ABDOMINAL ORGANS

ORGANS
Appendix

SIZE
The appendix
averages
11 cm in
length but can
range from 2
to 20 cm. The
diameter of the
appendix is
usually
between 7 and
8 mm.

SHAPE
Wormshaped

Stomach

About 12
inches (30.5
cm) long and is
6 inches. (15.2
cm) wide at its
widest point.
Average length
of the small
intestine in an
adult human
male is 22 feet
6 inches (6.9

Saclike
shape; Cshaped

Located between
the esophagus and
the small intestine

fan shape

located in between
the pyloric sphincter
(that is part of the
stomach) and the
ileocecal valve
(which is part of the

Small
Intestine

LOCATION
Located in the right
lower quadrant of
the abdomen, near
the right hip bone.,

FUNCTION
May harbour and
protect bacteria t
hat are beneficial
in the function of
the human colon;
rich in infectionfighting lymphoid
cells, suggesting
that it might play
a role in
the immune
system
It secretes
protein-digesting
enzymes and
strong acids to
aid in food
digestion
where the most
extensive part of
digestion occurs.
Most food
products are
absorbed in the

Large
Intestine

m), and in the

adult female
23 feet 4
inches (7.1 m);
approximately
2.53 cm in
diameter.
About 4.9 feet
(1.5 m) long,
which is about
one-fifth of the
whole length of
the intestinal
canal.

just a
long
intestine
thats its
just
squashed
in your
lower
body

Liver

Human liver
normally
weighs 1.44
1.66 kg (3.2
3.7 lb)

Unequal
shape;
triangle

Gallbladd
er

Adult: 8
centimetres
(3.1 in) in
length and 4
centimetres
(1.6 in) in
diameter

Small
pearshaped

Pancreas

About 7 inches
(17.8 cm) long
and 1.5 inches.
(3.8 cm) wide

Coneshaped
spongy
organ

large intestine)

small intestine.

Large intestine
begins where
the small intestine
ends. It goes all the
way, on the right
side of the body,
until the liver. It
then traverses
through the
abdomen, and goes
down to the anus
where it ends.
Located in the right
upper quadrant of
the abdominal
cavity, resting just
below
the diaphragm
Sits just beneath
the liver

Responsible for
absorption of
water and
excretion of solid
waste material

Lies in
the epigastrium and
left hypochondrium
areas of the abdome

Secretes digestive
enzymes (internal
secretions) and
hormones
(external
secretions);
produces the
body's most
important
enzymes, The
enzymes are

Detoxification, pro
tein synthesis,
and production of
biochemicals
necessary
for digestion
Aids mainly in
fat digestion and
concentrates bile
produced by
the liver.

designed to
digest foods and
break down
starches

BONES
Bones are calcified connective tissue
forming the major portion of the skeleton of
most vertebrates. There are about 206
bones in your body. Bones contain
more calcium than any other organ. A good
source of calcium can be found in
milk, yogurt, eggs, nuts and whole grains.
Bones begin to develop before birth. When
the skeleton first forms, it is made of
flexible cartilage, but within a few weeks it
begins
the
process
of
ossification.
Ossification is a process where cartilage is
replaced by hard deposits of calcium
phosphate and stretchy collagen. It takes
about 20 years for ossification to be
completed.
Bones are made of two types of tissue:
1.

Spongy inner layer called cancellous

bone. Spongy bone is lighter and less dense than compact bone.
2.
Hard outer layer called cortical (compact) bone.
Bones can be donated and transplanted.
Function of bones
The major functions of bones are:

provide a strong barrier that protects the inner organs

support your body against the constant pull of gravity
produce blood cells (the marrow inside of bones produce blood cells)
allow you to move
store important minerals
TYPES

There are five types of bones in the human body: long, short, flat, irregular, and
sesamoid.

Long bones are characterized by a shaft, the diaphysis, that is much longer
than it is wide. They are made up mostly of compact bone, with lesser amounts
of marrow, located within the medullary cavity, and spongy bone. Most bones of
the limbs, including those of the fingers and toes, are long bones. The exceptions
are those of the wrist, ankle and kneecap.

Short bones are roughly cube-shaped, and have only a thin layer of compact
bone surrounding a spongy interior. The bones of the wrist and ankle are short
bones, as are the sesamoid bones.

Flat bones are thin and generally curved, with two parallel layers of compact
bones sandwiching a layer of spongy bone. Most of the bones of the skull are flat
bones, as is the sternum.

Irregular bones do not fit into the above categories. They consist of thin layers
of compact bone surrounding a spongy interior. As implied by the name, their
shapes are irregular and complicated. The bones of the spine and hips are irregular
bones.

Sesamoid bones are bones embedded in tendons. Since they act to hold the
tendon further away from the joint, the angle of the tendon is increased and thus
the leverage of the muscle is increased. Examples of sesamoid bones are the patella
and the pisiform.

