EXPLORATORY LAPAROTOMY

Definition (HANNA)

Exploratory Laparotomy is a type of surgery that is being used to open up the abdomen
(belly area). This type of procedure is commonly performed emergently in trauma situations.

PURPOSE

- To examine abdominal pelvic organ and tissues.

- To determine the cause of a patient’s abdominal or pelvic pain.

INDICATION

- Indicated in cases of gunshot, stab wounds or blunt trauma.

- Indicated to patients with suspected of diseases related to:

o Liver

o Gallbladder

o Spleen

o Pancreas

o Kidneys

o Stomach

o Small intestine

o Large intestine

o Appendix

o Ovaries, fallopian tubes, and uterus

o Lymph nodes

o Abdominal blood vessels

o Membranes that line the abdominal cavity.

Possible Complications:

● Bleeding
● Infection
● Incision doesn’t heal well
● Damage, injury or problems with bowels
● Bad reaction to anesthesia

APPENDICITIS

Definition: (Aly)

Appendicitis is a most common causes of abdominal pain. Classic symptoms of

appendicitis include right lower quadrant pain, anorexia, nausea, constipation and vomiting.
Appendicitis is the inflammation of appendix. McBurney's sign maybe elicited by palpating the
left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal
distention develops as a result of paralytic ileus, and the patient condition become worsens.

CHARACTERS: (Introduce yourself)

Narrator: Krizzia Raymundo

Patient: Maryjan Gutierrez

Surgeon: Maureen Sanchez

Assistant Surgeon: Denise Lagata

Anesthesiologist: Glaira Valencia

Ward Nurse: Danica Tarusan

Scrub Nurse: Hanna Sarmiento

Circulating Nurse: Alyssa Joy Quibar

SITUATION: (Aly)

A 29 year old female named Maryjan was brought to emergency department. The patient
chief complaint was right abdominal pain, described pain as sudden onset, sharp and severe pain
with progressing intensity. Upon assessment in emergency department, her pain scale was 8/10
with 0 being no pain and 10 being the most pain possible. Night before admission, the patient
stated that she took a pain reliever of Dolfenal 250 mg which was given by her mother, but the
medication given didn’t alleviate the pain.
SCENE 1 - PREOPERATIVE PHASE; ENDORSEMENT

Narrator (SHATOK): The first part of the presentation will be the endorsement of the patient
between the Ward Nurse and the Circulating Nurse.

WARD NURSE (DANICA): Endorsing patient #121, temperature is 37.0C, respiration is 19

breaths per minute, pulse is 89 beats per minute, and blood pressure is 110/90 mmHg. With
contraptions of D5LR inserted at right metacarpal vein, regulated at 22 drops per minute, at the
level of 800cc. Upon physical examination, abdominal tenderness is present. Na-assesed po siya
ni Doc, upon palpation present po ang McBurney’s Sign which the patient is suspected for
appendicitis.

CIRCULATING NURSE (ALY): Carried out na po ba ang laboratory tests? Any

abnormalities?

WARD NURSE (DANICA): Yes po carried out na, and may results nadin po. Urinalysis po is
normal naman, when it comes to CBC po is elevated ang WBC resulting on 14,000 units. And
based po sa result ng ultrasound of whole abdomen, the patient is suffering from appendicitis.

CIRCULATING NURSE (ALY): Ilang oras po NPO ang patient?

WARD NURSE (DANICA): NPO for 8 hours po si patient prior to surgery. Last meal po ni
patient ay kaninang 6:00 AM prior to admission.

CIRCULATING NURSE (ALY): May mga medications po ba si patient? Ano ano po yung
na-take nya?

WARD NURSE (DANICA): Medication given are: Paracetamol 1amp PRN for fever po since
si patient po kanina ay may fever upon admission pero ngayon normal na po ang temperature
nya. Kortezor 30mg IV q8 for pain. For preoperative medication po, the patient was given
Levaquin 500mg IV. Ranitidine 100mg IV. There are no allergies recorded upon interviewing the
patient.

Cardiopulmonary clearance was done and attached to the medical record. General assessment
done and Dr. Aquino performed palpation upon affected area, McBurney’s Sign was positive.
The patient is with admitting diagnosis of Acute Appendicitis under the service of Dr. Aquino,
initially referred to Dr. Sanchez for emergency surgery. The patient is scheduled for exploratory
laparotomy of appendicitis at 3 pm po. There are no difficulties in voiding, last voided at 11:00
am. Pre op health teaching done. Consent for operation is verified with signature of patient
attached to the waiver.

CIRCULATING NURSE (ALY): Okay, noted. Thank you Nurse Tarusan!

SCENE 2- PREOPERATIVE; HOLDING AREA – INTERVIEW

Narrator (SHATOK): The second part of the presentation is the conversation of the circulating
nurse and the patient in the holding area.

CIRCULATING NURSE (ALY): Hello po, magandang umaga po mam. Ako po si Nurse
Alyssa at ako po ang magiging nurse ninyo sa operating room habang kayo po ay inooperahan.
Tanong ko lang po mam, Ano po ang inyong pangalan?

