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Nursing Surgery Staff In-Service

My approach to laparoscopic surgery, including the instruments that I use, differs from most of the gynecologists in this community. I believe that the team of healthcare professionals who work with me in surgery: scrub nurses, circulating nurses, and recovery room nurses could provide better care for my patients if they better understood the purpose behind some of the differences in my surgical approaches.

The objective of most of the surgery I do is to re-establish normalcy in the pelvis to enable pregnancy to take place or to eliminate pain while preserving future fertility. There are two major influences underlying my development as a surgeon and my philosophies in surgery. The first is the body of reproductive endocrinology literature that I was introduced to in my reproductive endocrinology fellowship at the University of Miami starting about 1986 concerning microsurgical techniques. It deals with how to get tissue to heal as you intend it to without forming dysfunctional connections between pelvic structures, that is, without forming adhesions. It involves principles such as minimal tissue handling, atraumatic grasping of tissues, small suture size, operating under magnification, precise establishment of hemostasis, carefully controlled energy delivery, and anti-adhesion adjuncts.

My second influence was Dr. Harry Reich, regarded by many as one of the grandfathers of laparoscopic surgery, who was my mentor in becoming an advanced laparoscopic surgeon. I showed up on his doorstep in 1989 and he generously introduced me to the world of advanced laparoscopic surgery at a time when gynecologists were using laparoscopes only for tubal ligations and diagnostic infertility and general surgeons had not yet discovered laparoscopies for surgical access. Harry Reich is a brilliant surgeon and a generous person. I continue to actively read the literature and attend conferences on advanced laparoscopic surgery, but many of the ideas and approaches that he introduced me to fifteen years ago have not been significantly improved upon.

One of the observations I learned from Dr. Reich, which plays an important role in my surgical practice, is that laparoscopic surgery is a clean but not always a sterile operation. This is in spite of everyone's attempts to make it sterile. One of the issues relates to the fact that most laparoscopic surgeries require insertion of instruments into the vagina and cervix (which can't be fully sterilized) and subsequent injection of fluid through those instruments into the abdomen that may carry bacteria with that fluid. Laparoscopic surgery also utilizes many very long instruments. Because of the length and number of those instruments, there is potential for inadvertent contamination (e.g. top of the surgical drape, ceiling light) that is not noticed.

I do a number of things to limit the potential impact of contamination, which requires the support of the nursing staff. I start by having the scrub nurse prep the patient's abdomen and vagina. I then repeat the prep of the vagina under direct visualization and of the umbilicus using instruments to improve access to the bottom of the umbilicus. This likely further limits introduction of bacteria in the entry sites that cannot always be sterilized. During the procedure, I avoid touching the ends of the instruments with my gloves in the event that they have touched a contaminated surface. (I also wince if a see a nurse pick up an instrument by the operative end.) At the end of the case I copiously irrigate the abdomen to remove any debris that might promote adhesions as well as any inadvertent bacterial contamination. Finally I leave about two liters of Lactated Ringers solution in the abdomen. This large volume of fluid dilutes any bacterial contamination. The potential to cause infection by bacteria is partly dose related and this dilution markedly decreases the bacterial concentration. This approach can even be used for effective treatment of abdominal abscess.

The primary reason that I place and leave a large quantity of fluid in the abdomen is to decrease adhesion formation and re-formation. Basic science studies show that adhesions begin to form within two hours of completing a surgery and potential adhesions are mainly in place within 24 hours. Surgically damaged surfaces secrete a mildly sticky substance that allows the damaged surface to attach to a normal surface. The damaged surface secretes substances that promote the growth of new blood vessels between the two surfaces. Healing nutrients can then be transported between the two surfaces. When the damage is severe, the connections between the surfaces become permanent. The first step in this adhesion formation is that "at risk" structures stay next to each other. Large quantities of fluid make it harder for that event to occur because the tissues will easily move about as the patient moves.

Critics of this approach have argued that physiologic fluid is too rapidly absorbed to be of benefit, and thus that the prior microsurgical literature on hydro-floatation does not apply. However there are two studies which show that if you start with as large a volume of fluid as I do, significant fluid stays in the abdomen for several days. There are also at least two randomized studies that demonstrate a benefit in adhesion prevention in gynecological surgery with installation of a large volume of abdominal fluid.