TYPES OF SUTURES

SUTURES
Definition:

A suture is a
piece
of
thread-like
material used to
stitch
or
approximate
tissues, and hold the wound together
until healing takes place.

any strand of material used to ligate

bleeders or used to approximate tissue.

any materials used to sew, sick or

hold tissue together until healing process
occurs.
Purpose of Suture:

to hold a wound together in good

apposition until such time as the natural
healing process is sufficiently well
established to make the support from the
suture
material
unnecessary
and
redundant.
Ligature or Tie refers to a suture material
that is tied around a blood vessel to occlude
the lumen.
Two types of ligature or tie:
1.
Free tie is a stand of material that
is handed or given the surgeon or
assistant to ligate a vessel. This stand is
not threaded on a needle.
2.
Stick tie or suture ligature the
suture material is threaded either on a
needle holder or on a right angle clamp
before occluding a deep or large vessel.
Atraumatic Suture a suture material
prepared or manufactured with a needle
attached to it. It is referred to as an eyeless
needle or atraloc-swage on needle.
Strand suture material prepared or
manufactured without a needle attached to
it.
Continuous Suture a suturing technique
wherein a surgeon start suturing at one
point and ends at the other point without
cutting the suture material. This may be
referred to as a running stitch and also used
to close the peritoneum and vessels
because it provide a leakproof suture line.
Interrupted Suture the suture is taken,
tied and out separately. This technique is
time consuming.
Subcuticular Suture a continuous suture
is placed beneath epithelial layer of skin in
short lateral stitches. It leaves a minimal
scar formation.
Buried Suture a suture placed under the
skin, buried either continuous or interrupted
suture.
Burse String or Inverting Stitch a
continuous suture is used as a draw string
method to invert the loose ends or edges of
tissue and tied the close the lumen. (for
example, stamp of the appendix.)

Traction Suture
tissue out of the way

is used to hold
during
the
operation.

Classification
Suture

of

Material:
1. Absorbable Suture. An absorbable
suture is made from material that can be
absorbed (digested) by body cells and
fluids. Rate of absorption depends on
various factors, including type of body
tissue, nutritional status of the patient, and
the presence of infection. Absorbable suture
is available prepackaged and presterilized
in various sizes graded by diameter and
length. Sizes range from number 12-0,
which is the finest, to number 5, which is the
heaviest. The length ranges from 12 to 60
inches.
a.Plain gut. Plain indicates a surgical gut
material that has not been treated to
lengthen its absorption time
in the tissue. This suture is absorbed more
rapidly than treated suture.
b. Chromic gut. Chromic surgical gut has
been treated with chromic oxide so that it
will delay its rate of digestion
or absorption.

c. Synthetic Absorbable Sutures

i. Polyglactin 910 (Vicryl).
ii. Polyglycolic Acid (Dexon).
iii. Polydioxanone (PDS).
2. Nonabsorbable Suture. This suture
material is not absorbed during the healing
process.
Nonabsorbable
suture
becomes encapsulated (enclosed in a
capsule) with tissue and remains in the
body until it is removed or cast off.
Silk, nylon, cotton, linen, polypropylene, and
corrosion-resisting steel wire are examples
of
nonabsorbable
sutures.
Sutures used for skin closure are usually
removed before healing is complete.
Suture Sizes:

Sutures are sized by the USP

(United States Pharmacopoeia) scale

The available sizes and diameters

are:

6-0 = 0.07 mm

5-0 = 0.10 mm

4-0 = 0.15 mm

3-0 = 0.20 mm

2-0 = 0.30 mm

0 = 0.35 mm

1 = 0.40 mm

2 = 0.5 mm
Suture characteristics:

Suture materials vary in their

physical characteristics

Monofilament
sutures
(e.g.
polypropylene) are smooth

The slide well in tissues but if

handles inappropriately they can fracture

Multifilament
sutures
(e.g.
polyglactin) are braided

They have a greater surface area

They are easier to handle and knot

well

Some suture materials have a

memory (e.g. polypropylene)

Return to former shape when

tension is removed
Catgut

Made from the submucosa of sheep

gastrointestinal tract

Broken down within about a week

Chromic acid delays hydrolysis

Even so it is destroyed before many

wounds have healed
Silk

Strong and handles well but induces

strong tissue reaction

Capillarity
encourages
infection
causing suture sinuses and abscesses
Vicryl

Tensile strength

65% @ 14 days

40% @ 21 days

10% @ 35 days

Absorption complete by 70 days

Polydioxone

Tensile strength

70% @ 14 days

50% @ 28 days

14% @ 56 days

Absorption complete by 180 days

Specifications for Suture Materials:
1.
It must be sterile
2.
It must be uniform in tensile strength
by size and material.
3.
It must be hypoallergenic and less
tissue reactive.
4.
It must be safe on each type of
tissue.
5.
It must be secure and tight when
knotted.
6.
It must be appose and maintain the
tied tissues together until it fully heal

INFECTION CONTROL MEASURES IN THE OPERATING ROOM

STANDARD PRECAUTIONS

Standard precautions contain a basic level of infection control precautions that

are designed for the care of all patients regardless of their diagnosis (Damani,
2003:96). According to Phillips (2007:257), standard precautions supplement
recommended practices for environmental controls and are the minimum
precautions for all invasive procedures, which is any procedure that involves any
entry into body tissues. The following table contains the standard precautions
with a description of each:
STANDARD PRECAUTIONS (Phillips, 2007:257-259).

STANDARD PRECAUTIONS

DESCRIPTION

1. Protective barriers and personal Personal protective equipment (PPE),

protective equipment.
prevents any contact of the skin and
mucous membranes with blood and
body
substances.
The
type
of
equipment used depends on the
degree
of
anticipated
exposure.
Examples are: gloves, eyewear, gowns,
hair covers and masks. Gloves are
worn for invasive procedures and
masks for protecting personnel from
aerosols and patients from droplets.
2. Prevention of puncture injuries.
Needles and knife blades (collectively
referred to as sharps) present a
potential hazard. It is therefore
important not to manipulate any
sharps by hand. Do not recap used
injection needles and keep the used
blades and needles in a punctureresistant container.
3. Management of puncture injuries.

