SURGICAL INSTRUMENTATION PROGRAM

TRAINING SURGICAL PLANNING

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STUDENT NAME: CODE: PRACTICE

LEVEL: IV
Anguie Tatiana Herrera Hernandez 01200021060

TEACHER'S NAME: Lidy Higuera PRACTICE STAGE: ICB NOTE:

SPECIALTY: CX SURGEON: DATE: 13/10/23

CARDIOVASCULAR Dr. Fabian Giraldo

NAME OF PATIENT: Roberto Silva Martinez MEDICAL HISTORY NUMBER: PATIENT AGE:

91068610 60 age

SURGICAL PROCEDURE TO PERFORM:

Aortic Valve Replacement + RVM

SURGICAL INSTRUMENTATION PROCESS

1. PLANNING STAGE:

1.1. Surgical Objective: (Make description)

Replace the aortic valve through a sternotomy with extracorporeal circulation to replace the damaged valve with
a valve implant

1.2. Anatomy and physiology: (Make graph and description).

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The aortic valve is located in the initial portion of the aorta, which is called the aortic root. This is the continuation of
the left ventricular outflow tract. The aortic root is related in 2/3 of its circumference with the interventricular septum
and in the remaining 1/3 with the anterior leaflet of the mitral valve. There are 3 aortic leaflets (right, left, and
noncoronary or posterior) that determine 3 sinuses of Valsalva. When the leaflets give way to the arterial portion, we
do not find a border area between the valvular portion and the tubular portion called the sinotubular junction. The 2
coronary arteries arise from this area.

When the heart compresses (contracts), the aortic valve opens, allowing blood to flow from the left ventricle into the
aorta. When the heart relaxes, the aortic valve closes, preventing blood from flowing backward.

You may need aortic valve surgery to replace the valve in your heart if:

The aortic valve does not close completely, so blood leaks back toward the heart. This is called aortic regurgitation.

The aortic valve does not open fully, so blood flow out of the heart is reduced. This is called aortic stenosis.

Since the coronary arteries carry blood to the heart muscle, any disorder or disease of the coronary arteries can lead to
serious complications by reducing the flow of oxygen and nutrients to the heart muscle. This can cause a heart attack or
death. Arteriosclerosis (a buildup of plaque on the inner lining of an artery that causes it to become narrowed and
blocked) is the most common cause of heart disease.

The coronary arteries arise from the root of the ascending aorta. The main divisions of the coronary arteries usually
travel just below the epicardium of the heart. However, its branches can embed deep into the myocardium as they
pass through the cardiac sulci.
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Upon entering the coronary sulcus, in the upper portion of the anterior interventricular sulcus, the ICA divides to give
rise to the anterior interventricular artery (still known to clinicians as the left anterior descending artery) and the left
circumflex artery.

Near its origin, the right coronary artery (RCA) gives rise to the branch of the sinoatrial node, which, as its name
implies, supplies the sinoatrial node. On its way down the coronary sulcus, it gives rise to the right marginal branch, this
is a large-calibre vessel that travels through the right edge of the heart towards the cardiac apex, without reaching it. It
then turns to the left toward the posterior aspect of the cross of the heart, where it gives origin to the branch for the
atrioventricular node.

1.3. Check list:

MEDICAL EQUIPMENT/ DRUGS AND

DEVICES SUTURES AND SOLUTIONS
INSTRUMENTAL
NEEDLES

-Eq. extracorporeal -Pack of Heart R. PERICARDIUM: -Saline solution

-Eq. Coronary -Accessory Robes -(2) Silk 0 needle ½ - infiltration

C.R. 26 mm de 75 cm
-Eq. Accessory -Skin fields for two - Nitroglycerine
ARTERIAL AND
-Valve Gauges -Handle bars VENOUS TOBACCO - Heparin

-Reciprocating Saw -Ioban BAGS:

-Sternal Retractor -Gloves -Polyester 2/0 needle ½

C.R. 25cm
-Breast Separator -Compresses
TOBACCO VENT
-Defibrillator paddles -Gauze BAGS, CARDIOPLEGIA
AND AORTIC
- Clamp dr. Giraldo -Gauze container
CLOSURE:
-League Clips of 100 -Sharps container
-Polypropylene 4/0
and 200
-Electro scalpel needle ½ C.R. 17cm
-Octopus
-Rubber Suction FIXATION OF
-Starfish CANNULAS:
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-Aortic valve -Yankawer cannula -Silk 1 Precut

-Aseptosyringe VALVE SETTING:

