Basic Surgical Techniques

Basic Surgical Techniques - pt. 1 One of the major jobs of a Surgical Technologist is to assist the surgeon during an operation. As a sterile team member, the Surgical Technologist may stand directly across from the surgeon in the role of the first assistant or function in the role of the "scrub nurse." Some of the duties of the assistant are to sponge and suction blood from the operative site, hold retractors and other instruments, and cut suture for the surgeon. An expanded role of a first assistant may include incising and suturing tissue as directed by the surgeon. The "scrub nurse" will pass instruments, supplies, and suture to the surgeon during the procedure. The unsterile "circulating nurse" will provide for the safety and comfort of the surgical patient and will be alert to the needs of the other members of the surgical team. For each role, it is vital for the Surgical Technologist to know the various steps the surgeon may take during most surgical procedures. This presentation on "Basic Surgical Techniques" will show the routines for a basic abdominal case, however most of these techniques will apply to any type of surgical procedure.

By using the surgeon's preference card, the supplies are collected for the surgical case. This may be done in the Operating Room by surgical personnel or in the Central Supply Department and sent to the Operating Room on a closed case cart.

Prior to opening the first case of the day, flat surfaces and overhead lights are cleaned with a damp cloth moistened with a hospital grade or high level disinfectant.

Both the scrub nurse and circulating nurse assist with opening the sterile supplies needed for the surgical procedure. Some hospitals have a set routine on where supplies are opened in the room, for example, the suture on the left side of the back table and the linen on the right side. Also unsterile equipment must be obtained. Teamwork is of utmost importance now, and through out the surgical procedure. Supplies and equipment should be obtained at this time because once the patient enters the room, the circulator's attention must be directed toward the patient.

The scrub nurse opens his/her gown and gloves last, preferably on a separate field and proceeds to perform the surgical scrub. Ideally, someone should stay in the room to maintain vigilance over the sterile field.

Surgery - pt. 2

Following the surgical scrub, the technologist dries his/her hands using a sterile towel, and dons his/her sterile gown and gloves using the closed gloving method. The Surgical Technologist proceeds to set up the surgical case following that hospital's routine.

The scrub nurse and circulating nurse perform a sponge, needle, and instrument count before the initial incision is made.

The circulating nurse obtains the patient's x-rays if necessary and checks on any blood products that may have been ordered.

The circulating nurse greets the patient who is in the pre-op holding area. The patient's chart is checked for appropriate information. The nurse verifies the patient's identity, the operative procedure and site, doctor, pre-op orders and lab work. An IV may be started at this time by the nurse or a member of the anesthesia team.

When the surgical team is ready, the patient is brought into the operating room and moved to the OR bed. The positioning should be performed by at least two persons, with one standing beside the locked stretcher and the other beside the OR bed. A safety strap is placed 2-3 inches above the patient's knees and the patient's arms are placed on arm boards. Monitoring devices such as blood pressure cuff, EKG pads, and pulse oxymeter are placed on the patient by the circulating nurse or a member of the anesthesia team..

Surgery - pt. 3

When the surgeon is ready to begin the operation, the patient is anesthetized. The circulating nurse should be readily available to assist the anesthesia personnel if needed.

Once the anesthesia personnel gives permission, the patient is placed in the appropriate position for the procedure. Positioning is the responsibility of the circulating nurse and the anesthesia personnel. The surgeon often supervises difficult positions.

The circulating nurse may insert a foley catheter, exposes the operative site, and performs the skin prep. On an abdominal hysterectomy the circulating nurse will also prep the cervix. If an electrosurgical unit (ESU) is used, the grounding pad should be placed on the patient at this time.

The circulator activates the overhead spot lights.

The lights are then moved into position over the operative field by the circulator.

Surgery - pt. 4

Following the surgical scrub, the surgeon enters the operating room and is gowned and gloved by the scrub nurse. The surgeon may ask for a moist towel to wipe the powder from his/her gloves.

The circulator ties the surgeon's gown in the back.

The surgeon then preps the patient's skin with an antiseptic solution. If performed on the abdominal area, the umbilicus is prepped last.

