The Patient and Surgeon Benefits of Laparoscopic Gastro-Intestinal Surgery - Research Proposal Example

Research The Patient and Surgeon benefits of laparoscopic gastro-intestinal surgery as compared to open surgery and its implications to the nursing practice. Chapter 1 Introduction Gastrointestinal surgeries are one of the most common surgeries being performed by surgeons in the hospital. It is a type of surgery which is “performed on the digestive system or its parts” (Intota, 2009). It is performed on the gastrointestinal tract (GIT) as an intervention or a treatment for diseases which include: hernia, inflammatory bowel, morbid obesity, colorectal diseases, and gall bladder and bile duct disease (University of Rochester Medical Center, n.d). The surgical options for these surgeries could either be open or close surgeries (laparoscopy-guided). Current medicine and surgical practices have now leaned towards close laparoscopy-guided GIT surgeries. The benefits of this surgery for patients and surgeons have not been fully established. This paper is an attempt towards establishing evidence-based proof to support the best type of surgery for GIT procedures. Background of the Study Laparoscopic GIT surgeries are “minimally invasive procedures commonly used to treat diseases of the gastrointestinal tract” (Medicine.net, 2009). This type of surgery is usually carried out without the usual incision down the center of the stomach; instead, keyhole incisions are made in the abdomen through which the scope and small surgical instruments are inserted. This laparoscopic surgery is often used to treat conditions like Crohn’s disease, colorectal cancer, diverticulitis, familial polyposis, bowel incontinence, rectal prolapse, ulcerative colitis, and colon polyps (Medicine.net., 2009). Kumar and Bellamy (2007) discuss that this type of surgery slowly gained popularity since its inception in the 1980s. Modlin, Begos, and Ballantyne (1996) also document that early attempts on the use of this type of surgery were first seen through Hippocrates’s primitive anoscope which he used to examine hemorrhoids. Other attempts that followed basically used natural light source in order to illuminate their attempts at close surgeries. Illumination through reflected sunlight, candles , and paraffin lamps were used in the early 1800s by physicians in more early attempts at minimally-invasive surgery (Berci, as cited by Modlin, Begos, and Ballantyne, 1996). In 1901, Kelling used the cystoscope in order to look into the abdomen of a dog. Then, in 1910, Jacobeus used the first human laparoscopy in order to investigate ascites. Other attempts in the use of the laparoscopy followed but were hampered by limited technology. In the late 1920s, Kalk suggested the use of a second puncture site in order to establish a pneumoperitoneum; a sophisticated lens system soon followed. The development of the fiberoptic technology soon followed and the surgeons were now able to conduct surgeries with more light. In the 1980s, the developments on the use of the laparoscope became more advanced and sophisticated. The surgeries which were undertaken through the laparoscope also became more sophisticated and complex. The technique also slowly gained support and approval from other surgeons and practitioners. And slowly, the modern laparoscopic era was started (Modlin, Begos, and Ballantyne). Appendectomies and lower GI surgeries are now being performed by surgeons preferably through this method of surgery. Interest and preference in this type of surgery is expected to grow as more surgeons are trained in laparoscopic GIT surgeries. Initially, it is also expected that the method will prove awkward for surgeons to adapt. However, “once the learning curve has been overcome, laparoscopic surgery has features that make it attractive to the patient, surgeon, and anesthetist” (Kumar and Bellamy, 2007). The idea behind laparoscopic surgery is the principle of minimally invasive surgery. Many practitioners recommend these types of surgeries because of their benefits (like lesser pain and shorter recovery time, among others) to patients. However, there are various considerations that have to be taken into account before this type of surgery can truly be adapted as the preferred method of surgery for GITs. Safety, technique, instrumentation, and therapeutic strategies are just some of these considerations. Problem Statement This study seeks to answer the following questions: 1. Are laparoscopic gastrointestinal surgeries more advantageous than open surgeries in terms of the following aspects: a. Benefits to patients b. Benefits to surgeons 2. What are the implications of laparoscopic surgeries to the nursing practice as far as the following factors are concerned: a. Amount of patient care involved b. Amount of manpower involved c. Duration of care involved for each patient d. New skills that have to be learned Aim/Purpose of the Study There are limited studies which have been conducted