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July 2011The self-study lesson on this central service topic was developed by STERIS. The lessons are administered by KSR Publishing, Inc.

Earn CEUsThe series can assist readers in maintaining their CS certification. After careful study of the lesson, com-plete the examination at the end of this section. Mail the complete examination and scoring fee to Health-care Purchasing News for grading. We will notify you if you have a passing score of 70 percent or higher, and you will receive a certificate of completion within 30 days. Previous lessons are available on the Internet at www.hpnonline.com.

CertificationThe CBSPD (Certification Board for Sterile Processing and Distribution) has pre-approved this in-service for one (1) contact hour for a period of five (5) years from the date of original publication. Successful completion of the lesson and post test must be documented by facility management and those records maintained by the individual until re-certification is required. DO NOT SEND LESSON OR TEST TO CBSPD. For additional information regarding certification con-tact CBSPD - 148 Main Street, Suite B-1, Lebanon, NJ 08833 • www.sterileprocessing.org. For more infor-mation direct any questions to Healthcare Purchasing News (941) 927-9345, ext 202.

Learning Objectives1. Explain common laparoscopic

procedures and their benefits for patients

2. Discuss the components of laparoscopic instruments

3. Understand the general guidelines for handling and reprocessing these devices

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Today’s global healthcare mandate calls for minimizing patient dis-comfort, helping to assure fewer complications, and offering surgical options with shorter healing times. This patient-centered culture provides an opportunity for surgeons to develop progressively less invasive laparoscopic surgical procedures. In turn, new minimally invasive methods often require more complex surgical tools. Since sterile processing professionals must handle and disinfect these devices effec-tively, it is helpful to gain a deeper under-standing of this type of instrumentation and the procedures for which they are used.

Scope components and functionA laparoscope is a device with tubes, or lumens, that are inserted into a body ori-fice or a tiny incision, to access structures or internal organs. Devices such as lapa-roscopes, arthroscopes, and cystoscopes often have rigid tubes. Endoscopes such as angioscopes, bronchoscopes and hysteroscopes typically have more flexible lumens, and semi-rigid endoscopes such as ureteroscopes allow some movement.

Laparoscopic surgery, also called minimally invasive surgery or MIS, involves making one or more small incision(s) near the patient’s navel to allow a laparoscope to be inserted. Laparoscopy is also called “keyhole surgery” because surgeons use instruments manipulated from out-side the patient’s body to perform the surgery rather than having their hands directly inside the body. There are also some procedures that combine the use of laparoscopic instruments with an enlarged inci-sion to permit direct access to the surgical site. This is necessary, for example, when the size of the organ is too large to be removed through the trocar (a narrow hollow tube used to remove tissue). Examples of these procedures include removal of all or part of the colon (colectomy; pronounced co-lek-toe-mee) and

A laparoscopic surgery primer for Spd professionalsby Monica Trepicone MS, BSN, RN

removal of the kidney (nephrectomy; pro-nounced nef-rek-toe-mee).

A laparoscope contains 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 and 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 also use monopolar or bipolar electrical circuits to cauterize tissue and reduce bleeding. Laparoscopic instruments may be disposable, reusable, reposable (reusable instruments with disposable cut-ting or coagulation tips), or a combination of these alternatives.

MIS equipment booms

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Laparoscopic devices also include such components as insufflation (inflating with gas) and suction-irri-gation systems. In addition, a multi-shelf video cart or ceiling-mounted equipment management boom holds a primary video monitor, light source, camera, printer and insufflator. A bi-polar electro-surgical unit, post-irrigation system, and other equipment might also be included, and a second cart or boom with a second moni-tor 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 con-nected through a cable system that carries the signals.

Benefits and risks for patientsPatients typically experience a number of advantages when laparoscopic procedures are used in place of traditional open surgi-cal procedures. These include:• Smaller incisions that reduce pain and

shorten recovery time• Less blood loss, which 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 scarringAlthough laparoscopy is a relatively safe

procedure, complications can occur as with any surgical intervention. These include: trocar injury to blood vessels or the small or large intestines; electrical burns from electricity leaking into surrounding tis-sue; infection after a procedure due to im-properly disinfected or sterilized devices; a patient’s inability to tolerate gas in the abdominal cavity, which can force an open procedure after the initial laparoscopic procedure has begun; or temporary pain caused by pockets of CO2 gas in the abdo-men before they dissipate.

Where and how they’re usedAlthough laparoscopy was first used in the early 1970’s to treat cancer patients by observing the liver and then conducting liver biopsies, laparoscopic procedures have inherent limitations. There has therefore been controversy over how ef-

fective these procedures are at completely removing cancerous growth and surround-ing tissues. Laparoscopy is used today extensively for noncancerous treatment procedures, but it can still be used to assess the spread of certain cancers.