Draping of the patient follows, according to procedure and the surgeon's preference. The scrub nurse should know the draping routine and have all necessary drapes ready in proper order.

For most basic abdominal draping, four towels are placed around the incision site and held in place with four towel clips. Some surgeons prefer to use a clear plastic drape over the four towels after the skin has been blotted dry with a towel.

Surgery - pt. 5

A fenestrated drape is applied as the final drape. A laparotomy sheet is used for most surgeries on the anterior trunk.

The surgeon steps into position to operate with the assistant standing across from him/her. The scrub nurse quickly brings up the mayo stand, back table, and ring stand, and places two lap pads at the incision site. A magnetic pad, to prevent instruments from falling from the field, may be placed near the incision site. This pad also contains a "no pass" area for sharps.

The (ESU) active electrode is secured to the sterile drape followed by the suction tip and tubing. An ESU tip cleaner may be placed on the magnetic pad.

The circulator attaches the distal ends of the active electrode and the grounding pad, applied earlier, to the power unit, and the end of the suction tubing to the suction canister. These units are then turned on by the circulator.

The circulator then moves the kick bucket into a convenient location.

Surgery - pt. 6

When the surgery is ready to begin, the scrub nurse passes the skin knife to the surgeon. The skin knife is usually the #20 knife blade attached to the #4 knife handle. The surgeon and first assistant hold the skin taut as the incision is made.

Bleeders will be encountered as the incision is made into the subcutaneous layer. The surgeon may elect to coagulate these blood vessels with the ESU or clamp the bleeders with hemostats and tie them off with absorbable suture material. A 3-0 Vicryl or Plain on a ligating reel may be used.

The first assistant is responsible for raising the hemostat so the surgeon can get the tie around it and then exposing the point so the knot can be tightened. The hemostat is then removed. Some surgeons prefer for the assistant not to remove the hemostat until they verbally request it.

After several additional knots are tied, the first assistant will cut the suture. Vicryl is a multifilament suture material and should be cut on the knot. Plain is monofilament and may come untied, so a 3 millimeter tail is left on the suture.

If the surgeon uses the ESU, the hemostat is held away from the skin edges. The hemostat is touched by the activate electrode and at the surgeon's request is removed by the first assistant. Care must be taken, by the first assistant, to activate the coagulation button on the active electrode instead of the cutting button.

Surgery - pt. 7

The surgeon deepens the incision through the subcutaneous layer with the ESU cutting element or the inside knife which is the #10 blade attached to the #3 handle. Whenever the surgeon is cutting, the scrub nurse should be ready to pass a hemostat, in case a blood vessel is encountered.

The next layer is the fascia. Since the fascia is a tough, white, fibrous layer, the surgeon may use the curved mayo scissors, the inside knife, or the ESU to deepen the incision A Goulet retractor is often used to retract the skin and subcutaneous layer at this time.

The next layer is the abdominal musculature. If a midline abdominal incision is used, the incision is made between the rectus abdominal muscles. The surgeon may use the handle of the #3 knife for blunt dissection to separate the muscles.

The next abdominal layer is the peritoneum. It is the thin serous membrane that lines the abdominal cavity. Since the abdominal organs are located directly under the peritoneum, the surgeon must take special precautions to avoid cutting these underlying structures. To enter the peritoneum, many surgeons grasp it with two hemostats and elevate the tissue. The surgeon then nicks the peritoneum with the inside knife.

Surgery - pt. 8

While the surgeon and the first assistant elevate the peritoneum with their fingers, the surgeon extends the incision with the metzenbaum scissors. In preparation for entering the peritoneum, the scrub nurse moistens two lap pads with saline and prepares a large self retaining retractor such as the Balfour. From this point, small sponges, if used, must be mounted on an instrument.

With the peritoneal incision complete, the surgeon is now able to visualize the abdominal contents. Usually most surgeons will perform a manual examination of the abdominal cavity to check for abnormalities. At the completion of this exam, the surgeon is ready to perform the proposed operative procedure.

