SUR 102 unit 4

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jb124
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175892
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SUR 102 unit 4
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2012-10-15 17:13:52
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Intraoperative routine wounds
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Intraoperative routine/wounds
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  1. 5 categories of surgical procedures
    • diagnosis
    • reconstruction
    • repair
    • removal
    • replacement or implantation
  2. what do the results of a diagnostic procedure provide?
    information about the nature of a medical problem and the options available for treatment
  3. what is done in reconstructive surgery?
    tissue is remodeled or replaced for functional or aesthetic reasons
  4. what is the goal of repair?
    to restore function to a structure, organ, or system
  5. what does tissue replacement involve?
    implantation of an organ or other anatomical structure that has lost function through disease or trauma
  6. implant derived from the patient or from another person or animal, or biosynthetic material
    graft
  7. lists cases and assigned personnel
    assignment board
  8. most commonly used method of gathering supplies
    case cart method
  9. who prepares wrapped sterile supplies and places on stainless steel case cart for transport to OR room?
    central supply
  10. what is surg tech responsible for after case cart is brought to OR room?
    completing it by using surgeon's preference card
  11. information listed on surgeon's preference card
    • instrument sets and special instruments required for case
    • special equipment
    • suture preferences
    • glove and gown size
    • skin prep and draping routine
    • intraoperative drugs, dosages and strength
    • surgeon's individual techniques
    • dressings
  12. preparing the OR room
    • arrange head of OR table in appropriate position and directly under lights
    • arrange room so contamination and clutter is prevented
    • furniture no closer than 18 inches from nonsterile surface
    • clean linen on OR table
    • connect suction tubing
    • gather diagnostic studies
    • assemble monitoring equipment
    • test power equipment
  13. recommendations for sterile setup
    • increase size of sterile working area
    • avoid shifting items from one place to another - try to handle sterile items only once
    • prepare items needed at beginning of the procedure first
    • avoid doing several things at once
  14. procedure setup sequence
    • towels distributed to team members, gowned and gloved
    • patient prepped
    • patient draped
    • suction tubing and electrosurgical pencil set up
    • sterile light handles are attached
    • two sponges placed on field
    • incision made
  15. items retrieval sequence
    • towels, gowns, gloves, drapes
    • light handles, suction tubing and electrosurgical pencil and holder
    • knife and basic instruments
    • sponges and sutures
    • "priority equipment"
  16. suture sequence
    • suture ties may be needed shortly after surgery begins
    • suture reels can remain on mayo stand
    • swaged (atraumatic) needles can be placed in small basin on the back table until needed
  17. sequence of instrument trays if they need to be stacked
    heavier trays on the bottom
  18. what is the mayo stand used for?
    • instruments and supplies frequently needed during surgery
    • supplies are exchanged from back table to mayo stand as case progresses
  19. when are irrigation and soaking solutions distributed?
    after the case is underway or just before case begins
  20. where are irrigation and soaking solutions distributed?
    into basins in a ring stand, solution warmer or slush basin
  21. what is the purpose of the count?
    to prevent items from being retained in the patient
  22. active responsibility of ensuring that no items are left within the patient lies with whom?
    scrub and circulating nurse
  23. when is count performed?
    • before surgery begins to establish a baseline count
    • before closure of hollow organ
    • before closure of body cavity
    • before skin closure
    • whenever suspicion of retained item arises
    • whenever permanent change in personnel occurs
  24. count is performed by how many people?
    2
  25. specific order in which items are counted
    • items on the sterile field
    • items on the mayo stand
    • items on the instrument table
    • items discarded from the field
  26. how is lost item reported?
    as a sentinel event
  27. when does anesthesia begin?
    only after surgeon has arrived and is ready to scrub
  28. mandatory steps for timeout procedure
    • verification that the correct patient is present
    • verification of correct side and site
    • agreement on the procedure to be done
    • verification of correct patient position
    • verification of availability of correct implants and any special equipment or requirements
  29. how are instruments handled as they are being passed back from the field?
