VATS NOTES FROM KRISTEN MEYER Flashcards
requires a division of one or more major chest wall muscles, along with spreading of ribs. Since ribs have limited flexibility, retractors use to spread ribs often result in fractures; depending on the surgical necessity of a wide versus narrow interspace between ribs, a rib may be entirely removed by the surgeon.
Thoracotomy
Due to the muscle division and potential bone fractures, duration and intensity of recovery is a concern…. this allows the surgeon to avoid both muscle division and bone fractures. “Port sites” are created, and a lighted camera (either a 5mm 30 degree, or a 10mm 30 degree) scope is inserted into the port, allowing visualization of both the anatomy and the surgical instruments used while operating.
VATS, or Video-assisted thoracoscopic surgery
Recovery time is significantly reduced, and since the incision is much less invasive, risk of infection or dehiscence is lower.
Vats
Biopsies are performed for diagnosis of pulmonary, pleural, or mediastinal pathology. Additional items to consider having in the room would include:
TRUECUT
TELFA
SCANLAN MEDIASTINOSCOPY FORCEPS
is performed to essentially remove offending tissue. To do this, the nodule is located, and lifted with a grasper. At this point, a Scanlan clamp is placed beneath the nodule (with a wide margin), and a stapler is passed below the clamp. Often, the surgeon will take a culture of the offending tissue. The remaining tissue will be sent to pathology as a “frozen section,” and the results will be read into the room in roughly 15-20 minutes. As a general rule, if the frozen results come back definitive (positive), the culture will not be sent. Verify with your surgeon before discarding the culture.
A wedge
for the scrub nurse purpose, can be viewed as a “large wedge.” The same procedure is followed.
A segment,
is performed to essentially remove offending tissue. To do this, the nodule is located, and lifted with a grasper. At this point, a Scanlan clamp is placed beneath the nodule (with a wide margin), and a stapler is passed below the clamp. Often, the surgeon will take a culture of the offending tissue. The remaining tissue will be sent to pathology as a “frozen section,” and the results will be read into the room in roughly 15-20 minutes. As a general rule, if the frozen results come back definitive (positive), the culture will not be sent. Verify with your surgeon before discarding the culture.
wedge
specimen containers needed for wedge
SPECIMEN CUP AND CULTURE TUBE
results of frozen specimen will be read into the room
15-20 mins
can be viewed as a “large wedge.” The same procedure is followed.
Segment
Removing an entire lobe is a bit more involved. During a wedge, the lung being removed isn’t actually attached to anything (typically). This means it can be simply located and stapled out. In a lobe, there are three structures to locate, dissect, and staple: the pulmonary artery, pulmonary vein, and bronchus.
Lobectomy
In lobectomy, Once these three structures are separated, the —- will then be divided, and your lobe is free.
fissure
Since the tissue being removed is larger, a —- may be employed to remove it safely from the chest. Since lung surgery is generally highly suspicious for cancer cells, care is taken to remove spreading the cells around the body more than is necessary. Use of which ensures the tissue remains contained.
bag
complete removal of an entire lung.
Pneumonectomy
The same structures are required to be separated as with a lobe, there’s just more points of attachment. Additionally, the fissure need not be separated since the entire lung can come out together. A very large bag (“parachute,” “vinyl,” or “anchor” depending on your surgeon) will be used to remove the lung from the chest. It may become necessary to extent the incision beyond what was used during surgery to remove all of the tissue safely.
pneumonectomy
bag for pneumonectomy
(“parachute,” “vinyl,” or “anchor” depending on your surgeon)
—- simply means removal of lymph nodes. Often, when viewed on a consent or posting, some nurses become confused as to whether or not it’s a VATS or a mediastinoscopy; if there’s no “oscopy” on the consent or posting, all lymph nodes will be removed by the VATS approach. This is generally in conjunction with another VATS procedure, such as a wedge or lobe.
Mediastinal lymphadenectomy
are performed for empyema, or a collection of pus in the pleural cavity. Items to have available would include: culture tube, luki trap, specimen cup, extra sponge balls, and antibiotic irrigation.