If a glove is punctured with a sharp

instrument during a procedure, then
the puncturing sharp must be removed
immediately and the glove changed
promptly. If the skin is cut then both
gloves must be removed, because the
risk of introducing microorganisms
from the remaining contaminated
glove is increased. The correct protocol
of the hospital needs to be followed
with a needle-stick injury.

4. Oral procedures.

5. Care of specimens.

6. Decontamination.

7. Laundry.

8. Waste.

9. Handwashing.

10.
Avoid
membranes.

touching

Blood-contaminated saliva and gingival

fluid is expected during dental and
surgical
procedures
in
the
oropharyngeal cavity; therefore mouth
protection, ambu bags and ventilation
devices
must
be
available
for
emergency
airway
resuscitation.
Respiratory
secretions
that
are
coughed up during endotracheal
procedures are usually infectious.
All specimens must be handled with
care and gloved hands to prevent any
contamination if spillage occurs. The
specimen must be contained to
prevent leaking during transport to the
laboratory.
All instruments must be thoroughly
cleaned
before
sterilization
and
furniture
and
floors
within
the
operating theatre must be cleaned and
decontaminated with a detergentdisinfectant.
Soiled woven fabrics must be handled
as little as possible and be transferred
to the laundry in leakproof bags.
Contaminated waste must be sent to a
sanitary landfill in sealed containers.
For disposal purposes, the waste must
be differentiated as infectious or
noninfectious, for example, red plastic
bags for contaminated waste and
white
bags
for
noncontaminated
waste, such as papers. These bags
must also be leakproof.
Thorough handwashing must be done
between patients or when in contact
with any contaminated items, with an
antimicrobial agent; before every
surgical
procedure
a
five-minute
surgical hands and arms scrub must be
done.
mucous Eating and drinking are prohibited in
any area where there is a risk of
exposure. Hand-to-mouth and hand-toeye contact can contribute to microbial
transmission.

11. Prophylaxis

Personnel who participate in invasive

procedures are at risk for blood-borne
exposure and should have an HBV
immunization. Personnel must be
encouraged to know their HIV and HBV
status, because the patient is at risk as
well.

ENVIRONMENTAL SERVICES
Environmental services are as important as the environmental controls.
According to Phillips (2007:255), environmental services that use effective
supplies, techniques and equipment are a most important aspect of infection
control; therefore microbial flora can be reduced by approximately 90%.

According to Searle (2000:245) scrupulous control of the environment

and of the equipment is imperative. Environmental services include
procedures such as cleaning and disinfecting the operating room complex
environment, handling soiled laundry and disposing of solid waste.
Equipment or procedures that require water in their operation can support
microbial growth.
Water especially supports the growth of gram-negative bacilli as well
as pseudomonas microorganisms. During the scrubbing of hands, airborne
particles are produced and can contaminate the area around the scrub sinks.
According to Phillips (2007:256), environmental services are relevant to
infection control and the prevention of cross-infection and therefore the
following points emphasise the importance of aseptic environmental control:
the water taps head should be of a type that can be removed for terminal
sterilization and the containers for antimicrobial handwashing agents should
be cleaned and terminally sterilised before refilling.
Secondly, no surface should remain wet, which would support
microbial growth. Organic debris should be promptly removed from walls and
any other surfaces with a disinfectant to prevent drying and airborne
contamination.

Thirdly, the operating lights should be cleaned after each surgical

procedure; the floors in the operating room complex should be cleaned with

a wet-vacuum system; the dry debris should first be removed with a dry
vacuum; and the floor should then be sprayed with a detergent-disinfectant
solution and then wet-vacuumed.
Fourthly, adequate time must be allowed between patients for proper
terminal disinfection of the operating room. A patient must not be assigned
to an inadequately cleaned operating room because it could lead to
infection.
Fifthly, disposable waste should be placed in separated bags for
infectious and noninfectious wastes and must be in impervious receptacles.
Waste should be contained at the source of origin to prevent aerosol
generation during handling. According to Meeker and Rothrock (1999:105),
sharps should be disposed in a container that is colour-coded, puncture
resistant and leakproof. Therefore the transmission of infection can be
prevented and accidental injuries such as needle sticks can be prevented
because the container is puncture-resistant.
Sixthly, the grills, vents and filters of the air-conditioning system
should be cleaned on a regular basis as defined by the institutional policy.
Housekeeping equipment should be cleaned and dried for storage since
moisture and darkness are conducive to microbial growth.

TYPES OF POSITIONS

SUPINE
PRONE

SITTING

LITHOTOMY

LATERAL
TRENDELENBURG

REVERSE

KRASKE
FOWLER
APPENDECTOMY

The excision of the appendix

usually performed to remove an
acutely inflamed organ.
Many surgeons perform an
appendectomy as a prophylactic
procedure when operating in the
abdomen for other reasons. This

procedure is then referred to as

an incidental appendectomy.

Position

Supine, with arms extended

on armboards

Incision Site

Packs/ Drapes

1.

2.

3.
4.

5.

Major Lap tray or minor tray

Internal stapling device

Supplies/ Equipment

Laparotomy pack
Four folded towels

Instrumentation

McBurney (muscle splitting)

incision.

