The first laparoscopic surgery was

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1 Laparoscopic-Assisted Colon Surgery DANNY HAGEMAN, RN, CNOR, AS-C; VICTORIA CAILLET, RN, CNOR; JEFF KOSTOHRYZ, RN, BSN, CNOR; SUE MADICK, RN, BA, CNOR 2.3 The first laparoscopic surgery was performed in 1901 by George Kelling, MD. 1 Dr Kelling was able to view the peritoneal cavity of a dog using two trocars, one to insufflate the abdomen with filtered air and the other to insert a cystoscope. The first laparoscopic procedure performed on a human occurred in The surgical procedure was performed by Hans Christian Jacobaeus, MD, to investigate ascites. 1 The surgeon performed the procedure using a single trocar site. The camera had a light at the distal end and also allowed air passage for insufflation. The light at the distal end of the camera, however, posed a thermal injury complication in early laparoscopy. Other complications in early laparoscopy included bowel and vascular injuries. 1 Numerous advances have been made since the early days of lapa roscopy (Figure 1). Since 1994, laparoscopic procedures have been improved using similar techniques and newer versions of the same devices. Laparoscopy, with smaller incisions and a shorter recovery time, has revolutionized abdominal surgery. Although most often performed on patients with benign disease, laparoscopy is now accepted more readily for patients with malignant disease as well. Some advantages of laparoscopic indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages and then completing the answer sheet and learner evaluation on pages You also may access this article online at versus open procedures include faster recovery and a shorter hospital stay, less postoperative pain and thus less need for narcotic analgesia use, faster return to activities of daily living, and improved cosmesis with smaller surgical incisions and resultant scars. 2 MINIMALLY INVASIVE COLORECTAL SURGERY Some recent studies show laparoscopic colectomy outcomes to be better than those for open sigmoid colectomy for the treatment of benign and malignant disease because of the advantages of laparoscopic techniques. 3,4 A variety of conditions can be treated by laparoscopic colectomy, including colorectal cancer, Crohn s disease, diverticular disease, polyposis disease, and ulcerative colitis. 2 An advantage of the laparoscopic ABSTRACT LAPAROSCOPIC-ASSISTED colon surgery is a safe alternative to conventional open colectomy. Using the laparoscopic approach, the surgeon uses tools through port sites to mobilize the section of colon to be removed, avoiding a large laparotomy incision. Usually, two to three 5-mm port sites and one 10-mm or 12-mm port site are created. ALTHOUGH THIS PROCEDURE often requires a small incision to remove the diseased portion of the colon, the incision is much smaller, causing less postoperative pain and shortening the hospital stay. This leads to a faster return to activities of daily living for the patient. AORN J 88 (September 2008) AORN, Inc, AORN, Inc, 2008 SEPTEMBER 2008, VOL 88, NO 3 AORN JOURNAL 403

2 SEPTEMBER 2008, VOL 88, NO 3 Hageman Caillet Kostohryz Madick FIGURE 1 Timeline of Laparoscopic Surgery from 1911 through ,2 A 1911 Bernheim introduces the first laparoscopic surgery in America. B 1918 Goetze develops a pneumoperitoneal needle that allows safe passage into the peritoneal cavity. C 1920 Zollikofer discovers that carbon dioxide is beneficial for insufflation. D 1929 Kalk introduces the 135-degree lens and advocates the use of a separate puncture site for achieving the pneumo peritoneum. E 1934 Ruddock describes laparoscopy as superior to laparotomy for diagnostic procedures and uses a forceps device with electrosurgical capability. F 1936 Boesch of Switzerland performs the first laparoscopic tubal sterilization. G 1938 Veress of Hungary develops the Veress needle to achieve a pneumothorax. H 1944 Palmer of France performs laparoscopic gynecological examinations in Trendelenburg position so air can fill the pelvis and stresses the importance of intraabdominal pressure monitoring. I 1966 Semm develops an automatic insufflation device capable of monitoring intraabdominal pressure. J 1977 Dekok performs the first laparoscopicassisted appendectomy. K 1977 Semm demonstrates endoloop suturing techniques for laparoscopic surgery. L 1978 Hasson proposes a mini-laparotomy that allows direct vision of the peritoneal cavity during trocar placement; the trocar has a sliding sleeve held tight against the fascia with stay sutures. M 1983 Semm performs the first completely laparoscopic appendectomy. N 1985 Muhe performs the first laparoscopic cholecystectomy in Germany. O 1987 Mouret performs the first laparoscopic cholecystectomy using video in France. P 1990 Jacobs performs the first laparoscopicassisted colectomy in Florida; the procedure (ie, a right hemi-colectomy) requires a mini-laparotomy to ligate mesenteric vasculature, perform extra corporeal anastomosis, and remove the specimen. Q 1990 Fowler performs the first laparoscopic sigmoid colectomy. R 1994 Computer Motion develops a robotic arm to hold the camera to improve safety and alleviate the need for a camera operator. 