Test 2 Flashcards
back table
- Most important piece of furniture
- some pricedures have 2
mayo stand
- to raise up: just pull, to lower: push pedal with foot
ring stand
- for basin sets (round or square)
Prep Table
- multiple in room
Step
- for shorties
- no more than 2 stools stacked
Kick Bucket
- put sponges in (countable)(try to only use for sponges)
OR Table
- has floor locks
- make sure this is locked when the patient is on
IV Pole
- A drape goes over patient’s head and is clipped to 2 IV poles
Surgical Lights
- vary on how many are in OR.
- if only one, can cast shadows
Video Tower
- endoscopic procedures
Trash/Linen Container
- will have a linen and a trash with different color bags
Electrocautery Unit: BOVIE
- use these in most cases (but not every)
Suction
May have single canister or multiple
- Neptune suction holds 30L
- has filter and docking station that pulls detergent in and goes out a drain
- Carousel- puts a type of powder inside to isolize, treat blood and creates a gel
Anesthesia Machine
Anesthesia Cart
- for their supplies
Sharps container
- No digging!
Count Board
- dry erase board
- not a legal document, just a visual
- will have
- KBs=
- Bovie tips=
- Needles=
- Raytecs=
- Laps=
- Hypos=
- Extras=
Rolling Stool
- some cases we do sit (hand/foot cases)
- should be hydrolic foot pedal
Fire extinguisher
- In each OR, department, and hallways
- PASS
- Pull
- Aim
- Squeeze
- Sweep
When setting up, your sterile field should be
away from the door
Unrestricted
- Street clothes (doesn’t matter what you’re wearing)
- no concerns about hair covering
- masks are not needed
- locations
- cafeteria
- OR lounge
- entering/exiting the facility
- OR board
- If coming from OR remove mask, hat, shoe covers when entering these areas.
Semi-Restricted
- OR department
- can often times enter certain areas like lounge and board as unrestricted
- delineated apart from unrestricted by a RED LINE (most of the time)
-
Scrubs
- usually hospital owned
- May be required to wear a “bunny suit”
-
hair covering is required
- hair completely covered
Restricted
- Scrubs must be worn
- hair cover and mask are required
- if in the sterile role, must be properly attired
- operating rooms
- sub-sterile areas (sterile supplies & autoclave)
- goggles are not required for unsterile role just a good idea to protect yourself
- If something happens OSHA will ask “did you have all PPE on?”
Sterile team members attire
- Sterile team members have additional requirements:
- Protective eyewear that wraps around eyes
- no jewelry
- no undershirts with sleeves which go beyond scrub sleeves
- makeup to a minimum
- facial hair trimmed very close to face
- hair must be completely contained
- no perfume/aftershave
- fingernails must be kept trimmed
- no nail polish, gel, or artificial nails
Once scrubbed we don sterile gowns and gloves
Other rules for ACC students
- keep tattoos covered
- no jewlry
- hair is natural color
- no cell phones
PPE…
MUST BE WORN
- goggles
- double gloves when scrubbed
- lead gown when in a case in which radiation will be used
- need to be turned toward the source of radiation when in lead gown or you are getting a double dose
- special laser masks
- laser goggles
- TB mask (duck mask)
Some cases require more PPE
- “space suits” some orthopedic cases
- should put shoe covers on if using same pair of shoes for regular use or have surgery shoes
About how many instruments does a major set have?
100
Order of hemostats from smallest to biggest
- Crile
- Kelly
- Rocjester-Pean
How does this principle of aseptic technique apply to opening?
Only sterile items are used within a sterile field
- need to inspect packaging
- don’t contaminate item coming out of the package
- you can contaminate only part of the feild
How does this principle of aseptic technique apply to opening?
Sterile persons are gowned and gloved
we are unsterile while opening
How does this principle of aseptic technique apply to opening?
Draped tables are sterile only at table level
- while draping table, may not be totallly even but we need to leave it for sterile reasons
- if something ends up over table, it is not sterile and we can’t fix it from unsterile (because of the 1 foot min. rule)
How does this principle of aseptic technique apply to opening?
