Fundamentals of the Perioperative Environment for Registered Nurses

Anesthesia-Related Risks and Considerations during MIS

Three main goals of anesthesia during MIS:

  1. Respiratory stability
  2. Appropriate muscle relaxation
  3. Hemodynamic stability

Some other considerations include:

  1. Trendelenburg positioning can cause intra-abdominal pressure to increase.
  2. Reverse Trendelenburg used in some laparoscopic cases can cause problems, as well. Venous pooling can occur causing decreased venous return, decreased cardiac output, and hypotension.
  3. High pressure of CO2 can cause CO2 gas emboli which could lead to circulatory collapse.
  4. Increased intra-abdominal pressures can cause hypertension which can result in excess bleeding.

(Ball, 2019)

Electrocautery Risks During MIS

During MIS procedures, there is a unique risk of internal burns to a patient including:

Direct Coupling occurs when an electrosurgical device is activated and accidentally touches a metal instrument that is not insulated. The energy can create a spark or flow up the metal instrument and cause a burn to any tissue touching it that is not protected. This can also happen if the surgeon activates the electrosurgical device and touches a metal clip resulting in a burn.

To avoid this, surgeons must only activate an electrosurgical device once they have the target tissue in proximity.

The following are components of an MIS using a laparoscope (select the + hotspots in the image to reveal information):

Capacitive Coupling

This can happen when energy is transferred through intact insulation of instruments to nearby materials or objects that are conductive. For this to occur, there need to be two conductors separated by an insulator which could be an organ, a conductive trocar or suction.

Insulation failure:

  1. Laparoscopic instruments have a coating to insulate them, protecting tissue that may contact the shaft when using electrosurgical energy.
  2. If the coating is cracked or nicked, this can expose metal within the shaft. When electrosurgical energy travels down the shaft, it takes the quickest path to be grounded which could mean exiting the exposed metal and causing a burn.
  3. Because of the increased risk of internal burns, it is vital to inspect laparoscopic instruments to ensure the protective insulation layers are intact and no damage to the outer coating is present.
Other Risks of MIS

One of the biggest considerations when performing MIS is that there is always the potential of converting to an open procedure. Reasons for this include difficulty visualizing, manipulating, or accessing the surgical site, as well as unexpected bleeding.

Because of this, the scrub nurse should always have minimal basic ‘open’ instrumentation on the sterile field, and the circulating nurse should always be prepared with further instrumentation and equipment.

Major surgical counts are always performed at the initial count in case a ‘convert-to-open’ surgery occurs.

(Ball, 2019)