1. Mishra RK. History of minimal access surgery. Accessed June 9, Phillips N. Operating Room Technique. 11th ed. St Louis, MO: Mosby Elsevier; 2007: approach to colectomy is that colon function normalizes faster after laparoscopic manipulation than after open exposure manipulation. Since the laparoscopic approach causes less intra-abdominal scarring and adhesion formation, the laparoscopic approach often is preferred, particularly because it may reduce the incidence of obstructive episodes. 2 DISADVANTAGES. A major disadvantage of the laparoscopic approach for colectomy is an increase in OR time. One study suggested a mean operating time increase of 55 minutes for laparoscopic colectomy versus open colectomy. 4 This time may decrease as surgeons become more experienced and perform increased numbers of laparoscopic procedures. Laparoscopic colectomy (ie, right or sigmoid) is a technically difficult procedure that requires a 404 AORN JOURNAL

3 Hageman Caillet Kostohryz Madick SEPTEMBER 2008, VOL 88, NO 3 steep learning curve for all involved health care providers. 5 Cost also is a disadvantage as a result of increased OR time and increased cost of instrumentation (eg, trocars, cannulas, staplers, fiberoptic light sources). CONTRAINDICATIONS. There is no indication at this time that the laparoscopic approach is associated with worse long-term outcomes than an open procedure; therefore, there are very few true contraindications. Some conditions make the laparoscopic approach more difficult, such as intra-abdominal adhesions from previous surgeries, bleeding disorders, obesity, and pregnancy. The laparoscopic approach may be contraindicated for patients suffering from severe restrictive pulmonary disease, which makes it difficult for the anesthesia care provider to provide adequate ventilatory support and decreases the patient s ability to tolerate the carbon dioxide (CO 2 ) insufflation necessary to achieve a pneumoperitoneum. The size of the lesion also may make the laparoscopic approach inappropriate because of the size of the incision necessary to remove the tumor from the abdomen. 6 PREOPERATIVE EVALUATION AND CANDIDATE SELECTION Preoperative evaluation should focus on issues that preclude surgery entirely, alter the planned surgical procedure either preoperatively or intraoperatively, or suggest the need for preoperative adjuvant therapy. The presence of a synchronous colonic neoplasia would exclude laparoscopic colectomy as a treatment option and, therefore, should be identified preoperatively by colonoscopy or air-contrast barium enema in combination with sigmoidoscopy. A preoperative carcinoembryonic antigen (CEA) level provides useful prognostic information because CEA is elevated in the serum of individuals with colorectal, gastric, pancreatic, lung, and breast cancer. If the CEA level An experienced physician should perform careful digital palpation in combination with rigid proctosigmoidoscopy for patients with rectal cancer. does not decrease after surgical removal of the tumor, this is an indication of tumor reoccurrence. Serum CEA levels also are increased in conditions such as ulcerative colitis, pancreatitis, and cirrhosis. Abdominal computed tomography (CT) or hepatic ultrasonography should be performed in patients with hepatomegaly or abnormal liver function tests. If preoperative radiation therapy is planned, abdominal CT is appropriate to exclude extrapelvic disease that would preclude preoperative radiation. The benefit of routine preoperative CT in patients with otherwise resectable colonic or rectal cancer remains unclear. 5 Patients with rectal cancer should undergo a careful digital palpation performed by an experienced physician combined with rigid proctosigmoidoscopy. Intrarectal ultrasonography may provide more objective data with regard to the extent of the local disease. INTRAOPERATIVE PATIENT CARE After the patient arrives at the preoperative holding area, the preoperative nurse prepares the patient for surgery and organizes the patient s medical records. The circulating nurse and RN first assistant (RNFA) evaluate the patient s chart for completeness, including current history and physical examination, laboratory values, and the surgical informed consent. After the circulating nurse introduces himself or herself to the patient and family members, the nurse confirms the surgical procedure, as well as the patient s NPO status, allergies, and AORN JOURNAL 405

4 SEPTEMBER 2008, VOL 88, NO 3 Hageman Caillet Kostohryz Madick current medications. The circulating nurse ensures that the preoperative antibiotic was administered as ordered by the surgeon and that the patient has on thromboembolic disease hose. The circulating nurse then develops a nursing care plan specific to the patient undergoing laparoscopic colon surgery (Table 1). Patients undergoing open-cavity surgery have an increased risk of substantial heat loss into the relatively cool environment of the OR. 7(p409) According to AORN s Recommended practices for the prevention of unplanned perioperative hypothermia, patients at risk of unplanned hypothermia should be prewarmed for a minimum of 15 minutes immediately before induction of anesthesia to minimize the effect of anesthesiainduced vasodilation. 