Robotic surgery represents the most significant advancement to date in minimally invasive surgery, Lisa Parks, MS, APRN-CP, ANP-BC, of James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center in Columbus, said during a session on Thursday, April 11, 2019, at the ONS 44th Annual Congress in Anaheim, CA.

Robotic Surgery

Advantages of robotic surgery include providing greater visualization with magnification and the ability to manipulate in close areas, Parks said. Compared with laparoscopic surgery, patients undergoing robotic surgery have shorter lengths of stay. However, robotic surgery does not reduce operating room time and surgeons have a learning curve to performing it.

Parks’ presentation addressed several nursing implications of robotic surgery.

  • Because of the shorter length of stay, patients and their families need extensive preoperative teaching regarding postoperative recovery, as well as stress and anxiety management.
  • Pain management will be multimodal, using intrathecal morphine or an epidural in combination with scheduled acetaminophen (650 mg) and ibuprofen (600 mg) every six hours. Oxycodone 5 mg should be used minimally as needed.
  • Early ambulation is recommended, in consultation with physical and occupational therapy.
  • Patients should start clear liquids postoperative day 0 or 1 based on prealbumin levels. Oral supplements may be added.

ERAS Protocols

Enhanced recovery after surgery (ERAS) protocols are multidisciplinary standardized plans of care protocol that use evidence-based interventions throughout the perioperative process, with the goals of improving the quality of patient care and accelerating recovery. Education during the preoperative phase is key to successful implementation of ERAS protocols.

Other features of an ERAS protocol include prehabilitation, perioperative glucose management, use of early ambulation and early return to diet, and preoperative use of carbohydrate loading.


Hyperthermic intraperitoneal chemotherapy (HIPEC) is used to eradicate micrometastatic disease by bathing the peritoneal cavity with chemotherapy. Heat increases the chemotherapy’s cytotoxicity, improves its penetration by increasing membrane permeability and improving membrane transport, and causes greater damage to malignant cells than to normal cells. Patients must undergo cytoreduction surgery (CRS) before receiving HIPEC.

Cancers treated with CRS and HIPEC include colorectal cancer, epithelial ovarian cancer, and synchronous peritoneal and liver metastasis. Common complications of HIPEC include anastomotic leaks and intestinal perforations.

Parks advised that nurses caring for patients receiving HIPEC should order oral supplements with meals and at bedtime as soon as the patient can take oral fluids and should educate patients to continue oral supplements after discharge throughout recovery period. Patients should be followed with serial computed tomography scans every six months for three years, then annually for two years. Patients with CEA, CA-125, or CA-19-9 markers should be followed every three months for the first three years and then annually for the next two years.