-20 and 10 ml syringe -Valve Kit

-Chest tube PROXIMAL

ANASTOMOSES:
-Nelaton probe #8 and 14
-(2) Polypropylene 6/0
-Pink needle # 18 needle 3/8 C.R. 13mm
-Pathology Flask de 75 cm

-Alligators DISTAL
ANASTOMOSES:
-Pleuroback
-(2) Polypropylene 7/0
RELEVANT DEVICES: needle 3/8 C.R. 9.3mm
de 75 cm
-Arteriotomy cannula
AORTA REPAIRS:
-Clips 100 and 200
-Silk 4/0 vascular
-Punch

-Ophthalmology scalpel
-Pacemaker wire
-Tourniquets
STERNAL:
-Arterial cannula
-Surgical Wire 5
-Venous Cannula
MUSCLE AND T.C.S. :
-Rigid pericardium
aspirator -(2) Poliglactin 910 0
needle ½ C.R. 36.4mm
-Vent aspirator
de 90cm
-CO2 rubber
SKIN:
- Ostium cardioplegia
-Poliglecaprone 3/0
cannula
needle 3/8 C.C. de
-Three-way tap 19mm de 70 cm
(cardioplegia)
CHEST TUBE
-Connectors FIXATION:

-Polyester 2/0 whit

plush

PACEMAKER WIRE
FIXATION:
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-Silk 2/0 SH

HEMOSTATICS:

-Bone Wax

-Bioglue

-1 Scalpel Blades 11

-1 Scalpel Blades 15

2. ORGANIZATION STAGE:

a. Arrangement of May tables and reservation (make scheme).

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2.2. Patient position (Name and graphic):

Supin Position
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2.3. Location of the Surgical Team (make a graph):

Anestesiologist

Nurse

Perfusionist
Surgeon

Assistant
S.I.
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3. EXECUTION STAGE:

a) Anesthesia (write the type of anesthesia):

General

b) Incision (write the type of approach and the name of the incision):

Esternotomy

c) Surgical Process (Describe the main steps of the surgical medical technique with the instruments to be used).

- May table arrangement and reservation

- Patient's dress
- Count of compresses and gauze
- Fixing pipes and lines with straight kellys
- Dress of the surgeon and assistant

STERNAL OPENING TIME:

- To make an incision, go to the surgeon MB# 7 and HB# 15

- Pass to surgeon dissection and electrocautery for deep tissue incision.
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- For sternotomy pass to surgeon reciprocanting saw equipment

- For manual separation of the sternum, go to the Farabeuf separator surgeon.
- Pass bone wax, electrocautery in 60 for hemostasis of the sternal periosteum and bone marrow.
- Pass to the surgeon the sternal protectors and the self-retaining retractor for the fixed retraction of the sternum.
- Pass to the surgeon vascular type dissection and electrocautery device in 40 for the opening of the pericardium.
- Pass needle holder with 0 silk suture to repair the pericardium.

DISSECTION OF THE MAMMARY ARTERY:

- Pass to the surgeon microvascular dissection and electrocautery in 20 for dissection of the mammary artery.
- For ligation and hemostasis of this, use Ligaclip forceps and the corresponding clip cartridge according to the caliber of
the vessel and Metzembaum scissors.
- Prepare moist gauze with nitroglycerin-impregnated solution for arterial vasodilation of the mammary artery.

- Pass to the surgeon vascular type dissection and electrocautery device in 40 for the opening of the pericardium.

- Pass needle holder with 0 silk suture to repair the pericardium.

VASCULAR TIME:

- Pass vascular dissection, T. Mayo and 2/0 polyester suture for the surgeon to make the tobacco pouches in:
o Ascending Aorta
o right atrium
- Prepare 4/0 polypropylene for the surgeon to make the tobacco pouches in:
o Right Upper Pulmonary Vein (Vent Aspirator)
- Prepare pass threads (tourniquet) and Kelly to refer the tobacco bags made by the surgeon.
- Prepare the appropriate cannula for the patient's infusion as appropriate.
- Go to the surgeon MB# 7 HB# 11 to perform the arteriotomy to perform the corresponding cannulation.
- Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
- Prepare tube clamp and gauze for purging the arterial cannula.
- Go to surgeon MB#7 HB#11 to make the incision in the right atrium.
Pass the long Metzembaum scissors to the surgeon to widen the incision and perform the corresponding cannulation.
- Prepare pre-cut silk 1 for fixing the placed cannulas by passing them through the surgeon's hand.
- Prepare suitable connectors for the connection of the cannula to the extracorporeal circuit.
- Go to surgeon MB#7 HB#11 to make the incision in the right upper pulmonary vein.
- Go to the surgeon P. Kelly Adson to widen the incision and perform the corresponding cannulation.
- Prepare total occlusion vascular clamp for the surgeon to perform aortic clamping.

