My session is updates in surgical oncology and I was asked to speak on three different topics within surgical oncology. The first topic I was asked to speak about was robotic surgery and nursing implications for robotic surgery. The second topic I was asked to speak on was enhanced recovery after surgery, which actually ERAS was developed in Europe and then came over to the States. I also spoke on HIPEC, which is heated intraperitoneal chemotherapy, which is infused after the tumour debulking or cytoreduction into the abdomen to kill any gross cancer cells.
The HIPEC procedure is basically hooking the abdomen up to a machine in the operating room which is most commonly similar to an open heart bypass machine. When somebody is having open heart surgery they go onto that bypass machine so that they can do surgery on the different vessels. So this is the same concept is that the abdomen is open and there are tubes that are inserted into the abdomen and the abdomen is first cleansed with saline and after that runs through for about half an hour then actually the chemotherapy is infused for another half hour and then the saline is reinfused to remove all of the chemotherapy. It all filters through this machine that’s heated to 42o centigrade and the whole concept behind that is that heating the chemotherapy actually enhances death of the cancer cell.
What are the benefits to using robotic surgery?
The benefits to robotic surgery are really a shorter length of stay for the patient. The patient doesn’t have the large incisions that they get with traditional surgery; they’re very small sites that are basically like puncture wound sites that allow the camera within the abdomen as well as three arms that can perform the surgical procedure. So the patient therefore doesn’t have all the incisional pain that accompanies an open procedure. It is very beneficial for the surgeon in that it magnifies the field about 10-12 times what the normal seeing eye can see. With those robotic arms they’re able to get into smaller spaces within the pelvis as well as in the head and neck to be able to operate where sometimes they wouldn’t be able to do that with just their own instruments and hands.
What is the role of oncology nurses when it comes to robotic surgery? How does it affect the care these patients require?
The big emphasis for oncology nurses is education. Because these procedures are not the classic open procedure, the robotic procedure has the smaller puncture sites for the arms and the camera, the patients don’t understand that they need to get up and get out of bed. The day of surgery we actually get our patients up into the chair and then we expect them to ambulate post-op day one. We do have early feeding for these patients with the robotic cases so they’re usually given sips of ice and water and then they’re advanced to a clear liquid diet the next day. Sometimes families not understanding that try to derail the nursing staff who are trying to actually take the best care of the patient that they can take. So we really emphasise education before surgery and then certainly after surgery try to re-emphasise what they were taught initially.
What challenges are there to providing robotic surgery?
The robot is a very expensive piece of machinery and so you’re going to see those in your larger academic centres. A smaller hospital may not have the funding to be able to purchase the robot so that certainly would impede somebody in a smaller community setting to be able to have robotic surgery. The cost is a huge factor in being able to even offer a robotic programme.
The other issue is that there is a skill level that needs to be developed. Surgeons initially were trained with open procedures and then when laparoscopic surgery became available in the 1990s they were also trained on that. This is a whole new training for them and the learning curve the literature is reporting to be about 60-80 surgeries before a surgeon is really comfortable and competent in doing that procedure.
What is the future of robotic surgery, and over what kind of timescale?
I see more cases of areas of solid tumours that we have not utilised robotic surgery yet in. I see other things being developed in a way that robotic surgery can be utilised. But we’ve been utilising it in the US since the late 2000s and so even though we have experience in some areas I certainly think there’s room for growth with that.
It’s still a developing field and, like I said earlier, I think finances will play a lot into being able to offer it to more patients. We all live in countries that have large urban areas and then smaller borough areas that may not over time even be able to offer robotic surgery to patients. Like I said, it’s an evolving field so I think we really are collecting data right now on things and we may find other areas of improvement.
What is the take home message for oncology nurses?
The take home message for nurses who attend the session is really education is a primary piece of taking care of all of these patients. Patients need to be educated on the robotic piece of it and the earlier return to mobilisation and eating as well as the ERAS protocols, also emphasise that also. Then with the cytoreduction and the HIPEC nurses need to really use their assessment skills and to be able to monitor vital signs. The patients that undergo cytoreduction and HIPEC have a lot of fluid shifts within the abdomen itself that come out of the vascular system so we’re always concerned about replacing those fluids so that we keep our kidneys perfused well. So there are also a lot of complications that can go along with the cytoreduction and HIPEC so that they need to really report things that they know are unusual in the post-op course.