Surgical Procedures

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					     OPERATING
       ROOM
     SURGICAL
    PROCEDURES
`




         By:
         DR. EMMANUEL I IROEGBU




                                  1
                                    SECTION 1
                       PROCEDURES IN PREPARING THE PATIENT


Lesson 1-1 Introduction

After completing this lesson, you should be able to:

       Identify common anesthesia terms and their definitions.
       Identify proper procedures for performing preoperative skin prep.
       Identify equipment used in positioning patients.
       Identify procedures for placing a patient in the supine, Trendelenburg, reverse
        Trendelenburg, lateral kidney, lateral chest, lithotomy, prone, jackknife, and
        sitting positions and position for spinal anesthesia.
       Identify procedures for draping a patient.

1-1. PURPOSE AND SCOPE

This subcourse and subcourse MD0928 deal with the care of the patient in the OR preceding and
during surgery. They deal particularly with procedures in surgery and emphasize the role of the
OR specialist. Principles, techniques, and procedures peculiar to the care of the patient in the OR
are emphasized. Nursing care given the surgical patient by ward personnel is mentioned when
appropriate--and this care is important in the cycle of care of the surgical patient--but details are
omitted in order to not duplicate instruction presented in other subcourses. For the same reason,
details concerning the preparation of materials by the centralized materiel section are omitted. In
accordance with the above information, this subcourse is directed towards the OR specialist
whose principal duties are performed in the OR.

1-2. OPERATING ROOM TEAM

The OR specialist is a member of a patient care team. In various ways, all team members assist in
the care and treatment of the patient during surgery. The team is assisted and supported by other
teams and components of the hospital. The team in the OR performs certain tasks in the care of
the surgical patient while he is in the OR. This team usually includes a surgeon (medical officer),
who may be assisted by other medical officers (such as first and second assistants); an
anesthesiologist (medical officer whose specialty is anesthesia) or anesthetist (An officer holding
military occupational specialty title "anesthetist"), or other persons who administers anesthesia,
and therefore serves as an anesthetist (such as the surgeon); a "scrubbed" ("sterile") worker
(either an OR specialist, or an officer or both may serve in this capacity depending upon the needs
of the operation); a circulator (OR specialist or professional registered nurse); and other team
members as appropriate for the surgical procedure.

1-3. THE ROLE OF THE OPERATING ROOM SPECIALIST

Because of his role in the care of the patient during surgery, the OR specialist requires mastery of
a number of procedures, all of which embody certain principles and techniques. The overriding
principle that should guide the specialist in the performance of every task connected with the
patient's surgery is the maintenance of asepsis. The specialist may abandon aseptic techniques
only upon order by the surgeon. The surgeon may sacrifice aseptic technique during grave
emergency when the time element is paramount in resuscitating the patient, such as during
cardiac arrest.

1-4. TERMINOLOGY


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a. General. Certain terms that have to do with anesthesia appear frequently in the following text.
Use of these terms in this portion of the text is not to introduce the subject of anesthesia. Rather,
the terms are used either to show the sequence of events or to indicate the reason for variations in
procedure. However, knowledge of these terms should enhance the specialist's understanding of
the procedures discussed. Other terminology related to anesthesia is presented in Lesson 3.

b. Anesthesia. A bodily state in which sensation is absent to the extent that the patient does not
experience pain during a surgical procedure. A description of general, regional, and spinal
anesthesia follows:

(1) General anesthesia. Anesthesia achieved by producing the loss of all modalities (means) of
sensation, including loss of consciousness.

(2) Local anesthesia. Anesthesia confined to one part of the body with administration of the
anesthetic agent by topical application, local infiltration, subcutaneous injection, nerve block (see
(3) below), or epidural or spinal injection. Local anesthesia may also be accomplished by
refrigeration, which is the application of a low temperature (perhaps by packing a limb in ice) to a
part of the body to anesthetize it.

(3) Spinal anesthesia. Anesthesia achieved by blocking nerve conduction within the spinal canal.

c. Anesthetize. To anesthetize a patient is to place him in a state of anesthesia.

d. Anesthesiologist. A medical doctor that specializes in the art and science of administering
anesthetics to produce the various stages of anesthesia.

e. Anesthetist. Although anesthesia is often administered by an anesthesiologist, the term
"anesthetist" is used throughout this text to indicate the person who administers anesthesia.

1-5. SPECIALIST-PATIENT RELATIONSHIP

One aspect important in the care of the surgical patient is the relationship between the specialist
and the patient. Although the OR specialist may be with the patient for only relatively brief
periods before anesthesia is administered to the patient, these contacts have important meaning
for the patient. For this reason, the specialist, through both attitude and deed, can do much to help
(or hinder) the patient through a successful operative procedure and thus toward recovery from
his illness.

1-6. THE PATIENT

The patient's mental attitude is influenced by normal fears such as the fear of general anesthesia
and surgery, fear of pain, disability, disfigurement, the unknown, and especially the fear of death.
Hospitalization is an abnormal way of life for him, and the very fact that he is losing his
independence for a time and placing himself completely in the hands of other persons contributes
to his anxiety. He does not always understand what is going on and is apt to feel lost and fearful.
Patients manifest anxiety in different ways. Some patients express their fears and are openly
anxious, while others are openly hostile. Some appear quite calm and seem to have little or no
feeling about the pending surgery.

1-7. THE OPERATING ROOM SPECIALIST

The specialist must always bear in mind that the patient is a person, not just an operative
procedure, and that the surgery for which he is scheduled is a major occurrence to him. The
specialist should be aware of the various kinds of behavior the patient may manifest and accept
the patient as he is. The treatment of emotional and behavioral problems is the responsibility of

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others, but approaching the patient with a confident manner, telling him what is going to be done,
and performing all procedures in a quiet, systematic, thorough way while demonstrating sincere
kindness, sympathy, and simple courtesy are effective means for dealing with the patient's anxiety
in the specialist-patient relationship. If the patient is convinced that the members of the surgical
team are interested in him as a person rather than as an operative procedure, the first step toward
a successful operation and his ultimate return to health is accomplished.



1-8. INTRODUCTION

The skin is the body's first line of defense against bacterial invasion. A break in the skin, even
though it is a surgical incision made with a sterile instrument, may permit microorganisms to
enter the body. The human, living skin cannot be sterilized. However, it can be rendered
"surgically clean." If skin is not prepared properly prior to surgery, infection may result from the
bacteria present on the patient's skin. The first step in this preparation of the patient's skin is to
shave the hair on and around the operative site. This not only helps to lower the population of
bacteria, but also helps to prevent hairs entering the wound as foreign bodies. In addition,
preparation of the patient for surgery includes a number of procedures--all of them important in
the chain of asepsis that protects the patient's life and contributes to his smooth recovery. The
aspects of preparation given consideration in this section relate to (1) the patient's mental
preparation and (2) principles and techniques of skin preparation ("prep") for surgery.

1-9. MENTAL PREPARATION

The first opportunity that the OR specialist has to begin building a trusting relationship between
himself and the patient occurs during the patient's preoperative skin preparation. Throughout this
preparation, the specialist should within the limits of the situation and his own capabilities answer
the patient's questions about pending surgery. The patient will have more confidence in the
specialist who is honest than in one who fabricates answers. Therefore, the specialist must not
guess or speculate about matters of which he has little or no knowledge. Throughout the
relationship, the specialist must show by his actions, attitudes, and words that he appreciates the
seriousness of the situation; and that he shows confidence and expectancy that the planned
surgical treatment will be successful.

1-10. PREOPERATIVE SKIN PREPARATION (PREP)

a. General. The starting point in the chain of asepsis, the patient's preoperative skin prep, consists
of cleansing and shaving the area of the operative site. The purpose of the prep is to render the
operative site as clean and free from bacteria as possible and therefore reduce the possibility of
infection. Thus, it is obvious that the shaving and cleansing of the skin must be performed with
utmost care and skill. The OR specialist normally does the shave prep on the day prior to surgery.

b. Assignment of Preps. The preps may be listed on a daily duty roster and may be assigned
along with other duties on the nursing service assignment roster. After the assignment has been
made, the specialist checks the OR schedule for the following day. Information provided on the
schedule includes the number and types of operations and, therefore, the number and types of
preps. The schedule also gives the location of the patient to be prepped. The specialist should also
note the scheduling of spinal anesthesia because these patients will need an 8-inch square area in
the lumbar region prepped. When the specialist is assigned several preps, he should either take a
copy of the schedule along or write the information on a sheet of paper. This will help to alleviate
errors.

(1) Preparation of the patient's skin for surgery is a treatment procedure; therefore, it must be
initiated by an order of the medical officer. The order may be written "routine prep," which would

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necessitate the use of a standing operating procedure (SOP) to delineate the area; or instructions
that are more specific may be included.

(2) Some medical officers may outline areas to be prepared using skin marking pencils. This
procedure is seen most often in neurosurgery.

c. Local Policy. After checking the assignment roster and determining what his duties are, the
specialist should refer to the local policy to know just how the preps are to be done. This
information, which may be listed on a series of cards or in a manual, includes the following: the
areas to be prepped for various operations, any special instructions, and the procedure to be
followed for unusual situations.

(1) Area of prep. The anatomic area of skin preparation is dictated by the operative procedure and
its approach. A general guideline that can be followed is to prepare an area "far and wide." More
specifically, an SOP usually outlines the area to be prepared for specific operations. The
following examples are generally accepted as appropriate for the various types of surgery (see
figure1-1).

(a) For abdominal surgery, the male patient's skin is shaved and cleaned from the nipple line to
the upper third of the thigh, including the pubes (hair over the pubic regions) from side to side
anteriorly (see figure 1-1 A). For a female, the upper boundary is the breast fold on the chest wall
(see figure 1-1 B). Particular care must be taken to assure adequate cleaning of crevices and
indentations in the skin. An example on the abdomen is the umbilicus.

(b) For kidney operations and surgery of the proximal third of the ureters, the skin is shaved from
the axilla (which is prepped) to the groin (see figures 1-1 C and D).

(c) For chest surgery, the skin is shaved and cleansed on the affected side from midhip over the
shoulder, including the axilla, to the shoulder on the unaffected side (see figures 1-1 E and F).

(d) For rectal surgery, support the legs and thighs in the lithotomy position (see figure 1-10).
Shave the pubic, perineal, thigh, and anal areas (in a radius of about 10 inches from the anus) (see
figures 1-1 G and H).

(e) For gynecological surgery (perineal prep) (see figure 1-1 I), support legs and thighs in the
lithotomy position and shave the anterior surface from the umbilicus down: the pubic area, the
external genitalia, the perineum, including the area around the anus, and the buttocks. Shave inner
thighs halfway to the knees from the middle of anterior to middle of posterior thighs.

(f) For surgery of the cranium (see figure 1-1 J), follow the outline indicated by the surgeon. Clip
the hair before attempting to shave the scalp. Find out if long hair is to be saved for the patient. If
so, follow local procedures. The actual shaving is often done in the surgical suite just before
surgery, and the preparation done on the ward may be limited to cutting or clipping the hair close
to the scalp.

(g) For surgery of the limbs (see figures 1-1 K, L, M, and N), the area includes the entire
circumference. The extent of the prep varies depending upon the type of operation. As an
example, for surgery of the hand, the prep would normally extend distally from the elbow. A
manicure or pedicure is also necessary. Fingernails or toenails must be clipped short, cleaned, and
scrubbed.




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                                          Figure 1-1. Skin areas to be prepared for surgery.
                                          (Shaded areas are those to be shaved.)

                                          (2) Other information. Local policy should also set forth
                                          instructions for performing surgical preparation of the
                                          skin when the procedure differs in some respect from
                                          that given below. For a discussion of principles and
                                          general considerations for preps in special situations, see
                                          paragraph 1-11.

                                          d. The Prep Tray. Dependent upon local SOP and the
                                          type of equipment used, it may be necessary to assemble
                                          a prep tray. Before beginning a prep, the specialist
                                          should check the prep tray for completeness. It is
                                          embarrassing for the specialist to start a prep and
                                          discover that some of the equipment is missing. Worse,
                                          the patient tends to lose confidence in the specialist
                                          when such incidents occur, thus causing the patient-
                                          specialist relationship to suffer. As the specialist checks
                                          the tray, he should think briefly of the purpose of each
article so that he will not overlook needed items. The equipment, if complete, is as follows:

(1) One tray--needed to hold and carry equipment.

(2) Two razors--one is to be soaked while the other is being used (although this is not a sterile
procedure, the razors should be cleaned and soaked after each usage).

(3) A container and disinfectant--needed to soak the razors.

(4) A new blade--for each patient; sometimes more than one blade per patient is required.

(5) Antibacterial surgical detergent as prescribed--needed to wash and cleanse the area to be
prepared.

(6) Two basins--one basin for the detergent, and the other basin for water.

(7) Cotton-tipped applicators--three or four are needed to clean skin indentations.

(8) Acetone--needed to remove adhesive tape marks, if they are present. (Try to avoid using ether
for this purpose. It is irritating to the tissues.)

(9) Gauze fluffs--needed for washing and rinsing the skin.

(10) Adhesive tape--for picking up loose hair. Adhesive tape should be wrapped around used
razor blades before disposing of the blades.

(11) Tissue--for wiping the razor.

(12) Scissors--for clipping long or excessive hair.

(13) A treatment sheet with cover--to protect the patient and the bed.

(14) Hand towels--to cover the tray and dry the patient.
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(15) Newspaper (or other paper)--for disposal of used razor blades and waste.

(16) Orangewood sticks.

(17) Fingernail and toenail clippers--as required.

e. Procedure.

(1) Take the tray to the area where the prep will be done. Some hospitals have the ambulatory
patients come to the OR suite; in other hospitals, the specialist does the prep on the ward.
However, principles of cleansing the area and the technique for doing it remain the same. In the
following discussion, it is assumed that a bed patient is to be prepped on the ward.

(2) Obtain a gooseneck lamp; one is usually available in each ward. (Note that this is the only
item of ward equipment used, and it is an absolute necessity. When a prep is done without a good
light, the OR light invariably shows hair that has been missed.)

(3) Locate and identify the patient. Tell the patient what is to be done and why. Screen the
patient for privacy. Adjust the lamp so the light will shine directly on the area to be prepared.

(4) Put water into both of the solution basins, and add detergent to one.

(5) Place the treatment sheet in to protect the patient and his bed.

(6) Turn on the lamp and look carefully at the patient's skin before beginning the prep. If he has a
rash, pimples, cuts, or other abnormal condition in the area to be prepped or if he has evidence of
infestation with parasites anywhere on his body, report the finding to the surgeon. He will make
the decision either to go ahead with the prep or to postpone surgery.

(7) Remove adhesive tape marks from the patient's skin (if any are present) with acetone.

NOTE: Acetone will neutralize the residual antiseptic properties of surgical soap such as
hexachlorophene; therefore, use acetone first, when needed; then wash it off and apply surgical
soap.

(8) Trim long or excessive hair in the area to be prepped with the scissors to avoid clogging the
razor.

(9) When necessary, clean the umbilicus with cotton-tipped applicators and antibacterial
detergent. For operations involving the hands and feet, trim and clean the nails, using scissors,
orangewood stick, and fingernail and toenail clippers as necessary.

(10) Wash the area to be prepped thoroughly with the antibacterial detergent and discard the
gauze fluffs as they are used (use newspaper for this; never put used fluffs back into the basins).

(11) Using your fingers, apply tension on the skin in the opposite direction in which you shave
(see figure 1-2 B). When no tension is applied, the hairs are difficult to cut (see figure 1-2 A);
however, when tension is applied (see figure 1-2 B) the skin is taut and the hair stands out
prominently.




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Figure 1-2. Applying tension on skin to raise hair.

(12) With the blade of the razor held at a 15-degree angle to the skin and using short strokes,
shave in the direction of the hair growth. Clean the razor frequently. Figure 1-3 illustrates a
disposable razor. Conventional safety razors can also be used.



                                                               Figure 1-3. Shaving the area.

                                                               (13) Rinse the area with wet gauze
                                                               fluffs and blot dry.

                                                               (14) Inspect the area thoroughly.
                                                               Move the light around and examine
                                                               the area from different angles.

                                                              (15) Pick up any loose hair on the
patient by holding a piece of adhesive tape taut and gently applying the sticky side to the shaved
area. When the loose hair has been removed, shave off any remaining hair.

(16) If the patient is able, he should shower and shampoo.

(17) Brush any loose hair from the patient's bed and remake the bed or tighten the sheets.

(18) If additional patients are to be prepped on the same ward, move the lamp to the next patient's
bedside; if no other patient is to be prepped on the ward, return the lamp to its place of storage.

(19) Take the prep tray to the ward utility room and clean it before prepping another patient.
Discard the newspaper containing waste and used razor blades; wash the razor, scissors, and the
solution basin; remove the second razor from the disinfectant solution and put the razor and the
scissors just used into the solution. (Since the scissors are not always needed, one pair is usually
enough.)

f. Resetting the Tray. When all of the assigned preps are completed, the specialist returns the tray
to the appropriate place in the OR suite and resets it, as follows:

(1) Dismantle the tray.

(2) Wash and autoclave the razors, solution basins, disinfectant container, tray, and scissors.

(3) Reassemble the tray and restock it with items set forth in paragraph d above.

g. Disposable Equipment. The ideal type of equipment is disposable. These prepackaged sets
contain all of the basic equipment needed to prepare a patient; and upon completion of the
procedure, the equipment is discarded, and the specialist thoroughly washes his hands. Hence, the
possibility of transferring microorganisms from one patient to the next is significantly reduced.
(Figure 1-3 illustrates a disposable razor.)

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h. Individually Packaged Preparation Sets. The use of individually packaged "prep" sets of
reusable basic equipment lends itself to a high degree of patient safety from cross-contamination,
inasmuch as used equipment is "isolated" from fresh and undergoes thorough decontamination
prior to reassembly and reuse. Upon completion of the procedure, the specialist discards the fluff,
tape, razor blade, and so forth, and places the reusable items in a predetermined area away from
the fresh supplies. He washes his hands thoroughly and completely assembles the next setup prior
to contact with the next patient.

i. Other Preparation of the Patient for Surgery. With completion of the above tasks, the specialist
concludes his preoperative preparation of the patient for surgery. Numerous other measures done
in the patient's preparation for operation are performed by the ward personnel.

1-11. PREPS IN SPECIAL SITUATIONS

a. Prep of a Painful Area. Such preps are usually individualized, the surgeon ordering whatever
special measures he determines to be necessary. Local policy should be checked, however, as it
may set forth procedures to be followed in certain cases or for some surgeons. The surgeon may
order that a narcotic be given just before the prep is done or, depending upon the patient's
condition and the nature and size of the painful area, he may order that the patient be anesthetized
for the prep to be done. If anesthesia is given for the prep, surgery may be done as soon as the
remainder of the preparation for surgery is done. Thus, the necessity for giving the patient
anesthetic twice is avoided. The surgeon or one of his assistants may elect to do the prep; in this
case, the specialist assembles the necessary equipment and assists as directed.

b. Preps for Emergency Surgery. In addition to the prep just discussed which may be done in a
designated part of the OR suite (paragraph a above), another prep that is frequently done in the
OR suite is that for the emergency surgical patient who is sent directly to the surgical suite upon
admission to the hospital. The shaving and other preparation has been previously discussed (see
paras 9 and 10). Whenever any prep is done in the OR suite, it should be done in a room other
than that in which surgery is performed because it is important that the OR be kept free from hair.

c. Prep with Depilatory Cream. In some situations, a depilatory cream may be used to remove the
hair. This is a chemical substance which, when spread on the skin surface, effects the removal of
hair. It is used according to printed instructions on the container.

d. Preps of Infected Patients. Preparation of a patient with a known or suspected infection or
communicable disease should follow all other "preps" to prevent contamination with a known
pathogenic microorganism. The OR SOP should include care of equipment in this situation, and
the hospital SOP will outline isolation techniques to be used for communicable diseases.

1-12. IMMEDIATE PREOPERATIVE SKIN PREPARATION

The final preoperative skin preparation (scrub prep) given the patient is done after the patient has
been placed on the OR table (or in a chair) in the desired position and just before the sterile
drapes are placed over him. This procedure is done by the surgeon or his medical officer assistant,
assisted by the OR specialist. Aseptic technique is used and virtually the same large area as that
outlined by the shave prep is given the scrub prep.

a. Equipment. The sterile items needed are provided by the circulator and are arranged by the
scrub. The scrub may set up the materials on a small sterile table so the medical officer (surgeon
or his assistant) doing the prep can obtain the needed items from the table himself, or the
specialist may hand the items to the medical officer from the instrument (back) table. The
following items are included for the prep:

       Four hand towels--one to dry hands, two to cover the patient's sheet at the distal and
        proximal edges of the operative field, and one to blot dry area.
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       Two small basins for solutions.
       Soap or antibacterial detergent and an antiseptic solution. Sterile physiological saline or
        sterile distilled water. Textured gauze sponges.
       Two cotton-tipped applicators.
       One pair of sterile rubber gloves.
       Two Chux ® (disposable bed pads).
       Two sponge forceps.

b. Procedure.

(1) All team members follow aseptic technique in preparing the patient.

(2) If an open stoma (colostomy or other) is present, the circulator seals it off using adhesive
strips, strips of cellophane tape, or an adhesive drape of appropriate size.

(3) The medical officer who is to perform the procedure scrubs his hands and arms. He dries his
hands and arms and puts on the sterile gloves.

(4) The medical officer opens a towel and places it across the patient at the lower margin of the
skin area to be prepared, then places another towel across the upper margin of the area to be
prepared. In addition to serving as markers for the preparation, the sterile towels also protect the
medical officer's hands and arms from the unsterile linen and the unshaved areas of the patient's
skin.

(5) If the scrub hands the needed items to the medical officer, he must not allow his gloved hands
or gown to come in contact with unsterile items or with any part of the medical officer's body,
except for the medical officer's gloved hands. Objects that come in contact with the skin are
unsterile because the skin is not sterile.

(6) The medical officer prepares flat surfaces by using textured gauze sponges saturated with a
detergent or soap, manipulating the sponges with a circular motion while applying light pressure.
He begins at the center of the proposed site and works toward the periphery. He uses a number of
sponges wet in the soap or detergent because a used sponge is never brought back to a washed
area. Crevices and indentations are cleaned using cotton-tipped applicators.

(7) The Chux ®, strategically placed, should absorb the moisture as it spills off the patient.

(8) When he has completed the scrub, the medical officer wipes the lather off with a sterile
towel. (Time for the scrub, usually 10 minutes, is established by local SOP.) He "paints" the area
with sponges wet in the antiseptic solution.

(9) The specialist removes the towels and Chux ®, being careful not to contaminate the prepared
area.

c. Special Procedure for Traumatic Injury to Limb. In rendering an open traumatic limb injury
surgically clean, there are two facets of contamination to be considered. In contrast to the routine
surgical incision made with sterile instruments through surgically clean skin, the tissues in an
open traumatic injury are contaminated, and additionally, are frequently damaged, providing
lowered natural body defenses against infection. Secondly, because of the injury, there are often
foreign bodies embedded in the tissue surfaces that carry microorganisms.

(1) In order to achieve an adequately prepared area, a more brisk scrub will usually be done, and
the area irrigated with large amounts of solution. In addition to the basic sterile "prep" set, extra
fluffs, a scrub brush, an asepto syringe, and irrigating solution are needed. Strategic placement of


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a large rubber sheet and kick bucket will prevent wetting of the patient and operating table,
thereby allowing for moisture-free drapes.

(2) In order to prepare the entire circumference, the limb should be suspended for the "prep."
Additionally, if there is bone damage, traction will have to be exerted throughout the time that the
limb is suspended. Usually, this is best accomplished by an assistant OR specialist and must be
maintained throughout the "prep" and part of the draping procedure.


                 1 PROCEDURES IN PREPARING THE PATIENT
            LESSON 1-2 PREPARATION OF THE PATIENT FOR SURGERY

After completing this lesson, you should be able to:

       Identify common anesthesia terms and their definitions.
       Identify proper procedures for performing a preoperative skin prep.
       Identify equipment used in positioning patients.
       Identify procedures for placing a patient in the supine, Trendelenburg, reverse
        Trendelenburg, lateral kidney, lateral chest, lithotomy, prone, jackknife, and
        sitting positions and position for spinal anesthesia.
       Identify procedures for draping a patient.

1-13. INTRODUCTION

a. General. The positioning of the patient for surgery is one of the most important nonsterile
procedures in which the OR specialist assists because placement of the patient in the proper
position safeguards the patient and affords him comfort while enabling the medical officer and
the anesthetist to work effectively.

b. Responsibility for Ordering the Patient's Position. The choice of position is made by the
surgeon, with minor adjustments, if necessary, for the type of anesthesia and its administration.
The responsibility for positioning the patient rests with the anesthetist; however, since he is
usually busy with the details of the anesthetic, he normally delegates this responsibility to the
specialist under his supervision. Important considerations in positioning the patient include the
following:

(1) The type of surgery scheduled. The operative area must be accessible and easy to keep sterile,
and the position must be conducive to speed and efficiency of the surgeon.

(2) The type of anesthesia to be given. The patient's position must permit sufficient space for the
necessary equipment.

(3) Protection of patient's vital processes. The patient's vital processes must not be impaired
because of his position for surgery.

c. Equipment for Positioning. Before he can effectively position patients, the specialist must
familiarize himself in detail with the mechanism of the operating table he will use, as well as the
table attachments and the various supplies used. Following the acquisition of this basic
knowledge, the specialist may gain skill and proficiency in the manipulation of the table and the
placement of the attachments through practice.

(1) The operating table (see figure 1-4). Operating tables differ among hospitals and among
rooms in the same hospital. However, most of the tables consist of a rectangular metal top that
rests upon a hydraulic, wheeled base. The table is designed for placement of the patient in many
different positions, while enabling his body structures and his vital processes to be safeguarded

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no matter what his surgical position is. Various features of the table that enable it to fulfill its
functions are as follows:



                                                                      Figure 1-4. Operating table.

                                                                     (a) The tabletop is divided into
                                                                     three or more hinged sections,
                                                                     each of which can be
                                                                     manipulated by means of a lever
                                                                     or a push button. The individual
                                                                     sections of the table can be
                                                                     flexed or extended so that the
patient may be placed in any desired position. This procedure of adjusting the sections is often
called "breaking" the table since the joints are referred to as "breaks."

(b) The table is equipped with a crossbar (body elevator) that can be used as an elevator for
gallbladder or kidney operations. The bar is manipulated by a lever.

(c) There are metal clamps along the sides of the table for the insertion of various table
attachments needed, such as the anesthetist's screen, the footboard, stirrups, shoulder braces, and
body rests.

(d) Levers and lifts enable the entire table to be tilted from side to side or end to end and raised
or lowered as desired. There is a brake locking the table base and a tiltometer that indicates the
degree of tilt between vertical and horizontal.

(e) A mattress or pad is designed to fit the table, constructed in sections, and covered with
conductive material for safety. This type of a covering also enables easy cleaning.

(f) The proper maintenance of the table is essential in ensuring that the table is always ready to
serve its purpose. After each use, the operating table is cleansed with antiseptic solution. If blood
or secretions are on the table, it is first washed with soap and water and then with an antiseptic
solution. The metal table can be cleaned quickly and easily. In addition, the table should be
checked daily for the stability and workability of all levers, brakes, and other mechanisms. Any
faults should be reported immediately for repair.

(2) Table attachments. All attachments used to secure the patient in the desired position must be
adequately padded to prevent trauma. Fresh padding is used for each patient.

(a) The anesthetist's screen is either a rectangular or a curved rod that keeps the sterile drapes off
the patient's face and separates the sterile from the nonsterile field at the head of the table. Sterile
drapes may be attached to intravenous (IV) standards on either side of the table rather than placed
over the anesthetist's screen.

(b) The leg strap is made of leather or heavy canvas and is covered with conductive rubber.
Sometimes called a restraint strap, it is used to restrain the patient's legs during induction of
anesthesia and for placement in many positions. (Lithotomy, paragraph 1-19, is an exception.)
The strap must be tight enough to prevent movement, yet not so tight that it will interfere with
circulation.

(c) The patient's arms are usually restrained in the "lift sheet," a draw sheet that is placed across
the operating table each time it is made up. The patient's arms should be tucked into the sheet


                                                                                                       12
before the anesthesia is started. Wristlets (leather cuffs) may also be used to secure the patient's
hands and arms.

(d) An armboard of metal or wood may be used in several instances, and it is slipped under the
mattress or attached directly to the table. Uses of an arm board include the following: support an
arm when an intra-venous infusion is employed; support the arm on the unaffected side when the
patient is in the lateral position; serve as an operating table when the site of operation is the arm
or hand; hold the arm away from the field when the patient's arm at his side would be in the way
of the operative area; or to support the arms when the patient is too obese for the table and hold
both his body and his arms.

(e) Body rests are curved pieces of metal padded with foam rubber. These are placed in metal
clamps on the sides of the table and slipped in from the table edge against the body to support and
stabilize it in certain positions.

(f) Kidney rests are wider than body rests, but are also curved metal pieces with grooved notches
at the base. They are slipped in from the side of the table along the kidney elevator (bar) to fit
snugly against the side of the patient, supporting his body during kidney surgery.

(g) The metal footboard can be attached flat to increase the length of the table when necessary, or
it may be placed at a 90-degree angle to the table and padded to support the feet in an upright
position. The soles of the feet rest securely against it.

(h) Shoulder braces are of curved metal and are used to prevent the patient form slipping toward
the head of the table while in certain surgical positions.

(i) Stirrups are metal posts; they are placed one on each side of the table at the lower (foot end)
break and are used to support the legs and feet when the perineal area is the site of operation. The
knees and lower legs may rest on padded metal supports or the feet may hang in canvas straps
attached to an upright bar.

(j) The cerebellar headrest is a frame that supports the patient's head when he is in the prone
position, and is used in spinal and posterior thoracic surgery. It is shaped to fit the face and has an
opening for the nose and mouth.

(3) Additional necessary supplies.

(a) Pillows of various sizes are used to immobilize or to relieve pressure on a part.

(b) The lift sheet is used to secure the patient's hands and arms during the operative procedure.

(c) Sandbags in various sizes are used to immobilize a part.

(d) Adhesive tape of various widths and lengths is used when the patient is placed in certain
positions to stabilize the body.

(e) Materials of foam rubber, sheet wadding, and cotton are used to pad attachments so that the
patient will not be injured.

(f) Extra sheets and towels are used for stabilization in certain positions.

(4) Dressing the table. The table is routinely "dressed" or made up by covering the pad with a
sheet doubled lengthwise and tucked in on the sides and ends. A lift sheet is placed across the
center of the table; it is folded in quarters (fan folded). Folding it thus keeps the ends of the sheet
from dangling down the side of the table, and enables the ends of the sheet to be moved without
                                                                                                       13
disturbing the rest of the lift sheet or the other linen on the table. The lift sheet facilitates moving
and lifting the patient, and it is used to secure his arms at his sides. The leg-restraining strap is
included in "dressing" the table.

d. Principles Influencing Positioning. The principles discussed below govern proper positioning.
The specialist should follow the principles every time he positions a patient. The observation of
these principles will ensure maximum safety and comfort for the patient.

(1) The patient should be told why he is being restrained, if he is awake.

(2) Unnecessary exposure of the patient should be avoided.

(3) The wheels of the operating table and the litter (or the bed) are always to be locked before the
patient is moved.

(4) A sufficient number of personnel must be present to assist with positioning. At least two
persons are required to place the patient in the surgical position desired.

(5) The patient is not to be touched or placed in position until the anesthetist indicates that it may
be done.

(6) The patient's body alignment must be correctly maintained while he is being positioned.

(7) The persons who position the patient must be thoroughly familiar with the mechanics of the
table and with its attachments.

(8) Personnel who position the patient must also know thoroughly the different types of positions
and the surgical procedures in which they are used.

(9) The specialist should assemble all attachments and supplies before the patient arrives.

(10) When it is necessary to change the patient's position, the specialist should perform the
procedure using movements that are slow, smooth, and gentle.

(11) All OR personnel must have a complete knowledge of the safety precautions that are
mandatory in positioning.

e. Precautions Mandatory in Positioning.

(1) Respiration must not be impaired by interfering either with the free movement of the chest or
with the airway. Therefore, anything that would constrict the chest or put pressure on it must be
avoided. A change in position must be executed slowly, gently, and smoothly to safeguard the
patient from respiratory embarrassment.

(2) Circulation must not be obstructed, either by pressure against the body parts or by too tight
application of restraining straps. Changing the position of the patient too rapidly may also cause a
circulatory depression (evidenced by a rapid fall in blood pressure). Free circulation helps prevent
thrombus (blood clot), phlebitis (vein inflammation), and other postoperative circulatory
disturbances. It also helps the flow of intravenous solution or a transfusion, if either is running
and helps to maintain an even blood pressure.

(3) Nerve damage must be avoided; nerve injury and paralysis may result from either pressure on
nerves or stretching of nerve tissue. To avoid such injury, the specialist should place attachments
correctly, making sure that they are well padded. He should also exercise care that the patient's
arms do not drop over the edge of the table, that they are not pressing against the edge of the
                                                                                                      14
table, and that they are not hyper-extended. Permanent paralysis of a part may occur because of
prolonged pressure on the nerves.

EXAMPLE: Paralysis of the arm may result from incorrect placement of the shoulder braces.

(4) Muscles, tendons, and bones must be protected from injury. Excessive stress on these
structures causes damage and must be avoided. Damage to these structures results in such
postoperative complications as backache, foot-drop, and wrist drop.

f. Positioning the Patient.

(1) Equipment. The circulator should assemble the equipment needed. He should take all needed
supplies into the room in preparation for the operation in addition to the equipment.

(2) Practice. The specialist should refer to the procedural manual and practice positioning until
he has acquired skill and confidence. Until he is well practiced in placing patients in various
positions, he should do practice trials of the position--preferably the evening before surgery--
using a co-worker as the patient. The specialist (if in doubt about any step of the procedure)
should consult his immediate superior at this time, not when the patient is anesthetized and ready
for positioning,

(3) Complications. Positioning looks easy on demonstrations, but the actual situation is usually
complicated by infusion tubes, drains, size of the patient, and his wound, or his anesthetized
condition. Sufficient assistance must be available before any position is attempted. Positioning
may also have to be changed during the course of surgery when the drapes, already in place,
present a complication. In this situation, a thorough understanding of how the table operates is of
primary importance.

g. Commonly Used Positions. Frequently used surgical positions are discussed in paragraphs 1-14
through 1-23. These positions may be modified to conform with local policy, or upon order of the
surgeon. In the illustrations of positions, covers are left off the patient for clarity of illustration
only. The specialist should avoid exposing a patient.




1-14. SUPINE POSITION (DORSAL RECUMBENT)

a. Use. This is the usual position (see figure 1-5) for administering general anesthesia and for
doing most surgery of the abdomen such as laparotomy, herniorrhaphy, and appendectomy. With
slight modifications, it is also used for other types of surgery, such as surgery on the arms or legs.

b. Equipment Needed.

(1) The anesthetist's screen.

(2) A sheet or bath towel. If support of the head is desired, a sheet or towel is folded and used--
not a pillow, as it would be in the anesthetist's way.

c. Procedure.

(1) Look at the operating table to be sure that it is parallel to the floor.



                                                                                                    15
(2) Place the patient flat on his back, his knees over the lower break of the table, feet slightly
apart. The soles of the feet are supported by a foam rubber support or a padded footboard.

(3) Place the patient's arms and hands at his sides. His elbows should be slightly flexed and his
fingers extended.

(4) Secure his hands and arms with the lift sheet.

(5) Place the leg strap at the distal third of his thighs, about two inches proximal to his knees.
Fasten the leg strap tight enough to secure his legs, but not tight enough to constrict circulation.
Check it by running a hand under it. If it is fastened too tightly to allow the hand to be run under
it, loosen it enough to correct this. The leg strap is secured before anesthesia is begun.

(6) Remove the covering from the operative area and adjust the light. (This step is done when the
anesthetist gives "OK," after patient is anesthetized.)

(7) Attach the anesthetist's screen.

(8) In order to prevent post-operative discomfort, flex the table slightly at both breaks or place a
rolled towel or small pillow under the knees. This padding should be very soft, and should not
make the strap too tight.

d. Precautions. Observe the precautions set forth in paragraph 1-13e.

e. Modifications of the Supine Position. The most usual modified supine position is one in which
the table is flexed slightly at both breaks. Sometimes the knees are flexed with a small pillow
instead. A number of other modified positions are mentioned in this paragraph. When the position
of the table is changed with the patient on his back, special precautions are necessary to protect
him.

(1) When the head is turned to one side or the other, it should be supported to keep the spine in
alignment and secured in the desired position with a doughnut cushion, sandbag, or special
headrest.

(2) Pressure over bony prominences where nerves and blood vessels run superficially must be
avoided. The eyes must be carefully guarded against pressure, and they must be protected as
drapes are placed to prevent corneal irritation from textiles, solutions, and other foreign bodies.

(3) For operations on the neck, the neck may be extended by placing a narrow support between
the shoulder blades or by lowering the headpiece of the table. There should be no gaps in the
support of the neck in this position. A special screen that protects the face may be used in thyroid
surgery.

(4) For anterolateral incisions and for surgery on the shoulder or the chest, the patient's affected
side may be elevated on rolls or pads. To prevent twisting of the spine, the full length of the body
needs support that will keep the hips and shoulders in a plane. Body supports or straps in
appropriate locations maintain the position and prevent rolling without interfering with the
surgical approach.

(5) An arm-board may be used to support the arm on the affected side. In some cases, both arms
are supported on arm-boards. In a few cases, the arm may be bandaged to the ether screen, using
specific precautions against nerve and circulatory disturbances. In many procedures, one arm is
usually extended on an arm-board to administer intravenous therapy. One or both arms may be
extended in radical mastectomy and other surgery on the upper extremity and chest regions.


                                                                                                      16
(6) The arm-board is padded to protect the skin and superficial tissues from pressure. The arm is
extended at an angle less than 90 degrees to the table and level with the table. The arm-board is of
the type that locks into position on the table to prevent inadvertent angle changes.
Hyperabduction at the shoulder may cause both vascular and neural damage. Venous thrombosis
may result when superficial veins are compressed by supports or straps or by the weight of body
structures. The subclavian or axillary arteries may be occluded in abduction.

1-15. TRENDELENBURG POSITION

a. Use. The Trendelenburg position (see figure 1-6) is used for operations on the bladder, prostate
gland, colon, female reproductive system, or for any operation in which it is desirable to tilt the
abdominal viscera away from the pelvic area for better exposure.




Figure 1-6. Trendelenburg position. Note that the knees are over the lower break in the table and
shoulder braces are in place.

b. Equipment Needed.

(1) Shoulder braces.

(2) Padding, made of sponge rubber or of folded hand towels.

c. Procedure.

(1) Place the patient in the supine (dorsal recumbent) position and adjust the mattress so that his
knee joints are directly over the lower break. The knees must bend where the table breaks to
prevent pressure on blood vessels and nerves in the popliteal region, avoiding complications of
phlebitis or paralysis of the leg. Secure patient's arms and legs.

(2) Attach well-padded shoulder braces to the table. Check to see that the braces are the same
distance from the head of the table.

(3) Adjust braces so that they are on the outer part (bony joint) of the shoulders rather than
against the neck. Braces should be adjusted one-half inch from shoulders to prevent excessive
pressure when the head of the table is lowered.

(4) Flex the table at the knees, dropping the leg portion usually to an angle of 30 to 40 degrees.

(5) Tilt the entire table, the head low, to the angle desired by the surgeon, usually 30 to 40
degrees. The head should be lower than the knees.

d. Precautions.

(1) The nerve supply to the upper extremities comes from the spinal cord, gathers at the brachial
plexus and emerges under the muscles in front at the root of the neck, where the neck and
shoulder join. It is very important to protect these nerves when using the Trendelenburg position.
This is done by using adequate padding on the shoulder braces, and by placing the braces at the
outer aspect of the shoulders over the acromion and spinous process of the scapula.



                                                                                                 17
(2) Careful positioning of the knees over the break is needed to prevent pressure in the popliteal
space and safeguard the perineal nerve. Breaking the table at the knees takes some of the body
weight off the shoulder braces and reduces pressure there. The legs are straightened before the
patient is returned to a horizontal position.

(3) While this is mainly the anesthetist's concern, you should also know that this position may
result in respiratory distress.

e. Modification of the Position. The Trendelenburg position is often mistakenly confused with
shock position (extreme Trendelenburg position). The two are the same, except that in shock
position, the table is straight (unbroken) at the knees so that the feet are higher than the head.

1-16. REVERSE TRENDELENBURG POSITION

a. Use. The reverse Trendelenburg position (see figure 1-7) may be used for surgery on the neck,
such as thyroidectomy, and for certain abdominal surgery, such as liver or gallbladder operations.

b. Equipment Needed.

(1) Two small pillows or two folded sheets.

(2) Footboard, padded.




Figure 1-7. Reverse Trendelenburg position.

c. Procedure.

(1) Place the patient flat on his back. Adjust the mattress so that his shoulders are at the upper
break of the table. If surgery is in the neck area, place a small pillow or a folded sheet
transversely under the neck and shoulders, as shown in figure 1-7.

(2) Attach the padded footboard at a 90-degree angle to the table and adjust it so that the soles of
the feet are resting against it. Place padding under the legs (see figure 1-7) to take pressure off the
heels.

(3) Secure the arms and legs.

(4) Tilt the table, foot forward, to the desired angle.

d. Elevator Bridge. Some surgeons make use of the elevator bridge of the operating table to
expose the gallbladder. When this is anticipated, the patient must be positioned with the costal
margin at the level of the elevator. If an elevator is lacking, the table may be flexed at this level,
or a pad may be inserted to achieve the desired position.




1-17. LATERAL KIDNEY POSITION
                                                                                                     18
a. Use. The lateral kidney position (see figure 1-8) is used for surgery on the kidney or the
proximal third of the ureter.



                                              Figure 1-8. Right kidney position.
                                              Note the kidney strap across the hips for stabilizing
                                              the body and raised kidney elevator for
                                              hyperextending operative areas.

b. Equipment Needed.

       One or two large, soft pillows.
       Strap.
       Armboard, well padded.
       Short kidney rest.
       Long kidney rest.
       Foam rubber cushion.

c. Procedure. The patient is in the dorsal recumbent position until he is anesthetized. When the
patient is ready for positioning, the circulator and his "unsterile" assistants are to proceed as
follows:

(1) Turn the patient onto his unaffected side and bring his back near the edge of the table. Then
wait until the anesthetist has checked the patient's blood pressure before continuing with (2)
below.

(2) Manipulate the mattress as necessary until the patient's kidney area (the area between the
crest of the ilium and the first rib cephalad from the iliac crest) is over the body elevator
(crossbar, para 1-13c(1)(b)) of the table.

(3) Flex the (lower) leg on the unaffected side at the knee, extend the (upper) leg on the affected
side and place a pillow lengthwise between the legs. Also, place padding under the leg in contact
with the table at the sites of bony prominences (hip, knee, and ankle).

(4) Place a restraining belt or adhesive strap across the hips and chest to stabilize the body.
Check the belt or strap for tightness by running your hand under it. Your hand should run
smoothly under the belt or strap. Adjust as necessary.

(5) Position the arms by bringing them to the front of the patient. Flex the elbows slightly and
place the arms on a well-padded double arm-board or Mayo stand. The arm of the unaffected side
is usually used for intravenous infusion or transfusion.

(6) A well-padded short kidney rest is placed at the patient's back.

(7) Place a long kidney rest, well padded, in front.

(8) Adjust the body elevator only upon the order of the anesthetist or the surgeon. When
manipulating the bar, move it slowly, because too sudden a change may result in complications in
the patient's respiration or circulation.

(9) Adjust the table to make the operative area horizontal.

1-18. LATERAL CHEST POSITION


                                                                                                    19
a. Use. The lateral chest position (see figure 1-9) is used for thoracoplasty, pneumonectomy, and
lobectomy.




Figure 1-9. Right lateral position. Note the strap across the hips and body rest for stabilizing the
body.

b. Equipment Needed.

       Single armboard.
       Small, hard pillow/form rubber cushion. Large, soft pillow.
       Two chest rests/sandbags.
       One or two kidney straps.
       Three inch adhesive tape.

c. Procedure.

(1) Place the patient on his unaffected side with his back near the edge of the table. This requires
two people: the anesthetist managing the head and shoulders, and the assistant moving the hips.

(2) Place the upper leg straight with the patient's body, and flex the leg on the lower side. Place a
pillow lengthwise between the legs.

(3) Place a folded sheet or a small hard pillow under the patient so that it is immediately beneath
the operative area (see figure 1-9). This relieves some of the pressure on the arm on the
unaffected side and permits the free flow of any replacement fluids infused through the vessels of
this arm.

(4) Place a chest rest near the lumbar area, and another at the level of the axilla.

(5) Bring the patient's arms and hands in front of him near his face and secure them. Secure the
arm on the unaffected side to a padded arm board and the other arm rests on a pad as it hangs
over the side of the table. This draws the scapula away from the operative area.

(6) A pad or small pillow is used to align the head and neck.

(7) Secure a strap over the hips. A second strap is sometimes used to stabilize the shoulder.

(8) Tilt the table slightly, with the patient's head towards the floor if the patient needs postural
drainage during surgery. If the patient's head is to be lowered, secure the mattress to the table to
prevent it from slipping.

1-19. LITHOTOMY POSITION

a. Use. The lithotomy (see figure 1-10) position is used for surgery in the perineal area, such as
drainage of rectal abscesses and perineal prostatectomies, and for gynecological surgery such as
vaginal hysterectomy.



                                                                                                   20
                                          Figure 1-10. Lithotomy position.

                                          In the lithotomy position, the patient is on his back with
                                          the foot section of the table lowered to a right angle with
                                          the body of the table. Knees are flexed and the legs are
                                          on the outside of the metal posts with the feet supported
                                          by canvas straps. The buttocks are even with the table
                                          edge.

                                          b. Equipment Needed.

                                               bucket.
       A double-ringed basin stand, or an extra Mayo stand.
       One pillow.
       A rubber sheet, a Kelly pad, or a disposable paper mat, and a kick
       Extra folded sheet or bath towel.
       Folded hand towels for padding the stirrups.
       Stirrups-upright bars with canvas straps.

c. Preliminary Preparation of the Table. The specialist makes some adjustment and preparation of
the table before positioning the patient.

(1) Pad a double-ringed basin stand or an extra Mayo stand with a pillow and place it at the foot
of the table. The stand is used as a temporary table extension. If the table has a removable
headrest, the headrest can be used as the temporary table extension.

(2) Cover the table from the knee break to the foot; first with a rubber sheet or a Kelly pad, and
then with an extra folded sheet or bath towel.

d. Procedure. For the administration of anesthesia, the patient is placed in the supine position with
buttocks at the edge of the knee break. In this position, the patient's legs will of course extend
beyond the end of the table, but they will be supported by the extra basin stand, Mayo stand, or
headrest. When the patient is anesthetized, the specialist and an "unsterile" assistant place the
patient in position as follows:

(1) Remove the leg restraint.

(2) Fold the patient's arms and hands either across his upper abdomen or across his chest. See
paragraph 1-19e, Precautions.

(3) Make sure the two stirrups are level, and at the proper height. Each of the two "unsterile"
team members takes a position on either side of the patient at the foot end of the table. Each team
member grasps a patient's leg near the knee with the other hand. The team members then flex the
patient's legs and simultaneously lift them and place them in the padded stirrups. It is important
that both legs be lifted at the same time to prevent injury to the patient.

(4) Place the legs in the padded metal supports and secure the straps. To position the legs using
canvas straps, bring the legs to the outside of the upright bars. Loop the strap once around the sole
of the foot and once around the heel. Pad the bars with folded hand towels in the areas where they
are touching the legs or where the legs may press against the bars.

(5) Remove the basin stand or Mayo stand, if used.


                                                                                                  21
(6) Remove foot section of the table mattress and break and drop the foot of the table.

(7) Pull the stirrups forward to extend slightly beyond the foot end of the table. Viewed from the
side, the legs should form a "Z" shape with the angle of the buttocks.

(8) Place the end of the Kelly pad (if one is used) in the kick bucket. This pad keeps the table dry
under the patient during the surgical prep. The pad is removed after the prep and before the
patient is draped.

e. Precautions. This unnatural posture is fraught with danger and discomfort for the patient, and
these hazards increase as the position is exaggerated for radical surgery. Extreme flexion of the
thighs impairs respiratory function by increasing intraabdominal pressure. Gravity flow of blood
from elevated legs causes blood to pool in the splanchnic region. Arms also require special care
in lithotomy position. The hands should not extend along the sides, since they will reach below
the break of the foot section of the table and be in danger of injury from manipulation of table
parts. They may be folded loosely across the abdomen and supported by the folded gown or cover
sheet, or one may be extended on an arm-board for infusion while the other is suspended from the
anesthesia screen. Be sure they do not impede chest movement.

1-20. PRONE POSITION

a. Use. The prone (see figure 1-11) position is used for surgical procedures-major or minor-that
are performed on the back, shoulders, neck, or back of the head. Placement of the patient in the
prone position for minor surgery, using local anesthesia, differs in some respects with placement
for general anesthesia.

b. Prone Position for Local Anesthesia.

(1) Equipment needed. This equipment is the necessary material to support the body in good
alignment and to relieve pressure on blood vessels and nerves. Pillows, sheets, towels, and
padded arm-boards are needed.



                                                     Figure 1-11. Prone position.

                                                     In the prone position, the patient lies on his
                                                     abdomen. Note shoulder rolls under axillae and
                                                     sides of chest to raise body weight from the
                                                     chest to facilitate respiration. The patient is
                                                     anesthetized and the endotracheal tube inserted
in dorsal position. He is then turned to prone.

(2) Procedure.

(a) Adjust the table so that it is flat and horizontal.

(b) Assist the patient in turning onto his abdomen, and have him turn his face to one side. Place a
small pillow or ring cushion under his head to avoid pressure on his ear.

(c) Place a pillow under his thighs and hips.

(d) Place a pillow under his feet so that it extends nearly to the knees.

(e) Flex the arms at the elbows and place alongside the patient's head, on padded arm boards.
                                                                                                  22
(f) Place a small pillow or a rolled sheet under each shoulder and down the sides of the chest, as
shown. This prevents pressure on the chest and allows for free respiration.

(g) Secure the leg strap to the lower third of the thigh and check it for tightness.

c. Prone Position for General Anesthesia (Extended Prone Position). When the surgical procedure
is to be done with the patient in prone position under general anesthesia, the cerebellar headrest is
used to allow the anesthetist access to the patient's respiratory tract.

(1) Equipment needed. In addition to that set forth above, the following items are needed:

(a) A well-padded cerebellar headrest.

(b) Shoulder braces, if the patient is to be placed in a head-low position.

(2) Procedure. The patient is placed in the dorsal recumbent (supine) position for the
administration of anesthesia. While the patient is being anesthetized, the specialist rolls two
sheets so that they will extend from the patient's axilla to his iliac crests. Turning the patient onto
his abdomen requires four persons plus the anesthetist, who manages the patient's head and any
tubing in use. The procedure is as follows:

(a) Lift the patient's head slightly, remove the hinged headpiece, and attach the cerebellar
headrest in its place.

(b) While the anesthetist manages the patient's head, two persons on each side of the patient turn
him first on his side, and then onto his abdomen. At the same time, pull him toward the head of
the table in order that his face and forehead will rest properly in the cerebellar headrest. Check to
see that there is not pressure on the patient's eyes, nose, or mouth.

(c) Place pillows.

(d) Place the two rolled sheets, one on each side, from the patient's axilla to his iliac crest, thus
raising his chest from the mattress and providing free respiration.

(e) Both arms are arranged on boards.

d. Precautions. These are as described previously (see para 1-13e).

