LESSON 8: Perioperative Nursing 1 (LO-HLTH8155)

SURGICAL MODALITIES

REQUIRED TEXT:

Alexander’s Care of the Patient in Surgery, 17th Edition, Chapter 8

LESSON INTRODUCTION:

This lesson will examine the surgical modalities that are common in the OR
today. In the upcoming chapters, the textbook describes many of the different
surgical procedures in both the traditional approach and MIS approach when
applicable. It is an exciting time in the world of perioperative nursing. As
technology advances and newer methods are discovered, surgical procedure time
is lessened, outcomes are more favourable for patients and wait times often
shortened. As perioperative nurses, we must understand the traditional surgical
techniques before we can appreciate the newer surgical methods. We are
expected to have a working knowledge of these modalities, to be able to
implement their use in a safe effective manner and to be aware of the
responsibilities associated with each one.

LEARNING OBJECTIVE:

Upon successful completion of this lesson the student will:

• Define the term MIS or Minimally Invasive Surgery
• Understand the basic equipment used, the care of the equipment and the
nursing responsibilities associated with the use of this equipment
• Identify the various types of endoscopes available and the basic
components of a rigid and flexible endoscope
• Describe basic laparoscopic instrumentation
• Describe the cleaning and disinfection of endoscopes and instrumentation
• Be aware of potential complications that can arise during laparoscopic
surgery
• Understand the use of lasers at the novice level
• Understand the use of electrocautery and the nursing responsibilities
associated with this equipment

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MINIMALLY INVASIVE SURGERY:

• Less invasive surgery methods result in decreased hospital and recovery

time for the patient
• From the 1990’s this area of perioperative nursing has continued to be a
rapidly growing and ever-evolving area
• It offers great challenges in learning and performing for both the
perioperative nurse and the surgeon
• Commonly referred to as laparoscopic and endoscopic procedures

RESPONSIBILITIES OF THE PERIOPERATIVE NURSE WOULD INCLUDE:

• Skill and knowledge in the use, maintenance, function of the equipment
• Ensuring disposable, reusable and multi-use instruments are used in the
proper manner
• Is knowledgeable in the correct assembly and use of the instruments
• ID Number for each piece of endoscopic equipment is assigned
• Video monitors are securely installed and visible to the team
• Ensuring that a preventative maintenance program is in place
• Ensuring that a brief description of the operating instructions is readily
available and attached to the equipment in the OR
• Documentation of equipment used

TYPES of EQUIPMENT and RELATED NURSING RESPONSIBILITIES:

Insufflators
• New single-use filter for the insufflator is provided for each case- a 2-way
filter is used to protect the patient from contaminants in the tank as well as
protection from organisms that colonize in the insufflator itself
• The insufflator tubing is flushed with gas prior to connection to the cannula
• Elevated above the level of the operative site
• Disconnect tubing from insufflator before turning off
• Second supply of gas is readily available
• What is the practice of insufflation? The patient is placed in
trendelenberg position to reduce the risk of perforation of internal organs.
A pneumoperitoneum is created to help visualize the abdominal structures.
An incision is made at the belly button through which a Verres needle or
Hasson trocar is inserted. The insufflation tubing can be connected to the
Verres needle or Hasson trocar once placement into the abdominal cavity
is confirmed. Carbon dioxide gas is used. This gas is used because it is
non-combustible, can be absorbed without serious adverse effect and is
cost-effective. The peritoneal cavity is filled with carbon dioxide to allow
safe visualization and manipulation of the abdominal or pelvic contents.
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 The flow rate is slow at first and then once placement is verified can be
increased to up to 9 L/min. Intraabdominal pressure should be maintained
between 14 and 16 mmHg.
• Information that should be visible on the insufflation unit: Rate of flow,
volume delivered and intraabdominal pressure
• Avoid OVERPRESSURIZATION as this increases risk to patient of: 1)
hypercarbia or elevated carbon dioxide levels in the blood-these elevations
would be detected by an end-tidal CO2 monitor. 2) decreases intrathoracic
space causing decreased cardiac and respiratory output. 3) increased
pressure on the diaphragm which could cause vomiting, regurgitation of
stomach contents and increased risk of aspiration
• Due to irritation of the phrenic nerve from the carbon dioxide the patient
may experience postoperative shoulder, neck and sub scapular pain
• At the conclusion of the procedure, some surgeons will leave one trocar in
place and push on the abdomen to facilitate the expulsion of as much
carbon dioxide as possible