PATIENT (MJ): Ay magandang umaga din, ako ay si Maryjan Gutierrez.

CIRCULATING NURSE (ALY): Kailan po ang birthday nyo po mam?

PATIENT (MJ): state ur bday sis

CIRCULATING NURSE (ALY): Kamusta po mam ang inyong pakiramdam?

PATIENT (MJ): Medyo okay naman na kesa kanina. Nasabi din sa akin nung doctor kung ano
gagawin sakin. Aba ay naintindihan ko at maigi ang kanyang pagkakasabi. Eto medyo
kinakabahan ako ngayon, masakit ba gagawin sakin don? Ako’y natatakot eh.

CIRCULATING NURSE (ALY): Mam, wag po kayo matakot. Hinga po muna tayo ng malalim
para kumalma po ang inyong pakiramdam. Huwag po kayo mag alala kasi may ituturok po sila
dun na anesthesia ibig sabihin po nun ay pampangime para hindi nyo po maramdaman ang sakit
habang kayo po ay andun po sa loob. Hindi lamang po ako ang kasama nyo dun, pati po ang
doctor, anesthesiologist at nurse. Kaya po pangunahin po naming kapakanan ay maging safe po
kayo habang kayo po ay nasa loob ng operating room.

PATIENT (MJ): Ay hala, ay salamat sa pagpapaunawa mo sa akin. Kahit papaano ay nabawasan

ang aking kaba na nararamdaman.

CIRCULATING NURSE (ALY): Sige po mam, ako lamang po ay may ilang katanungan.
Maari na po ba tayo po mag simula?

PATIENT (MJ): Ay oo sige at akoy komportable makipag usap sa iyo. Di naman yan mahirap
ang itatanong mo ano?

CIRCULATING NURSE (ALY): Ay hindi po mam, ilang katanungan laang po ito.

PATIENT (MJ): Ay sige, oo

CIRCULATING NURSE (ALY): (see checklist)

CIRCULATING NURSE (ALY): Okay po mam, kung may ilang katanungan po kayo ay wag
po kayo magdalawang isip na magsabi sa amin.

PATIENT (MJ): Maraming salamat, oo sige kayo ay akin nalaang tatawagin kung sakaling may
nais ako itanong.

INFORM THE DOCTORS ABOUT THE PROCEDURE

Narrator (SHATOK): Now is the third part of our presentation where in the circulating nurse
will inform and remind the surgeon, assistant surgeon and anesthesiologist about the schedule of
the procedure.
 CIRCULATING NURSE (ALY): Good morning po Doc Sanchez, Doc Lagata and Doc
Valencia, inform and remind ko lang po ulit kayo na 3 pm po ang surgery po ni Patient #121, OR
4 for Exploratory Laparotomy of Appendicitis po. Thank you po.

DRA. SANCHEZ: Sino nga ba yung patient natin? Di ko maalala pero familiar yung number.

CIRCULATING NURSE (ALY): Patient #121 po dra, si Ms. Maryjan Gutierrez, 29 years old
po.

DRA. RAYMUNDO: Okay, salamat sige later nalang.

CIRCULATING NURSE (ALY): Thanks po doc!

NOW WE WILL MOVE ON TO INTRAOPERATIVE PHASE, BUT FIRST THE NURSE

WILL PERFORM THEIR PRIOR DESIGNATED RESPONSIBILITIES BEFORE
FOCUSING ON THE TRANSFERRING THE PATIENT

INSIDE THE OPERATING ROOM

Narrator (Shatok): Now we are in the scene 4, wherein the circulating nurse and scrub nurse
will show their roles and responsibilities on preparing the operating room

CIRCULATING NURSE (ALY): As a circulating nurse my roles and responsibilities are:

Works on the perimeter of the operating room, monitoring patient care, ensuring that the
room stays sterile, and keeping track of instruments and sponges.
Responsible for managing the nursing care of the patient within the OR and coordinating
the needs of the surgical team with other care provider necessary for completion of
surgery
Observes the surgery and surgical team from broad perspective and assists the team to
create and maintain a safe and comfortable environment for the patient
Asses the patient’s condition before, during and after the operation to ensure an optimal
outcome for the patient
Must be able to anticipate the scrub nurse’s needs and be able to open sterile packs,
operate machinery and keep accurate records

SCRUB NURSE (HANNA): As a scrub nurse I am to one who is responsible for:

Ensures that the circulating nurse has checked the equipment

Ensures that the theater has been cleaned before the trolley is set
Prepares the instruments and equipment needed in the operation
Uses sterile technique for scrubbing, gowning and gloving
Receives sterile equipment via circulating nurse using sterile technique
 Performs initial sponges, instruments and needle count, checks with circulating nurse
Works directly with surgeon within the sterile field, passing instruments, sponges and
other items needed during the procedure
Member of the surgical team who prepares and preserves a sterile field in which the
operation can take place
Responsible for the sponge counts, the blades and needles and instruments check
throughout the operation

CIRCULATING NURSE (ALY): Scrub Nurse, I will check now all the equipment for proper
functioning of machines needed in the surgery, OR light and OR table, anesthesia machine are all
properly plugged in. Theater and environment is clean. All tangled wires are now entangled and
properly place to ensure safety to the surgery team. Placed a clean sheet, arm board and pillow
on the OR table, clean kick bucket and pail are also placed, and necessary stock and equipment
are now collected.

