Unit 3 Flashcards
(138 cards)
1
Q
Identify common surgical incisions.
A
Right upper paramedian; left lower paramedian
Right subcostal; right midline transverse; Pfannenstiel
Upper longitudinal midline; lower longitudinal midline
McBurney’s; right inguinal oblique
Right thoracoabdominal
Vertical incision; Median
Upper (epigastric or supraumbilical)
Lower (subumbilical)
Full midline (subxiphoid to symphysis pubis, curving around the umbilicus)
Vertical incision; Paramedian
Just off midline to right or left; superior or inferior
Oblique
Inguinal (not in table, but in figure; right or left)
McBurney’s (only one location – right side)
Subcostal (AKA: Kocher; right or left)
Transverse
Upper: bilateral subcostal
Lower: Pfannenstiel
Midline: right or left
Side: subcostal flank, right or left
Thoracoabdominal
2
Q
List tissue layers of the abdominal wall.
A
Skin Subcutaneous fat Scarpa’s fascia Muscle Transversalis fascia Peritoneum
3
Q
List patient factors that may affect surgical hemostasis.
A
Congenital (patient genetics)
Hemophilia
Acquired
Patient physiology/pathophysiology
Hypocalcemia
Liver disease
Anti-coagulant therapy
ASA (aspirin); warfarin (Coumadin); Heparin; Lovenox; many others
4
Q
List methods of hemostasis.
A
Mechanical (FYI: some are internal and some are external)
Clamps (hemostats; temporary)
Ligatures
Hemoclips/Ligaclips
Sponges (temporary)
Pledgets
Bone wax (forms a plug)
Tourniquets (temporary; vessel loops internal, pneumatic external)
Biological
Fibrin glue
Thermal
ESU (most common)
Laser (FYI: not all types are good for hemostasis)
Argon plasma coagulator
Harmonic scalpel
Electrocautery
Disposable, battery operated (DC)
Chemical
Silver nitrate
Monsel’s solution
Hemostasis in middle ear only
Epinephrine 1:1000
5
Q
Summarize procedure step sequence for specified surgical procedures.
A
Make an Incision Achieve Hemostasis Dissect tissue layers Retract tissue layers Irrigate the wound Achieve Hemostasis Close the wound in layers Dress the wound
6
Q
Define breast biopsy
A
Excision of a portion of breast tissue for pathology examination
7
Q
Surgical Anatomy and Physiology of the Breast Biopsy
A
Breast
Areola/nipple
Adipose tissue
Glandular tissue (lobes)
Lactiferous ducts
FYI: blood vessels and lymphatic drainage
Physiology:
Lactation/nourish infant
8
Q
Pathophysiology/Indication of Breast Biopsy
A
Breast mass or abnormal mammogram
we do not know if it is cancer or fibrocystic disease until the biopsy has been examined
9
Q
Special Considerations for a Breast Biopsy
A
Patient may be awake
Use warm prep solutions
Be very mindful of your conversations
Have mammograms available
There may be a wire in place (called needle or wire localization) to identify exact location of area
Placed by radiologist during confirmation mammogram immediately before surgery
10
Q
Equipment, Instruments, Supplies for breast biopsy
A
Equipment
N/A – nothing special
Instruments
Minor set
Supplies
Possible specimen grid for x-ray confirmation
Specimen may be sent to imaging prior to going to pathology just to make sure they have the area
Penrose drain is PRN, so don’t need to learn it here
11
Q
Medications/category/purpose for breast biopsy
A
1% lidocaine with epinephrine 1:100,000
Category:
Local anesthetic with vasoconstrictor
Purpose:
Block pain at surgical site; vasoconstrictor to help prolong action by slowing absorption
12
Q
Anesthesia/Position/Prep area for breast biopsy
A
Anesthesia:
Local with IV conscious sedation (MAC)
Position:
Supine
Aids: arm boards, pillow under knees
Prep area:
Over affected site; circular (no pressure)
Clavicle to subcostal area
Bed line on affected side to past midline
13
Q
Drape sequence and incision for a breast biopsy
A
Drape sequence
Sheet down, 4 towels, lap drape
Incision
Over affected area of breast
14
Q
Procedure Step Summary for breast biopsy
A
Inject local
Incision (#10 blade on #3 handle)
Hemostasis (ESU hand piece)
Dissect (Metz and Adson with teeth)
Retract (Senns x 2; if deep, rakes or Army-Navy)
Continue dissection with Metz and DeBakey
Grasp mass with Allis
Remove mass with deep knife (#10 blade on #3 handle), Metzenbaum, or ESU
Irrigate with Asepto, suction, emesis basin
Hemostasis - ESU
Close with suture, needle holder, Adson with teeth
Dress with wet one, dry one, and Steri-Strips, one 4x4 folded
15
Q
Counts and dressing for breast biopsy
A
Initial:
Sponges; sharps
First closing:
Sponges; sharps
Final closing:
Sponges; sharps
NOTE: May not do 2 closing counts depending on how deep it is; may just do an initial and a final closing
Dressing
Steri-Strips, 4x4; tape
16
Q
Specimen (labeled and handled) for breast biopsy
A
Specimen
Labeled: Breast mass, right or left
Handled: To radiology if needle localization, then pathology
Otherwise routine
Don’t let tissue dry out!
