SUR 102 unit 4
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5 categories of surgical procedures
- replacement or implantation
what do the results of a diagnostic procedure provide?
information about the nature of a medical problem and the options available for treatment
what is done in reconstructive surgery?
tissue is remodeled or replaced for functional or aesthetic reasons
what is the goal of repair?
to restore function to a structure, organ, or system
what does tissue replacement involve?
implantation of an organ or other anatomical structure that has lost function through disease or trauma
implant derived from the patient or from another person or animal, or biosynthetic material
lists cases and assigned personnel
most commonly used method of gathering supplies
case cart method
who prepares wrapped sterile supplies and places on stainless steel case cart for transport to OR room?
what is surg tech responsible for after case cart is brought to OR room?
completing it by using surgeon's preference card
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
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
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
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
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"
- 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
sequence of instrument trays if they need to be stacked
heavier trays on the bottom
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
when are irrigation and soaking solutions distributed?
after the case is underway or just before case begins
where are irrigation and soaking solutions distributed?
into basins in a ring stand, solution warmer or slush basin
what is the purpose of the count?
to prevent items from being retained in the patient
active responsibility of ensuring that no items are left within the patient lies with whom?
scrub and circulating nurse
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
count is performed by how many people?
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
how is lost item reported?
as a sentinel event
when does anesthesia begin?
only after surgeon has arrived and is ready to scrub
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
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
small, round or oval sponge covered with gauze
sponge dissector (peanut, pusher, etc.)
commonly used in neurosurgical procedures, especially around brain and spinal cord tissue and manufactured to resist shredding
surgical cotton ball
how are all instruments passed?
in closed/locked position unless surgeon requests otherwise
any item or instrument that can potentially puncture or cut through tissue
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
process the entire surgical team uses to care for tissues during surgery
what can rough handling of tissues cause?
extensive bruising, tissue swelling and ischemia
peristalsis ceases, possibly leading to intestinal obstruction
when does surg tech offer irrigation fluids?
when surgeon asks for it and whenever tissues appear dehydrated
signs of dehydration in internal tissues
- loss of surface elasticity
- tissue fraying
what type of fluid is used for irrigation?
warm normal saline
what are retractors used for?
to expose underlying tissue
large self-retaining retractor used for abdominal surgery
large self-retaining retractor used for thoracic surgery
small self-retaining retractor for groin
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
who is directly responsible for receiving and handling specimens?
when submitting a specimen for analysis, are you supposed to remove suture material?
when submitting a specimen for analysis, how are multiple specimens handled?
- each specimen should be identified separately
- "write down, read back"
can you remove a specimen from the sterile field without the surgeon's specific permission to do so?
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
should you discard any tissue?
why should you not use bone clamps, hemostats or other crushing instruments on specimens?
they can destroy cells
how does the circulator receive the specimen?
in a designated container
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
removal of tissue or cells for analysis by pathologist
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
in what setting are body fluids obtained?
- outpatient setting
- occasionally during surgery
from where are stones removed?
urinary tract, salivary ducts and gallbladder
where are removed stones submitted?
in a dry container
nontissue item obtained from the patient's body
how are all foreign bodies submitted?
dry unless surgeon requests another method
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
controlling bleeding with sutures, surgical instruments, thermal energy and drugs
why is bleeding controlled in the surgical wound?
to control infection and promote healing
how can blood be a barrier to healing?
blood forms a physical barrier between tissue edges
uncontrolled oozing or insecure hemostasis can lead to what?
collection of blood that may become a source of infection
- 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
coagulation is activated by 2 pathways:
intrinsic and extrinsic
intrinsic pathway is activated by?
factors present in the blood
extrinsic pathway occurs where?
in the tissues
proaccelerin, labile factor
serum prothrombin conversion accelerator (SPCA)
antihemophilic globulin (AGH)
plasma thromboplastin component
when applied to oozing tissue, what does topical thrombin do?
it combines with fibrinogen to promote coagulation
what is absorbable gelatin used for?
to promote coagulation in bleeding capillaries
what happens when absorbable gelatin is applied to tissue?
it absorbs blood quickly and forms an artificial clot
examples of absorbable gelatin
how is oxidized cellulose applied?
always applied dry
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
manufactured name for oxidized cellulose
collagen absorbable hemostat that is approved for use in all surgeries
how is hemostasis in bone achieved?
by occlusion using a waxy substance called bone wax
how must all bone hemostasis materials be prepared before use?
must be warmed slightly before use by kneading them between the gloved fingers
salvaging blood at the operative site and reinfusion into the patient
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
how is coagulation surgically performed?