1-21. JACKKNIFE (KRASKE) POSITION

a. Use. The jackknife (Kraske) (see figure 1-12) position is used for surgery on the coccyx,
buttocks, or rectum, particularly when the patient has had spinal anesthesia and there is no
objection to his being placed either face downward or head low.




Figure 1-12. Kraske position.
Note that the hips are over the table break, and the table is flexed at a 90-degree angle.

b. Equipment Needed. Pillows for support. Padded armboards. Adhesive straps. Body rolls.
                                                                                                        23
c. Procedure. The patient is anesthetized in the appropriate position, depending upon the type of
anesthesia used. When he is ready for positioning, the following steps are taken:

(1) Turn the patient on to his abdomen. (This is done by four persons plus the anesthetist as
described in paragraph 1-20c(2).

(2) Place the patient's hips directly over the break of the table. A pillow may be placed under his
hips (not shown in figure 1-12).

(3) Position the patient's head by turning it to one side. Place small pillow or a ring cushion
under his head as discussed above. The feet may be allowed to hang over the foot end of the table
to prevent pressure on the toes. Place a pillow or padding under the legs.

(4) Secure the leg strap and check it for tightness.

(5) Flex his arms and elbows, and place his arms on padded armboards or Mayo stands.

(6) Flex the table at the knee break to the angle desired by the surgeon. Tilt the table and the head
floorward to the angle ordered. The patient's hips are thus placed higher than the rest of his body.

(7) Separate the buttocks by securing strips of adhesive tape from the patient to the side of the
table. Before putting the tape on the patient, first paint the area where the tape is to be placed with
tincture of benzoin. Use a sponge forceps and a 4 x 4 sponge. Be careful not to let the tincture of
benzoin spill on the table or the floor. Let the tincture benzoin dry thoroughly before applying the
tape. An application of tincture of benzoin ensures that the tape will remain firmly in place and
will not be loosened, even during the prep. Patients who are hairy in the area where the tape is to
be placed should have this area shaved before being brought into the OR.

d. Precautions. These are discussed above and in paragraph 1-13e.

1-22. SITTING POSITION

a. Use. Included in surgery for which the patient sits upright are various operations on the nose
and throat, as well as some plastic surgical procedures. The sitting position (see figure 1-13) is
                                          described using the operating table as a chair.



                                           Figure 1-13. Sitting position.

                                           b. Equipment Needed. Most of the items discussed
                                           below for the support of the patient are omitted from
                                           figure 1-13 for clarity of illustration. The equipment
                                           needed are one pillow, two sheets, shoulder straps, and a
                                           padded footboard.

                                           c. Procedure.

    1.   Attach the footboard at a 90-degree angle to the table.
    2.   Secure adhesive straps across the mattress for stabilization.
    3.   Secure ends of lift sheet under the mattress.
    4.   Break the table into a sitting position.
    5.   Pad the footboard with a folded sheet.
    6.   Assist the patient onto the table.


                                                                                                     24
    7. Adjust and secure the leg strap. Adjust the footboard so that the feet are resting securely
       on it.
    8. Place a sheet around the patient so that it reaches from the axilla to the iliac crest. Leave
       the arms free. Tie the sheet behind the table, using a square knot.
    9. Place a pillow in the patient's lap to support his arms. The arms may then be restrained in
       the lift sheet.

1-23. POSITIONS FOR SPINAL ANESTHESIA

a. Discussion. The patient may be in either a lying or a sitting position for the administration of
spinal anesthesia. The position used will depend upon the condition of the patient and the
preference of the anesthetist.

b. Lying Position (see figure 1-14). Most subarachnoid blocks are given with the patient lying on
                                           his side.



                                             Figure 1-14. Lying position for spinal anesthesia.

                                           This is the Sims position and is often referred to as the
                                           curled lateral position and is useful in establishment of
                                           subarachnoid and epidural anesthesia. (From Martin,
J.T., M.D.; Positioning in Anesthesia and Surgery, ed. 2, Toledo, Ohio, 1987, W. B. Saunders
Company.)

(1) Principles. The two basic principles for the steps discussed are to get the spinous processes of
the vertebral column parallel to the table and keep them in that position while the patient is well
flexed in order to open the vertebral interspaces.

(2) Procedure.

(a) Adjust the table so that is flat and horizontal.

(b) Place the patient on his side with his back even with the edge of the table. Instruct the patient
(if he is able to do so) to bring his knees up toward his chest, and to flex his head (chin on chest).
Ask the patient to curl up, arching his back like an "angry" cat.

(c) Check to see that the patient's knees are together and that his shoulders are in alignment, one
directly above the other, to facilitate the anesthetist's entering the needle into the vertebral
interspace.

(d) Caution the patient not to move. Assist him in holding his position by placing one arm behind
his neck and the other arm behind his knees.

(e) Do not place the patient in the desired surgical position after the anesthetic has been
administered until instructed to do so by the anesthetist.

c. Sitting Position (see figure 1-15). Sometimes, the anesthetist has reason to believe that, due to
                                the condition of the patient, he may have difficulty in performing
                                the lumbar puncture satisfactorily with the patient lying down.
                                Faced with this type of situation, the anesthetist may order that the
                                specialist place the patient in a sitting position.



                                                                                                    25
Figure 1-15. Sitting position for spinal anesthesia.

(1) Equipment needed. A stool for the patient to rest his feet upon is needed.

(2) Procedure.

(a) Place the patient in a sitting position with his legs over the side of the table. Put the stool
under his feet.

(b) Instruct the patient to lean forward, his chin on his chest, and to arch his back as much as
possible. Caution him not to move.

(c) While the lumbar puncture is being performed and the anesthetic is being administered, stay
with the patient. Support the patient by holding his head and shoulder with one arm and his thigh
with the other arm. Watch the patient closely for any unusual signs or symptoms such as paleness,
weakness, and dizziness. Do not place the patient in the desired surgical position until the
anesthetist orders it done.


                        PROCEDURES IN PREPARING THE PATIENT
                           LESSON 1-3 SURGICAL POSITIONS

After completing this lesson, you should be able to:

       Identify common anesthesia terms and their definitions.
       Identify proper procedures for performing a preoperative skin prep.
       Identify equipment used in positioning patients.
       Identify procedures for placing a patient in the supine, Trendelenburg, reverse
        Trendelenburg, lateral kidney, lateral chest, lithotomy, prone, jackknife, and
        sitting positions and position for spinal anesthesia.
       Identify procedures for draping a patient.



1-24. INTRODUCTION

a. General. Draping is another of the precision routines performed in the OR. Surgical draping of
the patient is the placing of sterile coverings on him so that only the operative site is exposed.
Thus, the skin areas that have not been prepared for surgery are covered in order that they will not
contaminate any sterile items. The sterility of drapes depends upon their remaining dry and
undisturbed; therefore, the placing of drapes is the last procedure done prior to making the
surgical incision. In addition to the patient, the furniture to be used within the immediate surgical
area must be covered with sterile drapes to prevent contamination of the wound.

b. Purpose. The purpose of draping is to create a sterile field by means of the appropriate and
careful placement of linen before surgery begins and to maintain the sterility of surfaces on which
sterile instruments and gloved hands may be placed during the operation. These requirements
presuppose that all drapes are well secured with towel clips (where necessary) according to the
accepted procedure to prevent disarrangement and contamination, and that the nonsterile
anesthetist and the area required for him are excluded from the sterile area by a drape-covered
screen.

c. Extent of Draping.



                                                                                                      26
(1) Thickness of drapes. One drape (two thicknesses of material) provides an acceptable cover
for a sterile field under usual conditions. More than two thicknesses may be required, however,
especially in those areas where either instruments or sponges are laid if there are possible sources
of contamination, such as moisture, which may seep through to an unsterile surface beneath. Too
many layers of drapes over a patient are detrimental to him because they cause him to perspire
profusely. In addition, the excessive perspiration may soak through the drapes, thus
contaminating them.

(2) Area draped. The sterile drapes must extend over the sides and ends of the tables to prevent
contamination of either the sterile instruments or the gowns worn by members of the team.

d. Responsibility for Draping.

(1) Scrub. The scrub is responsible for providing an area large enough for all sterile supplies to
be used. He stacks the drapes for the patient, prepares the operating table in the proper order of
their use, and refolds towels as necessary for the case and handing these, with towel clips, to the
surgeon. If the surgeon has no medical officer assistant for the case, the specialist helps him drape
the patient.

(2) Surgeon. The surgeon is responsible for the draping of the patient. When the surgeon has
scrubbed and put on gown and gloves, he places the towels (securing them with towel clips)
outlining the incision area, after the skin has been prepped and has dried. This completed, the
surgeon may choose to place the drapes himself with the help of his assistant or to supervise their
placement by his assistants and the scrub.

e. Types of Drape Material.

(1) Synthetic and paper. Absorbent and nonabsorbent synthetic and paper disposable drapes are
available in presterilized packages. The most popular ones are soft, lint-free, lightweight,
compact, non-irritating and static free. They prevent heat retention by patients because of their
lightness, yet they do not usually require reinforcement to prevent moisture seepage. The main
disadvantage of synthetic drapes is that solvents, volatile (evaporating) liquids, and sharp
instruments may easily penetrate the barrier and cause contamination. The high cost is largely
offset by the elimination of laundering, folding, and sterilizing that is necessary for linen drapes.

(2) Impermeable plastic drapes. Impermeable (not permitting passage, especially of liquid)
plastic sheeting in various types and sizes is available with an adherent coating. Since it adheres
tightly to the skin, the initial skin incision is made through it; therefore, it may be used instead of
the skin towels and clips, especially since it serves as an excellent barrier at the incisional site and
the surrounding area. A Vi-drape is an example of an impermeable plastic drape. Impermeable
plastic drapes are especially useful for draping irregular surfaces, such as neck and ear regions, or
limbs and joints. This type of drape may also be used to isolate a contaminated area (such as the
stoma of a colostomy) from the operative site. The plastic drape isolates the wound completely
and prevents the contact of sterile materials with the patient's skin. When used, the plastic
adherent drape is applied first, and the remaining drapes are placed in the usual manner.

(3) Linen. The linen drapes most frequently used include:

(a) Hand towels used to outline the incision area.

(b) Sheets (ordinary bed sheets) are fan folded to cover the sterile field or to extend the sterile
area.

(c) Fenestrated sheets made in various sizes and with slits or windows of a size sufficient to
accommodate the length of the proposed incision.

                                                                                                      27
(d) Stockinette used as draping on limbs.

(e) Perineal sheets used with the patient in lithotomy position. They have leggings sewn on them
to cover the legs.

f. Basic Requirements for Drapes. Drape material must be free from holes and free from worn or
thin areas. A drape must be of sufficient thickness, and it must be fanfolded, so that it can be
opened quickly and placed without contamination.

g. Use of Packs. The use of linen packs for various types of surgery (laparotomy, perineal, or
orthopedic) saves time and effort as compared to opening individual packages of the many items
needed. All articles in a linen pack should be stacked on the sterile table in the order of their use
as a further timesaving device.

h. Procedure for Draping. Procedures for draping may vary somewhat among hospitals
depending on the types and the amount of linens available, but the principles pertaining to the
sterility and efficiency of the draping procedure remain the same. These principles are set forth
below.

i. Points to Remember.

(1) Sufficient time must be allowed for draping. Drapes carelessly placed without prior thought
or plan may mean contamination and further delay while the circulator procures and opens
additional sterile items.

(2) The scrub should have room enough to step back and open a drape sheet without contacting
other supplies or equipment.

(3) Drapes should be handled as little as possible.

(a) If there is any question as to whether or not a drape has been contaminated, discard it without
further handling.

(b) If a large drape opens incorrectly, do not try to rectify the error by "switching ends." Discard
it as contaminated and get another drape to replace it.

(c) Only the circulator may remove contaminated linen.

(4) Once the end of the drape falls, drops below table level, or touches the patient, it may not be
handled further. To do so would contaminate the gloves of the "sterile" person.

(5) The folded edge of the drape is always placed toward the incision area.

(6) Sterile drapes should never be handed to another person across an unsterile area.

(7) A folded drape is carried to the operating table and opened there. The placement of large
drapes requires two people.

(8) When drapes are being opened, they should be held above waist level, high enough to avoid
touching the table, and away from the body, but they must not touch the light fixture.

(9) Drapes are laid on the operative field, never dragged over it.

(10) Once the drape is placed, it should not be moved. The only exception to this rule is that a
drape may be pushed slightly away from the incision area; however, it must remain within the
                                                                                                    28
skin area that has been prepared using sterile technique. A drape may never be moved closer to
the operative area.

(11) Drapes contaminated or incorrectly placed should be removed by the circulator from the
operative area without contaminating the other drapes or the area.

(12) The initial drapes are placed on dry areas only, and the sterile field is kept as dry as possible
during surgery. If drapes should become damp during surgery, additional sterile towels may be
placed on the area, or a towel lined with sterile plastic may be used to drape the sterile area just
below the incision.

(13) The points of a towel clip are contaminated after placement through a drape. If the towel clip
is removed, it should be discarded to the circulator and a sterile drape placed over the area of
removal.

(14) Linen for draping must be thoroughly dry when it is placed.

(15) "Sterile" team members should always protect gloved hands in a fold of the drape being
placed.

(16) The circulator must move all buckets away from the OR table before draping of the patient
begins. This enables the other members of the team to avoid stumbling over the buckets, and it
prevents the buckets from being covered accidentally by the drapes.

j. Draping for Operations. Draping procedures for various operations, including methods, are
discussed in paragraphs 1-25 through 1-27. After mastering the principles and methods of
draping, the specialist should practice the arrangement and the placement of drapes until he has
acquired skill in the performance of the procedures. In the following procedures, the scrub and
the surgeon are the "sterile" team members in draping the patient.

1-25. LAPAROTOMY DRAPE

a. Use. Laparotomy drapes (see figures 1-16 A, B, C, D, and E) are used for operations on the
abdomen or on the back.

b. Procedures for Linen Drapes (Non-Disposable).

(1) The scrub stacks the drapes on the back table in the order of use: laparotomy sheet on the
bottom, one drape sheet, four towel clips, four hand towels refolded with a 4-inch cuff on one
long side, plus two drape sheets.

(2) The surgeon and the scrub open the drape sheet carefully, holding it high, and place it from
the knee area toward the bottom of the table.

(3) The second drape sheet is opened and placed with the smooth edge at the bottom (distal) edge
of the incision site down toward the foot of the table and overlapping the first sheet.

(4) The scrub moves to the surgeon's side of the table and hands the drape towels, one at a time,
to the surgeon--three towels with the cuff turned away from the surgeon and the last one with the
cuff turned towards him (see figure 1-16 C).

(5) The surgeon places the first towel at the operative edge nearest him, the second at the lower
edge of the operative site, the third at the upper edge, and the fourth on the side opposite him.



                                                                                                    29
(6) When all of the towels are in place, the scrub hands the towel clips, one at a time. They are
then placed by the surgeon.

(7) The final drape sheet is opened and placed above the incisional site (proximal edge) and over
the anesthetist's screen.

(8) The "sterile" team members drape the laparotomy sheet by placing the opening over the
operative area. The team members then open the lower fold over the patient’s feet and the upper
fold over the anesthetist's screen. During the process of unfolding the sheet, each team member
protects the gloved hand he is working with in a fold of the sheet and holds the sheet in place with
his opposite hand in order that the opening will remain over the incision area (see figure 1-16 D).

(9) The "sterile" team members cover completely any armboard in use, as though a part of the
table. If the armboard extends the edge of the laparotomy sheet, the team members place an
additional drape over it. The surgeon may need towel clips to secure the two sheets at the overlap;
or the circulator may grasp the sheet by its upper side as it hangs free below the patient's arm
where it is unsterile. He pins the sheet to an IV standard to relieve its weight and to allow the
anesthetist access to the arm (see figure 1-16 E).




Figure 1-16 A. Laparotomy drape.




Figure 1-16 B. Laparotomy drape.




                                                                                                    30
Figure 1-16 C. Laparoscopy drape.




Figure 1-16 D. Laparotomy drape (continued)




Figure 1-16 E. Laparotomy drape (completed).

c. Other Procedure. An alternative method of doing the laparotomy drape is to place as the first
drape one of adherent plastic or to spray the patient's skin, after it has been prepped, with a sterile
glue. Over this is applied a large sheet of very thin, sterile plastic which completely covers the
operative field and extends beyond it about 1 1/2 feet on all sides. Drape sheets and laparotomy
sheets are placed over this, as previously described. This procedure has three advantages. It
eliminates the use of drape towels, provides a sterile field through which moisture from above
cannot penetrate, and eliminates the need for skin towels, since the incision is made through the
plastic and the edges of the incision remain covered.

1-26. LITHOTOMY DRAPE

a. Use. A lithotomy drape is used for urological, OB/GYN rectal, and other procedures of the
perineal region when the patient is in the lithotomy position.

b. Procedure.

(1) The scrub checks and places the drapes in the proper order of use: lithotomy (perineal) sheet
on the bottom, three hand towels, four towel clips, one sterile translucent plastic adhesive towel
drape, and one drape sheet.

(2) The scrub gives the surgeon one drape sheet folded in quarters. The surgeon cuffs the sheet to
protect his hand as he places the sheet under the patient's buttocks.
                                                                                                    31
(3) If the procedure does not involve the anus or rectum, the scrub passes the plastic towel to the
surgeon who then covers the anus. This procedure is omitted for rectal or anal procedures.

(4) The scrub passes two towels folded diagonally, one towel folded end-toend, and four towel
clips which are used to secure the towels. The handles are turned away from the operative site.

(5) Apply the perineal sheet by handing one end of it to the assistant, opening out the folds, and
drawing the boots onto the feet and legs. Keep the hands on the outside of the sheet to avoid
contaminating gloves and gown. The circulator assists from the reverse side of the drape.

(6) Many hospitals are now using the disposable type lithotomy packs to drape for procedures
requiring the patient to be placed in the lithotomy position. These packs differ for each
manufacturer. The directions are supplied with the packs and should be followed.

(7) The "sterile" team members unroll the upper portion of the sheet over the abdomen.

c. Other Procedures.

(1) Using four drape sheets. If a perineal sheet with leggings is not available, four drape sheets
may be substituted as follows:

(a) The surgeon places one drape sheet under the patient's buttocks, folding a cuff of the sheet
over his gloves.

(b) The surgeon places a rectal towel and three diagonally folded towels as previously described
(see paras 1-26b(3) and (4)).

(c) The "sterile" team members place the second drape sheet over the patient's right leg and
thigh, the folded edge covering the drape towel, and the loose edges of the sheet fastened with a
towel clip behind the patient's leg; the opposite leg is draped in the same manner.

(d) The "sterile" team members may use a fourth drape sheet to drape the symphysis area and
extend over the abdomen.

(e) The surgeon may require additional towel clips to fasten the leg drape sheets to the sheet
under the buttocks.

(2) Using separate leggings. Another alternative method is the use of two drape sheets with a pair
of separate leggings.

(a) The surgeon places the first drape sheet under the buttocks, as described paragraph 1-
26c(1)(a).

(b) The surgeon and the circulator drape towels over the anus and the perineum as described
paragraphs 1-26b(2), (3), and (4).

(c) The surgeon slips a sterile legging over each leg, protecting his hands with the cuff.

(d) The circulator assists from the opposite side of the leg.

(e) The surgeon may use additional towel clips to secure the leggings over the draped towels.

(f) The "sterile" team members place the second drape sheet over the symphysis area and extend
it head-ward over the abdomen.

                                                                                                     32
1-27. DRAPING A LIMB

The procedure for draping a limb for a general surgical procedure differs from the procedure done
when orthopedic surgery is to be performed. Since the specialist will work with both types of
cases, he must know how to drape for both.

a. Draping for General Surgery.

(1) Draping of the arm will be described to point out the method of draping for general surgery
of a limb. Assume that the patient is to have a keloid (tumor) removed from the forearm.

NOTE: A lower leg may be draped using essentially the same procedure described below.

(2) Procedure. An armboard at least a foot wide or a Mayo stand is used as an operating table
under the arm.

(a) The circulator is required to keep the arm elevated during the skin prep and part of the
draping. He may support it by the elbow or by the hand. Holding it at the elbow is more
satisfactory, because this enables the circulator to hold the arm while he stands outside the sterile
field. In addition, the forearm may fall back on the upper arm unless held at the elbow. The arm is
especially likely to fall back on itself if the patient has had a brachial block. (If the arm should fall
back on itself, a second prep must be done.)

(b) The circulator should have an IV standard handy (near the head of the table) to which he may
pin the edge of a drape sheet.

(c) The scrub checks and stacks the drapes in the proper order of use: two drape sheets at the
bottom, the two hand towels, one cuffed as for a laparotomy drape and the other folded in half
from end-to-end, three towel clips, and a drape sheet on top.

(d) While the circulator elevates the arm, the "sterile" team members place the first sheet, folded
in quarters, over the armboard. It is necessary that the drape extend well below the end and over
the sides of the armboard (but it should not touch the floor). The folds of the drape are toward the
patient.

(e) A "sterile" team member places the hand towel folded in half on this drape sheet. The
circulator can then lower the patient's arm, releasing it to place the patient's hand within the towel
on the sheet.

(f) The surgeon folds this towel over the patient's hand and secures it with a towel clip. The
towel must extend into the prepped area, limiting the distal edge of the field. (If the area to be
operated upon is high on the forearm, two towels are necessary for the hand instead of one. They
are fully opened and placed one on top of the other to create a sterile cover of two thicknesses.)

(g) The surgeon places the second hand towel so that it limits the proximal edge of the prepped
area, and he places this towel over the arm rather than around it.

(h) Two "sterile" team members, one on either side of the armboard, open the second drape sheet
in the usual manner so that the fold in the sheet is toward the operative area and over the proximal
drape towel. The proximal edge may be fastened with towel clips on both sides of the arm to the
drape sheet below, to prevent slipping. The upper, loose edge of the drape sheet, toward the
patient's head, may be secured to an IV standard by the circulator.

(i) The "sterile" team members open the third drape sheet in the routine way and drape it
lengthwise along the operative side of the patient to extend the sterile field. One end of this sheet

                                                                                                      33
overlaps the edge of the second drape sheet. No additional drapes are used for the patient's feet
and the other side of his body, since they are well away from the sterile field.

b. Draping for Orthopedic Surgery (see figure 1-17). The drape for orthopedic surgery of a limb
differs in some respects from that described in paragraph 1-27a.



                                  Figure 1-17. Orthopedic drape of a leg.

                                  (1) Movement of limb. Orthopedic procedures usually require
                                  manipulation of the part during surgery to determine the degree
                                  and accuracy of fixation (in the case of fractures). Therefore, the
                                  drapes must be placed and secured in such a way that the part
                                  may be manipulated without dislodging the drapes.

                                  (2) Covering for skin. Since the patient's skin cannot be made
                                  sterile, it is covered as completely as is feasible for the type of
                                  orthopedic operation to be performed, which means that
                                  additional draping is required as compared to general surgery.
                                  Stockinette is employed as an additional covering for the skin in
                                  orthopedic surgery.

                                  (3) Procedure. The leg drape described below may be used for
                                  an open reduction with internal fixation of a fractured tibia and
for all other orthopedic operations on this part of the leg. An orthopedic drape of an upper limb is
done in a similar way.

(a) The circulator applies a pneumatic tourniquet to the thigh when the patient is placed on the
table and prior to the surgical prep but he does not inflate the tourniquet at this time. He pads the
skin beneath the tourniquet. The circulator supports the limb for skin preparation and part of the
draping procedure.

(b) After the surgeon or a "sterile" team member has prepped all of the operative area except the
foot, the circulator supports the leg at a point above the knee (using a sterile towel) and removes
the covering from the patient's foot. For this surgery, the entire lower leg is prepped, from slightly
above the knee footward, including the toes.

(c) The scrub checks the drapes and stacks them in the order of use: two or three drape sheets (as
required) at the bottom, then one 6-inch elastic bandage, one 6-inch leg stockinette doubled, and
one drape sheet on top.

(d) While the circulator supports the limb, two "sterile" team members open a drape sheet in the
usual way and place it over the lower end of the operating table and over the unaffected leg,
making sure that the end and sides of the table are well covered. Two thicknesses of material are
sufficient for this drape since additional covering will be draped over it later.

(e) The surgeon (or other team member) then places stockinette over the foot and rolls it upward
over the leg, keeping his fingers under the cuff of the stockinette to avoid contamination by the
patient's skin. (When the surgeon has applied the stockinette to the knee, a "sterile" team member
takes over the task of holding the leg, relieving the circulator.) The stockinette should be long
enough to cover the edge of the tourniquet.

(f) The surgeon applies the elastic bandage from the toes to the tourniquet (see figure 1-17 A).


                                                                                                    34
(g) The circulator inflates the tourniquet to the amount of pressure ordered by the surgeon. After
inflation of the tourniquet, the "sterile" team members remove the elastic bandage and lower the
leg to the table.

(h) The "sterile" team members open a second drape sheet; it has a 4-6-inch cuff, facing up, and
is placed under the leg just distal to the tourniquet.

(i) The "sterile" team members place the third drape sheet over the leg with the 4- to 6-inch cuff
facing down (see figure 1-17 B). Towel clips may be used to secure the upper and lower drape
sheets together, one on each side of the leg.

(j) The surgeon may desire the placement of an additional sheet, to cover the patient from his
lower abdomen and extending headward, over the anesthetist's screen. If the scrub knows that a
fourth sheet will be required, he places it at the bottom of the stack of drapes; but if the use of this
sheet has not been anticipated the circulator obtains the sterile sheet.

c. Developing Skill in Draping. Preplanning and continued practice will develop the skill needed
for correct draping. The surgeon depends on the specialist to know what he will need and how
each piece of drape is to be handled. This requires a careful check of all draping materials before
each operative procedure.




                      1 PROCEDURES IN PREPARING THE PATIENT
                          LESSON 1-4 DRAPING THE PATIENT

After completing this lesson, you should be able to:

       Identify common anesthesia terms and their definitions.
       Identify proper procedures for performing a preoperative skin prep.
       Identify equipment used in positioning patients.
       Identify procedures for placing a patient in the supine, Trendelenburg, reverse
        Trendelenburg, lateral kidney, lateral chest, lithotomy, prone, jackknife, and
        sitting positions and position for spinal anesthesia.
       Identify procedures for draping a patient.



                                    SECTION 2
                        PROCEDURES IN PREPARING MATERIALS

2-1. INTRODUCTION

Certain files that provide important information for the OR specialist and other members of the
OR team are located in the surgical suite. Among these files are: the instrument card file which
concerns the instruments necessary for a particular surgical procedure; the suture cards (surgeon's
preference cards) which contain the type of sutures, needles, and stitches preferred by individual
surgeons; and the procedure manual which contains local policy for the performance of certain
tasks, including the care and preparation of specimens. Section II of this lesson presents a
discussion on sutures.

2-2. KARDEX FILE

                                                                                                     35
Cards in this file contain information as to basic instruments and certain other items that are used
for the various operations to be performed.

a. Basic Instruments. These are the instruments that may be used to perform an operation.
Therefore, each card has recorded on it the names of instruments needed, the sizes (whenever
different sizes are available), and the number of each kind of instrument to be included. The
selection of instruments for a given operation can be made by the OR specialist by following the
information recorded on the appropriate instrument card.

(1) Instruments are identified by name in several ways.

(a) Name of the designer of the tool. Examples are shown in figure 2-1 A thru D.

       Kelly forceps
       Babcock forceps
       Mayo curved scissors
       Hegar-Mayo suture needle

(b) Specific anatomical part or organ and function. Examples are shown in figure 2-1 E thru G.

       Conjunctival forceps -- used to remove foreign bodies from the eye.
       Laryngeal mirror -- used to inspect the larynx.
       Bullet extracting -- forceps designer's name and functional name.

(c) Peculiar identifying characteristics. Examples are shown in figure 2-1 H and I.

       Mouse-tooth forceps -- sharp pointed teeth on the grasping end.
       Double blunt uterine scissors -- tips of both cutting blades rounded or blunted.




Figure 2-1. Instruments and their identification.

(2) During an operative procedure, the surgeon may use various means of asking for a particular
instrument. He may ask for it by proper or designer's name, by functional name, by a combination
of both proper and functional names, or by sign language. By sign language, he may indicate his
wishes for scissors by moving his forefinger and index finger in a scissors-cutting motion; by
holding those fingers together motionlessly, he indicates a need for a hemostat; and by moving
his index finger and thumb together, he may indicate a need for grasping (pickup) forceps.


                                                                                                  36
b. Other Items. Non-instrument items (such as drains and safety pins) needed to perform the
operations are also listed in the Kardex file.


                       2 PROCEDURES IN PREPARING MATERIALS
                           LESSON 2-1 INFORMATION ON FILE

After completion of this lesson, you should be able to:

       Identify basic instruments used in operations.
       Identify types of sutures and their uses.
       Identify the purposes of primary, secondary, and third intentions.
       Identify techniques of approximating tissue and characteristics of each technique.
       Identify the procedures for preparing sutures for use and for handling sutures.
       Identify the procedures for preparing and handling tissue specimens.
       Identify the procedures for handling cultures.
       Identify the procedures for handling tissue being processed for storage.

                              HANDLING AND USE OF SUTURES

2-3. INTRODUCTION

The OR specialist hears the surgeon's request for "suture" in practically every surgical procedure.
Because he handles sutures for use by the surgeon, the specialist must be able to identify them by
their correct name and size. Following are appropriate terminology and descriptions concerning
sutures.

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

b. 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.

(1) 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. Plain gut
suture is chosen most often by the surgeon for use in tissues that heal rapidly. As an example,
plain suture is used extensively in tying off subcutaneous bleeding points. Its source is the sheep's
intestine or beef serosa.

(2) Chromic gut. The second suture material in the absorbable category is the chromic surgical
gut. Chromic surgical gut has been treated with chromic oxide so that it will delay its rate of
digestion or absorption. Chromic sutures are treated to different (mild and medium) degrees to
retard absorption. Its source is the same as that of plain surgical gut. It is used in tissues that have
a relatively slow rate of healing and need support for a longer period. (An example is fascia.)

c. 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, and corrosion-resisting steel wire are
examples of nonabsorbable sutures. Sutures used for skin closure are usually removed before
healing is complete.


                                                                                                      37
(1) Silk. Silk suture material is obtained from the continuous thread spun by the silkworm. Silk is
used principally in clean surgery such as tendon repair, hernia repair, and surgery involving the
nerves and blood vessels. It ranges in size from very fine number 9-0 used in eye surgery, to
heavy number five used as a retention suture.

(a) Like the absorbable sutures, silk is available prepackaged, precut in many strands, and
presterilized. Prepackaged, precut, and presterilized sutures usually are 18 inches long for
interrupted sutures and 24 to 30 inches for continuous sutures.

(b) Silk is available braided and twisted. Braided is most commonly used because of the added
tensile strength provided by the braiding process. Silk is treated so that it is noncapillary; that is,
it is treated so that moisture and bacteria cannot enter the spaces or gaps within the woven silk
fibers.

(2) Nylon. Nylon is a synthetic material most commonly used in plastic surgery. Nylon is
stronger than silk. Nylon sutures are available in monofilament (single strand) in sizes ranging
from number 5-0 to 0, and the multifilament (braided) in sizes from number 6-0 to 5.

(3) Polypropylene. Polypropylene is a clear or pigmented polymer. This monofilament suture
material is used for cardio-vascular, general, and plastic surgery. Polypropylene is extremely inert
in tissue, has high tensile strength, causes minimal tissue reaction, and holds knots well. Surgeons
have indicated that polypropylene sutures can be tied into more secure knots than most other
synthetic suture materials. Sizes available are number 7-0 to 2, swaged to needles.

(4) Linen. Surgical linen is made of twisted linen thread that has sufficient tensile strength to be
used as suture material. It may be impregnated with a nonpermeable material that makes it
smooth and noncapillary. Linen is used almost exclusively in gastrointestinal surgery, sometimes
as a purse-string suture around the stump of the appendix or as a skin suture.

(5) Cotton. Surgical cotton is a nonabsorbable suture that is made from long staple cotton treated
to make it smooth. Cotton is used in the same areas in which silk is used. It is available in size
number 5-0 to 2. It is also available prepackaged, precut, and presterilized. Cotton suture is
twisted rather than braided. It is free from lint, fuzz, and knots, and has a smooth shiny surface.
Ordinary cotton has neither the smoothness nor the tensile strength required for suturing.

(6) Steel. Corrosion-resisting steel wire is used for metallic sutures. It is available precut,
prepackaged, and on spools. It is also available in single strands (monostrands) and multistrands
several strands of small diameter twisted together). Corrosion-resisting (stainless) steel is
available in sizes ranging from number 6-0, fine to 2, heavy. Steel size may also be expressed in
gauge: 18 to 40.

d. Dead Space. Space caused by a separation of wound edges that have not been closed by sutures
is dead space. A dead space may interfere with healing.

e. Ligature (tie). A ligature is a thread-like material used to tie off a blood vessel or other tube-
like tissue. A ligature or tie is usually of the same material as that used for sutures, but in some
cases, it may be a silver clip.

f. Stick-tie (Suture-ligature). This is a ligature threaded on a needle and used to suture a vessel
wall in addition to being tied around the vessel.

g. Tensile Strength. This refers to the amount of weight or pull that may be exerted on the suture
before it will break.



                                                                                                        38
h. Primary Suture Line. A line of sutures that holds the wound edges in approximation is known
as the primary suture line.

i. Secondary Suture Line. A line of sutures that relieves the primary suture line of unusual stress,
decreases or obliterates dead space, and prevents the collection of serum in the wound known as
the secondary suture line or retention stitch.

2-4. METHODS OF WOUND HEALING

To understand why a wound is sutured, the specialist must know how healing occurs. Injured
tissue is replaced by fibrous connective tissue (scar tissue), and the healing process may be
classified as follows:

a. Primary Intention. The type of healing that occurs when an aseptic, incised wound is closed
with sutures is primary intention. The healing takes place at all levels of the incised area; there is
no swelling, no infection, and no separation of wound edges. A minimum of scar tissue
("hairline" scar) follows this type of healing.

b. Secondary Intention. Secondary intention is the healing that occurs from the depth of the
wound outward or upward, each layer healing separately by granulation of tissue. This kind of
healing is usually attended by the formation of a large amount of scar tissue, or it may be
characterized by a weak union of tissue that breaks down later. This type of healing may occur as
the result of one of a number of factors, including the following: poor physical condition of the
patient, excessive trauma to tissue, loss of tissue, and infection. In the presence of infection, the
surgeon leaves the wound open purposely in order to be able to keep it cleansed and dressed
while it is healing. Whatever the reason is for healing by secondary intention, the union is
delayed.

c. Third Intention. When gross infection exists, when a large amount of tissue is removed, and for
some battle wounds, surgeons may leave wounds open for about four to seven days to observe
them for development of infection. Nevertheless, when it can be done, primary intention is
preferred over third intention because, in the former, minimum scar tissue results, healing occurs
more rapidly, less chance of contamination occurs, and a stronger union of tissue results.

2-5. TYPES AND LAYERS OF TISSUE REQUIRING CLOSURE

In order to accomplish wound closure, the sutures are placed to hold the edges of the tissue layers
in approximation until the wound is fairly well healed. The tissue layers that require closing vary
with the body area involved. For example, the tissue layers closed in abdominal surgery differ
from the layers closed in orthopedic surgery.

a. Abdominal Surgery. The layers of tissue to be closed, beginning with the deepest layer and
going toward the periphery, are: the peritoneum, the deep fascia, the muscle, the superficial
fascia, the subcutaneous tissue, and the skin. (There are two layers of fascia since muscle tissue is
covered or enclosed in fascia.) Many times the muscle and one layer of fascia are sutured together
because these structures are immediately adjacent to each other.

b. Orthopedic Surgery. The layers of tissue to be approximated following bone surgery (for
example, the tissue over the humerus) are: the periosteum or bone covering, the deep fascia, the
muscle, the superficial fascia, the subcutaneous tissue, and the skin.

2-6. TECHNIQUES OF APPROXIMATING TISSUE

Techniques of approximating tissue and the nomenclature for the various type of stitches are
discussed in the following paragraphs.

                                                                                                    39
NOTE: Figure 2-2 shows the principle suturing techniques.

a. Continuous Stitch (See figure 2-2). This is a running stitch with the suture tied only at the ends
of the incision.

b. Interrupted Stitch (See figure 2-2). With this technique, each stitch is taken and tied separately.
Each stitch may be tied when it is put in place, or the stitches may be tied after all have been
placed.

c. Purse-String Stitch (See figure 2-2). This is a continuous stitch placed so that it can be closed in
a drawstring manner. The technique is to place a running stitch around the lumen of a structure.
For example, it is used to close the intestinal wall when the appendix is removed and the stump
inverted. After placement, the suture is tightened by grasping both ends and drawing the lumen
closed.



                                              Figure 2-2. Principal suturing techniques.

                                            d. Tension (Stay or Retention) Stitch (See figure 2-2).
                                            This is an interrupted stitch used to reinforce a
                                            primary suture line. The suture is placed through
                                            many layers of tissue on each side of the incision
                                            (down to and sometimes including the peritoneum
                                            (serous membrane lining the abdominal cavity). Stay
                                            sutures are of a heavy, nonabsorbable material, such
                                            as wire or heavy silk (sizes 2 or 3). When a heavy
                                            suture is used, the skin beneath the knot must be
                                            protected to prevent its being cut by the suture.
                                            Therefore, when silk is used, surgical buttons may be
                                            used on both ends of the suture where it is tied. When
                                            wire is used, rubber shods (small pieces of rubber
                                            tubing) are used to protect the skin where the wire is
tied. The rubber shods extend over the incision line.

e. Subcuticular Stitch (See figure 2-2). With this technique, short continuous stitches are taken
laterally inside the incision. The stitches are placed in the dermis. The suture is brought through
the surface of the skin at each end of the incision only and is secured by either clamping a
perforated lead shot on each end of it or tying it at each end. This technique of skin closure leaves
a minimal scar; therefore, it is used frequently for closing the skin of the face and neck and for
surgery done on children. The suture may be removed by cutting off one end and pulling the
entire suture out at the other end. However, if the suture is absorbable, the surgeon may prefer to
leave it in permanently.

2-7. SURGEON'S PREFERENCE FOR SUTURES AND STITCHES

a. Types of Sutures to be Used. The surgeon prescribes the types of sutures, needles, and stitches
required for wound closure. This information is entered on a surgeon's card (see figure 2-3) for
each surgeon and each operation. The cards are kept on file in the surgical suite. The specialist
obtains this information by checking the card file. Information is entered on the card in an
abbreviated form, and the specialist is expected to be able to understand the information in order
that he may correctly prepare the necessary sutures for the procedure.

b. Example of Entries on Cards. Assume that Dr. Able is to perform an appendectomy, and the
card shown in figure 2-3 is to be used.

                                                                                                    40
             SAMPLE APPENDECTOMY                     Dr. ABLE
             CARD
                                                     Glove size--8 1/2
                     number 000 plain ties
                     number 3-0 black silk-- French-eye needle--purse-string
                     number 0 Chromic--number 3 Murphy needle--continuous--
                     peritoneum
                     number 0 Chromic-- number 3 Murphy needle--interrupted—
                     muscle and fascia
                     number 000 plain ties-- number 2 Murphy needle--interrupted—
                     subcutaneous
                     number 3-0 black silk--Keith needle--interrupted--skin

Figure 2-3. Suture (surgeon's preference) card.

(1) Plain size 000 ties (ligatures, para 2-3e). This indicates that "free" pieces of plain size 000
catgut are desired to tie off cut blood vessels in the subcutaneous tissues. The suture may be
wound around an unbroken suture tube or cut in 15-inch (single) lengths, depending upon the
surgeon's desire.

(2) Size 3-0 black silk--French-eye needle--purse-string. This means that size 3-0 silk, about 18
inches long, will be required for the purse-string, and that the silk is to be threaded into a French-
eye needle. The purse-string stitch will close the lumen in the cecum after the appendix has been
removed.

(3) Chromic 0-size 3 Murphy needle--continuous--peritoneum. This information means that a
single suture of chromic size 0 with a Murphy needle size 3 is required to close the peritoneum,
and that a continuous suture is used. Since a continuous suture is tied only at the ends of the
incision, the length of suture needed for this closure depends upon the length of the incision. For
many operations, half of a strand of suture is sufficient.

(4) Chromic 0-size 3 Murphy needle--interrupted--muscle and fascia. "Chromic 0" and "size 3
Murphy" have the same meaning as in (3) above. "Interrupted" means that this surgeon will place
and tie each stitch separately when closing the muscle. The length required for interrupted suture
is usually 15 inches long. However, the suture may need to be shorter or longer, depending upon
the depth of the tissue layer.

(5) Plain 000--size 2 Murphy needle--interrupted--subcutaneous. This indicates that for closure of
the subcutaneous tissue, the surgeon requires plain size 000 surgical gut (in quarter lengths) on a
size 2 Murphy needle, and that he will take each stitch separately. The needle is of a larger size
(see figure 2-4) than that mentioned in (4) above in order that it will go through the subcutaneous
layer of tissue.

NOTE: The higher the number of a needle, the smaller the needle.

(6) Size 3-0--black silk--Keith needle--interrupted--skin. According to this notation, the surgeon
will close the skin using a Keith (straight) needle that is used without a needle holder. Each stitch
is taken separately, the size 3-0 silk should be about 15 inches long.

c. Specialist's Duties in Maintenance of Card File. The cards may be taken into the OR for use,
but the specialist who uses them has the responsibility of returning them to their proper place for
future reference. The specialist has further duties in the maintenance of this file, as follows:



                                                                                                      41
                                 (1) Change in the surgeon's routine. The surgeon is at liberty to
                                 change his suture routine at any time. Whenever he does so, the
                                 scrub must report these changes to the OR supervisor in order
                                 that the changes may be entered on the card.



                                 Figure 2-4. Sizes of needles.

                                 (2) Preparation of new cards. When a surgeon, new to a hospital,
                                 operates for the first time, the specialist assigned for the case has
                                 the responsibility of making a list of the sutures, the types of
                                 stitches, and the needles desired. The list is given to the OR
                                 supervisor in order that the information may be entered on a card.

                                 2-8. PREPARATION BY SPECIALISTS

                                a. Circulator. The circulator supplies the necessary kind and
amount of sutures required for the operative procedure, according to the information listed on the
card for the surgeon and the operation.

b. Scrub. The scrub prepares all needed sutures for the case and hands them to the surgeon at the
appropriate time. The scrub's first step in the preparation of sutures is to check the appropriate
card for the operative procedure before scrubbing.

2-9. PROCEDURES FOR PREPARATION OF SUTURES

Sutures used in the OR are in a plastic packet or foil packet. First identify them; then open them.
When preparing sutures, always prepare them in order of use.

a. Opening Individual Sealed Containers. To open a foil packet, cut near the sealed edge or tear
along the dotted line of the packet and withdraw the suture (see figure 2-5 A).

b. Unwinding the Suture. To unwind the strand of suture, break a prong off the reel. Place one or
two fingers within the center of the loop while carefully unwinding and straightening out the
suture (see figure 2-5 B). Straighten the suture as follows: hold both ends of the suture in one
hand, the center of the loop in the other, and gently pull the hands apart (see figure 2-5 C). Never
stretch, jerk, nor test the strength of suture while handling it, as this would weaken the strand. Do
not run gloved hands over the suture to straighten kinks, and do not handle the suture any more
than is necessary. Always work over the sterile field as a precaution against contamination. Avoid
letting the suture ends drop over the edge of the table. The procedure for opening a package with
a swaged-on or a traumatic (affixed) needle is as that just described, except for two points:

(1) After taking the suture from the package, grasp the end of the suture with one hand; grasp the
other end of the suture, just below the needle, with the other hand.

(2) With the hands in the position described, gently straighten the suture. Do not exert any pull on
the needle.



Figure 2-5. Preparation of sutures.

c. Cutting the Suture into Lengths. The next step is to cut the suture into lengths appropriate for
its use and place it under the cover towel on the Mayo tray in the order of use. Standard
                                                                                                      42
absorbable suture comes in several lengths: 12, 18, 27, 36, and 54 inches. If necessary, this suture
is cut into halves, thirds, and fourths, and so forth, depending upon the area in which it is to be
used and the original length. Prepackaged silk suture comes in lengths of 18, 24, 30, 40, and 60
inches and on spools.

d. Threading a French-Eye Needle (See figure 2-6). Thread a French-eye needle by bringing the
suture down through the slit into the eye. Be careful when threading a French-eye needle because
the eye is easily broken. There is a spring opening through the end of the needle into the eye.
French eye needles are easily broken. Check to see that the needle's eye is intact before threading.



                                          Figure 2-6. Threading a French eye needle.

                                          e. Threading Other Curved Suture Needles (See figure 2-
                                          7). Thread the needle from inside its curve with the short
                                          end of the suture on the outside. This method helps
                                          prevent unthreading. Proceed as follows: grasp the
                                          needle on its flat surface about one inch away from its
                                          eye with a needle holder. Pull about 5 inches of the
                                          suture through the eye of the needle.



                              Figure 2-7. Threading of a curved suture needle.

                              2-10. PROCEDURES FOR HANDLING OF SUTURES

                              After handing a tie or suture to the surgeon, hand suture scissors to
                              his assistant.

                              a. "Free" Ties. Hand the length of suture on the reel to the surgeon
                              when he is ready for it. If the surgeon prefers to handle each tie
separately, hand quarter-length strands (15 inches) to the surgeon one at a time by holding one
end of the strand in each of your hands and placing the strand with gentle pressure across the
palm of the surgeon's hand.

b. Stick-Ties. Thread a quarter-length ligature on a curved, cutting-edge needle (a longer suture
may be needed if the surgeon is working very deep). When the surgeon requests a stick-tie, clamp
the needle firmly with the needle holder about 1/3 inch from the eye to prevent unnecessary stress
on the needle, possibly causing it to break when passed through the tissue. Pass the needle holder
to the surgeon by placing the handle firmly into his palm, the needle pointing as for use and the
suture material falling over the back of the hand, out of his way, and so that he may place the
suture without shifting the needle holder.

c. Purse-String Suture. Pass this suture to the surgeon on a needle holder as described in
paragraph "b" above. The purse-string suture is a fine silk suture, always prepared dry.

d. Peritoneal Suture. Pass the suture on a needle holder as previously described (paragraph "b"
above) and give the end of the suture to the assistant, who will hold it in order that it will not hang
over the edge of the sterile field and become contaminated. Pass a dressing forceps to the surgeon
in his other hand, which he uses to hold the peritoneum together while suturing.

e. Interrupted Sutures for Muscle and Fascia. Pass the suture that is used for the muscle and fascia
to the surgeon on a Murphy needle in the usual manner (paragraph "b" above). To save time and

                                                                                                    43
material, cut the remaining peritoneal suture and use it for these interrupted sutures (when the
same suture material is used for all of these tissues). In order to keep the surgeon supplied with
interrupted sutures, keep one suture ahead of the surgeon because when the surgeon finishes
placing a suture, the next one should be ready. Since speed is essential in this procedure, you
should practice until able to perform the procedure rapidly and accurately.

f. Interrupted Sutures for Subcutaneous Tissue. Pass these sutures to the surgeon on Murphy
needles as described above. Usually, the suture for subcutaneous tissue is the same as that used
for ties. Whenever this is the case, suture left over from the ties is utilized here.

g. Interrupted Sutures for Skin Closure. When passing the silk suture on a Keith (straight cutting)
needle to the surgeon, also hand him an Adson forceps with which to hold the skin edges. Prepare
the skin sutures so that as the surgeon finishes placing one suture, another is ready for him, as
with any other type of interrupted suture. Be careful in passing this suture in order that the point
of the Keith needle does not pierce or tear the surgeon's glove. Hand the needle with its eye
toward the surgeon. A good technique is to place three Keith needles on a folded towel with the
points of the needle placed through a thread in the towel. When the surgeon places a suture, he
returns the needle to the towel.

h. Metal Clips for Skin Closure. Although silk is usually used for closing the skin, the surgeon
may prefer to use skin clips. The clips used for this purpose are Michel clips (small metal clips
with prongs at either end). Prepare the clips for use by stringing several clips on a piece of wire
that serves as a holder. Cut off the ends of this wire holder to facilitate picking up the clips with
the applier. The surgeon applies the clips by means of an instrument, which holds them and
squeezes them so that the prongs go into the skin and the clip is bent into a "U" shape. The
surgeon uses tissue forceps to pull the skin in approximation while applying the clips. Stabilize
the clip holder on an unbroken tube of suture in order that the surgeon may grasp the clips more
easily.

i. Tension Sutures.

(1) Wire. When a wire tension suture is required, thread the wire through a heavy, large, curved,
cutting-edge needle at least 3 1/2 inches long. Avoid kinking the wire while threading it, and
thread rubber shods (see para 2-6d) over the wire to prevent it from cutting into the skin. Clamp a
hemostat on the long end of the wire to keep the rubber shods from slipping off prior to and
during use. Carefully bend, but never twist, the short end of the suture, as this would place too
much bulk at the needle's eye. No more than 3 or 4 of these sutures are needed for an incision 8 or
9 inches long.

(a) The surgeon usually places tension sutures before he sutures any of the layers of tissue. Pass
this suture to the surgeon along with the tissue forceps, and hand the hemostat on the long end of
the wire to the assistant for handling.

(b) Tension sutures are not tied until the skin closure has been completed. When the wire is ready
to be tied, pass scissors used only for cutting wire to the assistant. Do not pass the suture scissors
for this purpose, as the wire would dull them. The assistant cuts the sutures after they have been
tied by the surgeon.

(2) Silk. When silk is used for a stay or tension suture, a heavy size such as number two is used. It
is prepared at least 28 inches long. Using the fingers, thread this silk through two holes of a
button from the bottom upward, across the top of the button and downward again. The button will
then be hanging in the middle of the suture so that when the ends are brought together the smooth
(concave) surface of the bottom will be toward the ends of the suture. Grasp both ends of the silk
between the fingers, and thread them both simultaneously through the needle eye, as though a
single strand. Allow a tail about 4 inches long to hang free.

                                                                                                     44
(a) The surgeon inserts this suture approximately 1¼ inches from the edge of the incision and,
when he pulls it through, places the button against the patient's skin.

(b) When the surgeon is ready to tie this suture, hand the second button to his assistant, who
threads it with the free ends of suture on the opposite side of the incision. The knot is tied over
the second button. This suture does not cross the incisional line on the skin surface.

j. Summary. The skill of assisting with the aseptic procedure of suturing is developed through
practice and experience, but it is imperative that amounts and kinds of suture be determined
before starting an operative procedure, to avoid waste of time and materials. Suture is expensive
and must be handled accordingly. Suture cards must be checked frequently and maintained in
detail, if they are to be effective are a useful guide in the preparation of sutures for a surgical
procedure. Proficiency in the handling of suture material can and must be developed by the OR
specialist.
                         2 PROCEDURES IN PREPARING MATERIALS
                        LESSON 2-2 HANDLING AND USE OF SUTURES

After completion of this lesson, you should be able to:

       Identify basic instruments used in operations.
       Identify types of sutures and their uses.
       Identify the purposes of primary, secondary, and third intentions.
       Identify techniques of approximating tissue and characteristics of each technique.
       Identify the procedures for preparing sutures for use and for handling sutures.
       Identify the procedures for preparing and handling tissue specimens.
       Identify the procedures for handling cultures.
       Identify the procedures for handling tissue being processed for storage.

