1
Q
Draping Definition
A
- The act of covering the patient and surrounding areas with an impervious sterile barrier, creating a sterile field around the operative site
2
Q
Criteria for an effective barrier
A
- Fluid resistant
- Tear resistant
- Lint free
- Antistatic
- porous enough to allow heat to dissipate
- some breathability
- flexible to fit contours
- non-glaring
- for staff–need to see
- non-toxic
- flame resistant
*resistant not proof (can still get strikethrough, can still catch on fire)
3
Q
Draping materials
Drape=Sheet
A
- Paper (or pressed fiber cloth)
- Linen
- Plastic
- Polypropylene
4
Q
Paper Drapes
A
- a nonwoven fabric of compressed synthetic fibers
- a disposable, single-use item
- most medical centers have paper drapes
5
Q
Linen/Muslin Drapes
A
- a woven fabric with a thread count of at least 270
- reusable, often with water-resistant finish
- number of uses must be tracked to maintian a good barrier and any holes or tears must be patched before next use
6
Q
Plastic Type 1
A
- a drape sheet, usually with self-adhering edges, to be used in arthroscopy or other procedures involving irrigation. most common is the plastic U-drape. microscope drapes and C-arm drapes are also plastic
- not breathable
7
Q
Plastic Type 2
A
- Self-adhering plastic sheeting, aka incise drape:used at incision site, either under or over the main drape used for the procedure, at the fenestration in the drape
- may be impregnated with iodine or simply be self adhering on one side and not on the other (Ioban- brand name)
8
Q
Polypropylene
A
- a synthetic material that is more fire resistant than standard paper drapes
- laser procedures
- not widely used
- not breathable- does not dissipate heat well
9
Q
Common drape types
A
- Towels
- Fenestrated drapes
- leggings
- underbuttocks drape
- stockinette
- other
10
Q
Towels
A
- Most draping starts with towels
- usual exception to the above: extremity draping
- most towels are used as a set of four to “square off” the incision site
- may be woven or paper with self adhering edges
11
Q
Fenestrated drapes
A
- from the french “fenetre” for window
- laparotomy drape
- perineal & LAVH drape
- aperture drape
12
Q
Laparotomy drape
A
- may have longitudinal or transverse incision fenestration, or a large fenestration exposing most of the abdomen
- for minor procedures on adults, often a pediatric laparotomy drape is used
13
Q
Perineal & LAVH drapes
A
- used to create a sterile field for the pt. in lithotomy, the perineal drape has attached leggings and a fenestration that fits over the perineum
- LAVH has these features added to a large laparptomy drape, for access to perineum and abdomen
14
Q
Aperture drape
A
- usually an extremity drape
- has a small hole inside a stretchable synthetic polymer at the fenestration site
- hand or foot of patient placed through this aperture, which is stretched to accommodate the extremity
15
Q
Leggings
A
- supplied in pairs to cover the legs of a patient in lithotomy position
- big bag that goes over each leg
16
Q
Underbuttocks drape
A
- used in conjunction with leggings
- usually plastic
17
Q
Stockinette
A
- used to cover an extremity before the extremity (aperture) drape is used
- may be impervious or non impervious
18
Q
Other drape sheets
A
- split sheet– 2 sides to stick together (extremity, custom breast)
- 3/4 sheet/medium sheet/ half-sheet– just a flat drape with no fenestration (many uses)
- universal drape– 4 big flat sheets w/ a sticky on each side
19
Q
Basic Principles
A
- provide a wide cuff for the hand to avoid contamination
- almost always, best practice is to unfold drape at the incision site to avoid extra movement and contamination
- once placed, drapes should not be moved!
20
Q
Before placing the main drape…
A
- Preparation: stack drapes on backtable in order of use, with what goes against the patient’s skin of top and the outermost drape on the bottom
- Transferral: if squaring off with woven towels, carry all 4 towels to the surgeon at the same time to avoid extra steps and possible contamination. repeat for towel clips
21
Q
Draping tips
A
- remain a safe distance from the OR table when placing drapes
- be aware of unsterile items as you drape or move around the room
- hold drapes folded until directly over the area to be draped
- drapes should be placed precisley where they are intended to go and should not be moved after contacting the patient
- Drapes should be cuffed over gloved hands before moving the superior and inferior portions into position
- hands are not allowed to drop below table level
- any part of the drape that falls below table level is not touched again by a sterile team member
- if a towel clip is removed after being placed, the tips are considered contaminated
- remember that drapes are flammable
- removing contaminated drape usually causes a contamination but should be removed by circulator.
