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CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

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Lesson Plan CIS 213
Polar Express: Laparoscopic Surgical Procedures
[Reprinted from Communiqué: May/June 2009]

Newly employed Central Service technicians in many healthcare organizations are given a tour of the facility as part of their orientation process. This helps them discover the environment within which they work, and it emphasizes the significant role they will play in safeguarding the health and well-being of patients, their co-workers, and themselves. They also better understand the importance of their responsibilities as they see how instruments are actually used in surgical suites on patients, and they recognize that processing protocols must be consistently followed to make instruments safe for reuse. In this lesson, you will learn some of what those in orientation might discover about laparoscopes and their uses for several surgical procedures..

A laparoscope is one of three types of endoscopes which are tubes inserted into a body orifice or a tiny incision to access structures or internal organs. Endoscopes, such as laparoscopes (the topic of this lesson), arthroscopes, and cystoscopes, can be rigid. Endoscopes can also be flexible (examples include angioscopes, bronchoscopes, and hystereoscopes), and semi-rigid endoscopes, such as ureteroscopes, have some movement.

Laparoscopic surgery, also called “minimally invasive surgery” involves making one or more small incisions near the patient’s navel to allow a laparoscope to be inserted. Laparoscopy is also called “keyhole surgery” because surgeons use instruments manipulated from outside the patient’s body rather than their hands inside the body to perform the surgery. Note: some procedures combine the use of laparoscopic instruments with the enlargement of an incision to permit direct access (the surgeon’s hand) to the surgical site. This is necessary, for example, when the size of the organ being removed cannot be removed through the trocar (a hollow tube with a seal that prevents CO₂ from leaking from the incision). Examples include removal of all or part of the colon (colectomy) and removal of the kidney (nephrectomy). Some surgeons perform these procedures with a laparoscope and then make a larger incision at the end of the procedures for organ removal. Others make a larger incision earlier in the procedure and then use their hand inside the abdomen during the surgery.

A laparoscope is comprised of a telescopic lens system that is typically connected to a video camera that projects images to one or more video monitors. It also includes a fiber optic cable system that provides “cold light” to illuminate the surgical site such as the patient’s abdominal and pelvic organs. Several types of instruments (operating tips) including scissors, graspers, forceps, and dissectors are used in the same manner as they would be used during an open procedure, but they are designed to fit through the trocar and extend into the abdominal cavity from the skin’s surface. Some laparoscopic dissectors and scissors use monopolar or bipolar electrical circuits.¹

Other components of laparoscopic instruments include insufflation and suction-irrigation systems. In addition, a multi-shelf video cart contains a primary video monitor, light source, camera, printer, and insufflator. A bi-polar electrosurgical unit, post-irrigation system, and other equipment might also be included. As well, a second cart with a second monitor is normally located on the opposite side of the operating room table to allow the surgical team on that side of the table to view the procedure. Monitors are joined (connected) with a co-axial cable system.

Laparoscopic instruments may be disposable, reusable, reposable (reusable instruments with disposable cutting or coagulation tips), or a combination of these alternatives.

Laparoscopy may be performed at surgery centers or in a hospital. Local anesthesia may be used for biopsies and diagnostic procedures (removal of microscopic tissue samples), but general anesthesia is needed when operative procedures, including abdominal surgery, are being done. After the patient is anesthetized, a hollow needle is inserted into the abdomen in or near the navel, and carbon dioxide (CO₂) gas is pumped through the needle to expand the abdomen. Note: the CO₂ is later absorbed by the tissue and removed by the body’s respiratory system. The laparoscope is inserted through the incision, and additional small incisions may be made to insert other instruments used for specific surgical procedures.

Laparoscopy is used for numerous diagnostic purposes. For example, it is useful in taking biopsies of abdominal or pelvic growths and lymph nodes. Laparoscopic instruments can also be used to examine organs including the appendix, gall bladder, stomach, liver, and the female organs. Laparoscopy is also used for gastric bypass surgeries and to determine the causes of pelvic pain and gynecological concerns (those affecting female reproductive organs) that cannot otherwise be determined by physical exams or other methods.

Examples include ovarian cysts (bladder- like pouches containing fluids), endometriosis (a disease in which uterus-like tissue located elsewhere reacts to the menstrual cycle and causes inflammation and bleeding), and ectopic pregnancies (those which develop outside the uterus). Blocked fallopian tubes can also be diagnosed with laparoscopic instruments.

Laparoscopy is used extensively for noncancerous treatment procedures. Interestingly, it was first used (early 1970s) to treat cancer patients by observing the liver and then conducting biopsies on this organ; however, its use instead of additional (open) surgery to completely remove cancerous growth and surrounding tissues is controversial because laparoscopic procedures to remove cancerous and surrounding tumors and lymph nodes are more limited. However, it may be used to assess the spread of certain cancers.