    • they should be wiped clean to prevent blood and body fluids from drying on the surface
    • suction tips are cleared by running small amounts of water through them
  30. small, round or oval sponge covered with gauze
    sponge dissector (peanut, pusher, etc.)
  31. commonly used in neurosurgical procedures, especially around brain and spinal cord tissue and manufactured to resist shredding
    surgical cotton ball
  32. how are all instruments passed?
    in closed/locked position unless surgeon requests otherwise
  33. any item or instrument that can potentially puncture or cut through tissue
    sharps
  34. designated area established on the field near the surgical wound used specifically for passing sharps/instruments, avoiding passing from hand to hand
    neutral zone technique
  35. process the entire surgical team uses to care for tissues during surgery
    wound management
  36. what can rough handling of tissues cause?
    extensive bruising, tissue swelling and ischemia
  37. peristalsis ceases, possibly leading to intestinal obstruction
    paralytic ileus
  38. when does surg tech offer irrigation fluids?
    when surgeon asks for it and whenever tissues appear dehydrated
  39. signs of dehydration in internal tissues
    • dullness
    • loss of surface elasticity
    • tissue fraying
  40. what type of fluid is used for irrigation?
    warm normal saline
  41. what are retractors used for?
    to expose underlying tissue
  42. Balfour retractor
    large self-retaining retractor used for abdominal surgery
  43. Finochietto retractor
    large self-retaining retractor used for thoracic surgery
  44. Weitlaner retractor
    small self-retaining retractor for groin
  45. what can excess pressure of retractor or inattention to the retractor blade or tip result in?
    nerve damage resulting in loss of mobility and sensation for the patient
  46. who is directly responsible for receiving and handling specimens?
    scrub
  47. when submitting a specimen for analysis, are you supposed to remove suture material?
    negative batman
  48. when submitting a specimen for analysis, how are multiple specimens handled?
    • each specimen should be identified separately
    • "write down, read back"
  49. can you remove a specimen from the sterile field without the surgeon's specific permission to do so?
    nope
  50. what should you wrap a specimen with?
    • moist teflon pad to protect a bone or tissue specimen
    • place specimen in a conspicuous, protected area until it can be passed to circulator
    • do not use sponges
  51. should you discard any tissue?
    negatory
  52. why should you not use bone clamps, hemostats or other crushing instruments on specimens?
    they can destroy cells
  53. how does the circulator receive the specimen?
    in a designated container
  54. how must each specimen be identified?
    • identification of the patient with 2 identifiers
    • type of tissue
    • origin of specimen
    • clinical diagnosis and other information
    • any special markings and their significance
    • other registration information, date and time of removal, surgeon's name
  55. removal of tissue or cells for analysis by pathologist
    biopsy
  56. types of tissue biopsies
    • excisional biopsy - used when large, deep section of tissue required for analysis
    • fine-needle aspiration - long, fine needle to aspirate small pieces of tissue from a tumor
    • needle biopsy - large-bore, hollow trocar or needle used to collect tissue
    • brush biopsy - performed during flexible endoscopic procedures - fine brush used to collect cells on surface of mucous membrane tissue
  57. in what setting are body fluids obtained?
    • outpatient setting
    • occasionally during surgery
  58. from where are stones removed?
    urinary tract, salivary ducts and gallbladder
  59. where are removed stones submitted?
    in a dry container
  60. nontissue item obtained from the patient's body
    foreign body
  61. how are all foreign bodies submitted?
    dry unless surgeon requests another method
  62. principles of successful wound management
    • handle tissues gently
    • control bleeding as efficiently as possible
    • use correct instruments and sutures
    • careful but efficient use of time to minimize tissue exposure
    • meticulous aseptic technique to prevent infection
  63. controlling bleeding with sutures, surgical instruments, thermal energy and drugs
    hemostasis
  64. why is bleeding controlled in the surgical wound?
