Reducing positioning changes during robotic lead placement

AORN Journal, Feb, 2006 by Susan Underwood

As the use of robotics in surgery continues to evolve, the nursing practice that supports it also must evolve. Perioperative nurses are challenged to adapt their practice and to think creatively to care for their patients safely and efficiently as new procedures emerge. To reduce anesthesia and OR time, surgical complications related to repositioning, and the costs of a two-stage procedure to place biventricular pacing leads, perioperative team members at Cooper University Hospital, Camden, NJ, found a way to perform a robotic cardiac procedure without repositioning the patient.

ROBOTICS IN CARDIOTHORACIC SURGERY

The use of robotics is relatively new to cardiothoracic endoscopic surgery. Robotically assisted atrial septal defect repair, mitral valve repair, and coronary artery bypass grafting all have been reported in journals during the past decade. (1-3) More recently, the use of a robot in cardiac surgery has expanded to include the placement of epicardial leads in patients requiring biventricular pacing. (4) During the two-stage procedure, the patient is placed in a lateral position for the robotic lead placement and then repositioned in a supine position for creation of the pocket for the generator implantation. (4)

At Cooper University Hospital, perioperative team members have expanded the use of the robotic system to include pericardial lead placement for patients with congestive heart failure who require biventricular pacemakers. The cardiothoracic surgeons originally performed the procedure in two stages, as described. As the team members gained experience with the two-stage procedure, however, concerns arose. Some of these concerns were that

* changing a patient's position after endotracheal intubation increases patient risk;

* repositioning a patient requires increased anesthesia and OR time, which increases the risk of complications;

* repositioning increases the risk for patient injury; and

* two-stage procedures can be costly in both OR time and supplies,

A NEW APPROACH

In an attempt to avoid repositioning the patient, team members developed an approach that would allow the surgeon to perform the robotic procedure from the patient's back and still access the left sub-clavian area for the generator placement. The patient is placed in a classic lateral decubitus position to expose the patient's left chest. (5) Team members support the patient's torso with a vacuum-packed positioning device topped with a full-body gel pad and place pillows between his or her legs. The circulating nurse and anesthesia care provider place an axillary roll under the patient's right axilla. The circulating nurse supports the patient's left arm on a padded limb support and uses foam egg crate padding for all bony prominences.

To avoid repositioning, the circulating nurse places the patient's left hand in an orthopedic finger trap. This holds the hand up and away from the patient's body (Figure 1). The resulting change in position allows the circulating nurse to prep the patient's skin from the jaw line to the hip, from the front table edge to the back table edge, and from the extended left arm to the wrist.

[FIGURE 1 OMITTED]

The surgeons have modified the draping procedure to expose the patient's left shoulder. After completing the skin prep, the circulating nurse removes the patient's hand from the orthopedic finger traps and supports the patient's forearm arm while the surgeon aseptically places a stockinette over the patient's left hand and arm. The surgeon passes the patient's left arm through the opening of a fenestrated drape and uses a padded Mayo stand to support the left arm during the robotic stage of the procedure.

After the surgeon uses the robot to position the pericardial leads and the robotic part of the procedure is complete, the robotic instrument arms are removed, and the side cart is wheeled away from the patient. The surgeon then places a single chest tube and closes and dresses the small incisions. The surgeon then draws the patient's left arm down and back and positions the arm so it is resting on the patient's side with the elbow bent so the forearm rests at approximately waist level (Figure 2). This positioning aligns the arm and shoulder at the patient's side and exposes the anterior chest wall. The surgeon then is able to create the generator pocket, connect the leads, and complete the surgery. The entire procedure is performed without repositioning the patient, reprepping, or redraping.

[FIGURE 2 OMITTED]

ADVANTAGES

A review of 12 patient charts (ie, six patients who were repositioned during a two-stage procedure, six who were not repositioned) revealed that although the average surgical time remained the same, the average time the patient was in the surgical suite was reduced by 25 to 30 minutes. This can be advantageous for patients in several ways.

* Anesthesia time is effectively reduced because the team does not have to take down an entire sterile field and then reposition, reprep, and redrape the patient.