7 Therefore, the circulating nurse ensures that the patient is warmed with a forced-air warming blanket device for a minimum of 15 minutes in the preoperative holding area. The circulating nurse and anesthesia care provider transport the patient on a stretcher to the OR and help the patient move onto the OR bed in a supine position. After placing an upper body temperature-regulating blanket on the patient, the circulating nurse applies sequential compression device leggings and ensures that they are initiated before induction of anesthesia. The circulating nurse then secures the safety strap across the patient s thighs. At this point, the circulating nurse performs the surgical time out with all surgical team members and the patient. The time out includes stating the patient s name; the surgeon; the surgical procedure to be performed (eg, laparoscopic sigmoid colectomy); laterality (ie, left versus right); The circulating nurse ensures that the preoperative antibiotic was administered as ordered by the surgeon and that the patient has on thromboembolic disease hose. patient position; and any required equipment or test results (eg, x-rays, implants) and verifying all information with the patient, his or her completed informed consent, and the identification bracelet. After induction of general anesthesia and endotracheal intubation, the anesthesia care provider inserts an orogastric tube at the surgeon s discretion. SIGMOID COLECTOMY. For a sigmoid colectomy, the surgeon, circulating nurse, and RNFA place the patient in low lithotomy position using padded stirrups. Extending the patient s arms on padded arm boards is the preferred method but if this is not possible, the circulating nurse ensures that both of the patient s arms are padded and tucked at the patient s side. The circulating nurse checks for proper body alignment and ensures that all pressure points are padded. While the surgeon and RNFA perform surgical hand scrubs, the circulating nurse performs the surgical skin prep for a cystoscopy and placement of a left ureteral catheter that will facilitate identification of the left ureter intraoperatively. The nurse then performs two separate preps one of the patient s perineum and a second of the entire abdomen with an antimicrobial solution. The circulating nurse also inserts an indwelling urinary cathe ter. After the circulating nurse places the electrosurgical unit (ESU) dispersive pad on the patient s lateral thigh, the scrub person and RNFA assist the surgeon in draping the patient and preparing the sterile field, including securing the CO 2 tubing, light cord, camera cord, ESU hand piece, suction irrigator, suction tubing, and ultrasonic scalpel. Under direct vision, the surgeon inserts a specially designed trocar and port that can accommodate a 5-mm scope in the patient s right 406 AORN JOURNAL

5 Hageman Caillet Kostohryz Madick SEPTEMBER 2008, VOL 88, NO 3 Diagnosis Anxiety (X4) related to deficient knowledge (X30) and stress of surgery Risk for acute or chronic pain related to surgery (X38) TABLE 1 Nursing Care Plan for Patients Undergoing Surgery for Laparoscopic Colon Surgery Nursing interventions Assesses psychosocial status, knowledge level, and barriers to communication. Identifies readiness to learn, coping mechanisms, and availability of support systems. Explains sequence of events and reinforces teaching about treatment options. Provides preoperative and discharge instructions based on age and identified need, including family members when appropriate. Communicates patient concerns to appropriate surgical team members. Evaluates response to instruction. Assesses patient s pain preoperatively. Preoperatively identifies patient s desired level of postoperative pain control and provides pain management instruction based on a 0-to-10 pain scale and pain control options. Identifies cultural and value components related to pain and pain control. Implements pain guidelines by assessing pain control with pain scale; encouraging patient to use analgesic medications routinely; and providing instruction on noninvasive pain relief (eg, distraction, relaxation techniques). Evaluates patient s response to pain management interventions. Outcome measurement The patient verbalizes understanding of the procedure and expected outcomes, demonstrates knowledge of emotional responses to surgery, and verbalizes de - creased anxiety and an ability to cope through out the perioperative period. The patient s postoperative vital signs and other nonverbal symptoms remain stable, indicating adequate pain control. The patient demonstrates and reports adequate pain control throughout the perioperative period. Outcome statement The patient demonstrates knowledge of psychological responses to the surgical procedure (O17). The patient demonstrates knowledge of pain management (O20). Risk for injury related to the perioperative experience (X29) Verifies patient s identity, allergies, NPO status, and informed consent. Assesses skin integrity, sensory impairments, musculoskeletal status, and risk factors for ineffective tissue perfusion. Ensures appropriate positioning and adequate padding of pressure points. Evaluates for injury by comparing preoperative and postoperative neurovascular status. The patient s vital signs