SCRUB NURSE (HANNA): My responsibility as a scrub nurse is to ensure that the circulating
nurse checked the instruments and that the theater has been cleaned before the trolley set.

SCRUB NURSE (HANNA): Nurse Aly, maayos na ba ang instruments and theater na
gagamitin?

CIRCULATING NURSE (ALY): Yes po Nurse Hanna, theater is set na po.

Narrator (SHATOK): Since we are now in an online simulation, keep in mind that the trolley
set is done by the circulating nurse, but for now the Scrub nurse will prepare the trolley set. The
circulating nurse already picked up necessary supplies in a storage room. After that she will head
to the operating room

Now, the scrub nurse will perform the proper hand washing, scrubbing, gowning and gloving.

SCRUB NURSE (HANNA): PERFORMS HANDWASHING, SCRUBBING, DRYING

(THEN PUNTA KANA KUNWARI SA OPERATING ROOM)

CIRCULATING NURSE (ALY): The scrub nurse will now perform GOWNING PPE,
GLOVING.

SCRUB NURSE (HANNA) perform GOWNING PPE and GLOVING (demonstrate)

Narrator (SHATOK): During the gowning and gloving, the scrub nurse will receive help from
circulating nurse in unpacking the set. After scrubbing and putting on sterile gown and gloves,
with the assistance of circulating nurse they will start to prepare the instruments. Upon entering
the sterile field, the scrub nurse should ensure the following:
SCRUB NURSE (HANNA): As one of the scrubbed personnel inside the sterile area, I must
ensure that: (recite)

● If my gown or glove are contaminated, I must change as soon as is reasonably practicable

● I should remain close to the sterile field and not leave the immediate area. If I leave the
sterile field and exit the sterile area I must re-scrub before returning to the sterile field.
Leaving the sterile field increases the risk for potential contamination.
● A wide margin of safety should be given between scrubbed and non-scrubbed persons.
● I should ensure that when changing positions or moving between sterile areas, scrubbed
personnel should turn back-to-back to avoid contamination.
● And lastly, I should keep my arms and hands within the sterile field at all times. Because
contamination may occur if hands are moved below the level of the sterile field

Narrator (Maureen): Now, the scrub nurse will perform the draping of mayo table and
organizing the instruments.

SCRUB NURSE (HANNA): Trolley Preparation for Surgical Intervention. (recite)

The preparation of sterile instrument trolleys for surgical intervention requires adherence to a
strict aseptic technique throughout. (ir-recite lang lahat ito:)

● It is important to remember that trolleys must be prepared immediately prior to each

individual surgical intervention in accordance with the planned operative procedure and
individual patient needs.
● The CN will collect together all items expected to be required for each procedure in
advance of surgery. Any items not available must be detailed to the operator in charge of
the case prior to start of the procedure, to allow the operator to make an informed
decision regarding whether to continue.
● I must ensure that all instruments to be used must be inspected for sterility and damage

SCRUB NURSE (HANNA): I will now drape the Mayo stand with a sterile Mayo stand cover.
(Demonstrate and recite)

● I will firmly grasp the Mayo stand cover and situate my hands over the back table. I will
put my hands underneath the first flap and as I put my hands under the first flap I will to
slide to where it's at on either end. And then I'm opening up the Mayo stand cover by
grabbing the both sides to make a pocket
● Once I created a pocket, I’m going to slide it on the Mayo stand then I can bring the
Mayo stand closer to when dressing it and step down the mayo table to stabilize it. I will
now dress the Mayo stand from the front and place the opening of the cover around the
Mayo stand.
● And then continue to peel the cover over the Mayo stand.
 ● Put towels over the mayo table with a cover and make sure all the surfaces are covered.
Now that we have a sterile Mayo stand, I will begin to organize it.

SCRUB NURSE (HANNA): Opening of sterile trays and packages (recite)

All sterile items to be used during an operative procedure will be opened in a manner so as to
avoid any possible contamination, and therefore minimize the risk of cross infection to the
patient.

● Scrub nurse must check that the pack to be opened is intact such as no visible tearing of
either paper or drape.
● Any packaging that feels damp or contains moisture is not fit for use, and must be
discarded.
● Scrub nurse must be aware that all packaging has a shelf life and must therefore examine
each item before opening to check the expiry date has not been exceeded.
● Any tray or package that has auto-clave tape must be checked to ensure that the tape has
turned brown indicating the item has been through a correct autoclaving process.
● Trays must be opened in a manner whereby the unscrubbed circulating person does not
lean over any part of the sterile inner drapes.

SCRUB NURSE (HANNA): I will now prepare the instruments.

