Spring is on its way and with it often comes a rebirth of energy and potential. I invite you to exercise your writing skills, reach out, and share your talents with your fellow Surgical Oncology (SUR) SIG colleagues.

Regardless of where you practice, you have something to share. Whether you are a novice and would like to research and write about a topic or an expert with a “best practice” to share—consider sharing your “pearls of wisdom” with colleagues. Maybe you have a question about how others accomplish a task, teach patients, or support families—post it on the Virtual Community (VC) or submit it for the newsletter.

Have other talents to share, or want an opportunity to grow?

Many possibilities exist within ONS and our SIG. We specifically are looking for editorial help with the newsletter, which is published three times each year. As the editor (or co-editor) you will have a chance to interact with the National Office and other editors. As much communication can be done via e-mail, this can be accomplished from your home or office at any time, day or night.

We also would like to improve our VC and Networking site. The site could be much more visually appealing and has great potential to be more interactive. The VC is a fantastic vehicle for learning and sharing successes. Again, this is an opportunity to work with the organization but within the comfort of your home or office at a time that works for you.

If you are interested in hearing more about these and other opportunities, e-mail or call. Your professional growth is important! Christine Smith, RN, MSN, CNOR, ex-officio coordinator; Elizabeth Wooten, RN, MSN, editor; and I also will be available at our SUR SIG Planning/Networking Meeting at the 34th Annual ONS Congress in San Antonio, TX. We hope you will join us for our meeting on April 30 at 11:15 am. Grab a cup of coffee after opening ceremonies, and join us for education, discussion, and networking. Continuing nursing education contact hours will be available.

In this newsletter, we welcome the first in a series about urologic cancers, “Kidney Cancer.” This comprehensive article discusses the nuts and bolts of kidney cancer and its treatment. Also, in this newsletter is a thorough description of “Single Port Laparoscopy: The Next Surgical Frontier,” which serves as a reminder of the impact that technology, advances in medicine, and the changes in patient care has on our profession that we must continue to be prepared to address.

Single Port Laparoscopy
The Next Surgical Frontier

Christine Smith, RN, MSN, CNOR
Redwood City, CA
cesmith@comcast.net

Scientists envision the future re-engineering of endoscopy to be able to reproduce the same anatomic outcomes of surgery. Single port laparoscopic surgery accesses the abdominal cavity through one port placed through the umbilicus. This approach is also called radical endoscopy or stealth surgery. Stealth surgery is surgery that takes place without leaving a trace that it occurred (no scar). The actual surgery is the same; however, the access is the difference.

The current types of stealth surgery include the following.

MIS/MAS–Minimal access surgery/minimally invasive surgery
NOTES–Natural orifice transluminal endoscopic surgery
OPUS–One port umbilical surgery
SILS–Single incision laparoscopic surgery
SPA–Single puncture access
SPS–Single port surgery

The NOTES initiative is a joint effort of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for American Gastrointestinal Endoscopic Surgeons (SAGES). Together, these societies have formed the Natural Orifice Surgery Consortium for Assessment and Research™ (NOSCAR™), a group that provides guidance and oversight and evaluation of NOTES techniques and the related research required.

The first generation of modern laparoscopic surgery began in the early 1970’s in the gynecology specialty, used primarily for diagnostic direct (eye on the telescope eye piece) visualization of endometriosis, ectopic pregnancy, uterine fibroids, and later, laparoscopic tubal ligation with electrosurgery (there were occasional accidental bowel burns and ureteral transections) and deployed Teflon rings. These procedures were originally called Bandaid, keyhole, or belly button procedures.

The abdominal compartment is the most violated cavity of the body. Scalpel, scissor, and electrosurgery (cautery) dissection are mutilating and render these incisions prone to many serious morbidities. The three commonly used surgical approaches are notorious for leaving abdominal wall defects leading to hernias, dehiscence, evisceration, and unsightly scars. A patient with a large abdominal scar may be contraindicated later in life from restorative surgery in which an abdominal muscle flap is needed.