Laparoscopy is performed at outpatient surgery centers or in a hospital, depending on the complexity of the procedure. Local anesthesia may be used for biopsies and diagnostic procedures such as the removal of microscopic tissue samples, but general anesthesia is needed when procedures with abdominal surgery are being done.

After the patient is anesthetized, a hol-low needle is inserted into the abdomen in or near the navel, and carbon dioxide gas is pumped (insufflated) through the needle to expand the abdomen. This gas is used because it is eventually absorbed by the tissue and removed by the body’s respiratory system. The laparoscope is then 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 diag-nostic purposes. For example, it is useful for taking biopsies of abdominal or pelvic growths and lymph nodes. Laparoscopic instruments can also be used to examine internal organs including the appendix, gall bladder, stomach, liver, and the fe-male uterus, ovaries and fallopian tubes. Laparoscopy is also used for gastric bypass surgeries and to determine the causes of pelvic pain and symptoms related to female reproductive organs that cannot 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 that develop outside the uterus). Blocked fallopian tubes can also be diag-nosed with laparoscopic instruments.

In addition, laparoscopy is commonly used for a number of surgical procedures, including:• Cholecistectomy (pronounced ko-lee-

sis-tek-tomee) – the removal of the gall bladder. It is one of the most common laparoscopic procedures. 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 pa-tient’s navel.

• Hysterectomy (pronounced hiss-ter-ek-to-mee) – the removal of the uterus and sometimes the ovaries. A laparoscopic-assisted vaginal hysterectomy (LAVH) involves detaching the uterus and remov-ing it through an incision made at the top of the vagina. A total laparoscopic hysterectomy involves disconnecting the uterus and other structures and passing the removed tissue through the vagina or abdominal incisions. Even a large ovarian cyst can be removed without rupturing 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.

• Appendectomy (pronounced ap-pen-dek-toe-mee) – removal of the appendix, a small, finger-shaped portion of the large intestine that hangs down from the lower right side of the colon. This procedure involves making several tiny cuts in the abdomen and then inserting a laparo-scopic camera and surgical instruments to remove the appendix.

• Gastric bypass (bariatric) surgery – also known as weight loss surgery, this re-fers to surgical procedures used to treat obesity by modifying the gastrointestinal tract to reduce nutrient intake and/or ab-sorption. The surgeon uses laparoscopic instruments to create a small pouch that is attached to the middle part of the small intestine. Food then bypasses the upper part of the small intestines and stomach, so the amount of calories and nutrients absorbed by the body is reduced. 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.

• Esophageal (pronounced ee-sof-a-gee-al) surgery – also called anti-reflux surgery, this is performed to reduce the symptoms of heartburn and the backflow of stomach

See Self-Study SerieS on page 38

38 July 2011 • HEALTHCARE PuRCHAsing nEWs • www.hpnonline.com

sELf-sTudy sERiEs Sponsored by contents into the esophagus. The proce-dure 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 ac-commodate the laparoscopic instruments. Bi-polar shears, scissors, and forceps are among the laparoscopic operating tips that are used.

• 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 laparo-scopic ultrasound may be used to deter-mine the exact location and depth of the tumor. The cancerous tissue is enclosed in a pouch and is then retrieved through an expanded incision. This procedure is also done using a hand-assisted method.

A scope is a scope is a scope – not so!There are two important considerations to take into account when handling lapa-roscopic devices. First, endoscopes are delicate, complex, expensive and typically limited in number, so they require signifi-cantly greater special care and handling than simpler surgical instruments to safe-guard their function and effectiveness. In addition, new devices (such as robotic sys-tems) are constantly being developed, each with highly specialized components for specific surgical or diagnostic purposes, and each new scope requires additional training for the sterile processing department.

The second equally important consider-ation is patient safety. In order to assure the therapeutic benefits and avoid cross-contamination of patients, these complex lumened instruments must be carefully disassembled, thoroughly cleaned, and disinfected or sterilized while also being kept in pristine operating condition. Be-fore handling laparoscopic devices for the first time, and any time there is a question, sterile processing professionals should

review that device’s instructions for use, paying particular attention to instructions for disassembly, cleaning, disinfection and proper handling. Although general best practices for handling and reprocessing (such as those from AAMI and AORN) ap-ply to all soiled surgical instruments, there will also be specific requirements for each endoscope.

In general, all instruments should be inspected for defects and damage to the insulation before each use. During surgical procedures, they should be kept clean by wiping surfaces with a sponge moistened with sterile water. Lumened instruments should also be irrigated with sterile water to prevent the buildup of bioburden within the lumens. In addition, any instruments that were placed on the sterile field should be considered contaminated. Modular instru-ments should be taken apart according to the manufacturer’s directions, then flushed and inspected for damage before transport-ing them to the central sterile department. An enzymatic presoak/cleaner can be used to keep bioburden from drying on the in-struments during transport.