assessing the implications of laparoscopic gastrointestinal surgeries to nursing practice. Hence, this study now aims to improve the general understanding of laparoscopic gastrointestinal surgeries from a nursing point of view. It aims to describe the implications of laparoscopic gastrointestinal surgeries to the nursing practice. The purpose of this study is to assist this nurse in her practice as an operating room nurse. It also aims to enlighten the patients and the surgeons about the overall implications of the laparoscopic method in gastrointestinal surgeries. Objectives of the Study The aims of this study are: 1. To establish whether or not laparoscopic gastrointestinal surgeries are more advantageous than open surgeries in terms of: a. Patient benefits b. Surgeon benefits 2. To establish the implications of laparoscopic gastrointestinal surgeries to the nursing practice as far as the following factors are involved: a. Amount of patient care involved b. Amount of manpower involved c. Duration of care involved for each patient d. New skills that have to be learned Hypotheses/Assumptions The hypotheses of this study are: 1. Laparoscopic gastrointestinal surgeries are more advantageous than open surgeries in terms of the following aspects: a. Benefits to patients b. Benefits to surgeons 2. The implications of laparoscopic gastrointestinal surgeries to the nursing practice are as follows: a. New skills to learn; more obsolete knowledge for traditional nurses b. Less time focused on the care of one patient, and more time to spend on other patients c. Aid in addressing nursing shortage d. Aid in addressing financial shortage in healthcare e. Less work stress for nurses This research makes the following assumptions: 1. That laparoscopic gastrointestinal surgeries are being performed in the hospital alongside open gastrointestinal surgeries 2. That both laparoscopic and open gastrointestinal surgeries benefit the patients, the surgeons, and the nurses 3. That laparoscopic gastrointestinal surgeries impact on the nurses and the nursing practice in general in terms of the following factors affecting nursing care: a. Time management b. Present skills c. Nursing shortage d. Healthcare budget crisis e. Work-related stress f. Nursing management Significance/rationale/importance/justification This study is being undertaken because minimally-invasive surgeries are fast becoming the accepted trend in healthcare. In an effort to inflict less trauma on patients, many surgeons and even patients are opting for this type of surgery as opposed to the open surgery. The adaption of this method of surgery has various implications on the methods and requirements of care on the part of the healthcare team. Although the implications have already been laid out for surgeons, implications for nursing practice have yet to be clearly laid out. The benefits and implications of laparoscopic gastrointestinal surgeries have to established because the nurses are an important part of the healthcare and the OR team. They help implement doctor’s orders and they assist the surgeons in the conduct of the surgery. This study will help establish evidence which will either render or withdraw support in the performance of laparoscopic surgeries. Evidence-based practice is an important practice in healthcare. It is a practice which takes into consideration, first and foremost, the individual patient’s needs and well-being. In order to come up with the best-evidence-based practice to adapt for the patient, this paper is a step or a stride towards a deeper and more comprehensive examination of surgical techniques. Definition of Terms Laparoscopic Surgery/Laparoscopy. Cowles (2009) describes laparoscopic surgery or laparoscopy as “a group of operations performed with the aid of a camera placed in the abdomen”. For purposes of this research, it shall refer to surgeries performed with the aid of a scope, more particularly in the abdominal area. Open Surgery. This is a method of surgery which “involves making an incision in the abdomen, and repairing the hernia either by sewing tissues back together with sutures or covering the hernia with a patch or mesh” (Gore and Associates, 2009). For purposes of this research, open surgery is defined in contrast with the laparoscopic type of surgery. It shall refer to open surgeries conducted mostly in the abdominal area. Patient. A patient is defined by the Medicine.net (2009) as someone under health care. The site also defines it as someone who requires medical care or a person under a physician’s care for a particular disease or condition (Medicine.net., 2009). For purposes of this research, it shall refer to a person who has undergone abdominal surgery (open or laparoscopic) Surgeon. A surgeon is a “physician who treats disease, injury, or deformity by operative or manual methods” (Medicine.net., 1999). It is also defined as a physician who has had special training in removing organs, masses, and tumors and other procedures