Surgical Procedures Flashcards

Question

Transpalpebral enucleation

Answer 1

1. Copiously lubricate the eye(s). Clip periocular area, 2 in wide area around the eyelid with a No 40 blade clipper and prep with 0.5% povidone-iodine 2. Confirm that the procedure is being performed on the correct eye 3. Start with the closure of the eyelids with Allis tissue forceps or suture the lids closed with a simple continuous 3-0 or 4-0 suture leaving the ends left long, these may be used to position the close. 4. Circumferentially incise the anterior skin orbicular layer of the eyelids parallel to and 4-5 mm from the lid margins with a No 15 Nard Parker Scalpel or electrocautery. 5. From the initial skin incision, bluntly dissect the subcutaneous tissues with a small curved Metzenbaum scissor around the globe while keeping the plane of dissection outside the conjunctival sac. 6. Use Allis tissue forceps on the subcutaneous tissue inside the incision to keep the eyelids open dorsally and ventrally. 7. Cut the medial and lateral canthal tendons with Mayo scissors to free up the canthal area. 8. Palpate the bony dorsal orbital rim so it can be used as a landmark. 9. At the level of the dorsal orbital rim, deepen the incision by bluntly and sharply dissecting with the top of the scissors in the tissue the tissue until the yellowish sclera and extraocular muscle tensons are exposed. 10. Bluntly and sharply dissect 360 degrees around the globe, making the incision parallel to the limbus. 11. Don’t pull the eye because you can put traction on the optic nerve and cause trauma to the optic chiasm, resulting in blindness of the remaining eye. 12. Clamp the tissues at the posterior pole of the globe then remove the hemostat. 13. With enucleation scissors (strong curved ideally) or curved Metzenbaum scissors, cut the optic stalk halfway between the back of the eye and posterior orbit. 14. Remove the block of tissue containing the globe, lid margins, orbital lacrimal gland, conjunctiva, and third eyelid gland 15. Flush orbit 16. Close the orbital septum with 3-0 or 4-0 PDS in a horizontal mattress pattern, 3-0 or 4-0 polyglactin 910 suture for the subcutaneous tissue and then the skin, and place local anesthetic.

Answer 2

1. The most commonly used sites are the flat medial surface of the proximal tibia (1 to 2 cm distal to the tibial tuberosity), the tibial tuberosity itself, and the trochanteric fossa of the femur a. Alternative approachable points can be considered, such as the wing of the ilium, the ischium, and the greater tubercle of the humerus b. The tibia and the humerus are safe sites for IO access in neonates; however, care should be taken to avoid the epiphyseal plates 2. A preemptive skin stab incision over the site of penetration of the catheter may prolong the life of the needle. 3. For placement in the medial tibia, the needle must be directed into the bone slightly distally and away from the proximal growth plate. To prevent sciatic nerve injury during placement in the femur, the needle should be walked off the medial aspect of the greater trochanter into the trochanteric fossa, with the hip joint in a neutral or slightly extended and internally rotated position. Once the desired orientation of the needle is reached, firm pressure should be applied in clockwise and then counterclockwise rotation. a. This procedure normally generates a small depression that seats the needle in the bone; the pressure is then increased while the same rotation pattern is maintained, and the needle should proceed through the near cortex. b. A sudden loss of resistance indicates that the needle has fully penetrated the cortex. Before fluids or drugs are administered through an IO catheter, verification of correct placement is required. One of the most frequently reported causes of failure of IO catheterization is an error in identifying landmarks. c. A well-positioned catheter should be firmly seated in the bone and should move with the limb without being dislodged. d. Gentle aspiration should bring bone marrow into the syringe, although in older animals this may not always be possible. A bolus of heparinized saline solution should flow easily, and there should be no palpable accumulation of fluid in the subcutaneous tissue. e. If resistance is encountered, the needle can be rotated 90 to 180 degrees to move the beveled edge away from the inner cortex. IO catheters without a stylet may get a cortical bone that makes those unusable. 4. The subcutaneous tissue must be observed for fluid extravasation. If extravasation is detected, the needle should be removed to prevent further complications and an alternative bone should be used for catheter placement. 5. Once correct placement of the needle is verified, administration of fluids or drugs can be administered by syringe or use of a standard intravenous administration set. To maintain patency during intermittent usage, an infusion plug can be placed, and the catheter flushed with preservative-free heparinized saline solution. a. Initial infusion of fluids under pressure causes pain in conscious human patients and lasts approximately 1 to 2 minutes. It is therefore recommended to withdraw a small volume of bone marrow, and then slowly inject 1% lidocaine over 60 seconds before the infusion is initiated in people.