Sterile persons touch only sterile items or areas, while unsterile persons touch only unsterile items or areas
- ask yourself: Am I sterile? Is it sterile?
How does this principle of aseptic technique apply to opening?
Unsterile persons avoid reaching over the sterile field, while sterile persons avoid leaning over an unsterile area
- an example would be heavy/ expensive items need to wait
- open package away from you
- order: away, side, side, front
How does this principle of aseptic technique apply to opening?
The edges of anything that encloses sterile contents are considered unsterile
- think about 1” rule from where item is exposed
How does this principle of aseptic technique apply to opening?
The sterile field is created as close as possible to its time of use
we open around 30 minutes before but that may vary greatly
How does this principle of aseptic technique apply to opening?
Sterile areas are kept continuously in view
- once we open we create sterile field and need to watch for flies, humans, etc.
How does this principle of aseptic technique apply to opening?
Unsterile persons must avoid sterile areas
- really applies to opening
- don’t ever go between 2 sterile feilds
- ex: mayo stand and back table
- you can move the furniture
- face sterile feild
- pack on back table always opened first
How does this principle of aseptic technique apply to opening?
Destruction of the integrity of microbial barries results in contamination
you are responsible for your packaging
How does this principle of aseptic technique apply to opening?
Articles of doubtful sterility must be discarded
- don’t risk it
- when in doubt, thow it out
Abdominal Cavity
- Largest cavity in the body
- Can be artificially divided into:
- 2 areas
- 4 quadrants
- 9 regions
2 areas of the abdominal cavity
- Abdomen proper
- Pelvis
*usually call the whole thing abdomen
Quadrants
- Right upper
- bulk of the liver and the entire gallbladder
- hepatic flexure of colon
- Left upper
- most of pancreas and stomach, entire spleen
- spenic flexure of colon
- Right lower
- cecum, appendix (usually)
- Left lower
Regions
*know where they are*
- Right Hypochondric
- Epigastric
- Left Hypochondriac
- Right Lumbar
- Umbilical
- Left Lumbar
- Right Iliac
- Hypogastric
- Left Iliac
Layers of abdomen:
- Skin
- Subcutaneous/hypodermic
- Anterior fascia
- Muscle
- Posterior fascia
- Parietal Peritoneum
- Visceral Peritoneum
Skin
- Serves as a waterproof barrier from the external environment and pathogens
- First line of defense
- two main layers (has many layers)
- Epidermis (above dermis)
- Dermis (houses basil which is alive)
Subcutaneous layer
- A variable thickness layer composed of adipose tissue
- Since fat dows not heal, surgeons will close a thick subcutaneous layer to limit fluid accumulation and infections in this layer
- will create a dead space if not closed
Fascia and Muscles
- for any given muscle or muscle group, there will be a “covering” of fascia which wraps it (or, an anterior and a posterior layer of fascia) these layers are continuous with each other
- fascia is a dense fibrous connective tissue which gives strenth and pulling power to muscles and muscle groups
Aponeurosis
- Where fascia extends beyond muscles to form a dense, tendonlike structure which anchors muscles to bone, cartilage, or soft tissues such as other muscle/fascia groups (how it gets its pulling power)
Lateral abdominal muscles
- each of these exist as muscle on the right and left side of the body. At midline, muscles are absent but their fascia’s aponeuroses are present.