which use a scalpel or a knife (Medicine.net, 1999). For this paper, a surgeon refers to one who specializes in abdominal or gastrointestinal surgeries. Nurse. A nurse is one who is “especially prepared in the scientific basis of nursing who meets certain prescribed standards of education and clinical competence” (Free Online Dictionary, 2007). For purposes of this research, a nurse refers to an operating room nurse particularly involved in both laparoscopic and open gastrointestinal surgeries. Limitations and delimitation of the study This research shall compare the benefits of laparoscopic and open gastrointestinal surgeries. It shall discuss such benefits in relation to the patients, the surgeons, and the nurses involved in the surgery. It shall be conducted in_____ (hospital) from_____ (date). The population covered shall be patients undergoing GIT surgery, surgeons performing and nurses assisting in the GIT surgeries. It shall not cover patients undergoing GIT surgery through exploratory laparotomy (gunshot wounds, knife wounds, MVA) and other surgeries which undergo compulsory open surgeries. Surgeries covered shall be those which may be undertaken both through close or open surgeries. This will allow a comparison of overall benefits or effects on the patients and the members of the health care team. Chapter 2 There are various studies which have been conducted on the topic which are also described in this research. They are now assessed and evaluated below. Literature Review A study by Braga, et.al. (2002) sought to establish the impact of laparoscopic and open colorectal surgery on 30-day postoperative morbidity. The study was conducted because there is limited evidence-based data on the effect of laparoscopic colorectal surgery on a patient’s immune system and metabolism response. More random studies have to be undertaken in order to establish laparoscopy as a preferred and superior surgical option. All in all there were 269 patients that were assigned to either laparoscopic or open colorectal surgeries. The study later presented that the overall morbidity rate in the laparoscopic group was 20.6% and in the open group was 38.3%. There were more patients in the open group as compared to the laparoscopic group who registered with postoperative infections. In terms of length of hospital stay, the laparoscopic group patients had longer days in the hospital as compared to the open group patients. In terms of the proliferation of lymphocytes in both groups, they both registered similar levels, 3 days after the surgery; however, 15 days after the surgery, only the levels in the laparoscopic group returned to normal. The study was later able to conclude that laparoscopic gastrointestinal surgeries reduced postoperative morbidity. The lymphocyte proliferation and gut oxygen tension was better preserved in the laparoscopic group as compared to the open group (Braga, et.al., 2002). In another study, Nguyen and colleagues (2001) attempted to compare the outcome, quality of life, and costs of laparoscopic and open gastric bypass (GBP) surgeries. They conducted a prospective study in order to compare the outcomes in an open GBP and laparoscopic GBP. In the span of 2 years, they were able to cover 155 patients who had to undergo GBP. They assigned these patients to either open or laparoscopic surgeries. They considered operative time, blood loss, and time to return to activities of daily living and work. The study was able to register no deaths in either group. More operative time was spent in the laparoscopic GBP than in the open GBP. Blood loss however was lesser in the laparoscopic GBP group as compared to the open GBP group. The length of hospital stay in the laparoscopic group was shorter as compared to the open GBP group. There were also more wound complications in the open GBP group as compared to the laparoscopic group. Patients in the laparoscopic group were able to return to their ADLs and to their work faster as compared to the open group. The operative cost for the laparoscopic group was higher; however, the overall hospital cost was lower in this group as compared to the open group. Based on the above results, the authors concluded that laparoscopic GBP is a safer and more cost-effective type of surgery as compared to open GBP. A prospective study by Hutter and colleagues also sought to compare laparoscopic versus open gastric bypass procedures in terms of 30 day morbidity and mortality rates. The study covered several institutions covering patients undergoing laparoscopic gastric bypass procedures from 2000 to 2003. A total of 1356 patients underwent gastric bypass within the time period covered. There were no deaths in the laparoscopic group, and a .06% mortality rate in the open group. There were lesser complications in the laparoscopic group as compared to the open group. Consequently, the study concluded that laparoscopic gastrointestinal procedures are safer as compared to open gastric bypass