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Reason for selection: First time seeing used GELPORT to retrieve the specimen out.Reason for use of gelport is ,specimen was too big and not able to remove through normal 10mm port.Also used 15mm port and enocatch.But could not retrive the specimen.At the end have to use the gel port to retrive the specimen out and helped to avoid doing laparotomy.

In your essay, explore this clinical episode by introducing the patient and the reason you selected them; describing your nursing role (anaesthetic, instrument, or circulating); the clinical care you delivered during the intraoperative period; and provide a critical analysis about this care based on current literature and evidence.

Case Study

Laparoscopic Ovarian Cystectomy according to Emory University School of Medicine is a surgery that is meant to take out a cyst from the ovary by invasive surgery procedure using few and smaller slits(incisions) in the lower abdomen (Emory University, 2017, NHS, 2018). The reason for surgery is because many women often have an ovarian cyst at one stage in their life. The cysts may be cancerous or not. Non-cancerous cysts are removed with ease without necessarily removing the ovaries (Alobaid et al., 2013). The opposite happens with cancerous cysts through oophorectomy ("Laparoscopic Ovarian Cystectomy, About the Procedure and Recovery", 2018).

Ovarian cysts are painful and causes of discomfort to their subjects. Severe abdominal pain occurs especially when they rapture (Parker, 2013).The surgery involves a well-defined procedure and application of surgical instruments in the removal of the cysts. There are certain complications that result from the application of this technology like potential removal of the ovary.

This study will look at a case study where a GelPort was used to remove the cysts for Mrs. Y (Grace), something that is new to the instrument nurse. According to Scribner, Lara-Torre and Weiss (2013), a GelPort trocar is preferably used in a single site laparoscopy because it allows for the flexibility when  inserting trocars via it to augment the space between the cannulas, to inhibit the collision of instruments because the surgical instrument are limited to less triangulation as they rotate.

Mrs. Y (Grace) is a 36 year old married woman normal weight (60Kg) with 4 children and is set to undergo laparoscopic right ovarian cystectomy. She approaches the gynecological departments in serious pain complaining that her abdominal pain, pain during sexual intercourse and when on her periods. She also says that she experiences continuous bloating (abdominal enlargement).some of her other complains are severe back pains on the right side of the pelvis and irregular menstruation. On further examination, it was found out that she uses birth control pills and she is not pregnant. Her blood pressure was quite ideal of 110/80. She underwent a computer tomography (CT) scan for further assessment. Her pre – operative evaluation showed she had a dermoid cyst that was 4.2 inches on the right ovary and she is suspected of ovarian cancer. Her general conditions being good, she was advised to undertake a right laparoscopic surgery for the removal of the cyst using a GelPort. Grace strongly confirmed that she had her periods 2 weeks ago and therefore 2 weeks away from her next periods.

Justification of the Case Study Selection

The first and the very obvious reason is the fact that Grace is a woman and not a man. Only women can have ovarian cysts since ovaries are organs found in female reproductive system only. Therefore only women can have laparoscopic ovarian cystectomy (Song, Lee and Kim, 2014). Grace being married and already has 4 children is an important factor because it could allow for an easy consent to remove the ovary should need be. A woman without a kid would be very difficult to convince to accept signing the consent form that could lead to the removal of her ability to conceive. The laparoscopic surgery has to be on the right side because it is the right ovary that has the dermoid cyst (Hegde, 2013). The left ovary will be left intact.

Our subject in the case study has not reached menopause (she is 36 years old).That allows the study to introduce one symptom of ovarian cysts which is pain during menstruation. This is because it has been believed in the past that since birth control pills prevent the bursting of the cysts (ovulation), women used them to prevent them go away. But that does not seem to work with Grace because despite using the pills she still experience menstruation (Wu, Wu and Liu, 2013). Moreover, the doctors recommend a general ovarian cystectomy if one takes birth control pills, may not have started their period. This is supported by the fact that Grace is 2 weeks away from her next periods.

Grace being normal weight is important because obese patients are not tolerant to exercise and require screening for obstructive sleep apnea. That can only make the situation worse. That would add more technicality in the design for positioning during the intraoperative stage.