Narrator (Maureen): As the scrub nurse performs placing of instruments in the Mayo table, she
will perform the initial counting of instruments

Arrangement of the instruments:

NAME QUANTITY

Scalpel Handle No. 3 1

Scalpel Handle No. 4 1

Blade #10 1

Blade #15 1

Blade #20 1

17 cm Curved Mayo Scissor 1

17 cm Straight Mayo Scissor 1

14 cm Curved Metzenbaum Scissor 2

14cm Dissecting Forceps Narrow 2

12 cm Adson Dissecting Forceps 2

14.5 cm, 1x2 teeth Tissue Forceps 2

Yankauer Suction Tube 1

Yankauer Suction Tip 1

14 cm Mayo-Hegar Needle Holder 1

18 cm Mayo-Hegar Needle Holder 1

Allis Tissue Forceps 2

14 cm straight Crile Hemostatic Forceps 4

14 cm curved Crile Hemostatic Forceps 6

20 cm Kocher Hemostatic Forceps 4

12.5 cm Straight Halsted Mosquito Artery Forcep 2

13 cm Backhaus Towel Clamp Forceps 6

25 cm Foerster Sponge Forceps 1

21 cm Lagenbeck Retractor 2

US Army Retractor 2

Round bowl 1

22 cm Poole Suction Tube 1

16 cm Babcock Tissue Forceps 2

Sterilizing Case 1

Sponge 6

2-0 Vicryl Reel (Ligation) 2

2-0 Vicryl CT-1 (Peritoneum and Fascia) 2

3-0 Nylon (skin) 1

Taper-point needle 4
 Reverse cutting edge needle 1

Towel clips 4

TOTAL: 71

Narrator (SHATOK): After the arrangement of instruments needed in surgery, the Circulating
nurse will now assist and record the official counting of the instruments in the log book.

TRANSFERRING THE CLIENT TO THE OR

Narrator (SHATOK): Now is the scenario wherein the patient will be transferred in the
operating room.

CIRCULATING NURSE (ALY): Mam, ittransfer na po naming kayo ngayon sa operating

room. Ano po ang inyong nararamdaman mam?

PATIENT (MJ): Eto kinakabahan na naman ako, medyo inaantok din ako pero alam ko na
magiging successful tong operation.

CIRCULATING NURSE (ALY): Hinga lang po ng malalim mam, ako po kasama ang mga
doctor, anesthesiologist at iba pang nurse ay sisiguraduhin ang inyong kaligtasan habang kayo po
ay nasa operasyon.

PATIENT (MJ): Maraming salamat.

CIRCULATING NURSE (ALY): positioning the client in the operating table in supine
position.

INTRAOPERATIVE - ANESTHESIA INDUCTION

Narrator (SHATOK): After transferring and positioning the client, anesthesia induction will be
performed by the anesthesiologist with the assistance of the circulating nurse.

CIRCULATING NURSE (ALY): In this phase, my responsibility is to turn on the OR light and
get the initial vital signs of the patient before the anesthesiologist take on her own duty. But first
let me attach the pulse oximeter that is directly attached to the monitor.

Vital signs as follows: bp = 120/80 mmHg, RR: 18 bpm, PR: 88 bpm: Temperature: 36.6C,
o2 saturation: 97%.
ANESTHESIOLOGIST (GLAI): Patient #121, Maryjan Gutierrez, 29 years old, has confirmed
consent, anesthesia safety check completed, pulse oximeter on patient, ECG monitor are working
fine, patient has no known allergies for medications, no risk for aspiration. Levaquin and
Ranitidine was given to patient. General anesthesia will be given intravenously.

CIRCULATING NURSE (ALY): During the administration of the anesthesia, the responsibility
of the circulating nurse are:

· Assist the anesthesiologist in patient’s positioning.

· Reposition the patient accordingly to the demands of the anesthesiologist.

· Attached anesthesia screen and place the patient arm on the arm boards.

· Apply arm strap on the patient.

· Expose the area for skin preparation.

· Ensure the safety of the client before moving to next step.

ANESTHESIOLOGIST (GLAI): Nurse, paki-supine position naman si patient.

CIRCULATING NURSE (ALY): In supine position na po Dra. si patient.

Narrator (SHATOK): The anesthesiologist first put on the oxygen mask to the patient and
proceeds on administering general anesthesia intravenously.

ANESTHESIOLOGIST (GLAI): Mam, ano pong pangalan nyo po?

PATIENT (MJ): Ma-ma-maryjan gutierez po.

ANESTHESIOLOGIST (GLAI): Nasaan ka po ngayon mam?

PATIENT (MJ): Nasa o-o-ospital, operating room po.

ANESTHESIOLOGIST (GLAI): Kamusta pakiramdam mo mam?

PATIENT (MJ): A-ah… (nakatulog na)

ANESTHESIOLOGIST (GLAI): General anesthesia was given.

CIRCULATING NURSE (ALY): Vital signs as follows: bp = 110/80 mmHg, RR: 18 bpm,
PR: 86 bpm: Temperature: 36.3C, o2 saturation: 97%.
Narrator (SHATOK): The circulating nurse now will perform the skin preparation on the
surgical site of the patient for exploratory laparotomy of appendicitis. The incision site will be
transverse incision 1-3 inches above the McBurney’s Point.