procedures. In another study by Nguyen and colleagues (2001), they attempted to compare postoperative pulmonary function and analgesic requirements in patients undergoing either laparoscopic or open gastric bypass surgery. There were 70 patients who were included in this study and who were randomly assigned to the laparoscopic or to the open group. Pulmonary functions in both groups were taken preoperatively and postoperatively. Oxygen saturation and chest radiographs were also recorded. The study revealed that the laparoscopic group had significantly less impairment in pulmonary function as compared to the open group based on the first three postoperative days. On the 7th postoperative day, the laparoscopic group already had preoperative levels, the open group pulmonary functions still did not return to normal levels. The laparoscopic groups also used less morphine as compared to the open surgery patients. Pain levels graded based on the visual analog scale were lower in the laparoscopic group as compared to the open group. The study concluded that there was less postoperative suppression of pulmonary function; lesser pain; improved oxygenation, and less atelectasis in the laparoscopic group as compared to the open gastric bypass group. In a prospective study by Porte and DeVries (1996), they compared the results of laparoscopic cholecystectomy and open cholecystectomy for symptomatic cholelithiasis in elective surgery. 100 patients undergoing laparoscopic cholecystectomy from September 1990 to June 1992, and 100 open cholescytectomy patients from 1989 to 1990 were included in this study. The operation time for the laparoscopic group was significantly longer as compared to the open group. The hospitalization time was however shorter in the laparoscopic group as compared to the open group. Complications were seen in equal percentages in both groups. Hospitalization and operation cost was significantly higher in the laparoscopic group as compared to the open group. The study concluded that laparoscopic surgeries can be performed safely considering the number of complications for the open group. There is lesser trauma in the laparoscopic group, and faster recovery. As a result, insurers tend to benefit more from reduced postoperative disability and earlier discharge (Porte & DeVries, 1996). Conceptual/theoretical framework There are various theories which can be used to explain the problems and the solutions used in this research. Watson’s ‘Human Caring’ theory is the most appropriate theory which can be used in this research. Watson’s theory emphasizes on the practice of caring. She believes that it is “not just an emotion, concern, attitude, or benevolent desire. Caring connotes a personal response” (1979, as quoted by Kozier, 2004, p. 42). This practice of caring can be translated by the nurse’s concern for the best possible care for the patient. In comparing the open and the laparoscopic methods of treatment for the patient, Watson, prompts us to look into the choice which will best employ emotion, concern, and benevolent care to our patients. Pudner (2001, p. 1975) uses Maslow’s hierarchy of needs to explain the feelings and needs of the surgery patient. The patient’s needs, according to Maslow, start with his needs for sustenance and care. The nurse and the members of the health care team should make attempts to create a warm and caring environment for the patient. The patient will later become largely dependent on the health care team for his care and for his needs. Under ideal conditions, the members of the health care team can help the patient achieve higher levels of needs (Pudner, 2001, p. 1975). When the members of the health care team can offer better options of care for the patient, the latter can consequently reach ultimate levels of self-fulfillment in his health conditions. “All nurses have a responsibility and role to identify the health-related learning needs of patients and clients, their families and friends, and to participate in health promotion and prevention of illnesses (Nurses, Midwives and Health Visitors, 1983, as quoted by Pudner, 2001, p. 1975). Chapter 3 Methodology Research Design This paper shall be a quantitative descriptive retrospective study. This research design is being chosen for this study because it will help assess the most appropriate technique for gastrointestinal surgeries based on surgeries covering gastrointestinal patients. The effects of the relationships between the variables shall be expressed through statistics. Correlation, relative frequencies, and differences between means shall be used in order to evaluate this research. No attempt to change behavior or conditions will be made in order to measure the variables involved in this study (Hopkins, 2001). Research Site/setting This paper shall be conducted at the ____ . It shall cover operating room nurses participating in laparoscopic and open GIT surgeries. It shall also cover surgeons performing laparoscopic and open GIT