Answer 3

1. A venous cutdown is indicated when the veins are small (a small patient or a patient that is severely hypovolemic) or when the veins are obscured (e.g., due to obesity, subcutaneous edema, or hematoma) 2. Following aseptic skin preparation, awake animals will require local anesthesia of the region, which should be done with care so as not to inject any agent intravenously 3. A 1- to 2-cm incision is then made through the skin parallel to the vessel, with care exercised to avoid lacerating the vein. 4. The vessel is isolated using blunt dissection to free it from the surrounding tissue. 5. An encircling suture (absorbable) is placed around the vein proximal and distal to the intended venotomy site. 6. The catheter can be inserted directly through the superficial vessel wall or, if a catheter is to be used without a needle stylet, an incision can be made into the vein while traction is applied on the preplaced sutures. 7. If an incision is made, then once the catheter is inserted, both sutures are tied proximally to prevent bleeding 8. The skin is closed, and the catheter site is bandaged.

Answer 4

1. The lateral thorax is clipped in a wide area around the tube insertion site and surgically prepared 2. For large-bore thoracostomy tube placement or an open insertion technique, the animal is ideally anesthetized and placed in lateral recumbency, provided ventilation and oxygenation are sufficient in this position 3. For the Seldinger technique, light sedation and local anesthesia are usually sufficient, and the animal can remain in sternal recumbency for the procedure 4. Once the area is prepared and appropriate anesthesia or analgesia has been provided, the area is draped a. Seldinger i. In this technique the chest tube is advanced into the thorax with the use of a guidewire that has been inserted through a small needle or catheter ii. The length of the chest tube to be inserted in the thorax should be first determined by estimating the distance from the insertion site to the second rib iii. An over-the-needle catheter (or hypodermic needle) is inserted through a small skin incision over the seventh, eight, or ninth intercostal space, angled cranioventral in the direction desired for the chest tube iv. A guidewire is inserted through the intravenous catheter in a cranioventral direction v. The catheter is removed, leaving the guidewire in place. At this time a dilator can be passed over the guidewire to widen the tunnel through the tissue, although it may not be necessary when larger introducer catheters are used. vi. The small-bore thoracostomy tube is advanced over the wire to the desired length. If there is resistance to passage of the tube through the intercostal tissues, it may be prudent to use the dilator, if it has not already been utilized. vii. Once the tube is placed, the guidewire is removed and the tube is secured viii. Care is taken not to compromise the lumen of the catheter if a finger-trap suture is used. ix. The insertion site is covered with sterile gauze, and a bandage is applied to secure the thoracostomy tube to the chest wall and minimize risk of accidental removal

Answer 5

i. The key point is the generation of a subcutaneous tunnel by pulling the skin cranially prior to placement of the thoracostomy tube in the seventh, eight, or ninth intercostal space ii. The length of tube to insert into the thorax is estimated prior to starting the procedure by holding the chest tube alongside the chest with the tip aligned to the second rib, without compromising sterility iii. A small skin incision, slightly larger than the diameter of the tube, is made overlying the desired intercostal space midway between the dorsal midline and the center of the lateral thorax iv. The subcutaneous tissue and muscle layers are bluntly dissected with a hemostat v. The pleura is then penetrated bluntly using a large hemostat or Carmalt forceps vi. During this maneuver, the anesthetist is asked to stop ventilation to minimize injury to the lung vii. Also, injury to the underlying organs is minimized by holding the hemostat close to the tip with the nondominant hand to avoid overpenetration viii. Once the pleura is penetrated, the tips of the hemostat are opened, which creates an opening for the thoracostomy tube ix. Before insertion, the trochar (if present) can be retracted slightly so that the sharp tip is protected by the tube x. The tip of the tube is introduced into the thorax and is then advanced toward the uppermost elbow xi. Once the tip of the tube is well inside the thorax, the hemostat can be removed xii. The thoracostomy tube should be inserted so that the tip is roughly at the level of the second rib xiii. It is essential that all tube fenestrations be within the thoracic cavity. xiv. The stylet is then withdrawn and a tube clamp (Carmalt forceps if a tube clamp not available) can be used to occlude the tube 1. Alternatively, the tube can be connected directly to the suction device xv. As the skin is released and retracts caudally over the tube, a subcutaneous tunnel is created xvi. The Mac technique can be used to rule out kinking of the tube: the tube is twisted 180 degrees in each direction and then released. If the tube spins back into its position, this is indicative of kinking xvii. Depending on the urgency of pleural evacuation, suction is instituted before or after securing the tube xviii. A purse-string suture is placed around the skin incision if the fit is not firm xix. The tube is then fixed using a finger-trap suture pattern xx. A single interrupted suture is placed through the skin at the site of insertion xxi. This suture may pass through the periosteum of the rib (this requires additional local anesthetic) and is tied in a gentle loop, leaving equal and long suture tags xxii. The suture tags are used to create the finger-trap pattern by placing a single knot on top of the tube, crossing underneath the tube, and then placing another single knot on top of the tube, and so on xxiii. The tube is then connected to the suction system of choice xxiv. The insertion site is covered with sterile gauze, and a bandage is applied to secure the thoracostomy tube to the chest wall and minimize risk of accidental removal xxv. If no assistant is available to pull the skin forward, the subcutaneous tunnel can be made with a large hemostat or Carmalt forceps 1. The skin incision is made more caudally (eighth to tenth intercostal space), and the hemostat is tunneled cranially through the subcutaneous tissues by the length of two intercostal spaces to the desired insertion point at the level of the sixth to eighth intercostal space 2. Then the pleural space is entered, and the tube is inserted as described earlier