Do NOT put in formalin if frozen section (we almost never do a frozen section on a breast biopsy now)
17
Q
Post-op (destination, prognosis, complications, and wound classification) for breast biopsy
A
Post-op destination: PACU/ outpatient
Prognosis: Depends on diagnosis
Complications: Bleeding, SSI – both uncommon
Wound classification: Clean
18
Q
Define: Cholecystectomy with cholangiogram
A
Excision of gallbladder with a record or writing of the bile vessels
19
Q
Surgical anatomy and physiology of a Cholecystectomy with cholangiogram
A
Anatomy:
Gallbladder
Cystic duct
Cystic artery
Common bile duct
Liver
Hepatic duct and artery
Duodenum
Physiology:
Storage/concentration of bile to emulsify ingested fats
20
Q
Pathophysiology/indication for a Cholecystectomy with cholangiogram
A
Cholecystitis (Inflammation of the gallbladder); cholelithiasis (stones present in the gallbladder)
21
Q
Special considerations for a Cholecystectomy with cholangiogram
A
Have x-rays available; OR bed must be x-ray compatible
Wear lead apron or go behind lead wall
May do common bile duct exploration if stones present
Remove air bubbles from syringes prior to injection in CBD so bubbles don’t show up as possible stones!
22
Q
Equipment, Instruments, Supplies for a Cholecystectomy with cholangiogram
A
Equipment:
Translucent OR bed
C-arm
Lead aprons or portable lead wall
Instruments:
Major set
Gallbladder set (GB)
Hemoclip appliers
Large self-retaining retractor
“upper hand” or “upper arm” retractor
FYI: extra-long instruments if patient is large PRN
Supplies:
Hemoclips
30 cc syringes x 2
Cholangiogram catheter
Extension tubing with valve control
C-arm drape
Kitners (from step 2)
PRN: ESU extender tip; culture tubes; closed wound suction drain; magnetic instrument pad
23
Q
Medications/Category/Purpose for a Cholecystectomy with cholangiogram
A
Hypaque mixed with NaCl 50%/50% (per preference card)
Category:
Contrast media
Purpose: visualize CBD stones on x-ray
24
Q
Anesthesia/Position/Prep area for a Cholecystectomy with cholangiogram
A
Anesthesia: General anesthesia
Position/aids:
Supine; arm boards
Prep Area:
Right subcostal; mid-chest to symphysis pubis; deep right bed line to past midline
25
Draping and incision for Cholecystectomy with cholangiogram
```
Drape sequence
Sheet down (to cover legs)
Four towels (no clips if cholangiogram)
Laparotomy drape
Incision: Right subcostal
```
26
Procedure steps summary for Cholecystectomy with cholangiogram
Incision with #3 handle and #10 blade (skin knife)
Hemostasis with ESU
Dissect to deepen incision with deep knife and/or ESU, Metz and tissue forceps
Retract with Richardson retractors and then deeper using Deaver retractors or self-retaining retractor (Thompson); need moist laps to pack tissue behind bladesExpose and grasp gallbladder (Pean or Carmalt)
Identify cystic duct, cystic artery, and common bile duct (Mixter)
Ligate and divide cystic duct and cystic artery (clips, Metz)
Perform cholangiogram
Dissect and remove gallbladder (Metz, TF, ESU)
Irrigating with warm (not room temp) saline (NaCl) need pitcher and asepto
Hemostasis with ESU
Place drain PRN – T-tube; secure; attach drainage bag and/or place closed wound suction drain
Close the wound with suture/needle holder/ tissue forceps and scissors (call for first closing count)
Dress with “wet one dry one” and dressings in order
27
Counts and dressing Cholecystectomy with cholangiogram
```
Initial
Sponges; sharps; instruments
First closing
Sponges; sharps; instruments
Final closing
Sponges; sharps
Dressings (in order)
4x4’s, drain sponge PRN, tape
```
28
Specimen (labeled and handled) for Cholecystectomy with cholangiogram
Specimen labeled: Gallbladder
| Handling: routine
29
Post-op (destination, prognosis, complications, and wound classification) for a Cholecystectomy with cholangiogram
Post-op destination: PACU
Prognosis:Excellent
Complications: bleeding, infection, damage to hepatic duct, CBD, hepatic artery
Wound class: Clean-contaminated
Controlled entry into the biliary tract
30
Do NOT ligate/divide CBD! WHY?