surgeries. Patient benefits comparing laparoscopic and open surgeries shall also be covered by this paper. Study population/sampling The retrospective population for this paper shall be ____ and the method of sampling shall be computed based on Slovin’s formula (1/ 1+Ne2 ). The respondents shall be chosen randomly in order to ensure the validity of this study. Data Collection procedures and instruments Data shall first be gathered through a library catalogue search. Books on gastrointestinal surgery-laparoscopic and open surgery- shall first be searched and assessed for relevance. Medical and nursing journals shall also be hand-searched in order to review relevant and up-to-date information on the topic. These searches shall focus on the keywords: laparoscopic, open, gastrointestinal surgeries. The same key and search words shall be entered in the Google search engine in order to come up with more specific studies related to the present topic. The medical and nursing journals like the PubMed Central, British Medical Journal, American Nurses Association Journal, and similar journal databases shall also be searched via keywords previously mentioned. The main data for this paper shall be gathered through a prepared questionnaire. The questionnaire shall be semi-structured. The respondents would be answering a series of questions which contain choices where they can indicate their preference. Data analysis The data gathered shall be analyzed first by simple tallying and tabulation. Data gathered shall be entered through the SWSS system in order to be assessed for appropriate statistical treatment analysis. The data shall be entered by the researcher, later to be verified by an assistant. The data analysis shall also be checked by a statistician. The results of the data analysis shall then be used to answer the question raised by this paper. Ethics/ethical issues This research proposal shall first be shown to the ethics committee for approval. A letter of approval for the distribution of questionnaires shall first be submitted to the department in the hospital where the research will be conducted. The letter shall ensure the utmost confidentiality of the respondents’ answers and the fact that the study shall only be undertaken for academic purposes. The letter shall also explain to the respondents the data gathering and the data handling process. This will help assure the respondents of the precautions which will be undertaken in order to ensure their confidentiality. Ethical issues involved in this paper mainly involve the voluntary participation of respondents to this study (Trochim, 2006). This issue shall be resolved by gaining the informed consent of the respondents. The research process and the implications of this research shall be fully explained to the respondents. It shall be emphasized that their participation to this research is purely voluntary. There is also the issue of confidentiality (Trochim, 2006). This issue shall be resolved by keeping the information about the respondents confidential and by keeping all data records accessible only to the researcher. The ethics committee shall also ensure that the research ethical process is followed religiously by the researcher. Data handling and management The data gathered shall be handled by the researcher and by two other assistant researchers who will mainly be involved in the data gathering process. The data gathered shall be kept confidential. The questionnaires shall not bear the actual names of the patients; instead, numbers shall be assigned to each patient. The questionnaires answered shall be kept in a secure file and be kept under lock and key. Only the researcher shall have access to these files. These files shall also be entered into the SWSS data file. Only the researcher shall have access to these files. The files and the raw data used for this research shall be kept by the researcher and by the university in a secure setting for no more than 5 years after the publication of this research. Chapter 4 Summary Results This study was able to reveal that the laparoscopic approach as compared to the traditional open approach, showed a significant decrease with regard to the objectives set out. From the studies which were assessed, we can see the number of advantages for the patient that has had laparoscopic technique as compared to the patient who has had open technique done on him. The advantages established in the course of this research include the following: Decreased morbidity Decreased complications, i.e., infection, hemorrhage Increased pulmonary function and no ventilation Less pain and reduced amount of analgesics Faster healing time Shorter hospital stay In the course of this research, one cannot fail to acknowledge that with any surgical procedure, there will be risks involved; the same is true with laparoscopic surgery. These risks are minimal as manifested by studies. Anastomotic leak, which is a major complication of gastric surgery, was