue, trocars).

CAPACITORS: Two conductors separated by an insulator (eg, insulated active electrode, trocar cannula); instrument for storing electricity.

CRITICAL ITEM: Instruments or objects that are introduced directly into the human body, either into or in contact with the blood stream or normally sterile areas of the body; an item that enters sterile tissue or the vascular system.

DEMODULATION: The operation on a previously modulated wave in such a way that it will have substantially the same characteristics as the original modulating wave.

DIRECT COUPLING: Touching the laparoscopic active electrode to another surgical field.

ENDOSCOPIC MINIMALLY INVASIVE SURGERY (HIS): Surgical techniques that use endoscopic approaches rather than dissection.

HIGH-LEVEL DISINFECTION: A process that kills all microorganisms with the exception of high numbers of bacterial spores; using an Environmental Protection Agency-registered agent that kills vegetative bacteria, tubercle bacilli, some spores, fungi, and lipid and non-lipid viruses given appropriate concentration, submersion, and contact time. Manufacturers' recommendations may differ.

HYPERTONIC: Having a greater osmotic pressure (ie, higher solute concentration) than a reference solution. If a cell is surrounded by a hypotonic solution, osmotic pressure tends to force the water out of the cell, and the cell shrinks.

HYPONATREMIA: An abnormally low concentration of sodium ions in circulating blood.

DILUTIONAL HYPONATREMIA: a decrease in the serum sodium level due to intravasation of fluids, which dilute the soluble components of the serum.

HYPOTONIC: Having a lower osmotic pressure (ie, lower solute concentration) than a reference solution. If a cell is in a hypotonic solution, osmotic pressure tends to force the water into the cell, and the cell swells.

HYDROPHOBIC INSUFFLATION FILTER: An in-line filter that retains a high percentage of particulates greater than a specified size. The hydrophobic media protects against fluid backflow into the insufflation gas.

HYSTEROSCOPY: Endoscopic visualization of the uterine cavity and tubal orifices.

INSUFFLATION: The act or instance of insufflating.

INSUFFLATE: To blow into; to fill any cavity or orifice of the body.

INTRAVASATION: The entrance of foreign material into a blood vessel.

INVASIVE PROCEDURES: Surgical entry into tissues, cavities, or organs.

LIGHT CORD: A cable of fiberoptic filaments used to transport light to the surgical field.

MORCELLATION: The process of fragmenting tissue into small pieces.

OSMOTE: The standard unit of osmotic pressure; the molecular weight of a solute, in grams, divided by the number of ions or particles into which it dissociates in solution.

OSMOSIS: The passive movement of fluid through a semipermeable membrane from a region of lower solute concentration to a region of higher solute concentration.

OSMOTIC PRESSURE: The tendency and rate of water to move across a semipermeable membrane toward a region of higher solute concentration.

REPOSABLE: An instrument that has limited use or an instrument with a combination of reusable and disposable components.

SOLUTE: A dissolved substance suspended within a solution.

SOLUTION: A homogeneous mixture of two or more compounds.