The CBD is the joining of the cystic duct and the hepatic duct
Bile will no longer drain from the liver because the hepatic duct would have nowhere to drain – very bad thing – the bile will back up and eventually destroy the liver
31
Define Dilation and curettage (D&C)
Dilation of the cervix and curettage of the uterus
| Gradual expansion of the cervical opening to provide access to the uterus to remove a tissue sample
32
Surgical Anatomy and Physiology for a Dilation and curettage (D&C)
```
Anatomy:
Vagina
Cervix
Internal os
External os
Endocervical canal
Uterus
Endometrium (inner layer)
Physiology:
Reproduction; conception and growth of infant
```
33
Pathophysiology/indication for a Dilation and curettage (D&C)
DUB: dysfunctional uterine bleeding
Dysmenorrhea
Amenorrhea
Menorrhagia, hypermenorrhea: Heavy or prolonged bleeding
Metrorrhagia: Bleeding between periods
Assessment of infertility
Treatment for:
Miscarriage (D&E)
Uterine polyps (polypectomy)
Post partum bleeding (D&C)
Retained placenta (D&E)
Abnormal uterine bleeding (ablation)
Uterine cancer (place radium implants)
Retrieval of “lost” IUD
34
Special Considerations for a Dilation and curettage (D&C)
Patient modesty
Don’t put them in lithotomy position facing the OR door; keep them covered as long as possible
Patient may be grieving if miscarriage
35
Equipment, Instruments, Supplies for a Dilation and curettage (D&C)
```
Eqipment: Stool for surgeon to sit
Instrument:
D&C set & Vaginal set – only if D&C set is not a complete set for this
Supplies:
Telfa for specimen
Water-soluble lubricant
Marking pen for specimen PRN
```
36
Medications/Category/Purpose for a Dilation and curettage (D&C)
None
37
Anesthesia/Position/Prep area for a Dilation and curettage (D&C)
Anesthesia: Local, regional, or general
But local and regional are uncommon
Position:
Lithotomy; aids Stirrups/universal holders, arm boards
Prep area:
Perineum, pubis to rectum, inner proximal thighs, vagina (internal prep)
No Dura prep – why not?
Alcohol-based preps cannot be used on mucous membrane-lined cavities
38
Draping and incision for a Dilation and curettage (D&C)
Drape:
Under buttocks drape, towels, leggings, lithotomy sheet Or: just towels
Incision N/A
39
Procedure steps summary for a Dilation and curettage (D&C)
Retract vagina (Auvard and Heaney or Sims)
Grasp cervix (Schroeder tenaculum)
Sound uterus (Sims uterine sound)
Take endocervical specimen (Kervorkian curette and telfa)
Dilate cervix (Hegars or Hanks)
FYI: May check for polyps (Randall stone forceps)
Curette uterine cavity (Sims curettes and telfa)
FYI: Clean out with Bozeman/raytex or stick sponge•Dress with OB pad
40
Counts and dressings for a Dilation and curettage (D&C)
Counts:
Initial - Sponges
Final count – Sponges
Dressing: OB pad (peri-pad)
41
Specimen (labeled and handled) for a Dilation and curettage (D&C)
```
Labeled:
Endocervical tissue
Endometrial tissue
Uterine contents
Handled: Routine
```
42
Post-op (destination, prognosis, complications, and wound classification) for a Dilation and curettage (D&C)
Destination: PACU/ outpatient
Prognosis: Depends on diagnosis
Complications: Bleeding and infection (both rare)
Damage to uterus, e.g., perforation (rare) but often requires immediate hysterectomy
Damage to cervix
Wound classification: Clean-contaminated
Controlled entry into genitourinary tract (vagina)
43
Define Diagnostic Laparoscopy for Gynecology
Visual exam of the abdominal cavity
| With particular attention to the organs of the female reproductive system
44
Surgical Anatomy and Physiology for a Diagnostic Laparoscopy for Gynecology
```
Anatomy:
Vagina
Cervix
Internal os; External os; Endocervical canal
Uterus
Uterine tubes
Ovaries
Bladder
Ureters
Physiology: Reproduction; conception/growth of infant
```
45
Pathophysiology/indication for a Diagnostic Laparoscopy for Gynecology
```
This procedure is diagnostic for:
Unexplained gynecologic pain
Assessment of infertility
FYI: such as PID
Evaluation of masses
FYI: such as ovarian cysts or ovarian mass or fibroids
```
46
Special Considerations for a Diagnostic Laparoscopy for Gynecology
Have a separate back table (small one) for instruments for vaginal access (keep those instruments separate; considered contaminated from vaginal contact)
Change outer gloves after vaginal part of procedure
May use disposable or reusable trocars
Circulator will drain bladder during prep (Robinson)
May use Foley instead if lengthy procedure is anticipated
Learn how to use the uterine manipulator
47
Equipment, Instruments, Supplies for a Diagnostic Laparoscopy for Gynecology