- In order from suface to deep
- External Oblique Muscle
- Internal Oblique Muscle
- Transversus abdominus muscle
External Oblique Muscle
- Largest and most superficial of three lateral abdominal muscles
- fibers run medially and inferiorly (hands in pockets)
Internal Oblique Muscle
- underlies external oblique muscle
- fibers fun opposite external oblique, superio and lateral
- forms an X
Transversus abdominus
- Deepest of lateral three muscles
- fibers run transversley (horozontily)
- forms a girdle around sides at waist
Medial abdominal muscles
- paired rectus abdominus (right and left)
- thicker than lateral three muscles
Rectus abdominus muscles
- extend from pubis to ribs/sternum
- only medial muscles of the abdominal wall
- fibers fun longitudinally
- six pack
- needs reinforcement
- wall with raphes to hold ogans in
Fascia of the abdomen
- the lateral three abdominal muscles’ fascia all merge to become a very dense aponeurosis medial to the muscles
- these aponeuroses comprise three structures:
- rectus sheath
- linea alba
- raphes of the “six pack”
linea alba
- the “white line” divides right and left rectus muscles. so at midline, there is no muscle present, only a very thick aponeurosis
Surgical notes on muscle
- skeletal or voluntary muscle in excitable therefore if not paralyzed it will twitch when touched with bovie
- muscle always heals fastest when divided in the direction of its fibers
- generally the term closing fascia means closing posterior fascia, muscle, and anterior fascia as one layer
Peritoneum
- serous membrance of the abdomen (double layer)
- parietal portion is breached in surgery
- visceral portion is outer layer of abominal organs and other structures
- visceral and parietal are continuous with each other
- visceral peritoneum is very complex (carries own nerve supply) and folds upon itself to make many different structures
Notable structures of visceral pertoneum
- the omenta
- greater (bigger)
- lesser
- mesentary
Greater omentum
immediately viewable on entering abdominal cavity, impregnated with fat and hangs from greater survature of stomach to protect most intestines
Lesser omentum
located superior to greater omentum, attaches to liver and lesser curvature of stomach
Mesentary
- when the word “mesentary” is used in the OR, it is usaully in reference to the “webbing” between coils of intestine
The GI tract
(alimentary canal)
- donut analogy
- hole-unsterile (unsterile mouth to anus)
- bread of donut-sterile
- consists of esophagus, stomach, small intestine, large intesting, rectum
- 4 layers
- mucosa
- submucosa
- muscularis- smooth muscle except for esophagus
- Serosa-viceral peritoneum
Esophagus
- leaves thoracic cavity at the esophageal hiatus of the diaphram
- joins stomach at the cardiac orifice aka: gastroesophogeal junction, formally called cardiac sphincter
- abrasion resistant
- muscularis is made of skeletal muscle in its superior third to allow for voluntary swallowing
Stomach
- Primary function: digestion of food
- protection against acids
- muscularis has an extra layer
- when stomach empty, mucosa and submucosa form folds called rugae
Stomach regions
- cardiac region
- fundus (part of cardiac region)
- body
- pyloric region
- pyloric antrum
- pyloric canal
- pyloric sphincter (true sphincter before it heads to duodenum)
- greater curvature
- lesser curvature
The small intestine
- primary function: absorption of nutrients
- divisions in order:
- Duodenum
- Jejunum
- Ileum
Duodenum
- shortest segment of the samll intestine (25cm long)
- performs the majority of absorption in small intestine
Jejunum
- mid section of the small intestine
- about 2.5m long
- in some people may contain Mechel’s diverticulum
Meckel’s diverticulum
- most common anomaly of the GI tract
- may become inflamed like appendix
-
Rule of 2’s
- 2% of population
- 2 feet proximal to ileocecal valve
- 2 inches in length
- 2% are symptomatic
- 2 years: common age of symptomatic patients
- Boys are 2X more likely to present than girls
Ileum
- terminal section of small intestine
- about 3.6m long
- joins large intestine at ileocecal valve
The large intestine
- primary function: reabsorb water as it stores, packages, and eliminates waste
- colon
- distinct feature: haustra
- proximal end: cecum, at posteriomedial surface is usually the vermiform appendix
Divisions of the Large intestine
- Ascending colon
- hepatic flexure
- Transverse colon
- splenic fexure
- Descending colon
- Sigmoid colon
- Rectum
The liver
- largest gland in the body
- performs many funtions: excretory, metabolic, regulatory, storage, synthesis, removal/detox