Traditional laparoscopic port placement via triangulation is the fundamental concept of laparoscopic surgery, which involves placing the instruments on planes so that they meet to effectively support dissection within adequate visualization and identification of anatomy and pathology. Incorrectly placed ports can cause sword-fighting instruments and indirect access to the operative target. Challenges also exist in delivering intact specimens, for best diagnostic yield, through small ports. The increased intra-abdominal pressure from the insufflation of CO2 into the peritoneal cavity puts pressure on the diaphragm and femoral vessels. This can compromise patients with cardiac and respiratory disease and cause deep vein thrombosis. The venting of the CO2 at the end of the procedure is believed to have the potential of “blowing” cancer cells into the layers of the port site causing later cancer recurrence of the skin and subcutaneous layers of the abdomen. This has been proven to be a very rare event and probably not a concern that should eliminate laparoscopic approaches for patients with cancer. The immune impact of traditional surgery is of concern in patients with cancer for whom immune suppression may advance the opportunistic metastasis of cancer cells. Less invasive approaches to surgery are less stressful to the patient.

Traditional laparoscopic surgery has many advantages over traditional open surgical approaches; however, those advantages do not come without cost in terms of manipulative challenges. Considerable research has addressed the significance of surgery as a stressor and its impact on the immune response, providing evidence of the immune impact of open versus laparoscopic (or less immune stimulating) approaches. Formerly, a diagnosis of cancer was a contraindication for laparoscopy. Single port/puncture laparoscopy offers considerable advantages over traditional laparoscopy. With only three or four instruments, including a combined telescopic light/camera and two working tools, the emerging instrumentation that bends and/or flexes offers manipulative options not available with traditional laparoscopy. At the end of the procedure, the port is removed, and the umbilicus is gently folded back into its original shape.

Is the umbilicus considered a natural orifice? The umbilicus remains open during fetal development and only partially closes after birth. Because it has no muscle or fascia layer, umbilical incisions are safe and less painful than other incision sites. With only one incision site, less risk exists of penetration injuries, infection, and hernia. The growing capabilities of therapeutic flexible endoscopy have ushered in a new era in treatment of gastrointestinal conditions. Refinements in laparoscopic surgery have progressed to the point that complex surgical procedures, such as gastric bypass, now can be performed in a minimally invasive fashion. These trends have set the stage for the development of even less invasive methods to treat conditions in both the gut lumen and in the peritoneal cavity. It seems feasible that major intraperitoneal surgery may one day be performed without skin incisions. The natural orifices may provide the entry point for surgical interventions in the peritoneal cavity thereby avoiding abdominal wall incisions.

NOTES must be performed by a team that has the skills of an advanced therapeutic endoscopist and a laparoscopic surgeon who, in many instances, will bring unique but complementary skills.

Access is gained through the Hasson cut-down technique with a small scalpel and bladeless dissecting-tip trocar. The ports maintain pneumoperitoneum and retract the incision. The instruments are curved and flexible to accommodate space restrictions and afford range of motion that follows the movement of the surgeon’s hand.

Multiple instruments can be used via one port with standard digital technology (video systems and processors). Other advantages for the patient include decreased pain, blood loss, and morbidity; and no scarring; increased return to activities of daily living; and total recovery. Other advantages for the surgeon include increased visibility with light and magnification, larger field of view, flexible tips eliminate need to change instruments frequently, and easy transition to traditional laparoscopy. Operative costs are similar to traditional laparoscopy.

Many procedures that can be accomplished via laparoscopic access can be approached via single puncture as well. Contraindications include multiple prior abdominal surgeries (adhesions/altered anatomy), morbid obesity (decreased visibility and difficult movement inside cavity).

Costs may vary from hospital to hospital. Third party payers have mixed responses with some saying that NOTES is experimental and therefore not reimbursable. Recent surgeries include radical cystectomy, splenectomy, appendectomy, radical prostatectomy, donor nephrectomy, kidney tumor cryoablation, transabdominal colpoplexy for vaginal prolapse, etc. There exists a need for more comparative research. While SPL develops upon the platform of traditional laparoscopic surgery, new instrumentation will advance ergonomic and precision dissection.