The perioperative nurse will:

• Verify that the gas being used is medical grade carbon dioxide
• Flush the insufflator and tubing before attaching to Verres needle or
Hasson trocar and infusing into the patient
• Use a two-way filter
• Ensure that a second tank of carbon dioxide is readily available-monitor
usage
• Disconnect tubing before turning insufflator off

ESU
• Ensure that all cannulas are either all metal or all plastic. No combination
of the two are to be used.
• It is set at the lowest possible setting to achieve desired outcome.
• Ensure that inspection of the electrodes pre and post procedure is
completed

Lighting Source
• Decrease power prior to turning off
• Ensure that all endoscopic light cords are turned off or in stand-by mode
when not attached to the telescope
• Ensure that after procedure the disconnected ends are kept away from
contact with the drapes, the patient or any flammable fluids as they are
very hot and can cause fires and/or burns

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 • COLD LIGHT SOURCE- the heat of the light source is not transferred
along the telescope therefore there is minimal tissue damage to tissue at
the end of the scope
• Handle fiberoptic cords with great care as they contain hundreds of glass
fibers that aid in light transmission and can easily be damaged
• Recognizing that the cord should be checked for damage prior to use. Hold
one end of the cord towards a bright light source and observe the opposite
end for transmission of light. Do not use the actual light source and look
directly at the end of the cord as this may cause damage to your eyes.
• Be able to change the bulb in the actual light source and ensure that
proper bulbs are readily available
• Understand the procedure to WHITE BALANCE the scope. This allows the
camera to use white as a reference and therefore be able to identify all
primary colors properly. Connect light source to telescope. Turn light
source on, hold lens close to a white gauze and wait for the machine to
signal that white balancing has been successfully completed. This should
be done at the start of every procedure.

ENDOSCOPES
• A tube that can be inserted into a natural body orifice or tiny incision to
access internal organs or structures

Types of Endoscopes:

Flexible
• Allows for panoramic visualization
• Has four parts-control body, insertion tube, bending section at distal end,
and light guide connector
• Examples- bronchoscope, cystoscope, colonoscope, gastroscope

Nursing Responsibilities for Flexible Endoscopes

• Thorough inspection prior to use:
1) the control section for loose parts, irregularities
2) angulations knob- is it working
3) boot and tube for cracks, dents, holes, bulges
4) lens for scratches, chips, cracks, stains
5) the entire length of the insertion tube is free from rough edges or
projecting objects
• Understanding and compliance with correct method of pre-cleaning and
cleaning the endoscope
• Training should comply with the Canadian Society of Gastroenterology
Nurses Association and CSA Standards
• Leak-testing following each procedure

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 • Documentation-patient’s name, record number, procedure performed, date
and time, person performing procedure and present for the procedure and
the flexible endoscope serial number

Rigid
• Four parts-eyepiece, body, shaft, and distal end which houses the lens
• Can allow direct vision as in a zero degree scope or angled view i.e. 30, 70
degree
• Examples- hysteroscope, cystoscope, laparoscopes

Semi- Rigid
• Example- Ureteroscope
• Some movement, remains fairly rigid

Diagnostic
• For observation only, no operating channel
• Sealed at both ends
• Example- diagnostic hysteroscope

Operative
• Channeled for irrigating, suctioning, inserting and connecting accessory
instrumentation
• Example- operative hysteroscope

Videoscopes
• A video chip at the distal end of the scope provides the image, which is
directly viewed on a monitor.