```
Equipment:
“Lap” tower that includes:
Monitor/s
Camera
DVR
Light source
Insufflator
FYI: Laser PRN
Instrument set:
GYN laparoscopy set
Video camera/laparoscope/light cord set
D&C set (for vaginal access)
Uterine manipulator or a cervical cannula
Supplies:
Fog reduction device (FRED or other)
CO2 insufflation tubing
16 fr Robinson catheter
30 mL syringe
Uterine manipulator
Disposable trocars: 1- 10/12 mm; 1 – 5 mm
Veress needle
#12 blade (surgeon's preference)
```
48
Medications/Category/Purpose for a Diagnostic Laparoscopy for Gynecology
Methylene blue in saline (if doing a tubal dye study)
Category: Dye
Purpose: visualize patency of uterine tubes during tubal dye studies
0.5% bupivacaine with epinephrine 1:100,000
Category: Local anesthetic agent
Purpose: post operative pain control for port sites
49
Anesthesia/Position/Prep area for a Diagnostic Laparoscopy for Gynecology
Anesthesia: General
Position: Lithotomy with slight Trendelenburg
Aids: Stirrups/universal holdersArms out on arm boards
Prep area:
2 separate preps: Abdomen and vaginal/perineum
Subcostal to pubis; bed line to bed line
Pubis to rectum, inner proximal thighs
Vagina (internal prep)
NOTE: Drain bladder just prior to prep; NOTE: may use Duraprep on abdomen but NOT on vaginal prep
50
Draping and incision for a Diagnostic Laparoscopy for Gynecology
```
Drape:
Under buttocks drape, leggings, GYN laparoscopy drape
Incision:
Umbilical
Port for camera
Suprapubic x 1
Port for working instrument
Add other incisions PRN
```
51
Procedure steps summary for a Diagnostic Laparoscopy for Gynecology
Place vaginal speculum, grasp cervix
Apply uterine manipulator (change outer gloves)
Lift abdominal wall (may use 2 towel clips)
Make incision (umbilicus, 12 blade)
Insert Veress needle; verify placement in peritoneal cavity; insufflate abdomen with CO2; (remove Veress needle)
Insert 10/12mm trocar, laparoscope and camera
Suprapubic incision; place 5mm port and insert accessory instruments (such as probe)
EUA (New term - means “exam under anesthesia”)
Treat PRN
Could be tubal dye studies; remove ovarian cyst; do tubal ligation; laser endometriosis and other options
For an assessment: State an example of one thing we can treat
Irrigate
Hemostatasis
Desufflate
Closing
Dressing
Remove uterine manipulator
52
Counts and dressings for a Diagnostic Laparoscopy for Gynecology
```
Counts
Initial: sponges, sharps
Final closing: sponges, sharps
Dressing:
Dermabond or bandaids; OB pad (peri-pad)
```
53
Specimen (labeled and handled) for a Diagnostic Laparoscopy for Gynecology
Labeled: Varies by what was found
Handled: Routine
54
Post-op (destination, prognosis, complications, and wound classification) for a Diagnostic Laparoscopy for Gynecology
Destination: PACU/ outpatient
Prognosis: Depends on diagnosis
Complications: Bleeding, infection (both rare); damage to bowel, tubes, bladder, ureters; referred shoulder pain; gas embolus
Wound classification: Clean (abdomen) & Clean-contaminated (vaginal access)
55
Define Myringotomy and Tubes
Incision into tympanic membrane
| Placement of pressure equalization tubes
56
Surgical Anatomy and Physiology for a Myringotomy and Tubes
```
Anatomy:
External ear:
Pinna (auricle)
External auditory canal
Tympanic membrane (ear drum)
Middle ear cavity
Malleus (incus and stapes not relevant here)
Physiology: Amplifies and concentrates sound waves
```
57
Pathophysiology/indication for a Myringotomy and Tubes
Recurrent otitis media (Inflammation of the middle ear)
58
Special Considerations for a Myringotomy and Tubes
Usually children under 2
The eustachian tube (connects throat to middle ear) is at a straighter angle making it easy to get bacteria from mouth to middle ear
As they get older the angle changes
Record tubes as implants
Clean, not sterile procedure so only mask and sterile gloves required
59
Equipment, Instruments, Supplies for a Myringotomy and Tubes
```
Special equipment:
Microscope
Sitting stool for surgeon
Instrument sets/specials: M&T set
Special supplies:
Cotton balls
PE tubes
Disposable myringotomy knife blade
```
60
Medications/Category/Purpose for a Myringotomy and Tubes
Cortisporin otic suspension
A combination of: hydrocortisone (anti-inflammatory), neomycin and polymixin B (antibiotics)
Reduce post-operative inflammation and prevent post-operative infection
61
Anesthesia/Position/Prep area for a Myringotomy and Tubes
Anesthesia: General (mask airway)
Position/aids: Supine
Prep - None
62
Draping and incision for a Myringotomy and Tubes
Drape: Towel on patient’s chest