22
Q
mnemonic device for suture
A
MVP (most valuable players)
- Monocryl– 2 weeks
- Vicryl– 4 weeks
- PDS– 6 weeks
23
Q
Dermabond
A
- skin glue
- purple liquid
- no eyes
- uninfected wound/ no wetness
- seals for one week
24
Q
What do we use to control bleeding or blood loss?
A
- Clamps (we will clamp, clamp, cut, tie)
- Ligature (just a tie/strand of material)
- Ligating clips
- Suture or stitch (with a needle)
- Bovie
25
Principles of suturing
* The strength of the wound is related to the condition of the tissue and the number of sitches in the edges
* Also consider:
* pt.'s age
* health
* nutritional status
* severity of wound
* location
* type of wound (clean or dirty)
* amount of tissue they take with each "bite"
* blood still needs to flow
26
Methods of suturing
* The wound edges are brought together in a very deliberate way to promote the best possible healing. To evert skin edges you need adsons with teeth, if inverted, it won't heal properly. only invert for mucous membranes
* **Skin= everted**
* **Mucosa= Inverted**
* **simple continuous or running-** the suture is not cut until the full length of the incision is closed
* **simple interrupted-** each stitch is placed, tied and cut in a row or succession
* stronger of the two. If strand breaks, the whole thing doesn't come all the way undone
27
Cutting Sutures
* Suture tails are trimmed close to the knot
* unless **monofilament suture--1mm tail** (if you don't it will come unraveled)
* method of cutting suture:
* Stabilize scissors with index finger
* tips of scissors must be visible (so you know you're not cutting something past it)
* have hemostat available just in case surure gets cut
* always use straight mayo
28
Specifications for Suture Material
* **Sterile**
* Predictable and uniform
* Tensile strength (how long suture will hold tissue together)
* USP- determines the size ranges.
* 10 largest to 11-0 smallest
* Use as small a diameter as is safe (can cause reaction--least amount absorbed by body)
* Must have secure knots, remain tied, and give support to tissue.
* Cause as little foreign body tissue reaction (least inert of materials)
29
Suture Size
30
Choice of Suture Material
Two classifications of suture material:
1. **Absorbable**-- some sort of collagen material, sometimes treated with a coating
2. **Non-Absorbable**- body will encapsulate suture w/out harm
31
The two classifications (absorbable and non-absorbable) are divided into:
* **Monofilament** - single strand that is non-capillary (like a fishing line)
* **Multifilament**"braided"- Two or more strands held together by braiding or twisting. (like a shoestring.) Have capillary action which refers to the absorption of liquids along the length of the suture. If there is an infection, it can move up the suture
32
Suture Chart
33
Surgical Needles must be:
* Strong enough to prevent breakage
* if needle breaks all parts need to be accounted for
* Rigid enough to prevent bending
* Sharp enough to penetrate tissue
* Approximately the same diameter as the suture material it carries
* Appropriate shape and size for the type, condition of tissue to be sutured
* Free of burrs or corrosion
34
Primary and superior company for suture in ATX?
Ethicon
35
3 Basic components of a needle
1. Point
2. Body (or shaft)
3. Eye
36
Different points of a needle
* Cutting
* has beveled edges
* used for skin (skin is tough)
* Taper (like the end of a pencil)
* below skin
* Blunt (don't use very much)
* used on liver and kidneys because it won't create more bleeding
* they used to use on AIDS pts but realized it caused tissue damage
37
Body of a needle
* Different gauges
* diameter (some heavier)
* Depth of bite
* Straight or curved
* only skin
* called a Keith needle
38
Eye of a needle
* Eyed
* French Eyed
* delicate
* Swaged or eyeless
* "swedged"
* crimped on
39
Considerations for Needle choice and Suture material:
* Use the surgeons preference card
* Learn general classification of suture, needles, and tissue
40
Packaging
* 1, 2, or 3 dozen per box
* Primary packet - Over wrap is foil (old style is see through) and inside is sterile.