The reason for use of a GelPort for this case is because, after scan it was determine that the cyst was excessively big (4.2) not to be removed using normal 10mm port, 15mm port or and enocatch. Laparoscopic ovarian cystectomy can be recommended when the patient has cysts or other masses, when the cyst is larger than 3 inches in diameter, when the cyst is abnormal or malignant or if the doctor suspects ovarian cancer (Alobaid et al., 2013). That is the reason she is suspected of ovarian cancer. A GelPort is preferably used because it allows surgeons to interchange between hand access, straight laparoscopic and open surgical methods to ensure that the results are efficient enough ("GelPort Laparoscopic System | Applied Medical", 2018)

Preoperative Nursing Care for Grace

Pre-operative care stage is as important as the intraoperative care phase. The success of an operation in one way depend on the adequate preparation for it. These preparations are normally in the pre-operative phase and they have proved to prevent the incidences of patient mortality (Landoni, Ruggeri and Zangrillo, 2014). Therefore it is important to introduce Grace to all activities of pre-operative care to ensure that she goes through the operation successfully.

An informed consent must be obtained before any operation takes place. In the consent all complications that are involved in laparoscopy are reviewed (Keder and Olsen, 2018). Grace should therefore be informed that the operation puts her at a risk of wounding her blood vessels leading to serious bleeding, gastrointestinal organs to include the genitourinary system like the bladder, bowel and ureters. Performing this operation puts Grace at a risk of having recurrent operations does in the future (post-surgery) and she should be made to understand that.

In the case of removing her ovaries, that should be treated with seriousness because it may affect Grace’s possibility of bearing a child (Schollmeyer et al., 2013). The nurse therefore should advise her accordingly and even involving Grace husband’s in the consent to allow the removal of the ovary especially because it is prospected to be cancerous considering its large size (4.2 inches). Removal of the ovary would save her life by preventing the spreading of the cancerous ovary cells to the neighboring tissue. Again she should be made to understand that could affect her fertility post-surgery in that it becoming bigger, it could also become a factor to support the ovary removal.

Normally, the risk of injury during laparoscopy is very minimal but also inevitable (Keder and Olsen, 2018). Grace should be made to know that bleeding would occur towards the beginning of the operation and the possibility (though rare) of her succumbing to the surgery, should there be serious vascular injury. Since the laparoscopy involves pneumoperitoneum by use of carbon IV oxide gas, Grace should be informed of the risks and threats (side effects) that comes with pneumoperitoneum such as cardiovascular changes, air embolism among others (Keder and Olsen, 2018).

It is important to convince Grace to sign the consent form to allow the operation to take place because failure to do so is even worse. Moreover, there have been many women who have survived the operation and led smooth life post-surgery.

Consent

Pre-operation, it the duty of an instrument nurse to know that all tools required for the operation are in place or easily reachable (Bhat, 2017). That requires the nurse to work in collaboration with the department of logistics to certify that all the necessary equipment is in the operation room, altogether with the pre-operative nurse to ensure that all things are set in the operation room before interacting with the patient (Bhat, 2017). The operating theatre should be checked and confirmed to be in the right condition and all factors like lighting systems are working properly. Laparoscopy requires that there is brilliant illumination without shadows. The instrument nurse has a duty to ensure that the emergency cart is in place as well as the Advanced Cardiac Life Support (ACLS) is functioning properly.

It is necessary to ensure that all the factors relating to the Patient’s operation are assessed and kept constant as required. The assessment included identity, weight and pregnancy. Laparoscopy is still possible even during pregnancy but should be extra careful not to affect the unborn baby (Keder and Olsen, 2018). The temperature of the room should be assessed and kept low to inhibit bacterial growth in order to prevent infection during surgery. There should be examining oxygenation and breathing sounds to test for normal ventilation. Cardiac functioning assessment is also necessary. It is also necessary to ensure that the top and sides of the table that would be used for the operation as a step to prevent skin troma and hematomas.

As required by the international standards, it is the duty of the entire surgical team to ensure that the international accepted conventions of operation such as authentication before operation, marking the site of surgery and a time out (Keder and Olsen, 2018). Once the consent formed is signed the subsequent intraoperative practices administered. The role of the instrument nurse during the operation is monitor aspects such as heart rate and blood pressure at intervals of 5 minutes. Moreover, the nurse takes charge for supplication of all the necessities within the surgical theatre. The nurse should remain vigilant throughout the operation to check for changes in Grace’s conditions plus any intra-surgical complications so as to establish that the she is responds accordingly and appropriately.