Incision: In tympanic membrane
63
Procedure steps summary for a Myringotomy and Tubes
Retract (place ear speculum)
Remove cerumen (cerumen curette)
Incision in tympanic membrane (myringotomy knife)
Suction fluid (baron suction tip, 5 or 7 fr)
Place tube (alligator; manipulator)
Cortisporin and cotton ball•Repeat on other side
64
Counts and dressings for a Myringotomy and Tubes
Counts: N/A
Dressings: Cotton ball PRN
65
Specimen (labeled and handled) for a Myringotomy and Tubes
Specimen: N/A
66
Post-op (destination, prognosis, complications, and wound classification) for a Myringotomy and Tubes
Post-op destination: PACU/outpatient discharge
Prognosis: excellent; tube may fall out
Complications: none common
Wound class: clean contaminated
67
Define Knee Arthroscopy
Visual exam of the knee joint
68
Surgical Anatomy and Physiology for a Knee Arthroscopy
Anatomy:
Femur
Femoral condyles
Tibia
Tibial plateau
Patella
Ligaments
Anterior cruciate ligament (ACL)
Posterior cruciate ligament (PCL)
Medial (tibial) collateral ligament (MCL)
Lateral (fibular) collateral ligament (LCL)
Soft tissues
Joint capsule
Synovium
Suprapatellar pouch
Patellar tendon
Articular cartilage
Menisci; medial (1) and lateral (2)
Physiology: Support and movement
69
Pathophysiology/indication for a Knee Arthroscopy
```
Diagnostic procedure
But also used to treat:
Torn meniscus (most common)
Loose bodies
Worn patella
Torn ACL
```
70
Special Considerations for a Knee Arthroscopy
Have images available
Surgeon will often do EUA prior to prep
Usually young, athletic patient
But may be used to assess arthritis for total knee in older patients
Prime low pressure irrigator tubing before use
71
Equipment, Instruments, Supplies for a Knee Arthroscopy
```
Special equipment:
Tourniquet
Orthopedic (arthroscopy) video tower
Camera source, light source, monitor, power source for shaver, DVR
Low pressure irrigator (fluid pump)
May be on tower or separate unit
Instrument sets/specials:
Arthroscopy set
Arthroscopes/camera/light cord
Graspers/basket forceps
Shaver (meniscutome) hand piece and cord
Meniscal repair set
Special supplies:
Shaver blades
Low pressure irrigation tubing
18 ga spinal needle
```
72
Medications/Category/Purpose for a Knee Arthroscopy
```
0.25% bupivacaine w/epinephrine
Category: local anesthetic agent
Purpose: Post-op pain control
Depo-medrol, solu-cortef
Category: Steroid hormone
Purpose: PRN for post-injury inflammation
3000 cc bags of irrigation
Lactated Ringer’s; Saline
```
73
Anesthesia/Position/Prep area for a Knee Arthroscopy
Anesthesia: General, regional (spinal or epidural)
Position/aids: Supine; Knee holder (lateral post)
Note: lower foot of bed for better access
Prep area: Circumferential, tourniquet to foot (may or may not include toes)
74
Draping and incision for a Knee Arthroscopy
Drape:
Sheet down; stockinette and Coban; 2 U-sheets, arthroscopy sheet
Incisions: 3 port sites
75
Procedure steps summary for a Knee Arthroscopy
Incision for inflow cannula; distend joint with fluid
Incision for sheath & sharp trocar; change to blunt trocar then place arthroscope and camera
Incision for spinal needle and insert probe for EUA
Treat PRN (provide an example)
Trim (shave) meniscus, cartilage, or patella
Repair meniscus
Remove loose body
Irrigate, close, dress (FYI: may inject for post-op pain)
76
Counts and dressings for a Knee Arthroscopy
Counts:
Initial: sponges; sharps
Final closing: (sponges PRN;) sharps
Dressings:
Steri-strips, 4x4, webril or kerlix, ace
77
Specimen (labeled and handled) for a Knee Arthroscopy
Labeled: Meniscal tissue
Handling: Routine; if it goes to lab at all
78
Post-op (destination, prognosis, complications, and wound classification) for a Knee Arthroscopy
Destination: PACU/OP discharge
Prognosis: Depends on diagnosis
Note: text doesn’t reflect variation in what we find
Excellent for removal of loose bodies, but a torn ACL has a different prognosis depending upon rehabilitation
Complications: Bleeding/SSI (RARE); damage to articular cartilage
Wound class: Clean
79
Define Bunionectomy
Excision of hallux valgus with realignment of great toe
| A hallux valgus is a bony exostosis, meaning Abnormal condition where the great toe is displaced toward the other toes
80
Surgical Anatomy and Physiology for a Bunionectomy
Anatomy:
Metatarsal head (1st)
Phalanx (1st); AKA: great toe
Physiology: Support and movement
81
Pathophysiology/indication for a Bunionectomy
Hallux valgus
Medial side of first metatarsal head
Bony or soft tissue
Bony = exostosis; Soft tissue = “bunionette”