References

Barclay, L. (2008). Natural orifice transluminal endoscopic surgery may allow incisionless operations. Medscape Medical News. Retrieved July 27, 2008, from http://www.medscape.com/viewarticle/578108

Cleveland Clinic. (2008). Cleveland Clinic first to perform successful live kidney donation through single belly button incision. Health Orbit. Retrieved July 18, 2008, from http://healthorbit.ca/NewsDetail.asp?opt=1&nltid=140150708

Curcillo, P.G. (2007). High dexterity instrumentation in laparoscopic surgery. Abstract presented at the Society for Abstracts “Emerging technologies.”

Fowler, D. (2008). Single port laparoscopy or NOTES: A form of image guided therapy? Retrieved June 25, 2008, from http://cisst.org/wiki/seminar_2008_06_25_NOTES

Pasricha, P.J. (2005). Endoluminal surgery. In G.G. Ginsberg, M.L. Kochman, & C.J. Norton,.  Clinical Gastrointestinal Endoscopy. (pp. 841–843). Philadelphia: Elsevier Saunders.

Raman, J.D., Cadeddu, J.A., Rao, P., & Rane, A. (2008). Single incision laparoscopic surgery: Initial urological experience and comparison with natural-orifice transluminal endoscopic surgery. British Journal of Urology. Retrieved July 19, 2008, from http://www.advancedsurgical.ie/BJU_Online_Article/Default.245.html

Kidney Cancer

Shawn Turner, RN
Patient Care Resource Manager
Department of Urology
Arthur G. James Cancer Hospital and Richard J. Solove Research Institute

National Cancer Institute’s definition of kidney cancer: Cancer that forms in tissues of the kidneys. Kidney cancer includes renal cell carcinoma (cancer that forms in the lining of very small tubes in the kidney that filter the blood and remove waste products) and renal pelvis carcinoma (cancer that forms in the center of the kidney where urine collects). It also includes Wilms tumor, which is a type of kidney cancer that usually develops in children under the age of five.

Estimated new cases and deaths from kidney cancer in the United States in 2008:
New Cases: 54,390
Deaths: 13,010

Common symptoms include the following:

• Hematuia
• Flank pain
• Fatique
• Malaise
• Weight loss

Most Tumors are asymptomatic and found incidentally.

Who’s at risk? People who

• Smoke
• Are obese
• Have hypertension
• Are on long-term Dialysis
• Are male are at a greater risk than females
• Have Von Hippal Lindau’s Syndrome
• Have an occupation that would expose them to certain chemicals
• Have a genetic predisposition.

Diagnosis:

• Physical exam
• Urine and blood test
• Intravenous Pyelogram
• Cat Scan
• Ultrasound
• Biopsy
• Surgery

Treatment depends on the patient’s age, comorbitities, stage of the disease, as well as underlying kidney function. The physician can present treatment choices and discuss the expected outcomes.

Type of Treatments

SURGERY: Open or laparoscopic: includes simple nephrectomy, radical nephrectomy and partial nephrectomy. Surgery is the most common treatment for kidney cancer.

CHEMOTHERAPY: Renal Cell Carcinoma is generally resistant to chemotherapy.

RADIATION THERAPY: A small number of patients have radiation therapy before surgery to shrink the tumor. Some have it after surgery to kill cancer cells that may remain in the area. People who cannot have surgery may have radiation therapy to relieve pain and other problems caused by the cancer.

SYSTEMIC THERAPY: IMMUNOTHERAPY and TARGETED THERAPIES- used for patient’s with advanced disease.

- TARGETED THERAPIES interfere with the ability of cancer cells to grow, divide, repair and/or communicate with other cells. Examples of targeted therapies are Sutent, Nexavar Avastin, and Torisel.

- IMMUNOTHERAPY involves 2 modes of action. Immunotherapies that stimulate the body's own immune system to fight the disease are called Active. Immunotherapies that do not rely on the body to attack the disease and use immune system components (such as antibodies) made in a lab are called Passive.