ENDOSCOPIC INSTRUMENTATION:

Trocars and Cannulas

• Allow for creation of new orifice
• Cannula (sheath) along with trocar is inserted to access operative site
• Trocar removed once orifice is made and the cannula remains for duration
of the operation
• Different sizes according to type of operation and instrumentation to be
used

Dissecting Instruments
• Cut, divide or separate tissue
• Ends of endoscopic instruments use the design of open procedure
instruments
• Tips are the operative section of the endoscopic instruments

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 • Ensure you can see the tips of the instruments on the television screen to
avoid damage
• Endoscopic scissors can be straight or curved (hook scissors,
metzenbaums, mayo)
• Choice of instrument depends on tissue being operated on
• Tips usually blunt to allow for dissection while the jaws are closed
• May have an electrocautery connection site to allow for coagulation in
combination with the cutting
• Dissectors can separate and divide tissue, many different tips according to
use

Clamping Instruments
• Graspers, forceps and biopsy forceps
• Grasp and hold tissue or other materials
• Ratchets allow for locking of the instrument onto tissue or whatever is to be
grasped
• Graspers and forceps can be traumatic, with sharp teeth, usually used on
tissue that will be removed; or atraumatic, with smooth, serrated jaw
surface for use on bowel or liver, much more gentle
• May be insulated for use with electrocautery

Suturing and Stapling Instruments

• Deliver sutures, staples or clips to join, hold and secure tissue
• Needle holders, clip appliers, staplers
• Laparoscopic suturing materials: Loop Ligatures- pre-knotted suture loops,
loop placed over object/tissue to be tied, grasper used to hold object/tissue
as the pre-knotted suture loop is tightened down
• Extracorporeal Sutures- suture tied outside body and tightened down to
knot inside the body
• Intracorporeal Sutures- suture tied within body cavity

Retractors and Accessory Instruments

• Hold tissue and expose operative site
• Probes are blunt used to manipulate tissue
• Irrigation-aspirator- wash and suction internal operative site
• Electrosurgical probes, L-hook and spatula for hemostasis
• Endoscopic specimen bags, inserted with bag that can be opened to
collect specimen and then the opening of the bag closed to allow for
removal

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Care and Handling of Endoscopes and Instrumentation

• Sterility required for all laparoscopy, angioscopy, thoracoscopy, and

arthroscopy procedures where devices come in contact with sterile tissues
and vascular system
• High-level disinfection acceptable but sterilization is becoming the standard
of care in Canada for colonoscopy, laryngoscopy, bronchoscopy,
cystoscopy and other diagnostic procedures where instruments come in
contact with intact mucous membranes
• In many institutions the scope identification number is recorded on the
patient record as well as verification of sterilization
• If biopsies are to be taken sterility may be necessary rather than high-level
disinfection

Sterilization of laparoscopic instruments

• Steam if instrument is able to withstand heat

If cannot withstand heat:

• Peracetic Acid Sterilization- for instruments that can be immersed but are
heat sensitive, takes approximately 30 minutes, special machine used to
contain the instruments, sterilizing solution enters all lumens and ports,
entire instrument is sterilized. Must be used immediately or soon after
sterilization (STERIS) for scopes
• Plasma Sterilization System- hydrogen peroxide gas plasma sterilization,
not for flexible endoscopes due to lumen restrictions, takes 50 to 75
minutes
• Ozone Sterilizer- easy to use, low temperature, cost-effective, compatible
with anodized aluminum containers

Video Technology

• Consists of: scope, light cable, light source, camera head, camera scope
coupler, camera control unit and video monitor
• Lens fogging occurs when cool metal scope enters the warm body, can be
avoided with the use of sterile anti-fog solution on the lens or by warming
the scope prior to insertion either with warm sterile solution, a scope
warmer or with the use of a CO2 insufflator with warming abilities. If the
lens fogs and the surgeon does not wish to remove it from the abdominal
cavity touching the lens to an internal organ to warm it may clear the lens.
• When a second monitor is used it is known as the slave monitor. If two
video monitors are required usually one is placed on either side of the