    to control infection and promote healing
  65. how can blood be a barrier to healing?
    blood forms a physical barrier between tissue edges
  66. uncontrolled oozing or insecure hemostasis can lead to what?
    hematoma
  67. collection of blood that  may become a source of infection
    hematoma
  68. coagulation process
    • blood vessel is injured
    • vasospasm occurs - vessel retracts and constricts, reducing blood flow
    • platelet plug forms - initiates release of coagulation factors
    • coagulation begins - meshwork of fibrin strands forms around blood cells, creating clot
  69. coagulation is activated by 2 pathways:
    intrinsic and extrinsic
  70. intrinsic pathway is activated by?
    factors present in the blood
  71. extrinsic pathway occurs where?
    in the tissues
  72. factor I
    fibrinogen
  73. factor II
    prothrombin
  74. factor III
    thromboplastin, thrombokinase
  75. factor V
    proaccelerin, labile factor
  76. factor VII
    serum prothrombin conversion accelerator (SPCA)
  77. factor VIII
    antihemophilic globulin (AGH)
  78. factor IX
    plasma thromboplastin component
  79. factor X
    Christmas factor
  80. factor XI
    Stuart factor
  81. factor XII
    Hageman factor
  82. factor XIII
    fibrin-stabilizing factor
  83. when applied to oozing tissue, what does topical thrombin do?
    it combines with fibrinogen to promote coagulation
  84. what is absorbable gelatin used for?
    to promote coagulation in bleeding capillaries
  85. what happens when absorbable gelatin is applied to tissue?
    it absorbs blood quickly and forms an artificial clot
  86. examples of absorbable gelatin
    • Gelfoam
    • Gelfilm
    • Surgifoam
  87. how is oxidized cellulose applied?
    always applied dry
  88. what happens when oxidized cellulose becomes in contact with blood?
    it rapidly forms a gelatin clot, which is absorbed by the body during the healing process
  89. manufactured name for oxidized cellulose
    Surgicel
  90. collagen absorbable hemostat that is approved for use in all surgeries
    Avitene
  91. how is hemostasis in bone achieved?
    by occlusion using a waxy substance called bone wax
  92. how must all bone hemostasis materials be prepared before use?
    must be warmed slightly before use by kneading them between the gloved fingers
  93. salvaging blood at the operative site and reinfusion into the patient
    autotransfusion
  94. how is autotransfusion achieved?
    • Cell Saver device
    • blood is collected through a suction tip and routed through tubing in device, rinsed, anticoagulated, and blood cells separated from unwanted components
  95. how is coagulation surgically performed?
    • ESU
    • laser
    • high-frequency electricity
    • ultrasound
  96. what is a pneumatic tourniquet used for?
    used in limb surgery to create a bloodless surgical site
  97. how is pneumatic tourniquet used?
    • bandaging material Webril is wrapped around the limb
    • tourniquet is placed around Webril
    • Esmarch bandage wrapped from distal to proximal end of limb, pushing the blood proximally away from surgical site
    • tourniquet is inflated, preventing blood from flowing back into vessels
  98. period from pneumatic tourniquet cuff inflation to deflation
    tourniquet time
  99. how long can the pneumatic tourniquet remain inflated?
    • up to 1 hour on upper extremity
    • up to 1-1/2 to 2 hours on lower extremity
  100. who can apply pneumatic tourniquet?
    surgeon or RN circulator
  101. pneumatic tourniquet pressure
    • adult upper extremity - must not exceed 50-75 mmHg above systolic BP
    • adult lower extremity - must not exceed 100-150 mmHg above systolic BP
    • pediatric - upper limit is 100 mmHg above systolic BP
  102. how is pneumatic tourniquet used if surgery continues beyond recommended inflation time?