initially high in the laparoscopic approach; however, this was due to the learning curve and has since decreased This study was also able to reveal the risk of blood vessel injury and mainly common bile duct injury due to the fact that the initial trochar is inserted badly. It is important to note that this surgery is carried out by or under the direct supervision of a skilled surgeon, so that interventions can be timely carried out in case adverse outcomes are seen. Chapter 5 Conclusions This study concludes that the laparoscopic gastrointestinal surgery is more advantageous than the open surgery in terms of benefits for the patient, the surgeon, and the nurse. The patient has a faster recovery time, lesser blood loss, decreased hospital stay, lesser complications, and an immediate return to activities of daily living. On the part of the surgeon, he is now prompted to train in new and more efficient methods of surgery. The recovery of his patient would be faster. The operation time would however be longer for the surgeon to conduct. The nurse would have decreased patient monitoring time. Wound cleaning would be decreased because of minimal incisions on the patient. More time can now be spent for other patients. The problem of shortage in staff and increased health care cost would be reduced. The results in this paper were the expected results as hypothesized by this paper. This study also concludes that even though the laparoscopic technique as compared to the open technique can be technically demanding and challenging, when it is however conducted by a team that is clinically experienced, it is the safest and most efficient technique which can be used for gastrointestinal surgeries. The laparoscopic technique is highly beneficial to the patient. This study recommends that every patient should be given the option of laparoscopic technique, unless it is contraindicated by other factors. It also recommends that more prospective studies on the subject matter be conducted in order to accurately assess the most appropriate technique for gastrointestinal surgeries. Works Cited Braga, M., Vignali, A., Zuliani, W., Radaelli, G., Gruarin, P., DiCarlo, V., December 2002, Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome, Annals of Surgery, volume 236, number 6, pp. 759-767 Cowles, R., 27 August 2009, Laparoscopy, Medline Plus, viewed 20 September 2009 from http://www.nlm.nih.gov/medlineplus/ency/article/007016.htm Definition: Nurse, 2009, Free Online Dictionary, viewed 20 September 2009 from http://medical-dictionary.thefreedictionary.com/nurses Definition of Patient, 2009, Medical Terms, viewed 20 September 2009 from http://www.medterms.com/script/main/art.asp?articlekey=39154 Definition of Surgeon, 11 December 1999, Medical Terms, viewed 20 September 2009 from http://www.medterms.com/script/main/art.asp?articlekey=11994 Gastrointestinal Surgery Experts, 2009, Intota, viewed 20 September 2009 from http://www.intota.com/experts.asp?strSearchType=all&strQuery=gastrointestinal+surgery Gore, W. & Associates, 2009, Glossary of Hernia Terms: Open Surgery, Gore Medical, viewed 20 September 2009 from http://www.goremedical.com/hernia/glossary Hopkins, W., 2000, Quantitative Research Design, Sportscience, viewed 20 September 2009 from http://www.sportsci.org/jour/0001/wghdesign.html Hutter, M., Randall, S., Khuri, S., Henderson, W., Abbott, W., Warshaw, A., May 2006, Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program, Annals of Surgery, volume 243, number 5, pp. 662-666 Kumar, C. & Bellamy, M., 2009, Gastrointestinal and Colorectal Anesthesia, New York: Informa Health Care. Nguyen, N., Lee, S., Goldman, C., Fleming, N., Arango, A., McFall, R., Wolfe, B., & Sugerman, H., 2001, Comparison of pulmonary function and postoperative pain after Laparoscopic versus open gastric bypass : A Randomized Trial, Journal of the American College of Surgeons, volume 192, number 4, pp. 469-477 Porte, R. & De Vries, B., 1996, Laparoscopic Versus Open Cholecystectomy: A Prospective Matched-Cohort Study, Hindawi Publishing Corporation, volume 9, number 2, pp. 71-75 Pudner, R., 2001, Nursing the surgical patient, London: Elsevier Health Sciences Surgical Specialties: Gastrointestinal Surgery (n.d) Strong Health, viewed 20 September 2009 from http://www.stronghealth.com/services/surgical/Gastrointestinal/gastrointestinalsurg.cfm Trochim, W., 2006, Ethics in Research, Research Methods Knowledge Base, viewed 20 September 2009 from http://www.socialresearchmethods.net/kb/ethics.php Nurse Consent Consent is hereby given by (Patient’s name) of (city) to submit to the research process being undertaken for this study. I confirm that the anticipated nature and effect of this research has been explained to me, and that I have been informed of the implications of this research. I agree to answer the questions truthfully with the understanding that my answers shall be used for academic purposes only. Date___________ ________________ Name of Nurse Read More