Basin set
Blades
Needle counter
Penrose drain
Culture tubes
Solutions
Sutures
Internal stapling instruments
Medication

Procedure

An incision is made in the right

lower abdomen, either transversely
oblique (McBurney) or vertically (for
a primary appendectomy).
The surgeons assistant retracts
the wound edges with a Richardson
or similar retractor.
The appendix is identifies and
its vascular supply ligated.
The surgeon grasps the
appendix with a Babcock clamp,
and delivers it into the wound site.
The tip of the appendix may
then be grasped with a Kelly clamp
to hold it up, and a moist Lap
sponge is placed around the base of
the appendix (stump) to prevent

contamination of bowel contents, in

case any spill out occurs during the
procedure.
6.
The surgeon isolates the
appendix from its attachments to
the bowel (mesoappendix) using a
Metzenbaum scissors.
7.
Taking small bits of tissue along
the appendix, the mesoappendix is
double-clamped, and ligated with
free ties.
8.
The base of the appendix is
grasped with a straight Kelly clamp,
and the appendix is removed.
9.
The stump may be inverted into
the cecum, using a purse-string
suture on a fine needle, cauterize
with chemicals, or simply left alone
after ligation.
10.
Another technique is to
devascularize the appendix and
invert the entire appendix into the
cecum.
11.
The appendix, knife, needle
holder, and any clamps or scissors
that have come in contact with the
appendix are delivered in a basin in
the circulating nurse.
12.
The wound is irrigated with
warm saline, and is closed in layers,
except when an abscess has
occurred, as with
acute appendicitis.
13.
A drain may be placed into the
abscess cavity, exiting through the
incision or a stab wound.
14.
An alternative technique may
be use the internal stapling device,
by placing the stapling instrument
around the tissue at the
appendiocecum junction.
15.
By using the technique, the
possibility of contamination from
spillage is greatly reduced.

Perioperative Nursing
Consideration

Instruments used
for amputation of the appendix are
to be isolated in a basin.
2.
If ruptured, the case must be
considered contaminated, and the
surgeon may elect to use antibiotic
irrigation prior to closure of the
abdomen with an insertion of a
drain.
3.
There may be no skin closure of
the wound if the appendix has
rupture.

is given intra-venously. Most

patients doze through their
surgery. Just prior to surgery,
additional drops of anesthetic
are applied. Additional
anesthetic rinse will be given at
the time of the initial incision,
assuring patient comfort.

1.

2. Side-port minute incision

CATARACT SURGERY
Removal of the natural lens of
the eye (also called "crystalline
lens") that has developed an
opacification, which is referred
to as acataract. Metabolic
changes of the crystalline lens
fibers over time lead to the
development of the cataract
and
loss
of
transparency,
causing impairment or loss
of vision. Many patients' first
symptoms are strong glare from
lights and small light sources at
night, along with reduced acuity
at low light levels.
Following surgical removal of
the
natural
lens,
an
artificial intraocular lens implant
is inserted (eye surgeons say
that the lens is "implanted".

STEPS

3. Phacoemulsification

To begin the procedure, your

eye will be treated with an
anesthetic so that you will feel
little, if any
discomfort. Anesthetic eye
drops are instilled in the eye
pre-operatively. On arrival in the
operating room, a pleasant and
very effective relaxing medicine

Ultrasound softens the harder

portion of the cataract so that is
can be suctioned from the eye.

4. Cataract Incision

1. Anesthesia

A minute, painless initial "side

port" incision is made. Thick,
transparent fluid (viscoelastic) is
injected to hold open the space
between the cataract and the
delicate underside of the clear
cornea in front of it. Anesthetic
rinse is also applied at this time,
rendering the eye profoundly
numb

An extremely thin scalpel makes

a 3.0 mm incision for the
cataract removal. There is no
sensation at this time

5. Capsulorhexis (uniform
round cutting of the anterior
capsule of the lens)

Carefully a circular opening is

torn in the fragile clear sac that
holds the cataractous lens

6. Irrigation / Aspiration

The last remaining soft cataract

material (cortex) is vacuumed
out of the eye, leaving behind
the clear, empty lens capsule

7. Putting the artificial lens

(intraocular lens) inside the
eye
8. The flexible lens implant has
been rolled up for insertion by
the assistant, and is now
injected through a soft tube into
the vacant lens capsule
9. Final wash inside the eye

gratifying procedure for all the

members of the surgical team.
There are numerous indications for this

method of delivery, including dystocia

(failure to progress), cephalopelvic
disproportion; malrotation,
and placenta previa. Additionally,
uterine fibroids, which may block the
vaginal passageway, herpes, and
condylomata may also be indications
for cesarean section.
Previous C-sections are no longer

single indications for this procedure

unless the condition mentioned above
are also present.
Emergency C-sections are those
performed because of threatening
conditions to the mother and/ or the
baby.

The thick viscous elastic fluid

previously instilled in the eye is
removed, and any remaining
microscopic cataract fragments
are rinsed out as well.
Frequently, when the patient is
told that the surgery is
concluded, he (or she) is quite
surprised and says "I didn't
even realize you started!"

Positioning
Supine, with a small roll under the right
hip (to reduce vena cava compression);
arms extended on armboards.

Incision sites

Cesarean Section
(Caesarean, C-section)

Definition

The delivery of a viable fetus through

abdominal and uterine incisions (in the

operating room).

Discussion

Whether it is scheduled or emergent, it

is an exciting, fast-paced, and

Classic approach, vertical (low midline).

Packs/drapes
Extra drape sheet
Towels
Receiving pack for baby
Instrumentation
C-section tray
Delivery forceps
Cord clamp
Supplies/ Equipment
Basin set, Blades, Solutions
Suction, I.D bands, Sutures
Neonatal receiving unit

Self-contained oxygen,bulb syringe

1.