SKIN PREP

CIRCULATING NURSE (ALY): The patient’s gown is removed, the patient is also not
wearing undergarments. Now, i will put the blanket on the patient and expose only the abdomen
area. For the skin preparation, I have two solutions, first is the 7.5% iodine solution, to cleanse
the area, and lastly is the 10% iodine solution. And i will now wear my gloves.
First, i will prep the umbilicus using a cotton swab and discard it after use.
Second, I will now cleanse the exposed area using 7.5% iodine solution, starting from
inner to outer area in circular motion. The whole abdomen is being prep and up to the upper
thigh. Doing this 3 times.
Lastly, using 10% iodine solution, it will be applied in the same motion for 3x and wait
for 2-3 mins to dry.
CIRCULATING NURSE (ALY): I will ensure that the patient’s skin is prepared for surgery in a safe
and aseptic manner, exposing the patient as little as possible.

SURGEON ARRIVES AFTER SCRUBBING

SCRUB NURSE (HANNA): When the surgeon arrives after scrubbing, my responsibilities as a
scrub nurse are:

● Perform assisted gowning and gloving to the surgeon and assistant surgeon upon arrival
in the operating room.
● Assemble all the drapes according to use and needed. Start with towel, towel clips, draw
sheet and lap sheet.

DRAPING

SCRUB NURSE (HANNA): After hair was removed during the prep process as desired by the
surgeon, I will now cover the patient and surrounding areas with a sterile barrier to create and
maintain a sterile field during a surgical procedure. The purpose of draping is to eliminate the
passage of microorganisms between non sterile and sterile areas. Draping materials may be
disposable or non-disposable.

4 Towels:
I want to make sure that we've already prepared the towels ahead of time if we bring all four up
at the same time. So, my surgeon is going to grab the first towel and place it on their side. Next,
we're going to go superiorly or the top side, Inferiorly or the bottom side, and then the last side is
my side. Now, I always made sure that I was at least 12 to 18 inches away from the field even
though I'm protected by a drape I still don't want to risk contamination.

Laparotomy drape
So, I'm going to place this right at the incision site, we're going to unfold it, the surgeon is going
to grab one side, I'm going to grab the other, we're going to cuff our hands, and extend. We're
going to completely unfold the drape, cuff our hands again, and extend.

Considerations: (kahit hindi na i-recite)

1. Protect the gown by distance and the gloved hands by cuffing drapes over them. I should
ensure that all parts of the drape are under positive control at all times during placement
and should use precise and direct motion.
2. Draping is always done from sterile area to an unsterile area and by draping nearest
first I should never reach across an unsterile area to drape. When the opposite side
of the operating room bed must be draped, I must go around the bed to drape. Do
not flip, fan or shake drapes. Rapid movement of drapes creates air currents on
which dust, lint and droplet nuclei may migrate. Shaking a drape causes
uncontrolled motion of the drape which may cause it to come in contact with an
unsterile surface or object.
3. A drape should be carefully unfolded and allowed to fall gently into position by gravity.
The low portion of a sheet that falls below the safe working level should never be raised
or lifted back onto the sterile area.
4. Drape the incisional area first and then the periphery. Handle the drapes as little as
possible.
5. Never reach across the operating table to drape the opposite side; go around the table
6. Hold the drapes high enough to avoid touching nonsterile area but avoid touching the
overhead light
7. Hold the drape high until it is directly over the proper area, then drop (open fingers and
release sheet) it down where it is to remain. NEVER ADJUST ANY DRAPE. If the
drape is incorrectly placed, leave it in place and place another drape over it.
8. Protect the gloved hands by cuffing the end of the sheet over them. Do not let the gloved
hand touch the skin of the patient
9. In unfolding a sheet from the operative site toward the foot or head of the table, protect
the gloved hand by enclosing it in the turned back cuff of the sheet. If a drape becomes
contaminated, discard it immediately. If the end of a drape falls below waist level, do not
handle it further. Drop it and use another drape If in doubt about sterility, discard the
drape
10. If a hole is found in a drape after it is laid down, cover the hole with another drape or
discard the entire drape.
NARRATOR (SHATOK): Throughout the whole process, it is important that the scrub nurse
will maintain sterility throughout the procedure and be aware of the patient’s safety. Both the
circulating and scrub nurse will perform sponge count/ instruments count/ surgical needles
before the time out.