* Inside packet, and forms a dispensing mechanism
* Every package is loaded for right hand surgeon when delivered from package.
* NEVER re-sterilize suture
41
How suture is prepared
* Reels
* countable items under "other" section, have dots in plastic for size
* Precut lenghts
* Single suture with needle(s) attached
* Two types of Muti-packs (circle on package with number)
* M/S or Multi-Strand- swedged on
* C/R or Control Released- pop off needle
* Double armed suture- needle on each end
42
Label info. (primary packet)
* Size of suture
* Name of suture
* Stock number
* Characteristics
* Absorbable
* Length
* Needles – Type & Name & How many
* ex: Type= Taper, Name= CTX
* Color & material
43
Placement of needle in the needleholder:
* appropriate size jaws for the size of the needle
* appropriate length needle holder
* Clamp the body of the needle 1/4-1/2 from eye
* secured in tip of NH and 1 or 2 clicks
* Pass NH with needle pointed up and directed toward surgeons nose or thumb.
* Suture strand is free & untangled--can hold tail
44
Common Suture Usage and Indications
45
Tissue layers closed on an abdominal incision: (from inside out)
* Peritoneum
* Posterior Fascia
* Muscle
* _Anterior Fascia_
* Subcutaneous Tissue (Fat)
* Skin
* _Subcuticular continuous_
* * **Surgeons do not have to close peritoneum, just have to close anterior fascia and skin**
46
Healing of Tissues
* Suture General Rule of Thumb: Look at the speed/strength of the tissue that will be healing.
* Critical Wound Healing Period:
* Peritoneum 7-14 days
* Vicryl
* Fascia 14-28 days
* PDS
* Subcutaneous 7-14 days
* Plain/ Chromic yellow like fat
* Skin / Mucosa 5-7days
* Monocryl or nylon 3-0
* if you wait too long to take out, it gets hash marks in skin
47
Advantages of Staples
* Fast – saves time (takes a lot of time to hand sew everything)
* Less blood loss
* Leak proof or air tight
* Increase wound healing because
* less trauma
* Non-reactive metal (stainless steel- inert)
* Can be placed through endoscope - changed a lot of things for surgery
48
Disadvantages of staples
* Mis-fire
* Require training of the hospital staff & doctors
* Expensive
* OR time is also expensive though
49
Anticipating with suture and stapler
* Suture= one adson with teeth
* Stapler= 2 adsons with teeth
50
Skin staplers used for
* approximating skin
* Line up incision with arrow and squeeze the handle
51
Staple technology
* Thick tissue = stomach/lung
* cartridge usually green
* Thin tissue = bowel/appendix
* cartridge usually blue
52
LINEAR STAPLER
* Function -- Staple ONLY (no cutting)
* Provides a double line of staples in a row.
* Brand Names -- Both Ethicon & Covidien
* Autosuture --- **TA (thoracic anatimosis)**
* Ethicon --- **TX** and a **TL-- 2 letter name= staple only**
* 3 lengths of staple line
* 30/60/90mm will be on the device
53
LINEAR CUTTER
* Function --Staples & Cuts tissue, BOTH
* Provides two double rows of staples and cuts in between.
* can only be fired 8 times and you have to throw it away (blade gets dull) load from toe to heel
* wipe with raytec to clean poop & staples before reload
* Brand Names:
* Covidien -- **GIA** (gastrointestinal anastimosis)
* Ethicon --- **TLC** (titanium linear cutter)**-- 3 letters in name= staples and cuts**
* Usually comes in 2 Lengths -- 55mm & 75mm
* Cartridges
* Blue- thin tissue
* Green- thick tissue
54
INTRALUMINAL CIRCULAR STAPLER
* Function -- Transluminal stapling of the 2 ends of bowel
* Provides two double rows of staples and cuts in between in a circular fashion
* for low anterior colon resection, goes up the rectum, have sizers for rectum
* must check for "donuts" to make sure it was complete with no leaks
* Brand names
* Covidien-- **EEA (end to end anastimosis)**
* Ethicon -- **CDH-- (curved detachable head) staples and cuts--3 letters**
* CDH comes in 4 Sizes -- 21mm diam, 25, 29, & 33mm
55
ENDOSCOPIC Linear Cutter
* Function -- Staples and Cuts, but through and Endoscope
* Ethicon –ATS 45
* same device just in endoscopic instrument form
56
Ligating Clips
* Disposable Ligaclips are preloaded with approximately 20 clips.