Examples include cytokines, anti-CTLA-4, and cellular therapy: T cells, Allo SCT. A Medical oncologist would discuss the appropriate therapy for the patient.

ARTERIAL EMBOLIZATION: Shrinks the tumor. Sometimes it is done before an operation to make surgery easier. When surgery is not possible, embolization may be used to help relieve the symptoms of kidney cancer.

TUMOR ABLATION: Used with elderly patients, high surgical risk patient, concurrent malignancy, or patient declines standard therapy or watchful waiting. Tumors characteristics include: tumor size < 4 cm, posterior tumors not located to critical areas, such as vena cava, ureter, and bowel, anterior tumors, or in lower pole adjacent to ureter. Examples of tumor ablation technique include cryoablation and radiofrequency ablation.

CLINICAL TRIALS: Are available for patients with Renal Cell Carcinoma. A discussion between patient and physician should occur to see if the patient would be appropriate for a clinical trial.

The National Cancer Institute Web site has a link to find all the clinical trials available for Renal Cell Carcinoma. Check out another resource for clinical trials.

References

Abelof, M., Armitage, J., Neiderhuber, J., Kastan, M., & McKenna, W. (2004). Clinical oncology (3rd ed.). Philadelphia, PA: Elsevier Churchill Livingston.

Vogelzang, N., Scardino, P., Shipley, W., & Coffey, D. (1996). Comprehensive textbook of clinical oncology. Baltimore, MD: Williams & Wilkins.

http://www.cancercare.org/about_us/
http://www.nccn.org/patients/reference_links.asp
http://www.cancer.gov/cancertopics/wyntk/kidney/

News From National

ONS 34th Annual Congress Registration Now Open
Get ready to head to San Antonio, TX, April 30–May 3 to get the best oncology education around at the ONS 34th Annual Congress. Plus, you’ll get to celebrate your profession and the difference you make in the lives of patients and their families. Make your plans now to connect to 5,000 of your colleagues, get the latest cancer-care information, and enhance your career. Save $100 when you register by March 19!

New Resources Available From ONS!
Look for two new books from ONS! The Advanced Oncology Nursing Certification Review and Resource Manual can be used as both a study guide for advanced oncology nursing certification and a clinical resource. Order now and save on a special introductory discount offer! The new edition of the ONS Career Resource Guide: Marketing Yourself for Success will help you navigate your career path in these challenging times. Save when you order your copy today!

New Oncology Clinical Nurse Specialist Competencies
This document outlines specialty entry-level competencies for Oncology Clinical Nurse Specialists who care for adult and late adolescent patients throughout the continuum of cancer care. Download to learn more.

December ONS Connect Discusses Cancer Research in the Community
In the December issue of ONS Connect, ONS members explain how cutting-edge research is being offered in the community setting so that patients can get advanced treatments while remaining close to home. Read more in ONS Connect’s interactive e-magazine. Do your patients have access to clinical trials in your community? Take this month’s instant poll.

From the Editor
From prevention and identification of risk status to the development and use of targeted therapies, genomics is changing the face of oncology care. Check out the ONS Web site Clinical and Patient Resource Areas for information about cancer genetics and its implications.

Writing Mentorship Program Offers Even More Rewards and Eliminates Application Deadline

Now is the time to start writing for publication. Share your knowledge with colleagues, improve patient care, and reap professional accolades and rewards—all with the help of an experienced nurse author and ONS staff…and all from the comfort of your home or office.

The Clinical Journal of Oncology Nursing (CJON) is dedicated to developing the profession’s next generation of experts and authors through the CJON Writing Mentorship Program. CJON will pair each selected fellow with a previously published author who has knowledge in the area of interest, and ONS will offer the support of a publishing staff member and librarian. The project is completed without travel over a period of nine months, and expenses are reimbursed.

The program recently eliminated its deadline in favor of year-round application, and it now offers even more rewards.