TABLE 1 Technological Advances in Endoscopic Minimally Invasive Surgery The use of endoscopic surgery has increased exponentially during the past 10 years. Previously lengthy and difficult procedures now are being performed endoscopically. Advances in instrumentation, dissection and hemostasis techniques, and camera technologies have simplified surgical procedures and expanded application of the minimally invasive surgical approach. Following are examples of some of these advances. Instrumentation advances * Optical trocars allow for direct visualization when dissecting through layers of the abdominal wall into the peritoneum. (1) * Blunt-tipped trocars (eg, open Hasson technique) prevent insufflation leakage. An inflatable balloon on the trocar sheath and a compressed sponge collar form an external seal. (1) * Converterless trocars eliminate the need for adapters or converters when using different diameter instruments. (1) * Built-in flush ports clean instruments of blood and debris. (1) * One-handed control rotation wheels rotate instrument shafts. (1) * Smaller instruments (eg, 2 mm) allow use of miniscopes. (1) Dissection and hemostasis advances * Electrosurgical instruments enhance cutting and hemostatic techniques. * Ultrasonic energy delivered through a vibrating blade creates friction heat that denatures tissue proteins and forms a coagulum. (1) * High-pressure fluid streams deflect accurately to cleave tissue planes. (1) * Warming systems avoid potential hypothermia. (1) * Tripolar cutting forceps have been developed to grasp, coagulate, and transect tissue using bipolar electrosurgery. (1) * Argon beam coagulators have been adapted for laparoscopic hemostasis. (1) * Carbon dioxide lasers are being used for ablation of pulmonary bullae. (2) * Organ entrapment systems have been developed for removal of organs (ie, a plastic and nylon sack can be introduced, opened, and the organ placed inside for retrieval). (3) * Morcellation techniques (ie, fragmenting tissue into small pieces that then are suctioned out through the barrel of a morcellator). (3) Equipment advances * Laparoscopic smoke evacuation has improved visibility. * Digital documentation recorders allow procedures to be recorded. * Digital flat panel monitors provide improved images and more flexibility in mounting positions. * Robotic endoscope holders and positioners provide stability and improved motor control. * Voice activation is used to control devices. * Integrated ORs control the environment through touch-screen technologies. Camera advances * High resolution cameras using digital-signal processing and minimum illumination provide a distortion-free image. (1) * Videotape endoscopes have video chips at the tip, thereby placing the camera in the surgical field. (1) * Three-dimensional endoscopes offer depth perception to facilitate instrument manipulation and accurate internal structure interpretation. (4) (1.) J A Cadeddu et al, "Advances in laparoscopic instrumentation," Contemporary Urology (October 1997) 14-24. (2.) M Benner et al, "Thoracoscopic laser ablation of pulmonary bullae," The Journal of Thoracic and Cardiovascular Surgery 107 (July 1993) 883-890. (3.) D A Urban et al "Organ entrapment and renal morcellation: Permeability studies," The Journal of Urology 150 (December 1993) 1792-1794. (4.) D H Birkett, L G Josephs, J Este-McDonald, "A new 3-D laparoscope in gastrointestinal surgery," Surgical Endoscopy 8 (December 1994) 1448-1451. TABLE 2 Procedural Advances in Endoscopic Minimally Invasive Surgery (MIS) Like other technologies, procedural advances in MIS are ongoing. Improved technology, enables an ever-growing cadre of MIS procedures within surgical specialty areas. The following represent some of the advances in various surgical specialties. General surgery Procedures include mediastinoscopy, an early entry into MIS field; laparoscopic cholecystectomy; appendectomy; small bowel resection; bariatric procedures; gastrectomy; splenectomy; hernia repair; Nissen handoplication; thymectomy; various biopsies; node sampling; and others. * Carbon dioxide insuffiation is the standard for providing visualization of abdominal structures and offering safe pneumoperitoneum. (1) * Gasless laparoscopic procedures are performed to overcome adverse effects of pneumoperitoneum without altering cardiac function. (1) * Abdominal walls can be elevated by means of a subcutaneous lifting system of curved blades suspended from a mechanical arm attached to a rigid pillar. The arm then is elevated as far as necessary to obtain optimal exposure. (2) * Hand-assisted laparoscopic surgery has been introduced for use in laparoscopic-assisted splenectomy and colorectal procedures. The hand can be used as a retractor, dissector, and tactile sensor. (3) Gynecological surgery Initially, diagnostic procedures were performed, but with time, surgical procedures were performed, including abdominal wall lifting, gasless procedures, and robotics. Combination approaches blend the use of laparoscopy and vaginal approaches for taparoscopy-assisted hysterectomy. (4) * Endometrial ablation now is performed via hysteroscopy for menorrhagia. * In the 1980s, methods were developed including neodimium: yttrium-aluminum-garnet (Nd-YAG) laser ablation, transcervical resection of the endometrium, and rollerball electrocoagulation of the endometrium. (5) * In the 1990s, techniques improved, including balloon heating, intrauterine instillation of heated saline, endocnetrial laser thermal therapy using a diode laser, global three-dimensional bipolar ablation, punctual vaporization, photodynamic endometrial ablation, microwave endometrial ablation, radio frequency procedures, menostat, and cryotherapy. Discussion of single methods or comparison of two methods can be found in the literature. (5-8) Orthopedic surgery Procedures began as diagnostic and were limited primarily to the knee. Procedures now are both diagnostic and surgical. Shoulder, elbow, and ankle arthroscopy now are commonplace. Less commonly performed are hip and wrist arthroscopy. (9) * Lasers have been used to shrink stretched capsular tissues of the shoulder. When heated to the appropriate temperature, the tissue contracts. (9) * Articular tissue also can be replaced by various methods, including abrasion arthroplasty; harvesting the patient's own articular cartilage, growing it, and reinjecting it; and mosaicplasty, which consists of taking cores of bone with articular cartilage