NAME QUANTITY

Scalpel Handle No. 3 1

Scalpel Handle No. 4 1

Blade #10 1

Blade #15 1

Blade #20 1

17 cm Curved Mayo Scissor 1

17 cm Straight Mayo Scissor 1

14 cm Curved Metzenbaum Scissor 2

14cm Dissecting Forceps Narrow 2

12 cm Adson Dissecting Forceps 2

14.5 cm, 1x2 teeth Tissue Forceps 2

Yankauer Suction Tube 1

Yankauer Suction Tip 1

14 cm Mayo-Hegar Needle Holder 1

18 cm Mayo-Hegar Needle Holder 1

Allis Tissue Forceps 2

14 cm straight Crile Hemostatic Forceps 4

14 cm curved Crile Hemostatic Forceps 6

20 cm Kocher Hemostatic Forceps 4

12.5 cm Straight Halsted Mosquito Artery Forcep 2

 13 cm Backhaus Towel Clamp Forceps 6

25 cm Foerster Sponge Forceps 1

21 cm Lagenbeck Retractor 2

US Army Retractor 2

Round bowl 1

22 cm Poole Suction Tube 1

16 cm Babcock Tissue Forceps 2

Sterilizing Case 1

Sponge 6

2-0 Vicryl Reel (Ligation) 2

2-0 Vicryl CT-1 (Peritoneum and Fascia) 2

3-0 Nylon (skin) 1

Taper-point needle 4

Reverse cutting edge needle 1

Towel clips 4

TOTAL: 71

Time OUT of OR Team (5 Members) Introduction ng members

NARRATOR (SHATOK): Before proceeding with the surgery, there will be a time-out of the
OR team. The procedure is not started until all questions or concerns are resolved. During the
time-out, all team members should verify the name of the patient and the procedure.

Circulating Nurse (Aly): Are the team ready? Please state your name and role.

Surgeon (Maureen): I am Maureen Sanchez, Surgeon

Assistant Surgeon (Denise): I am Denise Lagata, Assistant Surgeon

Anesthesiologist (Glai): I am Glaira Valencia, Anesthesiologist

Scrub Nurse (Hanna): I am Hanna Sarmiento, Scrub Nurse

Circulating Nurse (Aly): Please confirm the patient name and the procedure.

Surgeon (Maureen): This is patient Patient #121, Ms. Maryjan Gutierrez, 29 years old Female.
We are doing an Exploratory Laparotomy. Diagnosis is Appendicitis. She is in a supine position.
Surgery will be for 60 minutes.

Circulating Nurse (Aly): The consent was already signed by the patient. For our
anesthesiologist, is there any antibiotic given or any specific patient concern?

Anesthesiologist (Glai): The patient has already confirmed her consent. Levaquin and
Ranitidine were administered. General anesthesia was given thru IV. IV access on the right
arm. There are no specific concerns for the patient.

Circulating Nurse (Aly): For the surgical team, has the sterility been confirmed?
Scrub Nurse (Hanna): Yes, the instruments are sterile. I have prepared the explore
laparotomy set which includes…. (nasa table)

Circulating Nurse (Aly): Are there any clarifications or questions about the procedure?
ALL HEALTHCARE TEAM: None
Circulating Nurse (Aly): Surgeon and other members of the team, are you agreeing to this
procedure?
ALL HEALTHCARE TEAM: YES!
Surgeon (Maureen): Okay, we can now start the procedure.

NARRATOR (SHATOK): Documentation should indicate that a time-out was performed in

accordance with the healthcare facility’s policy, and identify what was verified and who
participated in the time-out.

PROCEDURE: EXPLORE LAP/ OPEN APPENDECTOMY (?)

SURGEON (MAU): Incision time?
SCRUB NURSE (HANNA): 3:10 PM

1. NARRATOR (SHATOK): Transverse incision is deepened through the subcutaneous

tissue at 1-3 cm above McBurney’s point using scalpel handle 3 with size #10 blade to
expose the external oblique aponeurosis, hemostasis is secured.
SURGEON (MAU): Scalpel
SCRUB NURSE (HANNA): *hands the instrument*

2. NARRATOR (SHATOK): Edges are retracted using two US Army retractors. The
external oblique is opened in the line of the incision & the muscle layers split to expose
the peritoneum. The peritoneum is opened.
SURGEON (MAU): US Army retractor
SCRUB NURSE (HANNA): *hands the instrument*

3. NARRATOR (SHATOK): The superior and the inferior edges are grasp and the incision
are extended with a curved Metzenbaum scissor to expose the internal oblique muscle
SURGEON (MAU): Metzenbaum scissors
SCRUB NURSE (HANNA): *hands the instrument*

4. NARRATOR (SHATOK): The fibers are splitted along the fibers with curved Crile
Hemostatic Forceps and retracted with langenbeck retractor This exposes the
transversus abdominis muscles which is also splinted and retractor adjusted, the
peritoneum is exposed
SURGEON (MAU): Lagenbeck retractor
SCRUB NURSE (HANNA): *hands the instrument*
SURGEON (MAU): curved Crile Hemostatic Forceps
SCRUB NURSE (HANNA): *hands the instrument*

5. NARRATOR (SHATOK): The surgeon grasps the peritoneum with an curved Crile
Hemostatic Forceps, carefully verifying that intra-abdominal viscus is not inadvertently
grasped

6. NARRATOR (SHATOK): A small incision is made on the peritoneum with a scalpel

with size 15 blade.
SURGEON (MAU): scalpel
SCRUB NURSE (HANNA): *hands the instrument*
 7. NARRATOR (SHATOK): Aspirate taken for mucosa and the secretions suctioned with
suction tubing with the Yankauer tip.
SURGEON (MAU): Suction
SCRUB NURSE (HANNA): *hands suction*