* Brand –Hemoclips appliers are usually non-disposable & must be loaded by the Tech.
* Color coded with handles
* Yellow = baby or small hemoclip
* Blue = medium hemoclip (used the most)
* Green = medium/large hemoclip
* Orange = Large hemoclip
* have to know how to load these
* disposable and nondisposable hand clips
* V-shape
* Count racks not clips
* ligate instead of using a hemostat
* load one at a time
57
Suture
* **Verb**- to sew, by bringing the tissues together (apporximation) and holding them until they heal
* **Noun**- any strand of material used for ligation or approximation of tissue
58
Anastomosis
The surgical formation of a passageway between two spaces, hollow organs or lumens
59
Approximation
To bring body parts or tissue together by sutures or other means
60
Capillary action
refers to the absorption of liquids along the length of a suture
61
Free tie
a single strand is placed in the surgeons hand and has nothing attached to it
62
Banjo or tie on a pass
a single strand is placed on a hemostat (tonsil or crile depending on depth of incision)
63
Inert
causing little or no tissue reaction
64
Interrupted suture
each stitch is taken and tied separately
65
Ligate
to tie a thread or wire around a structure in order to constrict it "ligature or tie"
66
Plication
to stitch folds in the wall of a structure similar to a "dart"
67
Retention sutures
interrupted non-absorbable sutures that are placed on each side of the promary incision line to relieve tension on it
68
Stick tie
is always a suture with a needle usually an SH needle
69
Subcuticular suture
a continuous suture is placed beneath the epithelial layer of the skin in short lateral stitches; it leaves a minimal scar
70
Suture ligature or Stick tie
larger vessels (pulsating) may require a suture through the lumen to prevent it from slipping off the vessel. A "bite" will be taken with the neeedle through the vessel walls and the ligature tied around the vessel. This technique prevents slipping of the suture material
71
Purse-string suture
continuous sutures placed around a lumen and tightened like a drawstring to invert the opening. they may be placed around a stump of the appendix or to secure an intestinal stapling device
72
Names of needles
* FS
* PS
* SH
* CT
* For Skin-Cutting-- (FS-2, FS-1, FS, FSL, FSLX)
* Plastic Surgery--cutting-- for skin (smaller, cosmetic)(PS-3, PS-2, PS-1, PS, PSL, PSLX, PS-6, PS-5, PS-4, PS-4C)
* SH-- Small Half (circle) below skin taper SHit for bowel (SH-2, SH-1, SH)
* Circle Taper-- below skin (CT-3, CT-2, CT-1. CT, CTX)
73
Accessory Organs of Digestion
* Gallbladder
* Duct system/biliary tree
* Liver
* Pancreas
74
In Situ vs. Operative Positioning
* In situ: mostly hidden behind liver, fundus only showing
* Operative: Gallbladder reflected superiorly; turns it "upside down" from the usual position
75
Gallbladder Anatomy
* Relative to liver: posterior aspect, in gallbladder fossa of liver
* Associated with what serous membrane?
* visceral peritoneum/ lesser omentum
* blood suppply to gallbladder:
* The common hepatic artery further bifurcates into the left and right hepatic arteries to deliver blood the left and right sides of the liver. As the right hepatic artery approaches the gallbladder, it branches off to form the **cystic artery,** which supplies the gallbladder and cystic duct with oxygenated blood
76
Possible anomalies in gallbladder
77
Anatomical Features
* Dome-shaped inferior portion (in situ) is called the fundus
* bulge near cystic duct is called the infundibulum or hartmann's pouch
* ductal system connects it to liver and duodenum
78
Gallbladder physiology
* Primary function of the gallbladder: store bile (trash from the liver)
* Active ingredient in bile: bile salts (help immusify fat)
79
Gallbladder Pathophysiology
* **Cholelithiasis**: gall stones
* **Cholecystitis**: inflammation of the gall bladder
* **Gallbladder cancer**: rare, but prior cholelithaisis is a contributing factor
80
Biliary Tree Anatomy
* Name Fundus
* cystic duct
* hartmans pouch
* common hepatic duct
* cystic artery
81
Anatomy related to incision
* Trocar between linia alba
* layers are breached for placement of the subumbilical trocar
82
Calot's triangle
83
What 2 parts of the gallbladder are grasped with an endo-grasper?
