Minimally Invasive Surgery

Purpose

This document provides guidance for creating a safe environment of care for patients and perioperative personnel during minimally invasive surgical procedures. The guideline addresses

• distension media used during endoscopic surgery,

• hybrid operating rooms (ORs),

• hybrid ORs with intraoperative magnetic resonance (MR) imaging capabilities,

• computer-assisted navigation procedures, and

• robotic-assisted surgery.

The document provides guidance to

• perioperative personnel for reducing risks to patients and perioperative team members during minimally invasive surgery (MIS) and computer-assisted technology procedures,

• perioperative registered nurses (RNs) for assisting in the management of distension media (eg, gas, fluid) and irrigation fluid, and

• health care organizations for incorporating advancements in technology with consideration for workplace safety and ergonomics.

Minimally invasive surgery is an approach used in most surgical specialties. This guideline was initially developed to provide guidance during the emergence of endoscopic procedures in the 1990s but has expanded in scope to include other emerging technologies. Advances in computer software and hardware for medical devices allow surgeons to perform surgery through smaller incisions or no incisions under the guidance of various imaging modalities. The use of these new technologies requires interdisciplinary teams and departments to merge knowledge and skill mix in new environments to optimize patient outcomes. Technological enhancements, including those that support robotic surgery and computer-assisted navigation procedures, allow for improved efficiencies and management of surgical areas.

Advancements in MIS have accelerated in recent years. The literature on recent innovations in MIS identifies significant advancements in surgical instruments,^1,2  equipment, and technology^3-8 ; however, the literature is focused primarily on surgical technique, accuracy, and the technical aspects of hardware or software design, with limited applications to perioperative nursing practice. Additional research is needed to identify safer, more efficient workflow practices for perioperative teams and to identify perioperative nursing interventions that will contribute to positive outcomes for patients undergoing MIS procedures.

The following topics are outside the scope of this document:

• enhanced recovery after surgery;

• flexible endoscopic gastrointestinal procedures;

• care and cleaning of instruments and related equipment (See the AORN Guideline for Processing Flexible Endoscopes⁹  and the AORN Guideline for Care and Cleaning of Surgical Instruments¹⁰ );

• design of the physical environment, including the hybrid OR (See the AORN Guideline for Design and Maintenance of the Surgical Suite¹¹ );

• surgical smoke safety (See the AORN Guideline for Surgical Smoke Safety¹² );

• airborne infectious agents (See the AORN Guideline for Transmission-Based Precautions¹³ );

• fluid warming (See the AORN Guideline for Prevention of Hypothermia¹⁴  and the AORN Guideline for a Safe Environment of Care¹⁵ );

• warming and humidification of insufflation gases for the purpose of maintaining normothermia (See the AORN Guideline for Prevention of Hypothermia¹⁴ );

• fluoroscopy and other sources of ionizing radiation (eg, computed tomography) (See the AORN Guideline for Radiation Safety¹⁶ );

• patient positioning (See the AORN Guideline for Positioning the Patient¹⁷ );

• surgical energy devices (See the AORN Guideline for Electrosurgical Safety¹⁸ ); and

• surgical technique (eg, trocar entry techniques).

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from March 2016 through April 2021. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until January 2022. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included 3D, 4K, abdominal hypotension, access to health care, accidents (occupational), attitude of health personnel, autofluorescence imaging, availability of health services, back injuries, blood pressure, body temperature, carbon dioxide insufflation, cholangiopancreatography (endoscopic retrograde), compartment syndromes, computer-aided surgery, contraindications (procedure), contraindications (surgery), conversion to open surgery, cooperative behavior, cross-training, daVinci, distension media, distension medium, edema, electrolytes, endoneurosurgery, endoscopic retrograde cholangiopancreatography, endovascular aneurysm repair, endovascular procedures, extravasation of diagnostic and therapeutic materials, extravasation injuries, fetal surgery, Firefly, fluid imbalance, fluid management, fluid shifts, fluid therapy, fluorescence imaging, fluoroscopy, HD, health care inequalities, health personnel, health services accessibility, health services availability, healthcare disparities, heart rate, heated insufflation, hemodynamic monitoring, hernia*, humidified insufflation, hyponatremia, image-guided surgery, imaging safety, insufflation, integration, interventional magnetic resonance imaging, interventional radiography, interventional ultrasonography, intra-abdominal hypertension, intra-abdominal pressure, intraabdominal hypertension, intraabdominal pressure, intracranial hypertension, intraoperative care, intraoperative complications, intrauterine surgery, intravascular procedures, intravascular ultrasonography, keyhole surgery, laparoscopic assisted surgery, laparoscopic surgery, laparoscopic surgical procedures, laparoscopy, lavage, lead aprons, lead garments, lead shield, magnetic resonance guided interventional procedures, magnetic resonance imaging (interventional), medically underserved area, medically underserved population, minimal access surgical procedure, minimal surgical procedure, minimally invasive procedures, minimally invasive surgery, minimally invasive surgical procedures, monitoring (intraoperative), monitoring (physiologic), MR guided interventional procedures, musculoskeletal diseases, natural orifice endoscopic surgery, natural orifice transluminal endoscopic surgery, natural orifice transluminal endoscopy, neuronavigation, nurse’s role, nurses, nursing assessment, nursing staff, occupational accidents, occupational diseases, occupational injuries, ocular hypertension, operating room nursing, operating rooms, optical imaging, patient care team, patient safety, peritoneoscopy, perioperative nursing, physician-nurse relations, physician shortage area, picture archiving and communication systems, pneumoperitoneum (artificial), postoperative complications, puncture*, racial disparities, radiography (interventional), radiosurgery, respiratory rate, robot-assisted surg*, robot-enhanced procedures, robot-enhanced surgery, robot surgery, robotic procedure, robotic surg*, robotic surgical procedures, social determinants of health, staff development, staff nurses, Stryker, surgery (computer-assisted), surgical navigation, surgical procedures (operative), systems integration, telecommunications, telerobotic*, therapeutic irrigation, thoracic surgery (video-assisted), three-dimensional, transcatheter aortic valve replacement, TUR syndrome, TURP syndrome, ultrasonic surgical procedures, ultrasonography (interventional), underserved patients, underserved populations, vascular surgery, vascular surgical procedures, and video integration.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Historical studies were also included. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1. Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted in the event of a disagreement between the lead author and the primary evidence appraiser. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-rating.