    • tourniquet is deflated for 10 minutes and then reinflated
    • hemostasis must be maintained while it is deflated
  103. what is done with the Esmarch bandage once removed?
    surg tech should always roll it because it may be needed again during the procedure
  104. hold tissue together by suture
    approximate
  105. 2 main structural categories of sutures
    • monofilament suture - single continuous fiber
    • multifilament suture - many filaments combined to form one strand
  106. multifilament subcategories
    • twisted - multiple fibers twisted in same direction
    • braided - mulitple fibers intertwined
  107. what do multifilament sutures do?
    absorb moisture and hold body fluids (wicking/capillary action)
  108. why is some multifilament suture coated?
    to reduce tissue drag and wicking
  109. suture sizes
    range from 12-0 (thinnest) to 5 (thickest)
  110. Brown & Sharp sizing system
    from size 38/40 gauge (thinnest) up to 18 gauge (thickest)
  111. the amount of force needed to break the suture
    tensile strength
  112. tensile strength is influenced by these factors:
    • type of knot - 10-40% weaker when knotted
    • biological environment of the suture - vary in strength when exposed to body fluids
    • uniformity - must be uniform in diameter to maintain tensile strength
  113. suture's tendency to retain its shape or configuration after it is removed from the package
    memory
  114. high-memory suture
    springy and tends to tangle during preparation and use
  115. flexibility of a suture material
    pliability
  116. material's ability to stretch and then return to its former configuration
    elasticity
  117. ideal suture
    one that retains its strength throughout the healing period and then dissolves when healing is complete
  118. how do absorbable protein-based sutures dissolve?
    it is attacked by enzyme-releasing lysosomes that digest the suture
  119. how do absorbable synthetic sutures dissolve?
    they are degraded by hydrolysis
  120. body's response to suture
    bioactivity
  121. natural absorbable suture used on tissues that heal rapidly
    surgical gut (catgut)
  122. what is plain surgical gut suture used for?
    primarily in mucous membrane or in tissue where stones can form (biliary or urinary systems)
  123. sutures treated with chromic salt to resist digestion and absorption
    chromic gut
  124. chromic gut absorption
    usually absorbed in 7 to 21 days
  125. plain surgical gut absorption
    retains tensile strength for 7 to 10 days
  126. synthetic absorbable polymers
    • Monocryl
    • PDS II
    • Vicryl
  127. synthetic sutures tensile strength
    provide wound support for 3 weeks to 6 months, depending on material
  128. the use of very fine silk sutures placed in close approximation was developed by?
    William Halsted in the late 1800s
  129. sutures that are soft and pliable, and have excellent tensile strength
    silk sutures
  130. are cotton sutures still available in the US?
    nope
  131. first synthetic suture material available
    nylon
  132. nylon sutures
    • Dermalon
    • Ethilon
    • Monosof
    • Nurolon
  133. when are nylon sutures used?
    • when long-term strength is not required
    • passes very easily through delicate tissues of the eye or blood vessels
  134. sutures used in cardiovascular surgery, especially when grafts are used, because of its strength-to-size ratio
    polyester sutures
  135. sutures popular for plastic, ophthalmic, and vascular surgery, and for retention sutures in abdominal wall surgeries
    polypropylene
  136. strongest of all suture materials
    stainless steel
  137. when are stainless steel sutures used?
    in the approximation of bone and other connective tissue
  138. what are surgical needles made of?
    high quality steel alloy
  139. 3 parts of needle
    • point
    • body
    • eye
  140. 3 types of needle eyes
    • closed eye
    • French eye
    • atraumatic (swaged)
  141. what does closed eye needle look like?
    • resembles sewing needle
    • eye hole is round, rectangular or square
  142. what do French eye needles look like?
    have 2 eyes that are connected by a slit from the top through the eyes with ridges that hold the sutures in place
  143. what do swaged sutures look like?