and oxygen saturation remain within expected values; motion, sensation, and circulation are maintained or improved during the perioperative period. The patient is free from signs and symptoms of physical injury acquired during the perioperative period (O1). Risk for unplanned perioperative hypothermia (X26) Assesses patient s risk for experiencing unplanned perioperative hypothermia. Employs appropriate perioperative hypo - thermia prevention strategies to include actively warming patient preoperatively; applying a temperature-regulating blanket, minimizing unnecessary exposure, and using warmed solutions intraoperatively; and rewarming the patient postoperatively. Evaluates the patient s response to hypothermia prevention interventions. The patient s core body temperature remains in the expected range. The patient is at or returning to normothermia at the conclusion of the immediate postoperative period (O12). AORN JOURNAL 407

6 SEPTEMBER 2008, VOL 88, NO 3 Hageman Caillet Kostohryz Madick upper mid-abdomen (Figure 2). The surgeon then achieves the pneumoperitoneum by insufflating the patient s abdomen with CO 2 gas. This pushes the abdominal wall away from the intestines, allowing the surgeon room to work laparoscopically with specially designed instruments and a video camera. 1 During the entire procedure, the intraperitoneal pressure is maintained at 10 mm Hg to 12 mm Hg. The anesthesia care provider changes the OR bed position during the procedure as an additional measure as needed to facilitate retraction of the small bowel from the surgical field. 8 The surgeon places additional 5-mm trocars in the mid-epigastric area just above the patient s umbilicus and in the patient s suprapubic area. The surgeon also places a 10-mm or 12-mm trocar in the patient s right lower C D Figure 2 Port A, in the supraumbilical area, is used for a 5-mm scope; port B, in the suprapubic area, is used for a 5-mm scope; port C, in the right upper quadrant, is used for direct visualization with a 5-mm or 10-mm scope; port D, in the right lower quadrant, is used for the staples. A B quadrant. The RNFA inserts the 10-mm, 30- degree laparoscope through the right lower quadrant port. Using atraumatic graspers through the 5-mm ports, the surgeon moves the small bowel to see the colon. The surgeon then mobilizes the portion of colon to be resected and devascularizes it using the ultrasonic scalpel intracorporeally and uses endoscopic vascular clips to ligate major vessels. 2 To obtain adequate margins of normal colon proximal and distal to the diseased area, the surgeon frees the colon up to the splenic flexure. 5 During this portion of the procedure, the RNFA moves the laparoscope, under the direction of the surgeon, to allow the surgeon to best see the area of dissection. The surgeon dissects the colon free distally until the rectum can be identified. Care is taken during this entire dissection to identify and protect the left ureter with the ureteral catheter in place. After mobilization of the colon, the RNFA removes the 10-mm laparoscope and uses a 5-mm laparoscope through the right upper quadrant or epigastric port for the stapling portion of the procedure. The surgeon uses a contour stapler to transect the colon at the rectum and clamps an atraumatic grasper to the sigmoid end of the transected colon. The surgeon makes a transverse incision in the suprapubic area, extending the 5-mm trocar site, and the RNFA places retractors at the skin edge to provide a better view. The surgeon transects the rectus fascia transversely and incises the posterior fascia vertically. The surgeon and RNFA place a wound protector to wall off the incisional edges. Using the attached atraumatic grasper and a Babcock clamp, the surgeon delivers the distal end of the transected colon through the incision. The surgeon clamps the proximal end with a rubber shod clamp and clamps the diseased end to be removed with a Kocher clamp. The surgeon then transects the diseased portion of colon with a #10 knife blade and removes the transected portion. The surgeon places a 2-0 polypropylene purse-string suture in the end of the colon. He or she inserts the anvil of the circular anastomosis stapler into the colon and secures the purse string. After returning the colon to the 408 AORN JOURNAL

7 Hageman Caillet Kostohryz Madick SEPTEMBER 2008, VOL 88, NO 3 abdomen, the RNFA twists the wound protector to close off the incision so the abdomen can be reinsufflated. The RNFA moves to the rectal surgical field and irrigates the rectum with a diluted povidoneiodine solution (ie, 900 ml normal saline with 100 ml povidone iodine). He or she then digitally dilates the rectum and places the circular stapler into the rectum. Under the guidance of the surgeon, the RNFA advances the stapler to the distal rectal stump, and then advances the spike anterior to the staple line until the orange guide marker is visible. The surgeon pushes the anvil onto the spike until it clicks into place. After checking to ensure that the colon is not twisted and is in good alignment, the RNFA closes the stapler. Under the surgeon s guidance, the RNFA checks the stapler to make sure it is properly closed before firing. The RNFA then fires the stapler, opens the