                               PREPARATION OF SPECIMENS

2-11. HANDLING OF SPECIMENS

The care and handling of specimens in an OR and between the surgical suite and the laboratory is
an extremely important and sensitive procedure. It reflects upon not only the safety of the patient
but also the efficiency of the operating team.

a. Kind of Tissue Examined. A specimen is defined as anything surgically removed from the
patient; it may be bone, soft tissue, or foreign bodies. Any tissue removed during a surgical
procedure is examined for pathology unless the surgeon specifically orders otherwise. Both the
scrub and the circulator have certain duties in the processing of specimens for the laboratory.
Specimens are usually sent to the laboratory for routine examination, but they may also be
processed for tuberculosis organisms or as frozen sections. In addition, most specimens must be
handled using sterile technique to preclude the introduction of new bacteria.

b. General Considerations. Some general considerations must be taken into account when
working with specimens. They follow:

(1) Specimen for identification. Some specimens are for identification. Examples of these are the
appendix, hernia sac, veins, and tonsil tissue. In these instances, the surgeon knows, in advance of
surgery, the condition of the patient. Through surgery, he will remove an organ or part that is
diseased or endangering the patient's health. The specimen is sent to the laboratory, where it is
identified and pertinent information recorded in the patient's medical records by the pathologist.
An example is a vein and the location from which it is removed, especially specimens that are
located bilaterally in the body.


                                                                                                      45
(2) Specimen for diagnosis. Sometimes the surgeon does not know in advance, what is causing
the patient's symptoms. Through the results of diagnostic tests, which will be done on the
specimen in the lab, the surgeon will form a diagnosis. When the diagnosis is made, he will
determine the best way of treating the patient. Two examples of this type of specimen are a breast
biopsy and a fluid deposit within the body.

(3) Legal significance of specimen. Keep in mind the legal significance of any specimen. A
lawsuit may result from a specimen mislaid or otherwise handled improperly. Legal action other
than a suit may involve a specimen such as a bullet in a criminal case.

c. Routine Specimens. Different types of specimens may be handled in different ways; however,
most specimens are handled in the routine manner including those for identification (b(1) above)
where no great speed is necessary. Following are the duties of the scrub and circulator regarding
the routine handling of specimens.

(1) Duty of scrub. The scrub keeps the specimen in his care until he gets permission from the
surgeon to hand it "off," (using an instrument), to the circulator. The scrub verifies the kind of
specimen (tissue) with the surgeon and informs the circulator.

(2) Duty of circulator. The circulator does the following:

(a) Receives the specimen from the scrub.

(b) Verifies the kind of tissue to be used by asking the surgeon. He makes no assumption as to
what tissue to use.

(c) Selects the correct size lidded container, usually a jar, large enough where the specimen will
not be damaged, and ten percent formalin can be added to cover the specimen.

NOTE: Check with the surgeon before placing the specimen in formalin. If the specimen is to be
photographed, it is not placed in formalin since it may become discolored.

(d) Places a specimen to be photographed in a corrosion resistant steel (CRS) basin covered with
a moist towel or with normal saline solution.

(e) Identifies the specimens on all proper forms. A separate container is used for each specimen,
but several specimens from the same patient can be listed on one SF 515 (Tissue Examination)
(see figure 2-8). In addition to other information (para (f) below), a number should be placed on
the label of each specimen container. A corresponding number must go on SF 515 with the
correct specimen description. Local policy may provide additional guidance.

(f) Prepares labels for all specimens. Write on each label the date of operation, the patient's name
(last name, first name, and middle initial), ward number, hospital register number, social security
account number, the surgeon's name, and the kind of specimen. If the patient's hospital
identification has been stamped at the bottom of SF 515, the circulator may not be required to fill
in the patient's name in the blank space provided, depending again on the local policy. At the
bottom of the page, he fills in the spaces labeled age, sex, race, identification number, register
number, and ward number (see figure 2-8).

(g) Records each specimen in the OR specimen book. The specimen is then placed in the
designated area in the workroom. The circulator or designated person obtains the laboratory
specialist's signature in the specimen book for each specimen he receives.




                                                                                                     46
d. Specimens to be Examined for Tuberculosis Organisms. These specimens are prepared and
labeled as described above, except that the specimen is covered with normal saline or a moist
towel instead of formalin.

e. Frozen Sections. There is also a routine procedure to be followed for frozen section specimens.
A frozen section is exactly what the name implies.

(1) The specimen is quickly frozen so that extremely thin slices or sections can be made. These
then are examined by the laboratory personnel for signs of malignant conditions. Usually this
procedure is noted on the operation schedule. The laboratory should be notified in advance to
prepare for a frozen section.

(2) When the patient arrives in the OR, the specialist should obtain the necessary form from the
patient's chart and complete the label, specifying "Frozen Section." The scrub hands the specimen
in a moist, folded hand towel to the circulator. As with other specimens, it is recorded in the
specimen book and must be signed for by the laboratory specialist.

(3) It is taken to the laboratory immediately for examination and report. Usually the report of
laboratory findings is available in 10 minutes. If the report is negative, then the surgical
procedure will be completed. If the report is positive, then a more radical surgical procedure may
be instituted. Therefore, accuracy in relaying information is paramount.

2-12. HANDLING OF CULTURES

a. The Surgeon. The surgeon determines whether a culture will be done and, if done, he specifies
the laboratory test to be performed.

b. The Specialist. The specialist performs certain duties in the processing of a specimen for
culture as follows:

(1) Have the desired number of sterile culture tubes ready and available to the surgeon.

(2) Prepare a label..

(3) Prepare the appropriate laboratory form and indicate the test(s) that the surgeon orders done.

(4) Mark the labels numbers 1, 2, and so on when multiple specimens are obtained.

(5) Exercise care in handling the specimen. Even when the specimen does not look purulent,
handle it as though it is from an infected area. By following this principle, you will avoid
contaminating either yourself or the OR. If the culture tube with culture is broken, notify the
surgeon at once. The area in which the tube broke should be considered septic since infectious
bacteria may have been in the culture.

(6) Avoid contaminating the specimen. The entrance of outside contaminants makes a culture
worthless.

(7) Record the specimen in the book and see that it gets to the laboratory as soon as is practicable.
The material in the culture tube must not be allowed to dry because drying kills bacteria. A liquid
transport medium, if available, may be used to ensure that any microorganisms present do not die
by drying before a medium can be streaked with the sample. The laboratory specialist signs the
specimen book for the culture.

2-13. TISSUE TO BE PROCESSED FOR STORAGE


                                                                                                  47
a. Tissue "Banks." Certain hospitals have facilities for the preservation and storage of various
types of tissue. When tissue to be stored in a "bank" is excised, it is handled in accordance with
the local policy. The tissues most commonly stored in a "bank" are: skin, bone, cartilage, and
blood vessels.

b. Sources of Tissue. Subject to conditions prescribed by local policy, tissue may be obtained
from the following sources:

(1) A patient who has had the desired tissue excised during a scheduled surgical procedure.

(2) A voluntary donor.

(3) A cadaver.

c. Laboratory Tests. Cultures of the specimens are done in accordance with local policy.

d. Sterile Procedure. Sterility must be maintained throughout the procedure of removing and
processing the specimen.

e. The Specialist. The specialist has duties similar to those described for the processing of
specimens for pathologic examination. He is to do the following:

(1) Have ready any sterile items needed (culture tubes, petri dishes, or jars).

(2) Prepare the necessary forms for the laboratory.

(3) Enter the name of the donor, date of excision, and other required information on the
appropriate card or tag (for identification of the tissue).

(4) Perform other duties as indicated by local policy.


                         PROCEDURES IN PREPARING MATERIALS
                         LESSON 2-3 PREPARATION OF SPECIMENS

After completion of this lesson, you should be able to:

       Identify basic instruments used in operations.
       Identify types of sutures and their uses.
       Identify the purposes of primary, secondary, and third intentions.
       Identify techniques of approximating tissue and characteristics of each technique.
       Identify the procedures for preparing sutures for use and for handling sutures.
       Identify the procedures for preparing and handling tissue specimens.
       Identify the procedures for handling cultures.
       Identify the procedures for handling tissue being processed for storage.



                               SECTION 3
            PROCEDURES IN ANESTHESIA AND PARENTERAL THERAPY

3-1 INTRODUCTION
                   3 Procedures in Anesthesia and Parenteral Therapy
Lesson 3-1 Introduction

                                                                                                     48
After completing this lesson, you should be able to:

      Define common terms used in anesthesia.
      Identify methods of administering anesthesia (regional and general) and the
       procedures for each method.
      Identify the four stages of general anesthesia.
      Identify common anesthesia agents and the characteristics of each.
      Identify medical emergencies connected with anesthesia, to include their cause
       and management.
      Identify procedures for administering injections, intravenous infusions,
       transfusions, and for withdrawing blood.

3-1. GENERAL

a. Applicability to Specialist. Almost every procedure performed on patients in the OR
requires the administration of some type of anesthetic. The duties of the OR specialist
include assisting with the administration of both local and general anesthetic agents.
Therefore, the specialist should have a working knowledge of the basic agents, their
toxic effects, and the precautions to be taken with the use of each of these anesthetic
agents. The specialist must know his duties in assisting with the administration of the
various agents. The object of this lesson, then, is to present material that will help the
specialist to attain or refresh such knowledge.

b. Agents Discussed. The anesthetic agents considered here are those standard drugs
capable of producing anesthesia of a depth and for a sufficient period that the patient
may remain free from pain throughout the surgical procedure.

3-2. TERMINOLOGY

a. Analgesia. A state in which the perception of pain is lost or dulled without loss of
consciousness or the sense of touch.

b. Analgesic. A drug that produces analgesia.

c. Anesthesia. A bodily state in which sensation is absent.

d. Anesthetic. An agent that produces anesthesia. A state of anesthesia is deliberately
induced through the use of an anesthetic agent when a surgeon is to perform an
operation.

(1) Regional (local) anesthetic. Regional anesthetic agents exert their effect by blocking
the transmission of nerve impulses without producing loss of consciousness.

(2) General anesthetic. General anesthetic agents exert their effect by producing loss of
all modalities of sensation, including loss of consciousness.

(a) Induction is the period from the beginning of the administration of the anesthesia until
the patient loses consciousness.

(b) Intubation is the introduction of an endotracheal tube (see figure 3-1) into the larynx
through the nose or mouth, usually done after the patient is under the influence of a
general anesthetic.




                                                                                             49
                                  Figure 3-1. Endotracheal tube.

                                  (c) Extubation is removal of the endotracheal tube
                                  (with or without replacement by an airway) when the
                                  operation is finished.

                                  e. Toxicity. The toxicity of a drug is the least amount of
                                  it (in a certain concentration) necessary to produce
                                  symptoms of over dosage (toxic reaction) when given
                                  to a person in ordinary health.

                                  f. Toxic Reactions to Drugs. Either of the reactions
                                  described below is potentially dangerous to the patient.

                                   (1) Idiosyncrasy. Idiosyncrasy is an abnormal response
                                   to a drug, manifested in the patient by a reaction much
greater than that anticipated or of an unusual type. Examples of such reactions are seen
in the occasional patient who sleeps for 24 hours or longer following an average dose of
a barbiturate or in the patient who becomes excited following an injection of morphine.
The majority of reactions to anesthetic agents are due to idiosyncrasy.

(2) Hypersensitivity. Hypersensitivity (or sensitivity) is an allergic reaction to a drug.
Hypersensitivity may be manifested by skin rash, urticaria (eruptions of itchy patches of
skin), angioneurotic edema (nervous disorder affecting blood vessels attended by
swelling), drug fever, damage to certain organs, rhinitis (inflammation of nasal mucous
membrane), asthma, or anaphylactic shock. A drug need not be highly toxic for an
allergic reaction to result. Drugs of low toxicity may give rise to an allergic response.
Hypersensitivity reactions (especially anaphylactic shock) are usually more difficult to
manage than are reactions caused by idiosyncrasy. Fortunately, hypersensitivity
reactions do not usually occur with most drugs, including anesthetic agents.

3-3. THE ANESTHETIST AND THE SPECIALIST

a. The Anesthetist. He is as much a part of the surgical team as is the surgeon himself.
The specialist serving as the circulator should render assistance to him accordingly. The
anesthetist, particularly when administering general anesthesia, controls the patient's
vital life processes of respiration and circulation.

b. The Specialist. To perform effectively, the specialist must understand the fears of the
patient awaiting anesthesia and the principles of supporting the anesthetist with each
type of anesthetic agent used.

(1) Fears of the patient. The specialist should respect any fears that the patient exhibits
in relation to his pending anesthesia and surgery. Such fears should not be ridiculed by
telling him "Oh, you will be all right;" or "We do hundreds of these a year and nothing
happens," as if he were just a routine encounter for the day. The patient may need
further explanation by the surgeon, anesthetist, or OR supervisor to alleviate or minimize
his fears. The specialist can allay the patient's fears by his actions. The following
guidance is appropriate:

(a) Show respect for and acceptance of the patient as an individual.

(b) Display skill and quiet confidence.

                                                                                         50
(c) Do not discuss the patient's condition.

(d) Do not leave the patient alone unless properly relieved.

(2) Principles of supporting the anesthetist. The specialist provides maximum support to
the anesthetist by knowing what procedure the anesthetist will follow when administering
anesthetic agents and by performing his own duties skillfully and accurately.

3-4. PREANESTHETIC MEDICATION

Administration of preanesthetic medication is a procedure that helps the patient, both
mentally and physically for the ensuing operation. It is designed to make anesthesia
smoother and safer.

a. Effects on Patient. The preanesthetic medication the patient receives usually affects
his behavior. The OR specialist should understand that the patient may be drowsy, slow
to respond, poorly coordinated and thirsty. The patient may wish to cooperate, but he
needs sufficient time and explanation to do what is expected of him.

b. Preanesthetic Drugs Commonly Used. A brief discussion of preanesthetic drugs
commonly used, their purpose, and the probable time they are administered follows:

(1) Secobarbital and pentobarbital. The barbiturates, secobarbital and pentobarbital, are
oral sedatives given the night before and the morning of surgery. They and the opiates
tend to allay the anxiety and apprehension of the patient and to lower the metabolic rate,
thus reducing the amount of anesthetic necessary.

(2) Morphine and meperidine. The opiates, morphine and meperidine, are combined
with a belladonna derivative, such as atropine or scopolamine and given as a sterile
injection 45 to 90 minutes prior to surgery.

(3) Atropine and scopolamine. These belladonna derivatives, when used, tend to reduce
the amount of secretions in the mouth and respiratory tract and, thereby, help to
maintain a patent airway. They tend also to reduce certain harmful reflexes that may
occur during the operation.

3-5. FACTORS IN SELECTION OF ANESTHETIC AGENT

The surgeon, in collaboration with the anesthetist and the patient, determines the choice
of anesthetic agent.

a. Some factors that are considered in making a choice include the following:

      Age of the patient.
      Condition and size of the patient.
      Nature and length of operative procedure.
      Pharmacologic effects of the drug used.

b. Consideration is given to the above and other factors to ensure maximum safety of
the patient, a workable field for the surgeon, and a manageable depth of anesthesia for
the anesthetist.

                                        Section 4
                              Procedures in General Surgery


                                                                                         51
4-1. INTRODUCTION

a. Scope. The surgical specialty that includes the majority of cases performed in the OR is
general surgery; therefore, it is essential that the OR specialist know what his duties are when
assigned to scrub or circulate for general surgical procedures. General surgery encompasses the
basic practice of the operative treatment of disease. Although not all general surgical procedures
are included in this discussion, the others not discussed may be handled efficiently by the OR
specialist if he will make the necessary adaptations to meet the needs of the particular patient.

b. Classification.

(1) As operations became more numerous and complex, surgical specialties developed out of
general surgery which facilitate operations on specific areas of the body. Thus, plastic surgeons
perform cosmetic and reconstructive surgery on the skin and certain soft tissues. Orthopedic
surgeons operate on bones, joints, and tendons. Neurosurgeons operate on the nervous system:
brain, spinal cord, and peripheral nerves. Ophthalmologists are specialists in eye surgery and
otorhinolaryngologists in ear, nose, and throat surgery. Operations on the urinary system and
male reproductive system are performed by urologists. Gynecologists operate on the female
reproductive system. Thoracic surgeons operate on the lungs, heart, great vessels, and the
esophagus; however, a cardiovascular surgeon is more specialized in procedures pertaining to the
heart and great vessels and operates on these organs.

(2) In addition to the previously mentioned surgical specialties, general surgeons, too, have their
own specific areas of the body to treat. Surgery classified as general includes the following
categories: surgery of tissues of the limbs, the head and neck, the trunk (certain operations), the
abdominal wall, the gastro-intestinal tract, the accessory digestive organs, the peripheral blood
vessels (not including the intrathoracic great vessels), the lymphatic system, the endocrine glands,
the breasts, and surgery of the anus and rectum. In addition, the kind of defect and the reason for
surgery must be considered. For example, wound debridement of the muscular tissue of a limb is
classed as general surgery, but operation on the same musculature to correct a postural defect is
classed as orthopedic surgery. In other words, body areas and structures are useful as reference
points but not as absolute lines of demarcation for the classification of surgical procedures. In the
following text, general surgical procedures included in each of the above classifications except
surgery of the lymphatic system and surgery of the breasts are discussed.

4-2. SURGERY OF THE SKIN

The area of skin prepared preoperatively, the type and placement of drapes, and the position of
the patient all depend upon the location of the pathology (head, neck, limbs, or the trunk). For
example, if several small lesions are scheduled for excision, multiple prepping and draping are
done. The choice of anesthesia depends upon the kind and extent of pathology. The instruments
and sutures needed depend upon the kind, location, and depth of the pathology. Local policy and
the surgeon's preferences are followed. In the following paragraph, discussion of a specific
operation on the skin is set forth, with emphasis on the duties of the OR specialists.

4-3. SKIN GRAFT

a. Discussion. Skin lost (caused bthermal or other injury) may be replaced with skin obtained by
either homograft (taken from another person) or autograft (taken from the patient). If an autograft
is to be used, both the donor site and the recipient site must be prepped and draped. In the
operation described below, an autograft is taken from the anterior surface of the right thigh and
placed on the left arm.

b. Preparation of the Patient. Either general or local anesthesia may be used depending upon the
needs of the situation.

                                                                                                  52
(1) Prep. The specialist assigned to shave the patient preoperatively should exercise the greatest
care to avoid nicking the skin, especially that of the donor site. The prep done immediately
preoperatively is as has been discussed (see para 1-12).

(2) Position. The circulator is to place the patient in a modified supine position with the recipient
arm on an armboard.

(3) Drape. The surgeon and "sterile" team members drape the patient as described for draping of
the limbs for general surgery.

c. Preparation of the Operating Room. Instruments and other items for the procedure are selected
in accordance with information on the instrument card. These include either a dermatome
(electric or hand) or a skin grafting knife if a free graft is to be taken. The scrub is to set up a
separate table for equipment needed to remove the graft. Items to be placed on the table are as
follows:

(1) Dermatome or knife. If an electric dermatome (see figure. 4-1) is used, it should be checked
for proper functioning by scrub and circulator.

(2) Medicine glass.

(3) Tongue blades.




Figureure 4-1. Dermatome.

(4) Applicators.

(5) Mosquito forceps.

(6) Corrosion resistant steel basin.

(7) Normal saline.

(8) Gauze sponges.

(9) Fine mesh gauze sponge (for placement on the donor site).

(10)Sterile mineral oil.

d. Care of the Graft. Care of the graft is the duty of the scrub. He should perform the following
procedures:

(1) Take the skin off the dermatome.

(2) Uncurl edges of skin and flatten it on a gauze sponge moistened with saline.
                                                                                                    53
(3) Place it on a flat surface.

(4) An inverted flat pan is good for this purpose.

(5) Place the excised skin not used for grafting in a sterile container of penicillin solution, cover
the container, and put in the refrigerator, if ordered.

(6) Save any unused portion of the skin graft until ordered to dispose of it.

e. Suturing Types Usually Used. Plain catgut size 2-0 or 3-0--used for ties. Black silk size 4-0 on
affixed needle--used for suturing the graft in place.

4-4. DEBRIDEMENT OF SOFT TISSUE WOUND OF THE THIGH

a. Discussion. Surgical debridement is a mechanical, physical cleansing of a wound. Extensive
damage to muscles and adjacent soft tissues may be present when there is traumatic injury to soft
tissues. The continued presence of devitalized tissues in the patient may give rise to serious
complications and result in death. Accordingly, soft tissue wounds are treated by the wide and
deep excision of all devitalized tissues (tissues that do not bleed promptly upon incision).
Because the procedure selected for discussion involves only the soft tissue, it is done as a general
surgical procedure. If a fracture were continuous with the wound, the procedure would be
performed as an orthopedic surgical procedure. However, the specialist assigned to scrub or
circulate for debridement has duties similar to those described below no matter what may be the
area of body involvement or the surgeon's clinical specialty.

b. Special Preparation of the Operating Room.

(1) Instruments. The instruments needed include tissue forceps, scissors for both tissue and
sutures, scalpels, dressing forceps, hemostats, retractors, needle holders, and sponge-holding
forceps. The sizes of instruments should be appropriate for the body area involved; the number of
each included depends upon the extent of the area to be debrided and upon the preference of the
surgeon.

(2) Other equipment needed.

(a) Irrigating set.

(b) Asepto syringe.

(c) Medication cups (2).

(d) Metal basin.

(e) Vaseline gauze).

(f) Gauze sponges, fluffed gauze, and fine mesh gauze.

(g) Distilled water.

(h) Normal saline.

(i) Detergent or soap.

(j) Soft hand brush.

                                                                                                   54
(k) Fluids for infusion.

(l) Infusion standard. Bucket.

(m) Plastic sheeting.

(n) Adhesive strips.

(o) Plaster cast setup, if ordered.

(p) Splint, if ordered.

c. Preparation of the Patient.

(1) The patient is anesthetized. The clothing is then cut away over a large area, and dressings and
temporary splints are removed (the circulator is to assist as ordered during this procedure). A pad
of sterile gauze is held firmly over the wound while the skin over a large area adjacent to the
wound is thoroughly cleansed with soap and water and is painstakingly shaved. The entire
circumference of the limb is prepared. The circulator is to have the necessary supplies at hand for
the prep, and he is to assist with the prep as ordered.

(2) The circulator and the necessary number of "non-sterile" assistants place the patient in the
desired position for surgery when instructed to do so. The circulator is to put a tourniquet in
place, if ordered. Sterile drapes are placed as set forth previously (see para 1-27c).

d. Immobilization of Limb. Even when no fracture is present, the surgeon may elect to
immobilize the injured limb upon completion of surgery. Immobilization is done to rest the part,
to maintain correct positioning, and to promote healing. Immobilization may be done by splints or
by well-padded plaster casts. A plaster cast that encircles the limb is to be cut (as marked by the
surgeon) as soon as the plaster has set. The procedure of cutting the cast is never to be postponed.
The circulator cuts the cast if ordered.

e. Special Precautions.

(1) The precautions discussed for positioning the patient should be observed (see para 1-13e(1)-
(4). In particular, the specialist should be deliberate and gentle in maneuvering the patient, as the
patient is susceptible to both shock and hemorrhage.

(2) The adhesive strips applied over the dressing upon completion of surgery must not encircle
the limb. Encircling adhesive could act as a tourniquet when the limb swells postoperatively, as it
invariably does. This precaution is especially necessary if a plaster cast is used.

(3) Frequently, the doctor will order an antitetanus injection.

f. Handling of Specimens. Unless ordered otherwise, the circulator is to process tissue excised as
a specimen for the laboratory.

g. Suturing Types Usually Used. Absorbable sutures in a size desired by the surgeon are used for
ligatures and suture ligatures. Other sutures are not required at this time because the wound in the
limb is left open and is closed later (within 4 to 7 days after injury) by third intention. It may be
allowed to heal by secondary intention. When debridement and hemostasis have been completed,
the surgeon places strips of fine mesh gauze transversely across the wound, and then he packs
fluffed gauze loosely in the pocket formed by the strips. A gauze dressing is then laid over the
gauze in the wound and adhesive tape is applied either longitudinally or spirally (see precaution,
e(2), above). The scrub or the circulator applies the tape if ordered to do so.
                                                                                                   55
h. Suturing After Debridement of Other Body Areas. All debrided wounds are left widely open,
without suturing of the deep tissues or the skin, except for the following (in all cases, sutures are
of a type and size prescribed by the surgeon):

(1) Face wounds. These are closed primarily.

(2) Sucking chest wounds. The muscle is closed over a sucking chest wound following excision
of devitalized tissue. The skin is left open.

(3) Head injuries. The dura and the scalp are closed primarily. If the dura is opened, stay sutures
are placed in its edges.

(4) Hand injuries. These are closed primarily. Sutures of very fine silk and nylon are used.

(5) Injury of the joint capsule or synovial membrane. The joint capsule or the synovial membrane
is closed; the subcutaneous tissue and the skin are left open.

4-5. EXCISION OF PILONIDAL CYST AND SINUS

a. Discussion. A pilonidal cyst may be formed by a malformation (congenital) caused by a defect
in the formation of the vertebral column or by invagination of the ectoderm (during fetal
development) at the sacrococcygeal region. Repeated mild trauma of the sacrococcygeal region
may result in this type of penetration. Since military personnel often ride over rough terrain while
sitting on a hard surface, they are especially susceptible to pilonidal disease. Infection of a
pilonidal cyst may result in the formation of a sinus tract.

b. Indication. Excision is indicated for patients who suffer repeated attacks of inflammation
requiring incision and drainage and have not responded to conservative management.

c. Prep, Position, and Drape. The preoperative skin preparation includes the area of the perineum
and the lumbar region (see figure 1-1). The jackknife position is used with a modified laparotomy
drape (see figure. 1-16).

d. Instruments. A minor dissecting set usually suffices for this excision.

e. Special Considerations.

(1) A large curette is usually included to scrape the base of the wound to remove all gelatinous
tissue.

(2) Methylene blue dye should be available in the room because at times the surgeon needs to
inject it to trace the sinus tract.

(3) If the dye is needed, syringes and a blunt needle are required to inject the dye. The circulator
provides the scrub with these items.

(4) Absorbable suture (plain or chromic) size 0 or 1 may be used for ligatures and suture-
ligatures.

(5) If infection is present, the wound may be left open to heal by secondary intention. Packing is
usually inserted and a bulky dressing carefully applied.

f. Handling of Specimen. Tissue excised and scrapings of tissue obtained by curettage are to be
processed as specimens.

                                                                                                   56
4-6. COMMON SITES FOR ABDOMINAL INCISIONS

a. The paramedian rectus incision may be used for operations in the upper, mid, or lower
abdomen on the right or left side. The incision is made parallel to the midline, about four cm
lateral to it.

b. The longitudinal midline incision may be used for gastrectomy, resection of the colon, for
penetrating wounds of the abdomen, and for abdominal operations on women. The incision is
made through the linea alba in the upper or lower abdomen. The incision may be extended by
curving it around the umbilicus.

c. The McBurney (muscle-splitting) incision may be used for appendectomy, cecostomy, and for
drainage of appendiceal or pelvic abscess. A similar incision may be made on the left side for a
sigmoid colostomy or for repair or a hernia. The incision is made about 8 cm long and is made
parallel to the fibers of the external oblique muscle and fascia.



                                                                   Figureure 4-2. Abdominal
                                                                   incisions.

                                                                   d. The upper quadrant oblique
                                                                   (sub-costal) incision, when used
                                                                   for operations on the
                                                                   gallbladder, common duct, or
                                                                   the pancreas, is made on the
                                                                   right side. The incision is made
                                                                   on the left side when it is to be
                                                                   used for splenectomy. For this
                                                                   incision, the anterior sheath and
                                                                   rectus muscles are cut
                                                                   transversely.

e. The inverted "U" incision may be used for gastrectomy, resection of the transverse colon, and
operations of the gallbladder and its ducts. This incision divides the rectus muscle transversely.

4-7. SPONGE COUNT

a. Discussion. A sponge count is done in order to account for all sponges put on the sterile table
for use during an operation when the depth or location of the operative area is such that a sponge
could be accidentally lost or left in a patient.

b. Types of Cases for Which a Sponge Count is Taken. A sponge count is routinely taken for all
operations done inside the abdominal or chest cavity. Local policy may prescribe that a sponge
count be done routinely for hernia repair and for thyroid surgery. In addition, a count is taken for
other types of cases, including the following:

(1) Operations of the hip or shoulder joint.

(2) Operations on the spine.

(3) Radical surgery of the breast.

(4) Major vaginal surgery.


                                                                                                  57
(5) Any operation upon request of the surgeon.

c. Procedure. In the following text, a procedure for taking the sponge count is set forth. The
specialist should check local policy concerning the sponge count and adhere to it exactly.

(1) When the scrub opens a package of sponges, he is to remove pins and strings. (The exception
to this procedure is that Kitner sponges are left on the safety pin for counting.)

(2) The scrub is to pick up a pack of sponges with one hand and shake them slightly so that they
will separate easily for counting.

(3) The scrub and the circulator are then to count the sponges simultaneously with the scrub
counting aloud. Both the scrub and the circulator must see each sponge. Therefore, the scrub is to
separate each sponge from the pack while counting and stack the counted sponges on the table. A
registered nurse (RN) is required to witness all sponge counts in the OR.

(4) Both the scrub and the circulator are to check each sponge for opaque marking (sponges used
must be opaque to roentgen rays, except for Kitner sponges, which do not have opaque marking).

(5) The scrub is to separate laparotomy (lap) sponges for counting, and he is to open each one
fully so that he and the circulator may check each for opaque marking.

(6) If the scrub and the circulator do not agree on the count, they must take it again.

(7) If a package contains an incorrect number of sponges or a sponge without opaque marking,
the circulator is to remove the entire pack from the room immediately and obtain another
package.

(8) The circulator is to record the count on a sponge-count board, or in the place specified by
local policy. If additional sponges are needed during the case, they are counted and recorded in
the same manner.

(9) The surgeon will request subsequent sponge counts. Again, the scrub, the circulator, and the
RN must see each sponge. The sponges in the various areas are counted separately (those
discarded, those on the sterile tables, and those in the operative field) and then added to obtain the
total count. The sequence used in the sponge count is: start with the sponges around the incision;
then sponges on the Mayo tray; then sponges on the back table; and finally, the discarded
sponges. The procedures are as follows:

(a) The circulator used forceps to point to each sponge on the paper.

(b) The scrub is to handle the sponges remaining on the back table, separating each as it is
counted so that he, the circulator, and the RN can see each sponge.

(c) The surgeon may assist in counting the sponges remaining in the operative field.

(d) The three counts are added and should total the number recorded for the initial count plus any
additional sponges that were opened during the case.

(e) The scrub is to report the result of the sponge count to the surgeon: if the count is correct, he
will proceed with the closure of the wound. If the count is incorrect, all sponges are to be
recounted at once. The circulator is to check the kick bucket and the floor, and he will often need
to don rubber gloves to see that all sponges are separated; the surgeon may assist in recounting
sponges in the operative area, and the scrub is to check the instrument tables.


                                                                                                   58
(f) If the count remains incorrect after the recount, the OR supervisor, who is notified, normally
assists with another recount. An X-ray of the operative area may be ordered. If so, it will be taken
with portable X-ray equipment while the patient is still on the operating table.

d. Rules for the Scrub.

(1) Keep the sponges together on the back table. Do not scatter them, tuck them under towels,
use them to wrap specimens, nor for any other purpose except sponging.

(2) Place all sponges for use inside the cavity on a sponge forceps. Never hand a loose sponge
while the cavity is open.

e. Rules for the Circulator.

(1) Before the first count is taken, remove from the room all wrappers and sponges that are not to
be included in the count. After the first count has been taken, see that no sponge or linen of any
kind is removed from the room until the operation has been completed and the final sponge count
has been certified correct.

(2) Keep the discarded sponges collected throughout the case. Do not allow a large number of
used sponges to accumulate. Shake lap sponges carefully to make sure that no gauze sponges are
adhering to them.

(3) Put the collected sponges in the place provided for them. Local policy in various hospitals
may set forth other methods for the storage of used sponges during an operation. One method is
as follows: place a piece of wrapping paper in a designated area on the OR floor. Place the
sponges on this paper in rows and in groups according to the kind of sponge. This method
facilitates the taking of the final count.

4-8. ABDOMINAL WALL HERNIOPLASTY (HERNIORRHAPHY)

a. Discussion. Abdominal hernia is a protrusion of an internal structure through an abnormal
opening in the abdominal wall. It occurs because of weakness in the musculature of the wall.
Hernioplasties comprise a large share of elective general surgical cases. (Elective cases are those
performed when the patient is in his best possible condition for surgery, at a time convenient for
the surgeon and the hospital.) Hernias may be congenital or acquired, and they may be classified
according to both type and anatomical location.

b. Types of Hernias. Hernias may be reducible or irreducible.

(1) Reducible. The viscera can be restored by manipulation. A recurrent, reducible hernia is
repaired as a scheduled (elective) procedure.

(2) Irreducible. Irreducible is a hernia that cannot be restored manually. As a result, a portion of
the viscera has its blood supply blocked by compression, and the hernia becomes strangulated
(incarcerated). An incarcerated hernia requires emergency surgery.

c. Anatomical Location of Hernias. Included in this classification are hernias referred to as
inguinal, ventral, and incisional hernias.

(1) Inguinal hernia. This is the most frequently occurring hernia, accounting for 70 to 75 per cent
of all abdominal wall hernias, and it is 10 times more common in men than in women. It occurs in
the area of the inguinal canal (in the groin), the weakest part of the abdominal wall. Inguinal
hernioplasty is discussed in d below, as an example of abdominal wall hernioplasty.


                                                                                                   59
(2) Ventral hernia. This term indicates that there is a protrusion through the abdominal wall. An
epigastric hernia is a more specific term indicating a protrusion above the umbilicus, and
umbilical hernia, a protrusion through the umbilicus (see figure. 4-3). These hernias
characteristically occur in middle-aged men who work at manual labor (epigastric hernia) and in
obese men (umbilical hernia).



                                                               Figureure 4-3. Regions of the
                                                               abdomen.

                                                               (3) Incisional hernia. The incisional
                                                               hernia is a hernia that develops in
                                                               the scar of a surgical incision. The
                                                               hernia may occur after the surgery
                                                               before healing is complete or long
                                                               after surgery due to weakening of
                                                               the abdominal wall at the site of the
                                                               incision. Frequently, wound
infection results in incisional hernia.

d. Inguinal Hernioplasty.

(1) Instruments and equipment. A minor laparotomy set including Babcock forceps is used, plus
a Penrose drain to retract the spermatic cord, abdominal suction tip and rubber tubing connection,
and small Richardson retractors for general retraction. Kitners or moist gauze sponges are also
used for blunt dissection.

(2) Preparation of the patient. Either spinal or general anesthesia may be used. The specialist is to
assist with the administration of anesthesia as previously discussed in lesson 3. The patient is
placed in a supine position. An abdominal prep is done, and a laparotomy drape is used.

(3) Preparation of suction. Upon completion of draping, the scrub attaches the rubber tubing
connection for the abdominal suction to the laparotomy sheet and secures it with a sterile Allis
forceps. The scrub then places the suction tip on the tubing. The circulator attaches the free end of
the tubing to the suction machine and turns the machine on. The scrub places the suction tip in a
basin of sterile saline or water to test the suction. The circulator then turns the suction machine
off until it is needed. The scrub and the circulator should set up and test suction apparatus in
accordance with this procedure regardless of the operation for which suction is to be used.

(4) Special consideration. Because of the inguinal anatomy and the opening of the peritoneal
cavity, a sponge count is taken as prescribed by local policy for all hernia repairs.

(5) Surgical incision. The incision is usually about 4 inches long and 1 1/2 inches deep.

(6) Handling of specimen. The excised hernia sac is processed as a specimen and is sent to the
laboratory.

(7) Suturing types usually used.

(a) Absorbable gut sutures (plain or chromic) size 3-0 or 2- 0--used to ligate bleeding vessels.

(b) Nonabsorbable sutures, such as silk size 2-0 or cotton size 0—on Murphy needle size 3--used
to ligate the hernia sac.


                                                                                                   60
(c) Nonabsorbable sutures, such as silk or cotton size 2-0 or 3-0--12-inch lengths--on Mayo
needle size 4--used for the plastic reconstruction of the anatomic defect.

(d) Absorbable gut sutures size 3-0, or silk size 3-0-- interrupted sutures on Murphy needle size
3--used to close the subcutaneous tissues.

(e) Silk size 4-0 or nylon size 5-0 straight skin needles-- used to close the skin.

4-9. APPENDECTOMY

a. Discussion. One of the most common procedures of elective general surgery performed inside
the abdominal cavity is an appendectomy or the removal of the vermiform appendix, a worm-
shaped projection from the cecum. Some pathological conditions require appendectomy, which
are: gangrenous appendix, appendicitis with fecalith (concretion formed around fecal matter),
retrocecal (behind the cecum) appendix with appendicitis, and appendiceal abscess. A sponge
count is taken for appendectomy.

b. Surgical Approach. Because the appendix is located at the junction of the ileum and the
cecum, it is approached most frequently through a McBurney incision about 3 to 4 inches long,
near the iliac crest (about one-third the distance between the crest of the ilium and the umbilicus).

c. Equipment Needed. A minor laparotomy set (see para. 4-1 0c(2)) of instruments is needed,
plus Babcock forceps which are used for holding the mesoappendix and appendix. A suction tip
and rubber tubing connection are included in the setup.

d. Prep, Position, and Drape. The usual prep for a McBurney incision extends from waist to
pubis. The patient is placed in supine position, and a laparotomy drape is used. The scrub sets up
the sterile suction equipment; the scrub and the circulator test the equipment.

e. Special Item Needed. The gastrointestinal suture is used for the "purse-string" suture around
the stump of the appendix.

f. Handling of Specimen. The circulator is to process the specimen for the laboratory.

g. Suturing Types Usually Used. The type and size of sutures used for an appendectomy are
determined by the surgeon. The following are usually used:

(1) Absorbable gut size 3-0 or 2-0--ligatures.

(2) Gastrointestinal suture affixed on curved needle--purse-string.

(3) Absorbable gut size 3-0 on curved, cutting-edge needles--used to close peritoneum and
fascia.

(4) Silk size 3-0 on straight skin needle--used to close skin.

4-10. LAPAROTOMY

a. Discussion. This is a general term indicating that the abdominal cavity is to be entered
surgically. It does not indicate the therapeutic procedure performed, nor does it indicate the site of
the surgical incision. If the surgeon is uncertain of the specific procedure to be done, he may have
the operation scheduled as an exploratory laparotomy. As an example, a missile entering the right
hypochondriac region (see figure 4-3) of the abdomen and exiting directly posteriorly may have
damaged any or all of these organs: liver, gallbladder, right flexure of colon, small intestine, and
right kidney. The operative procedure is changed during surgery according to the pathology
                                                                                                   61
found. For example, if the patient is found to have a ruptured gastric ulcer, the operative
procedure is changed to read "Laparotomy for repair of gastric ulcer." A sponge count is taken for
laparotomy.

b. Prep, Position, and Drape. General anesthesia is employed, and an abdominal prep is done. The
patient is placed in supine position and the position is modified as may be necessary upon
determination of the pathology. A laparotomy drape is used and is usually placed for midline
incision (see figure 4-2 B).

c. Instruments. A major instrument set also known as a major laparotomy set is used, with large
self-retaining retractors and specific instruments for resections and anastomoses. Crushing clamps
may be used on portions of the digestive system to be permanently resected. On structures to be
anastomosed, a rubber-shod Doyen clamp is preferred to avoid excessive trauma. An abdominal
suction setup is to be prepared.

(1) A major laparotomy set contains a variety of instruments to include larger sizes of the basic
instruments. The major laparotomy set, because of its completeness, could be used alone or in
conjunction with a specialty set for the majority of intra-abdomi nal operative procedures.

(2) A minor instrument set known also as a minor laparotomy set differs from the major
instrument set in that the former contains fewer and smaller instruments. The minor laparotomy
set is the preferred instrument set for less major intra-abdominal operative procedures such as an
appendectomy or hernia repair.

d. Handling of Specimens. Any tissue excised is to be processed as a specimen unless the surgeon
directs otherwise.

e. Suturing Types Usually Used. Sutures included in the setup are those for ligatures and for
closure of the wound, as described for appendectomy (see para 4-9i). If the surgeon meets with
pathology in the abdomen that requires the use of additional types of sutures and needles, he will
request the needed items.

4-11. GASTRECTOMY

a. Discussion. This means the removal of the stomach, but in use, the term is used to indicate
either the removal of a part of the stomach (partial gastrectomy or subtotal gas-trectomy) or the
removal of the entire stomach (total gastrectomy). The surgeon tries to leave at least a small part
of the upper portion of the stomach intact. Gastrectomy is the surgical treatment for cancer or
other neoplasms and for ulcer. These conditions are diagnosed preoperatively by X-ray.

b. Anesthesia, Prep, Position, Drape, and Instruments. These are the same as for a laparotomy. A
sponge count is taken for gastrectomy.

c. Special Considerations. When gastrectomy is performed, normal gastrointestinal continuity is
interrupted. In order to re-establish this continuity, the surgeon does an anastomosis.

d. Gastrointestinal Anastomosis (see figure 4-4). This is the attachment of one tubular structure to
another to create a passage through the two parts. An anastomosis may be made either side-to-
side or end-to-end. Sutures used for the anastomosis are of silk (size 4-0 to 3-0) or cotton (size 4-
0) affixed on intestinal needles. Because the intestine has been opened, contamination occurs and
some special considerations may be observed. These are as follows.




                                                                                                  62
Figure 4-4. Gastrointestinal anastomoses.
(Arrows indicate direction of flow of intestinal contents.)

(1) Double setup.

(a) Extra gowns, extra gloves, and draping linens are placed on a separate table and covered with
a double thickness sterile sheet.

(b) Extra instruments and extra sponges are set up on a separate table.

(2) Procedure. When the anastomosis is completed, all instruments are removed from the area, all
sponges and laparotomy tapes are removed from the patient's abdomen, and the wound is covered
with a fresh, moistened, laparotomy tape. The top drape is then removed. The surgeon and all
other "sterile" workers change their gowns and gloves. The circulator helps uncover the extra
instruments. The patient is draped with a new sterile laparotomy sheet and the abdominal wound
is closed. Sutures used for closure are as described for appendectomy.

4-12. COLOSTOMY

a. Discussion. This is the surgical creation of an artificial opening into the colon and mobilization
(exteriorization) of the portion of bowel affected. A sponge count is required for this operation.

b. Indications. Colostomy is done when there is an obstruction of the colon or a diagnosed lesion
such as malignant tumor, which will result in obstruction if untreated. Colostomy may also be
done to enable the healing of the bowel distal to the surgical opening whenever there is infection,
perforation, or traumatic injury, because the colostomy diverts the flow of feces from the area of
surgical pathology.

c. Types. A colostomy may be either temporary or permanent.

(1) Temporary colostomy. A temporary colostomy is done to divert the feces from its normal
course for a long enough time to allow healing, to relieve an obstruction, or to serve as a
palliative measure. A loop of colon is brought through the abdominal wall and the skin and
underlying tissues are sutured around it. A device made of a glass rod and rubber tubing may be
used to prevent the colon from slipping back into the abdominal cavity. The rod is left in place
until the wound is well healed (about 10 days). A catheter may be secured in the proximal part of
the loop of colon for immediate decompression.

(2) Permanent colostomy. A permanent colostomy is done to redirect the flow of feces in
conjunction with surgery such as removal of the rectum. This type of colostomy consists of a
single, small opening in the abdominal wall with a portion of bowel (cut transversely) brought
through it; usually, this is the end of the sigmoid colon.

d. Preparation of the Patient. Anesthesia, prep, position, and drape are as described for
laparotomy.

e. Preparation of the Operating Room. Instruments are as set forth for laparotomy, with the
addition of the following items: two glass rods, soft rubber tubing, rubber tube drain, Vaseline
gauze, and catheters of the desired size and type. Soft rubber tubing is used to retract the colon.

f. Special Precautions. Whenever the large bowel is opened intentionally or accidentally, there is
always the possibility of contamination and infection of the abdomen because of the presence of
E. coli in the bowel; therefore, special precautions are taken as indicated by local policy. These
may include isolation of the bowel area with extra large laparotomy tapes, isolation of


                                                                                                      63
instruments used for the resection of the bowel, and the changing of all members of the sterile
team into fresh gown and gloves once the colostomy has been done.

g. Requirements. This isolation technique requires extra linen, instruments, and possibly the set-
up of an additional Mayo stand. It assures the carrying out of good aseptic technique in that no
so-called "dirty" (contaminated) instruments are used on other parts of the abdomen for the final
closure.

h. Suturing Types Usually Used. Sutures for ligation of bleeding vessels are as described for
appendectomy. Chromic gut size 2-0 affixed on curved, taper-point needles is used to close the
peritoneum beneath the loop of the colon. The fascia and skin are sutured beneath the loop. Silk
size 3-0 may be used for this purpose.

4-13. CHOLECYSTECTOMY

a. Discussion. Cholecystectomy is the surgical removal of the gallbladder. This procedure is
usually performed due to chronic cholelithiasis (formation of stones in the gallbladder), which
results in inflammation and abdominal pain. A sponge count is required for this operative
procedure.

b. Prep, Position, and Drape. The surgical prep extends from the nipple line to the pubis
(abdominal prep); the patient is placed in a reverse Trendelenburg position (see figure 1-7), and a
laparotomy drape is used.

c. Special Considerations and Instruments. The location of the gallbladder under and partly
adherent to the liver makes it a difficult organ to reach. Incisions frequently used are the upper
quadrant oblique (subcostal) incision, the right (paramedian) rectus incision, and the inverted "U"
incision (see figure 4-2). The same major instrument set is used for laparotomy. For the special
needs of this surgery, the following items are added:

(1) Curved Kelly forceps to hold Kitner sponges, which are used to assist the surgeon in blunt
dissection from the liver bed.

(2) Scoops and spoons that are especially adapted for the removal of stones from the gallbladder.

(3) Gallstone forceps, used to clamp the gallbladder and to extract stones from the common duct.
Common duct dilators are also included in the setup.

(4) A sterile T-tube for insertion into the common bile duct after removal of the gallbladder and a
sterile Penrose drain for placement in the abdominal incision.

d. Special Procedure. The surgeon may wish to have a cholangiogram done to check the common
duct for patency. A cholangiogram is the X-ray visualization of the biliary duct after the injection
of a contrast medium. This procedure would be performed to locate possible obstruction in the
common bile duct. Contrast media (hypaque or diodrast) is injected into the duct system and X-
rays are taken. Supplies needed include a syringe, blunt needle, and a polyethylene tubing. A
cassette holder must be placed on the table under the patient before surgery begins.

e. Suturing Types Usually Used. Ligatures for bleeding vessels are used as for appendectomy.

(1) Chromic gut size 0 or silk size 2-0 affixed on curved needles is used to suture the peritoneal
fold which overlies the liver after the fold is clamped and divided.

(2) Chromic gut size 0 and 2-0 is used to ligate the cystic duct and cystic artery.


                                                                                                  64
(3) Chromic gut size 1 or 0--suture-ligature is used to ligate bleeding vessels in the area of the
cystic duct and cystic artery. The wound is closed using materials as described for closure after
appendectomy.

4-14. SURGERY FOR VARICOSE VEINS

a. Discussion. Varicosities usually involve the saphenous vein. Surgery performed on varicose
(unnaturally swollen) veins is the most common type of elective surgery performed as treatment
for disorders of blood vessels.

(1) A distension or back-pressure affects the veins in the lower limb, thus causing venous stasis
(stoppage of the flow of blood). The techniques involved, including procedures of the saphenous
vein, have enabled surgeons to save limbs that formerly would have been amputated because of
gangrene caused by obstruction. The interruption or removal of diseased veins aids in prevention
of ulceration, pain, and fatigue in the limb.

(2) The prep includes the entire leg and groin region. The patient is placed in either a supine or a
semi-lateral position, according to local policy or the surgeon's preference. The affected leg is
slightly abducted, the knee flexed, and the leg and foot are supported on a padded rest. There are
two methods of doing surgery: ligation and excision. These are discussed in paragraphs b and c
below.

b. Ligation of Varicose Veins. In this procedure, multiple small incisions may be made over each
area of knotted veins, and the vein and its branches are ligated (tied).

(1) Special items needed in the setup of the OR are: one injection set, including syringe, needle
file, and medication (sclerosing agent); and elastic bandages, used as a part of the dressings
following surgery.

(2) Local anesthesia is usually used. The patient is draped as described for the general surgery
drape of limb (see para 1-27).

(3) Absorbable gut suture (plain) size 3-0 or silk size 4-0 may be used to ligate bleeding
subcutaneous vessels. Absorbable gut suture (chromic or plain) size 2-0, 0, or 1, or silk size 3-0
or 2-0 on a size 3 Murphy needle may be used to ligate the saphenous vein and its branches.
(After the saphenous vein has been ligated, its distal portion is injected with the sclerosing
solution.) The fascia and subcutaneous tissues are then closed, using interrupted sutures of plain
gut size 0, or chromic size 2-0, or silk size 3-0 on a size 3 Murphy needle. The skin is closed
using silk size 4-0 on straight needles.

c. Excision of Varicose Veins. The saphenous vein, a superficial one, is ligated and excised for
treatment of extensive varicosities of the lower limb. During this procedure, the saphenous vein is
stripped. This is done by inserting a vein stripper in the saphenous vein immediately distal to the
sapheno-femoral junction at the upper thigh, and passing it down the vein to the knee and
subsequently to the ankle, thus stripping the vein free of its attachments in the leg. The vein is
then doubly tied and removed.

(1) Special items needed in the setup include: vein retractors, Weitlaner self-retaining retractors,
a vein stripper, and elastic bandage.

(2) Anesthesia is as for saphenous vein ligation (b(2) above). The patient is draped as described
for the orthopedic drape of a lower limb (refer to Lesson 1, figure 1-17).

(3) Ligatures are as used for ligation of the saphenous vein. The saphenous vein is exposed and
ligated (at the sapheno-femoral junction), using the materials for suture-ligatures as described

                                                                                                     65
above. The end of the saphenous vein distal to the point of ligation is then threaded onto the vein
stripper and the stripper is pushed downward to a point near the knee. A second small incision is
then made near the knee. The vein is delivered through this opening and is doubly tied or
transfixed using absorbable suture (chromic size 0 or plain size 1) or silk size 1 or 0 on a size 3
Murphy needle. Segmental removal of the vein is continued to the ankle. Upon completion of the
vein stripping, the wound layers are closed using the suture materials set forth in paragraph 4-
14b(3).

4-15. THYROIDECTOMY

a. Discussion. Thyroidectomy is removal of part or all of the thyroid gland. While the thyroid
gland is not essential to life, it is important in iodine metabolism, and maintenance of metabolic
rate to keep the body healthy. An indication for surgery is hyperthyroidism (excessive functional
activity characterized by increased basal metabolism). It is associated with enlargement of the
thyroid gland. A sponge count may be taken for this operation according to local policy.

b. Special Items Needed. In addition to the standard setup, the following items should be
included:

(1) Dye or a length of suture. For cosmetic reasons, the surgeon may wish to mark the incision
line with a dye or by pressure using a length of suture.

(2) Small hemostats. Although thyroid surgery is not deep, it is performed in a vascular area, and
therefore requires the use of a great number of small hemostats.

(3) Cardiac arrest tray and tracheostomy tray. The circulator should have these items in the room.

c. Preparation of the Patient.

(1) Preoperative preparation. Pre-operatively, the male patient is instructed to shave his face as
usual. The OR specialist does the remainder of the prep--the neck and upper chest to the nipple
line. The immediate preoperative prep is as described previously (refer to lesson 1, paragraph 1-
12).

(2) Position. The reverse Trendelenburg position is used (refer to Lesson 1, figure 1-7) with the
neck hyperextended by a rolled sheet placed lengthwise between the scapulae.

(3) Drape. Draping presents a problem because the operative field is so close to the anesthetist
and the unsterile field. A Mayo table or a special wire screen can be used above the patient's face
to support the weight of the drapes and extend them. In addition, keeping the skin towels in the
proper position may prove difficult. For this reason, the surgeon may wish to sew the skin towels
in position using a cutting edge needle and heavy (number one) black silk. The scrub should have
the suture ready in case the surgeon requests it. Skin towels may also be clipped to the skin.

d. Handling of Specimen. The circulator is to process the excised thyroid tissue as a specimen.

e. Suturing Types Usually Used.