- 2 lobes visible anteriorly: R or L
- dual blood supply
- connected to gallbladder and pancreas via bile ducts
The gallbladder
- Primary function: to store and concentrate bile that the liver makes
- lies in a declivity on posterior aspect of liver called the gallbladder fossa
Pancreas
- Endocrine function: works with liver to create homestatic blood sugar levels
- Exocrine function: produces digestive enzymes and juices
- “wrapped” by duodenum
Spleen
- sits posterior/lateral to sotmach
- in Left Upper Quadrant
- stores about a cup of blood products
- 4 main functions
- site for immune proliferation, surveillance and response
- stores breakdown products of RBCs
- RBC production in the fetus
- Platelet storage
Kidneys
- Primary function: filter blood
- Located retroperitoneally, needs more cushioning than other organs of the abdomen (sits outside the peritoneal cavity
Ureters
cross from abdomen proper into pelvis, eventually leading to the bladder
the adrenal/suprarenal glands
- sit atop kidneys and share some of their cushioning layer
- Primary function: to produce and excrete corticosteroids and catecholemines
Factors influencing type of incision to make
- ease and speed of entry
- maximum exposure
- minimum trauma
- least postoperative discomfort to the patient
- maximum postoperative wound strength
3 methods of breaching muscle
- Cut- incise across direction of muscle fibers; most traumatic
- Split- make opening by separating the muscle in the direction of its fibers
- Retract- at midline only, an incision can be made in linea alba and muscles are retracted laterally
Longitudinal midline incision
- simplest to perform
- easiest & fastest–Trauma
- offers good exposure
- from sternal notch to symphisis pubis, laterally around umbilicus
- follows linea alba
- not a strong incision; wound dehiscence (fall apart) is high
Uses for longitudinal midline
- emergency laparotomy
- colon resections, small bowel, colostomy, AAA (abdominal aortic anurism)
- Proximal: bleeding ulcers, gastrectomy, upper quad organs
- Distal: Pelvic surgery, bladder, prostate, ect.
Paramedian incision
- another vertical incision
- about 4cm lateral to midline on right or left side
- rectus is either split vertically or retracted laterally
- good exposure to organs in that quadrant
- limits trauma, avoids nerve injury, easily extended, results in firm closure
Uses for paramedian incision
- pancreatic procedures or (more rare) biliary tract in upper right quadrant, sigmoid colon in lower left
- don’t use very often
Umbilical Incision
- AKA subumbilical incision
- a curvilinear incision just below the umbilicus
- previously used for umbilical hernias only, a smaller version of this incision is used for Hassan Trocar Placement
Mc Burney’s point
- (oblique)
- 2/3 of distance from umbilicus to anterior iliac spine in R lower quadrant or
- about 2 fingerwidths medial to inguinal crease
Mc Burney’s incision
- 8 cm, oblique (angled), muscle splitting incision
- goes through Mc Burney’s point and extends laterally and superiorly towards right flank
- changes direction to split the “lateral three” muscles
- not a whole lot of vision
- almost always perfomed on right side for appendix (open appendectomy)
- “one hit wonder”
Inguinal incision
- inguinal crease
- on right or left side
Uses for inguinal incision
- Primarily: inguinal herniorraphy (males)
- Also used for: femoral hernia (females), varicocelectomy, hydrocelectomy–men, orchiectomy (cancer)
Subcostal incision
- oblique incision that can be made on the right or left side
- at muscle layer, the external oblique is cut, the internal oblique and rectus may be divided or retracted
- limited exposure
- strong closure
- good cosmetic result
- very painful post-op to patient
- decreased in use since the advent of laproscopic colocystectomy (gallbladder removal)
Subcostal Modification
- chevron: usually for liver transplant or resection
- uses for single sides subsotal incision: open gallbladder or other biliary tract, splenectomy
Pfannensteil Incision
- a curved transverse incision across the lower abdomen made approximately 1.5 inches above the symphysis pubis
- skin, subcutaneous fat, and rectus sheath are all incised transversley
- incision then changes direction, as rectus muscle is split longitudinally. posterior fascia and pertioneum are breached longitudinally
- provides good exposure to pelvic cavity and good stong closure as well as good cosmetic result
- Uses: all types of pelvic surgery, ex: C-section, TAH, open bladder surgery
- bladder has to be retracted to get to uterus in C section