attached and impacting them into predrilled holes in arthritic areas. (9) Ear, nose, and throat surgery Visualization of the larynx was the first reported procedure. Procedural advances now include tumor removal, polyp removal, encephalocete repair, cerebrospinal fluid leak repair, septal reconstruction, pituitary surgery, and others. (10) * Equipment advances, such as the progression from distally-lighted endoscopes, to telescopic rod lens systems, to flexible fiberoptic systems have led to enhanced visualization. Brushings, washings, and biopsies can be taken from the upper lobes of the lungs. (11) * Microscopically controlled laryngoscopy allows for vocal cord procedures. * Laser surgery allows for precise excision of lesions of the larynx, trachea, and bronchi. (11) * Endoscopic sinus procedures relieve sinus obstruction. (10) Urological surgery Cystoscopy was the first urologic procedure using MIS. Now, this often is performed as an office procedure. Urological MIS procedures now include endoscopic nephrectomy, hand-assisted nephrectomy, and transperitoneal laparoscopic nephrectomy. Additionally, balloon insufflation has been used as a dissection technique in the upper retroperitoneal space allowing for nephrectomy, tumor nephrectomy, nephropexy, renal cyst marsupialization, and renal biopsy. (12) Cardiovascular/thoracic surgery Videotape assistance first was used for closed chest internal mammary artery harvests and congenital heart defect procedures. (13) Videotape-assisted thoracic surgery provides for more complete exploration than traditional mediastinotomy and allows better access for biopsies. * Mitral valve replacement has advanced to using videotape-directed, voice-activated, robotically-controlled cameras. (13) * Computer-enhanced instrumentation allows for endoscopic coronary artery bypass grafting. (14) * The first human laparoscopically-assisted aortobifemoral bypass was completed in 1993. With the development of damps, forceps, and best approaches, the procedure is performed entirely laparoscopically today. (15) * Endoscopic subfascial perforator ligation is performed for chronic venous insufficiency with results similar to open procedures and without the concomitant morbidity and mortality. (16) Plastic surgery * Endoscopically-assisted plastic surgery was introduced in the mid 1980s. (17) * Procedures evolving during the 1990s include forehead lifts, full facelifts, corrugator muscle resection, breast augmentation, carpal tunnel release, reconstructive breast surgeries, facial fracture reduction, and various muscle harvesting procedures. (17) Neurosurgery * The earliest reported endoscopic neurosurgery was performed in 1910 when two children were treated for hydrocephalus by endoscopic coagulation of the choroids plexus. (18) * By 1960, technological advances allowed for additional endoscopic procedures, such as fenestration, biopsy, partial or total removal of cystic lesions; partial or total removal of tumors; evacuation of intracerebral or subdural hematomas; spinal excision of herniated discs; and carpal tunnel release. (18) * Endoscopically-assisted procedures include aneurysm excision and repair, acoustic neuroma removal and transsphenoidal pituitary surgery. (18) (1.) A Vezakis et al. "Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy," Surgical Endoscopy 13 (September 1999) 890-893. (2.) A Alijani, A Cushier. "Abdominal wall lift systems in laparoscopic surgery: Gasless and low pressure systems," Seminars in Laparoscopic Surgery 8 (March 2001) 53-62. (3.) Y Miura et al. "Gasless hand-assisted laparoscopic surgery for colorectal cancer." Diseases of the Colon Rectum 44 (June 2001) 896-898. (4.) M Canestrelli et al. "The new techniques of gynaecologic laparoscopy: Gasless, open Hasson, optic trocar," Pamninerva Medica 41(December 1999) 371-374. (5.) O R Kochli "Endometrial ablation in the year 2000--Do we have more methods than indications?" in Contributions to Gynecology and Obstetrics vol 20 (Basel, Switzerland: Karger, 2000) 90-120. (6.) O Taskin et al, "Long-term histopathologic and morphologic changes after thermal endometrial ablation," Journal of the American Association of Gynecologic Laparoscopists 9 (May 2002) 186-190. (7.) F D Loffer, "Three-year comparison of thermal balloon and rollerball ablation in treatment of menorrhagia," Journal of the American Association of Gynecologic Laparoscopists 8 (February 2001) 48-54. (8.) M Pellicano et al. "Hysteroscopic transcervical endometrial resection versus thermal destruction for menorrhagia: A prospective randomized trial on satisfaction rate," American Journal of Obstetrics and Gynecology 187 (September 2002) 545-550. (9.) G K Miller "Operative arthroscopy into the next century," Comprehensive Therapy 24 (August 1998) 383-387. (10.) D W Kennedy, M Roth, "Functional endoscopic sinus surgery," in Otorhinolaryngology: Head and Neck Surgery, 15th ed, J J Ballenger, J B Snow, eds (Baltimore: Williams & Wilkins, 1996) 173-181. (11.) J B Snow, J A Schild, "Introduction to peroral endoscopy," in Otorhinolaryngology: Head and Neck Surgery, 15 ed, J J Ballenger, J B Snow, eds (Baltimore: Williams & Wilkins, 1996) 1189-1199. (12.) J J Rassweiler et al, "Retroperitoneal laparoscopic nephrectomy and other procedures in the upper retroperitoneum using a balloon dissection technique," European Urology 25 (1994) 229-236. (13.) W R Chitwood, L W Nifong, "Minimally invasive videoscopic mitral valve surgery: The current role of surgical robotics," Journal of Cardiac Surgery. 15 (January/February 2000) 61-75. (14.) V Falk et al, "Total endoscopic off-pump coronary artery bypass grafting," The Heart Surgery Forum 3 (February 2000) 29-31. (15.) Y M Dion, C R Gracia, O Hartung, "Laparoscopic vascular surgery," in Surgical Laparoscopy, second ed, K A Zucker, ed f Baltimore: Lippincott Williams & Wilkins, 2001) 709-719. (16.) W Schum, W S Thomas, "Endoscopic technique for subfascial perforating vein interruption," in Surgical Laparoscopy, second ed, K A Zucker, ed (Baltimore: Lippincott Williams & Wilkins, 2001) 720-726. (17.) P Giovanoli M Frey "The history of endoscopy in plastic and reconstructive surgery up to video assisted microsurgery," in Endoscopy and Microsurgery, M Frey, ed (New York: Springer-Verlag Wein, 2001) 1-4. (18.) J Caemaert "Endoscopic neurosurgery," in Operative Neurosurgical Techniques: Indications, Methods, and Results, vol 1, fourth ed, H Schmidek, ed (Philadelphia: WB Saunders, 2000) 535-570. NOTES

(1.) "Standards of perioperative clinical practice," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 181-183.

(2.) J L Flowers, K A Zucker, R W Bailey, "Complications," in Laparoscopic Surgery, ed G H Ballantyne, P F Leahy, I M Modlin (Philadelphia: WB Saunders, Co, 1994) 78-82.

(3.) K A Ball, "Surgical Modalities," in Alexander's Care of the Patient in Surgery, 12th ed, J C Rothrock, D A Smith, D R McEwen, eds (St Louis: Mosby, 2003) 41-96.

(4.) A J Luck et al, "Core temperature changes during open and laparoscopic colorectal surgery," Surgical Endoscopy 13 (May 1999) 480-483.

(5.) E Berber et al, "Intraoperative thermal regulation in patients undergoing laparoscopic vs open surgical procedures," Surgical Endoscopy 15 (March 2001) 281-285.

(6.) R M Colver, "Laparoscopy: Basic technique, instrumentation, and complications," Surgical Laparoscopy & Endoscopy 2 (March 1992) 3540.

(7.) "Recommended practices for positioning the patient in the perioperative setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 341-346.

(8.) K A Ball "Implementing and evaluation patient care," in Endoscopic Surgery (St Louis: Mosby-Year Book, Inc, 1997) 41-49.

(9.) W A Rutala, 1994-1996 APIC Guidelines Committee "APIC guideline for selection and use of disinfectants," American Journal of Infection Control 24 (August 1996) 313-342.

(10.) "Recommended practices for cleaning and processing endoscopes and endoscope accessories," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 261-266.

(11.) K A Ball "Basic endoscopic equipment," in Endoscopic Surgery (St Louis: Mosby-Year Book, Inc, 1997) 111-139.

(12.) "The patient is on fire! A surgical fires primer," ECRI Health Devices 12 (January 1992) 21.

(13.) "Entry of abdominal fluids into laparoscopic insufflator," ECRI Health Devices 21(May 1992) 181.