(1) Absorbable suture (plain size 2-0 or chromic size 3-0) or silk size 4-0--ligatures.

(2) Silk size 2-0 or chromic gut size 0--suture-ligatures for the superior thyroid vessels and the
inferior thyroid artery.

(3) Chromic gut size 0 or silk size 3-0 threaded or affixed on size 1 Murphy needles--used as
mattress sutures to approximate the pretracheal muscles if they have been divided.
                                                                                                     66
(4) Absorbable sutures (plain size 2-0 or chromic size 2-0) or silk size 4-0 threaded or affixed on
size 3 Murphy needles--interrupted-- subcutaneous tissue.

(5) Silk size 4-0 affixed on needles or threaded on Keith needles--skin closure.

4-16. HEMORRHOIDECTOMY

a. Discussion. Hemorrhoidectomy is the excision of dilated veins in the rectum. These veins are
excised and ligated to control bleeding and to relieve pressure and pain. Either spinal or general
anesthesia may be used.

b. Preparation of the Patient.

(1) Prep. The rectal area, perineal area, and the buttocks are prepared extending to mid-thigh on
the posterior aspect of the legs (refer to Lesson 1, figure 1-1).

(2) Position. The patient is placed in either a jackknife or lithotomy position.

(3) Drape. Draping is dependent upon the position used.

c. Special Considerations.

(1) Some surgeons precede hemorrhoidectomy with a sigmoidoscopy examination. The
sigmoidoscopy setup is made ready with a rectal speculum (see figure 4-5) and lubricant.

(2) The surgeon uses absorbable sutures of chromic catgut to close the incision that has been
made through the anal mucosa, thus eliminating the need to remove the sutures later.

(3) The surgeon inserts a petrolatum gauze packing directly into the rectum.




Figure 4-5. Rectal speculum, Pratt 8 1/2 inch.
                               4 Procedures in General Surgery
Lesson 4-1 Procedures in General Surgery

After completing this lesson, you should be able to:

       Identify procedures used in a sponge count.
       Identify the responsibilities of the scrub and of the circulator in the following
        surgical procedures: skin graft, debridement, excision of pilonidal cyst,
        herniorrhaphy, appendectomy laparotomy, gastrectomy, colostomy, \
        cholecystectomy, ligation, and excision of varicose veins, thyroidectomy, and
        hemorrhoidectomy.

                                           Section 5
                                   Procedures in Orthopedics

                                  5 Procedures in Orthopedics

                                                                                                 67
Lesson 5-1 General Orthopedic Surgery

After completing this lesson, you should be able to:

      Identify the procedures used in reducing fractures of the leg, thigh, hip, knee,
       ankle, foot, shoulder, arm, forearm, and wrist.
      Identify the procedures used in treating a dislocation of the hip.
      Identify the procedures used in A-K amputation.
      Identify the procedures used in repairing severed tendons in the fingers.
      Identify the types of plaster casts, their uses, and the procedures used in
       applying the casts.

SUGGESTION After completing the assignment, complete the exercises at the end of
this lesson. These exercises will help you to achieve the lesson objectives.



LESSON 5

PROCEDURES IN ORTHOPEDICS

Section 1. GENERAL ORTHOPEDIC SURGERY

5-1. INTRODUCTION

Orthopedic surgery is concerned mainly with disorders of the skeletal system,
particularly with those parts having to do with locomotion, and usually, not the bones of
the anterior chest and the head. Fractures, dislocations, deformities, and other disorders
of the skeletal system are included in the area of concern. Orthopedic surgery should
hold the interest of the OR specialist for several reasons: The operative areas involved
are usually large enough or accessible enough so that the specialist may see the
procedure easily. The functional results are often obvious and gratifying even at the time
of operation; and the exacting preparation and care of the patient and of the special
surgical instruments used challenge the skill of the OR specialist.

5-2. DUTIES OF THE SPECIALIST

Duties of the specialist in the preparation of the patient and the OR are much the same
for orthopedic surgery as for other kinds of surgery. However, special problems in
orthopedic surgery involved with the preparation of both the patient and the OR require
emphasis.

5-3. SPECIAL PROBLEMS IN PREPARATION OF THE PATIENT

a. Traumatic Conditions. Patients with acute injuries may present intensified problems
of pain, shock, hemorrhage, and respiratory difficulties. In addition, orthopedic patients
with open wounds or contusions in or near the proposed operative field present
problems in the preoperative skin prep.

b. Psychological Conditions. The patient scheduled for orthopedic surgery may be
looking forward to his operation as a means of relief from long suffering. On the other
hand, he may be quite apprehensive about his postoperative future. He may await
surgery with great dread, fearing disfigurement, dependence on others, or necessity for
relying on prosthetic devices. Such fears may be all out of proportion to the more likely

                                                                                             68
situation. The specialist must recognize the fact that an attitude of fear and dread, no
matter how unrealistic the patient's fear may seem, presents real problems for both the
patient and the specialist. The specialist is to do the following when he is prepping the
patient:

(1) Be especially alert when the patient seems either anxious or depressed. Watch for
any indications of suicidal tendencies.

(2) Be an especially good listener if the patient wants to talk.

(3) Report to the surgeon any extreme behavior that the patient exhibits.

c. Preparation of the Skin. The general principles of skin preparation apply to preps for
orthopedic surgery. Carry out procedures based on these principles as painstakingly as
possible because bacteria left on the skin may get into the incision and produce bone
infection. Bone infection is difficult to control and may cripple the patient for life.
Therefore, never rely on antibiotics as a substitute for good preparation technique. In
addition, exercise great care not to cut or otherwise traumatize the skin while shaving
and scrubbing the appropriate skin area. If the patient is to have an enema, wait until this
treatment has been completed (if feasible to do so) before starting the prep.

(1) When ordered, perform a regular skin prep procedure such as that described in
paragraph 1-1 0e, preferably 24 hours prior to orthopedic surgery.

(2) Immediately after completing thorough and atraumatic shaving, scrub the prep area
with antibacterial detergent for 10 minutes (or such length of time as is prescribed
locally), then rinse the area with clear water and dry it. This scrubbing procedure for
orthopedic surgery is sometimes referred to as a "sterile" prep. (If the area to be prepped
appears particularly grimy or hard to cleanse, soak it in a warm water solution of the
antibacterial detergent for 30 minutes prior to this scrub).

d. Cleansing of Orthopedic Open Wounds. Regardless of the orthopedic operation that
is to be performed, all open orthopedic wounds should be thoroughly cleaned and
irrigated either before the surgical prep is done, or as a part of the sterile prep
immediately prior to the operation (with the patient anesthetized).

(1) The wound should be cleansed of any dirt or other foreign matter, as their continued
presence would tend to result in osteomyelitis postoperatively. Osteomyelitis is an
inflammation of the bone and bone marrow caused by bacterial infection and is
sometimes very difficult to control. Varying amounts of bony tissue are destroyed.
Systemic reactions include fever, pain, swelling, and other evidence of general infection.
The chief results are weakness of bone and deformity. The bones most frequently
affected are the femur, tibia, and humerus.

(2) The circulator should prepare for the cleansing of such wounds by having ready
extra flasks of normal saline, asepto syringes, pans used to catch the waste solution,
and hand scrub brushes and orangewood sticks for the removal of imbedded dirt.

(3) Because of the possibility of bone infection, extremely rigid adherence to aseptic
techniques is practiced in orthopedics. More than the usual preparation of skin may be
done both in the area prepared and in the duration of the scrub.

e. Prep of Area Covered by a Cast. Procedures for prepping areas covered by a cast
are determined by the individual case, and policies vary among hospitals for these
procedures. The cast may be bivalved (split in half lengthwise, in order that it may be
                                                                                            69
removed) or a "window" may be made in the cast. In addition, the patient may be
anesthetized for the cast to be removed and the prep to be done (usually done in the OR
or the cast room). The surgeon may do these procedures with the specialist assisting. If
the specialist does the skin preparation, he must use extra care in order not to nick or
otherwise damage the sensitive skin that has been enclosed in the cast. The local policy
must be followed.

f. Immediate Preoperative Prep. For the immediate preoperative prep for orthopedic
surgery, rubber sheeting is placed beneath the part of the patient's body to be prepped
so that the sheet under the patient will not become saturated. Otherwise, the procedure
is as previously described (see para 1-1 2c). If the surgery is to be performed upon a
limb, the circulator lifts the limb from the table and holds it during the prep.

5-4. SPECIAL PROBLEM IN PREPARATION OF THE OPERATING ROOM

During most orthopedic operations, X-rays are taken at various times during the surgery.
The specialist should allow for the extra space needed for the X-ray machine by
removing all unnecessary furniture from the room. In addition, extra drapes are needed
because the foot of the table is often draped. Moreover, the X-ray cassette must be
covered with sterile pillowcases cases before it is placed in the region of surgery. The
crowded conditions caused by the presence of the X-ray machine may make the use of
sterile back-jackets necessary for the "sterile" members of the operating team.

5-5. OPERATIONS FOR DISCUSSION

a. General. For purposes of discussion, each different type of operation listed in b below
is described as it is performed on a specific body part. However, the orthopedic
operations may be performed upon various bones and joints. As an example,
arthrodesis operations (fusion of a joint) may be performed upon joints other than the
knee or hip whenever it is desirable to eliminate motion in the joint. When arthrodesis of
the spine is performed, the prep, position, drape, and the setup of the OR are modified
to meet the needs of the operation to be done.

b. Specific Operations. The operations listed below are discussed in paragraphs 5-7
through 5-33.

(1) Closed reduction of femoral shaft fracture with traction.

(2) Basic technique--open reduction of fractures.

(3) Bone-grafting of fractured bone.

(4) Treatment of fractured hips.

(5) Intertrochanteric fracture.

(6) Intramedullary femoral fracture.

(7) Dislocation of the hip.

(8) Arthroplasty of the hip.

(9) Total hip replacement.


                                                                                        70
(10) Arthrodesis of the hip.

(11) Intramedullary pinning for tibial fracture.

(12) Operation for tibial shaft fracture.

(13) Compression plating of fractures.

(14) Patellectomy.

(15) Reconstruction of the patella.

(16) Arthrodesis of the knee.

(17) Arthrotomy of knee joint.

(18) Treatment of fractures of the ankle and foot.

(19) Excision of exostosis.

(20) Bunionectomy.

(21) Ban kart operation.

(22) Treatment of fractures of arm, forearm, and wrist.

(23) Closed suction drainage.

(24) A-K (above knee) amputation of leg.

(25) Tenoplasty of fingers.

5-6. SKELETAL ANATOMY

Refer to Introduction to Anatomy, Unit 4: The Skeletal System

5-7. REDUCTION (SETTING) OF FRACTURES

This is the correct approximation of the broken portions (fragments) of the bone.

a. Closed Reduction (External Fixation). In closed reduction (external fixation), the
fracture is realigned to normal position through external manipulation of the part. Closed
reduction is accomplished under x- ray control to be certain that the fracture is in correct
position. Closed reduction is the method by which closed fractures are reduced most
commonly. Then the alignment is maintained by immobilizing the part by either of two
methods.

(1) A plaster cast may be applied to hold the fragments in correct alignment after a
fracture has been reduced.

(2) The other method of external fixation is the application of skeletal traction by means
of special pins or wire inserted through the soft tissue into bone that is distal to the

                                                                                          71
fracture.

b. Open Reduction (Internal Fixation). This is the reduction of a fracture by the
application of mechanical devices (see figure 5-1) (screws, plates and screws, pins,
intramedullary nails) through an incision directly to the bone.

5-8. CLOSED REDUCTION WITH TRACTION OF FEMORAL SHAFT FRACTURE

a. Definition. This is the reduction of the fracture by the insertion of a sterile pin or wire
through the soft tissue and bone distal to the fracture (usually the upper part of the tibia)
and the application of skeletal traction.

b. Indications. This method of fixation is indicated whenever contraction of the powerful
muscles in the area prevents the correct approximation (manually) of the broken
fragments.

c. Special Preparation of the Operating Room. A sterile tray called a Kirschner wire (K-
wire) set may be used. If a set is not to be used, however, the following items should be
prepared:

(1) Instruments. A sterile scalpel, needed to make small skin incisions (nicks) at the
points of insertion and exit of the wires or pins. Other sterile instruments needed are as
follows:




Figure 5-1. Types of internal fixation

(a) A heavy wire cutter, needed to cut off the excess length of wire or pin.

(b) A drill of appropriate size, used to pass the wires or pins through the soft tissue and
bone.

(2) Other equipment and supplies needed.

(a) Sterile Steinmann pins or Kirschner wires (K-wires). Because the femur is a large
bone surrounded by strong muscles, surgeons usually prefer Steinmann pins for its
fixation.

(b) Tractor bows (sterile) of appropriate size for the pins selected. Figure 5-1 D
illustrates a tractor bow for use with either Kirschner wires or Steinmann pins.

                                                                                            72
(c) Sterile cotton or fine mesh gauze for dressing the skin wounds.

(d) Plaster of Paris bandages, as ordered by the surgeon.

(e) Weights sufficient to supply the amount of traction desired by the surgeon.

(f) Corks, to be placed over the ends of the wire.

d. Preparation of the Patient.

(1) Anesthesia. The anesthesia of choice is local. The specialist assists.

(2) Position, prep, and drape. The patient is placed in a supine position, with knees over
the break of the table. The skin area must be shaved and scrubbed as described in
paragraph 5-3c since the insertion of a pin is a sterile procedure. The sterile prep done
just prior to surgery is as described above. Draping is as has been described for the
draping of an extremity for orthopedic surgery, except that no tourniquet is used for
external fixation.

e. Special Precautions.

(1) Aseptic technique. The most stringent precaution to be observed during all
orthopedic surgery is the maintenance of strict aseptic technique--and it must be
maintained by all personnel throughout the procedure. This precaution deserves
particular emphasis because any break in technique can produce a serious
postoperative bone infection (osteomyel itis).

(2) Other precautions. Other precautions to be observed by the specialist when
assisting with either the external fixation or internal fixation of fractures are as follows:

(a) When moving or positioning the patient, the specialist must support the limb both
above and below the site of the fracture, correctly maintaining manual traction when
traction is necessary. (The maintenance of traction may require the assistance of four or
five people.)

(b) The specialist is required to hold the limb in an elevated position while the immediate
preoperative prep is done. Since the prep requires 10 minutes or more, the circulator
must use good body mechanics when he assumes his stance or he may suffer strain or
injury to his back. The circulator can maintain good body mechanics while holding an
extremity by supporting his elbows against his body and keeping his back in line directly
over his feet. The circulator should stand on a footstool while elevating a patient's foot
for the sterile prep. This will place him in a better position for holding and will give the
sterile team space enough to drape without contamination.

(c) The scrub waits until the antiseptic solution used to prep the leg is dry before
handling any drapes.

(d) The specialist should exercise care to ensure that the sharp working surfaces of the
orthopedic instruments are not dulled or made blunt. Dull instruments inflict unnecessary
trauma upon the patient.

f. Handling of Specimen. No tissue specimen is obtained during this procedure.


                                                                                                73
g. Suturing Types Used. Since the only incision made is a small nick or nicks in the skin,
no suturing is done.

h. Treatment of Other Fractures by Closed Reduction with Traction.

(1) Indication. In general, closed reduction with traction is done on other bones when a
fracture is mechanically unstable, as is seen in certain fractures of the wrist and in
oblique fractures of the forearm or the leg. See figure 5-2 for types of fracture lines.

(2) Sites. The most common sites for closed reduction with traction in addition to that
described above are the olecranon (elbow), the calcaneus (heel), the lower tibia, tibial
tubercle, and the metacarpals. In addition, K-wire fixation without traction is frequently
employed for breaks of the phalanges. Such procedures on the phalanges are entered
on the OR schedule as "fixation distal interphalangeal (DIP) joint" or "fixation proximal
interphalangeal (PIP) joint."

(3) Specialist's role. The specialist's role, in assisting with the treatment of any fracture
by closed reduction with traction, is as that described above for a femoral shaft fracture.
The adaptations necessary are those having to do with the part of the body being treated
and the size of the pins or wires needed.

5-9. BASIC TECHNIQUE--OPEN REDUCTION OF FRACTURES

a. General. This procedure is used to repair broken fragments by means of pins, nails,
and screws, or with plates and screws, through an open wound. A blind method of
fixation may be used by applying a short nail (Smith-Petersen) or a long nail (Kuntscher
or Lottes) through the bone without opening the fracture site. Internal fixation is used
when a satisfactory closed reduction cannot be obtained or maintained or when soft
parts are situated between the fractured fragments. Whenever possible, this operation is
done before swelling has occurred or after swelling has subsided. It is not routinely done
in the presence of an infection.

b. Preparation of the Patient. Routine skin cleansing and draping are carried out
according to the site of the operation.




                                                                                             74
Figure 5-2. Types of fracture lines.

c. Operative Procedure.

(1) The stockinette, if used, is cut with bandage scissors to expose the proposed
incisional site. The skin and subcutaneous tissue are incised with a scalpel. The skin
edges are protected with towels or gauze pads that are secured in place with sutures or
metal skin clips. A synthetic surgical skin drape may be used, eliminating the need for
towel clips.

(2) The muscles are separated and retracted (with retractors). With a periosteal
elevator, the periosteum is divided and elevated. Scar and granulation tissue is
removed. Bleeding is controlled with hemostats and fine gut ligatures or cautery. Bone
wax may be needed to control bleeding of the bone. The fractured bone ends are
grasped and approximated by means of bone-holding forceps or with clamps.

(3) The fractured fragments are fixed by means of the desired plates and screws. The
drill bit used should be approximately the same diameter as the body of the screws. This
is accomplished with the screw measure and guide. Holes are drilled in the bone in this
fashion. An asepto syringe filled with normal saline solution is used to prevent the
spread of bone dust and eliminate unnecessary heat from the drilling process. The
screws are inserted when the desired holes are obtained.

(4) The periosteum, muscle, and fascia are closed with chromic gut or silk sutures. The
skin drape, towels, or pads are removed. The wound edges are protected with clean
towels. The subcutaneous tissue is approximated, skin edges are sutured together, and
dressings are applied to the wound.

(5) When applicable, the extremity is immobilized in a cast.


                                                                                         75
5-10. BONE-GRAFTING OF FRACTURED BONE

a. General. This procedure involves exposure of the fractured fragments, attachment of
healthy bone onto the bone fragments, and insertion of screws through holes made in
the graft and into the cortex of the fragments. The amount of grafting material used and
the type of graft done generally depends on the location of the non-united bone, the
condition of the ends of the fragments, and the preference of the surgeon. The
procedure may be used in the following circumstances:

(1) To fill cavities or defects resulting from cysts, tumors, or other causes.

(2) To bridge joints and thereby provide arthrodesis.

(3) To bridge major defects or establish the continuity of a long bone.

(4) To promote union or fill defects in delayed union, malunion, fresh fractures, or
osteotomies.

b. Patient Preparation. Routine skin cleansing and draping are carried out according to
the site of the operation.

c. Operative Procedure.

(1) The skin overlying the fractured bone is incised and the scar tissue is excised, as in
open reduction. To encourage healing, the sclerosed bone may be drilled or removed to
stimulate granulation tissue foundation.

(2) The graft is obtained, and the affected fragments are prepared to suit the graft. To
form a bed for an onlay graft, the periosteum and a portion of the outer cortex are
removed from the fragmented ends of the bone. To perform an inlay or sliding graft, a
special slot is made in the bone fragments for the reception of the graft. Occasionally, a
sliding graft is used for tibial fractures. The graft is cut from the proximal fragment of the
fractured bone and is slid into the prepared bed over the distal fragment of the bone.

(3) To obtain an inlay graft from the tibia, a curved incision is made along the
anteromedial surface of the tibia, with its convexity to the medial side. The periosteum is
incised and reflected with an osteotome. The graft is outlined with drill holes, and
removed with an electric oscillating bone saw that has a double blade. A fracture of the
entire thickness of the donor bone may occur if the osteotomy is not outlined by drill
holes.

(4) In an onlay grafting operation, bone-holding forceps are used on the operative site
as the drill holes are placed through both the graft and fragments. Screws are then
inserted through the holes of the graft and into the cortex of the bone's fragments. In
some cases, bone chips are laid over the fragments to be united.

(5) A cancellous graft consists of spongy bone, usually taken from the crest or wing of
the ilium. Depending on the position of the patient, the anterior or posterior third of the
ilium is used. Exposure of the ilium is relatively easy, but considerable bleeding may
occur. An incision is made along the subcutaneous border of the iliac crest. The muscles
on the outer table of the ilium are elevated. If chip grafts are required, they are removed
with an osteotome parallel to the crest of the ilium. After removal of the crest, the
cancellous bone maybe obtained by curetting the cancellous space between the two

                                                                                             76
intact cortices.

(6) The wounds are closed in layers and dressings applied. A plaster casing may be
applied to the fractured extremity.


5-11. TREATMENT OF FRACTURED HIPS

a. Definition of Terms. Fractures of the hip are in reality fractures of the upper end of the femur
and are classified under three main groups: (1) the intracapsular types, which include the capital,
subcapital, and transcervical fractures; (2) the extracapsular types, which include the
intertrochanteric fractures; and (3) the upper femoral epiphyseal separation, usually occurring in
young obese boys. The term intracapsular refers to the inside of the hip joint; extracapsular to the
outside of the hip joint.

b. General.

(1) A subcapital fracture is one that occurs in the upper end of the femur, within the hip joint just
beneath the femoral head. Older persons usually are the sufferers because they may fall more
often. A subcapital fracture, which may be impacted or grossly displaced, may be caused by
indirect violence, such as slipping on a rug or polished floor. The bone gives way, and the patient
falls to the floor. After the injury, the leg becomes externally rotated if the fracture is not
impacted.

(2) The patient with a displaced subcapital fracture is treated by the insertion of a suitable
appliance at the earliest time his general condition permits. If the fracture is close to the femoral
head, internal fixation may be supplemented by means of a bone-grafting operation. Delay or
nonunion may occur in subcapital fractures, especially in those where the fracture line is unstable.
The strong pull of the hip muscles often tends to produce a loss of normal angulation between the
shaft and femoral neck, resulting in shortening, external rotation, and adduction deformities.
Subcapital fractures are sometimes impacted. These are frequently managed without surgery if
they are inherently stable.

(3) A transcervical (intracapsular) fracture occurs in the mid-portion of the femoral neck. These
fractures usually require surgery. If possible, internal fixation of the fracture is carried out.
Otherwise, a femoral head prosthesis may be used.

(4) An intertrochanteric fracture is located farther from the region of the trochanter and may
occur when the person falls directly on the trochanteric region or when his leg is twisted. After
the injury, the limb intertrochanteric fractures usually run in different directions, but they
generally heal.

(5) Reduction of intertrochanteric fractures may be maintained by plaster hip spica cast, external
fixation and traction, or open operation. The latter includes the insertion of a pin or nail into the
neck of the femur and the attachment of a plate and screws, such as Jewett nail and plate, a
Smith-Petersen nail with a McLaughlin plate, or a Neufeld angled nail and plate, to the other side
of the femur.

(6) A separation or slipping of the upper femoral epiphysis (adolescent coxa vara) may occur
quickly or gradually. This condition causes a decrease of the angle between the femoral neck and
shaft. When this occurs, the femoral head rotates posteriorly and interiorly, and the femoral shaft
and neck move forward. This lesion usually is seen either in obese children between the ages of
10 and 16 or following a traumatic injury. Acute displacement or a chronic disability in the hip is
usually accompanied by a limp.


                                                                                                    77
(7) An acute displacement of the upper femoral epiphysis is treated by manipulative reduction
and introduction of multiple pins across the epiphysis or by manipulative reduction and
immobilization with a plaster spica cast. Procedures that are more elaborate are required when a
chronic condition exists and is accompanied by gross displacement,

5-12. INTERTROCHANTERIC FRACTURE (SEE FIGURE 5-3)

a. General. This is repaired by making an open wound and fixing the fragments with a metal
appliance such as a Jewett angled nail, a Smith-Petersen nail with a McLaughlin or Thornton
plate, a Neufeld nail, a Blount-Moore blade plate and screws, or a Lorenz screw nail and plate.
Frequently, a nail alone is not adequate for holding the parts in alignment. Therefore, a nail-plate
combination is needed to give fixation to the shaft of the femur.

b. Special Preparation of the Operating Room. Besides a basic orthopedic setup, metal appliances
as chosen by the surgeon, screws, and screwdrivers will be needed.

c. Preparation of the Patient. The patient is placed in a supine position on the fracture table. The
hip region is cleansed, and sometimes the prep is extended to include the entire extremity, the
abdomen, and the anterolateral portion of the chest. The patient is draped, using a fenestrated
sheet and regular sheets.



                          Figure 5-3. Open reduction of intertrochanteric fracture, with
                          Neufeld nail inserted into neck
                          and head and down shaft of femur, using divergent screws.

                          Nail is one-piece stainless steel with V-shaped flanges into neck and
                          head. (From Larson, C.B., and Gould, M.: Orthopedic Nursing, ed. 7,
                          St. Louis, 1970, The C. V. Mosby Co.)

                          d. Operative Procedure.

(1) With a scalpel, a skin incision is made in the thigh, beginning at the level of the superior
aspect of the greater trochanter and extending along the shaft of the femur. Bleeding is controlled.
Wound edges are protected with skin towels or pads.

(2) The deep fascia is incised and retracted with retractors, and the lateral great muscle is split
and retracted to expose the shaft and trochanter of the femur.

(3) With a Kirschner or Smedberg bone drill, a hole is drilled at a point midway between the
anterior and posterior cortex of the femur, using at the same time an Asepto syringe filled with
normal saline solution.

(4) The desired guide wire is inserted at a 45-degree angle to the shaft and may be changed by
starting the insertion of the wire at a lower point on the shaft of the femur. The guide pin is driven
up the neck of the femur. This is checked by X-ray films. The guide pin may be removed before,
during, or after insertion of the nail appliance.

(5) A desired nail appliance of the appropriate size is driven into the bone so that its plate will be
flush with the shaft. The plate attachment is fixed to the shaft with appropriate size screws. X-ray
films are taken before closure to determine the proper location and fixation of the nail.

(6) If the fracture is subcapital or intracervical, multiple Knowles pins or a Smith-Petersen nail
may be used. The exposure need not be as extensive as for the nail and plate combination since

                                                                                                      78
no side plate is attached to the femoral shaft. If multiple pins are used, they are placed in much
the same manner as a guide pin. Usually, four are inserted parallel to each other in a boxlike
pattern.

(7) If the fracture is subcapital or intracervical, the surgeon may decide to use a primary
prosthesis rather than attempt fixation of the fracture.

(8) The wound is closed in layers. Skin towels or pads are removed; dressings are applied, and in
some cases, plaster of Paris is applied.

5-13. INTRAMEDULLARY FEMORAL FRACTURE

a. General. The surgery for the repair of an intramedullary femoral fracture involves insertion of
a nail through the intramedullary canal of the proximal and distal fragments of the femur, usually
through a posterolateral incision. Most fractures of the femoral shaft are caused by direct
violence, which results in short, oblique, or transverse fractures; few result from indirect violence,
which produces a torsion force. The latter situation usually causes a spiral fracture. Others are
considered pathological fractures due to the presence of metastatic carcinoma, Paget's disease of
the bone, and dysplasia. Patients with a fractured femur suffer severe pain and shock not only due
to the injury itself, but because of associated injuries.

b. Special Preparation of the Operating Room. Besides a basic orthopedic setup, plates with
screws and intramedullary nails such as the Kuntscher, cloverleaf-shaped, or Hansen-Street
diamond-shaped nail will be needed according to the directions of the surgeon.

c. Patient Preparation. In addition to regular prep, position the patient on his side. Proper
supports to stabilize the patient will be needed along with X-ray equipment

d. Operative Procedure.

(1) Through a posterolateral incision made with a scalpel, the fracture site is exposed and
retracted, and wound edges are protected. Bleeding vessels are clamped and ligated or cauterized.

(2) A nail is selected and tested to fit the distal portion of the fractured bones according to their
width and size and then the proximal fractured fragments. The fragments are reamed with a
reamer that is the same size as the nail.

(3) The proximal fragment usually is reamed out up through the isthmus. This is the narrowest
portion of the intramedullary canal, where the nail might get caught during its insertion.

(4) A guide wire is driven in retrograde fashion up through the proximal fragment and out
through the greater trochanter until the guide wire emerges through the skin at the level of the
posterior lateral buttocks. Before this step is carried out, the thigh must be abducted and flexed so
that the guide pin will not be driven up into the chest or abdomen.

(5) A skin incision is made around the guide pin; then a reamer is inserted over the guide wire. A
hole is reamed into the top of the femur at the greater trochanter; then the nail is driven down
over the guide wire until it emerges at the fracture site. The guide wire should be withdrawn as
soon as the nail is firmly seated in the proximal fragment. Otherwise, the nail may bind on the
guide pin.

(6) The fracture is reduced and aligned correctly in regard to rotation. The nail is then driven into
the distal fragment (see figure 5-4) and its position is checked with X-ray films.



                                                                                                     79
(7) The wound is closed and dressings are applied. The affected leg usually is placed in balanced
suspension, and, on occasion, traction is applied. On the other hand, the leg may merely be placed
on a pillow.



                                       Figure 5-4. A-Fracture of upper end of shaft of femur.

                                       Displacement fracture at subtrochanteric site with
                                       interposition of torn vastus muscle. This is most common
                                       type of fracture in upper end of shaft causing nonunion B-
                                       Treatment by Kuntscher rod. (From Miller, D.S.: Surg. Clin.
                                       North Am. 45:38, 1965.)



                                       5-14. DISLOCATION OF THE HIP

a. General. Although dislocation of the hip does not commonly occur, it may be caused by a
severe blow that displaces the head of the femur out of the acetabulum. In some injuries, the head
of the femur is pushed centrally, carrying with it the floor of the acetabulum. In such conditions,
the lower extremity on the affected side appears to be shortened, and occasionally the rim of the
acetabulum or head of the femur may be fractured.

b. Pathological Dislocation. A pathological dislocation of the hip may be caused by (1) a severe
infectious disease such as scarlet fever, typhoid fever, or tuberculosis; (2) infantile paralysis; or
(3) a chronic arthritis resulting in destruction of the femoral head or the acetabulum.

c. Congenital Dislocation. The term congenital dislocation includes various degrees of
displacement of the femoral head from its normal position, as well as subluxations. In some
advanced cases, a shelf reconstruction operation is done; however, open reduction sometimes is
necessary in the early stages of the disease.

d. Mode of Treatment. The choice of operation depends on the degree of injury and the condition
of the patient. The types of operations that may be done to treat a dislocation of the hips include
(1) closed reduction with immobilization by plaster spica cast, (2) open reduction with screw
fixation for reducible fragments, (3) arthrodesis, or (4) arthroplasty.

5-15. ARTHROPLASTY OF THE HIP

a. General. In this operation, the diseased joint is severed, the hip dislocated, and the articulating
surfaces remodeled with the aid of a metallic cup or a prosthetic replacement. This is frequently
done when the joint is damaged by a degenerative disease such as arthritis or by a pyogenic
infection. Sometimes the femur is simply covered; but in other cases, it is replaced by a plastic or
metal prosthesis.

b. Preparation of the Operating Room. A basic orthopedic setup is needed plus appropriate
appliances, as well as special retractors, rasps chisels, osteotomes, gouges, extractors, and
reamers.

c. Preparation of the Patient. The patient is positioned on the operating table in a supine or lateral
position, the operative skin area is cleansed, and the patient is draped.

d. Operative Procedure: Mold Arthroplasty.


                                                                                                    80
(1) The skin is incised with a scalpel, and the bleeding vessels are controlled by cautery or
ligatures.

(2) The necessary muscles are divided or moved with their attachments to expose the hip joint.

(3) The capsule of the hip is incised or excised as necessary.

(4) The hip is dislocated to expose the head of the femur and the acetabulum.

(5) These are shaped and reamed to accept the mold or cup of choice.

(6) The hip is reduced, and the position is checked.

(7) The wound is closed in layers, reattaching or transplanting as needed all muscles that were
interrupted. Dressings are applied.

(8) Postoperatively, abduction and neutral alignment must be maintained until the patient is
capable of controlling this himself.

e. Operative Procedure: Prosthetic Arthroplasty.

(1) The skin is incised with a scalpel, and the bleeding vessels are controlled by cautery of
ligatures.

(2) The necessary muscles are divided or moved with their attachments to expose the hip joint.

(3) The capsule of the hip is incised or excised as necessary.

(4) The hip is dislocated to expose the head of the femur and the acetabulum.

(5) The acetabulum is examined and reamed if needed.

(6) The neck of the femur is osteotomized and the medullary canal reamed at the proper angle to
accept the appliance of choice.

(7) The prosthesis is seated in the femoral canal and the hip reduced.

(8) The wound is closed in layers, reattaching or transplanting as needed all muscles that were
interrupted. Dressings are applied.

(9) Postoperatively, abduction and neutral alignment must be maintained until the patient is
capable of controlling this himself.

5-16. TOTAL HIP REPLACEMENT

a. Room and Patient Preparation. Preparation of the room and patient are the same as for
paragraph 5-15 above.

b. Operative Process.

(1) The skin is incised with a scalpel, and the bleeding vessels are controlled by cautery or
ligatures.

(2) The necessary muscles are divided or moved with their attachments to expose the hip joint.

                                                                                                  81
(3) The capsule of the hip is incised or excised as necessary.

(4) The hip is dislocated to expose the head of the femur and the acetabulum.

(5) The acetabulum is shaped and reamed to accept the acetabular portion of the appliance. The
proper angle of this component is very important.

(6) The acetabular component is placed and stabilized, either by the use of methyl methacrylate
or by employing the proper guides and positioners for the appliance.

(7) The neck of the femur is osteotomized, and the medullary canal is reamed at the proper angle
for the chosen prosthesis.

(8) The femoral component is seated and stabilized as required.

(9) The hip is reduced, and the position is checked.

(10) The wound is closed in layers, reattaching or transplanting as needed all muscles that were
interrupted. Dressings are applied.

(11) Postoperatively, abduction and neutral alignment must be maintained until the patient is
capable of controlling this himself.

5-17. ARTHRODESIS OF THE HIP

a. General. This operation involves fusing together the articular surfaces of the hip joint by
means of osteotomy, insertion of a bone graft taken from the ilium or femur, and internal fixation
with a hip nail and screws. This may be done to treat tuberculosis of the hip or relieve pain and
dysfunction due to trauma or other lesions such as tumor. Some hip deformities and those
produced by muscle imbalance or instability may be treated by arthrodesis.

b. Preparation of Operating Room. This is the same as described for arthroplasty (see para 5-15b)
plus a bone-grafting setup.

c. Preparation of the Patient. Although, the patient may be positioned on the table in a lateral
position, prone or supine will often be used when a graft is to be taken from the femur.

d. Operative Procedure. This is similar to arthroplasty of the hip, as described in paragraph 5-15.


5-18. INTRAMEDULLARY PINNING FOR TIBIAL FRACTURE

a. General. This procedure involves the insertion of a nail through a short incision made over the
anterior aspect of the tibia and medial to the tibial tubercle. Proper alignment and apposition are
quite important to the success of this operation, as well as an accurate fit in the medullary canal.
This method obviates the need for plates.

b. Operating Room Preparation. A basic orthopedic setup will be needed, plus nails and other
instruments as requested by the surgeon.

c. Patient Preparation. The patient is placed in the supine position, and either the leg is placed in
traction to the foot or the table is bent so that the leg hangs freely, using gravity for traction.

d. Operative Procedure.

                                                                                                   82
(1) The fractured fragments are exposed in a manner similar to the procedure described for
intramedullary nailing of a femoral fracture. The fracture is reduced.

(2) A 3/8-inch drill hole is made through the outer cortex at the bend of the mid-portion of the
tibial tubercle. The nail is inserted in the drill hole with its flange facing outward. It is driven
down the fracture site and its position determined. X-ray films are taken.

(3) The wound is closed with chromic gut and silk sutures. The affected extremity is encased in a
cast.

5-19. OPERATION FOR TIBIAL SHAFT FRACTURE

a. General. For simple transverse fractures and many oblique fractures, the fragments are reduced
by external manipulation and the leg encased in a plaster cast. For severely fragmented fractures,
skeletal traction or the insertion of an appropriate appliance may be used. Usually, these fractures
are at the lower and middle thirds of the tibial shaft and at the junction of these two thirds. The
fractures that result from a direct blow often are the transverse or comminuted types, whereas
those that result from a twisting force are the spiral type.

b. OR Preparation. Skeletal traction or plaster cast setup will be needed. If prescribed, the
internal reduction setup with plates and screws of desired type and size, screws alone, transfixing
wires, or an intramedullary nail will be used. In nonunion cases, a bone-grafting setup is also
needed.

c. Patient Preparation. For the preoperative prep for orthopedic surgery, rubber sheeting is placed
beneath the part of the patient's body to be prepped so that the sheet under the patient will not
become saturated. Otherwise, the procedure is as previously described (see para 1-1 2c). If the
surgery is to be performed upon a limb, the circulator lifts the limb from the table and holds it
during the prep.

d. Operative Procedures. This is the same as in paragraph 5-9c.

5-20. COMPRESSION PLATING OF FRACTURES (SEE FIGURE 5-5)

a. General. The use of compression in achieving fixation and promoting union in cancellous bone
is now well accepted. This plate relies on the mechanical compression prior to fixation for its
function. It provides rigid fixation not only because of the compression, but also because it is a
very thick, heavy plate. The advantages of compression are the fixation is more rigid, the gap
between the fragments that must be bridged by new bone is narrowed, and the external
immobilization required after surgery is reduced or may even be eliminated.



                                                                Figure 5-5. Compression plating of
                                                                fractures.

                                                                (From Orthopaedic Instruments and
                                                                Procedures, Warsaw, Ind., 1970,
                                                                Zimmer of Canada, Ltd., The Fred
                                                                Schad Co., Inc., Columbus, Ohio.)

                                                                b. Operating Room Preparation.
                                                                The basic orthopedic instrument
                                                                setup is needed, with the addition of
                                                                the compression plating set. Several

                                                                                                       83
instrument companies manufacture various types of compression instruments and implant
systems. The purpose of such a system is to approximate the bone fragments under compression
during the act of applying an appliance for rigid fixation.

c. Patient Preparation. Positioning and preparation of the patient depends on the fracture site.

d. Operating Procedure. After the fracture has been reduced, the proper plate and screws are
selected. The periosteum is stripped in preparation for plating.

(1) To attach one end of the plate to the bone, the plate is centered over the fracture. Holes are
drilled in proximal fragment using a hand-held drill guide. After the hole is drilled, a self-tapping
screw is placed. (If the surgeon prefers, a separate tapping instrument is included in the set.)

(2) The plate is affixed to the proximal end with necessary screws. A locator drill guide hook is
placed in the elongated slot on the distal end of the plate and an anchor hole is drilled. A Trinkle
handle is provided which can be snapped to the locator drill guide.

(3) With compression clamp capstan handle in free position, the compress-ion clamp foot is
placed over the anchor hole. The anchor screw is inserted. The handles are pivoted toward the
anchor screw and the compression clamp hook is engaged into the slot on the distal end of the
plate. Capstan handles are locked across the compression clamp. Compression is applied by
turning the capstan handle knob clockwise.

(4) All remaining bone screws are then placed with full compression applied. Compression is
then released by swinging the capstan handle to a free position. The anchor screw and
compression clamp are removed.

(5) The wound is closed in the routine manner. The affected limb may or may not be placed in a
plaster cast.


5-21. PATELLECTOMY

a. General. This operation involves the excision of the bone portion of the patella (kneecap) and
repair of the quadriceps expansions. Fractures of the patella are of the transverse, comminuted
(stellate) or linear type. They are usually caused by direct contusion or muscular stress. The
fragments of bone, especially in a transverse fracture, may separate when the torn quadriceps
muscle pulls them apart. If this occurs, the quadriceps mechanism must be repaired. Linear or
comminuted fractures in which the fragments do not separate are immobilized in a cast. If one
pole of the patella is avulsed, it may be excised and the quadriceps repaired. A patellectomy is
done to aid knee function if the patella is diseased or too severely injured to be repaired.

b. Operating Room Preparation. The setup is the basic orthopedic setup, including Cave knee
retractors and Kocher retractor, bone awl, and rongeurs.

c. Patient Preparation. The patient is placed on the operating table in a supine position, with the
affected knee joint at a level with the break of the lower section of the table. The foot section of
the table is lowered, or the knee is flexed by placing a suitable sandbag beneath its posterior
aspect. The extremity is cleansed, and the patient is draped with sheets, as for draping a lower
extremity.

d. Operative Procedure.

(1) A curved, transverse, or paramedian incision is made over the knee, and the capsular tendon
ligament of the joint and the quadriceps are exposed.

                                                                                                   84
(2) The patellar ligament is incised to expose the anterior surface of the patella.

(3) The fragments of the patella are removed from the surrounding tendon by sharp dissection.

(4) In some cases, the quadriceps and patella tendon are sutured with chromic gut or fine
stainless steel wire.

(5) The defect in the patellar ligament is closed with sutures. The wound is closed and the
extremity immobilized in a cast.

5-22. RECONSTRUCTION OF THE PATELLA

a. General. This operation involves the fixation of the patella tendon and its bony attachments to
the tibia or application of the soft tissues on the medial side of the patella tendon. Its performance
is prompted by recurrent dislocation of the patella tendon, which may originate from a blow
against the inner side when the knee is flexed. More often, it is a congenial develop-mental
phenomenon associated with a shallow groove in the femoral condyles, a ball-shaped patella, or
knock-knee.

b. Operating Room Preparation. The basic orthopedic setup is needed, including a textile pack
for the lower extremity, plus instruments for internal fixation of fractures or patellectomy (see
para 5-21 b).

c. Patient Preparation. The patient is prepared as described for patellectomy (see para 5-21c)

d. Operative Procedure. One of several operations may be done, depending on the condition. The
most common operations are (1) transfer of the patella tendon and its bony attachments inward on
the tibia, similar to arthroplasty, (2) wedge osteotomy of the lateral femoral condyle, similar to
arthrodesis, or (3) tendon or fascia lata fixation of the patella to the inner condyle of the femur,
similar to patellectomy.

5-23. ARTHROPLASTY OF THE KNEE JOINT

a. General. In this operation, the tibial articular surfaces are replaced by a metallic prosthesis that
articulates with the femur. It is done in case of severe arthritic changes in the knee when the joint
appears salvageable. Otherwise, arthrodesis is done.

b. Operating Room Preparation. This is the same as that described for basic orthopedic setup and
patellectomy, including bone curettes, osteotomes, chisels, raspatories, and rongeu rs.

c. Patient Preparation. The patient is placed on the operating table in a supine position, with the
knees at the level of the lower break section of the table. The knee maybe flexed by breaking the
table. The posterior portion of the knee should be supported by a pad, and the leg should rest on
the table pad.

d. Operative Procedure.

(1) With a scalpel, a long skin incision is usually made down through the quadriceps tendon,
which is dissected free from the femur by means of curved scissors, tendon strippers, and an
elevator. Bleeding is controlled with hemostats and fine sutures. Skin towels are applied and
secured to the wound edges if a synthetic skin drape has not been used. The patella is separated
from the femur, using a tenotomy knife and bone hooks.

(2) The patella is elevated and inspected. Sometimes it is removed by means of bone elevators,
gouges, and rongeurs. The bony surfaces are smoothed.
                                                                                                    85
(3) A prosthesis (McKeever or Sbarbaro) is inserted for restoration of the anatomical contour and
for elimination of friction with the opposed cartilage. The prosthesis is anatomically contoured
and fits into the upper end of the tibia. It is designed to reestablish the anatomical outline of the
articular surface. A flat surface on the tibial condyle is first created with a saw or osteotome, and
the prosthesis is inserted.

(4) The wound is closed in layers. Surgical dressings are applied to the wound and secured with
bandages. The leg is immobilized in a plaster splint.

5-24. ARTHRODESIS OF THE KNEE

a. General. This procedure involves osteotomy and fusion (thus immobilization) of the joint with
insertion of metal screws or a nail. Compression arthrodesis by means of transfixion by pins
inserted through the femur and tibia and incorporated in turnbuckle clamps may be used.

b. OR Preparation. This is as described for arthroplasty of the knee, with suitable appliances such
as Charnley clamps, knee plates and screws, or intramedullary rods.

c. Patient Preparation. This is the same as for arthroplasty of the knee (see para 5-23c).

d. Operative Procedure. Similar to that described for arthroplasty of the knee joint (see para 5-
23d).

5-25. ARTHROTOMY OF KNEE JOINT FOR EXCISION OF TORN CARTILAGE (SEE
FIGURE 5-6)

a. General. In this operation, the knee joint is exposed and explored through an anteromedian,
paramedian, or oblique incision, and the torn meniscus (cartilage) is removed. This operation is
needed because of an injury caused by a twisting motion which ruptures the internal and external
semilunar cartilages. This injury may cause the anterior or posterior horn to become detached
from the upper tibia. Or the cartilage may split, allowing one portion to enter the central region of
the knee joint and the other portion to remain in its normal position along the outer margin of the
joint.



                                           Figure 5-6. Bucket-handle tear of internal semilunar
                                           cartilage.

                                             (From Richards, V. Surgery for General Practice, St.
                                                    Louis, 1956, The C. V. Mosby Co.)

                                           b. Operating Room Preparation. Setup is as described
                                           for patellectomy (see para 5-21 b), including a cartilage
                                           osteotome and tenotomy knives.

                                           c. Patient Preparation. This is the same as for
                                           patellectomy (see para 5-21c).

                                           d. Operating Procedure.

                                        (1) An incision is made in the knee joint and carried
through the subcutaneous tissue; wound edges are protected, as described for internal fixation.



                                                                                                    86
(2) The capsule of the knee is opened, and its edges are retracted; the synovial membrane is
opened.

(3) The medial and lateral men isci are identified, and the structures of the knee joint are
examined, using elevators and retractors. Broken cartilage and loose body or synovial tabs are
removed, using Ochsner forceps, a long knife, tenotomes, meniscectomy knives, and tissue
forceps. The knee joint is irrigated, using an asepto syringe filled with normal saline solution.

(4) The synovial layer is closed with plain gut number3-0 swaged to 1/2-circle, trocar point
Murphy needles.

(5) The wound is closed in layers and covered with dressings. The extremity is sometimes
stabilized in a splint or cylinder cast.

5-26. TREATMENT OF FRACTURES

a. General. These procedures involve the reduction of fractures and immobilization of fragments
by external fixation or by open reduction with fixation sutures, bolts, or screws.

b. Operating Room Preparation. The instrument setup is similar to that for a patellectomy (see
para 5-21 b), using smaller-

sized items to suit anatomical structures.

c. Patient Preparation. Draping of extremities is discussed in paragraph 1-27.

d. Operative Procedure. This depends on the exact location and extent of the damage.

(1) A fracture displacement of either the lateral or medial malleolus may involve a rupture of a
main supporting ligament on the opposite side of the ankle from that sustaining the damaging
blow. This ligament rupture would usually require surgery to avoid interposition and
malreduction.

(2) A posterior chip fracture of the tip of the tibia, which involves more than one of the articular
surfaces, is treated by internal fixation if it cannot be reduced by a closed reduction operation.

(3) A rupture of the lower tibiofibular ligament, situated just above the ankle joint, usually is
repaired by means of a transfixion bolt or screws.

(4) In falls from a height, the oscalcis may become fractured, and the attachment of the Achilles
tendon may be avulsed (torn away) by muscular contraction. The avulsion of the Achilles tendon
at its insertion or the displaced fracture of the tuberosity may be treated by open reduction and
insertion of sutures. If there is marked involvement of the subtalar joint, arthrodesis may be done
several weeks after the original injury.

(5) Fractures and separation of the internal malleolus are usually treated by open reduction and
fixation with screws or sutures.

5-27. EXCISION OF EXOSTOSIS

a. General. This procedure involves the removal of the bony protuberances about the tendon or
muscle insertions on a bone. It is done to restore function of a joint.

b. OR Preparation. The setup includes a basic patellectomy set, with fine chisels and osteotomes,
curettes, and rongeurs.
                                                                                                    87
c. Patient Preparation. The position and draping of the patient will depend on the operative site.

d. Operative Procedure.

(1) An incision is made over the prominence of the exostosis, using a scalpel, scissors, and tissue
forceps.

(2) The exostosis is dissected free and cut off at its base where it connects with the cortex of the
normal bone, using heavy scissors, tenaculum, Ochsner forceps, chisels, elevator, osteotome, and
mallet. The remaining bony surfaces are made smooth with a rongeur and file.

(3) The facial layer is closed with interrupted silk or chromic gut sutures numbers 3-0 and 2-0,
and the skin edges are approximated with fine wire, nylon, or silk. Surgical dressings are applied
to the wound and secured by applying a gauze bandage.

5-28. BUNIONECTOMY (SEE FIGURE 5-7)

a. General. The Mayo operation includes a partial excision of the head of the first metatarsal. The
Keller operation includes a resection of the proximal part of the first phalanx of the great toe. The
McBride operation includes the attachment of the adductor muscles of the great toe to the shaft of
the first metatarsal. The Silver operation includes the excision of the exostosis, formation of a
capsular flap, and insertion of sutures in the distal flap to adduct the great toe.



                               Figure 5-7. Bunionectomy. 1, Bunion: A-exostosis of metatarsal
                               head;
                               B-hallux valgus deformity; C, overlying bursa. 2, Operations for
                               hallux valgus.

                                (From Richards, V.: Surgery for General Practice, St. Louis, 1956,
                                                     The C.V. Mosby Co.)

                               b. Operating Room Preparation. The instrument setup is as for
                               arthroplasty of a small joint and is similar to that for excision of
                               exostosis. Refer to paragraph 5-27b.

                               c. Patient Preparation. The entire lower leg and foot are prepped,
                               and drapes placed in such a way as to support the foot as well as
                               cover the parts not exposed for the procedure.

                              d. Operative Procedure. A curved dorsal incision is made over the
metatarsophalangeal joint on its medial side, and the bursa and exostosis are removed, as
described in paragraph 5-27d. The wound is sutured with fine sutures, dressings are applied, and
the foot is usually immobilized in a plaster boot.


5-29. BANKART OPERATION

a. General. This operation is for repairing a defect of the glenoid cavity through a deltopectoral
incision. In some cases, this is augmented by the Putti-Platt repair, which is the bringing together
of the capsule and the subscapular muscle. The operation is indicated to treat recurring
dislocation of the shoulder joint. Other operations used to treat the same symptom are Magnuson,
DePalma, Neer, and Nicola operations.


                                                                                                      88
b. Operating Room Preparation. The basic orthopedic setup will be needed and also an internal
fixation set, including narrow curved osteotomes, chisels, bone drill and fine drill points, and a
prosthesis or staples, if desired. The Neer operation requires a special shoulder prosthesis, which
replaces the proximal humeral articulation. If bones are shattered, staples or wires may be needed
for fixation of fragments.

c. Patient Preparation. The patient is placed on the operating table in a supine position, with his
affected side turned at a 45-degree angle toward the other side and supported by sandbags and
padded braces. The table is tilted to provide a longitudinal operative site. Routine skin preparation
and shoulder draping procedures are done.

d. Operative Procedure.

(1) A curved skin incision is made over the anterior aspect of the shoulder so that the distal end
of the incision is over the deltopectoral groove.

(2) The exposure is made between the deltoid and the greater pectoral muscles. The cephalic vein
is ligated and retracted.

(3) The coracoid process is divided by an osteotome and then pulled downward.

(4) The tendon of the subscapular muscle is exposed, clamped, and divided.

(5) The joint capsule and the glenoid ligament are reattached to the exposed bone either by means
of sutures, which are inserted in drill holes with staples, or by means of pullout wire sutures, as
described for tendon repair. The redundant capsule is attached to the stabilized glenoid ligament
and to the periosteum on the neck of the scapula.