- high-frequency electricity
what is a pneumatic tourniquet used for?
used in limb surgery to create a bloodless surgical site
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
period from pneumatic tourniquet cuff inflation to deflation
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
who can apply pneumatic tourniquet?
surgeon or RN circulator
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
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
what is done with the Esmarch bandage once removed?
surg tech should always roll it because it may be needed again during the procedure
hold tissue together by suture
2 main structural categories of sutures
- monofilament suture - single continuous fiber
- multifilament suture - many filaments combined to form one strand
- twisted - multiple fibers twisted in same direction
- braided - mulitple fibers intertwined
what do multifilament sutures do?
absorb moisture and hold body fluids (wicking/capillary action)
why is some multifilament suture coated?
to reduce tissue drag and wicking
range from 12-0 (thinnest) to 5 (thickest)
Brown & Sharp sizing system
from size 38/40 gauge (thinnest) up to 18 gauge (thickest)
the amount of force needed to break the suture
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
suture's tendency to retain its shape or configuration after it is removed from the package
springy and tends to tangle during preparation and use
flexibility of a suture material
material's ability to stretch and then return to its former configuration
one that retains its strength throughout the healing period and then dissolves when healing is complete
how do absorbable protein-based sutures dissolve?
it is attacked by enzyme-releasing lysosomes that digest the suture
how do absorbable synthetic sutures dissolve?
they are degraded by hydrolysis
body's response to suture
natural absorbable suture used on tissues that heal rapidly
surgical gut (catgut)
what is plain surgical gut suture used for?
primarily in mucous membrane or in tissue where stones can form (biliary or urinary systems)
sutures treated with chromic salt to resist digestion and absorption
chromic gut absorption
usually absorbed in 7 to 21 days
plain surgical gut absorption
retains tensile strength for 7 to 10 days
synthetic absorbable polymers
synthetic sutures tensile strength
provide wound support for 3 weeks to 6 months, depending on material
the use of very fine silk sutures placed in close approximation was developed by?
William Halsted in the late 1800s
sutures that are soft and pliable, and have excellent tensile strength
are cotton sutures still available in the US?
first synthetic suture material available
when are nylon sutures used?
- when long-term strength is not required
- passes very easily through delicate tissues of the eye or blood vessels
sutures used in cardiovascular surgery, especially when grafts are used, because of its strength-to-size ratio
sutures popular for plastic, ophthalmic, and vascular surgery, and for retention sutures in abdominal wall surgeries
strongest of all suture materials
when are stainless steel sutures used?
in the approximation of bone and other connective tissue
what are surgical needles made of?
high quality steel alloy
3 types of needle eyes
- closed eye
- French eye
- atraumatic (swaged)
what does closed eye needle look like?
- resembles sewing needle
- eye hole is round, rectangular or square
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
what do swaged sutures look like?
- suture is inserted into the eye end and the area is crimped and sealed
- suture comes preattached
swaged suture that can be detached from the needle by pulling it straight back from the swage
swaged suture with a needle swaged to each end
what is a double-armed suture used for?
- circular tissue such as ophthalmic surgery
- hollow structures such as blood vessels or intestine
what is blunt needle used for?
does not puncture tissue, but slides between tissue fibers
what is tapered needle used for?
punctures tissue, making an opening for body of the needle to follow
what is cutting needle used for?
fibrous connective tissue such as skin, joint capsule, tendon
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
each loop of a suture knot
2 types of suturing techniques
single long suture length that is anchored at one end of the tissues
continuous suture (running suture)
continuous suture technique
needle is alternated from one side of the tissue edge to the other
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
suture used for cosmetic closure and in pediatric patients
subcuticular or buried suture
- needle is placed within the dermis from side to side
- brings the skin edges together in close approximation
continuous suture for closing the end of a tubular structure
one end of suture is anchored and stitches are placed around the periphery of the open "tube"
locking suture technique
as needle is passed through each side of wound edges, it is passed underneath one loop
sutures that are individually placed, knotted and cut
interrupted suture technique
tension of the wound edges is distributed over many anchor points
sutures that provide additional support to wound edges in abdominal surgery
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
what prevents retention sutures from cutting into the patient's skin?