Decortication
can be performed for recurrent pleural effusions or spontaneous pneumothorax. There are two types: mechanical and chemical. Both involve irritating the lining of the chest wall. Mechanical pleurodesis is performed by rubbing a scratch pad against the chest wall. Chemical can be performed through the introduction of either Talc (which comes in your med box) or Doxycycline (which needs to be picked up from the pharmacy). The medication will be introduced into the thoracic space using a red rubber and a dry asepto. If you already wet the asepto that came in your pack, you’ll need a new one from your circulator. For Doxycycline, just load into the asepto, place the red rubber on the end, and hand to the surgeon with a grasper with teeth. For talc, you’ll need a warm wet lap to place over the wound protector to ensure the powder doesn’t spray back out. Some surgeons prefer to cut extra holes in the end of the red rubber; verify with them prior to cutting. In the event that you perform a chemical pleurodesis, clamp the chest tube with a Kelly as soon as it’s sewn in; remove it before the patient leaves the room. This prevents the chest tube from immediately removing the agent you just introduced into the chest.
Pleurodesis
There are two types: Both involve irritating the lining of the chest wall. —-l pleurodesis is performed by rubbing a scratch pad against the chest wall. —- can be performed through the introduction of either Talc (which comes in your med box) or Doxycycline (which needs to be picked up from the pharmacy). The medication will be introduced into the thoracic space using a red rubber and a dry asepto. If you already wet the asepto that came in your pack, you’ll need a new one from your circulator. For Doxycycline, just load into the asepto, place the red rubber on the end, and hand to the surgeon with a grasper with teeth. For talc, you’ll need a warm wet lap to place over the wound protector to ensure the powder doesn’t spray back out. Some surgeons prefer to cut extra holes in the end of the red rubber; verify with them prior to cutting. In the event that you perform a chemical pleurodesis, clamp the chest tube with a Kelly as soon as it’s sewn in; remove it before the patient leaves the room. This prevents the chest tube from immediately removing the agent you just introduced into the chest.
mechanical, chemical
BASIN SETUP
CHEST BREAST DRAPE
LIGHT HANDLES
IOBAN
TOWELS
(CLIT!!!)
small items setup
Now that your basin set is on the table, you can place your small items in it. The laps go in the back of the square basin, the labels to the right side, the sponge balls, bovie scratch pad, and suture (not pictured) go in the little middle cups. Your needle box and pen can go in front of the basin set. It looks like this.
Your suction tubing, yankauer, and bovie will go to the far left back corner. Your table will look like this, and you are now ready to take instruments from your circulator.
scanlan setup
You are now ready to arrange your Scanlans. You’ll need to make a small roll, and place it to the left of your square basin. Arrange them in a way that you are comfortable with; the same way every time is preferable. The ones below are arranged in the following order: (one tonsil for port placement), Lymph node grasper, Medium faced long curved empty, Long curved empty, Dissector, Scanlan Clamp, Lung clamps x 2, Scanlan allis, Harken 2, Harken 1, Scanlan long right angle, and finally, your Scanlan scissors from the Thoracoscopy tray. On the far left sits the regular long curved empty from Chest A, and the same item (regular long curved empty) from the Thoracoscopy tray. Always have a regular long curved empty with a sponge loaded on your field. It is used to tamponade any unexpected bleeding, and will be the first item used in such an event.
FULL THROACOSCOPY SETUP
Your completed table will look like this. On the far left on the side closest to you, you will place your camera and light cord. Verify your scope size with the surgeon, and have your circulator open gloves after verifying latex status with the patient. You are now ready to break scrub and assist with positioning.
This is a universal stapler handle. It’s used to staple lung, and it was designed to replace hand sewing, although you may do this in addition to stapling (rarely) for repairs. It allows the surgeon to both staple and cut at the same time. You’ll need to open “loads”, or the actual staple in addition to the handle.
This is Chest B. It looks overwhelming at first, but it’s not too bad once you break it down into sections based on function. To count, there’s no stringer so there’s no real order. Be patient with your circulator since there isn’t an order, and call out items as you see them and move through the set. In an emergency, pull out the items you’ll need first (tuffier, sembs, elevator, balfour) and count the rest as you go.
FINOCHIETTO
When you count, note the screw on the left hand side. Also, make sure it isn’t loose, or it’ll fall apart when you hand it to the surgeon.
When you count, count the wingnut on handle and the four blades. It comes with four blades: two short and two long. Since the majority of the time you’ll use the short blades, go ahead and load these. It’ll look like this loaded.
On the top there is a narrow and wide malleable. Beneath those, there is a “pancake.” These two items are infrequently used. On the bottom left there are two sembs, which are used in every thoracotomy. The middle bottom is a scapula retractor, which is used with a fair amount of frequency. Finally, the bottom right shows an Allison retractor, also called a “whisk.” It is used to retract lung.
“rib stripper” section. These instruments are used to strip the muscle from the rib in preparation of cutting.
rib cutters.
there are two “etc” items that don’t fit a category.:
