AORN JOURNAL
DECEMBER 1992, VOL 56, NO 6
Laparoscopic Colotomy, Polypectomy INNOVATIVE MINIMALLY INVASIVE PROCEDURE
Lynne M. Zuro, RN; Catherine S. McCulloch, RN; Theodore J. Saclarides, MD
A
s surgeons become more familiar with laparoscopic instrumentation, innova.the minimally invasive procedures are replacing traditional surgical approaches. The limitations of minimal access surgical procedures are unknown, but it is likely that this technique will continue to be the forerunner in general surgery. Laparoscopic colotomy and polypectomy is an example of new innovative minimal access procedures.
Etiology, Treatment
C
olorectal polyps are usually benign, but there is considerable evidence supporting their premalignant nature.’ For this reason, polyps usually are removed when discovered. There are two kinds of polyps: pedunculated polyps have a stalk or pedicle; sessile polyps are broad-based and lack a stalk. Polyps can bleed very easily and can cause occult or profuse bleeding. Depending on size. location. and morpholo-
Lynne M . Zuro, RN, BSN, is a staff nurse in the operating i.ooni at Rush-Presbyterian-St Luke’s Medical Center, Chicago. She received her bachelor- of science degree in rnrrsing fiom Northwlestern Utiiivrsity. Chicago. Catherine S . McCulloch, RN, M S , is adniinistrative director of surgical seri’ices at Rush North Shore Medical Center, Skokie, Ill. She rec-eiied her. bachelor of science degree in nursI068
gy. polyps may be removed by a colonoscope or sigmoidoscope using a snare with cautery capability.? If a polyp is too large to remove by endoscopy, or if angulation and looping of the colon inhibit safe passage of the endoscope, the polyp is removed via exploratory laparotomy and a colon resection or colotomy and polypectomy. Laparoscopic removal of colon polyps provides an alternative to laparotomy for patients with colonic polyps not amenable to colonoscopic removal.
Preoperative Care, Teachirig
T
he patient is admitted to the hospital the day before scheduled surgery for a polypropylene glycol bowel lavage. The physician orders preoperative prophylactic oral and IV antibiotic medications to minimize the potential for postoperative infection. After admission to the hospital, the patient receives a clear liquid diet and takes nothing by mouth after midnight.
ing f r o m Catholic University of A m e r i c a , Washington, DC, and her master’s degree in nursing administration from the University of Illinois, Chicago. Theodore J . Saclarides, MD, is attending surgeon in the department of general surgery, RushPresbyter-ian-St Luke’s Medical Center, Chicago. H e received his doctor of medicine degree,fiom fhr Uniiiersity of Miami School of Medicine.
DECEMBER 1992, VOL 56, NO 6
AORN JOURNAL
The nurse discusses turning, coughing, and deep-breathing exercises, as well as the use of antithrombotic stockings and sequential compression devices for the patient’s legs, with the patient preoperatively. He or she also informs the patient about ambulation and the use of postoperative pain medications. Preoperatively. the nurse also describes the operating room, equipment, and procedures that may occur upon the patient’s arrival in the operating r o o m . T h e p e r i o p e r a t i v e n u r s e answers the patient’s questions or refers him or her to the appropriate resources. The perioperative nurse’s expertise and surgical knowledge can help alleviate the patient’s fears and concerns about the pending surgery.
Operutiq Room Psepurution
P
reparing the operating room for a laparoscopic colon polypectomy requires teamwork and good organizational skills. If possible, two circulating nurses should be assigned to the case. An exploratory laparotomy setup is required for all laparoscopic or minimal access procedures in the event that the surgery progresses to an exploratory laparotomy. The setup for an open procedure includes major abdominal instruments and retractors, laparotomy sponges, sterile towels, a needle board, a #10 scalpel blade, and a basin. The scope setup and the sterile laparotomy setup are combined on the back table to ensure easy accessibility of all instruments if the laparoscopic procedure evolves into an open procedure (Table 1). Other items needed for this case include an operating room bed with x-ray capability (Carm fluoroscopy is not necessary). If the procedure converts to an exploratory laparotomy, an x-ray may be needed if the counts are incorrect or if the general surgeon or anesthesiologist considers it necessary. A flexible sigmoidoscopy setup is required at the beginning of the l a p a r o s c o p i c c o l o n polypectomy and is used throughout the procedure. This equipment is set up by the circulating nurse on a separate back table using clean 1U70
technique. Two video cabinets (which house the television [TV] monitors), a videocassette recorder, insufflator, camera, xenon light source, and printer also are needed (Fig 1). The video cabinets are placed on opposite sides of the operating room bed at the head of the bed, which enables the surgical team to have an unobstructed view of the TV screens during the laparoscopic procedure. Stirrups, elastic bandages, and unsterile cotton fluff pads are needed to place the patient in the lithotomy position. The stirrups should be easily adjustable and should not put pressure on the popliteal fossa or lateral aspect of the patient’s lower leg. The circulating nurse checks all equipment preoperatively for proper functioning. It is important that the circulating nurse verify that there is adequate carbon dioxide in the insufflator tank. If there i s not, t h e tank must be changed before the start of any laparoscopic procedure. Medications used for this procedure include 1 L of normal saline containing 1,000 units of heparin, 1 L of antibiotic irrigation for the abdominal cavity, and 1 L of antibiotic irrigation for the colon during the flexible sigmoidoscopic examination. The heparinized saline decreases the potential for blood clots that may obstruct the small lumens of the endoscopic instruments. A pressure bag is used during the procedure to deliver the irrigating solution to the abdominal cavity at a high flow rate.
Intruoperutive Cure
W
hen the circulating nurse transports the patient to the operating room, he or she introduces the patient to the surgical staff and orients the patient to the unfamiliar surroundings. The nurse checks the patient’s identity, allergies, and NPO status. He or she reviews the surgical consent and inspects the patient’s skin integrity. The nurse checks the chart for laboratory results, a chest x-ray report, and a copy of the patient’s electrocardiogram. The nurse assists the patient initially into the
AORN JOURNAL
DECEMBER 1992, VOL 56, NO 6
Table 1
Laparoscopic Colon Polypectomy Setup Laparoscopic instrumentation assorted grasping forceps dissecting forceps needle holders probe suctionlirrigator hook dissector spatula 10-mm, zero-degree; 10-mm, 30-degree; 5-mm, zero-degree telescopes light source cord camera CO, tubing one 5-mm, two lO-mm, one 12-mm disposable trocars automatic suture disposable stapler Additional instruments eight curved peon clamps four Kelly clamps two mosquitos two mixters two Adson clamps two Kochers one heavy toothed tissue forceps one straight, one curved Mayo scissor one Metzenbaum scissor one Rochester needle holder two Webster needle holders two Senns, two Army-Navy retractors four large towel clips
supine position and tucks both arms to the patient’s side. Long antithrombotic hose, as well as sequential compression devices, are placed on the patient’s lower legs. The nurse places a warm blanket over the patient’s skin and secures a safety strap across his or her thighs. Anesthesia personnel induce and intubate the patient with the nurse’s help. A nasogastric tube is inserted. The nurse inserts a urinary catheter. The surgical team then places the
two Adson tissue forceps with teeth one Hays-Martin tissue forceps
Supplies for procedure Mayo stand cover mineral oil four paper gowns, appropriate gloves sterile marking pen two #15 blades 4 x 4 sponges 10-mL syringes irrigator-aspirator defogger hot water sterile pitcher metal ware suction tubing Yankauer suction tip electrocautery cord sterile adhesive bandages sterile 4 x 4 dressing prep sponges 114-inch adhesive wound approximating strips cutting suture, gastrointestinal suture disposable endo-GIA stapler or automatic suture Draping material laparotomy sheet, half sheet towels povidone-iodine impregnated adhesive drape (small) sterile leg covers
patient in the lithotomy position and secures his or her legs in the stirrups, taking care to protect them from injury. Elastic bandages are used to anchor the patient’s legs securely in the stirrups. The lithotomy position is used to ensure access to the rectum via the flexible sigmoidoscope throughout most of the procedure. An electrosurgical dispersive pad is applied to the patient’s thigh, and the nurse shaves the patient’s abdomen. 1071
AORN JOURNAL
Fig 1. Video monitor cabinet contains (top to botrom) television monitor, camera, insufflator, light source, videocassette recorder, printer, CO, tank.
DECEMBER 1992, VOL 56, NO 6
Fig 2 . Disposable automatic suture instruments include (top to bottom) ruler; endoclip applier; 12-mm, 10-mm, 5-mm trocars; surgiclips, two Verres needles; 5.5,4.5,3.5 converters.
Fig 3. Endo-GIA stapler used in procedure.
Fig 4. Instrumentation used in laparoscopic procedure (top to bottom): Verres needle; 10-mm, 5-mm trocars; telescope; microscissors; grasping forceps; straight scissors; irrigator; aspirator; clip applier; hook dissector; spatula; electrocautery cords. 1072
AORN JOURNAL
DECEMBER 1992, VOL 56, NO 6
During the initial flexible sigmoidoscopy, the surgeon irrigates the patient’s colon with the antibiotic solution. He or she uses a laparotomy sheet to drape the patient and creates pockets on either side of the operative field so cords and tubing can be secured into position. The circulating nurse attaches irrigator-aspirator tubing to the heparinized saline solution in the inflated pressure bag. The disposable (or reusable, depending on the surgeon’s preferences) items needed for this procedure include a single 5-mm trocar, as well as three 10-mm trocars and a single 12-mm trocar (Fig 2). A stapler (Fig 3), which fits through the 12-mm trocar sleeve, is part of the setup (Fig 4). The telescope is placed in a pitcher of hot sterile water to aid in defogging the lens. The scrub nurse places a towel in the bottom of the pitcher to avoid any potential damage to the lens tip.
Surgical Procedure
T
h e s u r g e o n inserts a 1 0 - m m trocar through an umbilical incision and then inserts a 12-mm trocar through a suprapubic incision. He or she inserts 10-mm trocars through left upper and left lower quadrant incisions. The sigmoidoscopist localizes the lesion for the laparoscopist by transilluminating the bowel wall at the site of the lesion. Because the sigmoidoscope is clean, not sterile, the surgical team must adhere to sterile technique when m o v i n g from t h e s i g m o i d o s c o p e t o t h e abdomen. The patient’s lithotomy position and the positioning of the drape sheets create a barrier between the sigmoidoscopy and abdominal areas. The surgeon creates a 3-cm transverse colotomy using electrocautery and extracts the mass through this incision into the abdominal cavity. He or she excavates the mass from its submucosal location until a narrow mucosal pedicle remains. This i s transected by the stapling device. Using the sigmoidoscope as an internal stent, the surgeon uses the stapler to close the colotomy. This must be accomplished without
narrowing the bowel lumen. The surgeon irrigates the left lower quadrant of the abdomen with antibiotic solution and places a drain in the pelvis after removing the scope and trocar sheaths.
Conclusion
I
nnovative laparoscopic or minimally invasive procedures continuously are being developed and evaluated. T h e range of operations that ultimately may be performed through the laparoscope is not yet known. Laparoscopic colotomy a n d polypectomy demonstrates this trend. General surgery perioperative nurses are in a key position to share and expand their knowledge of this new field. By doing so, their efforts to maintain excellence in quality patient care will continue. D
Notes 1. G C Vitale, J S Spratt, “The adenoma-carcinoma sequence: An update,” Problems in General Surgery 4 (March 1987) 24-38. 2. J A Coller, M L Corman, M C Veidenheimer, “Diagnostic and therapeutic applications of fiberoptic colonoscopy,” Geriatrics 29 (October 1974) 6773.
DECEMBER 1992, VOL 56, NO 6
Laparoscopic Colotomy, Polypectomy INNOVATIVE MINIMALLY INVASIVE PROCEDURE
Lynne M. Zuro, RN; Catherine S. McCulloch, RN; Theodore J. Saclarides, MD
A
s surgeons become more familiar with laparoscopic instrumentation, innova.the minimally invasive procedures are replacing traditional surgical approaches. The limitations of minimal access surgical procedures are unknown, but it is likely that this technique will continue to be the forerunner in general surgery. Laparoscopic colotomy and polypectomy is an example of new innovative minimal access procedures.
Etiology, Treatment
C
olorectal polyps are usually benign, but there is considerable evidence supporting their premalignant nature.’ For this reason, polyps usually are removed when discovered. There are two kinds of polyps: pedunculated polyps have a stalk or pedicle; sessile polyps are broad-based and lack a stalk. Polyps can bleed very easily and can cause occult or profuse bleeding. Depending on size. location. and morpholo-
Lynne M . Zuro, RN, BSN, is a staff nurse in the operating i.ooni at Rush-Presbyterian-St Luke’s Medical Center, Chicago. She received her bachelor- of science degree in rnrrsing fiom Northwlestern Utiiivrsity. Chicago. Catherine S . McCulloch, RN, M S , is adniinistrative director of surgical seri’ices at Rush North Shore Medical Center, Skokie, Ill. She rec-eiied her. bachelor of science degree in nursI068
gy. polyps may be removed by a colonoscope or sigmoidoscope using a snare with cautery capability.? If a polyp is too large to remove by endoscopy, or if angulation and looping of the colon inhibit safe passage of the endoscope, the polyp is removed via exploratory laparotomy and a colon resection or colotomy and polypectomy. Laparoscopic removal of colon polyps provides an alternative to laparotomy for patients with colonic polyps not amenable to colonoscopic removal.
Preoperative Care, Teachirig
T
he patient is admitted to the hospital the day before scheduled surgery for a polypropylene glycol bowel lavage. The physician orders preoperative prophylactic oral and IV antibiotic medications to minimize the potential for postoperative infection. After admission to the hospital, the patient receives a clear liquid diet and takes nothing by mouth after midnight.
ing f r o m Catholic University of A m e r i c a , Washington, DC, and her master’s degree in nursing administration from the University of Illinois, Chicago. Theodore J . Saclarides, MD, is attending surgeon in the department of general surgery, RushPresbyter-ian-St Luke’s Medical Center, Chicago. H e received his doctor of medicine degree,fiom fhr Uniiiersity of Miami School of Medicine.
DECEMBER 1992, VOL 56, NO 6
AORN JOURNAL
The nurse discusses turning, coughing, and deep-breathing exercises, as well as the use of antithrombotic stockings and sequential compression devices for the patient’s legs, with the patient preoperatively. He or she also informs the patient about ambulation and the use of postoperative pain medications. Preoperatively. the nurse also describes the operating room, equipment, and procedures that may occur upon the patient’s arrival in the operating r o o m . T h e p e r i o p e r a t i v e n u r s e answers the patient’s questions or refers him or her to the appropriate resources. The perioperative nurse’s expertise and surgical knowledge can help alleviate the patient’s fears and concerns about the pending surgery.
Operutiq Room Psepurution
P
reparing the operating room for a laparoscopic colon polypectomy requires teamwork and good organizational skills. If possible, two circulating nurses should be assigned to the case. An exploratory laparotomy setup is required for all laparoscopic or minimal access procedures in the event that the surgery progresses to an exploratory laparotomy. The setup for an open procedure includes major abdominal instruments and retractors, laparotomy sponges, sterile towels, a needle board, a #10 scalpel blade, and a basin. The scope setup and the sterile laparotomy setup are combined on the back table to ensure easy accessibility of all instruments if the laparoscopic procedure evolves into an open procedure (Table 1). Other items needed for this case include an operating room bed with x-ray capability (Carm fluoroscopy is not necessary). If the procedure converts to an exploratory laparotomy, an x-ray may be needed if the counts are incorrect or if the general surgeon or anesthesiologist considers it necessary. A flexible sigmoidoscopy setup is required at the beginning of the l a p a r o s c o p i c c o l o n polypectomy and is used throughout the procedure. This equipment is set up by the circulating nurse on a separate back table using clean 1U70
technique. Two video cabinets (which house the television [TV] monitors), a videocassette recorder, insufflator, camera, xenon light source, and printer also are needed (Fig 1). The video cabinets are placed on opposite sides of the operating room bed at the head of the bed, which enables the surgical team to have an unobstructed view of the TV screens during the laparoscopic procedure. Stirrups, elastic bandages, and unsterile cotton fluff pads are needed to place the patient in the lithotomy position. The stirrups should be easily adjustable and should not put pressure on the popliteal fossa or lateral aspect of the patient’s lower leg. The circulating nurse checks all equipment preoperatively for proper functioning. It is important that the circulating nurse verify that there is adequate carbon dioxide in the insufflator tank. If there i s not, t h e tank must be changed before the start of any laparoscopic procedure. Medications used for this procedure include 1 L of normal saline containing 1,000 units of heparin, 1 L of antibiotic irrigation for the abdominal cavity, and 1 L of antibiotic irrigation for the colon during the flexible sigmoidoscopic examination. The heparinized saline decreases the potential for blood clots that may obstruct the small lumens of the endoscopic instruments. A pressure bag is used during the procedure to deliver the irrigating solution to the abdominal cavity at a high flow rate.
Intruoperutive Cure
W
hen the circulating nurse transports the patient to the operating room, he or she introduces the patient to the surgical staff and orients the patient to the unfamiliar surroundings. The nurse checks the patient’s identity, allergies, and NPO status. He or she reviews the surgical consent and inspects the patient’s skin integrity. The nurse checks the chart for laboratory results, a chest x-ray report, and a copy of the patient’s electrocardiogram. The nurse assists the patient initially into the
AORN JOURNAL
DECEMBER 1992, VOL 56, NO 6
Table 1
Laparoscopic Colon Polypectomy Setup Laparoscopic instrumentation assorted grasping forceps dissecting forceps needle holders probe suctionlirrigator hook dissector spatula 10-mm, zero-degree; 10-mm, 30-degree; 5-mm, zero-degree telescopes light source cord camera CO, tubing one 5-mm, two lO-mm, one 12-mm disposable trocars automatic suture disposable stapler Additional instruments eight curved peon clamps four Kelly clamps two mosquitos two mixters two Adson clamps two Kochers one heavy toothed tissue forceps one straight, one curved Mayo scissor one Metzenbaum scissor one Rochester needle holder two Webster needle holders two Senns, two Army-Navy retractors four large towel clips
supine position and tucks both arms to the patient’s side. Long antithrombotic hose, as well as sequential compression devices, are placed on the patient’s lower legs. The nurse places a warm blanket over the patient’s skin and secures a safety strap across his or her thighs. Anesthesia personnel induce and intubate the patient with the nurse’s help. A nasogastric tube is inserted. The nurse inserts a urinary catheter. The surgical team then places the
two Adson tissue forceps with teeth one Hays-Martin tissue forceps
Supplies for procedure Mayo stand cover mineral oil four paper gowns, appropriate gloves sterile marking pen two #15 blades 4 x 4 sponges 10-mL syringes irrigator-aspirator defogger hot water sterile pitcher metal ware suction tubing Yankauer suction tip electrocautery cord sterile adhesive bandages sterile 4 x 4 dressing prep sponges 114-inch adhesive wound approximating strips cutting suture, gastrointestinal suture disposable endo-GIA stapler or automatic suture Draping material laparotomy sheet, half sheet towels povidone-iodine impregnated adhesive drape (small) sterile leg covers
patient in the lithotomy position and secures his or her legs in the stirrups, taking care to protect them from injury. Elastic bandages are used to anchor the patient’s legs securely in the stirrups. The lithotomy position is used to ensure access to the rectum via the flexible sigmoidoscope throughout most of the procedure. An electrosurgical dispersive pad is applied to the patient’s thigh, and the nurse shaves the patient’s abdomen. 1071
AORN JOURNAL
Fig 1. Video monitor cabinet contains (top to botrom) television monitor, camera, insufflator, light source, videocassette recorder, printer, CO, tank.
DECEMBER 1992, VOL 56, NO 6
Fig 2 . Disposable automatic suture instruments include (top to bottom) ruler; endoclip applier; 12-mm, 10-mm, 5-mm trocars; surgiclips, two Verres needles; 5.5,4.5,3.5 converters.
Fig 3. Endo-GIA stapler used in procedure.
Fig 4. Instrumentation used in laparoscopic procedure (top to bottom): Verres needle; 10-mm, 5-mm trocars; telescope; microscissors; grasping forceps; straight scissors; irrigator; aspirator; clip applier; hook dissector; spatula; electrocautery cords. 1072
AORN JOURNAL
DECEMBER 1992, VOL 56, NO 6
During the initial flexible sigmoidoscopy, the surgeon irrigates the patient’s colon with the antibiotic solution. He or she uses a laparotomy sheet to drape the patient and creates pockets on either side of the operative field so cords and tubing can be secured into position. The circulating nurse attaches irrigator-aspirator tubing to the heparinized saline solution in the inflated pressure bag. The disposable (or reusable, depending on the surgeon’s preferences) items needed for this procedure include a single 5-mm trocar, as well as three 10-mm trocars and a single 12-mm trocar (Fig 2). A stapler (Fig 3), which fits through the 12-mm trocar sleeve, is part of the setup (Fig 4). The telescope is placed in a pitcher of hot sterile water to aid in defogging the lens. The scrub nurse places a towel in the bottom of the pitcher to avoid any potential damage to the lens tip.
Surgical Procedure
T
h e s u r g e o n inserts a 1 0 - m m trocar through an umbilical incision and then inserts a 12-mm trocar through a suprapubic incision. He or she inserts 10-mm trocars through left upper and left lower quadrant incisions. The sigmoidoscopist localizes the lesion for the laparoscopist by transilluminating the bowel wall at the site of the lesion. Because the sigmoidoscope is clean, not sterile, the surgical team must adhere to sterile technique when m o v i n g from t h e s i g m o i d o s c o p e t o t h e abdomen. The patient’s lithotomy position and the positioning of the drape sheets create a barrier between the sigmoidoscopy and abdominal areas. The surgeon creates a 3-cm transverse colotomy using electrocautery and extracts the mass through this incision into the abdominal cavity. He or she excavates the mass from its submucosal location until a narrow mucosal pedicle remains. This i s transected by the stapling device. Using the sigmoidoscope as an internal stent, the surgeon uses the stapler to close the colotomy. This must be accomplished without
narrowing the bowel lumen. The surgeon irrigates the left lower quadrant of the abdomen with antibiotic solution and places a drain in the pelvis after removing the scope and trocar sheaths.
Conclusion
I
nnovative laparoscopic or minimally invasive procedures continuously are being developed and evaluated. T h e range of operations that ultimately may be performed through the laparoscope is not yet known. Laparoscopic colotomy a n d polypectomy demonstrates this trend. General surgery perioperative nurses are in a key position to share and expand their knowledge of this new field. By doing so, their efforts to maintain excellence in quality patient care will continue. D
Notes 1. G C Vitale, J S Spratt, “The adenoma-carcinoma sequence: An update,” Problems in General Surgery 4 (March 1987) 24-38. 2. J A Coller, M L Corman, M C Veidenheimer, “Diagnostic and therapeutic applications of fiberoptic colonoscopy,” Geriatrics 29 (October 1974) 6773.