Several advantages accrue to patients when laparoscopic (rather than traditional surgical procedures) are performed.

These include:

• Smaller incisions that reduce pain and shorten recovery time.
• Lessened blood loss that reduces the need for blood transfusions.
• Reduced pain and the subsequent need for pain medication.
• Shortened hospital stays (often same-day discharge).
• Reduced exposure of internal organs to possible external contaminants that increase the risk of infections.
• Smaller external scars and generally less internal scarring.

Laparoscopy is a relatively safe procedure but, as is true with any surgical intervention, complications can occur, and these include:

• Trocar injuries to blood vessels or the small or large intestines.
• Electrical burns unobserved by surgeons which occur from electricity leaking into surrounding tissue.
• An inability to tolerate gas in the abdominal cavity which can create the need to begin open surgery after the initial laparoscopic procedure has begun.
• The possibility of temporary pain caused by pockets of CO₂ gas in the abdomen before it is eliminated.

Laparoscopy is commonly used for several surgical procedures including:

• Cholecystectomy – This is the most common laparoscopic procedure and involves removal of the gall bladder. The laparoscope is inserted into the abdomen through trocars and enables very small operating tips such as graspers, scissors, and clip pliers to be used at the surgical site. Bile contained in the gall bladder is suctioned out, and the deflated gall bladder is then removed through the incision at the patient’s navel.
  
  
• Hysterectomy – This procedure involves the removal of the uterus and, sometimes, the ovaries as well. A laparoscopic-assisted vaginal hysterectomy (LAVH) involves detaching the uterus and removing it through an incision made at the top of the vagina. A total laparoscopic hysterectomy involves disconnecting the uterus and other structures, and all tissue to be removed is passed through the vagina or abdominal incisions. A large ovarian cyst can be removed without rupture inside the abdominal cavity by placing it in a surgical-grade pouch that is passed through the vagina. The cyst can also be collapsed inside the pouch so it can be passed through the laparoscopic incision.
  
  
• Laparoscopic Appendectomy – This procedure involves making several tiny cuts in the abdomen and then inserting a laparoscopic camera and surgical instruments to remove the appendix: a narrow, small, and finger-shaped portion of the large intestine that hangs down from the lower right side of the colon.
  
  
• Laparoscopic Gastric Bypass (Bariatric Surgery) – Also known as weight loss surgery, this refers to surgical procedures used to treat obesity by modifying the gastrointestinal track to reduce nutrient intake and/or absorption. The surgeon uses laparoscopic instruments to create a small pouch that is attached to the middle part of the small intestine. Food then by-passes the upper part of the small intestines and stomach. Weight loss occurs because it does not take much to fill the small pouch, and the patient has the feeling of “being full” after only a small amount of food or liquid is consumed, and the amount of calories and nutrients absorbed by the body is reduced.
  
  
• Laparoscopic Esophageal Surgery – Esophageal surgery, also called anti-reflux surgery, is performed to reduce the symptoms of heartburn and the backflow of stomach contents into the esophagus. The procedure involves wrapping the upper curve of the stomach (called the fundus) around the esophagus and sewing it so the lower portion of the esophagus passes through a small tunnel in the stomach muscle. This strengthens the valve (lower esophageal sphincter) between the esophagus and stomach and lessens the amount of acid that accumulates in the esophagus. This surgery can be performed using an initial and four subsequent small incisions to accommodate the laparoscopic instruments. Bi-polar shears, scissors, and forceps are among the laparoscopic operating tips that are used.
  
  
• Laparoscopic Partial Nephrectomy – This procedure involves removal of relatively small renal cell carcinoma tumors from the kidney. Small incisions can be made in the patient’s back or abdomen, and a laparoscopic ultrasound may be used to determine the exact location and depth of the tumor. The specimen is enclosed in a pouch and is then retrieved through an expanded incision. Note: This procedure may also be done using a hand-assisted method.

What’s in the Future?

Robotically-assisted laparoscopic surgery is increasingly available. For example, surgeons can work several feet from the operating room table while seated at computerized equipment that presents a three-dimensional view of the operating field at the surgical site. They operate controls similar to “joy sticks” that move mechanical arms on a robot with specialized instruments that conduct the hand-like movements required to perform the surgery. Robotic surgery may offer a possible tactic for developing nations in which a central hospital can operate several remote machines at distant locations. As well, military personnel are interested in robotically-assisted laparoscopic surgery because mobile medical care can be provided while keeping trained doctors away from battle areas.

Endnote:
1 See, for example, Sue Klacik. Polar Express: Monopolar and Bipolar Instrumentation
(Part I). CIS Self-Study Lesson. Communiqué. November-December, 2008.

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