(6) The subcapular muscle is reattached to the lesser tuberosity, and the coracoid process is
reattached. The muscle, subcutaneous tissue, and skin are closed in layers.

(7) Dressings are applied to the wound. The shoulder is supported by applying a Velpeau bandage
with the arm positioned close to the chest and the elbow flexed at about a 40-degree angle.




                                                                                                  89
90
Figure 5-8. Bankart operation (technique of Cave and Rowe)

5-30. TREATMENT OF FRACTURES OF THE ARM, FOREARM, AND WRIST

a. General. Treatment of fractures involves the reduction of the fragments of bones by means of
external or internal fixation.

(1) In fractures of the humerus, there is often overriding. Injury to the radial nerve is not
common. In supracondylar fractures of the humerus, the distal fragments may be displaced,
resulting in tension of the nerves, tendons, and vessels. If supracondylar fractures and dislocations
of the humerus cannot be reduced, they are treated by internal fixation using wires or plates and
screws, or they may be treated by overhead external skeletal traction applied through the
olecranon.

(2) Fractures of the olecranon process are commonly treated by open reduction with insertion of
wire sutures, Rush nails, or long malleable screws.

(3) Fractures of the forearm bones in children are usually treated by closed manipulation and
casting. In adults, however, these fractures usually require open reduction and internal fixation in
order to restore anatomical alignment. Plates, intramedullary nails, or compression devices may
be used. Occasionally, bone grafts are applied at the time of surgery.

(4) Fractures of the wrist bones generally are treated by closed manipulation and casting,
although some nonunions of the scaphoid may require bone grafting.

(5) Fractures of the bones of the hand may require open reduction and pin fixation, although
most can be treated with traction or closed manipulation and casting.

b. Operating Room Preparation. The setup includes a basic orthopedic set, plus intramedullary
nailing or plating instruments as requested.

c. Patient Preparation. The patient is placed in a supine position and the affected extremity
supported. Routine skin cleansing and draping are carried out.

d. Operative Procedure. This is the same as in paragraph 5-9c.

5-31. CLOSED SUCTION DRAINAGE OF THE ARM, FOREARM, AND WRIST

a. General.

(1) The use of suction drainage has become routine for most procedures involving the medullary
bone in which complete hemostasis cannot be obtained by the usual methods. It is important to
prevent the formation of hematomas since there appears to be a connection between these and
wound infections.

(2) The removal of blood and fluid in arthrodesis results in reduction of excess swelling and
closer apposition of bone chips, and should facilitate revascularization. There is the possibility
that by removing blood, less granulation and scar tissue is formed. This could result in better
motion, particularly in arthroplastic surgery.

b. Operative Procedure.

(1) A malleable needle comes with the closed-suction system. It is threaded onto small drainage
tubes. By using the needle to make stab wounds, the tubes are brought out beyond the area of the
incision.
                                                                                                     91
(2) These tubes are connected to a larger tubing that is part of the set.

(3) The larger tubing is connected to an evacuator. This unit exerts constant negative pressure
and has clear, marked walls to permit determination of the quality and quantity of drainage.

(4) The evacuator may be emptied without disturbance of the system.

(5) A retaining suture of silk number 2-0 may be passed through the skin and tied around each of
the drainage tubes. This minimizes the possibility of their accidental removal.


5-32. A-K AMPUTATION OF LEG

a. Definition. A-K amputation is the removal of a leg above the knee (B-K means below the
knee). The amputation may be either closed or open. Closed amputations are those in which the
stump is sutured at the time of surgery, while open ones are left to drain and are closed by a
subsequent procedure. Above-knee amputations are performed through the shaft of the femur.
The ideal length of stump is 10 or 11 inches measuring from the tip of the trochanter.

b. Indications. This procedure is necessitated by one of three causes. The most frequently
encountered cause is traumatic injury to the extent that the limb is not expected to survive.
Another cause is gangrene--death of the tissues caused by a lack of oxygen and nutrients resulting
from hampered circulation of blood to the affected part, seen in certain disease processes. The
final condition necessitating amputation is the presence of malignant neoplasms or cancerous
tumors of the bone or soft tissues of the limb.

c. Special Preparation of the Operating Room.

(1) Instruments. These comprise the routine setup for the amputation of a limb, and any
additional instruments that may be requested by the surgeon. Both a saw and an amputation knife
should always be included in the setup.

(2) Other items needed.

       Pneumatic tourniquet (as ordered by the surgeon).
       Rongeur.
       Bone-cutting forceps.
       Periosteal elevator.
       Bone raspatory.
       Asepto syringe.
       Injection syringe and needle.
       Basin used for the specimen.

d. Preparation of the Patient.

(1) Anesthesia. General (inhalation) anesthesia is used.

(2) Position. The patient is placed in a supine position with the knee of his affected leg flexed
and the leg supported.

(3) Surgical prep and drape. The area is prepped and draped as described previously (see paras 1-
27d, e; 5-3c).

e. Special Precautions. These are as described in paragraphs 5-3 and 5-4.


                                                                                                    92
f. Handling of Specimen. If bone from the amputated leg is to be sent to the bone "bank," it is
processed as previously described (see para 2-13). All specimens are labeled with the appropriate
information, and the amputated leg is disposed of according to hospital policy.

g. Suturing Type Usually Used.

(1) Chromic gut size 2-0 or 3-0 on curved, cutting-edge needles- used to close fascia and muscle-
interrupted stitches.

(2) Fine nylon or stainless steel wire size 5-0 or 4-0 used to close the skin flaps.

h. Comparison with Amputation of Other Limbs. The specialist prepares for and assists with other
amputations in a way similar to that described above. Necessary modifications are made in the
size of instruments and in the draping and positioning procedure, according to the area involved.

5-33. TENOPLASTY OF FINGERS

a. Definition. This procedure is the operative repair of severed tendons in the fingers.

b. Indications. The operation is indicated when a tendon (or tendons) is transected, since the hand
depends for its normal function upon the adequate movement of its small joints. This movement
is attained through the functioning of the tendons.

c. Special Preparation of the Operating Room.

(1) Instruments. The basic setup is as indicated on the instrument card for tendon repair of the
hand. Additional instruments requested by the surgeon for the case are included in the set.

(2) Other items needed.

       Pneumatic tourniquet.
       Plaster splint and elastic bandages.
       Metal splints for the hand and arm, if ordered by the surgeon.
       Stools for the surgeon and his assistant to sit upon.
       Electrocoagulation (Bovie) machine, if ordered.

d. Preparation of the Patient.

(1) Anesthesia. Regional nerve block anesthesia is usually preferred.

(2) Position. The patient is placed in a supine position with the affected arm extended and
supported.

(3) Surgical prep and drape. The area is prepped and draped in a similar manner to that described
previously.

e. Special Precautions. These are the precautions discussed previously (see para 1-15e).

f. Handling of Specimen. If a specimen is obtained, it is processed for the laboratory as described
previously (see para 2-11).

g. Sutures Usually Used.

(1) Silk or monofilament (single strand) stainless steel wire sutures, size 34-or 35-gauge, 10
inches and 18 inches long are used on straight, Bunnell needles or fine, curved (3/8) needles. The
                                                                                                   93
short end of the wire is twisted tightly around the strand. This suture is used to approximate the
severed tendon ends. The silk suture is used if the surgeon does an end-to-end union of the
severed tendon; wire is often used for endto-end pull-out sutures and is also usually used for
tendon-to-bone fixation. The ends of the pull-out suture are brought through the skin and secured
to a button.

(2) Chromic gut is used to approximate the tissue layers.


5-34. INTRODUCTION

a. General. Plaster-of-Paris casts are the most frequently used means of providing external
support to maintain a desired position of a body part. Casts are often used following surgical
procedures; as examples, a cast may be applied to hold the bone in position until it heals
following open reduction of a fracture and following an osteotomy. Casts may also be applied
following certain plastic surgical procedures. Since the OR specialist may often be required to
assist with casting, he should be familiar with certain aspects concerning the application of casts.
He should also know the types of casts.

b. Definition. Plaster-of-Paris is technically known as gypsum of anhydrous calcium sulfate. The
equipment needed for application of plaster casts includes plaster bandage. This is a gauze
impregnated with plaster-of-Paris. When the impregnated bandage is soaked in water, a chemical
reaction occurs causing the compound to set or harden.

c. Setting Time of Plaster. There are three types of plaster: slow setting, fast setting, and extra
fast setting. The slow setting, which is infrequently used, sets in approximately 18 minutes, the
fast setting hardens in about 8 minutes, and the extra fast sets in about 4 minutes. Slow setting
plaster is usually used in applying large casts, such as body casts or hip spicas, where it may take
a few minutes to get to the next layer. The slow setting plaster gives the needed time. The fast and
extra fast plaster is used for small parts such as an arm or leg, where extra time is not needed.
Setting time of plaster can be adjusted by using the following techniques.

(1) Setting time can be retarded by:

(a) Adding sugar to the water used to soak plaster.

(b) Using cold water.

(c) Permitting excessive water to remain in the plaster roll after soaking.

(2) Setting time can be accelerated by:

(a) Adding salt to the water.

(b) Using warm water (not over 80ºF).

(c) Removing most of the water from soaked plaster.

5-35. TYPES OF CASTS

a. Cylinder Cast. See figure 5-9 for a long leg cylinder cast. The cylinder cast is the most
commonly used type of cast, and therefore is the type with which the specialist most frequently
assists. It is a rigid plaster dressing, which encases a limb made by wrapping rolls of plaster
bandage around the limb. The cast should include the joint above and the joint below the affected
site when it is applied to immobilize a part, as is the usual case (see para 5-35f below, for
                                                                                                  94
exception). It may be used following open or closed reduction of fractures of bones of the limbs
or following operations on them. A cylinder cast may be either padded or unpadded. It may also
be modified in some special ways. A cylinder cast that is modified is typed or classified in
accordance with the modification (walking cast; wedge cast; and hanging cast).




Figure 5-9. Long leg cylinder cast.

(1) Padded cast. For this cast, the skin is padded with sheet wadding and felt. A cylinder cast is
usually padded and in particular, a padded cast issued for severe, fresh fractures, over infected
areas, when excessive swelling exists or is anticipated or immediately after surgery.

(2) "Skin-tight" cast. This cast is unpadded except for the use of stockinette, if desired.

b. Walking Cast (See Figure 5-10). This cast is made by the incorporation of a rubber "heel," a
portion of tire tread, or other durable material under the foot encased in a cylinder cast, thus
enabling the patient to be up and walking. The "walker" is fixed securely in place with plaster
bandage.




Figureure 5-10. Walking cast.

c. "Wedge" Cast (See Figure 5-11). This is a cylinder cast from which a wedge-shaped piece has
been removed to correct angulation (poor positioning) of a fracture following the application of
plaster-of-Paris. The angulation is corrected by manual pressure, then a team member holds the
edges of the cast together while another team member applies plaster bandage to maintain the
correction. This procedure may be done following osteotomy of a bone, and following a recent
fracture.



                                                                                                   95
d. Plaster Splint (Reinforcement Strip) (See Figure 5-12). This splint may be used for either
temporary immobilization or for the immobilization of a part in certain instances. The splint is
wet, applied to the posterior part of the extremity, and bound snugly in place with a bandage of
cotton or elastic.

e. Hanging Cast. This cast is usually used when plaster is applied following open or closed
fixation of fractures of the humerus. A heavy cylinder cast is applied to the arm (from axilla to
knuckles) with the elbow flexed at a 90-degree angle. A loop of either wire or plaster is
incorporated at the wrist, and the arm is suspended by passing a strip of muslin bandage through
the loop on the cast. This cast does not immobilize the humerus, but reduces the fracture as the
result of the traction exerted.




Figure 5-11. Wedge cast.




                                                                                                   96
Figure 5-12. Plaster splints.

f. Body Casts. These casts are applied to immobilize the spine. Two kinds of body casts are used:

(1) Body jacket. This cast encircles the trunk and extends from the axilla to the hips. It may be
used for immobilization following fractures or operations of the middle or lower portion of the
spinal column and as treatment for back pain.

(2) Minerva jacket. This cast is used when the upper part of the spinal column needs to be
supported and immobilized (as in fractures of the cervical or upper thoracic vertebrae). The cast
includes the head, lower jaw, and the neck, and extends downward to the pelvis.

g. Spica Cast. In order to provide adequate immobilization of a joint, a cast must include the body
part or parts adjacent to the joint. A spica cast includes a plaster "rope" brace. Examples of spica
casts are discussed below.

(1) Hip spica (see figure 5-13). This cast may be used following hip operations and certain
fractures of the femur. There are several variations of the hip spica cast, but all are applied to
include a part of the trunk and one or both legs (or a portion of the legs).

(2) Shoulder spica (see figure 5-14). This cast may be used following some operations on the
shoulder or the humerus or for a fracture of the humerus. The cast includes the entire trunk and it
extends to the knuckles of the affected arm, leaving the fingers and thumb free.




                                                                                                     97
            Note position of the plaster "rope," which adds to the strength of the cast.

Figure 5-13. Hip spica cast.




       Note the "salute" position and the incorporation of a plaster rope for added strength.

Figure 5-14. Spica of shoulders.

(3) Spica of the hand (see figure 5-15 A and B). This cast may be used when it is desirable to
obtain the most satisfactory immobilization of the thumb, and in some cases to hold a finger
firmly.

(a) A spica of the thumb includes the forearm and extends to the end of the thumb (see figure 5-
15 A).

(b) A spica or a finger includes the wrist and extends to the end of the finger (see figure 5-15 B).




                                                                                                  98
Figure 5-15 Spica of (A) the thumb and (B) the finger.

5-36. PLACEMENT OF CASTS

Casts are applied in various lengths and sizes, depending upon the part of the body to be
immobilized. A cast may be made by incorporating into it one or more plaster splints
(reinforcement strips) or it may be fashioned by the use of plaster bandages only. The more usual
procedure is to incorporate one or more splints into the cast. The particular method chosen by the
surgeon depends upon such factors as the amount of stress that will be exerted on the cast and the
expected duration of the patient's stay in it. If a cast is placed on a part that will undergo a
considerable amount of stress (hip spicas, long leg casts) the cast can be applied more quickly and
be made less bulky by the use of splints. All casts applied to immobilize a part should be long
enough to encase the joint above and below the affected part. See figure 5-16 for a long leg cast.

5-37. QUALIFICATIONS OF A GOOD CAST

a. The cast must fulfill the function of maintaining a desired position and must not be too tight or
too loose.

(1) If the cast is too tight, it may impair circulation (evidenced by swelling, numbness,
discoloration, or temperature change of the fingers or toes); and it may exert pressure upon bony
prominences (this causes pain, and if the pressure is not relieved, may result in the breaking down
of the tissue over the bone).

(2) If the cast is too loose, it will not maintain the position desired.

b. The cast should be as light and comfortable as possible, yet remain inflexible.

c. The entire length of the cast should be of about equal thickness.

5-38. ROLE OF THE SPECIALIST

The OR specialist's role in cast application is usually that of assisting the surgeon or the cast room
personnel. The specialist who is knowledgeable concerning them contributes greatly toward the
successful application of a cast and thus toward the patient's recovery. The specialist contributes
greatly toward the successful application of a cast and thus toward the patient's recovery. The
procedures for which the specialist is responsible have to do with the preparation of the patient;
preparation of the supplies, equipment, and work area soaking and handling the plaster, and
holding the part to be casted. When ordered, the specialist will also have the duty of cutting the
cast.

5-39. PRINCIPLES OF APPLICATION

                                                                                                   99
a. Introduction. The aim of the surgical team in the application of plaster is to produce a good
cast. Success in achieving this goal depends upon adherence to principles, which should be
observed whenever a cast of any type is to be applied. These principles are set forth in the
ensuing text (b through e).

b. Preparation of the Patient.

(1) The patient must be prepared physically and mentally for this procedure. The specialist
explains what is to be done and allays any fears. He tells the patient that casting the injured part
will help relieve pain. The specialist positions him as comfortably as possible, for it may take a
while to complete the procedure.

(2) The specialist prepares the patient's skin in the area to be casted. This is done to help prevent
irritation to the skin and to keep it as comfortable as possible. The skin should be inspected for
ulcers and rashes. The specialist should check local policy before preparing the patient. The usual
preparation is to wash the area with soap and water, dry it well, and dust it with powder. When
the cast is applied immediately following surgery, no additional preparation of the skin is done.

c. Preparation of Equipment and Supplies. The specialist should make sure that all items needed
are at hand, because there must be no interruption once the application of a cast is started. To stop
the procedure even temporarily may cause a cast to become laminated (layered) and thus
weakened. Therefore, the specialist should prepare and have ready the following items:

(1) Plaster rolls and splints. An adequate supply of these in the appropriate width for the cast to
be applied should be placed on the worktable; they should be unwrapped and ready for use.
(Standard items of plaster bandage include plaster rolls in widths of 3, 4, and 6 inches, as well as
a plaster splint 4 x 15 inches for the arm and a splint 5 x 30 inches for the leg.)

(2) Instruments (see figure. 5-17). These are used for trimming and cutting casts (monovalving
and bivalving, e(3) below) and are mostly of a cutting type. A cast knife and a pair of bandage
scissors are needed for trimming. An electric saw or a cast knife and a cast spreader are used for
monovalving and bivalving.




      (A) Electric cast cutter. (B) Plaster shears. (C) Plaster saw. (D) Plaster cast spreader.

Figure 5-17. Cast-cutting and trimming instruments.

                                                                                                  100
(3) Padding (see figure 5-18).

(a) The materials used for padding are stockinette, sheet webril, and felt or sponge rubber.

(b) The padding is placed before the plaster is applied. Most surgeons prefer the use of
stockinette and sheet wadding as basic padding (see figure 5-18). The specialist usually measures,
cuts, and applies the stockinette.

(c) All bony prominences are protected with an additional pad of felt or sponge rubber (see
figure 5-18). The pad is made by cutting it so that the material surrounds the prominence instead
of pressing directly upon it. When felt is used, it is never applied directly upon the skin;
stockinette or sheet wadding is used beneath it. (In figure 5-18, the stockinette is omitted and the
fitted pads are moved from the prominence for clarity of illustration.) Stockinette not only
protects the skin under the cast, but it also absorbs perspiration and prevents body hair from
becoming embedded in plaster.




Figure 5-18. Padding for casts.

(d) In the lower limb, points requiring pads are the heel, malleoli, the patella, the head of the
fibula, and the greater trochanter (see figure 5-19).

(e) In the upper limb, the prominences are the inner epicondyle of the humerus, the tip of the
elbow, and the styloid process at the wrist (see figure 5-19).

(f) Prominences of the torso are the sacrum and the anterior superior iliac spines (see figure 5-
19). In addition, provisions should be made for the intake of food and distension of the abdomen
when applying a body cast; otherwise, a portion of the cast must be cut out. Adequate space for
                                                                                                    101
the abdomen can be provided by inserting a folded towel beneath the stockinette over the
abdomen. The towel is removed when the plaster hardens.




Figure 5-19. Bony prominences that should be padded before application of casts.

(4) Buckets of water. Tepid water (70º to 80º F) is used for soaking plaster bandages. The
specialist should exercise care to ensure that the water is neither too hot nor too cold, since
unsatisfactory soaking of the plaster could result, and the plaster would not be the right
consistency to be applied. The water should feel neither hot nor cold when tested on the
specialist's wrist. In addition, the specialist should prepare two buckets of water if a large cast is
to be applied to prevent over saturation of the water with plaster. An excessive amount of plaster
in the water prevents the bandages from becoming wet throughout. Usually it is necessary to
change buckets after soaking five or six rolls.

(5) Protective covering. Paper and a piece of rubber or plastic sheeting is also needed. The paper
(wrapping paper or newspaper) should be spread on the floor in the area being used for casting.
The rubber sheeting should be placed beneath the part of the patient being casted in order to
protect the table and linen from spillage of plaster.

(6) Soaking splints. A plaster splint is soaked by dipping it and drawing it rapidly through the
water. The splint is then placed on a flat, smooth surface and the excess water is expressed from it
by running the palms of the hands firmly over it.

(7) Soaking the plaster bandage rolls.

(a) The rolls should be placed on end and covered by the water in the bucket to allow complete
water absorption.

(b) The bandages should not be disturbed while they are soaking because the plaster is easily
washed out of the bandage.

(c) The rolls should be left in the water until the air bubbles stop escaping from the bandage.
(This indicates that the bandage is sufficiently saturated with water.)



                                                                                                   102
(d) The roll is then grasped by both ends, removed from the water, the ends compressed by the
fingers and palm of each hand (to prevent the plaster from being squeezed out at the ends), and
gently squeezed and twisted slightly (not wrung) to remove excess water. Too rapid or too
vigorous squeezing distorts the roll and forces out too much water. Too rapid or too vigorous
squeezing distorts the roll and forces out too much water, leaving the plaster too dry. (A roll
should not be returned to the water once it has been removed, as to do so makes it useless.)
Plaster that is too dry or that is over-soaked might dry too fast is unsatisfactory for use. The
plaster bandage should be just dripping wet. If left excessively wet, the central part of the roll will
telescope and the roll will be useless.

NOTE: A bandage that has dry spots should be discarded.

(e) Another way to avoid the waste of plaster is by soaking one roll at a time. When half of the
first roll is applied, another roll is put into the water to soak. In this way, the specialist keeps just
ahead of the person applying the cast.

(f) When the cast is near completion, the specialist should ask whether another roll is needed.
Delay in having the next roll ready may result in lamination of the cast.

(8) Handing the plaster roll. When the roll has been squeezed, the specialist finds the end of the
bandage, unrolls about 2 inches of the plaster, and hands it to the team member applying the cast,
so that the roll is placed in the right hand and the end of the bandage in the left hand. This enables
the team member to apply the plaster in one smooth, continuous movement.

d. Smoothing the Plaster Bandage. The team member applying the cast strokes and molds the
plaster constantly as it is applied in order to make it conform to the body part and to make a
strong, cohesive cast with a smooth surface.

e. Cutting or Trimming the Cast. This is done after the plaster is set. A cast is trimmed to make
the edges smooth, thus preventing the injury of tissue and making the cast more comfortable. In
all procedures of trimming or cutting a cast, the surgeon marks the part to be trimmed or cut. If
the specialist is assigned to trim or cut the cast, he should carefully cut through the cast on the
marked lines. He should avoid dripping pieces of plaster (plaster "crumbs") inside the cast since
this could result in discomfort to the patient and could damage healthy tissues. The surgeon may
order a cast cut for one or more of several reasons:

(1) To correct the length. A cast may be applied somewhat above and below the desired area.
When this is done, the cast must be cut to correct the length, as marked by the surgeon.

(2) To make a "window." A "window" is a rectangular block cut from a cast. Usually, a window
is cut to relieve pressure or to allow observation of a wound. A window should never be cut in a
body jacket or a spica cast until the plaster has thoroughly dried because of the tendency of these
casts to buckle. Whenever the specialist cuts a window from a cast, he should replace the piece
cut out and secure it with adhesive tape or bandages; otherwise, the tissue underlying the window
may swell ("window edema") and cause circulatory disturbances and ulceration at the edges of
the window.

(3) To split the cast. A surgeon may mark a cast to be split lengthwise in order to prevent the
occurrence of circulatory disturbance. The cast maybe split by either monovalving or bivalving it.

(a) Monovalving a cast is splitting it lengthwise, usually on the anterior aspect of the limb.

(b) Bivalving a cast is splitting it lengthwise on both sides. If the cast is on a limb, it is split on
the medial and the lateral aspects of the limb; if it is on the body, it is cut down the sides. A cast
is often bivalved so that one part of the cast can be removed to dress wounds or prepare the skin

                                                                                                      103
for surgery. When the procedure is completed, both parts of the cast can then be secured with
bandages.

5-40. PROCEDURES IN APPLICATION

In the ensuing text, procedure is given for applying a cast of the forearm. The steps set forth are
those used for the application of any cast, with the necessary adaptations made in the fitting of
padding material and in selecting the size and amount of plaster bandages for use.

a. Padding the Arm.

(1) First, the specialist prepares the stockinette; he measures it for length, cuts a hole for the
thumb, and applies it.

(2) A piece of felt or sponge rubber is then cut to fit over the styloid process of the wrist.

(3) Sheet wadding is applied around the hand and arm to fill in the hollow spaces.

b. Preparing Plaster Bandage Rolls. The specialist soaks one roll of plaster, squeezes the excess
water from it, and hands it to the surgeon as described above (see para 5-39c(8)). He keeps the
surgeon supplied with bandages as described above.

c. Applying the Plaster Bandage.

(1) The bandage is permitted to lie where it falls naturally from the roll. Plaster bandage is never
twisted or reversed, as is done with ordinary bandage. If it is necessary to alter the direction of the
roll or to mold the plaster smoothly on the limb, a tuck is made by taking up the slack in the
bandage, then rubbing the folded tuck flat and smoothing it.

(2) The arm is maintained in the position desired until the cast sets. The wrist is usually placed in
moderate flexion.

(3) If reinforcement strips (plaster splints) are used, each is tied into the cast with a roll of plaster
bandage.

(4) The team member who holds the arm must avoid digging his fingers into the plaster. He is
allowed to touch the wet plaster with his palms only, and he must keep moving his hands by
sliding them back and forth constantly in order that he will not put enough pressure in one place
to distort the shape of the cast and to produce a pressure area.

(5) The plaster is rubbed and smoothed constantly as it is applied.

(6) The cast is not made any heavier than is necessary because a heavy cast is burdensome to the
patient.

(7) Plaster crumbs should not be allowed to drop between the stockinette and the skin.

(8) Before the final roll is applied, the surgeon folds the stockinette over the edges of the cast on
each end and applies plaster over it. He may also roll and mold the plaster at the edges at this
time. This protects the patient from the rough edges of plaster.

d. Trimming and Cutting the Cast. When the plaster is set, the specialist, if ordered to do so, trims
it around the thumb and the palm as marked by the surgeon. This trimming allows the patient full
range of motion of the fingers if the surgeon desires that the cast be monovalved or bivalved, he

                                                                                                     104
marks it at the area he wishes it cut. The cast may be cut using an electric saw or cast-cutting
knife.

6-1. INTRODUCTION

a. General. The anatomy, physiology, and the location of the eye make surgery upon the eye a
highly specialized field of surgery. Therefore, procedures done by the specialist when assisting
with eye surgery differ from procedures used for other surgical specialties. However, the
principles of asepsis and safe, skillful care apply as in all other surgery. The ensuing text presents
a discussion of the necessary considerations that are applicable in the majority of cases in this
specialty.

b. Special Care of Instruments. The specialist is to use exacting care when working with
instruments for eye, ear, nose, and throat surgery because most of these instruments are delicate.
Sharp surfaces of these instruments must be preserved to ensure the success of the operative
procedure. The specialist is to follow local policy in the care and handling of these instruments.

c. Anatomy and Physiology of the Eye. The eye is also referred to as the eyeball or globe. In the
adult, it is slightly less than one inch in its longest diameter. See figure 6-1 for parts of the eye.

(1) The lids and anterior surface of the eye, except for the center, are covered by the conjunctiva.

(2) The cornea forms the anterior center of the eye and transmits and refracts light. Behind it, the
anterior chamber contains the iris (which gives eye color and forms the pupil) and the aqueous
humor.

(3) The lens focuses light on the retina allowing for near and far vision.

(4) The posterior chamber contains the jelly-like vitreous humor, which helps give rigidity to the
eye.

(5) The retina receives light and converts it to impulses to the brain via the optic nerve.

(6) The main body of the eye is made of three layers called tunics. The external tunic includes
the sclera (the white part of the eye) and clear cornea. The middle tunic includes the choroid, the
ciliary body, and the iris. The iris is the colored part that changes the aperture size over the eye
lens. The internal tunic is sometimes called the nervous covering, but is usually referred to as the
retina. The retina is a thin network of nerve cells and fibers that receives the images of objects the
eye is seeing.




                                                                                                   105
Figure 6-1. Parts of the eye.

6-2. SPECIAL PREPARATION OF THE OPERATING ROOM

a. Instruments. All instruments used for eye surgery are made for this purpose, and are unlike
those for surgical procedures in other areas of the body. Preferences for instruments vary so
widely among eye surgeons that it may be necessary to list all instruments used for each operation
by each different surgeon. Therefore, the surgeon's card must be carefully checked when selecting
instruments for an eye operation.

b. Sponges. Gauze sponges are considered much too rough for use on an eyeball. Instead,
dampened cotton applicators are used. Special cellulose sponges, specifically designed and
prepackaged sterile by manufacturers for eye surgery, are also available.

c. Magnifying Glasses. The surgeon may wish to use special magnifying glasses during the
procedure; therefore, these must be cleansed and ready for use.

d. Lighting. Illumination for eye surgery may be furnished by a number of methods.

(1) One method is the use of the standard overhead light. The circulator may be responsible for
adjusting the light during surgery. If this need occurs, he should pay particular attention to not
contaminating the sterile field and scrubbed personnel.

(2) A second source is the use of an electric head lamp. This lamp is strapped to the surgeon's
head and is used in the same manner as a coal miner's helmet. The surgeon may redirect the light
during surgery.

(3) The third method is the use of the operating microscope. This is a device used to magnify the
site of surgery and enable the surgeon to do very delicate work with excellent illumination. This
device is draped with sterile material before the procedure is started, and the surgeon may make
any adjustments. The microscope is being used more and more for eye and other delicate surgery.


                                                                                                106
e. Medications. As many as 5 or 6 solutions may be kept within the sterile field for use during
eye procedures; examples of these are saline (for dampening the eyeball), local anesthetic agents,
and epinephrine. If these are not prepackaged and sterilized in individually labeled doses, the
specialist should label medicine glasses to show the name and the strength of each solution.
During preparation for an operation, the circulator should pour the solutions needed into the
medicine glasses, making sure that the solution he is pouring matches the label on the glass. Great
care should be taken to assure that ophthalmic solutions of the desired drugs are used.

f. Sterile Setup. If both of the patient's eyes are to be operated on for correction of defects
requiring muscle surgery or other extraocular procedures, only one Mayo table needs to be up.
However, if intraocular surgery is to be performed on both eyes, the specialist sets up two tables--
one for each eye. When the procedure on the first eye is completed, the surgeon and specialist
change only their gloves in preparation for the second eye.

NOTE: A large percentage of intraocular surgery does not require double setups. Advancement in
techniques and equipment makes the practice ineffective and costly.

6-3. PREPARATION OF THE PATIENT

a. Preoperative Prep. For a successful operation, the physical, spiritual, and emotional needs of
the person must be considered. Each member of the staff should endeavor to meet the needs of
each patient and help him to cope with his specific problems.

(1) Emotional factors.

(a) The loss of vision or any interference with the use of the eyes, even temporarily, has a severe
emotional effect on any person. It means loss of mobility and ability to take care of or protect
oneself. This tends frequently to make the patient nervous and sometimes depressed. The patient
is often awake during the entire operation. All operating staff members should allay the fears of
each patient. The emotional state of the patient is an important factor in a successful recovery.

(b) A quiet environment and a calm, kindly, understanding voice create confidence in the patient.
The patent's comfort is further enhanced by pleasant surroundings and freedom from noise and
confusion. When a patient is sedated, he is often unable to speak coherently, but is usually
conscious of noises, which become exaggerated in his mind.

(2) Drugs which may be given.

(a) To allay anxiety and reduce general muscle tone, the patient is usually given a barbiturate-
narcotic drug on call to surgery, as well as any ophthalmic drugs that may be prescribed. This is
often followed by topical anesthetic drops upon arrival at surgery (see figure 6-2).



                                                      Figure 6-2. Instillation of eye medication.

                                                      NOTE:

                                                      Observe the position of the dropper and the
                                                      capillary attraction.

                                                      (b) Mydriatic drops are used to dilate the
                                                      pupil with the patient retaining the ability to
                                                      focus his eye. This is usually 10 percent
phenylephrine (Neo-Synephrine ®).

                                                                                                 107
(c) Cycloplegic drugs dilate the pupil and prevent focusing of the eye. Commonly used
cycloplegics are 1 percent tropicamide (Mydriacyl), 1 percent atropine, and 1 percent
cyclopentolate (Cyclogyl®). Atropine has a long-lasting effect.

(d) Miotic drugs cause the pupil of the eye to contract. Commonly used miotics are 1 percent to 4
percent pilocarpine and 0.012 percent to 0.25 percent phospholine iodides®. Miotics improve the
ease with which the aqueous fluid escapes from the eye independent of their action on the pupil,
thereby resulting in decrease of intraocular pressure. Miotics are used in the treatment of
glaucoma. These drugs increase contraction of the sphincter of the iris, thus causing it to become
smaller.

Phospholine iodide® is usually discontinued before intraocular surgery is performed.

(e) A great number of corticosteroid preparations exist. They are used to prevent the normal
inflammatory response to noxious stimuli. Corticosteroids reduce the resistance of the eye to
invasion by pathogens; therefore, they are not used in the presence of infection.

(f) Topical antibiotics are often used prophylactically to prevent infection. Antibiotic instillation
may be given prior to intraocular surgery to help prevent wound infection. Zinc sulfate, 0.25
percent, is used to reduce redness and swelling and to soothe tissue. It may be ordered in
combination with a 0.125 percent preparation of phenylephrine. Zinc also is a necessary cofactor
in wound healing. Lubricating drops or ointments such as Methylcellulose, 0.5 percent, are often
used to protect the cornea.

(g) Hyperosmotic agents increase the osmolarity of the serum and, by the effect of the induced
osmotic pressure gradient, shrink the vitreous body and reduce the intraocular pressure. These
drugs are used routinely in the preoperative medication of patients about to undergo ophthalmic
surgery, as well as therapeutically in cases of uncontrolled glaucoma. These drugs, given either
orally or by injection, induce diuresis, so nursing personnel have urinals and sterile catheters on
hand.

b. Admission into the Operating Room. When the patient is admitted to the operating room, the
nursing team should:

(1) Make positive identification of the patient by name, dealing with him in a gentle, kind, and
professional manner.

(2) Check the patient's name on his wristlet band with the name on the chart.

(3) Prepare the operating table, making sure all the necessary attachments for the table are in
proper readiness.

c. Preparation of the Patient's Face.

(1) Preparation of the patient is done under aseptic conditions. Topical anesthetic drops are
administered first if the patient is to be given a local anesthetic. A sterile preparation tray
containing sterile normal saline solution, irrigation bulbs, basins, cotton, sponges, towels, and
antibacterial skin disinfectant should be near the operating table.

(2) Neither the clipping of eyelashes nor shaving of eyebrows is done routinely. When eyelashes
are clipped, this is done prior to the skin preparation. A thin film of petrolatum is smoothed over
the cutting surfaces of the curved eyelash scissors so that free lashes will adhere to the blades.
This prevents the free eyelashes from falling into the eyes or onto the face.



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(3) The preparation includes cleansing the eyelids of both eyes, lid margins, lashes, eyebrows,
and surrounding skin with an antibacterial soap or disinfectant. To prevent the agent from
entering the patient's ears, they may be temporarily plugged, using cotton pledgets. Care is taken
to keep the agent out of the eyes. The preparation area is washed with warm sterile water, using
soft-texture gauze or cotton sponges. The operative area is painted with an aqueous nonirritating
skin antiseptic.

(4) When toxic chemicals or small particles of foreign matter must be removed, the eyes may be
irrigated with tepid sterile normal saline solution. The conjunctival sac is thoroughly flushed,
using an irrigating bulb or an Asepto syringe.

d. Draping the Patient. For general eye surgery, the basic draping procedure is as follows:

(1) A large, folded sheet is needed to cover the patient and operating table.

(2) The head is draped with a double-thickness half sheet and two towels or appropriate
disposable drapes.

(3) A fenestrated eye sheet, 14 inches square, with a center opening of 2 1/2 x 3 inches, is placed
over the operative site. More recently, disposable plastic drapes have been used.

e. Anesthesia. Local anesthesia is frequently preferred and indicated for eye surgery, especially
in elderly individuals and in those with circulatory and other systematic diseases. A sedative is
given the night before surgery and again two hours prior to surgery.

(1) Anesthesia setup. The operating room staff assembles the sterile local anesthesia setup as
ordered by the surgeon before the patient enters the operating room and checks the bottles of
drugs to make sure they are the correct medications and of the proper strength.

(2) Needles and syringes.

(a) Subcutaneous injection and infiltration. Two Luer-Lok 2-ml syringes and two 25-gauge
needles, 1/2-inch length may be used.

(b) Subconjunctival injection. Two Luer-Lok 2-ml syringes and two 26-or 27-gauge needles, 6-
or 1 1/2-inch length.

(c) Retrobulbar injection. Two Luer-Lok 2-or 5-ml syringes or one 10-ml syringe and two 24-
gauge needles, 6-or 1 1/2-inch length.

(3) Frequently-used drugs.

(a) Tetracaine hydrochloride (Pontocaine hydrochloride) in a 2 percent solution may be instilled
into the eye before an operation. For local anesthesia

in adults, 2 percent lidocaine (Xylocaine) with epinephrine hydrochloride in a 1:150,000 or
1:200,000 dilution is frequently used.

(b) Hyaluronidase (Wydase, Alidase) is commonly mixed with the anesthetic solution (75u/1
0ml). The enzyme increases the diffusion of the anesthetic through the tissue, thereby improving
the effectiveness of the anesthetic nerve block. For cataract surgery, an effective retrobulbar
injection reduces intraocular pressure by preventing positive muscle contraction, thus becoming a
surgical safeguard against vitreous loss. Hyaluronidase is nontoxic and is effective over a wide
range of concentrations.


                                                                                                 109
(c) In cataract surgery, alpha chymotrypsin in a 1:5,000 or 1:10,000 solution may be used to
dissolve the zonular fibers that suspend the cataract within the eye. To produce eye muscle
paralysis in intraocular surgery, tubocurarine chloride or

succinylcholine chloride may be administered intravenously by the anesthesiologist.

(d) Epinephrine in a 1:1,000 solution may be applied topically to mucous membranes to decrease
bleeding. Epinephrine in a 1:500,000 to 1:200,000 solution may be combined with injectable
anesthetics to prolong the duration of anesthesia. Epinephrine in a 1:1,000 solution is not used in
local anesthetics because if it were used in such concentrations, the patient could succumb to
cardiac arrhythmia.

(4) Methods used for administration of local anesthetics. The three methods of administration are
instillation of eye drops, infiltration, and block or regional anesthesia.

(a) Instillation of eye drops. With the patient's face, tilted upward, the first drop is placed in the
lower cul-de-sac, and the following drops (number depends on the type of operation to be
performed) may be placed from above, with the patient looking downward and the upper lid
raised. However, the natural blinking of the lids distributes the drug evenly on the eye surface,
regardless of where the drop is placed. When a toxic drug is instilled, the inner corner of the
eyelids should be dried of excessive fluid with a tissue or clean cotton ball after the instillation of
each drop, thereby minimizing systemic absorption of the drug. The tip of the applicator must not
touch the patient's skin or any part of the eye.

(b) Infiltration method. The surgeon injects the anesthetic solution beneath the skin, beneath the
conjunctiva, or into Tenon's capsule, depending on the type of surgery. Retrobulbar injection is
usually performed 10 to 15 minutes before surgery to produce a temporary paralysis of the
extraocular muscles.

(c) Block or regional anesthesia. The solution is injected into the base of the eyelids at the level of
the orbital margins or behind the eyeball to block the ciliary ganglion and nerves. For eyelid
repairs, the solution is introduced through the lower lid. For operations on the lacrimal apparatus,
the anesthetic is injected at the level of the anterior ethmoidal foramen in order to anesthetize the
internal and external nasal nerves. In the Van Lint block method, procaine solution is injected
into the orbicular muscle and reaches the ends of the facial nerve.

(5) General anesthesia. A general anesthetic, with or without intravenous injection of thiopental
sodium (Pentothal Sodium) is used when a patient is unable to cooperate because of youth,
dementia, or nervousness, or because the solutions of 20 percent mannitol (Osmitrol®) or 5
percent glucose in water are given intravenously during surgery. A sedative is given the night
before surgery, and a drying agent (atropine or scopolamine) and an analgesic are given 1 to 1 1/2
hours prior to surgery. The patient must not eat or drink anything for 6 hours prior to induction

.6-4. CONSIDERATIONS AT THE COMPLETION OF SURGERY

a. At the completion of the operation, the surgical area is cleansed, using saline sponges.

b. Antibiotic ointment may be thinly spread over the skin and eyelashes to prevent adhesion of
the bandage. This is frequently done after plastic procedures on the lids or lacrimal duct.

c. Dressings are applied to prevent palpebral movements, protect the operative wound from dust
and external contaminants, and absorb any blood and tears that are produced.




                                                                                                   110
d. The initial dressing usually consists of a piece of fine cotton. An eye pad that is commercially
prepared and sterilized is applied over the cotton splint. The eye dressing may be held in place by
means of paper tape.

e. After intraocular operations, when external pressure on the eyes might be very harmful, the
initial dressing is covered with a protector such as a wire gauze cap, perforated aluminum plate,
convex perforated metal cup, convex flexible celluloid plate, or some other kind of shield.

f. A pressure bandage may be used in some cases when a compression effect is desired. The
gauze roller bandage is applied over the initial dressing, encircling the head.

g. The instruments are carefully cleaned and sterilized.

6-5. SPECIAL SAFETY PRECAUTIONS

The precautions set forth for eye surgery should be scrupulously observed by the specialist as
well as all other members of the operating room team, because errors or carelessness could cost
the patient his sight.

a. Eye Medications. There must be absolutely no error in the administration of any solutions. In
addition, all solutions must be sterile and fresh.

b. Room to Breathe. There must be sufficient ventilation for the patient beneath the drapes.

c. Quiet, Calm Room.

(1) To perform eye surgery satisfactorily, the surgeon must have a skilled and steady hand, and
he must be able to concentrate on the operation. To maintain the needed quiet, calm atmosphere,
all team members should keep conversation low and at a minimum. The movements of all team
members should be executed smoothly and gently. This is especially important for persons
working near the operative area. In addition, a sign should be placed outside the door to warn
others that eye surgery is in progress and to keep traffic with its noise and confusion out of the
area.

(2) When the patient has been given local anesthesia, it is necessary that he lie still without
moving his head. Even though he is awake, his unaffected eye may be left uncovered; he may
move if there is a loud noise or hurried activity near him.

(3) Eye instruments should be cleaned after each use during the operation with a nonfibrous
sponge. After the operation, the instruments should be cleaned and dried thoroughly before
storage. Microsurgical instruments should undergo ultrasonic cleaning with distilled water and
appropriate cleansing agent. They should be individually hand held or immersed in ultrasonic
cleaner as long as they are not touching each other. The instruments should be rinsed with
distilled water and thoroughly dried.

NOTE: A regular preventive maintenance program should be established for sharpening,
realigning, and adjusting the precision eye instruments.

d. Instruments and Their Care. Eye instruments are delicate and are assembled and stored in
specialized instruments cases. They are easily bent, broken, or dulled. These instruments are also
expensive and they must be handled with these characteristics in mind.

(1) Eye instruments are never to be stacked--before, during, or after a surgical procedure. The
specialist should carefully arrange the instruments on the table so that no instrument is touching
another, and they must not be stacked or thrown down carelessly at any time.

                                                                                                  111
(2) Eye knives require even more scrupulous care. The blades must be protected by suspension at
all times when they are not actually touching the patient's eyes. In some instances, they are tested
before use with a thin kidskin stretched over a drum. The knives must be capable of cutting
without any pressure being applied to the knife.

(3) A basic eye surgery instrument set with the addition of other instruments, supplies, and suture
materials as preferred by the surgeon, will usually suffice for all of the more detailed minor
surgery performed on the eye. Examples of such minor surgery are tarsorrhaphy, repairs of eyelid
lacerations, and repair of conjunctival lacerations. The basic eye instrument set will include:

(a) Self-retaining eye speculum.

(b) Lid retractor.

Muscle hooks.

Knife handle.

Scissors (tenotomy, stitch, corneal, and iris). Forceps (suturing fine and heavy, iris, fixation,
tying). Caliper.

Needle holders (micro and heavy).

Irrigating cannula (19- and 27-gauge).

Iris spatula.

6-6. HANDLING OF SPECIMENS

Tissue removed during eye surgery is to be either examined for pathology or processed for
storage in a "bank."

6-7. SUTURING TYPES USUALLY USED

Preferences vary among eye surgeons both as to the size and kind of sutures used and the type of
stitch used. Therefore, the specialist should carefully check the surgeon's preference card for the
procedure before preparing any sutures. In general, the sutures used for eye surgery are much
smaller than those used for operations on other parts of the body. Silk, size 6-0, is frequently
used, as is plain catgut in small sizes. In addition, double-arm sutures (a suture with a needle
swaged on both ends) are used for many operations. The specialist prepares this suture as
described for swaged-on sutures, taking care not to exert pull on either of the needles. He must
also avoid pricking his gloves with the needles. Both of the swaged-on needles are clamped into
needle holders before the suture is handled. Either interrupted or continuous stitches may be
taken, depending upon the preference of the surgeon.

6-8. OPERATIONS ON THE EYES

a. Introduction. In the following text, some examples of surgical procedures on the eyes are
defined in order to acquaint the specialist with these operations. When the specialist is assigned to
scrub or circulate for an eye operation, he is to perform duties as indicated in paragraphs 6-3
through 6-7, using whatever modifications may be prescribed locally.

b. Extraocular (Outside the Eye) Procedures. The operations discussed in paragraphs 6-9 through
6-11 are those done outside the eye. Anesthesia used maybe either general or local depending
upon the needs of the situation.
                                                                                                    112
c. Intraocular (Within the Eye) Procedures. Operations performed within the eye are discussed in
paragraphs 6-12 through 6-17. Anesthesia of choice is usually--though not always--local.

6-9. PROCEDURES ON EYELIDS

a. Plastic Repair of Eyelid. Various reconstructive techniques may be employed by the surgeon in
repairing the eyelid following lacerations or burns. Plastic repair may also be indicated as
treatment for acquired malfunctions of the eyelid. Such malfunctions sometimes result from scars
that form after the healing of injuries or burns of the lids. These malformations may be classified
as follows:

(1) Ectropion. This is the rolling outward of the eyelid margin so that a portion of the conjunctiva
is exposed. It is usually accompanied by epiphora (tears running down the cheek). This condition
may be caused by injury or it may occur spontaneously in elderly persons with no history of
injury.

(2) Entropion. This is the rolling inward of the lid margin so that it presses against the cornea and
the eyelashes are in contact with the eyeball.

b. Tarsorrhaphy. This is the surgical closure of the lids by a plastic operation. It is indicated when
the lids cannot close sufficiently to cover the cornea during sleep (exposure of the cornea results
in the drying of its surface and produces corneal ulcer).

c. Excision of Chalazion. A chalazion is a small benign tumor of the eyelid. The removal of a
chalazion is indicated when the chalazion fails to disappear without surgical intervention in the
course of several weeks. (Approximately 70 percent of chalazia require excision.) In addition,
excision is indicated if the chalazion progressively enlarges.

(1) The surgeon may excise the chalazion through either the conjunctival surface or the skin of
the lid (see figure 6-3). The route of excision depends upon the surface upon which the chalazion
is located. Very fine silk suture on a swaged-on needle is used if excision is through the skin
surface. No suture is required if excision is through the conjunctival surface.

(2) A chalazion set is used with other instruments, supplies, and sutures according to the
surgeon's preference.

d. Excision of Pterygium (Benign Growth of Conjunctival Tissue Over the Cornea). Removal of
a pterygium is indicated when the pterygium is progressive and is invading the cornea.

e. Hordeolum (Sty). A sty is an infection of one or more glands of the skin of the eyelid. A
painful lump occurs in the skin and the abscess, which can form may break through the surface
and drain pus. Although the common treatment is application of hot compresses, pointing may
necessitate opening and draining.

f. Ptosis. Ptosis is a drooping of the upper eyelid. It can be caused by neurological disorder,
ocular conditions such as microphthalmus (abnormal smallness of the eves), and local injury such
as traumatic rupture of the levator muscle as well as other malfunctions. Lid surgery may be
indicated if other treatments cannot remove the causes.

Figure 6-3. Preparation of eyelid for Chalazion removal. The incision on the inner lid

surface is to avoid scarring.

6-10. PROCEDURES ON LACRIMAL APPARATUS (TEAR-DUCT SYSTEM)


                                                                                                  113
a. Dacryocystectomy. A dacryocyst is a lacrimal (tear) sac. Therefore, dacryocystectomy is
excision of the wall of the lacrimal sac. It is indicated as treatment for acute dacryocystitis. A
lump may appear under the skin at the inner corner of the eye as the tear sac fills with pus. If the
pus cannot be discharged from the sac by pressing on it, the ducts may be blocked and surgical
incision and drainage of the sac is required to relieve the condition.

b. Dacryocystorhinostomy. This is the construction of an opening from the tear sac into the nasal
cavity. The surgery may be done as treatment for chronic dacryocystitis, trauma to the
nasolacrimal duct, or congenital malformation of the duct. In children, early probing of the
nasolacrimal duct (before age of 1) may prevent the need for a dacryocystorhinostomy later.

6-11. PROCEDURES ON EXTRAOCULAR MUSCLES

a. General. Operations on muscles outside the eyeball are done for correction of strabismus.
Strabismus is a term describing muscle imbalance between two eyes. An eye deviating outward
or away from its fellow eye is a condition termed exotropia. If the eye deviates inward, it is
termed esotropia.

b. Objective of Surgery.

(1) To secure binocular single vision by performing accurate binocular alignment.

(2) To achieve alignment that allows the best possible cosmetic effect and enables maintenance
of the effect for as long as possible.

c. Kinds of Operations. Strabismus may be treated surgically by procedures done either to
strengthen weak muscles (refer to paragraphs 6-11d, e, and f below) or to weaken overactive
muscles (refer to paragraphs g and h below).

d. Tucking. A tuck is sutured in the muscle, thus shortening it and increasing its effective
strength.

e. Advancement. The muscle is freed at its attachment point, and it is reattached closer to the
cornea, thus increasing its leverage.

f. Resection (Shortening). Part of the tendon of a extraocular muscle is excised. The muscle is
reattached to the sclera at the original point of insertion.

g. Tenotomy. This is transection of the muscle sheath and tendon.

h. Recession (Lengthening). The muscle is detached from the eyeball and is sutured to the sclera
posterior to the original insertion.

6-12. PROCEDURES ON THE EYEBALL

a. Enucleation. This is excision of the eyeball and its muscles, with or without introduction of an
implant (device made of glass or plastic used to prevent unsightly appearance of the eye and to
form, a base for a prosthesis). Enucleation is sometimes indicated as treatment following
penetrating or crushing wounds of the eyeball, and upon diagnosis of certain other conditions--
especially the threat of sympathetic ophthalmia. (Sympathetic ophthalmia is bilateral
inflammation of the entire uveal tract.) The condition is nearly always secondary to a perforating
wound of the eye. Sympathetic ophthalmia nearly always progresses to blindness unless the
injured eye ("exciting eye") is removed before the disease is well underway in the other eye
("sympathizing eye"). The anesthesia of choice for this operation is general anesthesia.


                                                                                                  114
b. Evisceration. In contrast to enucleation, evisceration is excision of the cornea and removal of
all contents of the globe, leaving the scleral shell and muscles intact. The procedure is indicated
following injury when a virulent organism invades the eye. Evisceration provides less danger of
the transmission of infection to the brain than does enucleation. General anesthesia is usually
used for this procedure.

c. Exenteration of Orbit. This is the removal of the entire contents of the orbit (eye, tendons,
muscles, fatty and fibrous tissue). The operation is indicated as treatment for malignant tumor.
General anesthesia is usually given for this procedure.

6-13. PROCEDURES FOR REPAIR OF DETACHED RETINA

a. General. A retinal detachment is a separation of the portion of the retina that contains the rods
and cones from the portion of the retina called the pigment epithelium. As a result, the rods and
cones lose nutrition and cease to function. Thus, the visual defect will vary with the extent and
location of the detachment.