    • suture is inserted into the eye end and the area is crimped and sealed
    • suture comes preattached
  144. swaged suture that can be detached from the needle by pulling it straight back from the swage
    Control-release (De-tach)
  145. swaged suture with a needle swaged to each end
    double-armed suture
  146. what is a double-armed suture used for?
    • circular tissue such as ophthalmic surgery
    • hollow structures such as blood vessels or intestine
  147. 3 types of needle points
    • blunt
    • tapered
    • cutting
  148. what is blunt needle used for?
    does not puncture tissue, but slides between tissue fibers
  149. what is tapered needle used for?
    punctures tissue, making an opening for body of the needle to follow
  150. what is cutting needle used for?
    fibrous connective tissue such as skin, joint capsule, tendon
  151. dispensing methods of sutures
    • suture-needle combination - one combination per pack
    • multiple suture strands
    • suture reel - spool of suture material
    • multiple suture-needle combinations
    • double-armed suture - one suture strand/needle per pack
  152. each loop of a suture knot
    throw
  153. 2 types of suturing techniques
    • continuous
    • interrupted
  154. single long suture length that is anchored at one end of the tissues
    continuous suture (running suture)
  155. continuous suture technique
    needle is alternated from one side of the tissue edge to the other
  156. pros/cons of continuous suture technique
    rapid and uses relatively little suture material, but does not allow surgeon to make adjustments in aligning wound edges
  157. suture used for cosmetic closure and in pediatric patients
    subcuticular or buried suture
  158. subcuticular technique
    • needle is placed within the dermis from side to side
    • brings the skin edges together in close approximation
  159. continuous suture for closing the end of a tubular structure
    purse-string suture
  160. purse-string technique
    one end of suture is anchored and stitches are placed around the periphery of the open "tube"
  161. locking suture technique
    as needle is passed through each side of wound edges, it is passed underneath one loop
  162. sutures that are individually placed, knotted and cut
    interrupted sutures
  163. interrupted suture technique
    tension of the wound edges is distributed over many anchor points
  164. sutures that provide additional support to wound edges in abdominal surgery
    retention sutures
  165. retention suture technique
    heavy sutures are placed through all tissue layers of the body wall several centimeters from the primary suture line, perpendicular to the incision line
  166. what prevents retention sutures from cutting into the patient's skin?
    plastic or rubber bolsters are threaded through the suture
  167. used to ligate a large bleeding vessel
    suture ligature (stick tie)
  168. what are the most delicate needle holders used for?
    microsurgery and ear and ophthalmic surgery
  169. what are smooth forceps used for?
    mucous membrane organ tissue and any tissue that bleeds easily
  170. what are toothed forceps used for?
    connective tissue including the skin
  171. vascular forceps
    specially designed with a scored insert at the working tip, preventing puncturing of the blood vessel but provides sufficient friction to hold
  172. before passing suture to the surgeon, how far from the end of the swaged section should the needle be mounted?
    about 0.5 mm
  173. left-handed surgeon sutures in what direction?
    counterclockwise
  174. right-handed surgeon drives needle in which direction?
    clockwise
  175. with a back-handed suture, left-handed surgeon drives needle in which direction?
    clockwise
  176. with a back-handed suture, right-handed surgeon drives needle in which direction?
    counterclockwise
  177. suture strand lengths
    precut or full-length strands ranging from 12-60 inches
  178. what are continuous reels or rolls of sutures used for?
    repeated blood vessel ligation
  179. when suture reels are used, how much of the reel is passed?
    entire reel
  180. what clamps are commonly used to pass a tie?
    right-angle or long, curved clamp
  181. what types of sutures are used on circular or tubular suture lines?
    double-armed sutures
  182. what works best for pulling out an old suture embedded in scar tissue?