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 patient or one at the foot so the surgeon and assistant can both view the
screen simultaneously
• Many systems will have a printer or a recordable media unit to allow for
photography and documentation of the procedure
• All of the components, the camera, light source, insufflation unit, printer,
recording unit, etc., can be stored on a tower/storage unit for ease of use,
movement and storage capacity

Complications and Anesthetic Considerations During Endoscopic Minimally

Invasive Surgery

• Trendelenburg position increases intraabdominal pressure possibly

effecting respiration resulting in hypoxia/hypoxemia
• Reverse trendelenburg may decrease venous return, cardiac output and
blood pressure
• Signs of CO2 embolus (pulmonary embolism) sudden decrease in BP,
dysrhythmias, heart murmurs, cyanosis, pulmonary edema and an abrupt
increase in end tidal CO2. Immediately deflate pneumoperitoneum, place
patient in left lateral position, aspirate CO2 gas through CVP catheter.
• Hypotension or hypertension = decrease insufflation rate
• Gastric Reflux –increased risk with obesity, history of hiatus hernia or
excessive pneumoperitoneum. Insert naso/oro gastric tube prn.

ENERGIES USED DURING SURGERY:

Laser (light amplification by stimulated emission of radiation)
• Less invasive, decreased hospitalization, less post-op complications

Laser biophysics
• Non-ionizing radiation that is safe, does not present a hazard to cellular
DNA
• Negatively charged electron orbits positively charged nucleus while atom is
in resting state, at its lowest possible energy level
• Outside source of energy excites the atom moving the electron to a higher
energy level, less stable orbit
• Almost immediately electron moves back to more stable lower level
releasing light energy known as a photon, atom resumes resting state;
photons travel in wave form
• When photon encounters other excited atoms, it will cause the atom to
return to its resting state and release another photon of laser light
• Photons travel together encountering other atoms creating more laser light

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Characteristics of Laser light
• Monochromatic- composed of photons of same wavelength and colour,
consists of only one colour or wavelength
• Collimated- wave run parallel to each other, very little or no divergence,
when pass through a lens the light pattern can be changed and the light
focused into a tiny spot of concentrated energy
• Coherent- waves are orderly and in phase with each other as they travel in
the same direction

NOTE: Laser Power- measured in watts

Tissue Interaction
Four different interactions can occur when laser energy is delivered to the target
site. Extent of reaction depends on laser wavelength, power settings, spot size,
length of time the beam is in contact with the tissue, and the characteristics of the
tissue
1. Reflection
Beam direction changes after contact with an area; may be done intentionally
to reach difficult areas, poses risk if not controlled and able to contact
untargeted areas
Beam can reflect off shiny objects and cause eye and fire risks
2. Scattering
Beam disperses as spreads over large area of tissue; decreases intensity
3. Transmission
Beam passes through tissue or fluid without thermally affecting the area; can
be used in eye surgery as the beam does not affect the cornea, lens, and
vitreous but passes through to affect the retina
4. Absorption
This may lead to a change in the oxygenation of the tissue and inevitable
tissue destruction may occur
Tissue altered from absorption of beam:

Parts of a laser system

1. Laser head- where laser energy is generated and amplified

2. Excitation source
• Supplies energy to excite active medium in laser head
• Sources include; flash lamps, electricity, radio waves, batteries, chemicals,
other laser systems

3. Ancillary components
• Other laser parts required to produce the laser energy, ie. Cooling system
to prevent overheating

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 4. Control panel
• Board that regulates the delivery of laser energy

5. Delivery system
• The device or accessory that conducts the laser energy from the laser
head to the target area; articulated arms with mirrors, fibers

TYPES of LASERS:

CO2 Laser
• Versatile and used frequently
• Light emitted is invisible thus a helium-neon beam is transmitted along with
it to serve as an aiming beam
• The longer the beam is in contact with tissue the greater the destruction
and the deeper the penetration
• CO2 lasers that use electricity or radio waves as the excitation source:
• Free-flowing CO2 laser system – requires external cylinder of laser gas
mixture of CO2, helium, and nitrogen; gas pulled into laser head by
vacuum pump, laser energy is generated
• Sealed-tube CO2 system – mixture of CO2, helium, and nitrogen within
tube that is sealed. Catalyst added to cause regeneration of the gas
mixture to allow lasing action.
• Laser beam delivered through articulated arm, which contains mirrors to
direct the laser beam. Beware of jarring or damaging the arm as it could
misalign the mirrors and therefore where the laser beam will be aimed. The
spot size changes and therefore the intensity of the beam changes as the
CO2 hand piece is brought toward or away from the tissue.
• Smoke produced can be purged with a tubing attachment or a smoke
evacuator