• Get your byline published in a respected peer-reviewed publication that is read by more than 35,000 nursing colleagues, other healthcare personnel, and pharmaceutical professionals.
• Establish yourself as an expert in a specific clinical topic.
• Earn a scholarship to an ONS educational event.
• Receive points toward oncology nursing certification renewal.
• Be recognized in the ONS awards publication, at an ONS Congress reception, and in a letter to your employer.

For more information about the CJON Writing Mentorship Program, including eligibility criteria, visit the ONS Web site or contact ONS Staff Editor Keightley Amen at 412-859-6258 or kamen@ons.org.

ONS Social Media Sites of Interest

Do you want up-to-the-minute information about the next conference? Would you like to network with other oncology nurses? Do you want to stay in touch with other ONS members? Now, it’s easier than ever because ONS has joined social media sites that help you do all of this and more. Sign-up is free and easy, and you can always control your privacy settings. Already have an account? Share your story, and make the most of all these sites have to offer. Be sure to invite others to join as well. 

ONS is now on Facebook!

• Connect with other oncology nurses, get updates on ONS news, and explore other social media-related sites.

• Oncology Nursing Month is in May and ONS wants you to share your stories. As an oncology nurse, you take on the role of teacher, listener, and shoulder to lean on. You help people through some of the most trying times of their lives. Celebrate and share the work you do at

• ONS Foundation has funded more than 2,022 scholarships, grants, and awards since 1981, and they need your help to continue that support. Join their cause, spread the word, and make a donation.

ONS is now on Twitter!

• Twitter is a free service that lets you keep in touch with people through the exchange of quick, frequent answers to one simple question: What are you doing? Join today to start receiving ONS’s updates.

ONS Connect Launches New Blog to Continue the Conversation

Join the online conversation as ONS Connect’s new blog, RE:Connect, brings together a diverse group of oncology nurses talking about life at work and at home.

When ONS’s monthly news magazine, ONS Connect, was redesigned in 2007, some of the intent was to address the interests of those new to the field and provide quick news and information to busy professionals. RE:Connect offers an extension of these goals by establishing an online community for readers to talk about issues and share experiences that they deal with on a daily basis. The RE:Connect blog was launched in November in conjunction with ONS’s annual Institutes of Learning and Advanced Practice Nursing Conference.

ONS members have been tapped to initiate the dialogue by posting to the blog on a regular basis.

• Erin Elphee, RN, MN, CON(C), primary clinic nurse for Lymphoma and Malignant Hematology Disease Site Groups at CancerCare Manitoba in Winnipeg, Canada
• Kimberly George, MSN, RN, ACNS-BC, OCN^®, adult health CNS in Wichita Falls, TX
• Jeanine Gordon, RN, MSN, OCN^®, clinical nurse specialist/nurse manager from Brooklyn, NY
• Kari Wujcik, nursing student at Belmont University and a nurse extern in the pediatric intensive care and cardiology units at Monroe Carell Jr. Children’s Hospital at Vanderbilt University

These bloggers will share their thoughts about day-to-day challenges at work, juggling busy lives at home, and keeping up to date with the magnitude of information available for practicing nurses. Readers are encouraged to join in on the conversation and connect with other oncology nurse readers by posting their own stories, tips, ideas, and suggestions in the comments section at the end of each blog post.

Check out RE:Connect today, and share this link with your friends and colleagues!

ONS Articles of Interest
Surgical Oncology SIG Members May Enjoy These Recently Published Articles

Check out the Oncology Nursing Forum (ONF) and the Clinical Journal of Oncology Nursing (CJON) for interesting articles about surgical oncology.