stapler, and removes it from the rectum. The RNFA checks the tissue in the stapler to ensure that the proximal and distal pieces of donut-shaped tissue are completely present. The surgeon instills fluid into the patient s abdomen. The RNFA then inserts the rigid sigmoidoscope and instills air into the patient s rectum. Absence of air bubbles in the peritoneal cavity indicates that there are no leaks at the anastomosis site. The surgeon irrigates the patient s abdominal cavity and removes all trocars under direct vision. The RNFA assists the surgeon with fascial closure of the Pfannenstiel incision and the 10-mm or 12-mm trocar site; then the RNFA closes the skin of the incision and all of the trocar sites. At the beginning of wound closure, the circulating nurse and scrub person perform a sponge, needle, and instrument After checking to ensure that the colon is not twisted and is in good alignment, the RN first assistant closes the stapler and checks to make sure the stapler is properly closed before firing. count. They count the sponges and needles again at skin closure. The scrub person and RNFA clean the surgical site and apply sterile dressings. The RNFA then removes the ureteral catheter. RIGHT HEMICOLECTOMY. For a right hemicolectomy, the patient is placed in the supine position. A ureteral catheter is not inserted. The OR bed is placed in the Trendelenburg position with the bed rotated so the patient s right side is upward. After adequate mobilization of the diseased right colon, the surgeon makes a small incision over the area of the abdomen that will provide the best access to deliver the segment of resected colon. The surgeon performs the resection and anastomosis of the diseased segment extracorporeally either with staples or with sutures. 5 After resection, the surgeon returns the anastomosed colon to the abdominal cavity. POSTOPERATIVE PATIENT CARE After the circulating nurse and RNFA return the patient to the supine position, the circulating nurse removes the ESU dispersive pad and checks the site for burns or skin irritation. The circulating nurse applies warm blankets for patient comfort and then helps the anesthesia care provider and RNFA transfer the patient to the postanesthesia care unit (PACU) bed, maintaining the patient s proper body alignment throughout the process. In the PACU, the circulating nurse provides the RN-to-RN transfer paper to the PACU nurse and gives a verbal transfer report. The PACU nurse monitors the patient s vital signs and level of pain and provides pain management as needed. The RNFA writes postoperative orders to be checked and countersigned by the surgeon. When the patient is AORN JOURNAL 409

8 SEPTEMBER 2008, VOL 88, NO 3 Hageman Caillet Kostohryz Madick stable, the PACU nurse transfers the patient to the medical-surgical patient care unit. FOLLOW-UP CARE Approximately 148,000 new cases of colon and rectal cancer are diagnosed in the United States annually. 9 Of these cases, approximately 75% of patients will have had the disease entirely removed during an initial surgical procedure; therefore, approximately 110,000 patients per year should receive follow-up care from their primary health care provider or oncologist. 9 Although follow-up care improves survival, ensures better outcome monitoring, identifies other treatable diseases earlier, and ensures provision of better emotional and psychological support, 9 it also may increase physical, financial, and psychological stress. 9 The Standards Practice Task Force and the American Society of Colon and Rectal Surgeons jointly wrote practice parameters for follow-up care. 9 These practice parameters include the following: Offering follow-up for patients with completely resected colorectal cancer is justified. Routine office visits should be a part of a follow-up program for patients who have completed treatment for colon and rectal cancer. Carcinoembryonic antigen evaluation should be used as a part of follow-up for colorectal cancer; the use of other tumor markers remains experimental. Periodic anastomotic evaluation is recommended for patients who have undergone resection/anastomosis or local excision of rectal cancer; this is accomplished by: ensuring that the patient is seen in the office and undergoes CEA evaluations at least three times per year for the first two years after surgery, and having the patient undergo colonoscopies at three-year intervals. There is insufficient data to recommend for or against chest x-ray as part of routine follow-up. Serum hemoglobin, guaiac test for fecal occult blood, and liver function tests should not be routine components of a follow-up program. Routine hepatic imaging studies in the follow-up of colorectal cancer should not be performed. CASE STUDY Ms K, a 54-year-old woman, was diagnosed with multiple diverticula after a routine screening colonoscopy at age 50. At that time, she had no symptoms and did not change her diet. Until recently, she had not had any problems. One month ago, Ms K experienced left lower quadrant pain and a fever and complained of a twisting sensation. Her primary care physician diagnosed acute diverticulitis and admitted Ms K to the medical-surgical unit for further treatment. A CT scan of her abdomen indicated