Associated pathology – “hammer toes”
82
Special Considerations for a Bunionectomy
Multiple techniques but all involve osteotomy and realignment
83
Equipment, Instruments, Supplies for a Bunionectomy
```
Special Equipment
Tourniquet
Power source for saw; usually use the micro saw – nitrogen poweredInstruments sets/specials
Instruments sets/specials
Small bone set (includes rongeurs)
Inge lamina spreader
Micro-oscillating saw (or sagittal as in text)
Pin cutter
Lambotte osteotomes
Special Supplies and Medications
Saw blade
ESU needle tip
```
84
Medications/Category/Purpose for a Bunionectomy
Bone wax
Category: hemostatic agent – bone hemostasis
Possible antibiotic irrigation – reduce chance of SSI
85
Anesthesia/Position/Prep area for Bunionectomy
Anesthesia: General or regional (spinal)
Position/equipment: supine, arm boards
Prep area: toes to tourniquet; circumferential
86
Draping and incision for a Bunionectomy
```
Drape:
U-sheet down, U-sheet up, extremity sheet (stockinette PRN)
Incision:
Midline on great toe over MTP joint
Metatarsal-phalangeal joint
```
87
Procedure steps summary for a Bunionectomy
```
I/H/D/R
Osteotomy to remove exostosis
Release soft tissues
Realign joint; fixate with screws
I/H/C/D
```
88
Counts and dressings for a Bunionectomy
```
Counts
Initial: sponges, sharps
Final closing: sponges, sharps
Dressing:
Non-adherent layer (adaptic, xeroform); 4x4’s, kling wrap or cast padding; Ace; may do a bootie cast
```
89
Specimen (labeled and handled) for a Bunionectomy
Labeled: bunion, right or left
Handled: Routine
90
Post-op (destination, prognosis, complications, and wound classification) for a Bunionectomy
Destination: outpatient
Prognosis: good to excellent
Complications: Bleeding, infection
Wound classification: Clean
91
Define Cystoscopy
Visual exam of the urinary bladder
92
Surgical Anatomy and Physiology for a Cystoscopy
```
Anatomy:
Urethra
Bladder
Bladder trigone
Ureters
Ureteral orifices (openings)
Physiology: Storage and emptying of urine
```
93
Pathophysiology/indication for a Cystoscopy
Diagnostic exam for:
Recurrent UTI (urinary tract infection); hematuria
Urinary retention
Cystitis, tumors, fistulae, stones, incontinence
94
Special Considerations for a Cystoscopy
Patient modesty; keep the patient covered and do not have perineum facing door
May use flexible cystoscope for males with very limited mobility
If so, then procedure is done supine
Instruments and endoscopes must be sterilized now
95
Equipment, Instruments, Supplies for a Cystoscopy
Special equipment:
Drainage pan
Video tower (light source, camera, monitor)
Instruments:
Cystoscopy set
Rigid cystoscopes, stopcock, bridge, sheaths & obturators, etc
Urethral dilators (Van Buren)
Video camera and fiberoptic light cord
Special supplies:
Cystoscopy irrigation tubing
96
Medications/Category/Purpose for a Cystoscopy
Water-soluble lubricant
To lubricate sheaths prior to insertion
Lidocaine jelly
Category: Topical anesthesia if done under local
Bags of irrigation solution, contrast media
Indigo carmine (to anesthesia)
category: dye
Purpose: to visualize difficult ureteral orifices
97
Anesthesia/Position/Prep area for a Cystoscopy
Anesthesia: Local or Local MAC (for higher ASA status patients)
Regional: spinal (rare, it takes longer than the procedure)
General: Children, cognitively-impaired patients, and any suitable candidate requesting a general anesthetic
Position/aids:
Low lithotomy
GU bed in special room or regular OR bed; stirrups and holders
Prep area:
No Dura prep (not for use on mucous membranes)
Pubic area and perineum
Don’t bring prep from rectum to urethra
98
Draping and incision for a Cystoscopy
Drape:
Under buttocks drape; leggings; cystoscopy sheet (with screen)
Incision: N/A
99
Procedure steps summary for a Cystoscopy
The urethra is dilated only PRN
Lubricate and insert sheath/obturator
Remove obturator
Take urine sample; insert cystoscope
Fill bladder with irrigation solution; EUA
Treat PRN
Give an example such as remove stones, biopsy bladder, remove bladder tumors
Empty bladder; remove instruments
Foley is inserted only after certain procedures, not routine for simple cystoscopy
100
Counts and dressings for a Cystoscopy
Counts – N/A
| Dressings – N/A
101
Specimen (labeled and handled) for a Cystoscopy
Labeled: possible UA
Handling: take UA to Lab ASAP
102
Post-op (destination, prognosis, complications, and wound classification) for a Cystoscopy
Destination: PACU/OP discharge
Prognosis: depends on diagnosis
Complications: damage to urethra
Wound class: Clean-contaminated
103
Define (TURP)