• “Recovery After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction Surgery,” by Deena Damsky Dell, MSN, RN, BC, AOCN^®, Carolyn Weaver, MSN, RN, AOCN^®, Jeannie Kozempel, PT, DPT, MS, and Andrea Barsevick, PhD, RN, AOCN^® (ONF, Vol. 35, pp. 189–196)
• “Homecare Referrals and 12-Week Outcomes Following Surgery for Cancer,” by Kathryn H. Bowles, PhD, RN, FAAN, Ruth McCorkle, PhD, FAAN, RN, and Isaac F. Nuamah, PhD (ONF, Vol. 35, pp. 377–383)
• “Failure to Rescue in the Surgical Oncology Population: Implications for Nursing and Quality Improvement,” by Christopher R. Friese, RN, PhD, AOCN^®, and Linda H. Aiken, RN, PhD, FAAN, FRCN (ONF, Vol. 35, pp. 779–785)
• “Identifying the Educational Needs and Concerns of Newly Diagnosed Patients With Breast Cancer After Surgery,” by Patrice A. Stephens, MS, RN, AOCN^®, Maryjo Osowski, MSN, RN, AOCN^®, Mary Sue Fidale, MA, RNC, LCPC, Cathy Spagnoli, RN, BS (CJON, Vol. 12, pp. 253–258)

For access to the full-text versions of these and other ONF and CJON articles, visit the Publications area of the ONS Web site.

Membership Information

SIG Membership Benefits

• Network with colleagues in an identified subspecialty area around the country.
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• Acquire information with a click of a mouse at http://ons.org/membership including
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Join a Virtual Community

A great way to stay connected to your SIG is to join its Virtual Community. It’s easy to do so. All you will need to do is

• Log on to the ONS Web site (http://www.ons.org/).
• Select "Membership" from the tabs above.
• Then, click on "ONS Chapters and Special Interest Groups."
• Scroll down to "Visit the ONS Special Interest Groups (SIG) Virtual Community" and click.
• Now, select "Find a SIG."
• Locate and click on the name of your SIG from the list of all ONS SIGs displayed.
• Once the front page of your SIG’s Virtual Community appears on screen, select "New User" from the top left. (This allows you to create log-in credentials.)
• Type the required information into the text fields as prompted.
• Click "Join Group" (at the bottom right of the text fields) when done.
  
  Special Notices
  
  
• If you already have log-in credentials generated from the ONS Web site, use this information instead of attempting to generate new information.
• If you created log-in credentials for the ONS Web site and wish to have different log-in information, you will not be able to use the same e-mail address to generate your new credentials. Instead, use an alternate e-mail address.

Subscribe to Your SIG’s Virtual Community Discussion Forum
Once you have your log-in credentials, you are ready to subscribe to your SIG’s Virtual Community discussion forum. To do so,

• Select "Log In," located next to "New User," and enter your information.
• Next, click on the "Discussion" tab on the top right of the title bar.
• Locate and select "Subscribe to Discussion"
• Enter e-mail address.
• Click "Finish."
• You are now ready to begin participating in your SIG’s discussion forum.

Participate in Your SIG’s Virtual Community Discussion Forum

• First, log in. (This allows others to identify you and enables you to receive notification [via e-mail] each time a response or new topic is posted.)
• Click on "Discussion" from the top title bar.
• Click on any posted topic to view contents and post responses.

Sign Up to Receive Your SIG’s Virtual Community Announcements
As an added feature, members also are able to register to receive their SIG’s announcements by e-mail.

• From your SIG’s Virtual Community page, locate the "Sign Up Here to Receive Your SIG’s Announcements" section.
• Select the "Click Here" feature, which will take you to a link to subscribe.
• Once the "For Announcement Subscription Only" page appears select how you wish to receive your announcements.
• As individual e-mails each time a new announcement is posted
• One e-mail per day comprised of all new daily announcements posted
• Opt-out, indicating that you will frequently browse your SIG’s Virtual Community page for new postings
• Enter your e-mail address.
• Click on "Next Page."
• Click "Finish"
• You are now subscribed to receive announcements.

Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Specialist Carol DeMarco at cdemarco@ons.org or 866-257-4ONS, ext. 6230.

View past newsletters.

ONS Membership/Leadership Team Contact Information

Angie Stengel, MS, CAE, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, MBA, CAE, CMP, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Specialist
cdemarco@ons.org
412-859-6230

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

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