Imagine this scene in the OR: A surgeon who is performing a tedious laparoscopic procedure starts to experience hand-eye fatigue. The assistant holding the camera for the surgeon’s visualization experiences involuntary tremor. That in turn results in motion artifacts on the video resembling an earthquake. Other members of the surgical team aren’t spared, either: They are getting “seasick” as they watch the wavering image on the screen. Obviously, all of this is affecting the team’s concentration and performance of critical tasks.

 

Now a solution exists: robotic-assisted laparoscopy. The surgical team uses a robot with three to four mechanical arms to perform complex surgery without the problem of human hand-eye fatigue — and with a high degree of precision. In fact, the movement possible with robotic “hands” and instrument tips is superior to that possible with the human hand.

 

As robotic-assisted laparoscopy grows more widespread, more nurses are likely to encounter patients scheduled for or recovering from such surgery — or be a member of a surgical team that uses robots. To fully appreciate the impact of robots in the OR during laparoscopy, the nurse must have a fundamental knowledge of endoscopy, which is the use of telescopes and long instruments to enter the body through a natural body orifice or a series of tiny incisions in the skin. The term endo means inside, and scopy means to look. Endoscopic procedures are usually named for the entry point location of the body, such as neuroendoscopy for the ventricles of the brain or hysteroscopy for procedures of the uterus. The use of endoscopes in abdominal surgery is termed laparoscopy.¹ (Laparo means loins or flank.)

 

 

Endoscopy has a long history, with roots in ancient Greek medicine, as in Hippocrates’ use of tubular specula for examination of natural body orifices. This was a tenuous procedure, since lighted candles and torches were used for illumination. Visualization of internal structures was poor, and procedural tissue manipulation was restricted to grasping instruments and metallic cauterization tips heated by fire.^{2 Level B} Endoscopic techniques through natural orifices improved in the 19th century as the use of mirrors and other reflecting elements enhanced illumination. But reflected illumination generated uncontrolled heat in the patient’s tissues, causing burns. (Methane in the colon was a source of combustion.) Later, small electric bulbs were used with some success. However, the risk of electrocution was significant.¹

 

In the late 1800s, urologists and opticians made major strides in technique and safety by creating a telescope illuminated by an external light source for viewing inside a patient’s urinary bladder. This invention, the cystoscope, increased the field of vision by directing light through a lens to the interior of the working space, which was created by sterile water in the bladder. (Bladder endoscopy is called cystoscopy.)¹

 

In the early 20th century, surgeons developed a new method to create a working space: insufflation of air into a body cavity. Surgeons experimented by using ambient air to expand the peritoneal cavity and look inside with the newly developed cystoscope. But problems included fires and explosions caused by electric sparks in an oxygen-enriched environment.

 

Surgeons later switched to carbon dioxide (CO₂), which is readily absorbed by the peritoneal membrane of the abdomen and easily excreted from the body via the pulmonary system. CO₂ is nonflammable and safe for use in endoscopy.¹

 

In the mid-20th century, surgeons refined endoscopy to incorporate the measurement of intra-abdominal pressure and the use of refined electrosurgical techniques for procedures including tubal coagulation for female sterilization. The introduction of fiberoptic technology permitted videotaping and photographing of internal structures, thus enabling more advanced procedures, such as cholecystectomy (removal of the gall bladder) and bariatric surgery. The next step was robotic control for precise movement within the working space.