Procedure

Using the appropriate incisions,

consistent with the estimated size of the
fetus, the abdomen is opened, the rectus
muscle are separated, and the peritoneum
incised (similar to an abdominal
hysterectomy), exposing the distended
uterus.
2.
Large vessels are clamped or
cauterized, but usually no attempt to
control hemostasis is made since it may
delay delivery time ( 3-5 minutes after
initial incision is ideal).
3.
The scrub person must be ready with
suction, dry laps, and a bulb syringe.
4.
The bladder is retracted downward with
the bladder blade of the balfour retractor
and a small incision is made with the
second knife and extended with a bandage
scissors (blunt tip prevents injury to the
babys head).
5.
The amniotic sac is entered and
immediately aspirated the fluid.
6.
The bladder blade is removed, and the
assistant will push on the patients upper
abdomen while the surgeon simultaneously
delivers the infants head in an upward
position.
7.
The babys airways are suctioned with
the bulb syringe, and the baby is
completely delivered and placed upon the
mothers abdomen.
8.
The umbilical cord is double clamped
and cut.
9.
The baby is wrapped in a sterile
receiving blanket and transferred to the
warming unit for immediate assessment
and care.
10.
Once the bay has been safely
delivered, the emergent phase of the
procedure has been ended.
11.
Using a nonecrushing clamp, the
uterine wall is grasped for traction during
closure.

12.

The closure is performed in two layers

with a heavy absorbable suture, using a
continuous stitch, the second overlapping
the first.
13.
Following closure of the uterus, the
bladder flap is reperitonealized with a
running suture, and the uterus is pushed
back inside the pelvic cavity.
14.
The cavity is irrigated with warm
saline, and closed in layers.
15.
Skin is closed with the surgeons
preference. If a tubal ligation is to be
performed, it is done prior to the abdominal
closure sequence.

Perioperative Nursing
Considerations

1.

2.
3.
4.

A C-section requires an additional

uterine count of sponges, sharps, and
instruments prior to its closure.
Oxytocin should be available for the
anesthesiologist to administer I.V.
Once the uterus is opened, immediate
suctioning is necessary.
A warm, portable isolette should be
available to transport the infant to the
newborn nursery.

Cholecystectomy
Cholecystectomy is a
surgical OPERATION to remove
the GALLBLADDER.
May be performed if the
gallbladder contains gallstones
(cholelithiasis), is inflamed or
infected (cholecystitis), or is
cancerous
Under General Anesthesia

PROCEDURE:
1. You will be asked to remove any
jewelry or other objects that may
interfere with the procedure.

2. You will be asked to remove

clothing and be given a gown to
wear.
3. An intravenous (IV) line will be
inserted in your arm or hand.
4. You will be positioned on the
operating table on your back.
5. The anesthesiologist will
continuously monitor your heart
rate, blood pressure, breathing,
and blood oxygen level during the
surgery.
6. The skin over the surgical site will
be cleansed with an antiseptic
solution.

Open method
cholecystectomy:

7. An incision (open method) will be

made. The incision may slant
under the ribs on the right side of
the abdomen, or it may be an upand-down incision in the upper
part of the abdomen.
8. The gallbladder is removed.
9. In some cases, one or more
drains may be inserted through
the incision to allow drainage of
fluids or pus.

Laparoscopic method
cholecystectomy:

7. Three to four small incisions will

be made in the abdomen. Carbon
dioxide gas will be introduced
into the abdomen to inflate the
abdominal cavity so that the
gallbladder and surrounding
organs can be more easily
visualized.
8. The laparoscope will be inserted
through one of the incisions and

instruments will be inserted

through the other incisions to
remove the gallbladder.
9. When the procedure is
completed, the laparoscope will
be removed.

Procedure completion, both

methods:

10. The gallbladder will be sent to the

lab for examination.
11. The skin incision(s) will be closed
with stitches or surgical staples.
12. A sterile bandage/dressing or
adhesive strips will be applied.
NURSING MANAGEMENT
1. Administer pain relievers as
prescribed by the physician to
promote comfort.
2. Advice the client to have a
nutritious diet and avoid
excessive fats
3. Post-op: remind the patient to
cough hourly to prevent
atelectasis
4. Post op: instruct the patient to
use a pillow to splint incision.
5. To prevent bleeding, assess
periodically for increased
tenderness or rigidity of the
abdomen and report it to the
physician; instruct the patient
and family to report change in
color of stools
6. Monitor VS closely, inspect
incision for bleeding
7. When administering medications,
teach the patient about its
actions and possible side effects
that are to be expected
8. Instruct the patient to report
immediately in case symptoms of
jaundice, dark urine, pale stools,
pruritus, or signs of infection
9. Provide written and verbal
instructions to the patent and

operating table. Once asleep, your

head is placed in a 3-pin skull
fixation device, which attaches to
the table and holds your head in
position during the procedure (Fig.
2). Insertion of a lumbar drain in
your lower back helps remove
cerebrospinal fluid (CSF), thus
allowing the brain to relax during
surgery. A brain-relaxing drug
called mannitol may be given.

family about managing pain and

about signs and symptoms of
intra-abdominal complications
that should be reported such as
loss of appetite, vomiting, temp
elevation
10. Emphasize the importance of
keeping follow-up appointments

CRANIOTOMY

Step 2: make a skin incision

After the scalp is prepped with an
antiseptic, a
skin
incision is
made,
usually
behind
the
hairline.
The
surgeon attempts to ensure a good
cosmetic result after surgery.
Sometimes a hair sparing
technique can be used that
requires shaving only a 1/4-inch
wide area along the proposed
incision. Sometimes the entire
incision area may be shaved.

Step 3: perform a craniotomy,

open
the
skull
The skin and muscles are lifted off
the bone and folded back. Next,
one or more small burr holes are
made
in
the
skull
with
a
drill. Inserting
a
special
saw
through the burr holes, the surgeon
uses this craniotome to cut the
outline of a bone flap (Fig. 3). The
cut bone flap is lifted and removed
to expose the protective covering
of the brain called the dura. The
bone flap is safely stored until it is
replaced at the end of the
procedure.