* Fundus
* Hartman's pouch
84
Open chole
* Incision: Subcostal
* Cuts "against the fibers":
* external oblique
* Internal oblique
* sometimes, right rectus abdominus
85
TAH Anatomy Involved
* Uterus
* Endometrium
* Myometrium
* Perimetrium
* Endocervix
* Ligaments (hold structure in place)
* Round
* Ovarian
* Broad
* Cardinal
* Uterosacral
* Fallopian Tubes and Ovaries
* Vaginal Canal
86
TAH anatomy label
* bladder sits anterior to uterus
* Broad ligament- like a cape
* Ureter sits very near to the ligaments
87
Adjacent Anatomy
* Bladder
* Ureters
88
3 types of hysterectomy
1. simple
2. modified radical
3. radical (everything)
89
Commonly used instruments
* Heaney needle holder (curved)
* Heaney clamps (tooth midway down helps grasp ligament)
* Balfour retractor (self retaining) **OR**
* O'connor O'sullivan retractor (self retaining)(some like this one better)
* Jorgensons, Jacobs, or right angle scissors
* need for cervix cut off vaginal wall
90
What's taken in a typical TAH?
* Excised
* cervix
* entire uterus
* Preserved
* fallopian tubes
* ovaries (want to leave these for younger pts for hormones)
* Straight Kocher & Jorgensens touch "dirty" vaginal wall, they need to be isolated in emisis basin
91
INDICATIONS FOR TAH
* Leiomyofibromas ( fibroids, fireballs, myomas) benign masses
* Pelvic cancer
* Uterine Prolapse
* Extensive endometriosis
* Cervical or uterine cancer
* Debilitating dysmenorrhea (excessive bleeding)
92
Things to remember for a TAH
* Wound Classification
* Class III Contaminated
* Any instruments that grasp and/or enter the vaginal cuff are considered dirty and are handled appropriately
* If a Salpingo-oophorectomy is done, Identify the left ovary from the right ovary if detached from uterus
* Verify pregnancy results if appropriate prior to surgery
93
Reasons for Dilation & Curettage
* Diagnostic
* Dysmenorrhea
* Rule out Endometrial Disease
* Rule out Pregnancy prior to elective sterilization
* Determine cause of infertility
* Therapeutic
* Removal of suspected Pathology
* Treatment of postpartum bleeding
* Evacuate retained placenta
* Retrieval of IUD
* Placement of radioactive carriers (devices up near cervix to treat cancer stand 6 feet back)
* Treatment of polyps
* Incomplete abortion
* Dysmenorrhea
94
outer Anatomy involved in D&C
95
Internal anatomy involved in D&C
* You will usually have 2 specimens
1. Endocervical
2. Endometrial
96
Operative prep for D&C
* Anesthesia
* General Preferred
* Maybe Regional Block
* Position
* Lithotomy
* Prep
* Vaginal Prep
* Draping
* Lithotomy
97
Equipment and Instruments for D&C
* Stirrups
* Dr.’s Choice
* Suction Machine if Suction D & C
* Cover when patient is entering the OR
* D & C Set
98
Patient and team position for D&C
99
Different types of D&C Procedures
* suction curettage
* insertion of canula
* gentle suction motion to aspirate contents
* uterine contents evacuated
100
Things to Remember for a D&C
* Fractional D & C
* Endocervical specimen taken separate from endometiral specimen
* D & E-Dilation and Evacuation
* After 13 weeks of pregnancy
* Wound Classification
* Class III - Contaminated
SRGT 1509
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