ERBIUM: YAG Laser

• Solid crystal laser- Beam highly absorbed by water = shallow tissue
penetration
• For dermatology- skin resurfacing and ablation

HOLIUM: YAG Laser

• Can produce a photoacoustic effect to break up urinary stones and
gallstones

ND: YAG Laser

• Near infrared, invisible, accompanied by visible helium-neon beam or other
colored light to provide an aiming source
• Tends to scatter within tissue causing thermal damage for 3 – 5 mm

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KTP Laser
• Visible beam
• Colour selective and highly absorbed by hemoglobin, melanin, other similar
pigmentation

ARGON Laser
• Visible beam with intense blue-green light
• Ophthalmology, dermatology, and general applications

DIODE Laser
• Extremely compact and reliable
• Used in DVD players and computers
• Medical applications- laser photo-coagulators for ophthalmic and urologic
procedures
• Direct application or through a microscope

EXCIMER Laser
• Used to sculpt corneas and to ablate plaque in arteries, treat psoriasis and
vitiligo

Benefits of Laser Technology

• Seals small blood vessels
• Seals lymphatics
• Seals nerve endings
• Sterilizes tissue
• Decreases postoperative stenosis
• Produces minimal tissue damage
• Reduces operative and anesthesia time
• Allows a shift to more ambulatory surgery procedures
• Allows more use of local anesthesia instead of general anesthesia
• Provides quicker recovery and return to daily activities

Responsibilities of the Laser Perioperative Nurse

• Turning off the laser machine and removing the key if the machine is to be
left unattended in the OR
• Allowing the laser to run a self-check prior to using and noting any
concerns
• Calibrate and test fire the laser prior to bringing the patient into the room
• Positioning the foot pedal for the surgeon when ready to fire, remove all
other foot pedals at this time
• Only the surgeon can operate the laser foot pedal

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 • One nurse for laser responsibilities only- a separate perioperative
registered nurse dedicated to circulating duties
• Laser is in stand-by mode at all times except when the surgeon is holding
the hand piece
• Keep exposed tissue around the operative site covered with moist towels
or other moist non-flammable material
• Monitor all staff in room and ensure they are wearing appropriate protective
equipment
• Remove any volatile solutions
• Ensure skin prep has dried before allowing drapes to be applied

*NOTE: Standards and safety guidelines should be in place prior to use. They
should include:

Eye protection
• Area of possible damage depends on wavelength used. CO2 damage to
the cornea, argon and Nd: YAG damage the retina following refocusing by
the lens.
• Maximum permissible exposure (MPE) = the level of laser radiation to
which a person may be exposed without hazardous effects to the eye or
skin. determined by wavelength, power, exposure time and pulse
repetition.
• Nominal hazard zone (NHZ) = the space where the level of the direct,
reflected, or scattered radiation during normal laser operation exceeds the
MPE; eye, skin, and fire safety precautions must be followed while one is
working within this hazard zone; for simplicity the area within the surgical
suite is considered to be within the NHZ
• Goggles should be labeled with their filtering capabilities and adequate
optical densities (capability of the lens material to absorb a specific
wavelength) appropriate to the wavelength they are protecting the wearer
from
• Darker lens does not mean better protection
• Avoid damage and scratching of goggles
• If different wavelength lasers are used during a single procedure goggles
will need to be changed as needed. goggles that protect against a greater
variety of wavelengths are difficult to see through.
• An individual’s prescription glasses should not be used if within the NHZ as
they have not been tested for laser protective qualities and are not
inscribed with the appropriate wavelength
• Microscope optics provide protection against CO2 laser energy
• Risks of fiber fracture or disconnection of the articulating arm indicate a
need to always wear eye protection during laser use
• Patient’s eyes must also be protected, cover with wet gauze, eye pads, tin
foil or a towel and tape eyelids closed
• If patient is awake appropriate goggles should be provided
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 • If working near the eye a special laser eye shield can be placed on the
surface of the eye after a drop of ophthalmic local anesthetic