recurring diverticulitis, and the patient was treated with ciprofloxacin and metronidazole. In three days, the patient was discharged and instructed to eat a high-fiber diet. Two weeks later, Ms K began feeling ill with recurrence of left lower quadrant pain and a fever, as well as left back pain radiating to her sacroiliac area. Her primary care physician ordered a repeat CT scan that identified diverticulitis and gallstones. Ms K was referred to a general surgeon who recommended that she undergo a laparoscopic sigmoid colectomy as well as a laparoscopic cholecystectomy and laparoscopic appendectomy. The patient is admitted for surgery with a diagnosis of recurring diverticulitis, cholecystitis, and potential for appendicitis. After induction of general anesthesia, the circulating nurse, RNFA, and anesthesia care provider place the patient in the low lithotomy position. After the circulating nurse performs the skin prep, the surgeon performs a cystoscopy and inserts a left ureteral catheter and an indwelling urinary catheter. After the circulating nurse applies the ESU grounding pad, the scrub person and RNFA drape the patient and prepare the sterile field. Under direct vision, the surgeon then places a specially designed 5-mm trocar and port in the patient s right upper abdomen and insufflates the patient s abdomen to a pressure of 12 mm Hg. The surgeon then places two additional 5- mm ports to the left and right of the patient s umbilicus for the cholecystectomy. The surgeon transects the omentum of the gallbladder using 410 AORN JOURNAL

9 Hageman Caillet Kostohryz Madick SEPTEMBER 2008, VOL 88, NO 3 A variety of diseases have been treated successfully using the laparoscopic approach, including malignant diseases. the ultrasonic scalpel and bluntly dissects to clearly identify the cystic duct and the cystic artery. The surgeon uses endoscopic clips, two proximally and one distally, to secure the cystic duct and then secures the cystic artery in the same manner. After severing both the cystic duct and cystic artery, the surgeon dissects the gallbladder free from the liver bed using a hook ESU device. The surgeon placed the gallbladder in a retrieval bag but leaves it in the abdomen during the remainder of the dissection. At this time, the surgeon places a 12-mm port in the right lower quadrant and an additional 5-mm port in the suprapubic area under direct visualization. Using a 10-mm, 30-degree laparoscope, the surgeon dissects the sigmoid colon. He then uses the ultrasonic scalpel to incise the mesentery and dissect adhesions. The surgeon makes a window in the mesentery of the sigmoid colon with the ultrasonic scalpel and frees the sigmoid colon up to the splenic flexure using the same technique. The surgeon performs further dissection with the ultrasonic scalpel to completely free the transverse colon. When the colon has good mobility, the surgeon transects it at the pelvic rim using two firings of the endoscopic stapler. After performing the colectomy as described earlier and checking the anastomosis for leaks, the surgeon makes a window in the mesoappendix and uses a standard 45-mm stapler to transect the appendix flush with the cecum. The surgeon then transects the mesoappendix with a vascular stapler and uses endoscopic clips and the ESU for hemostasis. The surgeon places the appendix in a retrieval bag and removes it through the 12-mm trocar site, after which he removes the gallbladder through the same site. To close the right lower quadrant trocar site, the RNFA uses a 0-polyglactin suture in a figure-8 fashion and then removes all trocars under direct vision. The RNFA reapproximates all wound edges using 4-0 poliglecaprone. The RNFA and scrub person apply one-quarter inch self-adhesive skin approximating strips over which they apply nonadherent dressing pads to dress the wounds. After the RNFA removes the ureteral catheter, the circulating nurse and RNFA remove the patient s legs from the stirrups and place Ms K back into the supine position. After extubating the patient, the circulating nurse and RNFA help the anesthesia care provider move Ms K to the bed, maintaining her body alignment, and then transfer her to the PACU. Postoperatively, the patient receives IV morphine sulfate for pain. In the nursing unit, nurses encourage Ms K to use her incentive spirometer to minimize postoperative respiratory complications. Initially, Ms K is able to tolerate ice chips and on postoperative day one, she is started on clear liquids. The nurse notes that bowel sounds are present but diminished, and the patient has some red discharge from the rectum, which is expected after this surgery. Ms K also starts ambulating on postoperative day one. On postoperative day two, Ms K is afebrile and the indwelling urinary catheter is removed. She continues to have some red discharge from her rectum. The nurses manages Ms K s pain with oral acetaminophen and hydrocodone. By postoperative day three, Ms K is tolerating full liquids and passing flatus. The nurses discharge Ms K, instructing her to advance her diet as tolerated and follow up with her surgeon in 10 days. In an interview two months after surgery, Ms K states she was able to discontinue all pain medication one week after surgery and is not having any problems. ADVANCES IN LAPAROSCOPIC COLON RESECTION Great advances have been made in laparoscopic surgery during the past 20 years, from diagnostic procedures to colon resections. A AORN JOURNAL 411