The future of laparoscopyThe latest innovation in laparoscopy is robotically assisted laparoscopic surgery, which is becoming increasingly available in today’s hospitals. With this amazing new technology, surgeons can now work several feet from the operating room table – or even remotely from another room – while seated at computerized equipment that presents a three-dimensional view of the surgical site. They operate controls sim-ilar to “joy sticks” that move mechanical arms on a robot. The robot uses highly specialized instruments that perform extremely precise, delicate hand-like movements to complete the surgery.

In the future, robotic surgery may offer a pos-sible tactic for de-veloping nations, in which a central hospital may be able to operate sev-eral remote robotic systems at distant loca-tions. Military person-nel are also interested in robotically assisted lapa-roscopic surgery because it offers the ability to provide mobile medical care while keep-ing trained doctors away from battle zones.

It is clear that laparoscopy of all kinds is here to stay. The therapeutic benefits are enough to justify minimally invasive methods, and innovative surgeons will continue to refine these procedures even more for the benefit of patients. But these reusable medical devices cannot be used successfully without the commitment of the sterile processing professionals who prepare them for each new surgical case. Armed with a thorough understanding of how and why they are used, and how they must be handled, these technicians can help to optimize the function, safety and useful life of their facility’s advanced surgical technologies. HPn

References:

1. ANSI/AAMI ST081: 2004 Reusable Laparoscopic Instrument Care and Handling Guidelines. Association for the Advancement of Medical Instrumentation, www.aami.org.

2. ANSI/AAMI ST79: 2010 Comprehensive guide to steam steril-ization and sterility assurance in health care facilities. Association for the Advancement of Medical Instrumentation. www.aami.org April 1, 2011.

3. Association of periOperative Registered Nurses: Standards, Recommended Practices and Guidelines, www.aorn.org. Denver, 2010.

4. Rothrock J. Alexander’s Care of the Patient in Surgery. 12th edition, 41-68, 358-377, 410-413. 2003.

Monica Trepicone, MS, BSN, RN is the clinical education development specialist at STERIS Corporation. She plays a key role in the develop-ment of curriculum for STERIS University and provides educational development for internal and external STERIS Customers. She works closely with instructional designers, subject matter experts, and the clinical team in develop-ing various training applications and methods. Trepicone has extensive healthcare experience as a neurosurgical operating room nurse, a clini-

cal education specialist, an OR education coordinator and a nurse consultant. She holds a Bachelor of Science Degree in Nursing from Thiel College, Greenville, Pennsylvania; and a Master of Science Degree in Organizational Leader-

ship from Mercy College, Dobbs Ferry, NY. She is a professional member of the Association of periOperative Registered Nurses (AORN), the International As-sociation of Healthcare Central Service Materiel Management (IAHCSMM), the Society for Gastroenterology Nurses and

Associates (SGNA) and the As-sociation for Professionals in Infection Control and Epide-miology (APIC). Trepicone has presented at local, regional and national conferences, as well authored numerous lesson plans for continuing education.

Self-Study SerieS from page 37

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ConTinUing EdUCATion TEST • JUly 2011

ConTinUing EdUCATion TEST • JUly 2011

A laparoscopic surgery primer for Spd professionals

1. A laparoscope is a ________ endoscope.A. RigidB. Semi-rigidC. FlexibleD. Semi-flexible

2. A trocar is:A. Element in a laparoscopic video cameraB. Sealed hollow tube that prevents CO2 leaks from incisionsC. Operating tip for a laparoscopeD. Another name for a laparoscopic scissor

3. Some laparoscopic dissectors use ________ electric circuits.A. MonopolarB. BipolarC. TripolarD. A and B above

4. Reusable instruments with disposable cutting tips are:A. DisposableB. Reusable C. Reposable D. Single use

5. laparoscopy was first used to treat patients with:A. Endometriosis B. Ovarian cysts C. Blocked fallopian tubesD. Cancer

6. Which is the most common laparoscopic procedure?A. Hysterectomy B. ColectomyC. Cholecistectomy D. Partial nephrectomy

7. laparoscopic devices also include such components as:A. Insufflation and suction-irrigation systemsB. Multi-shelf video carts or ceiling-mounted equipment management boomsC. Video monitors, cameras and printers D. All of the above

8. laparoscopy is performed only in hospital settingsA. True B. False

9. patients experience many benefits with laparoscopic procedures, such as:A. Smaller incisions and scars, reduced pain and shorter recovery timeB. Less blood loss, so fewer blood transfusionsC. Shortened hospital staysD. a, b and cE. a and b only

10. laparoscopes require significantly greater special care and handling than simpler surgical instruments because:A. They are delicate, complex and expensive B. There are often limited inventories of them in a facilityC. They must be carefully disassembled, thoroughly cleaned, and disinfected

or sterilized to assure therapeutic benefits and avoid cross-contamination of patients

D. all of the above

Circle the one correct answer:

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