Controlled access
• Avoid inadvertent access to laser room by placing warning signs at all
entrances
• The sign should include the word danger and the universal symbol for
laser- remove when procedure is complete
• Cover windows and doors into laser room with laser appropriate covers
• Store laser key separate from the laser- preferably in a locked cupboard

Fire safety
• Sterile water or saline available to put out small fires on patient or drapes
etc.
• Laser-appropriate fire extinguisher- halon for control of fires
• Keep sponges and towels within surgical field wet
• Use non-reflective instrumentation with ebonized coating, anodized or
surfaced finishes can decrease reflective properties of instrumentation
• Avoid flammable skin preparations for skin cleansing and prepping
• If working in the rectal area block the rectum with wet pack to avoid
methane gas escape and risk of explosion
• Use laser-retardant endotracheal tubes during oral, tracheal or esophageal
laser procedures that require general anesthesia. Inflate cuff with dyed
sterile saline
• Have tracheostomy set in room as a just in case measure

What to do in case of endotracheal fire:

• Stop ventilation
• Extinguish all flames with saline
• Remove the endotracheal tube, ensuring the entire tube is removed
• Ventilate the patient by mask or re-intubate immediately to prevent
laryngospasm
• Examine the airway for burns or foreign bodies or both
• Decide on the next course of action; cancel or continue with procedure

Endoscope Safety
• View at least 1 cm of tip of laser fiber prior to activating, if the end of the
fiber is touching the tip of the endoscope when activated the optics and
channel of the scope can be damaged

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Smoke (plume) evacuation
• In-line smoke evacuation filter for small amounts of plume. Use with a filter
on the routine suction line; replace wet filters.
• Individual smoke evacuator for greater amounts of surgical smoke. Have
filtration system of charcoal filter to remove toxic gases and odor and an
ultra-low penetration air (ULPA) filter to remove small particulate. Change
filters as directed by manufacturer, wear protective gloves, place in plastic
bag and discard in waste following local/provincial/federal regulations.
• Centralized smoke evacuation systems used simultaneously by several
surgical suites. But risk of malfunction affects several suites.
• Special laser masks should be worn and fitted properly

Documentation
• For safety and medical legal reasons
• Laser log including type of laser used, power and pulse duration, other
laser parameters
• Patient name and identifying number
• Treatment performed
• Physician activating the laser
• Name of the perioperative laser nurse
• Laser
• Hand-piece used
• Parameters used
• Eye protection used
• Skin protection used
• Length of treatment and power setting
• Use of smoke evacuation

ELECTROSURGERY:
• ESU
• Includes electosurgery units and diathermy or cautery
• For patient safety remove all metal jewelry
• Ensure alarm on ESU is not turned off and at an appropriate audible level
• When two ESUs are used simultaneously each requires its own dispersive
electrode pad
• When foot pedals are used they should be run only by the operator
• The active electrode will be placed in a cautery holster when not in use,
this prevents inadvertent burns
• Smoke evacuators should be used when surgical plume is expected

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Electrosurgical Modes

Monopolar
• Electrical energy flows from the generator through an active electrode to
the patient
• Patient needs to be grounded
• Dispersive electrode pad applied as close to the surgical site as possible,
to a well vascularized, dry area, ensure good contact with skin, avoid
placing over bony prominences, metal implants, excessively hairy or
lotioned areas or scar tissue as this can negatively impact the
effectiveness of the grounding pad
• Do not cut or adjust the size of the electrode
• Avoid placing in a location that may become wet
• Poor contact with the patient’s body can result in electrical energy
concentration and result in burns
• Most popular form of electrosurgery