(1) There are many causes for a retinal detachment. These include trauma, high myopia (causing
a thin retina), degeneration, diabetes, infections, and tumors. The danger of a small retinal
detachment is that eventually the entire retina will separate and the eye will lose all vision.

(2) Blood or fluid may be present as a result of direct or indirect trauma, severe inflammation, or
certain diseases.

b. Operative Procedures.

(1) If the retina is detached as a result of tumor, enucleation may be the operation indicated.

(2) Retinal detachment due to the presence of blood or fluid offers a choice of several operative
procedures to the surgeon. All operations are based on the principle of sealing off the area in
which the tear has been located, of draining off sub-retinal fluid, and of creating a watertight
adhesion between the choroid and the retina. A frequently used operation involves the use of
electrocautery. The surgery may be performed using general or local anesthesia.

6-14. PROCEDURES FOR REMOVAL OF INTRAOCULAR FOREIGN BODIES

a. General. The presence of an intraocular foreign body usually represents a serious ocular
problem. Disturbance of the function of the eye results from several sources, including the
destruction of or damage to the tissues caused by the entrance of a missile; infection introduced
by the missile; and destruction of or damage to the delicate intraocular tissues caused by reactions
to the intraocular intruder, such as siderosis caused by iron or inflammation caused by wood
particles.

(1) Before surgery is undertaken, the size and location of the foreign body must be determined.
This is done by special X-ray procedures of the skull with special bone-free X-ray using dental
film and other techniques.

(2) In addition, metal-locating instruments and ultrasonic probes are employed to locate the
foreign bodies.

b. Operative Procedures. The operation performed depends upon the size, location, and magnetic
property of the embedded object. Local anesthesia is used because the cooperation of the patient
is required.



                                                                                                  115
(1) The magnet tip may be directed to the eye and the foreign body removed without incision
into the eye if the size and location of the object makes this procedure feasible.

(2) If the size, shape (jagged edges), or the location of the foreign body is such that passage of
the object would endanger structures vital to vision, the sclera is incised and the magnet tip is
advanced into the vitreous, humor for removal of the object.

(3) A nonmagnetic foreign body is removed by incision and extraction, but it must be seen to be
removed.

6-15. PROCEDURES IN THE TREATMENT OF CATARACT

a. General. Cataract is a clouding or an opacity of the crystalline lens, its capsule, or of both. A
cataract may result from local or systemic disease, from eye injury, or the cataract may be
congenital. Cataracts seen in the elderly are referred to as primary or senile cataracts. Medical
treatment of cataracts is not available. Only surgical removal of the lens is of any significant
assistance and this is indicated when the patient's vision is sufficiently depressed.

b. Operative Procedures.

(1) Discussion, or needling of lens. The capsule is incised and the lens substance is broken up.
The aqueous humor exerts a solvent action on the exposed lens tissue, thus a clear opening for the
passage of light is obtained. The principal use for needling is in cases of cataract due to trauma
and in cataract surgery performed on children.

(2) Iridectomy. A sector of the iris is removed as a preliminary step in extraction of the cataract
(lens extraction).

(3) Lens extraction, intracapsular. The entire lens within the capsule is removed intact through a
corneoscleral incision (see figure 6-4).



                                                     Figure 6-4. Intracapsular lens extraction.

                                                     (4) Lens extraction, extracapsular. The
                                                     anterior capsule is cut, and the lens substance
                                                     is delivered through the opening in the capsule.
                                                     The posterior lens capsule is left in place.
                                                     Therefore, in extracapsular cataract extraction,
                                                     the major portion of the lens is removed but
                                                     some remnants of the lens tissue remain.

                                                     c. Precautions After Surgery. After surgery,
                                                     the patient is usually kept at bed rest for a short
                                                     period, then gradually allowed to ambulate,
                                                     depending on postoperative conditions. All
                                                     patients are generally cautioned not to stoop
                                                     over, lift heavy objects, or strain themselves
                                                     physically. This warning is maintained during
                                                     the time when the wound is healing.




                                                                                                   116
6-16. PROCEDURES IN THE TREATMENT OF GLAUCOMA

a. General. In glaucoma, there is increased tension or pressure within the eye. Increased
intraocular pressure may lead to hardening of the eyeball and blindness. Glaucoma may result
from iritis or from trauma.

b. Operative Procedures. The various operations used are aimed at reducing tension in the eye by
improving intraocular drainage of fluid. The operation performed depends upon several factors,
one being the status of the glaucoma (acute, subacute, or chronic).

(1) Iridotomy. This is incision of the iris. The operation is done to create a communication
between the anterior and posterior chambers and thus relieve the acute phase of the attack of
glaucoma.

(2) Iridectomy. This is excision of part of the iris. A sector of the iris is removed to increase
drainage and relieve tension on the eye.

(3) Iridencleisis. This is the formation of an artificial pupil. A fistula is created to provide an
outlet for aqueous humor. The iris is incised through an incision at the corneoscleral junction. The
free ends are brought out and covered with conjunctival flap.

(4) Trephine. An opening is made by inserting a trephine through the cornea at the corneoscleral
junction and cutting through the globe down to the posterior layer of corneoscleral tissue. The
trephine is then removed and an iridectomy is performed. The surgeon may perform a trephine
operation as the first surgical procedure in the treatment of glaucoma.

(5) Cyclodialysis. A new drainage channel is constructed from the anterior chamber so that
aqueous humor drains into the suprachoroidal space. This operation is often done as treatment for
glaucoma following cataract extraction.

6-17. PROCEDURES ON THE CORNEA

a. Repair of Laceration. A flap of the conjunctiva is used to seal off the tear.

b. Removal of Foreign Body. This is done very gently using aseptic technique to avoid secondary
infection.

(1) Serious damage to the ocular structures often results from the careless or unskilled removal of
foreign bodies from the eye.

(2) The foreign bodies which most commonly cause injury and irritation of the conjunctiva or
cornea are dust particles from grinding wheels, cinders, street dirt, gravel, and grains of sand.
Foreign bodies such as splinters of wood, metal, or glass which become embedded in or penetrate
the eye often cause serious damage.

(3) A foreign body, which is lying on the cornea, is embedded in, or penetrates the eye, is always
removed by a medical officer.

c. Graft of Cornea. Opaque corneal tissue is excised and healthy corneal tissue of the same size
and shape is placed. The operation is done to restore vision by permitting light to enter the eye.
An important factor in the success of this surgery is that the donor tissue absolutely be fresh. If
                                                                                                    117
opacity (the condition in which light cannot penetrate) has begun to develop in the graft tissue,
the success of the operation is doubtful. Eye "banks," similar to other tissue "banks," provide for
acquisition, preservation, and transportation of healthy corneal tissue to the hospital where the
operation is to be done.


                     6 Eye, Ear, Nose, and Throat (EENT) Surgery
Lesson 6-1 Eye Surgery

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to EENT surgery.
       Identify preparation procedures of the operating room and of the patient for
        EENT surgery.
       Identify special safety precautions related to EENT surgery.
       Identify specific EENT surgical instruments.
       Identify specific surgical procedures used for EENT surgery.
       Identify procedures for tongue and neck surgery.

                     6 Eye, Ear, Nose, and Throat (EENT) Surgery
Lesson 6-2 Ear Surgery

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to EENT surgery.
       Identify preparation procedures of the operating room and of the patient for
        EENT surgery.
       Identify special safety precautions related to EENT surgery.
       Identify specific EENT surgical instruments.
       Identify specific surgical procedures used for EENT surgery.
       Identify procedures for tongue and neck surgery.


6-18. GENERAL ANATOMY AND PHYSIOLOGY OF THE EAR

The ear (see figure 6-5) is made up of three distinct divisions: the external ear, the middle ear, and
the inner ear. The middle and inner ear structures are situated in the temporal bone cavity.

a. External Ear. The external ear consists of an auricle, or pinna, and an external auditory meatus
(a tube ending at the tympanic membrane or ear drum). The auricle collects the sound vibrations
in the air and sends them through the external canal to the ear drum.

b. Tympanic Membrane. The tympanic membrane (see figure 6-6) is a trilayered membrane
stretched across the end of the external meatus. The sound waves come through the meatus and
vibrate the membrane.




                                                                                                 118
Figure 6-6. Landmarks of right tympanic membrane.

c. Middle Ear. Inside the tympanic membrane is a narrow, irregular, oblong, air-conditioned
cavity in the tympanic part of the temporal bone. This air-filled space contains three small bones,
which transfer the vibrations from the tympanic membrane to the inner ear. Figure 6-7 shows the
ossicles of the middle ear.

d. Inner Ear. The inner ear is a complex structure located in the petrous portion of the temporal
bone. It is made up of two distinct parts, each of which contains its own kind of fluid. Sound
vibrations carried by the bones of the inner ear are transferred by way of the oval window to the
fluid in the cochlea and received through a fine membrane by the organ of Corti, the delicate
neural end organ for sound. A second function of the inner ear is the maintenance of balance,
controlled by the movement of fluid in the labyrinth in relation to neuroepithelial cells.

e. Temporal Bone. The temporal bone houses the middle and inner ear as well as the mastoid
sinuses.



                                                              Figure 6-7. Ossicles of the middle
                                                              ear (separated and articulated).

                                                              6-19. EAR OPERATIONS

                                                              Ear operations are done on the
                                                              canals, the middle and inner ears,
                                                              and the mastoid sinuses (airspaces
                                                              within the temporal bone). Surgery
                                                              may be done to correct the effects of
                                                              trauma or disease, or in an effort to
                                                              correct hearing disorders.

                                                              6-20. PREP FOR EAR SURGERY

a. For operations involving the ear, preparation normally consists of washing the outer ear and
surrounding skin with an anti-bacterial detergent and irrigating the canal with a mild antiseptic
solution. The canal may also be cleaned with cotton applicators. The hair should be shampooed.
                                                                                               119
b. Depending upon the approach in surgery and local policy, a 2-inch strip may be shaved at an
area of incision. This would also be true in mastoid operations. If hair is to be shaved from the
patient's head, the specialist should check local policy regarding the disposition of the hair.

c. Positioning and draping.

(1) Quietness and immobility of the patient are most important in otological (ear) surgery. The
head must be carefully immobilized by whatever method is prescribed for a particular procedure.
The patient is to be placed on his back with his head turned to the side, with the affected ear up.
Great care must be taken in alignment of the patient, especially if the procedure is time
consuming.

(2) In the presence of infection, disposable sheets and towels should be used. An opening can be
readily made with scissors in the sterile sheet or towel to expose the operative site. A standard ear
pack is used.

(3) Three towels are folded lengthwise and placed around the operative site. The first one is
placed horizontally above the ear, the second towel is placed diagonally on the outer prepared
skin area surrounding the ear, and the third vertically in front of the meatus. A folded fenestrated
sheet is unfolded over the patient and table, with the operative site in view through the opening.

(4) The draped tables with sterile instruments and the operating microscope are positioned
around the patient. For example, if the operation involves the left ear, the sterile instrument table
is placed near the left side of the operating table. The scrub usually sits or stands near the
instrument table and passes the instruments to the surgeon in such a manner that he does not have
to turn away from the operative microscope.

(5) All safeguards should be taken to prevent explosive hazards. This is most important because
there are many electrical appliances in use during otological surgery.

d. Anesthesia for ear surgery may be local or general depending upon the severity of the surgery
to be performed and the age of the patient.

e. The dressing applied following surgery is usually one of two types. For internal canal work, an
ear wick may be inserted. For surgery on the mastoid sinuses or any posterior approach, a large
compression type dressing commonly referred to as a mastoid dressing is applied.

6-21. INSTRUMENTS AND SUPPLIES

Check the surgeon's card carefully, and make sure that all instruments and equipment are
assembled. The operating microscope, suctioning equipment, and drill are often required. All
equipment must be in working order. Since the operating microscope is used in such close
proximity to the surgical wound, it is draped with disposable microscope drapes before use.
Electric cautery equipment is also sometimes needed.

6-22. INCISIONAL APPROACHES

a. The endaural (vertical) incision frequently is used for temporal operations, except for simple
mastoidectomy. The first incision extends from the superior meatus wall, and the second extends
directly upward to a point between the meatus and the upper edge of the auricle, where the two
incisions join.

b. The high posterior incision may be used in operations on infants or young children. The
incision is placed at a higher posterior level than is the endaural incision, thereby avoiding
possible damage to the facial nerve.

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c. The postaural incision may be used to expose the mastoid process. It follows the curve of the
postaural fold, beginning at the upper attachment of the auricle and continuing behind the
postaural fold downward to the tip of the mastoid process.

d. For stapes surgery, a circumferential incision is made in the posterior half of the canal, starting
at the inferior aspect of the annulus and ending posterior to the short process of the malleus.

e. For myringotomy, a circumferential (posteroinferior) incision is made. It provides for wide
drainage and removal of pus or fluid under pressure from the middle ear.

6-23. MYRINGOTOMY

a. General. Myringotomy is an incision through the tympanic membrane. This may be done when
an inner ear infection produces pus that is causing undue pressure on the membrane. It may also
be done to correct hearing loss due to fluids in the middle ear.

b. Preparation of the Operating Room. Sterile instruments are set up in accordance with local
policy and the surgeon's preference. Non-instrument items in the setup include cotton-tipped
applicators, cotton (for plugging the canal after surgery), and culture tubes.

c. Operative Procedure.

(1) Through microscopic visualization, the aural speculum is inserted in the canal. Using a sharp
myringotomy knife, a small curved incision is made in the posteroinferior quadrant or the pars
tensa, and the thickened membrane is cut.

A culture is taken to determine the type of organisms present. Pus and fluids are suctioned out.

A plastic tympanotomy tube prosthesis is usually put into place.

6-24. RADICAL MASTOIDECTOMY

a. General. Radical mastoidectomy involves the removal of the mastoid air cells, the tympanic
membrane, the involved malleus, incus, chorda tympani, and mucoperiosteal lining which
converts the middle ear and the mastoid into one cavity. This procedure may be used to treat a
chronic otitis media (inflammation or infection of the middle ear) that has spread into the mastoid
air cells, and when skin from the external auditory canal has grown into the middle ear
(cholesteatoma) where it acts as a foreign body. Radical mastoidectomy may also be done to
provide adequate exposure in the treatment of facial nerve decompression to drain an extradural
abscess in the bony labyrinth.

b. Preparation of Operating Room. This requires an extensive setup of instruments and other
sterile items. These are set up in the appropriate sizes and numbers, as prescribed locally.

c. Operative Procedure.

(1) An endaural or postural incision is made using a Bard-Parker knife. Bleeding vessels are
clamped and ligated. With a second knife, the periosteum (connective tissue over bone) is incised
and freed to form a flap. The wound is retracted with a self-retaining retractor.

(2) The meatus flap is cut, exposing the mastoid area by means of a circumferential knife, narrow
periosteal elevator, and curved scissors.

(3) The mastoid antrum is exposed. By means of round cutting burrs attached to an electric drill,
the bone of the outer cortex is removed. The osseous metal walls are removed with rongeurs or
                                                                                                  121
burrs. The wound is irrigated and suctioned. Cotton pledgets are used for sponging the operative
site.

(4) The thin bridge of bone between the meatus and antrum is removed with angular dissectors
and fine currettes.

(5) The tympanic membrane, malleus, incus, and mucoperiosteal lining of the middle ear cavity
are excised by means of stapes instruments, as for a stapes operation.

(6) The tympanic cavity is cleaned. The wound is closed with sutures. A musculo-plasty may be
done by taking a strip of temporalis muscle from above the ear and placing it in the mastoid
cavity. In time, the skin grows over the muscle.

(7) The mastoid cavity is usually packed with a strip of 1/2 x 8 inch gauze packing that has been
impregnated with petrolatum or an antibiotic ointment. The wound is closed.

(8) The ear dressing is applied, including a shaped ear pad. Fluffed 4 x 8 inch gauze sponges are
placed around and behind the affected ear and then flat compresses over the affected ear. A gauze
bandage is applied in a particular manner to hold the dressings in place and avoid pressure.

6-25. SIMPLE MASTOIDECTOMY

a. General. Simple mastoidectomy involves the removal of the air cells of the mastoid process
without disturbing the contents of the middle ear. It may be done occasionally to treat acute
empyema (accumulation of pus) of the mastoid, but has been made almost obsolete by antibiotics.

b. Operative Procedure. A postural or endaural incision is made. Perform procedures for a radical
mastoidectomy as stated in paragraphs 6-24c(1), (2), (3), and (6).

NOTE: A modified radical mastoidectomy may also be done in which the middle ear is not
involved, but in which the thin bridge of bone between the external canal wall and antrum is
removed.

6-26. TYMPANOPLASTY OPERATIONS

Tympanoplasty involves a large variety of reconstructive operations of the middle ear designed to
restore or improve hearing in patients with middle ear or conductive-type hearing loss. In various
operations of this type, tissue grafts of different kinds are often used.
                          6 Eye, Ear, Nose, and Throat (EENT) Surgery
Lesson 6-3 Nose Surgery

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to EENT surgery.
       Identify preparation procedures of the operating room and of the patient for
        EENT surgery.
       Identify special safety precautions related to EENT surgery.
       Identify specific EENT surgical instruments.
       Identify specific surgical procedures used for EENT surgery.
       Identify procedures for tongue and neck surgery.


6-27. OPERATIONS ON THE NOSE



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Operations on or through the nose (see figure 6-8) may be required to correct results of trauma to
the nose and related structures; to correct deformities that interfere with breathing, such as
deviated nasal septum, hypertrophy of the turbinates, and polyps or other neoplasms; and to
relieve the effects of sinusitis.

6-28. ANATOMY AND PHYSIOLOGY OF THE NOSE

The nose is divided into the prominent external nose and the internal nose known as the nasal
cavity. The chief purpose of the nose is the preparation of air for use in the lungs.



                                                                     Figure 6-8. Nasal skeletal
                                                                     framework.

                                                                     a. External Nose.

                                                                     (1) The external nose projects
                                                                     from the face. The upper
                                                                     portion of the nose is formed
                                                                     by the nasal bones and the
                                                                     frontal process of the
                                                                     maxillae. The lower portion is
                                                                     formed by a group of nasal
cartilages and connective tissue covered with skin. The nostrils and the tip of the nose are shaped
by the major alar cartilages. The nares are separated by the columella, which is formed by the
lower margin of the septal cartilage, the medial parts of the major alar cartilages and the anterior
nasal spine, all of which are covered by skin.

(2) The nasal septum is composed of three structures: the nasal cartilage, the vomer bone, and the
perpendicular plate of the ethmoid bone. The septum is covered by mucous membrane on either
side. The deviated or fractured septum may be repaired surgically by mobilization of the fracture
or removal of the deformed cartilage or bone.

b. Internal Nose.

(1) The internal nose or nasal cavity is divided into two parts at its midline by the nasal septum.
The nasal cavity communicates with the outside by its external openings, called the anterior
nares. The nares open into the nasopharynx behind through the choanae. The nasal cavity is also
associated with each ear by means of the eustachian tube and with the paranasal air sinuses (see
figure 6-9) (frontal, maxillary, ethmoid, and sphenoid) via their respective orifices (meatuses).
The nasal cavity communicates with the conjunctive through the nasolacrimal duct as well.




                                                                                                123
Figure 6-9. The paranasal sinuses (lateral and anterior aspects).

(2) The nasal cavity is separated from the lingual cavity by the hard and soft palates and from the
cranial cavity by the ethmoid bone. The nasal cavity is held together by periosteal covering and
by perichondrium, which extends over the cartilages.

c. Turbinate Bones and Sinuses.

(1) The turbinate bones of the nasal structure are arranged one above the other, separated by
grooves (the meatuses). These act as drainage passages of the accessory sinuses and are known as
the sphenoethmoidal recess and the superior, middle, and inferior meatus, respectively.

(2) The nasal sinuses serve as air spaces and communicate with the nasal cavity via the meatuses.
Anteriorly, on each side of the skull, the frontal sinus, the anterior ethmoid cells, and the
maxillary sinus (antrum of Highmore) drain into the middle meatus; posteriorly, the ethmoid cells
and the sphenoid sinus drain into the superior meatus and the sphenoethmoidal recess. A
passageway for the flow of air is provided by the irregular air spaces present between these
structures. Because of their shape, the air is forced to flow in thin airwaves.

d. Nerve and Blood Supplies.

(1) The sensory nerve supply of the nasal cavity is derived from the trigeminal nerve.

(2) The nose and sinuses receive their blood supply from branches of the internal maxillary
artery. There are masses of communicating veins below the epithelial layer of the turbinated
bones, and those veins lying just beneath the mucosa anastomose (communicate) freely.
Dilatation of the superficial veins may cause the turbinated bone mucosa to swell, whereas
contraction of these vessels may cause the mucosa to shrink.

6-29. PREP, POSITION, DRAPE, ANESTHESIA, AND LIGHTING

All procedures performed prior to the start of surgery must be explained to the patient to avoid
fright and apprehension.

a. The male patient shaves his face prior to surgery. The immediate preoperative prep may
include clipping the hairs within the nostrils using small tenotomy scissors. The specialist is to
coat the blades of the scissors with a film of vaseline so that the patient will not aspirate the nasal
hairs. The patient's face is then washed with antibacterial detergent and sponged dry. His eyes
should be protected during this procedure with damp gauze compresses. No solution is applied
inside the nose.


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b. The patient is placed in either the supine position or the reclining position. For procedures
done using local anesthesia, the reclining position enables the patient to expectorate any fluid
collecting in his mouth and thus helps keep the operative area free from drainage.

c. A large drape sheet is placed lengthwise over the front of the patient and is secured bib-
fashion. Suction tubing is pinned to the sheet. Sterile towels may be wrapped around the patient's
head and secured with towel forceps, leaving his face exposed but his eyes covered. Another
method of draping the head is to cover it with a small fenestrated sheet through which the nose
and mouth are exposed.

d. Local anesthesia is usually employed for nasal surgical procedures on adults. The method of
administration is a combination of topical (nasal packs) and infiltration anesthesia. The specialist
assists the surgeon as necessary in packing the nose. Use of local anesthesia enables the patient to
cooperate with the surgeon and avoids the complication of vomiting.

e. Illumination is provided by either of two methods: the electric head lamp or the overhead light.
The two devices are sometimes used in conjunction.

6-30. SEPTECTOMY, OR SUBMUCOUS RESECTION

a. General. Septectomy, or submucous resection (SMR) deviations of the nasal septum may result
from faulty development of the septum or from injury to the nose. The patient's symptoms
include inadequate or difficult nasal breathing or obstruction of nasal drainage. Septal deviations
tend to cause sinus disease and the formation of polyps. The operation consists of removing the
bent parts of the nasal septum that lie between the flaps of mocous membane to establish a
straight partition.

b. Preparation of the Operating Room.

(1) The setup of sterile instruments and other equipment is done as prescribed locally. Gauze
packing is included for use as a pressure dressing.

(2) The room is darkened before the patient arrives. The surgeon usually uses an electrical head
lamp that will focus a beam into the nostrils. The circulator is to connect and carefully check all
special lighting equipment prior to the start of the procedure.

(3) This operation is generally done with the patient under local and/or topical anesthesia. Before
the patient arrives, the operating table is made into a reclining chair by use of a foot-piece and
pillows placed for protection of feet from pressure and relief of strain on vessels and tendons of
the lower extremities. The reclining chair is adjusted to meet the physical characteristics and
comfort of the patient. The table is raised or lowered to accommodate the surgeon.

c. Preparation of the Patient.

(1) In some cases, the hair of the nostrils may be clipped with fine, curved scissors. Sterile
mineral oil drops or an antibiotic ointment may be put in the eyes of the patient to protect them
from prepping solutions. The face is scrubbed with a mild soap and water. The face prep and
draping of the patient is done prior to anesthetizing. The circulating nurse should observe changes
in the vital signs of the patient. When cocaine or some similar narcotic agent is used, a thiopental
(Pentothal®) sodium setup and oxygen equipment should be in the room. Topical medications
that have changed color should not be used. The amount of the topical agent dispensed for the
operation must be recorded on the anesthesia record and on the pharmacy's narcotic form.

(2) The patient is draped with sterile towels and sheets as follows:


                                                                                                   125
(a) Place the small sheet with two towels on top of it over the head of the table and under the
head of the patient.

(b) Bring the uppermost towel around the head, including the hairline.

(c) Secure the ends of the uppermost towel with a towel forceps and tuck the free ends under the
patient's head.

(d) Drape a large sheet over the patient, bringing its upper end up to the chin.

(e) Place the tray with the instruments in position for the surgeon.

(f) Adjust the lighting system.

(g) Record the vital signs of the patient.

(h) Reassure the patient if awake.

d. Operative Procedure. The operative procedure will vary with the individual surgeon. A general
review of most procedures is as follows:

(1) The nostril is opened with a speculum. An incision is made through the mucoperichondrium
and mucoperiosteum of the septum with a knife, blade number 15. The tissues are separated and
elevated, using a Freer knife.

(2) The cartilage is incised with a knife, and the mucous membrane is elevated with a septal
elevator; part of the septal cartilage is excised with a Ballenger knife; deviated cartilage and bony,
thickened structures are removed with a septum punch and a nasal cutting forceps.

(3) The mucous membrane is freed from the bony septal base by means of a chisel, gouge and
mallet, or punch forceps. Bleeding is controlled by cotton sponges; suctioning is used to expose
the field.

(4) The perpendicular plate of the ethmoid may be removed, as well as the vomer, by means of
the S-retractor, chisel and mallet, and a suitable septum-cutting forceps.

(5) The incision may or may not be sutured with silk #3-0 fused to a small 1/2-circle taper-point
needle on a Crile needle holder.

(6) Nostrils are packed with petrolatum gauze in order to keep the septal flaps in a midline
position. The face is cleansed with both moist and dry compresses.

e. Specimens. Excised tissue is processed as a specimen.

6-31. OTHER NASAL OPERATIONS

The specialist assigned to scrub or circulate for the operations duties are similar to those
described for submucous resection. The specialist is to check local policy carefully concerning
instruments, sutures, and other items in the setup for the operation to be performed.

a. Excision of Nasal Polyps. Polyps are soft, benign tumors of the nasal mucosa caused by
chronic nasal allergy (see figure 6-10).




                                                                                                  126
                                                   Figure 6-10. Nasal polyps.

                                                   (1) Operation. Polyps that arise from the
                                                   border of the middle turbinate may be removed
                                                   by means of a submucous resection setup,
                                                   using a nasal snare. Polyps that arise above this
                                                   level may involve a sinus cavity, thus
                                                   necessitating surgery of the sinus. In this event,
                                                   the instruments and other setup are determined
                                                   by the specific sinus cavity involved.

                                                   (2) Indications. The pressure exerted by nasal
                                                   polyps results in obstruction to the passage of
                                                   air through the nostrils. The obstruction may
                                                   lead to a condition of chronic infection of the
                                                   nose and give rise to frequent attacks of
                                                   nasopharyngitis. The infection may extend also
                                                   into the nasal sinuses, thus obstructing
drainage from the affected sinus. The patient suffers pain in the region of the sinus involved.
Treatment of the condition is excision of the polyps.

b. Turbinectomy. Turbinectomy is the surgical removal of hypertrophied portion of a turbinate
bone.

(1) Hypertrophy of the turbinate prevents adequate breathing and drainage through the nose and
produces painful pressure against the floor of the nose. Treatment is the removal of the
hypertrophied turbinate.

(2) Excision of the hypertrophied portion of the turbinate is done using a setup as described for
removal of nasal polyps.

c. Intranasal Antrostomy (Antral window).

(1) General. This procedure involves making an opening in the lateral wall of the nose under the
inferior turbinate. It is done to relieve headaches, edema, infection, or swelling of the membranes
lining the sinuses.

(2) Operative procedure. After prep and anesthesia, a postnasal plug is inserted. The inferior
turbinate is elevated superiorly by means of a large elevator or tonsil dissector. An opening is
made into the maxillary sinus beneath the inferior turbinate by means of a gouge, perforator, or
antrum cannulae. The opening is enlarged with cutting forceps and antrum punches. Accessory
polyps and degenerate mucosa are removed with a snare, septum forceps, and suction. The sinus
is irrigated with saline solution by means of a Thornwald irrigator and suction apparatus; the
sinus is packed with petrolatum impregnated iodoform gauze, and the face is cleaned and dried.

d. Radical Antrostomy (Caldwell-Luc Operation).

(1) General. This procedure involves an incision into the canine fossa of the upper jaw and
exposure of the antrum for removal of bony diseased portions of the antral wall and contents of
the sinus, or establishment of drainage by means of a counteropening into the nose through the
inferior meatus.

(2) Operative procedure.

                                                                                                127
(a) The upper lip is elevated with a retractor, and a transverse incision is made in the
gingivolabial sulcus just above the teeth; the incision is carried down to the underlying bone.
Periosteum and soft tissue are elevated with dissectors and periosteal elevators.

(b) The thin bony plate is perforated with a gouge, the antrum is entered, and its opening is
enlarged with nasal rongeurs. The anterior angle of the sinus may be opened by enlarging the
window with Jansen-Middleton septum-cutting forceps, double-action rongeurs, and Kerrison
forceps.

(c) The mucous membrane of the antrum is removed with Coakley or Myles angled currettes.

(d) Nasoantral drainage may be established by removal of a portion of the nasoantral wall below
the inferior turbinate by means of cutting forceps and rasps.

(e) The antrum is packed with petrolatum gauze.

(f) The labial incision may or may not be sutured. The face of the patient is cleaned and dried.

e. Frontal Sinus Operation.

(1) General. This procedure involves making an incision through the eyebrow of the affected side
and through the anterior wall and floor of the frontal sinus for removal of the diseased tissue,
cleansing of the sinus cavity, and drainage. It may be made necessary in acute frontal sinusitis
with persistent headaches and edema of the upper lid when other modes of therapy have failed.

(2) Operative procedure.

(a) An incision is made over the affected frontal sinus, extending from the base of the nose
through the eyebrow as far as the supraorbital notch. A self-retaining retractor, hook retractor,
knife, sponges, fine hemostats, fine ligatures, and suction set are needed.

(b) Either the anterior wall of the frontal sinus or the floor of the sinus is opened by means of
dental burrs, chisel, mallet, gouges, septum-cutting forceps, curettes, and nasal forceps. Drainage
is established by either the nasofrontal duct or the insertion of drains.

(c) An ethmoidal incision is made behind the nasal process of the superior maxillary bone with a
chisel and mallet. The lacrimal duct is identified and preserved. Ethmoid cells are curetted.

(d) A Penrose drain is introduced; the external wound is approximated with fine silk sutures and
dressing applied. The patient's face is cleaned and dried.

f. Ethmoidectomy.

(1) General. This is for removal of the diseased portion of the middle turbinate, opening and
removal of ethmoid cells, and removal of diseased tissue in the nasal fossa through a nasal
approach or external approach. It reduces the many celled ethmoid labyrinth into one large cavity
to ensure adequate drainage and aeration.

(2) Operative procedure. For the nasal route, the procedure is similar to intranasal antrostomy
described previously. For the external route, the procedure is similar to the frontal sinus
operation.

g. Sphenoidectomy.



                                                                                                    128
(1) General. This involves making an opening into one or both of the sphenoid sinuses by the
intranasal or external ethmoidectomy approach. It is difficult to visualize the cavity of the
sphenoid sinus because of its depth. Surgery of the sphenoid sinus is usually done intranasally or
through an external ethmoidectomy approach.

(2) Operative procedure. This is the same as for intranasal antrostomy.

h. Fracture of the Nose.

(1) General. This procedure involves the manipulation and mobilization of fractured nasal bones
and cartilages. Early reduction is important.

(2) Operative procedure. A rubber-covered narrow forceps is inserted into the nostril; the nasal
bones are elevated and molded into place by external manipulation.

                      6 Eye, Ear, Nose, and Throat (EENT) Surgery
Lesson 6-4 Throat, Tongue, and Neck Surgery

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to EENT surgery.
       Identify preparation procedures of the operating room and of the patient for
        EENT surgery.
       Identify special safety precautions related to EENT surgery.
       Identify specific EENT surgical instruments.
       Identify specific surgical procedures used for EENT surgery.
       Identify procedures for tongue and neck surgery.

6-32. THROAT OPERATIONS

Surgery of the throat (see figure 6-11) may be done to halt or correct the effects of trauma or
disease, including neoplasm. Structures included in throat surgery are the pharynx, larynx,
trachea, tongue, palate, tonsils, and adenoids.



                                                           Figure 6-11. Sag ittal section of the
                                                           face and neck.

                                                           6-33. ANATOMY AND
                                                           PHYSIOLOGY OF THE THROAT
                                                           AND NECK

                                                           The word throat refers to those
                                                           structures of the neck in front of the
                                                           vertebral column, including the mouth,
                                                           tongue, pharynx, tonsils, larynx, and
                                                           trachea.

                                                             a. The Mouth. The mouth extends from
the lips to the anterior pillars of the fauces. The portion of the mouth outside the teeth is known as
the buccal cavity and that on the inner side of the teeth as the lingual cavity. The tongue occupies
a large portion of the floor of the mouth. The hard and soft palates form the upper and posterior
boundaries of the oral cavity, separating it from the nasal cavity and the nasopharynx. The soft
palate emerges from the posterior border of the hard palate to form the uvula, a fingerlike

                                                                                                   129
movable projection. On either side, the uvula is adjacent to the base of the tongue anteriorly and
the pharynx posteriorly.

b. The Pharynx.

(1) The pharynx serves as a channel for both the digestive and respiratory systems. It is situated
behind the nasal cavities, mouth, and larynx. The food and air passages cross each other in the
pharynx. The pharynx is a funnel-shaped structure, wide above and narrower below, about 12 cm
in length. It is composed of muscular and fibrous layers and lined with mucous membrane. It is
associated above with the sphenoid and the basilar part of the occipital bone. Below, it joins the
esophagus. Seven cavities communicate with the pharynx: the two nasal cavities, the two
tympanic cavities, the mouth, the larynx, and esophagus. The cavity of the pharynx may be
subdivided from above downward into three parts: nasal, oral, and laryngeal. Infection may
spread from the pharynx to the middle ear via the auditory tube. This auditory tube can be
catheterized through the nostril.

(2) The nasopharynx communicates with the oropharynx through the pharyngeal isthmus, which
is closed by muscular action during swallowing. The oropharynx and the laryngopharynx cannot
be closed by muscular action during swallowing. The oropharynx and the laryngopharynx cannot
be closed off from each other; both service respiratory and digestive functions.

(3) The pharynx is made up of three groups of constrictor muscles. Each muscle fits within the
one below, and each inserts posteriorly in the median line with its mate from the opposite side.
The constrictor muscles provide constriction of the pharynx for dilatation. Between the origins of
the constrictor muscle groups, there are so-called intervals through which pass ligaments, nerves,
and arteries. The recurrent laryngeal nerve is closely associated with the lower portion of the
pharynx.

c. The Tonsils.

(1) The tonsils are situated one on each side of the oropharynx, lodged in a tonsillar fossa that is
attached to folds of membrane containing muscle. One pair, the palatine tonsils, is the only
lymphatic organ covered with stratified squamous epithelium. The lateral surface of each tonsil is
usually covered with a fibrous capsule. The anterior and posterior tonsillar pillars join to form a
triangular fossa, with the posterior lateral aspects of the tongue at its base. The so-called palatine
tonsils are lodged in each fossa. The adenoids (pharyngeal tonsil) are suspended from the roof of
the nasopharynx and consist of an accumulation of lymphoid tissue.

(2) The arteries of the tonsils enter the upper and lower poles. The tonsils are supplied with blood
primarily by the tonsillar branch and the ascending palatine branch of the facial artery (branches
of the external carotid artery). The external carotid artery on each side lies behind and lateral to
each tonsil. The nerves supplying the tonsils are derived from the middle and posterior palatine
branches of the maxillary and glossopharyngeal nerves.

d. The Larynx and Associated Structures.

(1) The larynx.

(a) The larynx is located at the upper end of the respiratory tract and is situated between the
trachea and the root of the tongue, at the upper front part of the neck. The larynx has three main
functions: a passageway for air, a valve for closing off air passages from the digestive system,
and the pharynx, and a voice box on which sound and speech depend on to a degree.

(b) The larynx is a cartilaginous box, situated in front of the fourth, fifth, and sixth cervical
vertebrae. The upper portion of the larynx is continuous with the pharynx above, and its lower
portion joins the trachea. The skeletal structure provides for patency of the enclosed airway. The
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complex muscle action and arrangement of tissues within the structure provide for closure of the
lumen for protection against trauma and entrance of foreign bodies and for phonation.

(2) Cartilages. The skeletal framework of the larynx consists of cartilages and membranes. There
are nine separate cartilages-- three of them single and six arranged in pairs. The main cartilages of
the larynx include the thyroid, cricoid, epiglottis, two arytenoid, two corniculate, and two
cuneiform. The thyroid cartilage (Adam's apple) forms the anterior portion of the voice box. The
cricoid cartilage, which resembles a signet ring, rests beneath the thyroid cartilage and within the
laryngotracheal space. The epiglottis is a slightly curled, leaf-shaped, elastic fibrous membrane. It
is prolonged below into a slender process, attached in the midline to the upper border of the
thyroid cartilage. When the cricothyroid muscle contracts, it pulls the thyroid cartilage and the
cricoid cartilage, thereby tightening the vocal cords and, if unopposed, closing the glottis. The
arytenoid cartilages, which rest above the signet ring portion of the cricoid cartilage, support the
posterior portion of the true vocal cords.

(3) Laryngeal ligaments.

(a) The extrinsic ligaments of the larynx are those connecting the thyroid cartilage and epiglottis
with the hyoid bone and the cricoid cartilage with the trachea. The intrinsic ligaments of the
larynx are those connecting several cartilages of the organ to each other. They are considered the
elastic membrane of the larynx.

(b) The mucous lining of the larynx blends with the fibrous tissue to form two folds on each side
of the larynx. The upper set are known as the false cords. The lower set are called the true vocal
cords because they are primarily concerned with the speaking voice and protection of the lower
respiratory channels against the invasion of food and foreign bodies.

(4) Laryngeal muscles.

(a) The laryngeal muscles perform two distinct functions. There are muscles (extrinsic type) that
open and close the glottis and those (intrinsic type) that regulate the degree of tension of the vocal
cords.

(b) It should be noted that the spoken voice also depends on the sphincter action of the soft
palate, tongue, and lips. The muscle action of the larynx permits the glottis to close either
voluntarily or involuntarily by reflex action. The closure of the inlet by this mechanism protects
the respiratory passages. The closure of the glottis and the action of the vocal cords are precisely
coordinated to produce the spoken voice.

(c) Two branches of the vagus nerve supply the intrinsic muscles. The recurrent laryngeal nerve
branch of the vagus nerve is the important motor nerve of the intrinsic muscles of the larynx. The
sensory nerve, which is derived from the branches of the superior laryngeal nerve, supplies the
mucous membrane of the larynx.

(d) When both the recurrent laryngeal nerves become divided or paralyzed, the glottis remains
closed so tightly that air cannot be drawn into the lungs. As a lifesaving measure, an endotracheal
or tracheostomy tube is inserted immediately.

(e) The larynx derives its blood supply from the branches of the external carotid and subclavian
arteries.

e. Trachea. The trachea, a cylindrical tube about 15 cm in length and from 2 to 2.5 cm in
diameter, begins in the neck and extends from the lower part of the larynx, on a level with the
sixth cervical vertebra, to the upper border of the fifth thoracic vertebra. The tube descends in
front of the esophagus, enters the superior mediastinum, and divides into right and left main
bronchi. The trachea is composed of a series of incomplete rings of hyaline cartilage. The carina
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is a ridge on the inside at the bifurcation of the trachea. It is a landmark during bronchoscopy and
separates the upper end of the right main branches from the upper end of the left main branches of
the bronchi. Branches given off from the arch of the aorta--the brachiocephalic (innominate) and
left common carotid arteries--are in close relation to the trachea. The cervical portion of the
trachea is related anteriorly to the sternohyoid and sternothyroid muscles and to the isthmus of the
thyroid gland.

f. Salivary Glands.

(1) The salivary glands consist of three paired glands: the sublingual, submaxillary, and parotid.
They communicate with the mouth and pour their secretions into its cavities. The combined
secretion of all these glands is termed saliva. The salivary glands consist of tissue found in the
mucosa of the cheek, tongue, palate, floor of the mouth, pharynx, lip and paranasal sinuses. A
tumor of a salivary gland may occur in any of these structures.

(2) The external carotid artery supplies the salivary glands and divides into its terminal branches:
the internal maxillary and superficial temporal. The superficial temporal and internal maxillary
veins unite to form the posterior facial vein.

(3) The sublingual gland lies on the undersurface of the tongue beneath the mucous membrane of
the floor of the mouth at the side of the frenulum linguae, in communication with the sublingual
depression on the inner surface of the mandible. It is supplied with blood from the submental
arteries. Its nerves are derived from the sympathetic nerves. The many tiny ducts of each gland
separately enter into the oral cavity on the sublingual fold.

(4) The submandibular gland lies partly above and partly below the posterior half of the base of
the mandible and on the mylohyoid and hyoglossus muscles. This gland is closely associated with
the lingual veins and the lingual and hypoglossal nerves. The external maxillary artery lies on the
posterior border of the gland. Its duct (Wharton's duct) enters the mouth at the frenulum of the
tongue.

(5) The parotid gland, the largest of the salivary glands, lies below the zygomatic arch in front of
the mastoid process and behind the ramus of the mandible. This gland is enclosed in fascia,
attached to surrounding muscles, and divided into two parts--a superficial and a deep portion--by
means of the facial nerve. The parotid duct (Stensen's duct) pierces the buccal pad of fat and the
buccinator muscle, finally opening into the oral cavity opposite the crown of the upper second
molar tooth. The superficial temporal artery and small branches of the external carotid arise in the
parotid gland behind the neck of the mandible.

g. General Structures of the Neck.

(1) The general topography of the organs lying in front of the prevertebral facial has been
described. A layer of deep cervical fascia surrounds the neck like a collar and is attached to the
trapezius and sternocleidomastoideus (sternocleidomastoid) muscles. In front of the neck, the
deep fascial layer is attached to the lower border of the mandible.

(2) The pretracheal fascia of the neck lies deep in the strap muscles (sterno-thyroid, sternohyoid,
and omohyoid) and partially encloses the thyroid gland, trachea, and larynx. The pretracheal
fascia is pierced by the thyroid vessels. It fuses with the front of the carotid sheath on the deep
surface of the sternocleido-mastoid. The carotid sheath consists of a network of areolar tissue
surrounding the carotid arteries and vagus nerve.

(3) Laterally, the carotid sheath is fused with the fascia on the deep surface of the
sternocleidomastoideus; anteriorly, it is fused with the middle cervical fascia along the lateral
border of the sternothyroideus muscle. Lying between the floor and roof of this triangular

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formation of muscles are the lymph glands and the accessory nerve. Arteries and nerves traverse
and pierce this triangle.

h. Lymphatic System of the Neck. The lymph glands of the neck are closely associated with the
salivary glands and the lymph plexus. The submaxillary nodes, located in the submaxillary
triangle, drain the cheek, side of the nose, upper lip, side of the lower lip, gums, side of the
tongue, and medial palpebral commissure. Lymph from the facial and submental nodes also
drains to these glands. The superficial cervical nodes, following the external jugular vein, drain
the ear and parotid area to the superior deep cervical nodes. The cervical nodes are in close
contact with the larynx, thyroid gland, nasal cavities, ear, nasopharynx, palate, esophagus, and
skin and muscles of the neck.

6-34. PREP, POSITION, DRAPE, AND ANESTHESIA

a. The face is prepped with an antibacterial detergent, as for surgery of the nose. The inside of
the mouth is not prepped. When the approach is through the lower throat, the area from the jaw
line to the upper clavicle is prepped.

b. The supine position is usually employed during surgery of the throat. If a local anesthetic is
used for an adult tonsillectomy, the patient is placed in a sitting position.

c. The patient's head is covered with sterile towels and he is draped with a sheet as for nasal
surgery.

d. For surgical procedures other than an adult tonsillectomy, a general anesthetic may be used. A
local anesthetic is given to the adult for tonsil surgery unless that patient is allergic to the drug.
To administer the local anesthetic, special tonsil needles are used. They are longer than the
normal needles used for local infiltration and have a ridge which prevents their being inserted too
deeply.

6-35. LARYNGOSCOPY

a. General. This procedure is a mode of direct visual examination of the interior of the larynx by
means of an electric-lighted speculum known as a laryngoscope, in order to obtain a specimen of
tissue or secretions for pathological examination or to instill a drug. Both psychological and drug
preparation are needed in order to have the patient relaxed. An oral sedative is given the night
before and again about an hour before the examination.

b. Setup. Check the surgeon's card for the exact equipment required. It will also be necessary to
find out the type of anesthetic needed. Very small infants will probably not need an anesthetic;
children and adults who cannot relax are given a general anesthetic; adults who are well prepared
do very well with the application of a topical anesthetic of lidocaine (Xylocaine®), tetracaine
(Pontocaine®) or cocaine.

c. Preparation of the Patient. The patient is placed in a supine position, and an assistant holds the
patient's head in the proper position for good visualization of the vocal cords.

d. Operative Procedure.

(1) The spatula end of the laryngoscope is introduced into the right side of the patient's mouth
and directed toward the midline; then the dorsum of the tongue is elevated, exposing the
epiglottis.

(2) The patient's head is first tipped backward and then elevated and lifted upward as the
laryngoscope is advanced into the larynx.

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(3) The larynx is examined, a biopsy is taken, secretions are aspirated, and bleeding controlled.

(4) The patient's face is cleansed. The patient is reassured and taken to his room or the recovery
room.

6-36. TONSILLECTOMY AND ADENOIDECTOMY

a. General. Tonsils and adenoids that are hypertrophied or chronically infected are removed,
which is called a tonsillectomy and adenoidectomy (T&A). Acute bacterial infections can attack a
ring of lymphoid tissue encompassing the tonsil and adenoid tissue. Pain, malaise, anorexia, and
increased temperature are typical symptoms.

b. Preparation of the Operating Room.

(1) The instruments in the setup include those needed for either sharp or blunt dissection,
according to the method preferred by the surgeon.

(2) The number of tonsil sponges, with cords attached for applying pressure to the tonsil fossa, is
included.

(3) The lighting of the room is provided for in accordance with the desire of the surgeon. The
circulator is to carefully check all details of lighting.

(4) Tonsil snare wires must be prepared correctly. The loop in the snare wire must be large
enough to pass over the handle of the tenaculum, but it must not be so large that its size prevents
cutting through the pedicle of the tonsil. The scrub is to prepare the snares in accordance with
local policy.

(5) The mouth gag used must be of a correct size (not too large) to avoid inflicting injury to the
patient's gums and lips and to avoid the danger of dislodging or breaking any teeth.

(6) Special straight or curved needles with a security stop are used for the injection of the local
anesthetic agent.

(7) Sponges are normally handed on a curved hemostat.

(8) Suction cautery is used for control of bleeding.

c. Preparation of the Patient.

(1) If a general anesthetic is to be administered, the patient is anesthetized first, then placed in a
slight Trendelenburg position. The neck is hyperextended by placing a roll under the shoulders. If
a local anesthetic is to be administered, the patient is placed in a sitting position.

(2) The patient's face may be cleaned with a germicide. The patient is draped as follows:

(a) An opened sheet and two opened towels are placed under the head of the patient.

(b) The uppermost towel is wrapped around the head and secured by forceps, and the free ends of
the towel are tucked under the head.

(c) A second sheet is placed over the patient.

d. Operative Procedure.

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(1) When a general anesthetic is used, the mouth is retracted open with a self-retaining retractor,
the tongue depressed with a blade retractor, and an anesthesia tube placed in the corner of the
mouth. An efficient suction apparatus is most important. The tonsil suction tube is introduced
gently and passed along the floor of the mouth, over the base of the tongue, and into the pharynx.
During the procedure, the suctioning ensures adequate exposure of the operative site and prevents
blood reaching the lungs.

(2) The tonsil is grasped with a pair of tonsil-grasping forceps and the mucous membrane of the
anterior pillar incised with a knife; the tonsil lobe is freed from its attachments to the pillars with
a tonsil dissector, curved scissors, and gauze sponges on a holder. The tonsil is withdrawn with
forceps.

(3) The posterior pillar is cut with scissors, and the tonsil is removed with a snare. In some cases,
the LaForce or Sluder tonsil guillotine clamp may be used.

(4) A tonsil sponge is placed in the fossa by a hemostat.

(5) Bleeding vessels are clamped with tonsil forceps, tied with slipknot ligatures of absorbable
suture and the free ligature ends are cut.

(6) The adenoids are removed with an adenotome or curette. Bleeding is controlled by pressure
with sponges.

(7) The fossa is carefully inspected, and any bleeding vessels are clamped and tied. Retractors
are removed, the face of the patient is cleaned, and his head is turned to one side. The patient is
kept in the semirecumbent (Fowler) position or on his side horizontally, to avoid aspiration of
blood and venous engorgement.

e. Handling of Specimens. Tissue excised is processed for examination by the laboratory.

f. Suturing Types Usually Used.

(1) Absorbable suture of size specified by the surgeon--used for free ligatures.

(2) Absorbable suture, of size specified by the surgeon, affixed on tonsil needle--used for suture-
ligature.

6-37. SURGERY OF THE ORAL CAVITY

a. General. This procedure consists of the excision of benign or malignant lesions of the tongue,
floor of the mouth, alveolar ridge, buccal mucosa, or tonsillar area. Benign or small malignant
tumors of the oral cavity may be excised without neck dissection. In the presence of tongue
cancer without evidence of metastasis, a "prophylactic" neck dissection may be performed in an
effort to control a cancerous growth in the upper jugular chain of the neck. When treating a
typical carcinoma of the floor of the mouth with involvement of the mandible, a portion of the
tongue and the mandible are removed. When there is a lesion of the tonsil or an extensive lesion
at the base of the tongue with pharyngeal wall involvement, a resection of the ascending ramus of
the mandible is necessary, and portions of the base of the tongue, pharyngeal wall, and the soft
palate are removed to secure an adequate margin of normal tissue about the lesion.

b. Patient Preparation. The patient is placed in dorsal recumbent position with shoulders
elevated. Generally, endotracheal anesthesia is used, and a pharyngeal pack of moist gauze is
inserted in the mouth.



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c. Operative Procedure. Although the case may be scheduled as a local excision, frequently
lesions of the oral cavity require more extensive excision than planned preoperatively. The setup
should be designed to include the instruments for a neck dissection, or to have them available. In
most tumors of the oral cavity, a tracheostomy is performed to assure an airway postoperatively.

6-38. ELECTIVE TRACHEOSTOMY

a. General. This procedure involves opening the trachea and inserting a cannula through a
midline incision in the neck, below the cricoid cartilage. It is used as an emergency procedure to
treat upper respiratory tract obstruction and as a prophylactic measure in the presence of chronic
lung disease in which an obstruction could occur. A prophylactic tracheostomy is performed at
the time of surgery, thus providing for easy and frequent aspiration of the tracheobronchial tree
and diminishing the dead space that exists from the opening of the mouth down to the
supraclavicular region. The creation of a new clearance (tracheostomy) nearer to the functional
areas in the lung provides for greater volume of air for the patient with a partly destroyed lung.
Anesthesia may be maintained via a prophylactic tracheostomy.

b. Preparation of the Operating Room. The standard instruments and other items needed are kept
sterile in a pack, ready for immediate use. In addition, the circulator is to have a cardiac arrest
tray immediately available.

c. Preparation of the Patient. The patient is placed in a dorsal recumbent position, with the
shoulders raised by a folded sheet to hyperextend the neck and head. The neck is cleansed and
sterile drapes applied as for operations of the thyroid.

d. Operative Procedure.

