Professional Documents
Culture Documents
Prior to opening the first case of the day, flat surfaces and
overhead lights are cleaned with a damp cloth moistened with a
hospital grade or high level disinfectant.
Both the scrub nurse and circulating nurse assist with opening the
sterile supplies needed for the surgical procedure. Some hospitals
have a set routine on where supplies are opened in the room, for
example, the suture on the left side of the back table and the linen
on the right side. Also unsterile equipment must be obtained.
Teamwork is of utmost importance now, and through out the
surgical procedure. Supplies and equipment should be obtained at
this time because once the patient enters the room, the circulator's
attention must be directed toward the patient.
The scrub nurse opens his/her gown and gloves last, preferably on
a separate field and proceeds to perform the surgical scrub.
Ideally, someone should stay in the room to maintain vigilance
over the sterile field.
Surgery - pt. 2
Surgery - pt. 3
The lights are then moved into position over the operative field by
the circulator.
Surgery - pt. 4
Surgery - pt. 5
When the surgery is ready to begin, the scrub nurse passes the
skin knife to the surgeon. The skin knife is usually the #20 knife
blade attached to the #4 knife handle. The surgeon and first
assistant hold the skin taut as the incision is made.
After several additional knots are tied, the first assistant will cut
the suture. Vicryl is a multifilament suture material and should be
cut on the knot. Plain is monofilament and may come untied, so a
3 millimeter tail is left on the suture.
If the surgeon uses the ESU, the hemostat is held away from the
skin edges. The hemostat is touched by the activate electrode and
at the surgeon's request is removed by the first assistant. Care
must be taken, by the first assistant, to activate the coagulation
button on the active electrode instead of the cutting button.
Surgery - pt. 7
Surgery - pt. 8
While the surgeon and the first assistant elevate the peritoneum
with their fingers, the surgeon extends the incision with the
metzenbaum scissors. In preparation for entering the peritoneum,
the scrub nurse moistens two lap pads with saline and prepares a
large self retaining retractor such as the Balfour. From this point,
small sponges, if used, must be mounted on an instrument.
With the peritoneal incision complete, the surgeon is now able to
visualize the abdominal contents. Usually most surgeons will
perform a manual examination of the abdominal cavity to check
for abnormalities. At the completion of this exam, the surgeon is
ready to perform the proposed operative procedure.
The first assistant also keeps the wound free from blood and other
body fluids by using the suction and lap sponges. An expanded
role of the first assistant would include maintaining hemostasis by
clamping bleeders or using the ESU to coagulate bleeders.
Surgery - pt. 9
The first assistant must also be ready to cut the suture or "tag" it
with a hemostat at the appropriate time.
The surgeon may ask the first assistant to "flash" a clamp. This
technique requires releasing the clamp slowly and just enough for
the surgeon to get the suture around the tissue. The clamp is then
closed while the surgeon ties the suture around the clamp.
With additional training, the first assistant role may include the
manipulation and suturing of tissue.
The scrub nurse assists by observing the operative procedure and
passing the appropriate instruments to the surgeon and first
assistant. The general rule for passing instruments is to pass in a
firm manner in the direction of use. The surgeon should not have
to readjust an instrument once it is in his/her hand. Always pass
the curve of the instrument toward the surgeon's other hand.
The surgeon will then cut in between the two clamps with
scissors. For delicate tissues such as blood vessels, ovaries, and
intestines, metzenbaum scissors are used. For tougher tissue such
as the muscle, uterus, or breast, the curved mayo scissors will be
used.
The surgeon will then tie what was cut using the appropriate
suture , frequently on a ligating reel.
If the surgeon nicks the scrub nurse's glove with a needle, tell
him/her before they pass the needle through the patient's tissues.
The needle should be discarded from the sterile field. The
circulating nurse will retain the needle for the final count. The
scrub nurse will turn away from the field and the circulating nurse
will remove his/her contaminated glove. A new glove is donned
using the open method of gloving. Remember, the closed method
of gloving can not be used once the hand has passed through the
cuff.
The scrub nurse needs to keep clean lap pads on the field at all
times. He/she should discard used sponges in the kick bucket as
necessary. Small sponges such as peanuts or probangs should
remain on the field to avoid loss.
The circulating nurse should retrieve the used sponges from the
kick bucket by using a sponge stick or his/her gloved hand. The
used sponges should be placed in a clear sponge counting bag..
The anesthesia personnel and the surgeon will need to view the
sponges to determine the patient's estimated blood loss (EBL).
Surgery - pt. 12
This is the hand signal for the knife or scalpel. The scrub
nurse passes this with the blade down and the handle pointed
toward the surgeon. Care must be taken to avoid injury
when passing the scalpel. A "no pass" zone should be
established on the field.
Surgery - pt. 13
This is the hand signal for forceps. Pick ups with teeth are used on
tougher tissue and smooth forceps are used in delicate areas.
This is the signal for a suture on a needle. The surgeon will make
a fist and simulate the motion used when suturing. Suture is
passed with the needle pointing toward the surgeon's chin.
This is the hand signal for a free tie. The scrub nurse grasps the
strand of suture by its ends and places the suture in the surgeon's
palm.
Other general duties while scrubbed include keeping the field clear
of instruments. If instruments are extremely bloody, they should
be wiped with a sponge moistened with sterile water. Saline
should never be used to clean instruments as it could cause rust to
form on the instrument.
The overhead lights may need to be readjusted during the case.
The scrub nurse uses the sterile light handle for this maneuver.
Surgery - pt. 14
Surgery - pt. 16
The next layer is the muscle. Suture, when placed in this layer, is
usually of the same material used on the peritoneum. Most
surgeons choose not to close this layer.
Following the muscle is the fascial layer, which is the toughest
layer that prevents a hernia from occurring. Suture for this layer
varies greatly from a 0 to 2-0 nonabsorbable such as Surgilon
using an interrupted stitch, to 0 to 1 Prolene using a continuous
stitch. If an interrupted suturing technique is used, the scrub nurse
must prepare these sutures rapidly and keep an accurate count of
the many needles.
Interrupted suture may be tied after each stitch but cut all at the
same time. A short pair of tissue forceps with teeth is used on this
layer and medium needle holders are used.
Surgery - pt. 17
The skin is the next layer. Suture technique in skin closure varies
greatly among surgeons. A nonabsorbable monofilament suture
on a curved cutting or straight keith needle, size 3-0 or 4-0
Prolene or Ethilon may be used. The curved cutting needle is
placed on a short needle holder and the keith needle is held by
hand. A subcuticular stitch using an absorbable suture may also
be used. Special adson or dura forceps are used during skin
closure. The retention sutures are now tied.
Some surgeons prefer to close the skin using skin staples. The
surgeon usually uses two adson forceps to evert the skin edges
while the skin staples are applied by the first assistant.
Surgery - pt. 18
Following skin closure, the surgeon will want a wet lap pad to
cleanse the skin and then a dry one. Note a penrose drain has been
inserted through a separate stab wound.
The surgeon is now ready for the dressing. If drainage is
expected, a bulky dressing such as an ABD pad may be applied
after the gauze sponges.
The operation is now complete. The scrub nurse pushes the mayo
stand away from the table. In many hospitals, it is policy to keep
the mayo stand sterile until the patient leaves the room. This
facilitates reopening of the wound in case of an emergency.
The scrub nurse checks the drapes for stray instruments and rolls
the drapes off of the field. The circulating nurse tapes the dressing
in place.
Surgery - pt. 19
Surgery - pt. 20