Craniotomy is any bony opening

that is cut into the skull. A section
of skull, called a bone flap, is
removed to access the brain
underneath. There are many types
of craniotomies, which are named
according to the area of skull to be
removed (Fig. 1). Typically the bone
flap is replaced. If the bone flap is
not replaced, the procedure is
called a craniectomy.
PROCEDURE:

There are 6 main steps during a

craniotomy. Depending on the
underlying problem being treated
and complexity, the procedure can
take 3 to 5 hours or longer.

Step 1: prepare the patient

No food or drink is permitted past
midnight the night before surgery.
Patients are admitted
to
the hospital
the
morning
of the
craniotomy.
With an
intravenous (IV)
line placed
in your arm,
general anesthesia
is
administered while you lie on the

Step 4: exposure the brain

After opening the dura with surgical
scissors, the surgeon folds it back
to expose the brain (Fig. 4).
Retractors placed on the brain
gently open a corridor to the area
needing repair or removal.
Neurosurgeons use special
magnification glasses, called
loupes, or an operating microscope
to see the delicate nerves and
vessels.
Step 5: correct the problem
Because the brain is tightly
enclosed inside the bony skull,
tissues cannot be easily moved
aside to access and repair
problems. Neurosurgeons use a
variety of very small tools and
instruments to work deep inside
the brain. These include longhandled scissors, dissectors and
drills, lasers, ultrasonic aspirators
(uses a fine jet of water to break up
tumors and suction up the pieces),
and computer image-guidance
systems. In some cases, evoked
potential monitoring is used to
stimulate specific cranial nerves
while the response is monitored in
the brain. This is done to preserve
function of the nerve and make
sure it is not further damaged
during surgery.
Step 6: close the craniotomy
With the problem removed or
repaired, the retractors holding the
brain are removed and the dura is
closed with sutures. The bone flap
is replaced back in its original
position and secured to the skull
with titanium plates and screws
(Fig. 5). The plates and screws
remain permanently to support the
area; these can sometimes be felt
under your skin. In some cases, a

drain may be placed under the skin

for a couple of days to remove
blood or fluid from the surgical
area. The muscles and skin are
sutured back together. A turbanlike or soft adhesive dressing is
placed over the incision.

EXPLORATORY
LAPAROTOMY
This is an open surgery of the
abdomen to view the organs and
tissue inside.
Problems that may need to be
examined with an exploratory
laparotomy include:

A hole in the bowel wall

Ectopic (outside the womb)
pregnancy
Endometriosis
Appendicitis
Damage to an organ from trauma
Infection in the abdomen
Cancer

Prior to Procedure

Leading up to your procedure:

Your doctor may perform the

following:
o Physical exam
o Blood and urine tests
o Ultrasound a test that
uses sound waves to
visualize the inside of the
body
o CT scan a type of x-ray
that uses a computer to
make pictures of the inside
of the body
o MRI scan a test that uses
magnetic waves to make
pictures of the inside of
the body

Talk to your doctor about your

medicines. You may be asked to
stop taking some medicines up to
one week before the procedure,
like:
o Anti-inflammatory drugs
(eg, aspirin )
o Blood thinners,
like clopidogrel (Plavix)
or warfarin (Coumadin)
Arrange for a ride home.
The night before, eat a light meal.
Unless told otherwise by your
doctor, do not eat or drink
anything after midnight.

Anesthesia

General anesthesia (almost

always used)blocks pain and
keeps you asleep through the
surgery; given through an IV in
your hand or arm
Spinal anesthesia (used in very ill
patients)the area from the
chest down to the legs is numbed
Procedure

At Home

It may take several weeks for you

to recover.

Follow your doctor's instructions .

The doctor will remove the
sutures or staples in 7-10 days.
Take proper care of the incision
site. This will help to prevent an
infection.
Ask your doctor about when it is
safe to shower, bathe, or soak in
water.
During the first two weeks, rest
and avoid lifting.
Slowly increase your activities.
Begin with light chores, short
walks, and some driving.
Depending on your job, you may
be able to return to work.
To promote healing, eat a diet
rich in fruits and vegetables .
Try to avoid constipation by:
o Eating high-fiber foods
o Drinking plenty of water
o Using stool softeners if
needed

The doctor will make one long

incision in the skin on abdomen.
The organs will be examined for
disease. The doctor may take
a biopsy . If the problem is
something that can be repaired
or removed, it will be done at this
time. The opening will be closed
using staples or stitches.

Post-procedure Care
At the Hospital

You may need to wear special

socks or boots to help prevent
blood clots.
You may have a foley catheter for
a short time to help you urinate.

You may use an incentive

spirometer to help you breathe
deeply.

MASTECTOMY
Definition
Removal of the breast, with or
without surrounding structures.
Discussion
Mastectomies can be performed
in four distinct methods,
depending on the diagnosis and
the extent of the pathologic
findings.

1.
2.

3.
4.

Partial Mastectomy: Excision of

breast tumor, leaving appropriate
tumor-free margins.
Subcutaneous Mastectomy:
Removal of all breast tissue.
Overlying the skin and nipple are left
intact.
Simple Mastectomy
Radical Mastectomy:

Modified radical removal

of breast and axillary lymph nodes.
Most frequently performed.

Classic radical includes

removal of the entire breast,
pectoralis muscles, axillary lymph
nodes, fats, fascia, and adjunct
tissue.