Answer 6

1. Cystostomy tube placement is performed by a stab incision in the abdominal wall in a paramedian position convenient to positioning of the external tubing 2. A purse string suture of absorbable material is placed in the bladder and a small stab incision made within it 3. Following the stab incision into the bladder, the internal end of the cystostomy tube is placed within the bladder and secured 4. Commonly, three to four sutures are placed around the cystostomy site and the abdominal wall to facilitate adhesion between bladder and abdominal wall 5. The external tube is secured to the body wall 6. The urinary bladder should be emptied via cystostomy tube three to four times per day 7. Minimizing contamination of the tube and stoma by careful handling and daily cleaning is essential. 8. Removal of cystostomy tubes may be performed under sedation 14 days following placement once a robust stoma has formed 9. Rate of complications are high, occurring in 49% of patients, and most included inadvertent removal or displacement from the bladder, chewing on the tube, tube breakage, and fistula formation a. Minor complications may include irritation or inflammation around the tube exit site, or urine leakage, hematuria, tube obstruction, or complications with fixing the construct to the skin

Answer 7

1. Patient anesthetized, intubated, and placed in right lateral recumbency + Mouth held open with oral speculum 2. Surgical field prep – mandibular ramus to the thoracic inlet extended to the dorsal and ventral midlines 3. Feeding tube premeasured from caudal to the larynx to the 8th/9th intercostal space + Tip will lie in distal esophagus + Long enough to allow several cm to remain exterior to the skin + Sizing: + 12-14 Fr cats + 20 Fr Dogs + Variety of materials available + Red rubber, polyurethane, or silicone tubes 4. Curved forceps placed in the mouth and advanced to the mid-cervical esophagus, distal to the hyoid apparatus – forceps are pushed dorsally to tent the skin until able to be externally palpated 5. Jugular is identified to avoid injury 6. Incision made over tented skin through the esophageal wall then exteriorized by blunt dissection 7. Grasp tube with forceps and pull through incision and out of the mouth 8. Lubricate end of the tube, retroflex, and push down esophagus while proximal end is slowly retracted a few cm 9. Proximal end of tube will rotate cranially as tube straightens – slide to pre-marked site 10. Inspect oropharynx to confirm tube is not present 11. Clean incision site and secure tube with finger-trap and non-absorbable suture 12. Confirm placement radiographically 13. Place non-adherent pad over surgical site and lightly wrap 14. Mark tube at exit site to monitor for migration 15. Flush with sterile saline and assess for cough – cap tube when not in use

Answer 8

* PEG 1. Patient anesthetized and placed in right lateral recumbency 2. Left flank is clipped and surgically prepped from costal arch to mid-abdomen in cranial and caudal direction, and from the transverse processes of the lumbar vertebrae to the level of the ventral end of the last rib 3. Endoscope passed into stomach which is insufflated 4. Location of G-tube placement in area of gastric body away from the pylorus – identified externally via transillumination 5. Assistant pushes into abdominal wall with finger – endoscopist observes indentation with the endoscope  confirmation of no organs between gastric and abdominal wall 6. Stab incision with scalpel blade at this site 7. Large bore needle passed through incision into stomach 8. Long suture fed through needle by assistant – firm grasp of external end 9. Suture inside stomach grabbed by endoscopic forceps and suture is pulled from stomach while retracting endoscope out of the mouth 10. Mouth end of suture is looped and knotted to swaged on suture of the feeding tube 11. Feeding tube is lubricated 12. Assistant pulls on suture at the abdominal wall  pulling feeding tube through the esophagus and into the stomach then out of the body wall  may need to widen stab incision 13. Mushroom end of tube laid firmly against abdominal wall  checked with endoscope 14. Tube secured to abdominal wall using flanges in the kit 15. Endoscope removed after confirmation of ideal placement. End of tube is cut to suitable length. Placement of feeding adaptors. 16. Sterile dressing applied to stoma site and tube is secured to body with a wrap or stockinet

Surgical Procedures Flashcards

(34 cards)