A self retaining retractor such as the Balfour may be used. Large moistened lap pads may be used to protect the tissue edges under the blades of the retractor and to pack the abdominal contents away from the operative site. Usually the first organ observed is the omentum. The omentum is attached to the transverse colon and hangs loosely over the abdominal organs.

During the case, the first assistant is responsible for adequate exposure of the field. This includes manipulating retractors and other instruments and requires the knowledge of the proper techniques in tissue handling.

The first assistant also keeps the wound free from blood and other body fluids by using the suction and lap sponges. An expanded role of the first assistant would include maintaining hemostasis by clamping bleeders or using the ESU to coagulate bleeders.

Surgery - pt. 9

When the surgeon is placing a continuous stitch, the first assistant "follows" the suture by grasping the end and keeping it taut.

The first assistant must also be ready to cut the suture or "tag" it with a hemostat at the appropriate time.

The surgeon may ask the first assistant to "flash" a clamp. This technique requires releasing the clamp slowly and just enough for the surgeon to get the suture around the tissue. The clamp is then closed while the surgeon ties the suture around the clamp.

With additional training, the first assistant role may include the manipulation and suturing of tissue.

The scrub nurse assists by observing the operative procedure and passing the appropriate instruments to the surgeon and first assistant. The general rule for passing instruments is to pass in a firm manner in the direction of use. The surgeon should not have to readjust an instrument once it is in his/her hand. Always pass the curve of the instrument toward the surgeon's other hand.

When the surgeon is beside the scrub nurse, in an effort to avoid bumping arms, it is generally best to pass with the hand opposite from where the surgeon is standing. It is usually easier to pass instruments when the scrub nurse is standing across the table from the surgeon.

Surgery - pt. 10

Most clamps are used in pairs. A basic maneuver used repeatedly during an operative procedure is clamp, clamp, cut, tie, tie. For example, if the surgeon is dissecting he/she will double clamp with hemostats to prevent the spillage of contents from the vessel or organ.

The surgeon will then cut in between the two clamps with scissors. For delicate tissues such as blood vessels, ovaries, and intestines, metzenbaum scissors are used. For tougher tissue such as the muscle, uterus, or breast, the curved mayo scissors will be used.

The surgeon will then tie what was cut using the appropriate suture , frequently on a ligating reel.

Other common surgical techniques include: When the surgeon is cutting, the scrub nurse should have hemostats or the appropriate size clamp ready to pass to the surgeon or first assistant to clamp bleeders.

When the surgeon is tying off bleeders, the scrub nurse should have the suture scissors ready to pass to the first assistant, or a hemostat to "tag" the end of the suture.

When passing suture to the surgeon or first assistant, pass it with the tip of the needle pointing toward his/her chin. This is the position in which he/she will use the suture and will also help avoid a dangerous needle stick. The surgeon will usually want a pair of tissue forceps for his/her other hand.

Surgery - pt. 11

If the surgeon nicks the scrub nurse's glove with a needle, tell him/her before they pass the needle through the patient's tissues. The needle should be discarded from the sterile field. The circulating nurse will retain the needle for the final count. The scrub nurse will turn away from the field and the circulating nurse will remove his/her contaminated glove. A new glove is donned using the open method of gloving. Remember, the closed method of gloving can not be used once the hand has passed through the cuff.

To avoid the loss of a needle, they should always be passed to the surgeon on an exchange basis. NEVER take back an empty needle holder.

Once the needle is returned to the scrub nurse, it is placed in the needle counter in the appropriate space. This is best done with one hand to avoid sticking the finger of the hand holding the counter.

The scrub nurse needs to keep clean lap pads on the field at all times. He/she should discard used sponges in the kick bucket as necessary. Small sponges such as peanuts or probangs should remain on the field to avoid loss.

The circulating nurse should retrieve the used sponges from the kick bucket by using a sponge stick or his/her gloved hand. The used sponges should be placed in a clear sponge counting bag.. The anesthesia personnel and the surgeon will need to view the sponges to determine the patient's estimated blood loss (EBL).

Surgery - pt. 12

If the surgeon asks for a "tie on a passer" he/she wants a strand of suture on a right angle clamp. This is used to tie a structure deep in a cavity where the surgeon's hands can't reach.