(1) A vertical or transverse incision may be used. A vertical incision is made in the midline from
approximately the cricoid cartilage to the suprasternal notch. When a transverse incision is made,
it extends approximately one fingerbreadth above the suprasternal notch parallel to it and from
the anterior border of one sternocleidomastoid muscle to the opposite side. Soft tissues and
muscle are divided, and the isthmus of the thyroid gland that joins both lobes of the gland in the
midline over the trachea is retracted in an upward direction with Cushing retractors, thus resulting
in exposure of the underlying tracheal rings, usually the third and fourth. In some cases, two
curved clamps may be inserted through this incision across the isthmus and the isthmus
transected. The transected ends of the isthmus are secured with chromic gut sutures.

(2) With a knife and #15 blade, a vertical incision is made in the trachea directly across the two
tracheal rings. The cut ends of the cricoid cartilage are retracted with a hook.

(3) The previously prepared tracheostomy tube (see figure 6-12) is inserted into the trachea, the
obturator is quickly removed, and the trachea is suctioned with a catheter.

(4) The wound edges are lightly approximated with silk sutures or the wound edges are allowed
to fall together around the tube. One or two skin sutures are inserted above the tube. The lower
angle of the wound may be left open for drainage.




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Figure 6-12. Metal tracheostomy tube.
A-Parts of a metaltracheostomy tube.
B-Tracheostomy ties and gauze pants in place.

(5) The tracheostomy tube is held in place with tapes tied with a square knot behind the neck.
The inner tube is then inserted. A gauze dressing split around the tube is applied to the wound.
Assembler

6-39. EXCISION OF THE SUBMAXILLARY GLAND

a. General. This operation involves the removal of the gland and tumor through an incision made
in the neck, just beneath the chin. It is performed to remove mixed tumors and multiple calculi
associated with extensive chronic inflammation.

b. Preparation of the Patient. The patient is placed on the table in a dorsal recumbent position,
with the affected side uppermost, and prepared as for neck surgery.

(1) A small skin incision is made below and parallel to the mandible, extending forward to
beneath the chin. The platysma is incised with scissors; the skin flaps and undersurface of the
platysma and cervical fascia covering the gland are undermined, using fine hooks, tissue forceps,
and Metzenbaum scissors.

(2) The mandibular branch of the facial nerve is retracted away with a small loop retractor.

(3) The submaxillary gland is elevated from the mylohyoid muscle. The edge of the muscle is
retracted to expose the lingual veins and nerve and the hypoglossal nerve.

(4) The gland is freed by blunt dissection, and the submaxillary (Wharton's) duct is clamped,
ligated, and divided.

(5) The external maxillary artery is clamped, ligated, and divided. The submaxillary gland is
removed.

(6) The wound is closed with interrupted fine silk or chromic gut sutures. The skin edges are
approximated with nylon sutures. A Penrose drain is inserted in the submaxillary bed and secured
to the skin. Dressings are applied.

6-40. PAROTIDECTOMY


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a. General. This operation involves the removal of a tumor and gland through a curved incision
in the upper neck and behind the lobe of the ear, or through a Y-type incision in both sides of the
ear and below the angle of the mandible. The majority of benign tumors of the salivary glands
occur in the parotid gland. These benign tumors are of the same types as are those found in soft
tissues in other parts of the body. The closeness of the parotid gland to the facial nerve makes it
difficult to remove the entire tumor. Parotidectomy is indicated for removal of all benign and
some malignant tumors, for inflammatory lesions, for vascular anomalies, and for metastic cancer
involving lymph nodes overlying the gland. When malignant tumors are found to involve
adjacent structures, the operation may have to be extended to become a more radical procedure.

b. Preparation of the Patient. The patient is placed on the operating table in a dorsal recumbent
position with the entire affected side of the face uppermost. The entire side of the face, the mouth,
the outer canthus of the eye, and the forehead are prepared and left exposed.

c. Operative Procedure.

(1) The incision may extend from the posterior angle of the zygoma downward in front of the
tragus of the ear and behind the lobule of the ear backward over the mastoid process, then
downward and forward on the neck parallel to and below the body of the mandible. (A chin
incision may be used.) Bleeding vessels are controlled by hemostats and fine ligatures.

(2) Using fine-toothed tissue forceps and scissors, the skin flaps are elevated as described for
thyroidectomy. The skin wound edges are retracted away by means of silk sutures fastened to the
clamps.

(3) The upper portion of the sternocleidomastoid muscle is exposed and retracted, the auricular
nerve is identified, and the lower part of the parotid gland is elevated, using curved hemostats.

(4) The superficial temporal artery and vein and external jugular vein are identified by means of
blunt dissection.

(5) The parotid tissue is dissected from the cartilage of the ear and the tympanic plate of the
temporal bone. The temporal, zygomatic, mandibular, and cervical branches of the facial nerve
are identified and preserved.

(6) The superficial portion of the parotid gland containing the tumor is removed. In some cases,
the entire superficial portion is removed, followed by ligation and division of the parotid duct.

(7) When the deep portion of the parotid gland must be removed, the facial nerve is retracted
upward and outward by nerve hooks; then the parotid tissue is removed from beneath the nerve.
Kocher retractors are used to retract the mandible. The external carotid artery is identified. In
many cases, the internal maxillary and superficial temporal arteries are clamped, ligated, and
divided.

(8) The wound is closed in layers with fine silk sutures. A small Penrose drain is inserted, and a
pressure dressing is applied.

6-41. LARYNGOFISSURE

a. General. This operation involves the opening of the larynx for exploratory, excisional, or
reconstructive procedures. It is performed whenever access to the intrinsic larynx is necessary.
The thyroid cartilages are split in the midline, and the true vocal cords and false vocal cords are
incised at the midline anteriorly.



                                                                                                 138
b. Patient Preparation. The patient is placed on the table in a dorsal recumbent position. The
operative site is prepared and the patient draped with sterile sheets, as for thyroidectomy.

(1) A tracheostomy is performed, and an endotracheal tube is inserted. A general anesthetic is
administered, or the surgeon may elect to do the procedure with local anesthesia.

(2) A transverse incision is made through the skin and first layer of the cervical fascia and
platysma muscles, approximately 2 cm above the sternoclavicular junction or in the normal skin
crease by means of a knife handle #3 with a blade #10. The upper skin flap is undermined to the
level of the cricoid cartilage; then the lower flap is undermined to the sternoclavicular joint.

(3) Bleeding vessels are clamped with mosquito hemostats and ligated. The strap muscles are
elevated and incised in the midline.

(4) The thyroid cartilages are cut with a Stryker saw, and the true vocal cords are visualized
through an incision into the cricothyroid membrane. The true vocal cords are divided in the
midline (anterior commissure), and the interior of the larynx is exposed.

(5) The tracheostomy tube must be left in place postoperatively to ensure an airway.

6-42. PARTIAL LARYNGECTOMY

a. General. This operation involves the removal of a portion of the larynx. It is done to remove
superficial neoplasms that are confined to one vocal cord or to remove a tumor extending up into
the ventricle on the anterior commissure or a short distance below the cord. Cancers confined to
the intrinsic larynx are generally of a low grade of malignancy and tend to remain localized for
long periods.

b. Preparation of the Patient. The patient is placed on the table in a dorsal recumbent position.
The operative site is prepared and the patient draped with sterile sheets, as described for
thyroidectomy.

c. Operative Procedure.

(1) A tracheostomy is performed as previously described and an endotracheal tube is inserted.

(2) A vertical incision or a thyroid incision with elevation of a flap may be employed.

(3) The sternothyroid muscles are separated in the midline and retracted by means of loop
retractors.

(4) The fascial covering over the thyroid cartilage is incised with a knife, and the perichondrium
is elevated from the cartilage on the side of the tumor with a Freer periosteal elevator.

(5) The thyroid cartilage is divided longitudinally in midline by means of a Stryker power saw.

(6) The cartilages are retracted with loop retractors. The cricothyroid membrane is incised with a
knife. A blunt-nosed laryngeal scissors is introduced between the vocal cords to divide the
mucosa of the anterior wall of the glottis.

(7) The divided cartilages are retracted with Kocher retractors to expose the interior of the
larynx. A small pack of moist gauze may be placed in the trachea to prevent aspiration of blood
or mucous. A 10 percent solution of cocaine may be applied to the larynx to prevent laryngeal
muscular spasm. The extent of the intrinsic laryngeal tumor is determined.

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(8) With a small periosteal elevator, the mucosa on the involved side of the larynx is freed; the
false cord and mucosal layer of the region are lifted by means of a periosteal elevator and hooks.
The involved cord is excised, using straight scissors.

(9) In some cases, the thyroid cartilage may be removed with a knife and straight scissors.
Bleeding is controlled with hemostats and fine chromic gut ligatures and sutures.

(10) The gauze pack is removed from the trachea. The perichondrium is approximated with
chromic gut #2-0 sutures. The strap muscles are approximated in the midline with chromic gut
#2-0 sutures; then the platysma and the skin edges are approximated separately with fine silk
sutures.

(11) A tracheal-laryngeal tube is left in place. It is removed at a later date when the airway is
adequate. Dressings are applied to the wound and around the tube.

6-43. SUPRAGLOTTIC LARYNGECTOMY

This procedure is the excision of the laryngeal structures above the true vocal cords. It is
indicated in cancer of the epiglottis and false vocal cords. It is designed to remove the cancer, yet
preserve the phonatory, respiratory, and sphincteric functions of the larynx. A neck dissection is
always performed.

6-44. TOTAL LARYNGECTOMY

a. General. This procedure involves the complete removal of the cartilaginous larynx, the hyoid
bone, and the strap muscles-connected to the larynx and possible removal of the pre-epiglottic
space with the lesion. The tumor may have produced immobility of the vocal cords, or be in the
extrinsic larynx and hypopharynx where there is greater danger of metastasis. The lymphatics are
often removed.

b. Psychological Aspects. Laryng-ectomy presents many psychological problems. The loss of
voice that follows this procedure is a most tragic event for the patient and his family. The patient
may be taught to talk either by using esophageal voice or with an artificial larynx. Esophageal
voice is produced by the air contained in the esophagus rather than by that in the trachea. Speech
requires a sounding air column. With instruction and practice, the patient is able to control the
swallowing of air into the esophagus and re-introduction of this air into the mouth-with
phonation. The sounding air column is then transformed into speech by means of the lips, tongue,
and teeth.

c. Patient Preparation.

(1) The patient is placed on the table in a dorsal recumbent position with his neck extended and
shoulders raised by a rubberized block or folded sheet. The table is slanted downward to elevate
the upper part of the body for the convenience of the surgeon.

(2) An endotracheal anesthetic is administered. An effective suction apparatus is most essential.

(3) The proposed operative site--including the anterior neck region, lateral surfaces of the neck
down to the outer aspects of the shoulders, and the upper anterior chest region--is cleansed in the
usual manner.

d. Operative Procedure.

(1) A tracheostomy may be performed to control the airway.


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(2) A midline incision is made from the suprasternal notch to just above the hyoid bone. Skin
flaps are undermined on each side. The sternothyroid, sternohyoid, and omohyoid muscles (strap
muscles) on each side are divided by means of curved hemostats and a knife.

(3) The suprahyoid muscles are severed from the portion of the hyoid to be divided. The hyoid
bone is divided at the junction of its middle and lateral thirds with bone-cutting forceps. Bleeding
vessels are clamped and ligated.

(4) The superior laryngeal nerve and vessels are exposed and ligated on each side, using long
curved fine hemostats and fine chromic gut or silk ligatures.

(5) The isthmus of the thyroid gland is divided between hemostats. Each portion of the thyroid
gland-is dissected from the trachea, using fine dissection with Stevens and Metzenbaum scissors
and fine tissue forceps. The superior pole of the thyroid is retracted in a Greene retractor. The
superior thyroid vessels are freed from the larynx by a sharp dissection.

(6) The larynx is rotated. The inferior pharyngeal constrictor muscle is severed from its
attachment to the thyroid cartilage on each side.

(7) The endotracheal tube is removed. The trachea is transected just below the cricoid cartilage
over a Kelly or Crile hemostat previously inserted between the trachea and esophagus. The upper
resected portion of the trachea and the cricoid cartilage are held upward with Lahey forceps. A
balloon-cuffed tube (endotracheal) or a Foley catheter is inserted in the distal trachea.

(8) The larynx is freed from the cervical esophagus and attachments by sharp and blunt
dissection. A moist pack is placed around the endotracheal tube to help prevent leakage of blood
into the trachea.

(9) The pharynx is entered. In most cancers of the intrinsic larynx, the pharynx is entered above
the epiglottis. The mucosal membranous incision is extended along either side of the epiglottis;
the remaining portion of the pharynx and cervical esophagus is dissected well away from the
tumor by means of fine-toothed tissue forceps, Metzenbaum scissors, knife, suctioning, and fine
hemostats. The specimen is removed en massa.

(10) A nasal feeding tube is inserted through one nares into the esophagus; closure of the
hypopharyngeal and esophageal defect is begun, using continuous inverting fine sutures of
chromic gut #3-0. The nasal tube is guided down past the pharyngeal suture line.

(11) The pharyngeal suture line is reinforced with interrupted sutures; the suprahyoid muscles are
approximated to the cut edges of the inferior constrictor muscles.

(12) The diameter of the tracheal stoma is increased by means of a knife and heavy straight
scissors. The two portions of the thyroid behind the tracheal opening are approximated with
interrupted silk sutures, thereby obliterating dead space posterior to the upper portion of the
trachea.

(13) A small Penrose drain or catheter is inserted through two separate stab wounds on each side
of the neck just below the pharyngeal suture line. If a closed suction system is used, catheters
connected to a suction apparatus are used.

(14) The edges of the deep cervical fascia and the platysma are closed separately with interrupted
fine silk sutures. When a great amount of the fascia and platysma has been removed, the wound
edges are approximated with silk sutures.



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(15) A laryngectomy tube is inserted into the tracheal stoma; a pressure dressing is applied to the
wound and neck.

6-45. RADICAL NECK DISSECTION

a. General. This operation involves the removal of a tumor, surrounding structures, and lymph
nodes en massa, through a Y-shaped or trifurcate incision in the affected side of the neck. It is
done to remove the tumor and metastatic cervical nodes present in malignant lesions and all
nonvital structures of the neck. Metastasis occurs through the lymphatic channels via the
bloodstream. Disease of the oral cavity, lips, and thyroid gland may spread slowly to the neck.
Radical neck surgery is done in the presence of cervical node metastasis from a cancer of the
head and neck, which has a reasonable chance of being controlled. It may also be done in a
slightly less radical form when there is cancer of the tongue and no firm evidence of metastasis.

b. Preparation of the Patient.

(1) The patient is placed on the table in a dorsal recumbent position, with the head in moderate
extension and the entire affected side of the face and neck facing uppermost. During surgery, the
face of the patient is turned away from the surgeon.

(2) The preoperative skin preparation is extensive. The patient is draped with sterile towels and
sheets, leaving a wide operative field. Endotracheal anesthesia is used. The anesthetic is
administered before the patient is positioned for surgery. During the operation, the
anesthesiologist works behind the sterile barrier, away from the surgical team.

c. Operative Procedure.

(1) One of several types of incisions may be used, including the Y-shaped, H-shaped, or
trifurcate incision.

(2) The upper curved incision is made through the skin and platysma, using a knife, tissue
forceps, and fine hemostats and ligatures for bleeding vessels. The upper flap is retracted; then
the vertical portion of the incision is made and the skin flaps retracted anteriorly and posteriorly
with retractors. The anterior margin of the trapezius muscle is exposed by means of curved
scissors. The flaps are retracted to expose the entire lateral aspect of the neck. Branches of the
jugular veins are clamped, ligated, and divided.

(3) The sternal and clavicular attachments of the sternocleidomastoid muscle are clamped with
curved Rochester-Mayo clamps and then divided with a knife. The superficial layer of deep fascia
is then incised. The omohyoid muscle is severed between clamps just above its scapular
attachment.

(4) The internal jugular vein is isolated by blunt dissection and then doubly clamped, ligated with
medium silk, and divided with Metzenbaum scissors. A transfixion suture is placed on the lower
end of the vein.

(5) The common carotid artery and vagus nerve are identified. The fatty areolar tissue and fascia
are dissected away, using Metzenbaum scissors and fine tissue forceps. Branches of the
thyrocervical artery are clamped, divided, and ligated.

(6) The tissue and fascia of the posterior triangle are dissected, beginning at the anterior margin
of the trapezius muscle, continuing near the brachial plexus and the levator scapulae and the
scalene muscles. During the dissection, branches of the cervical and suprascapular arteries are
clamped, ligated, and divided.


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(7) The anterior portion of the block dissection is completed. The omohyoid muscle is severed at
its attachment to the hyoid bone. Bleeding is controlled. All hemostats are removed, and the
operative site is covered with warm, moist laparotomy packs.

(8) The sternocleidomastoid muscle is severed and retracted. The submental space is dissected
free of fatty areolar tissue and lymph nodes from above downward.

(9) The deep fascia on the lower free edge of the mandible is incised; the facial vessels are
divided and ligated.

(10) The submaxillary triangle is entered. The submaxillary duct is divided and ligated. The
glands with surrounding fatty areolar tissue and lymph nodes are dissected toward the digastric
muscle. The facial branch of the external carotid artery is divided. Portions of the digastric and
stylohyoid muscles are severed from their attachments to the hyoid bone and on the mastoid. The
upper end of the internal jugular vein is elevated and divided. The surgical specimen is removed.

(11) The entire field is examined for bleeding and then irrigated with warm saline solution.
Penrose drains are placed in the wound and brought out through a stab wound, and #12 Fr
catheters may be used.

(12) The flaps are then approximated with interrupted fine silk sutures. A bulky pressure dressing
is applied to the neck. Gauze dressings are applied to the wound edges and covered with sterile
fluffed gauze to provide even pressure. A wide gauze roller bandage is wrapped snugly around
the neck and in some cases encircles the head. The dressing may then be covered with elastic
bandage that is wrapped around the neck and anchored to the chest wall.




                                      Section 7
                  Procedures in Gynecological and Obstetrical Surgery
                 7 Procedures in Gynecological and Obstetrical Surgery
Lesson 7-1 Anatomy of the Female Reproductive System

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to obstetrical and
        gynecological surgery.
       Identify the anatomy of the female reproductive system.
       Identify patient preparation for obstetrical and gynecological surgery.
       Identify procedures used for vaginal, abdominal gynecological, and obstetrical
        surgery.


7-1. INTRODUCTION

a. A general understanding of the anatomy and physiology of the female pelvis, reproductive
organs, and associated structures (such as the bony pelvis) is necessary for the operating room
staff. Application of anatomy is extremely important in positioning the patient for surgery, in
selecting the proper instruments and sutures for a specific type of operation, and in understanding
the plan of surgery.

b. The female reproductive organs and their relationships are shown in figure 7-1. The adult
female structures directly and indirectly associated with the process of reproduction include the

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bony pelvis, the associated ligaments and muscles, the soft tissues and contents of the pelvic
cavity, and the external organs (vulva).

Figure 7-1. Female reproductive organs.

7-2. THE BONY PELVIS

a. The Latin word pelvis means basin. The pelvis is that part of the trunk which is surrounded by
the bony pelvis. The bony pelvis (see figure 7-2) is made up of the ilium, pubis, ischium, sacrum,
and coccyx. The so-called pelvic brim divides the abdominal (false) portion from the true portion
of the pelvis. The abdominal (false) pelvis is the part above the arcuate line. The true pelvis is the
part below this line. It forms the passageway through which the infant passes during parturition.

Figure 7-2. The pelvic girdle.

b. The true pelvis may be considered as having three parts: the inlet, cavity, and outlet. The
muscles lining the pelvis facilitate movement of the thighs, give form to the pelvic cavity, and
provide firm elastic lining to the bony pelvic framework. All organs located in the pelvis are
covered by pelvic fascia. The fascia covering some muscles is dense and firm, whereas that
covering other organs is thin and elastic. The nerves, blood vessels, and ureters passing through
the anatomical structures are closely associated with the muscular and fascial structures.

c. The pelvic fascia may be divided into three general groups: parietal, diaphragmatic, and
visceral. The parietal pelvic fascia covers the muscles of the true pelvic wall and the perineum.
The diaphragmatic fascia covers both sides of the pelvic diaphragm, which is made up of the
levator ani and coccygeal muscles. The visceral fascia is thin flexible fascia that covers the pelvic
organs. The floor of the pelvis, known as the pelvic diaphragm, gives support to the abdominal
pelvic viscera in this region. The pelvic diaphragm, consisting of the levator ani and coccygeal
muscles with their respective fascial coverings, separates the pelvic cavity from the perineum.
The basis of modern vaginal surgery is concerned with the function of the levator ani muscles and
the provision of an effective lower outlet.

d. The levator ani muscles, varying in thickness and strength, may be divided into three parts:
the iliococcygeal, the pubo-coccygeal, and the puborectal muscles. The fibers of the levator ani
blend with muscle fibers of the rectum and vagina. The fibers (pubovaginal) of the
pubococcygeal part of the levator ani muscles, lying directly below the urinary bladder, are
involved in the control of micturition. The pubococcygeal fibers of the levator ani control and
pull the coccyx forward and assist in the closure of the pelvic outlet. The fibers pull the rectum,
vagina, and bladder neck upward toward the symphysis in an effort to close the pelvic outlet and
are responsible for the flexure at the anorectal junction. Relaxation of the fibers during defection
permits a straightening at this junction. During parturition, the action of the levator ani directs the
fetal head into the lower part of the passageway.

e. The uterus gains much of its support by its direct attachment to the vagina and by indirect
attachments to nearby structures such as the rectum and pelvic diaphragm. The ligaments and
muscles on each side of the uterus are the broad, round, cardinal (Mackenrodt), and uterosacral
ligaments and the levator ani muscles.

7-3. THE UTERUS

The uterus, which occupies a central place in the pelvis, is a pear-shaped organ directed
downward and backward. At the upper lateral points, the uterus receives the uterine tubes
(Fallopian tubes). The fundus of the uterus is the upper rounded portion situated above the level
of the tubal openings. The main portion of the uterus is called the body. Below, the body of the
uterus joins the cervix, from which it is separated by a slightly constricted canal, called the
isthmus. The cervix lies at the level of the ischial spines. The lumen of the body of the uterus
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communicates with the cervical canal at the internal orifice, called the internal os. The cervical
canal ends at the vaginal opening of the cervix called the external os. This is a small oval aperture
situated between two lips.

7-4. THE STRUCTURE OF THE UTERUS (FIGURE 7-3)

a. The Greek word for uterus is hystera. The uterus lies behind the bladder and in front of the
rectum (see figure 7-3). The uterine body has three layers: (1) the outer peritoneal, or serous
layer, which is a reflection of the pelvic peritoneum; (2) the myometrium, or muscular layer,
which houses involuntary muscles, nerves, blood vessels, and lymphaticus; and (3) the
endometrium, or mucosal layer, which lines the cavity of the uterus.

b. The cervix consists of a supravaginal and a vaginal portion. The supravaginal portion is
closely associated with the bladder and the ureters. The vaginal portion of the cervix projects
downward and backward into the top of the vaginal vault.

Figure 7-3. Pelvic region of female, median sagittal section. 7-5. UTERINE (FALLOPIAN)
TUBES

a. The Greek word "salpinx," meaning trumpet or tube, is used in referring to the uterine tube.
Bilateral tubes, each consisting of a musculomembranous channel about 4 to 5 inches long, form
the canals through which the ova from either ovary are conveyed to the uterus. Each uterine tubes
leaves the upper portion of the uterus, passes outward toward the sides of the pelvis, and ends in
fringelike projections, called fimbriae. These are situated just below the ovaries. The fimbriae
catch the ova, and the tubes convey the ova to the cavity of the uterus. This channel also transmits
spermatozoa in the opposite direction. The tubes are covered on their outer surfaces by
peritoneum. Each tube receives its blood supply from the branches of the uterine and ovarian
arteries.

b. How the ova are transported from the ruptured follicle into the uterus is unknown. One
theory is that the transfer is accomplished through vascular changes, together with contraction of
the smooth muscle fibers of the tube and that the peristaltic movements of the tube push the ova
toward the uterus.

c. The right tube and ovary are in close relationship to the cecum and appendix, and the left
tube and ovary are associated with the sigmoid flexure of the colon. Both are closely associated
with the ureters.

7-6. THE OVARIES

a. Each ovary, situated at the side of the uterus, lies within a depression (ovarian fossa) on the
lateral wall of the pelvic cavity on the posterior surface of the broad ligament. The ovary is
attached to the posterior surface of the broad ligament by the mesovarium and is kept in place by
the ovarian ligament. The ovary, a small, flattened, almond-shaped organ, is composed of an
outer layer, known as the cortex, and an inner vascular layer, known as the medulla. The cortex
contains ovarian (graafian) follicles in different stages of maturity. After ovulation, the corpus
luteum is developed within the ovary by reorganization of the graafian follicles. The medulla,
lying within the cortex, consists of connective tissue containing nerves, blood, and lymph vessels.
The ovary is covered by epithelium, not by peritoneum.

b. The ovaries are homologous with the testes of the male. They produce ova after puberty and
also function as endocrine glands, producing hormones. The estrogenic hormone is secreted by
the ovarian follicle. It controls the development of the secondary sexual characteristics and
initiates growth of the lining of the uterus during the menstrual cycle. The progesterone hormone,
which is secreted by the corpus luteum, is essential for the implantation of the fertilized ovum and
for the development of the embryo.
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7-7. THE LIGAMENTS OF THE UTERUS

a. Broad Ligaments. From each side of the uterus, the pelvic peritoneum extends laterally,
downward, and backward. A double fold of pelvic peritoneum forms the layers of the broad
ligament, enclosing the uterus. These layers separate to cover the floor and sides of the pelvis.
The uterine tube is situated within the free upper border of broad ligament. The part of the broad
ligament lying immediately below the uterine tube is termed the mesosalpinx. The ovary lies
behind the broad ligament.

b. Round Ligaments. These fibromuscular bands are attached to the uterus. Each round
ligament passes forward and laterally between the layers of the broad ligament to enter the deep
inguinal ring.

c. Transverse Cervical Ligaments. These cardinal ligaments are composed of connective tissue
masses with smooth muscle fibers that are strong support for the uterus in the pelvis.

 d. Uterosacral Ligaments. These are a posterior continuation of the peritoneal tissue, which
forms the cardinal ligaments. The ligaments pass posteriorly to the sacrum on either side of the
rectum.

7-8. THE VAGINA

This is a tubelike organ for copulation and the excretory duct for the products of menstruation. It
is directed downward and forward, situated in front of the rectum and behind the bladder. The
upper part of the vagina lies above the pelvic floor and is surrounded by visceral pelvic fascia.
The lower half is surrounded by the levator ani muscles.

7-9. THE FORNICES

a. The projection of the cervix into the vaginal vault divides the vault into four regions which
are called fornices (anterior and posterior, right and left lateral).

b. The posterior fornix is in close contact with the peritoneum of the pouch of Douglas. The
rectovaginal septum lies between the vagina and rectum. The dense connective tissue separating
the anterior wall of the vagina from the distal urethra is called the urethrovaginal septum.

7-10. FEMALE EXTERNAL GENITAL ORGANS (VULVA)

a. The external organs are referred to collectively as the vulva. The vulva is comprised of the
paired labia majora, the paired labia minora, the clitoris and the vestibule. The vulva occupies the
central portion of the perineal region. The mons veneris, urethra, and Skene's glands are in close
proximity to the vulva.

b. The mons pubis (veneris) is a rounded elevation of tissue covered by skin and, after puberty,
by hair. It is situated in front of the symphysis pubis.

c. The labia majora are two folds of skin that extend downward and backward. They unite
below and behind to form the posterior commissure and in front to form the anterior commissure.
They form the lateral boundaries of the vulva. A Bartholin gland is situated in each of the labium
majus.

d. The labia minora are the two delicate folds of skin that lie within the labia majors.
Anteriorly each labium minus splits into lateral and medial parts. The lateral part forms the
prepuce of clitoris, and the medial part forms the frenulum. The posterior folds of the labia are
united by a delicate fold extending between them. This forms the fourchette.

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e. The clitoris is the homologue of the penis in the male. It hangs free and terminates in a
rounded glans (small sensitive vascular body). Unlike the penis, the clitoris is not traversed by the
urethra.

f.    The vestibule is a smooth area surrounded by the labia minora, with the clitoris at its apex
and the fourchette at its base. It contains openings for the urethra and the vagina.

g. The urethra, which is about 4 cm long, is in close relationship with the anterior vaginal wall
and connects the bladder with the outside, acting as an excretory duct. At each side of the external
urethral orifice (meatus) lie two small ducts, termed the paraurethral ducts, which drain small
urethral glands (Skene's).

h. The vaginal opening lies behind the urethral orifice, and in the virgin it is almost closed by
the hymen, a fold of vaginal mucosa.

i.    The vestibular glands (Bartholin) lie one at each side of the lower end of the vagina. They
are homologous of the bulbourethral glands of the male. The narrow gland duct opens into the
vaginal orifice on the inner aspects of the labium minus.

7-11. VASCULAR, NERVE, AND LYMPHATIC SUPPLY

a. The blood supply of the female pelvis is derived from the internal iliac branches of the
common iliac arteries and is supplemented by the ovarian and median sacral arteries, which are
branches of the aorta.

b. The nerve supply of the female pelvis comes from the autonomic nerves, which enter the
pelvis in the superior hypogastric plexus (presacral nerve).

c. The lymphatics of the female pelvis either follow the course of the vessels to the iliac and
preaortic nodes or empty into the inguinal glands.


        7 PROCEDURES IN GYNECOLOGICAL AND OBSTETRICAL SURGERY
                        LESSON 7-2 VAGINA SURGERY

After completing this lesson, you should be able to:

       Identify terms and their definitions that are related to obstetrical and
        gynecological surgery.
       Identify the anatomy of the female reproductive system.
       Identify patient preparation for obstetrical and gynecological surgery.
       Identify procedures used for vaginal, abdominal gynecological, and obstetrical
        surgery.


7-12. PATIENT PREPARATION

a. Surgery on the structures of the reproductive system in the female may be done either for
diagnostic purposes or as a form of therapy in the treatment of a pelvic condition such as uterine
bleeding or suspected cancer. Surgery is also done to remove tumors or repair structures.

b. For vaginal and perineal surgery, the lithotomy position is generally used. For abdominal
surgery, the patient is placed in a modified or extreme Trendelenburg position. Care should be
taken to prevent the patient from nerve injury and provide for circulatory and respiratory
functioning.

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c. Skin preparation and draping procedures are routine. A sterile lithotomy pack is needed for
vaginal surgery, a laparotomy pack for abdominal surgery.

d. Because pelvic and vaginal procedures involve manipulation of the ureters, bladder, and
urethra, indwelling urinary drainage systems are frequently established during surgery. Either the
urethral Foley catheter or the suprapubic Silastic cannula directly into the bladder may be used,
depending on the surgeon's preference and the type of surgery.



7-13. SIMPLE VULVECTOMY

a. General. This operation involves the removal of the labia majora, the labia minora, and
possibly the clitoris and perianal area, with a Z-plasty closure. Simple vulvectomy may be done
to treat leukoplakia vulvae because of its known association with carcinoma of the vulva, an
intractable pruritus in older women, or other types of skin lesions such as kraurosis and vitiligo. It
may also be used for carcinoma in situ of the vulva, Bowen's disease of the vulva, and Padget's
disease of the vulva.

b. Patient Preparation. The patient is anesthetized and placed in the lithotomy position. The
operative site is cleansed, using the standard sterile vaginal set, and the patient is draped for
lithotomy.

c.   Operative Procedure.

(1)       The affected skin is incised, usually starting anteriorly above the clitoris. The incision is
continued laterally to the labia majora, to the midline of the perineum, and around the anus if it is
involved. A knife, holding forceps, gauze sponges on holders, tissue forceps, and Allis forceps
are needed. Bleeding vessels are clamped. Bleeding is controlled by the electrosurgical unit or
plain or chromic gut ligatures.

(2)      Periurethral and perivaginal incisions are made. Bleeding of this vascular area is
controlled by means of Kelly or Crile hemostats, ligatures, and sponges on holders. Allis-Adair
forceps are used for holding diseased tissues.

(3)      All skin and subcutaneous tissues are undermined and mobilized, using curved
dissecting tissue forceps, scissors, Allis forceps, and sponges on holders.

(4)     The wound is closed, usually by simple bilateral Z-plasty closure with chromic gut
number7-0 or number3-0. In some cases, an excision of the skin is made around the anus to
accomplish a slide skin flap.

(5)     Drains or continuous suction sometimes are placed in the dependent areas, an indwelling
system or urinary drainage is established, and gauze packing is placed in the vagina. Petrolatum
gauze and dressings are applied and held in place with plastic tape and a binder.

7-14. RADICAL VULVECTOMY AND GROIN LYMPHADENECTOMY

a. General. This operation involves abdominal and perineal dissection, which may be
performed as a one-stage or two-stage operation. A mass dissection is done on the following
structures: a large segment of skin from the abdomen and groins, the labia majora, labia minora,
clitoris, mons pubis, and terminal portions of the urethra, vagina, and other vulvular organs, as
well as the superficial and/or deep inguinal nodes, portions of the round ligaments, portions of the
saphenous veins, and the lesion itself. It also involves reconstruction of the vaginal walls and
pelvic floor and closure of the abdominal wounds. At a later date, placement of full-thickness

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pinch grafts may be done if the denuded area of the vulva appears too large for normal
granulation.

b. Preparation of the Patient. The patient lies supine and may be placed in the Trendelenburg
and lithotomy positions, as required for the various stages. The skin preparation includes both the
abdomen and vulva, and the skin of the thighs is usually prepared down to the knees. As in other
radical surgery, the nursing team should be prepared to measure blood loss and anticipate
procedures to combat shock.

c.    Operative Procedure (see figure 7-4). (1) Lymphadenectomy portion of the surgery.

(a)      The first skin incision is made on the side opposite the primary lesion. The end of the
incised skin is grasped with Allis forceps. The incision is carried down to the aponeuroses of the
external oblique muscle.

(b)      The fascia over the inguinal ligament and the fascia lata of the upper thigh are exposed,
separated, and freed, using retractors, knife, scissors, hemostats, and sponges.

(c)      Bleeding vessels are clamped and ligated, including the superficial iliac artery and vein,
the epigastric artery and vein, and the superficial external pudendal artery and vein using Crile
hemostats and ligatures or chromic gut or silk number0 or number 7-0.

(d)    The fibers of the inguinal, hypogastric, and femoral nerves are resected, using
Metzenbaum or Harrington scissors, tissue forceps without teeth, and long-bladed retractors.

(e)      The lymphatic node beds may be identified with silk or metal clips. Fine,        long,
sharp dissection scissors are needed.

(f)        The large tissue surfaces are exposed for complete dissection by means of retractors
and protected by warm, wet laparotomy packs. High saphenous vein ligation is performed, using
scissors, forceps, hemostats, and chromic gut or silk suture ligatures.

Figure 7-4. Radical vulvectomy and groin lymphadenectomy.

A-Outline of incisional lines for simple or radical operations for vulval cover.

B-Dissection completed, involving nerves, saphenous veins, and muscles when dissection of
distal half of femoral canal has been completed.

C-Upper edges of abdominal incisions may be partially closed. D-With indwelling catheter in
bladder, wound is dressed with layers of petrolatum gauze and held in place with light pressure
dressing.

(g)      The femoral canal is cleaned of its lymphatics, and the round ligament is clamped, cut,
and ligated.

(h)      The peritoneum is freed from the muscles, fascia is dissected free, deep lymphatic nodes
and areolar tissue are removed, and vessels and their attachments are clamped, cut, and ligated,
using long curved scissors, long tissue forceps, hemostats, and ligatures.

(i)       The lesion is removed. In deep pelvic lymphadenectomy, the ureter may be exposed.

(j)        The inguinal canal is reconstructed, and the wound is partially closed, using chromic
gut and silk sutures. An indwelling system of urinary drainage is established, and the wound is
dressed.
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(2) Vulvectomy portion of the surgery.

(a)      The skin incisions of the abdomen and thigh join with those for vulvectomy. The
incisions in the vulva encircle the urethra.

(b)        In the vulval dissection, terminal portions of the urethra and vagina, the mons pubis,
clitoris, frenulum, prepuce of the clitoris, and Bartholin's and Skene's glands, plus fascial
coverings of the vulva are removed with the specimen.

(c)     Reconstruction of the vaginal walls and the pelvic floor is completed. An indwelling
system or urinary drainage is established, suction drains are placed into the denuded area, the
wound is dressed with layers of petrolatum gauze, and a light pressure dressing is applied.

7-15. VAGINAL PLASTIC OPERATION (ANTERIOR AND POSTERIOR REPAIR)

a. General.

(1)       This operation involves reconstruction of the vaginal walls, the pelvic floor, and the
muscles and fascia of the rectum, urethra, bladder, and perineum. It involves a vaginal repair to
correct a cystocele and/or rectocele, restore the bladder to its normal position, and strengthen the
vagina and the pelvic floor.

(2)       A cystocele is formed when the portion of the anterior vaginal wall that is between the
cervix and the urethra and the base of the bladder herniate inferiorly. The hernia of the bladder
protrudes through the torn musculofascial components of the vaginal anterior wall, with
protrusion into the vaginal outlet. A defect in the anterior vaginal wall is usually caused by
childbirth or an inherent weakness. A large herniation may cause a sensation of pressure in the
vagina or present as a mass at or through the i ntroitus.

(3)       A rectocele is formed by a herniation of the anterior rectal wall (posterior vaginal wall)
into the vaginal outlet. In general, the anterior rectal wall forms a bulging mass beneath the
posterior vaginal mucosa. It is created as the mass pushes downward into the lower vaginal canal.
The rectum, may be torn from its dense connective tissue, the fascial and muscular attachments of
the urogenital diaphragm, and the pelvic wall. The levator ani muscles become stretched or torn.
The symptomatic signs are a mass protruding from the vagina, difficulty in evacuating the lower
bowel, and a feeling of pressure.

(4)       An enterocele is a protrusion of the cul-de-sac of Douglas and some of the pelvic small
intestine within the peritoneal sac. It pierces through a weakened area between the attenuated
anterior rectal and posterior vaginal walls.

(5)      An enterocele may also be seen in multiparous women as part of a massive lesion, in
which a large sac contains the bladder, lower portions of the ureters, and the prolapsed uterus. In
some cases, a Kelly or Marshall-Marchetti operation may be necessary to treat urinary
incontinence and uterine prolapse.

(6)       During parturition, the outer fibrous layers of the vagina may be torn, thereby permitting
the adjoining viscera to herniate into the vaginal outlet. Because of unrepaired perineal
lacerations, gradual pulling apart of the underlying fascia and muscles of the pelvic floor and
outlet takes place. The woman has symptoms of relaxation and displacement of the pelvic organs.
Accidents, gradual deterioration of tissues, or congenital weakness, may also result in mechanical
disturbances of the pelvic structures.




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b. General Operative Procedure. Dilatation and curettage may be done. The labia are held open
with retractors and the cervix is grasped with a tenaculum. Adair forceps are used to retract the
cervix; self-retaining or Sims retractors are used to expose the operative site.

c.   Anterior Wall Repair.

(1)       Areolar tissue between the bladder and vagina at the bladder reflection is exposed with
the knife handle. The full thickness of the vaginal wall is separated up to the bladder neck, using a
knife, curved scissors, tissue forceps, Adair or Allis forceps, and sponges on holders. Bleeding
vessels are clamped and tied with ligatures (see figure 7-5 A).

(2)      The urethra and bladder neck are freely mobilized, using a knife, gauze sponges, and
curved scissors (see figure 7-5 B), to develop the strong free edge of, the vesicovaginal fascia on
each side.

(3)      The free edges of the fascia are sutured, using chromic gut sutures number7-0. Sutures
are placed in a manner that after they have been tied, there results

a double inverting of the tissue, a narrowing of the bladder neck, and a delineating of the
posterior ureterovesical angle (see figure 7-5 C).

(4)     The connective tissue on the lateral aspects of the cervix is sutured into the cervix with
chromic gut number 7-0 sutures swaged on curved needles. This is done to shorten the cardinal
ligaments.

(5)       Allis forceps are applied to the edges of the incision, and the left flap of the vaginal wall
is drawn across the midline. Edges are trimmed according to the size of the cystocele (see figure
7-5 D). This process is repeated on the right flap of the vaginal incision. Adair forceps, tissue
forceps, and curved scissors are needed.

(6)     The anterior vaginal wall is closed with interrupted chromic gut number 7-0 sutures in a
manner resulting in reconstruction of an anterior vaginal fornix.

d. Posterior Wall Repair.

(1)     Allis forceps are placed posteriorly at the mucocutaneous junction on each side, at the
hymenal ring, and just above the anus.

(2)       Skin and mucosa are incised and dissected from the musculature beneath, using a knife,
tissue forceps, curved scissors, and sponges.

(3)      Allis-Adair forceps are placed on the posterior vaginal wall, scar tissue is removed, and
dissection is continued to the posterior vaginal fornix and laterally, depending on the size of the
rectocele.

(4)       The perineum is denuded by sharp dissection; the trimming of the posterior vaginal wall
is carried out, using Allis forceps, curved scissors, and sponges on holders.

(5)     The free edges of the levator ani muscle on each side are brought together in front of the
rectum by insertion of interrupted chromic gut number 0 sutures.

(6)       Bleeding is controlled, and the vaginal wall is closed from above downward to the
anterior edge of the puborectal muscle, using continuous chromic gut number7-0 suture. The
rectocele is repaired from the posterior fornix to the perineal body. Remains of the transverse


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perineal and bulbocavernosus muscles are used to build up the perineum. The anterior edge of the
levator ani sling may be approximated.

(7)       The mucosa and skin are trimmed, and the remaining closure is effected by interrupted
sutures. The skin is closed with subcuticular sutures, chromic gut number 7-0.

(8)      The vagina is packed with 7-inch vaginal packing. An indwelling urinary drainage
system is established. A perineal pad may be applied to the wound and held in place by means of
a perineal binder.

Figure 7-5. Correction of cystourethrocele.

A-Cervix pulled down as far as possible with tenaculum. Vertical incision made entirely through
to vaginal wall.

B-Vaginal flaps further dissected upward. Urethral meatus and pubocervical fascia separated
from vaginal wall with Mayo scissors.

C-Fascia brought together with continuous surgical chromic suture, beginning at lowest point and
ending near external urethral meatus. A few interrupted sutures (chromic gut or silk) placed
secondarily.

D-Excess portion of vaginal wall carefully removed, leaving sufficient amount to be closed with
tension.

E-Completed operation, maintaining bladder and urethra in normal position.

7-16. VESICOVAGINAL FISTULA REPAIR

a. General.

(1)       Through the vaginal outlet, the mucosal tissue of the anterior vaginal wall is dissected
free, the opening from the bladder into the vagina is closed, the fascial attachments between the
bladder and vagina are repaired, and temporary drainage is established.

(2)       The fistulas vary in size from a small opening that permits only slight leakage of urine
into the vagina to a large opening that permits all urine to pass into the vagina.

(3)       Vesicovaginal fistulas may result from radical surgery in the management of pelvic
cancer, from radium therapy without surgery, from chronic ulceration of the vaginal structures,
from penetrating wounds, or from childbirth.

(4)      A urethrovaginal fistula usually causes constant incontinence or difficulty in retaining
urine. This condition occurs after damage to the anterior wall and bladder or following radiation,
surgery, or parturation. A ureterovaginal fistula develops as a result of injury to the ureter. In
some cases, reimplantation of the ureter in the bladder or ureterostomy may be done.

b. Operative Procedure--Vaginal Approach.

(1)      Traction sutures are placed about the fistulous tract; tissues are grasped with Adair
forceps and plain tissue forceps.

(2)       The scar tissue about the fistula is excised, cleavage between bladder and vagina is
located, and clean flaps are mobilized, using scissors, forceps, and sponges.

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(3)      The bladder mucosa is inverted toward the interior of the bladder with interrupted
sutures of chromic gut number 4-0 swaged to fine curved needles held with a Mayo needle holder
and tissue forceps. The suture is passed through the muscularis of the bladder down to the
mucosa.

(4)      A second layer of inverting sutures is placed in the bladder and tied, thereby completely
inverting the bladder mucosa toward the interior.

(5)      The vesicovaginal fascia is repaired with interrupted number 7-0 chromic gut sutures.

(6)       The vaginal wall is closed with interrupted chromic gut sutures in the direction opposite
to the closure of the bladder wall.

(7)        The bladder is distended with distilled sterile water to determine any leaks. A catheter is
left in the bladder; dressing are applied and held in place with a nonirritating plastic tape and a
binder.

c.    Operative Procedure--Trans-peritoneal Approach.

(1)      With the patient in a slight Trendelenburg position, a median abdominal incision is
made, as for laparotomy.

(2)      The fistulous tract is identified; the vaginal vault and the adjacent adherent bladder are
separated with scissors, forceps, and sponges.

(3)      The vesicovaginal septum is dissected down to the healthy tissue beyond the site of the
fistula.

(4)       The fistulous tract is mobilized. The bladder site of the fistula is inverted into the interior
of the bladder with two rows of inverting sutures of chromic gut number4-0. The muscularis and
mucosa layers of the vagina are inverted into the vaginal vault by means of two rows of sutures.

(5)       The flaps of peritoneum are mobilized both from the bladder and from the adjacent
vaginal vault, and are closed to form a new vesicovaginal reflection of peritoneum below the site
of the old fistulous tract.

(6)      The wound is closed in layers, as for laparotomy. Dressings are applied and held in
place with adhesive or plastic tape, and an indwelling catheter is left in the bladder.

7-17. RECTOVAGINAL FISTULA REPAIR--VAGINAL APPROACH

a.    General.

(1)      This procedure involves vaginal repair of the perineum, fascia, and muscle-supporting
structures between the rectum and vagina, thereby closing the fistula formed between the rectum
and the vagina.

(2)       A rectovaginal fistula occurs between the rectum and the vagina. In the presence of a
large rectovaginal fistula, a colostomy may be done.

b.    Operative Procedure.

(1)       The scar tissue and tract between the rectum and vagina are excised; edges of fresh
tissue are approximated with sutures of chromic gut number4-0.

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(2)      The rectum and vaginal walls are mobilized; the rectum is closed in layers with
inversion of the mucosa into the rectal canal.

(3)       The levator ani is approximated between the rectum and vaginal.

(4)       The vagina is closed transversely or in a sagittal plane different from that of the rectal
canal; the vaginal mucosal layer is inverted into the vaginal wall; an indwelling urinary drainage
system is established; and dressings are applied to the wound.

7-18. OPERATIONS FOR URINARY STRESS INCONTINENCE

a.    General.

(1)     This operation involves the repair of the fascial supports and pubococcygeal muscle
surrounding the urethra and the bladder neck. It is done through either a vaginal or an abdominal
approach.

(2)      Normal micturition (urination) depends on a finely coordinated group of voluntary and
involuntary movements. As a result of volitional impulses, voiding may be inhibited or stopped
by contraction of the perineal and periurethral musculofascial structures.

(3)       The type of operation selected depends on the severity of stress incontinence, the extent
of the lesion causing it, the patient's ability to use the anatomical mechanism for voluntary
inhibition of urination, and the operations that have already been performed for correcting it.
Stages of stress incontinence are classified in relation to frequency and degree of incontinence,
the presence of other diseases, and the function of the pubococcygeus muscle (levator ani).

(4)       The aim of any operation for urinary stress incontinence is to improve the performance
of a dislodged or exhausted bladder neck. The surgeon endeavors to restore or reconstruct the
supporting structures, the operation thereby resulting in the effective closure of the bladder neck.

(5)      Previous pelvic operations may have resulted in scarring and distortion, with
displacement of the bladder neck to an unfavorable position for proper functioning. Conditions
such as uterine prolapse, cystocele, urethrocele, cystourethrocele, or urogenital fistulas following
therapy may be associated with stress incontinence.

b.    Operative Procedure--Vaginal Approach.

(1)       A Foley catheter is passed into the bladder. The posterior vaginal wall is retracted, and
an incision is made through the anterior vaginal wall down to the urethra and bladder.

(2)      The vaginal wall is dissected from the bladder and urethra; the neck of the bladder is
sutured together with fine chromic gut. The wound is closed, as described for vaginal repair.

c. Operative Procedure--Vesi-courethral Suspension (Marshall--Marchetti Procedure).

(1)      Through a suprapubic abdominal incision, the space of Retzius is entered, and the
bladder and urethra are freed from the surrounding structures.

(2)      Mattress chromic gut sutures number1 or Mersilene number 0 are inserted through the
supporting fascia of the vaginal wall on either side of the urethra and bladder neck; they are then
passed through the muscle associated with the symphysis pubis, thereby providing support to the
urethra and bladder neck.



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(3)       Additional sutures are introduced in the lower and lateral portions of the bladder wall
and are attached to the posterior portion of the rectus muscles, thereby pulling the bladder
anteriorly to obliterate the space of Retzius.

(4)      The wound is closed and may be drained with a Penrose drain.

7-19. EXCISION OF FIBROMA OF THE VAGINA

a. General. This procedure involves the removal of the lesion through a transverse or longitudinal
incision of the wall of the vagina. Small cysts or small benign tumors that distort the vagina or
those that are ulcerated and infected are the kind of lesions removed in this surgery.

b. Operative Procedure.

(1)       The vaginal vault is retracted, using lateral and Sims retractors. Traction sutures of
chromic gut number 0 or silk number 7-0 are placed on each side of the tumor. The posterior lip
of the cervix is grasped with a Jacobs vulsellum forceps and drawn anteriorly to expose the
operative site.

(2)      The vaginal wall is incised, and the edges are grasped with traction sutures on curved,
taper point needles or with Allis forceps.

(3)      The cyst and its capsule are excised, using a knife and curved scissors; bleeding vessels
are clamped and ligated, using Halsted forceps and fine sutures.

(4)      The vaginal incision is closed with interrupted sutures of chromic gut number 7-0, and
dressings are applied.

7-20. CONSTRUCTION OF VAGINA

a. General. This operation involves taking a skin graft and then using it for vaginal reconstruction
to repair or overcome congenital or surgical defect.

(1)      Skin is taken from the abdomen or anterior thighs. The donor sites are dressed in the
routine manner with pressure dressings over nonadhesive gauze.

(2)      A vaginal orifice is created by sharp dissection, and a molding is made of dental
compound or plastic shaped to size. Donor skin, is sutured over the mold, and the mold is secured
in the vaginal opening with sutures and pressure dressings.

7-21. TRACHELORRHAPHY

a. General. This operation involves removal of torn surfaces of the anterior and posterior
cervical lips and reconstruction of the cervical canal. It is done to treat deep lacerations of a
cervix (1) that is relatively free of infection and (2) in women past the childbearing age.

b.    Operative Procedure.

(1)      The labia are retracted with Allis-Adair forceps or sutures. The cervix is grasped with a
Jacobs vulsellum forceps.

(2)      The affected tissue of the exocervix is denuded with a knife. The flaps are undermined
by means of a knife and curved scissors. Bleeding vessels are clamped and ligated. The mucosa is
dissected from the cervix.

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(3)       A small distal portion of the cervical canal is coned to remove infected tissue by means
of a knife. Bleeding vessels are clamped and ligated with chromic gut number7-0 ligatures.

(4)        The denuded and coned areas are covered by suturing and mucosal flaps of the
exocervix transversely, using six to eight interrupted chromic gut number0 sutures swaged to 1/7-
circle, trocar-point needles. Tissue forceps, hemostats, and sponges on holders are needed. The
sutures are placed in such a manner that the fibromuscular tissue of the cervix is included, thereby
eliminating dead space where a hematoma may form and providing a complete reconstructed
cervical canal.

(5)      The wound is cleansed and dressings are applied and held in place with a binder. A
retention catheter may be introduced in the bladder.