Bipolar
• Dispersive electrode not required as the energy flows between the tips of
the bipolar instrument completing the circuit; energy returned directly from
the instrument to the generator to complete the circuit, eliminating the flow
of current through the patient’s body

NOTE: Impedance meters have an alarm type system that can be used to notify
the surgeon when tissue desiccation is occurring or complete

Tissue Effects
• Waveform range from pure cut to pure coagulation
• Pure cut- frequency high, voltage low, produces a constant bombardment
of electrons on the tissue, heat is produced, cells are ruptured and tissue is
cut
• For maximum activity hold the electrode slightly above the tissue
• Pure coagulation- frequency decreased, voltage increased, intermittent
delivery of electrons causes cells to heat up and then cool, produces
coagulation
• Blend mode allows simultaneous cutting and coagulation

NOTE: Tissue effect influenced by tissue type;

• Adipose tissue, poorly vascularized, does not conduct electrical energy
well and may require higher settings
• Muscle highly vascularized requires less power to achieve tissue effect.

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NOTE: Eschar- burnt tissue and debris impedes flow of electrons, therefore keep
tips of active electrode clean to allow them the function properly. If the operator
requests a continual increase in power, personnel should check the entire ESU
and accessories circuit for correct/complete installation.

Types of ESUs:
• Grounded
• Isolated
• Dispersive Electrode Monitoring- Adhesive electrode pad or capacitance
pad to ground the patient
• Tissue Response Monitoring System - uses computer controlled tissue
feedback system adjusting current and output voltage to maintain a
constant surgical effect. This decreases risk of patient injury.

Argon-Enhanced Electrosurgery
• Limit the flow of gas to the lowest amount possible i.e. 4l/min. or less
• Never place the tip less the several millimeters from the surgical site
• Flush the abdominal cavity with several liters of CO2 between use
• Always leave one cannula open as a vent
• End-tidal CO2 monitoring to alert to development of PE
• Equipment must have pressure alarms
• Combines argon gas with electrosurgical energy to improve effectiveness
of electrosurgical current
• Flow of argon gas clears site of blood and fluids, decreases formation of
surgical smoke
• Increased risk for the formation of gas embolism-to avoid this often during
the administration of the gas another port is left open to allow any excess
gas to be evacuated

Special Electrosurgery Considerations During Endoscopic Minimally

Invasive Surgery
• Direct Coupling- occurs when active electrode touches a non-insulated
metal instrument, can result in a burn
• Insulation Failure- when insulation coating has a crack or break along the
shaft of the instrument allowing electrical energy to escape at the point of
defect and burn untargeted tissue
• Capacitive Coupling- natural phenomenon occurs when energy is
transferred through intact insulation on the shaft of the laparoscopic
instrument to nearby conductive materials

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Documentation of Electrosurgery should include:
• Type of unit and serial number
• Hair removal
• Location of dispersive electrode
• Cutting and coagulation settings
• Name of perioperative registered nurse applying the dispersive electrode
• Condition of skin before and after removal of the dispersive electrode

ULTRASONIC DEVICE SURGERY:

• Ultrasonic, high-frequency sound waves travel to the tip to produce
ultrasonic energy
• Vessels are sealed or sealed and divided
• Only a small amount of water vapor is produced rather than the smoke
plume of electrosurgery
Advantages of ultrasonic devices for cutting and coagulation:
• No surgical plume or odor
• Less adjacent tissue is damaged compared with that which occurs with use
of laser and electrosurgical devices
• Tactile feedback is provided
• No nerve or muscle stimulation is present because no electrical current is
delivered to the target area
• No stray electrical or laser energy is produced
• Precise cutting and control are offered

HYDRODISSECTION and IRRIGATION:

• Normal saline with caution
• Conductive, risk with monopolar electrosurgery
• Sterile water or other nonconductive solutions are recommended