If the surgeon asks for a "stick tie", "suture ligature", or "transfixion suture" they want a strand of suture on a needle. Since this is usually used to tie off a blood vessel, it may be a nonabsorbable suture, size 3-0 on a small gastrointestinal needle.

There are a number of hand signals used by surgeons. This is the signal for a hemostat or other appropriately sized clamp. This is the position of the surgeon's hand when accepting most instruments. If the surgeon makes this signal and you are unsure what he/she needs, the safest instrument to place in his/her hand is a hemostat.

This is the hand signal for scissors. When the surgeon needs dissecting scissors the Surgical Technologist must be aware of the strength of the tissue. For tougher tissue (fascia, breast, muscle, uterus) the surgeon needs the curved mayo scissors. For delicate tissue (ovaries, bowel) and for most general dissection, the surgeon uses the metzenbaum scissors. The length of the scissors depends on the depth of the wound. Specialty scissors are used on certain tissues. For example, Jorgenson scissors are used to cut across the cervix during an abdominal hysterectomy.

This is the hand signal for the knife or scalpel. The scrub nurse passes this with the blade down and the handle pointed toward the surgeon. Care must be taken to avoid injury when passing the scalpel. A "no pass" zone should be established on the field.

Surgery - pt. 13

This is the hand signal for forceps. Pick ups with teeth are used on tougher tissue and smooth forceps are used in delicate areas.

This is the signal for a suture on a needle. The surgeon will make a fist and simulate the motion used when suturing. Suture is passed with the needle pointing toward the surgeon's chin.

This is the hand signal for a free tie. The scrub nurse grasps the strand of suture by its ends and places the suture in the surgeon's palm.

Other general duties while scrubbed include keeping the field clear of instruments. If instruments are extremely bloody, they should be wiped with a sponge moistened with sterile water. Saline should never be used to clean instruments as it could cause rust to form on the instrument.

The overhead lights may need to be readjusted during the case. The scrub nurse uses the sterile light handle for this maneuver.

Surgery - pt. 14

The active electrode of the electrosurgical unit (ESU) should be kept clean. A special "scratch" pad is available for this purpose. The ESU tip should stay in its plastic holder to avoid inadvertently activating the tip and causing a burn.

The mayo stand must never rest on the patient's feet or legs. When the patient is placed in the trendelenburg position, the scrub nurse should check the level of the mayo stand.

The scrub and circulating nurses work together to observe the sterile field, at all times, for possible contamination. If the scrub nurse's gown becomes contaminated, the circulating nurse should don unsterile gloves, untie the gown in the back, and assist in removing the gown and then the gloves. The scrub nurse should don a new gown and gloves using the closed method. A rescrub would be unnecessary. The scrub nurse and the circulating nurse should watch the surgeon and the progress of the procedure, listen, and try to anticipate the needs of the surgical team. The circulating nurse should control traffic and noise in the room.

Other duties of the circulating nurse include keeping accurate records of the case. This may be done with the help of a computer.

The circulating nurse maintains communication with other areas of the operating room suite and may be responsible for sending for the next patient. He/she may need to communicate with other hospital departments such as pathology. Also the circulating nurse may be responsible for answering the surgeon's pages and relaying messages.

Surgery - pt. 16

If the surgeon is concerned about wound disruption he/she may elect to insert several retention sutures to reinforce the incision. These sutures are also called "through and through", "tension", or "stay" sutures and are placed in a secondary suture line. A nonabsorbable monofilament such as Ethilon or Prolene size 2 is frequently used. Since this suture passes through all tissue layers except the peritoneum, the needle swaged on to this suture is extremely large. To prevent the suture from having a sawing effect on the skin, rubber bolsters or plastic bridges are used.

To prepare a retention suture the scrub nurse places the bolster on the suture, tags the end with a hemostat, and places the needle on a needle holder.

The next layer is the muscle. Suture, when placed in this layer, is usually of the same material used on the peritoneum. Most surgeons choose not to close this layer.