I always use a right angle scope with an operative channel and prefer to use instruments that can be used though that channel. Generally, unless tissue is being removed, I do not use an instrument to grasp it, but rather use instruments through my lower ports to hold it in place so I can operate on the tissue through the operative port. There is less loss of depth perception through this port and I am able to operate closer to the tissue with more magnification. This results in less tissue trauma and many of my tissue dissections are nearly bloodless. Less essential, but still helpful, are the shortened Hunt-Reich lower ports. They enable surgery to take place closer to the abdominal wall without difficulty as well as suture more simply (using normal abdominal sutures and needles).

Controlling bleeding requires the application of some form of energy. The problem is that heating and tissue damage can occur below and to the sides of where that energy is applied. The best situation is avoiding bleeding or causing small capillary bleeding that stops by itself. With the long straight operating scissors and the magnification of the laparoscope, this can often be achieved during laparoscopy by visualizing and cutting the adhesions at their insertions into other tissue. If bleeding requires coagulation, I usually utilize bipolar energy. Here the electrical current, which heats tissue, runs between the paddles. The smaller the paddles used, the less adjacent spread of heat into normal tissue. I use micro tip (1 mm) paddles whenever possible.

Endometriosis presents with a different situation in which abnormal tissue (of varying depth) needs to be excised or vaporized. Here my preferred instruments are the CO2 laser or the harmonic scalpel. The only setting in which I use unipolar energy is ovarian drilling. Here, the surgical objective is different; I am trying to create intra-ovarian fibrosis or scar tissue.

Recovery Room Nursing Issues

Leaving a large quantity of fluid in the patient's abdomen complicates immediate post- operative care. Obviously I believe that the benefits of this approach strongly outweigh the problems. Some patients will begin leaking fluid in the immediate post-operative period, which can make keeping the patient dry and comfortable more difficult. Some patients feel discomfort from the abdominal distension, but not to a degree sufficient to cause complaints of pain or true difficulty breathing.

In the fifteen years that I have been using this approach, I am aware of only three types of problems my patients have experienced attributable to this fluid abdominal distension. The first and most significant of these is urinary retention. It seems that the abdominal fluid slows the return of the sensation of a distended bladder and/or the ability to fully void. When I first started doing these surgeries at Hershey Medical Center, the recovery room nurses felt that all patients were voiding adequately at discharge, but several patients presented later in the night with pain from a distended bladder in the emergency room. Dr. Harry Reich has had similar experiences. Since that time I have required that the urine output be measured and that the patient void at least 200 ml prior to discharge. If the patient is not able to do that, I will place a Foley catheter for passive drainage over the night and remove it in the morning. All patients appear to be able to void by the morning. This management is complicated by the fact that many of my patients have had a bowel prep (Go-lytely), and their surgeries may not have been completed until late afternoon. Since they are likely to be dry, I like to use a high IV fluid rate and use fluid boluses before concluding that they have a voiding problem. The incidence of a patient requiring a catheter is only one every several years.

A second problem may occur if the fluid tracks out of the abdomen above the peritoneum or fascia at the site of my suprapubic incisions. The fluid is then trapped there and resolves on its own or with a heating pad over the next few days. It appears as a "bump" near these lower incisions. Keeping a pressure dressing over these lower incisions during the immediate hours following surgery can prevent it. When this abnormal fluid tracking occurs, it looks odd, and recovery room staff becomes concerned that it may be a reflection of bleeding. It does not cause the patient pain or have any patient consequences other than their being concerned that something may be wrong. If pressure dressings are applied, I have never seen this occur.

The third problem may occur when the congenital connection between the abdomen (insertion of the round ligament) and the labia majora remains open. Fortunately, this is rare, but when it occurs, fluid tracks down to one or both labia, which become quite distended. This can be very uncomfortable, but also resolves on its own with bed rest and a heating pad. If fluid is tracking to the labia, the patient should be off her feet as much as possible to prevent the labia from being the most dependent part. If this can be noticed in the recovery room, it likely can be completely prevented from becoming a problem.

One benefit in the immediate post-operative period of leaving a large quantity of fluid in the abdomen after surgery is the near elimination of post-op shoulder pain. The theory behind the development of post-op shoulder pain is that the CO2 used to distend the abdomen forms carbonic acid, which irritates a nerve under the left diaphragm leading to left sided shoulder pain. The large quantity of fluid I place in the abdomen is thought to dilute this acid so that it is no longer irritating. Patients who previously have had laparoscopies accompanied by post-op shoulder pain clearly prefer the abdominal distension over the experience of that pain.

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