CRYOSURGERY:
• Freezing tissue, skin tumors, liver tumors, prostatic cancer, and cervical
dysplasia
• Freeze, thaw, freeze cycle
• -50*C and colder- some produce -240*C
• Cooling source = gaseous nitrogen or super cooled liquid nitrogen systems
• External tumor direct application of liquid nitrogen
• Internal tumors liquid nitrogen circulated through length of cryoprobe with
an insulated shaft to confine freezing to the distal tip
• Dead tumor cells will eventually be absorbed into surrounding tissue

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ROBOTICS
• Research continues to allow for the advancement of robotic technology in
the perioperative setting. Combined with laparoscopic procedures,
computer assisted surgery or image guided surgery, the possibilities and
benefits are immediately recognized by the surgical team. Robotic devices
may be used to assist with holding and maneuvering equipment thereby
freeing team members to perform other tasks. Advances in this area
facilitate the procedures, promote safety and may even shorten the
procedure time. The benefits to patients include; decreased hospital stay
time, reduced complications, faster recovery period and improved
outcomes following surgery. Robotic surgery has been accepted in
cardiothoracic, general, urology, gynecology and otolaryngology services.
Look for exciting and challenging opportunities in this area as more
research is completed and new technology evolves.

LESSON SUMMARY:

Lesson 8 has examined various surgical modalities that are common today in
the OR setting. The topics addressed have included a basic description of the
modality and common interventions related to each modality. Minimally invasive
techniques are common place in the perioperative setting today and offer many
advantages to the patient and perioperative staff. Many traditional procedures can
now be performed laparoscopically thanks to technology and education.

LEARNING ACTIVITIES:

The following activities are designed to enhance your level of comfort with the
lesson’s material and to prepare you for the final exam. They are not to be
submitted for marking.

1. Today, many procedures are completed in this rapidly growing and ever-
evolving area
M __________________ I ___________________ S__________________

2. With relation to insufflation, what am I?

a) I am the gas used in insufflation
b) Irritation of my nerve can cause postoperative shoulder, sub scapular, or
neck pain
c) The patient is placed in this position
d) I am the numerical values at which intra-abdominal pressure should be
maintained

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 e) I must be readily available for ‘back-up’

3. Types of sterilizations for laparoscopic instruments include.

a) E _ _ _ _ E _ E O_I_E
b) _ E _ A _ E _ I _ A_I_
c) _ _ A _ _ A __E_I_I_A_IO_
d) O _ O _ E __E_I_I_E_

4. Unscramble these signs of CO2 embolus

a) ddsune tehysiponno d) earth urmrum
b) yacosins e) rhdyysmitha
c) mopulryna madee

5. Four interactions that can occur when laser energy is delivered to a target
site
R ________________
S ________________
T ________________
A _________________

6. Match up these types of lasers

i) ERBIUM: YAG LASER a) ablates arterial plaque

ii) HOLIUM: YAG LASER b) for dermatology
iii) KTP LASER c) photocoagulation
iv) ARGON LASER d) breaks up calculi
v) EXCRIMER LASER e) highly absorbed by hemoglobin
vi) DIODE LASER f) used in ophthalmology

Answers:

1. Minimally Invasive Surgery

2. a) carbon dioxide
b) phrenic
c) trendelenburg
d) 14 to 16 mmHg
e) second CO2 tank

3. a) ethylene oxide
b) peracetic acid
c) plasma sterilization
d) ozone sterilizer

4. a) sudden hypotension

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 b) cyanosis
c) pulmonary edema
d) heart murmur
e) dyssrhythmia
5. reflection, scattering, transmission, absorption

6. i) b, ii) d, iii) e, iv) f, v) a, vi) c

Visit the following websites to become more familiar with the material covered in
this lesson.
https://www.youtube.com/watch?v=sPyZRkkxqNs

https://www.youtube.com/watch?v=67k-SrkiJyU

https://www.youtube.com/watch?v=9sEf9kLC1Mk

https://www.youtube.com/watch?v=ZFNRjxrToRo

Can’t ctrl-click on this underlined link? Just copy and paste the complete address into the
location bar of your browser and click “enter”.

Now that you have completed Lesson 8 please proceed to Lesson 9 as per
the course schedule.

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