Following the muscle is the fascial layer, which is the toughest layer that prevents a hernia from occurring. Suture for this layer varies greatly from a 0 to 2-0 nonabsorbable such as Surgilon using an interrupted stitch, to 0 to 1 Prolene using a continuous stitch. If an interrupted suturing technique is used, the scrub nurse must prepare these sutures rapidly and keep an accurate count of the many needles.

Interrupted suture may be tied after each stitch but cut all at the same time. A short pair of tissue forceps with teeth is used on this layer and medium needle holders are used.

Surgery - pt. 17

After the fascia is the subcutaneous layer. Subcutaneous fat does not tolerate sutures particularly well. However, if the layer of fat is thick, it is often necessary to place a few interrupted stitches to hold the wound edges together to prevent dead space. A dead space may allow tissue fluids to accumulate, delay healing, and predispose the wound to infection. Absorbable suture is used in this layer, usually size 3-0 Plain or Vicryl placed on a short needle holder.

The skin is the next layer. Suture technique in skin closure varies greatly among surgeons. A nonabsorbable monofilament suture on a curved cutting or straight keith needle, size 3-0 or 4-0 Prolene or Ethilon may be used. The curved cutting needle is placed on a short needle holder and the keith needle is held by hand. A subcuticular stitch using an absorbable suture may also be used. Special adson or dura forceps are used during skin closure. The retention sutures are now tied.

Some surgeons prefer to close the skin using skin staples. The surgeon usually uses two adson forceps to evert the skin edges while the skin staples are applied by the first assistant.

The final sponge, needle, and instrument count is performed during the skin closure by the scrub and circulating nurses.

The circulating nurse opens the dressing material after the final count is complete. For most abdominal wounds, plain 4x4s are used and are prepared by the scrub nurse.

Surgery - pt. 18

Following skin closure, the surgeon will want a wet lap pad to cleanse the skin and then a dry one. Note a penrose drain has been inserted through a separate stab wound.

The surgeon is now ready for the dressing. If drainage is expected, a bulky dressing such as an ABD pad may be applied after the gauze sponges.

The operation is now complete. The scrub nurse pushes the mayo stand away from the table. In many hospitals, it is policy to keep the mayo stand sterile until the patient leaves the room. This facilitates reopening of the wound in case of an emergency.

The scrub nurse checks the drapes for stray instruments and rolls the drapes off of the field. The circulating nurse tapes the dressing in place.

Surgery - pt. 19

When the anesthesia personnel gives permission, the patient is moved to the recovery room bed. A minimum of four people are needed to accomplish this effectively. A devise such as a Davis roller or a mechanical mover may be used to facilitate the move.

The suction should remain functional until the patient leaves the room in case it is needed by anesthesia personnel to suction the patient's airway. The entire surgical team should stay in the room until the patient leaves the room.

The circulating nurse and anesthesia personnel accompany the patient to the PACU. A verbal report is given to the nurse who will be taking care of the patient and the circulating nurse completes the patient's records.

The scrub nurse is responsible for the care of the instruments and supplies following the case. All trash is placed in impervious biohazard bags. Knife blades are removed from their handles by using a needle holder. The blades are placed in puncture proof containers such as the needle counter for proper disposal.

Surgery - pt. 20

All instruments must be prepared for terminal sterilization. Used instruments are soaked in water, opened, and placed in a mesh bottom tray. Heavy instruments are placed on the bottom. The tray is then placed in a closed case cart or placed in a plastic bag for transportation down the hall.

All sharps are placed in an appropriate sharps container.

All linen is placed in an impervious bag and sent to the laundry to be washed, which rehydrates the fabric prior to sterilization.

The scrub nurse removes his/her gown and gloves after all contact with soiled instruments and supplies is completed.

Cleaning of the room is next. Walls are not considered contaminated and require no cleaning unless they have been splashed with blood. Flat surfaces of the mayo stand, back table, and OR table are cleaned with a hospital grade disinfectant.

Surgery - pt. 21

The floor is terminally cleaned with either a wet vacuum or a clean mop head wet with a hospital grade disinfectant . Wheels of furniture should be pushed through the disinfectant.

Suction contents may either be flushed down a hopper or treated with a special solution and discarded in the proper receptacle.

The room is now ready for the next surgical procedure.

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