General anesthesia is the best anaesthesia practice to perform for Grace’s operative laparoscopy. This is because it is the most common even though regional anaesthesia is also applicable. Anaesthesia allows for optimal ventilation and regulates pain especially by the fact that laparoscopy surgery comes with shoulder pain as one of its side effects (Keder and Olsen, 2018). There is injection of the anesthetic medicine into the patient’s vein to make her body numb and give a calming effect on the patient’s body. Shoulder pain results from the retained carbon IV oxide gas introduced at the beginning of the operation rising to the diaphragm and consequently causing irritation on the shoulder. The effects of anesthesia are respirational depression, unconsciousness, paralysis, decreased sensation, suppress cardiovascular functions or heighten cardiovascular irritability.

Intraoperative Nursing Care for Grace

Positioning for laparoscopy involves placing the body in the supine or dorsal lithotomy position (Keder and Olsen, 2018). This latter is preferred as it allows for access of the vagina to manipulate the uterus and the rectum. Positioning should be careful so as to prevent injuries to the peroneal and femoral nerves. It requires that hips be bent between 600 or at 1700. The body should at the same time be adapted at 900 or less for inhibition of rotation. The knees should bend between 900 and 1200. This positioning technique is important to reduce the chances of lower extremity nerve damage because nerves are at a greater chance of becoming damaged with increased duration of operation. Grace’s hands are preferably to be tucked by her sides to allow the surgeon to stand with ease at her shoulders (Keder and Olsen, 2018).

The setup for surgical instruments should be in variety and with ease of accessibility to allow for different procedures to be performed laparoscopically (Keder and Olsen, 2018). Instruments used vary in shape; blunt and pointed to assist in different types of dissection. For Grace’s case, there is the use of a specialized device (GelPort) because the specimen is too large. There are other instruments that would apply for the operation like coagulation energy devices (mono-polar, ultrasonic sources, bipolar). These sources are meant to thicken blood vessels for safe ligation (Keder and Olsen, 2018).

Operative laparoscopy involves wide range of procedures. The abdominal muscles are slowly separated so as to be able to access the ovary easily and in this case the blood vessels supplying blood to the artery had to be tied so as to prevent excessive bleeding. This process is facilitated by the pumping of carbon IV oxide into the abdomen during anesthesia.

Hydro dissection was utilized from the beginning of the process. This system involves employing a pressurized stream of water to develop planes of tissues or to divide certain soft tissues less traumatically than ordinary sharp dissection (Castle, 2014). This is to prevent destroying smaller blood vessels and other tubular structures. It is also used to develop tissue planes and separate adhesions. It also facilitates dissection of diseased parietal pleura in order to treat malignant pleural effusion

For the cyst to be removed out of the body, it is put in a distinctive bag that will ease the removal process as well as precluding spillage of fluids into the cavity (Hurd, 2007). Any masses doubtful for distortion are put in the ice-covered section for proper examination. In the section, the pathologist examines it. The next step was for the pathologist reviewing all units of the mass to confirm no cancer (Grabowski, Korlacki and Pasierbek, 2014).

Postoperative Nursing Care for Grace

Forced air warming devices are frequently used to prevent hypothermia in anesthesia. Radiant warming devices could still be used but they are not common (Dubey, 2012).

Because the ovarian cysts in Grace’s case was too large, they could not fit in the retrieval bag (Hurd, 2007). That necessitated drainage of the cyst before the cystectomy was done. A suction irrigation tool was used to remove the content of the cyst (Mishra, 2013). When the content of the cysts spill into the peritoneal cavity, copious irrigation is necessary. Warmed irrigation fluid minimizes the risk of hypothermia which is associated with the use of a lot of cold irrigation fluid (Hurd, 2007).

A high definition camera called a laparoscope is introduced into the abdomen for an inherent magnification (Dubey, 2012). A laparoscope is a useful tool for diagnostic and therapeutic functions. The camera uses the modern technology to yield extremely good resolution perform those factors. The camera was used for Grace’s ovarian cystectomy to inspect the activities of pelvic cavity (Dubey, 2012).

Rolling technique was utilized at the end of the procedure to attain the desired results. This process only removes the cyst and does not touch the ovaries, but because the cyst was extremely outsized in this case, the surgeon had to remove the whole ovary (Hubert and Wiklund, 2013).  The abdominal muscles are stitched and the cut sealed with sews.

