Operating Theatre Procedures Flashcards
What are some potential pelvic fractures?
- Symphysis pubis dislocation
- Pubic ramus fracture
- Iliac fracture
- Sacro-iliac joint dislocation
- Sacrum fracture
90% of pelvis fractures will have other associated injuries which may require radiographic support in theatre. Give examples.
- Retrograde urethrogram to demonstrate the urethra, bladder and ureters
- Angiography with embolisation for arterial injuries
- The pelvic fracture will also need to be stabilised
What types of hip fracture are there?
INTRACAPSULAR
- femoral head #
- subcapital #
- femoral neck #
- transcervical #
- basicervical #
EXTRACAPSULAR
- intertrochanteric #
- subtrochanteric #
- shaft #
How does a femoral head fracture occur?
Normally result from high energy trauma and associated with a dislocation
Where can the femoral neck fracture?
The femoral neck lies between the femoral head and the greater trochanter.
Subcapital - at the junction between head and neck
Transcervical - mid-neck
Basicervical - base of femoral neck
What are inter- and sub-trochanteric fractures?
Intertrochanteric fractures are between the greater and lesser trochanters, and subtrochanteric fractures are within 5cm distally of the lesser trochanter. Intertrochanteric fractures may also extend into the shaft, therefore having a “subtrochanteric extension”.
—> Intertrochanteric fractures are the most common hip fracture
What is a dynamic hip screw?
Most common procedure for repairing an intertrochanteric fracture.
- Control AP + lateral taken to reduce fracture
- Guide wire is inserted and then repositioned using AP and lateral screening
- Dynamic hip screw is then positioned and secured with plate with screws in femur
What is a cannulated hip screw?
Used to repair femoral neck fractures. Cannulated hip screws (or AO screws are positioned through the greater trochanter to femoral neck and head.
What is arthrography?
Radiological examination for the demonstration of the soft tissue structures in joints following the injection of contrast media +/- air
- Demonstrates menisci, ligaments, tendons, articular cartilage and bursae
- Most common joints:
- Shoulder
- Knee
- Hip
What are the indications for a hip arthrography?
- Clicking hip
- Dysplasia of hip joint
- Loose hip prosthesis
- Congenital abnormality
What is intermedullary femoral nailing?
Procedure for the repair of proximal mid-shaft fractures of the femur.
- Bone may be realigned through external fixation
- Reaming nail inserted in caudally from the greater trochanter
- Proximal locking screws through greater trochanter, neck and head
- Intermedullary nail through the cancellous bone, through the fracture and full length of the femur
- Distal locking screws at distal end of intermedullary screw, before beginning of condyles
What is a LISS plat?
Less Invasive Stabilisation System - used for distal femoral fractures
- Plate is measured and placed under X-ray control
- Screws at points along length for fixation
How are patients positioned for a DHS?
- Patient lies on table from head to bottom
- Unaffected leg is bent in air and to one side
- Operating leg is suspended straight out
- Arm of affect side is suspended over chest
- C-arm in space created by separated legs, easily able to move from AP to lateral
How are patients positioned for an intermedullary femoral nailing?
- Patient lies on table from head to bottom
- Both legs are suspended straight in front, with the unaffected leg also elevated
- C-arm rests in an ‘oblique’ position between the legs
How do tibial plateau fractures occur?
Usually the result of high impact trauma.
How is the patient positioned for the repair of tibial plateau fractures?
- Patient lies on table from head to bottom, with the table extending the full length of the leg on the unaffected side
- Affected side is suspended at the knee over a metal frame
What theatre procedures for extremity trauma require radiographic support?
- Manipulation Under Anaesthetic (MUA)
- Open Reduction and Internal Fixation (ORIF)
- Kirschner wires (K-wires)
May be done for wrist, shoulder, ankle, etc.
What spinal procedures require radiographic support in theatre?
- Spinal decompressions
- Spinal disectomy
- Spinal pain relief and injections
How are patients positioned for spinal surgery?
- Patient lies prone on table, with supports under the waist and ankles for support
- Arm is abducted to one side
- C-arm positioned perpendicular to table
What are the indications for spinal decompression?
- Herniated of prolapsed intervertebral discs
* Spinal stenosis
What is a laminectomy?
The removal of the entire bony lamina, a portion of the facet joints and thickened ligaments overlying the spinal cord and nerve.
What is a laminotomy?
Removal of small portion of lamina and ligaments, usually on one side.
What is a foraminotomy?
Removal of bone around the neural foramen (the space between the verterbrae where the nerve root exits the spinal canal) .
What is a laminoplasty?
Expansion of the spinal canal by cutting the lamina of one side and swinging them open like a door
Only carried out in cervical spine
What is spinal fusion?
A process using bone graft to allow opposing bony surfaces to grow together.
What are the indications for spinal fusion?
- Degenerative disc disease
- Disc herniation
- Discogenic pain
- Spinal tumour
- Spinal fracture
- Scoliosis
- Kyphosis
- Spondylolisthesis
- Spondylosis
- Other degenerative conditions or conditions that cause spinal instability
What is spondylolisthesis?
A condition where a vertebra slips out of position, either anteriorly or posteriorly. Most common in the lumbar spine.
What are the types of spinal fusion?
- Postero-lateral fusion
- Interbody fusion
- Arthrodesis
- Spinal fixation
What is postero-lateral fusion?
Places bone graft between transverse processes of spine
Vertebrae fixed in place with screws and wires through the pedicles of each vertebrae, with a metal rod on each side
What is interbody fusion?