(14.) O Istre, "Fluid balance during hysteroscopic surgery," Current Opinions in Obstetrics and Gynecology 9 (August 1997) 219-225.

(15.) R H Harrison, J S Boren, J R Robison, "Dilutional hyponatremic shock: Another concept of the transurethral prostatic resection reaction," Journal of Urology 75 (January 1956) 95-110.

(16.) D Gravenstein "Transurethral resection of the prostrate (TURP) syndrome: A review of the pathophysiology and management," Anesthesia Annals 84 (February 1997) 438-446.

(17.) S L Corson "Hysteroscopic fluid management," The Journal of the American Association Gynecological Laparoscopists 4 (May 1997) 375-379.

(18.) K L Bennett, C Ohrmundt, J A Malone, "Preventing intravasation in women undergoing hysteroscopic procedures," AORN Journal 64 (November 1996) 792-799.

(19.) K B Isaacson, "Complications of hysteroscopy," Obstetrics and Gynecology Clinics of North America 26 (March 1999) 39-51.

(20.) D M Morrison, "Management of hysteroscopic surgery complications," AORN Journal 69 (January 1999) 194-209.

(21.) F D Loffer et al, "Hysteroscopic fluid monitoring guidelines," The Journal of American Association of Gynecological Laparoscopists 7 (February 2000) 167-168.

(22.) R C Odell, "Electrosurgery principles and safety issues," Clinical Obstetrics and Gynecology 38 (September 1995) 610-621.

(23.) S Rohlf, "Electrosurgical safety considerations for minimally invasive surgery," Minimally Invasive Surgical Nursing 9 (Spring 1995) 26-29.

(24.) R D Tucker, C R Voyles, "Laparoscopic electrosurgical complications and their precautions," AORN Journal 62 (July 1995) 51-71.

(25.) W Ming-Ping et al, "Complications and recommended practices for electrosurgery in laparoscopy," American Journal of Surgery 179 (January 2000) 67-73.

(26.) "Recommended practices for standard and transmission-based precautions in the perioperative practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 361-366.

(27.) K A Ball, "Care and maintenance of instruments," in Endoscopic Surgery (St Louis: Mosby-Year Book, Inc, 1997) 83-110.

(28.) "Recommended practices for electrosurgery," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 245-260.

(29.) "Recommended practices for laser safety in practice settings," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 319-324.

(30.) "Recommended practices for cleaning and caring for surgical instruments and powered equipment," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 309-317.

(31.) T G Vancaillie, "Electrosurgery at laparoscopy: Guidelines to avoid complications," Gynaecological Endoscopy 3 (Spring 1994) 143-150.

(32.) K A Ball, "Endoscopic instruments," in Endoscopic Surgery (St Louis: Mosby-Year Book, Inc, 1997) 51-82.

(33.) K Ornate et al, "Self-guided robotic camera control for laparoscopic surgery compared with human camera control," The American Journal of Surgery 177 (April 1999) 321-324.

(34.) "Recommended practices for documenting perioperative nursing care," in Standards, Recommended Practices, and Guidelines (Denver: AORN Inc, 2004) 241-243.

(35.) S C Beyea, ed, Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary, second ed (Denver: AORN, Inc, 2002).

(36.) "Quality improvement standards for perioperative nursing," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 187-196.

(37.) US Food and Drug Administration, "Medical devices; Device tracking: Final rule and request for comments," Federal Register 58 (Aug 16, 1993) 43442-43450.

(38.) M A Heller, Guide to Medical Device Regulation, vol 2 (Washington DC: Thompson Publishing, 1998) Appendix 2000; 366.

(39.) "Standards for privacy of individually identifiable health information; Final rule," Federal Register 164 (Aug 14, 2002) 53183-53273.

RESOURCES

Ballantyne, G H. Atlas of Laparoscopic Surgery (Philadelphia: WB Saunders, 2000).

Eubanks, S; Swanstrom, L. Mastery of Endoscopic and Laparoscopic Surgery (Philadelphia: Lippincott Williams & Wilkins, 2000).

Talamini, M. Advances in Minimally Invasive Surgery! (Philadelphia: Lippincott Williams & Wilkins, 2001).

Zucker, K. Surgical Laparoscopy, second ed, K A Zucker, ed (Baltimore: Lippincott Williams & Wilkins, 2001).