Extended radical bloc

removal of breast, axillary
contents, pectoralis muscles, and
internal mammary lymph nodes.
Position
Supine, with arms extended on
armboards; folded sheets or sandbag
under the affected shoulder.
Incision Site
Dependent on the proposed
technique
Packs/ Drapes
Major Lap pack
Impervious stockinette
Extra drape sheets
Extra Mayo tray cover
The affected arm, once draped
with stockinette, is brought through
the fenestration.
Instrumentation
Major Lap tray
Curved Crile hemostasis
Hemoclip
Rake retractors
Lahey clamps
Intraductal probes
Minor tray
Supplies/ Equipment

Basin set
Blades
Needle counter
Drainage system
Pressure dressing
Suture
Solutions saline water
Medications

1.

Procedure Overview

Partial Mastectomy

The incision is usually made over

the lesion. The skin is elevated and
the breast mass is excised.
2.
Hemostasis is controlled, and the
wound is irrigated with warm saline or
water.
3.
The wound is closed in a routine
fashion, and if a drain is used, it is
secured.

Simple Mastectomy

1.

The skin is incised using an

elliptical incision around the breast.
2.
The incision is deepened with the
cautery pencil or second knife, and
the skin flaps are elevated.
3.
Kocher or Allis clamps are placed
along the skin edge and retracted
upward as dissection continuous.
4.
Once the skin flaps have been
raised, the breast is freed from the
chest wall at the level of the fascia.
5.
If the incision extends at the
axilla, sharp dissection is performed.
6.
If a lymph node is needed for a
frozen section examination, the tissue
is gasped with an Allis clamp and
dissected free.
7.
Once the breast is completely
mobilized, it is removed en bloc, and
placed in a basin for fixed
specimen evaluation.
8.
The wound is irrigated with warm
saline and the drainage system
established.
9.
If a Hemo Vac drain is used, the
drainage tubes are brought out of the
skin flap through two stab wounds
created with the Hemo Vac trocar.
10.
The skin is then closed, and the
drains are secured with the surgeons
choice of suture and skin closure
material.

Modified Radical
1.
A transverse or longitudinal skin
incision is performed.
2.
The dissection is performed and
the incision is extended well into the
axilla.
3.
The axillary contents are
dissected free from the vascular and

4.
5.
6.

1.

2.
3.
4.
5.

nerve structures, and are carefully

removed.
Care must be taken to avoid
injury to the nerve supply to various
muscles.
After the hemostasis is achieved,
the skin flaps are approximated over
the drains.
The wound is irrigated with a
warm saline and closed as described
for a simple mastectomy.
Perioperative Nursing
Considerations
If a mastectomy is to follow a
biopsy, the drape should be
reinforced with clean towels, the team
should change gloves, and the biopsy
instruments are removed.
Additional personnel may be
needed to hold the arm during a
circumferential extremity skin prep.
Several knife maybe needed
because of the fibrous nature or the
tissue incised.
Irrigation solution may be water in
place of saline in order to lessen the
survival of the tumor cells.
Estrogen and progesterone may
be requested.

 If you know that you have

problems with your blood
pressure, your heart, or your
lungs, ask your family doctor to
check that these are under
control.

Check the hospital's advice

about taking the Pill or hormone
replacement therapy (HRT).
Check you have a relative or
friend who can come with you
to the hospital, take you home,
and look after you for the first
week after the operation.
Sort out any tablets, medicines,
inhalers that you are using.
Keep them in their original
boxes and packets. Bring them
to the hospital with you.

ANESTHESIA
General Anesthesia

NEPHROLITHOTO
MY

The
surgical
procedure to
remove kidney stones.
Kidneys make urine, which then
passes through the ureters,
before leaving the body.
Kidney stones usually occur at
the junction of the ureters and
kidney

Before the operation

Stop smoking and try to get

your weight down if you are
overweight.

PROEDURE
1. You
will
have
a
general
anesthetic, and will be asleep
for the whole operation.
2. A cut is made in the skin over
your kidney, usually round the
back in the line of your lowest
rib. Sometimes the cut is made
in the front of the tummy,
especially when the kidney is to
be taken out.
3. The stone(s) are taken out, with
or without the kidney.
4. The wound is stitched up.

 NURSING CONSIDERATIONS
Patients feel disoriented, for
approximately
24
hours
after removal of
kidney
stone surgery,
due
to anesthesia.
There might also be some
discomfort which is controlled
with pain killers.
Patients are
usually
encouraged to get out of bed
after the first day and start
moving about gradually.
In most cases, patients feel no
pain within 7-10 days after the
operation.
Full recovery after removal of
kidney stone surgery can take
up to two months.
Patients can return to light
physical activities a month
after surgery, while it can take
up to two months to restart
more strenuous activies.

OPEN
REDUCTION
INTERNAL FIXATION

General advice

The operation should not be

underestimated, but practically
all patients are back to their
normal duties within two
months. These notes will help
you through your operation.
They are a general guide. They
do not cover everything. Also,
all hospitals and surgeons vary
a little. If you have any queries
or problems, please ask the
doctors or nurses.

