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Safe Minimally Invasive Surgery
Mark Davis
Publish Date: October 10, 2007   |  Tags:   Patient Safety

Mark S. Davis, MD, FACOGOR workers have to mentally multitask when sharps are in use, focusing simultaneously on patient and worker safety. The human tendency is to devise a pecking order, and most often, patient safety comes first. Even if there is unexpected bleeding during a procedure, and speed becomes a factor, patient safety is still at the fore, right? This is by no means wrong - it's just that you must give worker safety nearly as much attention. The major shift from open to minimally invasive surgery (MIS) might mean fewer sharps devices in use, but that doesn't mean you can forget good safety practices when they are. It's easy to let your guard down because MIS prevents sharps injuries in many ways:

Mark S. Davis, MD, FACOG\

  • There is an overall decrease in the number of sharps on the sterile field.
  • There is less skin suturing.
  • The scalpel is used infrequently.
  • Cutting and other hazardous tasks occur mostly inside the patient, protecting the hands of the surgical team from injury.

Oddly, in MIS, the safety barrier protecting the people operating on the patient from a sharps injury becomes the patient's own tissues. There are still inherent risks associated with MIS.

Some things remain the same
The devices that cause the majority of sharps injuries during minimally invasive surgery are suture needles, scalpel blades and hollow syringe needles, just as with open surgery. While it is to a lesser degree, this equipment is still in the mix. Here are four things to keep in mind for dealing with these old hazards (even if you've already heard them, it's always good to hear them again):

  • Sharp suture needles used to close skin incisions will always be a hazard. For laparoscopic incisions, you can use tape or skin adhesives.
  • If you use small, sharp, curved cutting needles for skin closure, as favored by plastic surgeons, use the no-touch technique (forceps, not fingers) to handle needles.
  • Straight, sharp, hand-held needles are associated with frequent sharps injuries. Don't use them to close skin, whether in the OR or other hospital settings. Choose a safer alternative, such as staples, a skin adhesive or, if necessary, a sharp curved needle on a needle carrier.
  • Safety scalpels reduce the risk of injury in MIS.
  • Use a neutral zone (safe zone) for no-hands-passing of small sharps. This could be a dedicated Mayo stand (well-suited to orthopedic procedures), a mat, a towel, a tray or a designated area on the sterile field. Position it flat and level on the sterile field, within easy arm's reach of the surgeon. Pass all hollow syringe needles, as well as sharp trocars, sutures and scalpels, through this neutral zone, rather than passing them hand-to-hand, just as with open surgery.
  • Keep hands away from the neutral zone. To prevent injury to a worker from a sharp's being returned by the surgeon, it's very important that the scrub person or assistant not hold or keep his hands in, on or near the tray or other device designated the neutral zone.

New hazards introduced
Some of the instruments needed to perform minimally invasive procedures can pose a safety risk.

Sharp trocars can injure OR professionals, as can laparoscopic scissors, long needles, wires and probes. Blood aerosols created by the use of laser and electrocautery within the abdomen or other space can cause a bloodborne exposure to your mucous membranes due to spray when an instrument is withdrawn from a port, if the port lacks a tight seal. Lasers and electrocautery produce the same types of airborne contamination. And we all know the dangers of surgical smoke. Here's how to deal with the new hazards.

  • Pass long laparoscopic or other instruments that don't fit in a neutral zone, such as needle-tip electrocautery or sharp-pointed scissors, to the surgeon handle-first with the tip pointing down.
  • When placing long, pointed electrocautery needles, hollow-bore needles or other long sharps into port sleeves, use two hands - preferably one person's hands - and then angle the handle toward the surgeon's waiting hand.
  • Wherever possible, use blunt expanding trocars rather than sharp ones.
  • If intra-abdominal suturing is required through the scope, use blunt-tipped suture needles as you would with open surgery.
  • Avoid sprayback; use trocar sleeves with valves to protect the surgical team from exposures to the mucous membranes.
  • Wear full and appropriate personal protective equipment as with open surgery. If you need to convert a minimally invasive procedure to an open procedure as an emergency, you won't have time to correct deficiencies in PPE or protective apparel.
  • Aspirate all gas, fluid and blood from the abdomen before closure.
  • Periodically or continuously suction electrocautery smoke and laser plume.

Benefits of safe behavior
OSHA has fined facilities for failure to use a neutral zone, safety scalpels and blunt suture needles - and all these can be used in MIS. Use of the safety devices and safe work practices described here facilitates compliance with OSHA standards. Additionally, preventing sharps injuries and exposures saves facilities money and reduces liability for facilities and surgeons.