    straight, fine-tipped hemostat
  183. clamps the tissue against the staple cartridge
    anvil
  184. places a single line of staples across the incision border and is used for closing a skin incision
    skin stapler
  185. places a double row containing two staples in each row and severs the tissue between rows when fired
    ligation-dividing stapler
  186. used for end-to-end intestinal resection (cutting and rejoining) - joins two arms of intestine with double row of staples
    circular or end-to-end stapler
  187. right-angle firing section that fits around deep structures for resection and anastomosis - commonly used in lung or abdominal surgery
    thoracoabdominal stapler
  188. performs same function as purse-string suture and places circumferential nylon sutures and staples
    purse-string stapler
  189. small, V-shaped staples that close down and occlude vessel or duct
    hemostatic or vessel clips
  190. used to join wound edges without using sutures
    synthetic tissue adhesive
  191. examples of tissue adhesives
    • Indermil
    • Dermabond
  192. where are tissue grafts usually obtained?
    from registered tissue bank or from the patient's body
  193. tissue graft derived from human tissue
    allograft
  194. obtained from the patien'ts body and implanted in another site
    autologous autograft
  195. tissue graft of beef origin
    bovine graft
  196. migration of epithelial cells into the wound during healing
    epithelialization
  197. any type of tissue replacement or device placed in the body
    implant
  198. graft taken from pig tissue
    porcine graft
  199. tissue used to cover large defects in skin
    wound cover
  200. graft taken from a different species than that of the donor
    xenograft
  201. what is porcine graft used for?
    full thickness injury
  202. what is an amniotic membrane graft used for?
    to cover spina bifida defects and in corneal surgery
  203. 2 layers of placenta
    • amnion
    • chorion
  204. biosynthetic dressing made of silicone film in which nylon fabric is partially embedded
    Biobrane
  205. skin substitute derived from human fibroblasts
    TransCyte
  206. semipermeable silicone layer that acts like epidermis
    Integra Bilayer Matrix Wound Dressing
  207. only approved skin substitute that regenerates dermis
    Integra Dermal Regeneration Template
  208. epidermal replacement generated from biopsy of skin taken from the patient
    Epicel
  209. how often are keratinocytes duplicated
    2-3 weeks
  210. has 2 layers, human-derived epidermis and bovine collagen dermis
    Apligraf
  211. used for structural support and to stimulate new bone growth in defect caused by trauma or congenital anomaly
    bone grafts
  212. 2 types of bone used for grafting
    cancellous and cortical bone
  213. bone that is porous in which tissue fluid can reach, allowing most of the bone cells to live
    cancellous bone
  214. bone that is very rigid and strong
    cortical bone
  215. grafts made from nonliving cadaver bone
    allogenic grafts
  216. grafts made of a combination of cadaver bone, morcelized allograft bone and marrow
    composite grafts
  217. processed material made from collagen, protein, and growth factors
    demineralized bone matrix
  218. what is used in vascular surgery to replace an artery when saphenous autografting is not feasible?
    human umbilical cord
  219. types of synthetic implants
    • metal
    • methylethacrylate
    • resorbable implants
    • polyethylene
    • silicone
    • woven synthetics
  220. what type of implant is used for orthopedics?
    metal
  221. what type of implant is used to secure prosthetic implants into bone and for remodeling during cranioplasty?
    methylethacrylate
  222. what type of implant is used for orthopedic and maxillofacial surgery?
    resorbable implants
  223. what types of implants are used in facial reconstruction?
    polyethylene
  224. what type of implant should not be handled with bare hands?
    silicone
  225. what type of implants are used for vascular grafts?
    woven synthetics
  226. when are drains placed in the wound?
    before complete closure
  227. drain that creates a passage from the tissue inside the wound to the outside of the body
    passive drain
  228. simple tubular length of nonlatex material similar to surgical glove material
    Penrose drain
  229. drain that is used in wounds or hollow structures that produce significant amounts of fluid but do not require suction for removal
    gravity drain
  230. examples of gravity drainage
    • T-tube
    • Pezzer
    • Malecot
    • Foley

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