Bone graft placed between vertebrae in the area usually occupied by intervertebral disc
What is arthrodesis?
Bone graft that can be taken from the patient’s pelvis
What is spinal fixation?
Placement of metallic screws, rods or cages to stabilise the vertebrae
What are the important considerations for treating spinal trauma?
- Requires immediate treatment at the site of injury to prevent further injury to the spinal cord
- Initial immobilisation of the head and whole spine
- Steroids given to control swelling
- Surgery to evaluate the state of the spinal cord, to stabilise any fractured vertebrae and to release pressure from the injured area
What complex spinal conditions might spinal pain relief be given for?
- Annular tear
- Disc prolapse
- Spinal stenosis
- Foraminal stenosis
- Spondylolisthesis
What spinal pain relief procedures are there?
- Nerve root blocks
- Facet joint injections
- Discography
How are nerve root blocks performed?
- Procedure under sedation
- Contrast media may be used to check location of needle
- Steroid injected into nerve root
How are facet joint injections performed?
- Under sedation
- Injection of steroid anti-inflammatory medication which can anaesthetise the facet joint and block the pain
- May use contrast media to check position of facet joint
How is discography performed?
- Procedure deliberately provokes the patient’s pain symptoms in order to pin point the source and level of the pain they are experiencing
- Contrast media injected into intervertebral discs
- Creates a pain road map which can be used for surgery planning
- Steroid can also be injected at end of procedure to settle pain
What is a ureteroscopy?
- An optical device is passed in a retrograde fashion through the urethra and the bladder
- The device passes directly into the ureter to inspect the lumen
- The examination can be performed with either a flexible or rigid fibre optic device
- A retrograde pyelogram may also be performed
What are the indications for ureteroscopy?
- Kidney and/or ureteric stones
- Ca kidney or ureter
- Ureteric stricture or narrowing
- Balloon dilatations of the ureter
- Insertion of ureteric stents
- Trauma to ureter
What occurs during a ureteroscopy and retrograde pyelogram?
- Guide wire inserted under fluoroscopic control
- Ureteric catheter placed over guide wire
- Guide wire removed
- Contrast media injected (retrograde pyelogram)
- identifies any stones blocking ureter
- Stones can be removed by ultrasound, laser or basket removal
What is a percutaneous nephrolithotomy (PCNL)?
- This procedure uses a needle through the skin percutaneously
- Needle travels directly into the kidney
- Used to either remove a stone – lithotomy
- Or break up the stone – lithotripsy
- Normally used for large stones, e.g. staghorn calculi
How is a PCNL prepared?
- A ureteric stent is inserted to enable blue dye to be injected into the kidney so that the radiologist/surgeon can check the exact position when they enter the kidney percutaneously
- The patient is in a prone semi-recumbent position
How is a PCNL performed?
- Cannula is place percutaneously into the kidney
- A guide wire is inserted down the kidney
- A small incision is made in the patient’s back and a tract is made into the kidney using dilators
- The final dilator is left in situ
- Through the tract a fibre optic telescope is placed in to either remove or break up the stone into small pieces using laser, ultrasound or a pneumatic device
- A nephrostomy tube will be placed post procedure to allow the kidney to drain and to heal
What is a dilatation?
- An enlargement made in a body aperture or canal for surgical or medical treatment
- Restoration to normal patency of an abnormally small body opening or passageway e.g. the anus or oesophagus
What conditions require dilatation?
- Achalasia
- Ca oesophagus
- Post oesophagectomy
- Stricture post bariatric surgery
- Peptic strictures associated with a hiatus hernia
How is an oesophageal or gastric dilatation performed?
- A guide wire is passed via endoscopy into the stomach
- The endoscope is removed with guide wire left in situ
- Dilators fed over guide wire down the oesophagus
- The guide wire and dilators are removed
- The endoscope is re-inserted to check the anatomy of the oesophagus
What is an Endoscopic Retrograde Pancreatogram (ERCP)?
A radiographic examination of the pancreatic and biliary systems following intubation of the ampulla of vater by a fibre optic endoscope and the injection of contrast media
What are the indications for an ERCP?
- Pancreatitis
- Acute cholycistitis
- Investigation of gall stones
- Ca - obstructive jaundice
- Stent insertion
- Bile leaks
- Trauma to pancreas
How is an ERCP performes?
- Endoscope is passed down the oesophagus to the second part of the duodenum to be level with the ampulla of vater
- Cannula is passed down the endoscope and positioned at the entrance to the ampulla of vater
- Contrast media is injected through the cannula into the bile and pancreatic ducts
- At this stage a decision is made as to the next form of treatment:
- A sphincterotomy can be performed to enlarge the ampulla of vater
- Gallstones can be removed
- Stents can be inserted
What is a central line used for?
- Chemotherapy treatment
- Giving antibiotics
- Giving intravenous fluids
- Taking blood samples
- Feeding (nutrients)
What is operative cholangiography?
The injection of contrast media directly into the ducts of the biliary tract during gall bladder surgery
What are the indications for operative cholangiography?
- To check for common bile duct stones
* To visualise the anatomy
What are the indications for angiography in theatre?
- Arterial stenosis
- Trauma
- After surgery
- To insert an arterial stent
- To undertake angioplasty
- To undertake embolisation
- To check anatomy
- EVAR - Endovascular aneurysm repair (or endovascular aortic repair)