10 SEPTEMBER 2008, VOL 88, NO 3 Hageman Caillet Kostohryz Madick variety of diseases have been treated successfully using the laparoscopic approach, including malignant diseases. The advantages of the minimally invasive approach make it the treatment of choice for patients requiring a colectomy. The laparoscopic technique has a shortened recovery time, allowing the patient to return to normal activities sooner. This approach may be a better option than open colectomy for select high-risk patients, such as those who are elderly or obese. Laparoscopic colectomy presents new challenges for perioperative nurses and RNFAs. Patients who may meet the criteria for this procedure range from the young to the elderly, from the actively ill to patients with chronic conditions. Perioperative nurses must be prepared to care for members of the diverse population that may undergo these procedures. REFERENCES 1. Mishra RK. History of minimal access surgery. _laparoscopy.htm. Accessed June 9, Ahad S, Figueredo EJ. Laparoscopic colectomy. MedGenMed. 2007;9(2): Noel JK, Fahrbach K, Estok R, et al. Minimally invasive colorectal resection outcomes: short-term comparison with open procedures. J Am Coll Surg. 2007;204(2): Kahnamoui K, Cadeddu M, Farrokhyar F, Anvari M. Laparoscopic surgery for colon cancer: a systematic review. Can J Surg. 2007;50(1): Tilney HS, Lovegrove RE, Purkayastha S, Heriot AG, Darzi AW, Tekkis PP. Laparoscopic vs open subtotal colectomy for benign and malignant disease. Colorectal Dis. 2006;8(5): Ballantyne GH. Laparoscopic colectomy: an update. Accessed June 9, Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008: Sgambati SA. Minimally invasive surgery for diseases of the colon & rectum: the legacy of an ancient tradition. In: Jager RM, Wexner S, eds. Laparoscopic Colorectal Surgery. Churchill & Livingstone: New York, NY; 1995: Anthony T, Simmang C, Hyman N, et al; Standards Practice Task Force; American Society of Colon and Rectal Surgeons. Practice parameters for the surveillance and follow-up of patients with colon and rectal cancer. Dis Colon Rectum. 2004;47(6): Danny Hageman, RN, CNOR, AS-C, is an RN first assistant and perioperative educator at Wooster Community Hospital, Wooster, OH. Mr Hageman has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Victoria Caillet, RN, CNOR, is a facility administrator at Wooster Orthopedic and Sports Medicine Surgery Center, Wooster, OH. Ms Caillet has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Jeff Kostohryz, RN, BSN, CNOR, is a staff nurse at Wooster Community Hospital, Wooster, OH. Mr Kostohryz has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Sue Madick, RN, BA, CNOR, is a per diem RN at Wooster Community Hospital, Wooster, OH. Ms Madick has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Future Congress Dates and Locations Make plans now to attend AORN Congress in upcoming years. Following is a list of future Congress dates and locations: 2009 March 15 to 19, Chicago, Illinois 2010 March 14 to 18, Denver, Colorado 2011 March 19 to 24, Philadelphia, Pennsylvania 2012 March 25 to 29, New Orleans, Louisiana 2013 March 3 to 7, San Diego, California 412 AORN JOURNAL

11 Examination 2.3 Laparoscopic-Assisted Colon Surgery PURPOSE/GOAL To educate perioperative nurses about caring for patients undergoing laparoscopic-assisted colon surgery. BEHAVIORAL OBJECTIVES After reading and studying the article on laparoscopic-assisted colon surgery, nurses will be able to 1. compare the advantages of the laparoscopic versus open approach to colectomy, 2. discuss contraindications for the laparoscopic approach to colectomy, 3. identify diagnostic tests that should be performed preoperatively and postoperatively, 4. discuss perioperative nursing care of patients undergoing laparoscopic-assisted colon surgery, 5. describe laparoscopic-assisted colon surgery, and 6. discuss postoperative follow-up care recommended for patients who have undergone laparoscopic-assisted colorectal surgery. 1. Advantages of the laparoscopic versus open approach to colectomy include that 1. colon function normalizes faster after laparoscopic manipulation than after open exposure manipulation. 2. less intra-abdominal scarring and adhesion formation result. 3. operating time is markedly reduced. 4. the incidence of obstructive episodes may be reduced. 5. the laparoscopic approach is significantly less expensive than open techniques. a. 2 and 3 b. 1, 2, and 4 c. 2, 3, 4 and 5 d. 1, 2, 3, 4, and 5 2. The laparoscopic approach may be contraindicated for patients suffering from severe restrictive pulmonary disease because of the patient s inability to tolerate carbon dioxide (CO 2 ) insufflation. a. true b. false QUESTIONS 3. The presence of a synchronous colonic neoplasia should be identified preoperatively by a. pulmonary function tests in conjunction with thoracic ultrasound. b. colonoscopy or air-contrast barium enema with sigmoidoscopy. c. rigid sigmoidoscopy and barium swallow. 4. Preoperative nurses should ensure that patients who are at risk for experiencing unplanned perioperative hypothermia are prewarmed for a minimum of minutes immediately before induction of anesthesia. a. 15 b. 30 c. 45 d For laparoscopic sigmoid colectomy, the circulating nurse, RN first assistant, and surgeon place the patient in the position. a. lateral decubitus AORN, Inc, 2008 SEPTEMBER 2008, VOL 88, NO 3 AORN JOURNAL 413