Transurethral resection of the prostate
104
Surgical Anatomy and Physiology for a (TURP)
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Anatomy:
Prostate gland
Penis
Urethra
Bladder neck
Bladder
Physiology: Secretion of seminal fluid
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105
Pathophysiology/indication for a (TURP)
Benign prostatic hypertrophy (BPH)
| Hyperplasia
106
Special Considerations for a (TURP)
Set up like cystoscopy plus ESU
Track input and output to monitor fluid (in case of bladder damage)
Intravasation – fluid goes into venous sinuses and may cause vascular fluid overload
Extravasation – bladder damaged and fluid goes into peritoneal cavity
107
Equipment, Instruments, Supplies for a (TURP)
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Special Equipment
Lap tower, monitor, camera, light source, drain pan)
Fluid warmer PRN
ESU
Tandem suction set (or Neptune)
Instruments sets/specials
Cystoscopy set
Van Buren sounds
Video camera, light source cord
Resectoscope set
Special Supplies
Y-irrigation tubing
Cutting loop
Ellik evacuator, Toomey syringe or Urovac evacuator
3 way Foley 24 fr/30 cc
ESU cord
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108
Medications/Category/Purpose for a (TURP)
1.5% Glycine or 3% Sorbitol
Category: irrigating fluids; isotonic, nonhemolytic
Purpose: to distend bladder
Water soluble lubricant to reduce trauma during instrument insertion
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Anesthesia/Position/Prep area for a (TURP)
Anesthesia: Spinal
Position: lithotomy
Positioning equipment: stirrups and connectors
May use fixed urology OR bed in dedicated “cysto” room, has built-in fluoroscopy
Or set up regular OR bed in any room with drain pan attachment
PrepoPerineum, pubis, and penis
110
Draping and incision for a (TURP)
Drape:
4 towels and cystoscopy drape
Or leggings, top sheet; Urologic drape with rectal sheath and specimen screen
Incision: N/A
111
Procedure steps summary for a (TURP)
Dilate urethra (VB sounds), cystoscopy, EUA
Insert resectoscope sheath, remove obturator
Insert resectoscope with cystoscope (telescope) and camera, fill the bladder
Start cutting, clear bladder of fragments, repeat until complete
Hemostasis, place Foley on traction with continuous bladder irrigation (CBI)
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Counts and dressings for a (TURP)
Counts N/A
| Dressings N/A
113
Specimen (labeled and handled) for a (TURP)
Labeled: TURP: Portion of prostate gland
Handling: Routine
Labeled: BT: bladder tumors
Handling: routine (for microscopic exam)
114
Post-op (destination, prognosis, complications, and wound classification) for a (TURP)
Destination: PACU
Prognosis: good, but may reoccur
Complications: Bleeding, intravasation, damage to: urethra or bladder
Wound classification: Clean-contaminated
115
Define McVay Inguinal Herniorrhaphy
Suture (repair of) a tear in the transversalis fascia
| Suture (repair of) a hernia
116
Surgical Anatomy and Physiology for a McVay Inguinal Herniorrhaphy
Anatomy:
Transversalis fascia
Inguinal canal; inguinal ligament; Cooper ligament
Internal and external inguinal rings
Hesselbach triangle
ilioinguinal nerve
Spermatic cord
Vas deferens, Testicular vessels, Cremaster muscle is attached
Physiology:
Male reproduction (spermatic cord)
Abdominal body wall support (transversalis fascia)
117
Pathophysiology/indication for a McVay Inguinal Herniorrhaphy
Inguinal hernia; direct or indirect
Direct inguinal hernia:
A hernia that occurs within Hesselbach’s Triangle
Indirect inguinal hernia:
A hernia that occurs outside of Hesselbach’s Triangle
118
Special Considerations for a McVay Inguinal Herniorrhaphy
Several different types of repairs: mesh, a tension-free repair or TEP
Have bowel items ready if this is an emergency strangulated inguinal hernia
119
Equipment, Instruments, Supplies for a McVay Inguinal Herniorrhaphy
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Special Equipment:
Nothing special for open approach
Instrument sets/specials:
Minor set and Weitlaner retractors
Special Supplies:
Penrose drain for spermatic cord
Mesh implant
Kitners
Bowel items and C&S for strangulated only
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120
Medications/Category/Purpose for a McVay Inguinal Herniorrhaphy
Local anesthetic agent
lidocaine with epinephrine for local PRN
May block ilioinguinal nerve on the way out with Marcaine w/epinephrine for postop pain block
Purpose: Provides 8-12 hour pain block
Antibiotic irrigation