8. NARRATOR (SHATOK): Edges of the peritoneum grasped with two curved Crile
Hemostatic Forceps and extended
SURGEON (MAU): curved Crile Hemostatic Forceps
SCRUB NURSE (HANNA): *hands the instrument*

9. NARRATOR (SHATOK): The Langenbeck retractor is placed within the peritoneal

cavity to elevate the anterior abdominal wall
SURGEON (MAU): Lagenbeck retractor
SCRUB NURSE (HANNA): *hands the instrument*

10. NARRATOR (SHATOK): The caecum is delivered into the wound and the taenia coli is
followed to identify the appendix

11. NARRATOR (SHATOK):Before the appendix is delivered, the wound edges are
protected with four fresh sponge near the wound edge.
SURGEON (MAU): Sponges
SCRUB NURSE (HANNA): *hands the sponge separately per pieces*

12. NARRATOR (SHATOK): Once the appendix is delivered, it is held in a Babcock's

forceps, while the mesentery is viewed against light. If pus is evident a culture swab is
taken for microbiological assessment.
SURGEON (MAU): Babcock forcep
SCRUB NURSE (HANNA): *hands the instrument*

13. While addressing the mesoappendix, it is advisable to wrap the inflamed appendix in a
sponge to avoid direct contact with the wound margins and thus prevent wound
infections.
SURGEON (MAU): Sponge
SCRUB NURSE (HANNA): *hands the sponge*

14. NARRATOR (SHATOK): Now the surgeon will clamp and ligate the mesoappendix. A
small window in the mesoappendix near the base is created this allow application of two
curved Crile Hemostatic Forceps
SURGEON (MAU): two curved Crile Hemostatic Forceps
SCRUB NURSE (HANNA): *hands the instrument*
 15. NARRATOR (SHATOK): The surgeon will now ligate the mesoappendix with Vicryl
2-0 suture.
SURGEON (MAU): Vicryl 2-0 suture
SCRUB NURSE (HANNA): *hands the instrument*
SURGEON (MAU): Cut
SCRUB NURSE (HANNA): *cut using metz scissor*
SURGEON (MAU): Suction
SCRUB NURSE (HANNA): *suction*

16. NARRATOR (SHATOK): When the appendiceal mesentery is completely separated

from the appendix, the surgeon crushes the base of the appendix and the contents of the
appendix are milked distally to 1 cm creating proximal and distal crush marks using two
Straight Crile Hemostatic Forceps
SURGEON (MAU): two Straight Crile Hemostatic Forceps
SCRUB NURSE (HANNA): *hands the instrument*

17. NARRATOR (SHATOK): An absorbable suture ligature is applied by the surgeon to

the appendiceal base (proximal to the clamp). The clamp is loosened by the surgical
assistant while the ligature is secured. Another ligature is placed by the surgeon at the
distal crush mark.
SURGEON (MAU): Vicryl 2-0 suture
SCRUB NURSE (HANNA): *hands the instrument*
SURGEON (MAU): Cut
SCRUB NURSE (HANNA): *cut using metz scissor*

18. NARRATOR (SHATOK): Then the appendix is transected with a scalpel (between the
suture and the forceps).
SURGEON (MAU): Scalpel
SCRUB NURSE (HANNA): *hands the instrument*

19. NARRATOR (SHATOK): The base is then doubly ligated with 2-0 absorbable sutures
to facilitate inversion of the appendiceal stump.

SURGEON (MAU): Vicryl 2-0 suture

SCRUB NURSE (HANNA): *hands the instrument*
SURGEON (MAU): Cut
SCRUB NURSE (HANNA): *cut using metz scissor*

CLOSURE
 1. NARRATOR (SHATOK): The peritoneum is grasped with curved Crile Hemostatic
Forceps and approximated with 2-0 Vicryl SH suture
SURGEON (MAU): Crile Hemostatic Forceps
SCRUB NURSE (HANNA): *hands the instrument*
SURGEON (MAU): 2-0 Vicryl SH suture
SCRUB NURSE (HANNA): *hands the instrument*

2. NARRATOR (SHATOK): The transversus and internal oblique muscle layers are
irrigated and loosely approximated with Vicryl 2-0 suture
SURGEON (MAU): Vicryl 2-0
SCRUB NURSE (HANNA): *hands the instrument*
3. NARRATOR (SHATOK): The external oblique fascia is repaired with continuous
Vicryl 2-0 suture

NARRATOR (SHATOK): Before the surgeon closes the incision site, both the scrub nurse and
circulating nurse can count the instruments.

SURGEON (MAU): Anesthesiologist, kamusta vital signs ni patient?

ANESTHESIOLOGIST (GLAI): Stable naman po si patient, vital signs are bp = 110/80

mmHg, RR: 16 bpm, PR: 80 bpm: Temperature: 36.2C, o2 saturation: 98%.

SURGEON (MAU): Okay, thankyou.