CORRECTION TIME:

(AORTIC VALVE REPLACEMENT)

- Pass to the surgeon MB#3 HB# 11), and vascular dissection to incise the aorta, then pass long tissue scissors.

- Pass the suction cannula of the machine, to collect the blood.

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- Pass coronary perfusion cannula, for direct antegrade cardioplegia in coronary ostium.

- Silk pass 4-0 to repair the walls of the aorta.

Pass vascular grasping forceps and scissors for dissection and removal of the aortic valve.

- Keep in mind that when the valve is calcified, the surgeon removes the valve using allix forceps, scissors and vascular
grasping forceps.

- It is washed with saline solution, remember to place an extension to the aseptosyringe

- The valve is measured with the gauge approved by the surgeon and confirmed.

- The nursing assistant is asked for the valve device to be implanted, confirmed aloud.

- If the valve to be implanted is biological, wash it according to the valve device washing protocol.

- Pass the valve to the assistant surgeon.

- Support the surgeon in the passage of the sutures in the valve annulus.

- The surgeon is passed a 2-0 vascular polyester suture in each of the posts and the respective repair, then the following
sutures are passed, taking special care not to repeat the color of the thread.

- After implantation of the medical device, pass a closing suture (prolene 4-0 16mm round needle with pledget).

- Ready root suction.

- 4/0 polypropylene pass for aortic root purse string, tourniquet and antegrade cardioplegia cannula for deaeration.

(MYOCARDIAL REVASCULARIZATION)

- Give the surgeon compresses and gauze to improve exposure.

- Give the surgeon a scalpel with a 15 blade, and vascular apprehension, to dissect the epicardial fat and locate the
coronary artery to be revascularized.
- Pass the cardiac retractor to the surgeon to improve the surgical area
- Pass to the surgeon with umlaut instruments, microvascular elastic apprehension to perform the coronary arteriotomy
(scalpel handle blade 15) and to extend the incision pass antegrade and/or retrograde Potts type microvascular scissors
depending on the cut.
- Pass the coronary shunts (1.0,1.5,2.0,2.5) to the surgeon using a fine elastic grasping forceps in order to maintain
coronary flow
- Prepare the 7/0 and/or 8/0 polypropylene synthesis and suturing instruments for the surgeon to perform the distal
anastomoses.
- For better exposure of the surgical field at the anastomosis site, use continuous CO2 aeration with a suction line and
cannula.
- If it is necessary to reinforce the suture, prepare microvascular synthesis instruments, microvascular dissection forceps
and suture.
- Hemostasis check.

CLOSING TIME:
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- Prepare warm saline solution, to speed up patient warming.

- Prepare for aortic unclamping and removal of the patient from extracorporeal circulation.
- Pass Mayo scissors, vascular dissection and assist the surgeon at the time of removal of the cardiovascular cannulas,
anticipating partial occlusion clamp and reinforcing sutures with and without supportfrom pledget.
- Pass pacemaker wire so that the surgeon can position them ashe sees fit in the atrium and ventricle.
- Pass HS#3 SB#15, vascular dissection, suture and Long Metzenbaum Scissors and chest tubes so that the surgeon can
position them as he sees fit in the pleurae and mediastinum respectively.
- Nelaton 14 probe is inserted for chest tube aspiration
- Assist the surgeon in general hemostasis with electrocautery of the surgical area, providing suture material, gauze,
compresses and hemostasis elements.
- Verification of counts
- Prepare number 5 surgical wire, Rochester, needle holder, and wire cutters for the surgeon to face the sternum.
- Prepare 2/0 or 3/0 polypropylene to face the muscles and subcutaneous tissue with needle holder, claw dissection, and
Mayo scissors.
- Prepare poliglecaprone to face the skin with needle puller, adson dissection with claw and mayo scissors.
- Make the patient heal by cleaning and covering the wound with dressings and/or adhesive tapes.

WEEKLY REPORT FORMAT OF TRAINING PRACTICE

SURGERY ASSISTANCE RECORD FORM - TRAINING PRACTICE IQX-FT-024-UDES

STUDENT SIGNATURE: TEACHING SIGNATURE: __________________________