Conclusion:

Grace’s survival post-surgery depends on how adequate she is prepared for the operation and how professional her operation is performed by the surgical team. Ovarian cystectomy is very necessary for Grace to ensure that she does not succumb from ovarian cancer. Considering that her cyst is excessively big, cystectomy is necessary. Nevertheless, there a bunch of risks that come with the operation. But that should not be the obstacle because risks can be managed if the surgical team is experienced enough. Preoperative care is very necessary for better results and for reduced mortality probability. The worth of preoperative practices and care is of the same value as the surgical operation itself. All aspects of both phases of care like obtaining an informed consent, anesthesia, correct positioning, tests and assessments, ease of access to the instruments, optimization of conditions, rolling techniques, irrigation, suctioning, warming devices, among others  are all important for Grace’s survival.

References:

Alobaid, A., Memon, A., Alobaid, S. and Aldakhil, L. (2013). Laparoscopic Management of Huge Ovarian Cysts. Obstetrics and Gynecology International, 2013, pp.1-4.

Bhat M, S. (2017). Srbs surgical operations - text & atlas. JP Medical Ltd, pp.618-620.

Castle, E. (2014). Robotic surgery of the bladder. New York, pp.45-87.

Dubey, A. (2012). Infertility; Diagnosis, Management and IVF. New Delhi: Jaypee Brothers Pvt. Ltd., p.223.

Emory University (2017). Laparoscopic Ovarian Cystectomy. [online] Gynob.emory.edu. Available at: https://www.gynob.emory.edu/patient_care/patient_education/ovarian_cystectomy.html [Accessed 25 Aug. 2018].

Grabowski, A., Korlacki, W. and Pasierbek, M. (2014). Laparoscopy in elective and emergency management of ovarian pathology in children and adolescents. Videosurgery and Other Miniinvasive Techniques, 2, pp.164-169.

Hegde, P. (2013). Extragonadal omental teratoma: A case report. Journal of Obstetrics and Gynaecology Research, 40(2), pp.618-621.

Hurd, W. (2007). Clinical reproductive medicine and surgery. Philadelphia, PA: Mosby/Elsevier, p.748.

John, H. and Wiklund, P. (2013). Robotic Urology. Berlin, Heidelberg: Springer Berlin Heidelberg, pp.20-76.

Keder, L. and Olsen, M. (2018). Gynecologic Care Cambridge medicine. Cambridge University Press, pp.58-65.

Landoni, G., Ruggeri, L. and Zangrillo, A. (2014). Reducing Mortality in the Perioperative Period. Cham: Springer International Publishing, pp.109-11.

Laparoscopic Ovarian Cystectomy, About the Procedure and Recovery. (2018). Retrieved from https://www.draliabadi.com/surgeries/laparoscopic-ovarian-cystectomy/

Metwally, M. and Tin-Chiu, L. (2015). Reproductive Surgery in Assisted Conception. London: Springer London, p.39.

Mishra, R. (2013). Textbook of practical laparoscopic surgery. New Delhi: Jaypee Medical, p.361.

Nezhat, C., Nezhat, F. and Nezhat, C. (2013). Nezhat's video-assisted and robotic-assisted laparoscopy and hysteroscopy. Cambridge, UK: Cambridge University Press, p.245.

NHS (2018). Treatment - Ovarian cyst. [online] nhs.uk. Available at: https://www.nhs.uk/conditions/ovarian-cyst/treatment/ [Accessed 25 Aug. 2018].

Parker, S. (2013). MRCS. London: JP Medical Ltd., p.393.

Schollmeyer, T., Ru?ther, D., Mettler, L. and Alkatout, I. (2013). Practical Manual for Laparoscopic & Hysteroscopic Gynecological Surgery. JP Medical Ltd, p.154.

Scribner, D., Lara-Torre, E. and Weiss, P. (2013). Single-Site Laparoscopic Management of a Large Adnexal Mass. JSLS : Journal of the Society of Laparoendoscopic Surgeons, [online] 17(2), pp.350-353. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771809/ [Accessed 25 Aug. 2018].

Song, T., Lee, S. and Kim, W. (2014). Additional benefit of hemostatic sealant in preservation of ovarian reserve during laparoscopic ovarian cystectomy: a multi-center, randomized controlled trial. Human Reproduction, 29(8), pp.1659-1665.

Wu, L., Wu, Q. and Liu, L. (2013). Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis. Gynecological Endocrinology, 29(10), pp.883-890.

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