SCRUB AND CIRCU COUNTS INSTRUMENTS

NAME QUANTITY

Scalpel Handle No. 3 1

Scalpel Handle No. 4 1

Blade #10 1

Blade #15 1

Blade #20 1

17 cm Curved Mayo Scissor 1

17 cm Straight Mayo Scissor 1

14 cm Curved Metzenbaum Scissor 2

14cm Dissecting Forceps Narrow 2

12 cm Adson Dissecting Forceps 2

14.5 cm, 1x2 teeth Tissue Forceps 2

Yankauer Suction Tube 1

Yankauer Suction Tip 1

14 cm Mayo-Hegar Needle Holder 1

18 cm Mayo-Hegar Needle Holder 1

Allis Tissue Forceps 2

14 cm straight Crile Hemostatic Forceps 4

14 cm curved Crile Hemostatic Forceps 6

20 cm Kocher Hemostatic Forceps 4

12.5 cm Straight Halsted Mosquito Artery Forcep 2

13 cm Backhaus Towel Clamp Forceps 6

25 cm Foerster Sponge Forceps 1

21 cm Lagenbeck Retractor 2

US Army Retractor 2

Round bowl 1

22 cm Poole Suction Tube 1

16 cm Babcock Tissue Forceps 2

Sterilizing Case 1

Sponge 6

2-0 Vicryl Reel (Ligation) 2

2-0 Vicryl CT-1 (Peritoneum and Fascia) 2

 3-0 Nylon (skin) 1

Taper-point needle 4

Reverse cutting edge needle 1

Towel clips 4

TOTAL: 73

Scrub Nurse (Hanna): Good morning Doc Raymundo and Doc Lagata. I am your scrub nurse,
Hanna Sarmiento. All instruments are counted, total of 73 instruments po and complete na po.
Surgeon (Shatok): Are you sure?
Scrub Nurse (Hanna): Yes po, Doc.
Circulating Nurse (Aly): Are there any instrument problems need to be addressed?
Scrub Nurse (Hanna): None

4. The subcutaneous tissue is irrigated, and the skin will be incised using a 3-0 Nylon, a
non-absorbable suture.
SURGEON (MAU): 3-0 Nylon
SCRUB NURSE (HANNA): *hands the instrument*

END OF OPERATION (SCRUB NURSE)

After the operation, the scrub nurse clears away the instrument and equipment.

Scrub Nurse (Hanna): After operation I have to help with the application of dressing and
removes and dispose of drapes. After that, I can now remove the PPE.
I am also responsible in:
● Cleaning the patient and preparing for PACU
● Preparing the patient for recovery room.
And the circulating nurse are responsible for:
● Completing documentation.
● Handing patient over to recovery room.

Circulating Nurse (Aly): I have to get the initial vital signs of the patient before transferring in
PACU
Vital Signs are as follows: bp = 120/90 mmHg, RR: 16 bpm, PR: 82 bpm: Temperature:
36.2C, o2 saturation: 98%.
Circulating Nurse (Aly): Ensures specimen are properly labeled and signed.
LABEL INCLUDES:

1. Patient name, medical record number, age and sex.

2. Date and time of collection

3. Requesting physician's name.

Circulating Nurse (Aly): Then the circulating nurse will transfer the specimen to the laboratory.
Endorsement: Specimen taken from patient #121 at 3pm. Procedure is an open appendectomy
performed by Doctor Sanchez.
LABORATORY CLERK: Okay po, san po ako pipirma nurse?
Circulating Nurse (Aly): Dito po mam. Ayan, thankyou po.
NARRATOR (SHATOK): After leaving the laboratory station.. The nurse return to her post.

Circulating Nurse (Aly): will transfer the client from OR table to stretcher.
NARRATOR (SHATOK): The Circulating Nurse will now transfer the client to the PACU.

Circulating Nurse (Aly): *taps the shoulder* mam, tapos na po ang inyong operation. Ililipat na
po namin kayo sa recovery room.
PATIENT (MJ): A--ahh ay tapos na ba?
Circulating Nurse (Aly): Opo mam, tapos na po. Wala po bang masakit sa inyo?
PATIENT(MJ): Nu-nurse, medyo antok pa ko. Wala nasakit sakin.
Circulating Nurse (Aly): Okay po mam, transfer na po namin kayo.
PATIENT (MJ): Uhh-oo.

IN PACU:
The OR and PACU nurse check the identification band before the report is given as per patient
identification policy.
Circulating Nurse (Aly): Good afternoon po, endorsing patient #121, Maryjan Gutierrez 29
years old female. The patient undergone exploratory laparotomy due to acute appendicitis this
afternoon. Dra. Sanchez performed the surgery 3:00-4:00 pm. With contraptions of D5LR at
200cc, iv insertion at right metacarpal vein, regulated at 22 drops per minute. Patient blood loss
during the procedure is 100 ml. No blood transfusion performed, no allergic reaction occurred.
Latest vital signs of patient are: Temperature 36.5C, RR=18bpm, PR = 85 bpm, BP= 110/70
mmHg. O2 sat=97%.
NARRATOR (SHATOK): The OR nurse is responsible for a complete report to the PACU
nurse.

Circulating Nurse (Aly): Then, I have to ensure that the theater is ready for the next case.