MIS/Hybrid ORs

Get clinical answers to frequently asked questions about minimally invasive surgery and hybrid ORs.

  • How do you select distention media for MIS procedures?

    The distention media is chosen based on the properties of the gas or fluid media, the procedure type, energy generating devices to be used and the patient’s history.

    • Gas distention media is used during MIS procedures for creating a pneumoperitoneum or space to visualize the surgical field with the endoscope. Carbon Dioxide (CO2) is the most commonly used gas for insufflation.
    • Fluid distention media should be selected based on the medium least likely to cause complication in the event of excess fluid absorption and on compatibility with energy-generating devices. Hypotonic solutions such as 1.5% glycine, 3% sorbitol, or 5% mannitol are most often selected when monopolar instrumentation is required for gynecological and urologic endoscopic procedures. An isotonic solution, normal saline 0.9%, is most frequently selected as distention fluid and is safe in procedures where bipolar instruments will be used for resection.

    Resources:

    • AORN Guideline for Minimally Invasive Surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 1, 2016

  • What is the adverse reaction to excess absorption of hypotonic solution?

    Fluid overload and hyponatremia can occur when excess hypotonic solutions are utilized as distention media for MIS procedures. This is sometimes referred to as TUR syndrome because it was first reported in transurethral resection of the prostate (TURP) procedures.

    The fluid can be absorbed through the disrupted vessels or when the pressure in the cavity is higher than the mean arterial pressure. The absorption of excess hypotonic solution changes the plasma sodium concentration and the tonicity of the cells resulting in a fluid shift. The plasma sodium concentration decreases rapidly if the volume of fluid infused into the patient exceeds the capacity of the kidneys to excrete the excess fluid.

    Cases have been reported of complication from excess fluid absorption including heart failure, cerebral edema and pulmonary edema. Fluid distention-related complications occur in less than 1% of procedures but the risks increase with the length of the procedure and the degree of dissection of the surrounding tissues. Most healthy adults can accommodate the fluid absorption, but patients with co-morbidities (i.e. cardiovascular or renal dysfunction) are at higher risk for complications.

    Resources:

    • AORN Guideline for Minimally Invasive Surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 1, 2016

  • What is best practice for staffing the Hybrid OR?

    A minimum of one RN circulator dedicated to each patient undergoing an operative or other invasive procedure facilitates the provision of safe, quality patient care in the perioperative setting. Additional personnel should be assigned depending on the type of procedure and the skill mix required. The skill mix required is dependent on the procedure and requires unique coordination of ensuring the right personnel are in the room at the correct time due to the phasing of most hybrid procedures. A centralized team and the use of the Health Failure Mode and Effects Analysis (HFMEA) has been reported to provide a systematic approach to help ensure room readiness and personnel competency for the complex Hybrid OR environment. Use of change management strategies in the development of clinical, infection control and radiation protocols assists the team working in a hybrid room.

    Resources:


    Updated December 1, 2016

  • What are the safety zones for an MRI environment?

    Magnetic Resonance Imaging (MRI) equipment contains a strong magnetic force that can pose a safety risk if the environment is not screened and secured. The safety zones define areas of exposure or risk to the magnetic force of the imaging equipment.

    • Zone IV designates the area that is closest to the magnetic force and is the most restricted area. Only non-ferromagnetic equipment can be in this zone because metal objects can become projectiles if they are in Zone IV. Anesthesia machines and O2 tanks should be screened to meet these restrictions.
    • Zones II and III are transition areas for patient waiting and movement into the imaging area. All patients and personnel entering Zone III should first pass an MRI safety screening process. Patients and personnel are screened for implants, tattoos, and other items that may cause injury if exposed to the magnetic force.
    • Zone I is the least restricted and furthest from the magnet.

    Resources:

    • AORN Guideline for Minimally Invasive Surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 1, 2016

  • Is the MRI magnet always on in a hybrid OR?

    A hybrid OR with MRI imaging equipment generally stores the magnet in an area that allows the OR to be safe from the magnetic force of the imaging equipment until it is brought into the room. Checklists help the healthcare providers screen patients, personnel and the environment to assure it is safe prior to bringing the imagining equipment into the room.

    Resources:

    • AORN Guideline for Minimally Invasive Surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 1, 2016