12 SEPTEMBER 2008, VOL 88, NO 3 Examination b. supine c. prone d. low lithotomy 6. The expected outcome for the nursing diagnosis Anxiety related to deficient know ledge and stress of surgery is that the a. patient demonstrates knowledge of pain management. b. patient is free from signs and symptoms of physical injury acquired during the perioperative period. c. patient demonstrates knowledge of psychological responses to the surgical procedure. d. patient is at or returning to normo - thermia at the conclusion of the immediate postoperative period. 7. Care is taken during dissection of the colon to identify and protect the a. mesoappendix. b. liver. c. left ureter. d. urethra. 8. During a right hemicolectomy, the surgeon uses staples or sutures to perform the resection and anastomosis of the diseased segment a. extracorporeally. b. intracorporeally. 9. The practice parameters written by the Standards Practice Task Force and the American Society of Colon and Rectal Surgeons for follow-up care of patients who have undergone resection/anastomosis or local excision of rectal cancer include 1. performing routine follow-up hepatic imaging studies. 2. ensuring that the patient is seen in the office at least three times per year for the first two years after surgery. 3. routinely obtaining follow-up serum hemoglobin, a guaiac test for fecal occult blood, and liver function tests. 4. ensuring that the patient undergoes carcinoembryonic antigen evaluation at least three times per year for the first two years after surgery. 5. having the patient undergo a colonoscopy at three-year intervals. a. 1 and 3 b. 2, 4, and 5 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and On postoperative days one and two, it is normal for a patient to have red discharge from the rectum after undergoing colectomy. a. true b. false The behavioral objectives and exam ination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accred ited as a provider of continuing nursing education by the American Nurses Creden tialing Center s Commission on Accredit ation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. 414 AORN JOURNAL

13 Answer Sheet 2.3 Laparoscopic-Assisted Colon Surgery Event #08049 Session #1313 Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to: AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO or fax with credit card information to (303) Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit. Signature 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 2.3 continuing education contact hour (138-minute) program. 4. Enclose fee if information is mailed. AORN (ID) # Name Address City Phone number RN license # Fee enclosed State Zip State or bill the credit card indicated MC Visa American Express Discover Card # Expiration date Signature (for credit card authorization) Fee: Members $11.50 Nonmembers $23 Program offered September 2008 The deadline for this program is September 30, 2011 AORN, Inc, 2008 A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. SEPTEMBER 2008, VOL 88, NO 3 AORN JOURNAL 415

14 2.3 Learner Evaluation Laparoscopic-Assisted Colon Surgery This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5. PURPOSE/GOAL To educate perioperative nurses about caring for patients undergoing laparoscopic-assisted colon surgery. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Compare the advantages of the laparoscopic versus open approach to colectomy. 2. Discuss contraindications for the laparoscopic approach to colectomy. 3. Identify diagnostic tests that should be performed preoperatively and postoperatively. 4. Discuss perioperative nursing care of patients undergoing laparoscopic-assisted colon surgery. 5. Describe laparoscopic-assisted colon surgery. 6. Discuss postoperative follow-up care recommended for patients who have undergone laparoscopic-assisted colorectal surgery. CONTENT To what extent 7. did this article increase your know ledge of the subject matter? 8. was the content clear and organized? 9. did this article facilitate learning? 10. were your individual objectives met? 11. did the objectives relate to the overall purpose/goal? TEST QUESTIONS/ANSWERS To what extent 12. were they reflective of the content? 13. were they easy to understand? 14. did they address important points? LEARNER INPUT 15. Will you be able to use the information from this article in your work setting? 1. yes 2. no 16. I learned of this article via 1. the Journal I receive as an AORN member. 2. a Journal I obtained elsewhere. 3. the AORN Journal web site. 17. What factor most affects whether you take an AORN Journal continuing education examination? 1. need for continuing education contact hours 2. price 3. subject matter relevant to current position 4. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): Author names and addresses: 416 AORN JOURNAL SEPTEMBER 2008, VOL 88, NO 3 AORN, Inc, 2008