Agent varies by surgeon preference; may be used when placing an implant to help prevent SSI; less frequently now as surgeons examine effective uses for antibiotics
121
Anesthesia/Position/Prep area for a McVay Inguinal Herniorrhaphy
Anesthesia: Local, regional (spinal or epidural), or general; depends on patient condition
Position/aids: Supine; arm boards
Prep area: Umbilicus to symphysis pubis; past midline to bed line; scrotum
122
Draping and incision for a McVay Inguinal Herniorrhaphy
Drape:
Sheet down; towel under scrotum; 4 towels, lap drape
Incision: Inguinal/oblique
123
Procedure steps summary for a McVay Inguinal Herniorrhaphy
I/H/D/R
Mobilize spermatic cord and place Penrose drain
FYI: Kitners, Metz & TF (smooth or DeBakey)
Dissect and push hernia sac back into peritoneal cavity (McVay)
Size inguinal ring, select mesh, suture in place
I/H/C/D
124
Counts and dressings for a McVay Inguinal Herniorrhaphy
Counts:
Initial: Sponges; sharps, instruments
First closing: Sponges; sharps (can usually eliminate instrument count if peritoneum was not opened)
Final closing: Sponges; sharps
Dressing:
4x4’s and tape
FYI: for babies will use just a tegaderm to protect under diaper
125
Specimen (labeled and handled) for a McVay Inguinal Herniorrhaphy
None - Hernia sac is pushed back in with mesh
126
Post-op (destination, prognosis, complications, and wound classification) for a McVay Inguinal Herniorrhaphy
Destination: PACU/OP discharge
Prognosis: Excellent; recurrence is reduced using tension-free repair
Complications: Bleeding, infection
Other: Damage to cord or ilioinguinal nerve
Wound Classification: Clean
127
Define Tonsillectomy & Adenoidectomy
Excision of palatine tonsils & Excision of adenoids (Resembling; gland)
128
Surgical Anatomy and Physiology for a Tonsillectomy & Adenoidectomy
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Anatomy:
Mouth
tongue
uvula
Palatine tonsils
tonsil mucosa
tonsillar pillar
Pharyngeal tonsils
Blood supply from external carotid
Physiology: Unclear immune function (make lymphocytes)
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129
Pathophysiology/indication for a Tonsillectomy & Adenoidectomy
Recurrent tonsillitis
| Adenomegaly (enlarged adenoid)
130
Special Considerations for a Tonsillectomy & Adenoidectomy
Children; age appropriate communication
Surgeon may stand at head or at side
Usually do tonsils first, then adenoids but may be reversed by surgeon preference
Some surgeons use a stitch for hemostasis; some use free ties; others just ESU or other method
Clean, not sterile procedure
131
Equipment, Instruments, Supplies for a Tonsillectomy & Adenoidectomy
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Special equipment
Headlight and light source
Instrument sets/specials
T&A set
Special supplies
Tonsil sponges
ESU suction device (suction cautery, is insulated)
#12 blade
Asepto syringe (bulb with barrel)
Robinson catheter/s (nasally; to retract uvula or expose adenoids)
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132
Medications/Category/Purpose for a Tonsillectomy & Adenoidectomy
Medications/Purpose: N/A
133
Anesthesia/Position/Prep area for a Tonsillectomy & Adenoidectomy
Anesthesia: General
Position/aids: Supine; Roll under shoulders (hyperextend neck), Headrest (foam donut)
Prep area: N/A
134
Draping and incision for a Tonsillectomy & Adenoidectomy
Drape
Head drape (2 towels and clip to make turban)
Body sheet
Incision: In tonsil mucosa
135
Procedure steps summary for a Tonsillectomy & Adenoidectomy
Place retractors (Jennings and Wieder, Davis, or McIvor)
Grasp tonsil (White tonsil forceps)Incise pillar (12 blade on 7 handle)
Dissect tonsil from fossa (Hurd pillar dissector – the other end of pillar retractor)
Remove tonsil (using snare or ESU; guillotine is really old)
Pack fossa with tonsil sponge
Repeat on other sideRemove adenoids (Barnhill)
Pressure placed (tonsil sponge)
Remove packs one at a time; hemostasis at each area
Irrigate; remove retractors
136
Counts and dressings for a Tonsillectomy & Adenoidectomy
Counts
Initial - Sponges (tonsil); sharps;
Final closing - Sponges (tonsil); sharps
Dressings: N/A
137
Specimen (labeled and handled) for a Tonsillectomy & Adenoidectomy
Labeled: tonsils (left or right); adenoids
Handling: Routine
138
Post-op (destination, prognosis, complications, and wound classification) for a Tonsillectomy & Adenoidectomy
Destination: PACU/OP discharge
Prognosis: excellent
Complications: Bleeding; Big bleeding RARE but possible
Re-operate; may have to tie off part of external carotid artery
Wound class: Clean-contaminated