Involves the implementation of

implants to guide the healing
process of a bone, as well as the
open reduction, or setting, of the
bone itself.
Open reduction refers to open
surgery to set bones, as is
necessary for
some fractures. Internal
fixation refers to fixation of
screws and/or plates,
intramedullary bone nails
(femur, tibia, humerus) to enable
or facilitate healing.
Rigid fixation prevents micromotion across lines of fracture to
enable healing and prevent
infection, which happens when
implants such as plates
(e.g. dynamic compression plate)
are used.
Prior to Procedure

Since broken bones are caused

by trauma or an accident, an
ORIF surgery is typically an
emergency procedure. Before
your surgery, you may have:
Physical examto check your
blood circulation and nerves
affected by the broken bone
X-ray, CT scan, or MRI scantests
that take a picture of your broken
bone and surrounding areas

 Blood tests
Tetanus shotdepending on the
type of fracture and if your
immunization is current
Questions your doctor may ask
include: How did you break your
bone? How much pain do you
feel? Do you take any bloodthinning medicines?
Questions you should ask include:
Will I need rehabilitation after
surgery? What will I need to
assist in my recovery (eg,
wheelchair, crutches)?
An anesthesiologist will talk to
you about anesthesia for your
surgery.
Arrange for a ride home from
surgery.
If your surgery is urgent, you may
not have time to fast beforehand;
make sure to tell your doctor and
the anesthesiologist when you
last ate and drank.
If your surgery is scheduled, you
may be asked to stop taking
medicines that thin the blood, like
warfarin (Coumadin), clopidogrel
(Plavix), or aspirin. If surgery is
urgent, make sure to let your
doctor know if you take any
blood-thinners or other
medicines.
Anesthesia

General anesthesia may

be used. It will block any pain and keep
you asleep during the surgery. It is given
through an IV (needle in your vein) in
your hand or arm. In some instances, a
spinal anesthetic, or more rarely a local
block, may be used to numb only the
area where the surgery will be done.
This will depend on where the fracture is
located and the time it will take to
perform the procedure.

b) Once the bone is placed in its

proper position, screws, pins,
plates or nails are attached to
stabilize it. Longer bones may be
repaired with a nail placed
directly in the bone cavity.
c) If part of the bone has been lost
because of the fracture, the
surgeon may opt for a bone graft
to keep healing on track.
d) Bone grafts will either be taken
from the patients own bone or
from a donor.
e) The incision is then closed in
layers and may be drained.
f) A dressing is applied, followed by
a cast or splint.

PROCEDURE

a) An incision is made over the

fractured bone.

Immediately After Procedure

After your surgery, you will be
taken to the recovery room for
observation. If all is well, your
breathing tube will likely be
removed while you are there.
Your heart rate, respirations,
blood pressure, and temperature
will be checked often. Your pulse
and the nerves close to the
broken bone will also be checked.

THYROIDECTOMY

Definition

Removal of all or a portion of

the thyroid gland.

The procedure is usually

performed to treat various disease
of the thyroid gland that may not be
treated effectively by
chemotherapy or medication.
A total thyroidectomy is
indicated for certain carcinomas
and to relieve tracheal or
esophageal compression.

Discussion

Position

Supine with rolled towel or

sandbag between the scapulae,
hyperextending the neck. If table is
placed in reverse Trendelenberg
position, a padded foot board
should be used to prevent the
patient from slipping down toward
the end of the table.

Pack/ Drapes

Laparotomy pack with small

fenestrated sheet
Rolled sheet/ towels

Instrumentation

Major Lap tray

Thyroid tray
Lahey clamps
Spring retractor

1.
2.
3.

4.

5.
6.

Supplies/ Equipment
Basin set
Suction
Blades
Needle counter
Dissector sponge
Small drain

Solutions
Sutures

The incision is made above the

sternal notch.
The platysma muscle is incised
and retracted.
The strap muscles are
separated or divided, and blunt and
sharp dissections are employed
until the thyroid is exposed.
The gland is then mobilized, and
all or part is removed depending on
the involved pathology.
Hemostasis is obtained, and the
wound is irrigated with warm saline.
A drain may be inserted, and
the incision is closed in layers by an
interrupted method.

1.

Procedure Overview

Perioperative Nursing
Consideration

The surgeon may request a fine

silk suture to use to mark the
incision line.

2.

The dressing is usually secured

by a thyroid collar using a towel
folded in thirds lengthwise. The
towel is placed around the neck and
crisscrossed in front, then fastened
with tape.
3.
The scrub person should
maintain the sterility of the back
table/ Mayo until the patient is
extubated and breathing is
stabilized.
4.
An emergency tracheostomy
tray will accompany the patient to
the postanesthesia care unit and
later to the patients room until
breathing is unlabored and the
chance of airway obstruction
secondary to edema has passed.

DEFINITION

Surgical procedure involving

removal of prostate tissue using
resectoscope inserted through a
urethra.

Widely used technique for

managing BPH(Benign Prostatic
Hypertrophy/Hyperplasia)

INDICATIONS

BPH (Benign Prostatic

Hyperplasia/ Hypertophy)
Enlarged lateral lobes of the
prostate
Enlarged median lobes

SURGICAL POSITION

---LITHOToMY

SURGICAL PROCEDURE

1. The operation is performed

through a modified cyst scope
(resectoscope).
2. Prostatic tissue is resected using
an electrically energized wire
loop
3. Bleeding is controlled with a
coagulation current.
4. Continuous irrigation is necessary
to distend the bladder and to
wash away blood and dissected
prostatic tissue
5.
NURSING MANAGEMENT of
the SURGICAL CLIENT

TRANSURETHRAL
RESECTION OF THE
PROSTATE (TURP)

PREOPERATIVE CARE

1.) Assess the clients ability to

empty his bladder.
2.) Assess client in the intake of
drugs or supplements
(anticoagulants)
3.) Assessment of expectations in
the changes of voiding and
sexual function.
4.) Respond to the concerns of the
client and significant others in
empathetic listening.
5.) Restating explanations (Informed
consent)

1.) Observe V/S and urinary

drainage. (closed bladder
irrigation)

2.) Frequently assess clients

urine output.

3.) Ensure catheter patency

POSTOPERATIVE
CARE