plastic or rubber bolsters are threaded through the suture
used to ligate a large bleeding vessel
suture ligature (stick tie)
what are the most delicate needle holders used for?
microsurgery and ear and ophthalmic surgery
what are smooth forceps used for?
mucous membrane organ tissue and any tissue that bleeds easily
what are toothed forceps used for?
connective tissue including the skin
specially designed with a scored insert at the working tip, preventing puncturing of the blood vessel but provides sufficient friction to hold
before passing suture to the surgeon, how far from the end of the swaged section should the needle be mounted?
about 0.5 mm
left-handed surgeon sutures in what direction?
right-handed surgeon drives needle in which direction?
with a back-handed suture, left-handed surgeon drives needle in which direction?
with a back-handed suture, right-handed surgeon drives needle in which direction?
suture strand lengths
precut or full-length strands ranging from 12-60 inches
what are continuous reels or rolls of sutures used for?
repeated blood vessel ligation
when suture reels are used, how much of the reel is passed?
what clamps are commonly used to pass a tie?
right-angle or long, curved clamp
what types of sutures are used on circular or tubular suture lines?
what works best for pulling out an old suture embedded in scar tissue?
straight, fine-tipped hemostat
clamps the tissue against the staple cartridge
places a single line of staples across the incision border and is used for closing a skin incision
places a double row containing two staples in each row and severs the tissue between rows when fired
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
right-angle firing section that fits around deep structures for resection and anastomosis - commonly used in lung or abdominal surgery
performs same function as purse-string suture and places circumferential nylon sutures and staples
small, V-shaped staples that close down and occlude vessel or duct
hemostatic or vessel clips
used to join wound edges without using sutures
synthetic tissue adhesive
examples of tissue adhesives
where are tissue grafts usually obtained?
from registered tissue bank or from the patient's body
tissue graft derived from human tissue
obtained from the patien'ts body and implanted in another site
tissue graft of beef origin
migration of epithelial cells into the wound during healing
any type of tissue replacement or device placed in the body
graft taken from pig tissue
tissue used to cover large defects in skin
graft taken from a different species than that of the donor
what is porcine graft used for?
full thickness injury
what is an amniotic membrane graft used for?
to cover spina bifida defects and in corneal surgery
biosynthetic dressing made of silicone film in which nylon fabric is partially embedded
skin substitute derived from human fibroblasts
semipermeable silicone layer that acts like epidermis
Integra Bilayer Matrix Wound Dressing
only approved skin substitute that regenerates dermis
Integra Dermal Regeneration Template
epidermal replacement generated from biopsy of skin taken from the patient
how often are keratinocytes duplicated
has 2 layers, human-derived epidermis and bovine collagen dermis
used for structural support and to stimulate new bone growth in defect caused by trauma or congenital anomaly
2 types of bone used for grafting
cancellous and cortical bone
bone that is porous in which tissue fluid can reach, allowing most of the bone cells to live
bone that is very rigid and strong
grafts made from nonliving cadaver bone
grafts made of a combination of cadaver bone, morcelized allograft bone and marrow
processed material made from collagen, protein, and growth factors
demineralized bone matrix
what is used in vascular surgery to replace an artery when saphenous autografting is not feasible?
human umbilical cord
types of synthetic implants
- resorbable implants
- woven synthetics
what type of implant is used for orthopedics?
what type of implant is used to secure prosthetic implants into bone and for remodeling during cranioplasty?
what type of implant is used for orthopedic and maxillofacial surgery?
what types of implants are used in facial reconstruction?
what type of implant should not be handled with bare hands?
what type of implants are used for vascular grafts?
when are drains placed in the wound?
before complete closure
drain that creates a passage from the tissue inside the wound to the outside of the body
simple tubular length of nonlatex material similar to surgical glove material
drain that is used in wounds or hollow structures that produce significant amounts of fluid but do not require suction for removal
examples of gravity drainage
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