7-22. REMOVAL OF PEDUNCULATED CERVICAL MYOMA

a. General. This operation involves the removal of a tumor by the snare method or by dissection
from the cervical canal with a knife (or with cold-knife conization). Cervical polyps stem from
the endocervical canal. They may vary in size and are soft, red, and friable. Bleeding may result
from the slightest trauma. Usually, the surgeon performs an endometrial and endocervical
curettage and a cytological smear is taken.

(1)     The anterior lip of the cervix is grasped with a Jacobs vulsellum forceps. The canal is
sounded and dilated to either visualize or palpate the base of the pedicle.

(2)        If the pedicle of the tumor is thin, a tonsil snare may be placed over the body of the
tumor, permitting the snare to crush the base of the tumor and to control bleeding. If the tumor is
large, its base is dissected out with a knife. Bleeding is controlled by the use of warm, moistened
gauze sponges on holders.

(3)     Retractors are withdrawn; vaginal packing may be introduced into the cervical canal.
The tenaculum is removed from the cervix, and a dressing applied and held in place with a
binder.

7-23. AMPUTATION OF THE CERVIX

a. General. This operation involves the removal of a portion of the portio vaginalis of the
cervix. This cervical amputation, without repair of the pelvic floor, is usually done in the presence
of an intraepithelial cancer, with preservation of the remainder of the female genital organs. In
specific cases, such as mycotic or venereal infections of the cervix, this may be done by excision
of the cervix.

b.    Operative Procedure.

(1)      A dilatation and curettage may be performed before excision of the cervix.

(2)    The labia are retracted; the cervix is grasped with a Jacobs tenaculum and drawn sharply
downward.

(3)      A circular incision is made through the full thickness of the vaginal wall by means of a
knife. The distal end of each cardinal ligament is clamped, cut, and ligated, using Heaney clamps,
long curved Ochsner forceps, scissors, and chromic gut number 0 ligatures.

(4)       A portion of the portio vaginalis of the cervix is amputated by an oblique circular
incision; the canal is coned, using a knife. Bleeding vessels are clamped and ligated with chromic
gut number 0 ligatures.
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(5)       Anterior and posterior Sturmdorf sutures of chromic gut number 0 and number 7-0 on
1/7-circle, trocar-point needles are placed. Bleeding vessels are clamped and ligated.

(6)       The vaginal wall flaps are approximated, covering the denuded cervix by means of six to
eight interrupted chromic gut number 7-0 and 0 sutures swaged to 1/7-circle, taper point needles.
The patency of the cervical canal is tested, using a sound; urinary drainage may or may not be
established; vaginal dressings are applied and held in place with nonirritating plastic tape and a
binder.

7-24. DILATATION OF THE CERVIX AND CURETTAGE

a.       General. The dilatation of the cervix and curettage (D AND C) operation involves the
introduction of instruments through the vagina into the cervical canal and then into the uterus and,
in some cases, removal of substances and blood. It is done either for diagnostic purposes or as a
form of therapy for a variety of pelvic conditions such as incomplete abortion, abnormal uterine
bleeding, or primary dysmenorrhea. A D and C may be performed when carcinoma of the
endometrium is suspected, in the study of infertility, or prior to amputation of the cervix or an
operation for prolapse of the uterus.

b.      Operative Procedure.

(1)       A Kelly or Auvard retractor is placed posteriorly in the vagina. A Sims or Kelly retractor
is placed anteriorly to expose the cervix. The anterior lip of the cervix is grasped with a
tenaculum.

(2)     The direction of the cervical canal and the depth of the uterine cavity are determined by
means of a blunt probe or graduated pliable uterine sound.

(3)     The cervix is gradually dilated by means of graduated Hegar or Hand dilators and a
Goodell uterine dilator.

(4)      Exploration for pedunculated polyps or myomas may be done, using a polyp forceps.

(5)       The interior of the cervical canal and the cavity of the uterus are curetted to obtain either
a fractional or a routine specimen. For specific identification of the site of specimens, the
endocervix is scraped with the curette first, and the specimen is separated from the curettings of
the uterine endometrium. In a routine curettage, all curettings are sent together for identification
of tissue cells.

(6)     Fragments of endometrium or other dislodged tissues are removed with warm, wet
gauze sponges on holders.

(7)      Multiple punch biopsies of the cervical circumference (at 12, 3, 6, and 9 o'clock) may be
taken with the Gaylor biopsy forceps to supplement the diagnostic workup.

(8)      Retractors are withdrawn; packing of iodoform or plain gauze secured to dressing
forceps may be inserted into the cavity. The tenaculum is removed from the cervix. A perineal
pad is applied.

7-25. UTERINE ASPIRATION (SUCTION CURETTAGE)

a. General. This operation involves the vacuum aspiration of the contents of the uterus. This
has proven to be a safe and effective method for early termination of pregnancy and for use in
missed and incomplete abortions. Advantages include less dilatation of the cervix, less damage to
the uterus, less blood loss, less chance of uterine perforation, and reduced danger of infection.
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b. Patient Preparation. The patient is placed in the lithotomy position under general anesthetic.
An external and internal vaginal prep is done.

c.    Operative Procedure.

(1) The cervix is exposed using an Auvard weighted speculum and an anterior retractor; then the
cervix is grasped with a sharp tenaculum and drawn toward the introitus (see figure 7-6).

Figure 7-6. Uterine aspiration. A-Insertion of the cannula. B-Gentle suction

motion to aspirate contents. C-Uterus evacuated.

(2)     The cervix is dilated in the routine manner, allowing 1 mm of cannula diameter for each
week of pregnancy.

(3)     The appropriate sized cannula is then inserted into the uterus until the sac is
encountered. The vacuum is turned on with immediate disruption and aspiration of the contents.
Continued gentle motion of the cannula will remove the entire uterine contents.

(4)      Depending on the diagnosis, conventional curettage may then be employed.

(5)      Retractors and tenaculum are withdrawn; a perineal pad is applied.

(6)     The specimen is contained in the vacuum bottle, from which it is removed for laboratory
examination.

7-26. SHIRODKAR OPERATION (POSTCONCEPTIONAL)

a. General. This operation involves the placement of a collar-type ligature or other material at the
level of the internal os to close it. It is made necessary by incompetence of the cervix, a condition
characterized by habitual midtrimester spontaneous abortions. The operation is designed to
prevent the cervical dilatation that results in release of uterine contents.

 Figure 7-7. Principles of Shirodkar operation for treatment of incompetent internal cervical os
during pregnancy.

b. Operative Procedure (see figure 7-7).

(1)       Anterior and posterior vaginal retractors are placed, and the cervix is pulled down with
smooth ovum or sponge forceps. With thumb forceps and dissecting scissors, the mucosa over the
anterior cervix is opened to permit the bladder to be pushed back.

(2)       The cervix is lifted, and the posterior vaginal mucosa is similarly incised at the level of
the peritoneal reflection. With ligature carriers, the lateral mucosa is tunneled on either side.

(3)       The prepared ligature is placed at the desired level and anchored posteriorly with silk
suture, then drawn tight in front to close the cervix. The suture is tied.

(4)     The collar ligature is anchored with silk sutures anteriorly. The anterior and posterior
mucosal incisions are closed with chromic sutures number 0 or number 7-0 to complete the
procedure.

7-27. CONIZATION AND BIOPSY OF THE CERVIX

a.    General.
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(1)       This procedure is the removal of diseased cervical tissue to treat strictures of the cervix
and chronic cervicitis. The conization may be performed either by scalpel resection and suturing
or by the application of cutting electrosurgical current with an active electrode inserted into the
cervical canal.

(2)       Endometrial biopsy is done to determine the menstrual phase and carry out histological
study of the endometrium. Scalpel conizations are done for diagnostic purposes, such as when the
patient has a positive Papanicolaou (Pap) smear. Conization of the cervix may be done in some
cases in which hysterectomy is indicated and in which benign disease of the cervix is present. It
may also be done in those cases in which total hysterectomy is not feasible.

b.   Operative Procedure.

(1)       The posterior vaginal wall is retracted by a speculum and the anterior vaginal wall by
lateral retractors. The outer portions of the cervix are grasped with a tenaculum, and the cervix is
drawn toward the introitus; then the anterior speculum is removed. Cystic cervix may be treated
with a needle electrode. Endometrial biopsy may be done. Bleeding points may be coagulated.

(2)      For cauterization, the electrode is passed into the cervical canal, and the diseased
membrane is removed. In patients with a positive Pap smear, the cervical cone is excised with a
scalpel and bleeding controlled by coagulation and pressure.

(3) The cervical canal is cleansed with an antiseptic solution. If a wide conization is performed,
the cervix may be sutured.

7-28. RADIUM INSERTION FOR CERVICAL MALIGNANCY

a. General. This procedure involves the insertion of radium into the cervix for the treatment of
cancer. The procedure may be accomplished with X-ray film control to ensure accurate placement
of the radium. Precautions to protect personnel from undue exposure are taken, and the procedure
is monitored by the radiology department.

b. Operative Procedure--Intravaginal or Intrauterine Application. The bladder is identified and
decompressed by inserting a Foley catheter. The Foley bag is inflated with a radiopaque medium
such as conray for visualization. The patient is placed on an X-ray table or operating table with a
cassette, and radium is inserted.

c. Operative Procedure--Interstitial Application. Radium and cobalt needles are available in
various lengths with a small diameter for insertion into the tissue surrounding the cervix. They are
inserted vaginally with a needle applicator and are used as a supplement to intravaginal or
intrauterine sources. To facilitate removal, the needles have wires or threads attached to their
distal end.

7-29. CULDOSCOPY

a. General. The diagnostic procedure provides visualization of pelvic structures through a
tubular instrument similar to a cystoscope, which is introduced through a small incision in the
posterior vaginal cul-de-sac. Direct observation of the passage of dye from the uterus through the
fimbriated ends of the tube is possible with the culdoscope to help determine tubal patency, the
presence of ectopic pregnancy, unexplained abdominal or pelvic pain, the nature of pelvic
masses, and to evaluate normal functioning of the genital tract. This examination may enable the
surgeon to avoid unnecessary pelvic surgery. Laparoscopy is the preferred procedure today.

b. Patient Preparation. The patient is prepared as for a vaginal operation (refer to paragraphs 7-
12 and 7-13). A local or regional anesthetic may be used. When a general anesthetic is used, the

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patient is intubated. The patient is usually placed in a knee-chest position, kneeling on the
footboard with a kneestrap around the thighs, the chest supported on pillows, and the arms
comfortably flexed above the head.

c. Operating Room Preparation. Instruments may be placed on a table so that the surgeon may
serve himself. However, there is still need for a circulator. The lens of the scope may fog if the
instrument is introduced cold, so the tip is dipped in warm water and wiped dry before being
used.

d.    Operative Procedure (see figure. 7-8).

(1)       The trocar of the culdoscope is inserted into the fornix behind the cervix; the trocar is
then introduced into the pelvis between the two uterosacral ligaments.

(2)       The trocar is withdrawn from the sheath; the sterile culdoscope is inserted through the
sheath. The culdoscope does not touch the vaginal mucous membrane thus reducing the
possibility of infection to a minimum.

(3)       The uterus, tubes, broad ligaments, uterosacral ligaments, rectal wall, sigmoid, and small
intestine may be visualized through manipulation of the scope (see figure 7-8).

Figure 7-8. Culdoscope. Sagittal section showing culdoscopy viewing pelvic viscera.

(4)       In the study of sterility, a self-retaining screw-lipped cervical cannula is introduced in
the cervical canal, and it is connected by a plastic tube to a syringe containing a dye. If the uterine
tube is patent, the dye solution is seen dripping from the fimbriated end.

(5)       The culdoscope is withdrawn, the sheath is left in place, and the patient is placed on her
side. Pressure is exerted on the abdomen to force the air out of the peritoneal cavity, thereby
eliminating postoperative discomfort and potential air embolus. The vaginal wound is not sutured.
The patient is returned to bed.

7-30. EXCISION OF BARTHOLIN DUCT CYST OR ABSCESS

a. General. This procedure consists of removing or incising and draining the cyst through the
vaginal outlet. A cyst in the vulvo- vaginal gland usually follows acute infection and is treated by
marsupialization when it is quiescent. Such cysts are nonneoplastic and result from retention of
glandular secretions due to blockage somewhere in the duct system.

b.    Operative Procedure.

(1)       The labia minora are sutured to the perineal skin on each side to expose the vaginal
introitus. Silk or plain gut sutures swaged to 3/8-circle, cutting edge needles on a needle holder,
tissue forceps, and suture scissors are needed.

(2)      An elliptical incision is made in the mucosa, which is distended over the cyst.

(3)      The cyst wall is dissected and blunt-pointed scissors are used for complete removal of
the gland. A drain may be inserted, and a dressing or perineal pad is applied.

7-31. COLPOTOMY

a. General. Needle culdocentesis is the insertion of an aspirating needle through the posterior
fornix of the vagina. Posterior colpotomy is an incision through the vagina and peritoneum and
the removal of pus and blood. The needle procedure is done to diagnose ectopic pregnancy or to
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detect intraperitoneal bleeding or cul-de-sac hematoma. Posterior colpotomy is done to evacuate
pus and establish drainage from a cul-de-sac abscess or tubo-ovarian abscess, or in a search for
blood when a tubal pregnancy is suspected.

b.   Operative Procedure.

(1)      For needle culdocentesis, a 15-gauge needle attached to a syringe is inserted through the
posterior fornix of the vagina. Suspected intraperitoneal bleeding is confirmed if dark or red
blood flows freely into the syringe. Failure to obtain blood does not rule out the possibility of
pregnancy completely.

(2)      For posterior colpotomy, a transverse incision using angular blade scissors is made
through the vagina and peritoneum behind the cervix at the superior point of the posterior fornix.
The cul-de- sac is punctured with a long Rochester-Pean hemostat. The jaws of the hemostat are
spread apart to enlarge the opening and permit the flow of liquid from the cul-de-sac. The cavity
is explored; drains may be inserted.

(3) In either procedure, bleeding of the vaginal wall is controlled by sutures of chromic gut
number 7-0; dressings are applied to the wound surface and held in place with a binder.

7-32. FOTHERGILL-HUNTER OPERATION FOR PROLAPSE OF THE UTERUS

a. General. This procedure, following D and C, involves a complete repair of the vaginal
walls. This is done from above downward, correcting faulty supportive structures of the pelvic
floor. It is usually done on women of childbearing age who desire preservation of the
childbearing function.

b.   Operative Procedure.

(1)     Dilatation of the cervix and curettage of the uterus is done, as previously described in
paragraph 7-24.

(2)      An inverted V incision is made through the full thickness of the vaginal wall. It extends
from the bladder reflection to the urethral meatus.

(3)     The cervix is circumscribed and bleeding vessels ligated. A knife, Allis-Adair forceps,
hemostats, tissue forceps, moist sponges on holders, and chromic gut number 7-0 ligatures are
used.

(4)      The mucosal flaps are dissected free laterally and posteriorly to expose the cardinal and
uterosacral ligaments, which are clamped, ligated, and cut close to the cervical sutures. The
cardinal and uterosacral ligaments containing vesical arteries are secured with chromic gut
number 0 or 7-0 sutures swaged to 117- circle, taper-point needles.

(5)      The cervix is amputated at a site to permit shortening of the ligament. The remaining
portion of the cervix is grasped with a Jacobs vulsellum forceps. The rectovaginal septum is
exposed by blunt and sharp dissection.

(6)       The upper portion of a rectocele is repaired, as described for posterior vaginal plastic
repair. A wedge-shaped incision is made with a knife in the portion of vaginal wall to be
removed. Repair is performed, using an inverting suture to bring the flaps of the vagina over the
sutured fibromuscular tissue of the cervix. Interrupted sutures, chromic gut number 0 swaged to
1/7- circle, trocar-point or taper-point needles are placed to approximate the posterior wall.



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(7)      Cardinal ligaments are sutured in the midline with interrupted sutures of chromic gut
number 0 to shorten the parietal connective tissue, thereby permitting them to provide more
support for the pelvic floor.

(8)      An anterior and posterior Sturmdorf-type suture is placed in the upper and lower vaginal
wall. Flaps are grasped with Allis forceps, the excised vaginal wall is resected on each side using
Metzenbaum scissors, and the anterior vaginal wall is closed and reconstructed.

(9)       A plastic reconstruction of the genital aperture is done, using interrupted chromic gut
number-O and 7-0 sutures. The musculature of the perineum is reconstructed by placement of
sutures in such a way that the bulbocavernosus and the remaining transverse perineal muscles
decrease the genital aperture and add support of the pelvic viscera.

(10) A urinary drainage system is established, packing is placed in the vagina, and vaginal
dressings are applied.

7-33. COLPOCLEISIS (LE FORT OPERATION) FOR PROLAPSE OF THE UTERUS

Colpocleisis is the closure of the vagina by approximation of the anterior and posterior vaginal
walls, with or without an attendant vaginal hysterectomy. The patient must be apprised of the fact
that she will no longer possess a functioning vagina.

7-34. VAGINAL HYSTERECTOMY

a. General. In this procedure, the uterus is removed through an incision in the vaginal wall.
This may be done unless there is pelvic malignancy or a large uterine tumor, both of which call
for abdominal surgery.

b.    Operative Procedure.

(1)       The labia are retracted back with sutures of silk or chromic gut number 7-0 swaged to
3/8 circle, cutting-edge needles held by Crile short needle holders. Tissue forceps and suture
scissors are needed. An Auvard or Sims vaginal retractor is inserted to retract the vaginal wall.

(2)      A D and C is performed.

(3)      A Jacobs vulsellum forceps or chromic gut number0 suture ligature is placed on both the
posterior cervical lips to permit traction of the cervix.

(4)      The vaginal wall is incised. The incision is made anteriorly on the cervix through the full
thickness of the wall. The bladder is pushed off the cervix by the knife handle; the bladder is
freed from the anterior surface of the cervix and positioned with Kelly retractors.

(5)       The vesicouterine peritoneum is carefully opened and the incision is extended laterally
as far as the broad ligament. The body of the uterus and the adnexa are palpated and the fundus is
delivered through the opening.

(6)      The vaginal incision is carried around the cervix; the posterior wall flaps are grasped
with Allis forceps. The cul-de-sac peritoneum is opened with a knife. A suction set and small
laparotomy packs may be used. The peritoneal edges are sutured to the posterior wall with silk or
chromic traction sutures swaged to 1/7- circle, taper-point needles secured on Crile-Wood needle
holders.

(7)     The uterosacral ligaments containing blood vessels are doubly clamped, ligated, and cut.
The ends of the ligatures are left long and tagged with a clamp.
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(8)      The uterus is drawn downward and the bladder held away with retractors and moist
small laparotomy packs.

(9)      If the bladder is entered, the opening is closed with two layers of interrupted chromic gut
number 4-0 sutures swaged to 1/7- circle, taper-point needles secured to long needle holders. The
vesicouterine reflection is sutured to the anterior vaginal wall by means of traction sutures and
free ends held in a clamp.

(10) The cardinal ligament on each side is doubly clamped, cut, and doubly ligated. The uterine
arteries are doubly clamped, cut, and ligated.

(11)    The fundus is delivered through the anterior route with the aid of a uterine tenaculum.

(12) When the ovaries are to be left, a Kocher clamp is placed from below and two from above
to grasp the pedicles, which are then cut and doubly ligated on both sides; the uterus is removed.

(13) The peritoneum between the rectum and vagina is approximated with a continuous suture
of chromic gut number 7-0. The retroperitoneal obliteration of the cul-de-sac is done by sutures
that pass from the vaginal wall through the infundibulopelvic ligament and round ligament,
through the cardinal ligament, and out through the vaginal wall. The suture is tied on the vaginal
aspect of the new vault. The uterosacral ligament on each side is sutured in the midline. The
round, cardinal, and ureterosacral ligaments may be individually approximated for additional
support.

(14) An existing rectocele and the perineum are repaired, as described for vaginal plastic
repair. In the presence of prolapse, reconstruction of the pelvic floor is done.

(15) An indwelling system of urinary drainage is established; the vagina may be packed; and a
perineal pad is applied.


7-35. LAPAROSCOPY (PERITONEOSCOPY, CELIOSCOPY)

a. General. This procedure involves the endoscopic visualization of the peritoneal cavity
through the anterior abdominal wall after the establishment of a pneumoperitoneum. It provides
the gynecologist the same anatomical view of the pelvic organs as is seen at the diagnostic
laparotomy. The pathological condition can be seen, the ancillary procedures such as aspiration of
cysts, tubal plastics, and tissue biopsies can be performed. Hemostasis can readily be obtained by
using the active electrode probe. This procedure may enable the surgeon to avoid unnecessary
pelvic surgery.

b. Preparation of Patient. The patient is placed in the supine position, given general anesthetic,
and skin prepped as for a laparotomy. A Foley catheter is inserted, and the table is placed in
extreme Trendelenburg position with shoulder braces correctly placed.

c.     Operative Procedure.

(1)       A 1-cm incision is placed below or to the left of the umbilicus.

(2)      The skin is elevated with hooks. The trocar and valve sleeve are inserted first
subcutaneously, then thrust boldly through the remaining layers of the abdominal wall into the
peritoneal cavity. The angle taken by the trocar is approximately 45º toward the concavity of the
pelvis.



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(3)      The trocar is removed, the valve sleeve closed, the rubber tubing from the gas source
attached, and a pneumoperitoneum produced. Care must be taken to prevent overdistention of the
abdomen.

(4)       After the patient is placed in the Trendelenburg position, the laparoscope is introduced
and inspection begun. Should the biopsy or cautery forceps be needed, they are introduced by
trocar through a separate small incision in the abdomen.

(5)     The scopes are withdrawn; gas is allowed to escape from the sleeve before it is
withdrawn. Subcuticular closure of the skin is followed by the application of a small dressing.

7-36. TOTAL ABDOMINAL HYSTERECTOMY

a. General. This operation involves the opening of the abdomen and the peritoneal cavity, with
removal of the entire uterus, including the corpus and the cervix. It is done in the presence of
fibroids (myomas) of the uterus resulting in uncontrollable bleeding, degeneration, or in some
cases, endometriosis or adenomyosis that is far advanced. Total hysterectomy is also indicated in
older women with endometriosis when the bowel and bladder are involved and there is
impairment of the normal function of the urinary and gastrointestinal tracts.

b. Preparation of the Patient. An internal and external vaginal prep precedes the skin prep. A
Foley catheter is inserted to provide constant bladder drainage during the operation. The supine
and high Trendelenburg positions are used.

c.   Operative Procedure.

(1)      As the skin is incised, the head and upper section of the operating table are lowered
slowly, approximately 10º at a time. When the peritoneal cavity is opened, as described
previously for laparotomy, the patient is in the desired position for pelvic surgery.

(2)      In cases of obese patients or for exploration of the upper abdominal cavity, a left rectus
or midline incision is made. For simple hysterectomy, a Pfannestiel incision may be used. The
abdominal layers and the peritoneum are opened as for laparotomy.

(3)       The round ligament is grasped with Allis-Adair forceps, clamped with curved
Rochester-Pean hemostats, and ligated with medium silk or chromic gut sutures swaged to 1/7-
circle, taper-point needles secured on long needle holders. Pedicles are cut with Metzenbaum
scissors; sutures are tagged with a hemostat to be used as traction later. The procedure is done on
both sides.

(4)      The uterus is pulled upward, exposing the anterior surface of the uterus, and the
peritoneum at the cervicovesical fold is incised.

(5)      By use of the surgeon's fingers, the layer of the broad ligament close to the uterus is
separated on each side; bleeding vessels are clamped and ligated. The fallopian tube and the
utero-ovarian ligaments are doubly clamped together with Ochsner or Carmalt clamps or Heaney
hemostats, cut with a knife, and tied doubly with suture ligatures.

(6)      The uterus is pulled forward to expose the posterior sheath of the broad ligament that is
incised with knife and Metzenbaum scissors. Ureters are identified. The uterine vessels and
uterosacral ligaments are doubly clamped with Ochsner, Heaney, or Carmalt hemostats, divided
with a knife at the level of the internal os, and doubly ligated with suture ligatures.

(7)       The severed uterine vessels are bluntly dissected away from the cervix on each side with
the aid of sponges on holders, scissors, and tissue forceps.

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(8)      The bladder is separated from the cervix and upper vagina with a knife or scissors and
blunt dissection assisted by sponges on holders.

(9)     The bladder is retracted with a laparotomy pack and a retractor with an angular blade.
The vaginal vault is incised with a knife close to the cervix.

(10) The anterior lip of the cervix is grasped with an Allis or tenaculum forceps. With
Metzenbaum scissors, the cervix is dissected and amputated from the vagina. As the vagina is
opened, the anterior and posterior walls are approximated with Allis or Teale forceps. The uterus
is removed. Potentially contaminated instruments used on the cervix and vagina are placed in a
discard basin and removed from the field (including sponge forceps and suction). Bleeding is
controlled with hemostats and sutures.

(11) The vaginal vault is reconstructed with chromic interrupted sutures. Angle sutures anchor
all three connective tissue ligaments to the vaginal vault.

(12) Vaginal mucosa is approximated with a continuous chromic gut suture swaged to a 3/8-
circle needle on a long needle holder. The muscular coat of the vagina is closed with figure-of-
eight sutures to make the vault of the vagina firm and provide resistance against prolapse.

(13) The peritoneum is closed over the bladder, vaginal vault, and rectum. The laparotomy
packs are removed, and the omentum is drawn over the bowel.

(14)     The abdominal wound is closed in the regular way.

7-37. SUBTOTAL (SUPRACERVICAL) HYSTERECTOMY

Through an abdominal incision, the peritoneal cavity is opened and the body of the uterus is
removed, leaving the cervix in place. This subtotal hysterectomy is seldom done in modern
gynecology, except in emergencies to terminate a procedure because of shock or cardiac arrest or
in abdominal carcinomatosis in conjunction with the removal of the primary tumor in the ovary.

7-38. ABDOMINAL MYOMECTOMY

a. General. This operation involves the removal of fibromyomas from the uterine wall through
an abdominal incision. It is usually done in young women with symptoms that indicate the
presence of tumors and who have had no children. The tumors may be removed because of
infertility or habitual abortion or because of distortion of the bladder and other organs.
Myomectomy may be performed in conjunction with other abdominal pelvic surgery as a
prophylactic measure.

b.     Operative Procedure.

(1) The patient is prepared as for abdominal hysterectomy. A midline or Pfannenstiel incision is
used and the uterus exposed.

(2)      To contract the musculature of the uterine wall, a suitable drug may be injected into the
fundus. If the tumor is riding over the bladder or to free the ligament from the tumor, the round
ligament may be doubly clamped, cut, and ligated, as in hysterectomy. The broad ligament may
be opened to determine the course of the ureter or to free the bladder by means of curved
hemostats and Metzenbaum scissors.

(3)      An incision is made in the uterine wall down to the fibroid tumor which is grasped with
a tenaculum.


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(4)      Each tumor is shelled out of its bed, using blunt and sharp instruments. Bleeding vessels
are controlled by deep interrupted sutures number 7-0 chromic gut.

(5)       The uterus is reconstructed with interrupted chromic gut number 7-0 sutures swaged to
3/8- circle trocar-point needles held on long needle holders.

(6)      The round ligament is reapproximated by several interrupted sutures, and the anterior
sheath of the broad ligament is closed. The perimetrium is closed over the operative site. The
abdominal wound is closed.

7-39. UTERINE SUSPENSION

a. General. The operation involves the shortening of ligaments by suturing to muscle structures
through an abdominal incision. Uterine suspension is rarely done today, except as part of the
conservative surgical treatment of some types of pelvic inflammatory disease or endometriosis
when the uterus is bound down on the cul-de-sac.

b.    Operative Procedure.

(1)      The abdomen is opened, as for myomectomy as stated in paragraph 7-38.

(2)      As part of salpingectomy, a modified Coffey suspension may be done to hold the uterus
forward and suspend the ovaries so that they cannot prolapse into the cul-de-sac. The round
ligaments are sewn toward the bladder. The wound is closed in layers as for laparotomy.

7-40. OOPHORECTOMY AND OOPHOROCYSTECTOMY

a. General. Oophorectomy is the removal of an ovary. Oophorocystectomy is the removal of an
ovarian cyst. A wide variety of tumors, both benign and malignant, are found in ovaries.
Functional cysts comprise the majority of the ovarian enlargements, follicle cysts being the most
common. The choice of operation depends on the patient's age and symptoms, findings on
physical examination, and direct examination of the adnexa during exploration. If the ovarian
tumor is recognized as benign, only the visibly diseased portions of the adnexa are removed. In
the presence of dermoid, follicle, and corpus luteum cysts, the cyst is usually enucleated, and
most of the ovarian parenchyma is preserved. In tubal pregnancy, the pregnant tube is removed
and, in some cases, the ovary also.

b. Operative Procedure. The abdominal peritoneal cavity is opened, the cyst is removed.

(1)      For removal of a large ovarian cyst, a purse-string silk suture is placed in the cyst wall,
and a trocar is introduced in its center; the suture is tightened around the trocar as the fluid is
aspirated. The trocar is removed, and the purse-string suture is tied. All normal ovarian tissue is
preserved.

(2)      For removal of dermoid cyst, the field is protected with laparotomy packs, since the
contents of such cysts produce irritation if they are spilled into the peritoneal cavity. An incision
is made along the base of the cyst between the wall and the normal ovarian tissue. The cyst is
dissected free and removed intact. The ovary is closed with interrupted fine chromic gut sutures.

(3)      For decortication of the enlarged ovary and bridge resection, a large segment of the
ovarian cortex opposite the hilum is removed. The cysts are punctured with a needle point and
collapsed. A wedge of ovarian stroma, extending deep in the hilum, is resected with a small knife;
the cortex of the ovary is closed with interrupted chromic gut number 3-0 suture.



                                                                                                  166
(4)      To prevent prolapse of the tube into the cul-de-sac, it may be sutured to the posterior
sheath of the broad ligament.

(5)      The abdominal wound is closed as for laparotomy.

7-41. SALPINGO-OOPHORECTOMY

a. General. This operation is the removal of a tube and all or part of the associated ovary. It
may be done in some young women who are anxious to have children after all other methods of
treatment have failed to cure chronic salpingo-oophoritis, in patients with ectopic tubal gestation,
or in those with tuberculosis of the adnexa or large adnexal cysts. If both tubes and ovaries are
diseased, they are removed with total hysterectomy.

b.    Operative Procedure.

(1)      The abdominal wall and peritoneal cavity are opened, as for laparotomy.

(2)      The affected tube is grasped with Allis or Babcock forceps. The infundibulo-pelvic
ligament is clamped with Mayo hemostats, cut, and ligated with chromic gut number 0 or number
7-0, swaged to a 1/7- circle, taper-point needle, or number 7-0 silk on a French-eye needle.

(3)      The mesosalpinx is grasped with Kelly hemostats and divided with the suspensory
ligament of the ovary.

(4)      The cornual attachment of the tube is excised with a knife or curved scissors. Bleeding
vessels are controlled with suture ligatures.

(5)      The edges of the broad ligament are peritonealized from the uterine horn to the
infundibulopelvic ligament, as for hysterectomy.

(6)      The wound is closed as for laparotomy; dressings are applied and held in place with
adhesive or plastic tape.

7-42. SALPINGOSTOMY (TUBAL PLASTY)

a. General. This operation involves the removal of the obstructed portion of the tube and
suspension of the remaining portion to the side of the pelvic wall or placement of it into the
uterine cavity. These procedures are for the purpose of restoring fertility.

b. Operative Procedure. One of several techniques is carried out after salpingectomy has been
performed. The Estes technique or some modification of it is usually followed. In the Estes
technique, the convex surface of the ovary is excised and implantation of the remainder is made
in the myometrium, communicating with the cavity.

7-43. TUBAL LIGATION

a.    General.

(1)        This operation is the interruption of fallopian tube continuity, resulting in sterilization of
the patient. In general, the indications for sterilization can be divided into three groups:
psychiatric, medical, and obstetrical and gynecological. Evaluation and recommendation of
sterilization is made by the attending physician. A sterilization permit and a procedure consent
form must be signed by both the husband and wife.



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(2)        The optimum time for sterilization is approximately 24 hours after vaginal delivery, but
an objection to this is that the danger of hemorrhage still exists soon after delivery. If a cesarean
section is done, the tubes are ligated at this time; with a normal delivery, tubal ligation is done on
the first to third postpartum day.

b. Patient Preparation. The patient is placed in a supine position and a catheter placed in the
bladder. Skin prep and draping is as for laparotomy.

c.   Operative Procedure.

(1) The location of the fundus is determined, and a midline incision is made approximately 2
inches below it. The abdomen is opened in the usual manner.

(2)       Each tube is delivered and grasped with two Babcock forceps and clamped with two
Crile forceps.

(3)       The section between the Babcock forceps is resected with Metzenbaum scissors and
saved as a specimen. Each tube is doubly ligated with silk sutures number 7-0 about I inch from
the uterine cornu. The sutures on the proximal end of the tube are left long. This tubal stump is
then mobilized by dissecting it free from the mesosalpinx.

(4)      A very small cut is made in the serosa on the posterior surface of the uterus near the
cornu, and the musculature is penetrated with a Crile forceps for about 1/2 inch, spreading the
clamp sufficiently to admit the tube.

(5)      One of the ligatures attached to the tubal stump is threaded on a needle, sutured to the
bottom of the pocket and carried out to the uterine surface. The other suture attached to the tubal
stump is treated in a similar manner. Traction is placed on the sutures, thus the tubal stump is
buried in the uterine musculature.

(6)       The sutures are tied together, and silk sutures number 4-0 are used to close the edges of
the pocket more tightly about the tube. The end of the tube may also be buried within the leaves
of the broad ligament.

(7)   The abdominal incision is closed in layers and the wound dressed. 7-44. CESAREAN
SECTION

a. General.

(1)      This operation involves the delivery of an infant through an incision made in the
abdominal and uterine walls. This procedure is indicated in instances of previous section, primary
and secondary uterine dystocia, cephalopelvic disproportion, placenta previa, abruptio placentas,
toxemia, fetal distress (prolapsed cord), diabetes, Rh sensitization, tumors, previous vaginal
surgery, abnormal presentation, and many others. In some instances, the cesarean section may be
scheduled according to the estimated date of confinement, estimated fetal weight, and definite
auscultation of fetal heartbeat at or before 20 weeks from the last menstrual period. At other
times, Cesarean section may be performed on an emergency basis.

(2)       Several methods for abdominal delivery are accepted: classic cesarean section, low or
cervical cesarean section, extraperitoneal operation, and cesarean hysterectomy. The low segment
section is today considered standard; however, the classic method may be chosen in some
circumstances.

b. Patient Preparation.


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(1)       The extent of preoperative planning and preparation will depend on the urgency of the
delivery and should be paced accordingly. Whole blood should be available. When the patient
arrives in surgery, she may or may not be in labor. The circulator should auscultate the fetal heart
tone with a fetuscope. The patient is positioned supinely on the table, and restraints are applied;
the patient is never left unattended. A Foley retention catheter is inserted and connected to gravity
drainage. Choice of anesthetic agent is made by the anesthesiologist after reviewing the condition
of the mother and fetus.

(2)      Adequate personnel should be available to individually care for the mother and child,
since simultaneous urgent needs may arise.

c. Operative Procedure (Low Cervical Method).

(1)      A 17- to 15-cm long skin incision is made from below the umbilicus to above the
symphysis. As the incision is continued through the fascia and rectus muscles to expose the lower
portion of the cervix, blood vessels may be clamped with Crile forceps and ligated with plain gut
suture number 3-0.

(2)      The exposed peritoneum is incised transversely with a scalpel and Metzenbaum scissors
between the two round ligaments. By blunt dissection, the bladder is freed and retracted with the
universal DeLee retractor to expose the lower segment of the uterus.

(3)       Using a new scalpel blade and bandage scissors, the uterus may be opened either
transversely in the manner of Kerr or longitudinally in the manner of Kronig. Using the Kerr
technique, a lunar incision is made through the myometrium extending to within one inch of each
uterine artery.

(4)      The membranes are ruptured and suction immediately applied.

(5)       The fetal head is delivered by inserting a hand between the head and the symphysis,
rotating the face posteriorly, and exerting upward traction. With the Kronig technique, the face is
rotated anteriorly.

(6)       The fetal body is delivered. The cord is double cross clamped with Rochester-Pean
forceps and cut with bandage scissors. The baby is given to the assistant (pediatrician) for
resuscitation and care.

(7)      The placenta and all membranes are manually removed from the uterus.

(8)      The uterine edges are grasped with Pennington clamps and a layered closure begun. A
continuous suture of chromic gut number 0 or number 7-0 is placed through the deep
myometrium (and possibly endometrium). A second layer of similar sutures is placed in the
superior myometrium and serosa. A sponge count is taken as the uterine cavity is closed.

(9)      A tubal ligation may be done at this time.

(10) The bladder flap of peritoneum is sutured to the visceral layer with a continuous chromic
gut suture number 7-0 swaged to a taper-point needle.

(11) The fascia and skin are closed as for laparotomy. A pressure dressing is applied to the
abdomen and a pad to the perineum.

                                   SECTION 8
                     PROCEDURES IN GENITOURINARY SURGERY
                    8 PROCEDURES IN GENITOURINARY SURGERY

                                                                                                169
 LESSON 8-1 ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY ORGANS

After completing this lesson, you should be able:

       Identify terms and definitions that are related to genitourinary surgery.
       Identify the anatomy and physiology of the genitourinary organs.
       Identify general considerations in genitourinary surgery.
       Identify operations on the kidney, ureter, and adrenal glands.
       Identify operations on the bladder and prostate.
       Identify operations on the scrotum, penis, and urethra.


8-1. INTRODUCTION

The urinary organs in the male or female include two kidneys that excrete urine, two ureters that
convey urine from the kidneys to the bladder, which in turn serves as a reservoir for the reception
of urine, and a urethra through which the urine is discharged from the body. In the male, the
reproductive system consists of the testes, vas

deferens, seminal vesicles, penis, urethra, prostate, and bulbourethral glands. These organs have a
direct or indirect function in the process of procreation. The reproductive system in the female
has been discussed in lesson 2.

8-2. THE KIDNEYS

a. The kidneys are situated in the retroperitoneal space on the muscles of the posterior abdominal
wall, one on each side of the vertebral column at the level of the twelfth thoracic to third lumbar
vertebrae. Their position may vary slightly, but usually the right kidney lies lower than the left
because of the space occupied by the liver. The placement of the kidneys is shown, in figure 8-1.

Figure 8-1. Male urinary organs in relation to other structures.

b. Each kidney is surrounded by a mass of fatty and loose areolar tissue, known as perirenal fat.
Each kidney and fat capsule is surrounded by a sheath of fibrous tissue called Gerota's capsule, or
renal fascia, which is connected to the fibrous tunic of the kidney by trabeculae. The kidneys are
held in place by the renal fascia, which connects with the fascia of the quadratus lumborum
muscle of the loins, the psoas major muscles, and the diaphragm.

c. On the medial side of each kidney there is a concave notch (called the hilum) through which
the ureter, arteries, and veins enter and leave and where the renal pelvis is found.

d. The substance of the kidney (see figures 8-2 and 8-3) consists of an outer portion called the
cortex, and an inner portion, called the medulla. The cortex contains the glomeruli (see figures 8-
3 and 8-4) and the functioning tubules. The medulla contains many collecting tubules and
papillary ducts. Each of the latter empties on a papilla within a minor calyx. Several of these join
to form a major calyx. These unite to form--and therefore in turn empty into--the renal pelvis,
consisting of smooth muscles lined with epithelium. The funnel-shaped renal pelvis of each
kidney is continuous with the ureter below.

Figure 8-2. The kidney.



Figure 8-3. A "typical" nephron.


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Figure 8-4. Renal corpuscle.

e. The kidneys are very vascular because one-fourth of the entire volume of blood passes through
them at any one time. They receive their blood supply through the renal arteries that originate
from the aorta. Each renal artery divides into several branches called afferent vessels.

f. The lymphatic supply for the most part drains into the lymph nodes that are located between
the renal vessels and the aorta, and it accompanies the venous drainage.

g. The nerves of the autonomic (involuntary nervous) system carry pain sensations from the
urinary organs. The nerve supply to the kidney comes from the lumbar sympathetic trunk and
from the vagus nerves. Removal of the nervous pathways disrupts the ability to feel pain without
impairing kidney function.

8-3. THE URETERS

Each ureter is a continuation of the cuplike calyces and renal pelvis. The ureter extends from the
renal pelvis to the base of the bladder as a cylindrical tube. Each tube is about 25 to 30 cm long
(10 to 12 inches) and 4 to 5 mm (1/5 inch) in diameter. Each consists of three layers: an outer
adventitial layer, a muscular layer, and an inner epithelial lining. See figure 8-5.

Figure 8-5. Genitourinary system (male).

8-4. URINARY BLADDER

a. The urinary bladder (see figure 8-5) is a musculomembranous sac situated in the pelvic cavity
behind and below the symphysis pubis, in front of the rectum, and above the prostate gland in the
male. The bladder lies in front of the neck of the uterus and the anterior wall of the vagina in the
female. When the bladder becomes full and distended, it begins to ascend above the symphysis
pubis, pushes its peritoneal covering ahead of it, and partially becomes an abdominal structure.

b. The bladder is connected to the pelvic wall by fascial attachments that extend from the back of
the pubic bones to the front of the bladder. Other muscular fibers also pass from the base of the
bladder to the sides of the rectum.

c. The bladder consists of a thick muscular wall with outer adventitial and inner mucosal layers.
In addition, a peritoneal layer partially covers and is attached to the bladder dome. The blood
supply of the bladder is derived from branches of the anterior trunk of the hypogastric artery.

d. As a result of the peristaltic muscular contraction of the renal pelvis and ureter, the urine is
actively propelled from the kidney to the bladder and expressed from the ureteral orifice.

e. The size, position, and relation of the bladder to the intestines, rectum, and reproductive
organs vary according to the amount of fluid it contains. The process of emptying the bladder
appears to be initiated by nerve cells from the sacral divisions of the autonomic nervous system.
These sacral reflex centers are controlled by higher voluntary centers in the brain. Stimulation
from the sacral centers results in contraction of the bladder muscle and relaxation of the bladder
outlet sphincters. Muscle tone maintains closure of the sphincters when the bladder is at rest.

8-5. MALE URETHRA

The male urethra (see figure 8-5) is a tube about 20 cm (8 inches) in length that forms an S curve.
It is the terminal portion of both the urinary and reproductive tracts. The male urethra has three
divisions: the prostatic urethra, which passes through the prostate gland, the membranous urethra,
which contains the external sphincter of the bladder, and the remainder, called the bulbous

                                                                                                      171
urethra. The male urethra is composed of mucous membrane that is continuous with that of the
bladder and merges with the submucous tissue, which in turn connects the urethra with other
structures that it traverses.

8-6. FEMALE URETHRA

The female urethra (see figure 2-2 of Lesson 2) is a narrow membranous hollow tube about 4 cm
(1/2 inches) in length and 6 mm (1/4 inch) in diameter. When it is not in use, however, its walls
collapse. This structure lies behind and beneath the symphysis pubis and anterior of the vagina.
The external urethral orifice (urinary meatus) lies anterior to the vaginal opening and posterior to
the clitoris.

8-7. MALE REPRODUCTIVE ORGANS

a. The male reproductive organs (see figure 8-5) include the two testes, epididymides, seminal
ducts (vas deferens), seminal vesicles, Cowper's glands, and ejaculatory ducts, as well as the
single reproductive organs of the prostate, penis, and urethra. The scrotum is located behind the
base of the penis and in front of the anus. This loose sac contains and supports the testes, the
epididymides, and some of the spermatic cord. The two sides of the scrotum are separated from
each other by a median raphe. Within the scrotum there are two cavities or sacs that are lined with
smooth and glistening tissue, known as the tunica vaginalis. Normally, a small amount of clear
fluid is contained in the tunica vaginalis. The condition known as hydrocele denotes an abnormal
accumulation of this fluid.

b. The testes manufacture the spermatozoa and also contain a specialized cell (Leydig) that
produces the male hormone. Each testis consists of many tubules, in which the sperm are formed,
surrounded by a dense capsule of connective tissue. The tubules coalesce and continue into the
adjacent epididymis where the sperm mature and are stored.

c. The epididymis is a long narrow organ that lies along the posterior border of each testis. It
connects the testis with the seminal duct. The vas deferens (ductus deferens, or seminal duct) is a
distal continuation of the epididymis. Each is the excretory duct of the testis and conveys the
sperm from the epididymis to the seminal vesicle.

d. The vas deferens lies within the spermatic cord in the inguinal region. The spermatic cord also
contains the veins, arteries, lymphatics, nerves, and surrounding connective tissue (cremaster
muscle) that give support to the testes.

e. The seminal vesicles are structures that unite with the vas deferens on either side. The terminal
portion of each vas deferens is called the ejaculatory duct, which passes between the lobes of the
prostate gland and opens into the prostatic urethra.

f. The prostate gland is an accessory sex organ. It lies just below the bladder in front of the
rectum and surrounds the prostatic portion of the urethra. The entire prostate gland, which
consists of five lobes, is surrounded by a fibrous capsule, through which the ejaculatory ducts
enter to pass through the gland. Behind the prostatic capsule, there is a fibrous sheath that
separates the prostate gland and the seminal vesicles from the rectum. The lobes of the gland
secrete a highly alkaline fluid that dilutes the testicular secretion as it comes from the ejaculatory
ducts. The prostate gland receives its blood supply from the internal pudendal, inferior vesical,
and hemorrhoidal arteries.

g. Two small bodies called Cowper's glands are situated on either side of the membranous
portion of the urethra inferior to the prostate. Each gland via its duct empties mucous secretions
into the urethra.


                                                                                                  172
h. The penis is a pendulous organ suspended by the fascial attachments of the pubis arch and
supported by the suspensory ligaments. The penis contains three distinct vascular sponge-like
bodies: the two upper bodies are called the right and left corpus cavernosum and the lower body,
the corpus spongiosum urethras. The tissue contains a network of vascular channels that fill with
blood on erection. At the distal end of the penis, the skin is doubly folded to form the so-called
prepuce, or foreskin, which serves as a covering for the glans penis. The glans penis contains the
urethral orifice.

8-8. ADRENAL GLANDS

The adrenal glands lie retroperitoneally beneath the diaphragm at the medial aspect of the
superior pole of each kidney. On the right side, the gland is adjacent to the inferior vena cava; on
the left side, the gland is posterior to the stomach and pancreas. Each adrenal gland has a medulla,
which secretes adrenaline, and a cortex which secretes steroids and other hormones. The glands
are freely supplied with arterial branches from the phrenic and renal arteries and from the aorta.
The venous drainage is accomplished on the right by the inferior vena cava; on the left, by the left
renal vein.


              8 PROCEDURES IN GENITOURINARY SURGERY
LESSON 8-2 GENERAL CONSIDERATIONS IN GENITOURINARY SURGERY

After completing this lesson, you should be able:

       Identify terms and definitions that are related to genitourinary surgery.
       Identify the anatomy and physiology of the genitourinary organs.
       Identify general considerations in genitourinary surgery.
       Identify operations on the kidney, ureter, and adrenal glands.
       Identify operations on the bladder and prostate.
       Identify operations on the scrotum, penis, and urethra.


8-9. INTRODUCTION

a. Operating room personnel must have a good understanding of the procedure that is planned in
order to properly prepare the patient, room, equipment, and supplies. Safety is the prime
consideration since the patient is positioned in a lateral, prone, or lithotomy position. These
positions are frequently exaggerated to give better access to the organs involved, as for a radical
operation on the prostate and bladder. Care must be taken to avoid displacement of the joints in
lithotomy as the anesthetized patient is positioned. This is especially true in aged or debilitated
patients.

b. In positioning a patient laterally for kidney surgery, the spine is extended to give more access
to the retroperitoneal space. This patient should have padding and stabilizing support from
rubber-covered pillows, sandbags, and straps. If the electrocautery unit is to be used, care must
also be taken to see that no part of the patient touches metal equipment other than the indifferent
electrode plate attached to the cautery unit.

c. In some procedures involving stones of the kidneys or ureters, it may be necessary to make X-
ray examinations during the procedure. A cassette holder must be placed under the patient who is
in the supine, prone, or lithotomy position. The patient positioned laterally will be X-rayed by a
cassette held in a sterile wrap.

8-10. ASEPTIC TECHNIQUES AND SAFETY MEASURES


                                                                                                173
a. Aseptic techniques in skin preparation and draping must be carefully maintained. Difficulty
may be encountered in cleansing and preparing the perineal area. Spray apparatus may be
preferred to gauze sponges on forceps for application of antiseptic in perineal skin preparations.

b. Draping procedures for laparotomy are described and illustrated in Subcourse MD0927.

c. The disposable O'Connor perineal drape with finger cot may be used.

d. Transurethral passage of instruments and catheters requires meticulous aseptic technique to
prevent retrograde infections of the urinary system. The use of transurethral instruments is
facilitated by darkening the room. There should be provision for proper adjustments in lighting.

e. Electrosurgical units and battery cords are frequent adjuncts in urological surgery. The staff
must be familiar with their use and with the precautions necessary to prevent fire, explosion, or
burns.

8-11. DISTENTION OF THE BLADDER

When the bladder is to be opened or manipulated, it is frequently distended with irrigating fluid
prior to surgery. Provision must be made in positioning and draping of the patient and in
instrument selection for filling and draining the bladder prior to or during the course of the
operation.

8-12. DRAINAGE TUBES AND CATHETERS

a. Ureteral catheterization may also precede radical operations. Preoperative preparations of the
patient and cystoscopy instruments with catheterizing telescopes are needed.

b. Whenever the urinary tract is opened, there is the danger of leakage of urine. All such wounds
require careful drainage. Drainage tubes in the urinary tract must be kept open at all times and the
surgeon should be notified immediately if there is no drainage. The tube or catheter used to drain
the bladder suprapubically must be stiff enough to prevent collapse. An angulated tube or catheter
may be useful in preventing kinking if bulky dressings are used. The catheters or tubes should be
tested for patency, flushed and suctioned prior to use. Modern vacuum drainage collectors (of the
Hemovac type) have been successful in maintaining drainage and keeping wounds dry.

c. Ureterostomy and nephrostomy tubes must be carefully identified, fixed in position, and
guarded to prevent dislodgment or obstruction. There are various types of catheters available for
specific situations. Catheters are used for diagnostic purposes and to explore the urethra for
stenosis, discover residual urine in the bladder, and introduce contrast medium into the bladder.

d. Filiform tips and followers are used to dilate narrow strictures. Graduated woven ureteral
catheters are used to introduce radiopaque material or obtain a sterile urine specimen from the
renal pelvis and to help determine renal function.

e. The olive-tipped bougies are used to calibrate the urethra. The silk woven catheter may be
used to manipulate past enlarged prostatic lobes. In some cases, a catheter stylet is used to insert a
catheter. The catheter should be lubricated before the stylet is inserted. The catheter is drawn taut
over the stylet so that its tip cannot become dislodged. Catheters with inflatable balloons are used
for drainage and for pressure to help control bleeding.

              8 PROCEDURES IN GENITOURINARY SURGERY
LESSON 8-3 OPERATIONS ON THE KIDNEY, URETER, AND ADRENAL GLANDS

After completing this lesson, you should be able:

                                                                                                  174
       Identify terms and definitions that are related to genitourinary surgery.
       Identify the anatomy and physiology of the genitourinary organs.
       Identify general considerations in genitourinary surgery.
       Identify operations on the kidney, ureter, and adrenal glands.
       Identify operations on the bladder and prostate.
       Identify operations on the scrotum, penis, and urethra.



8-13. GENERAL CONSIDERATIONS

a. Stones, infections, and tumors are the most common causes of urinary tract obstruction
necessitating operations to prevent renal destruction or failure. Obstruction may also be due to
malformations of the urinary tract.

b. Although the causes of kidney stones are obscure, certain conditions such as obstruction,
stasis, or body chemistry predispose to their formation. Stones may form from various elements:
calcium oxalate, calcium phosphate, magnesium ammonium phosphate, uric acid, and calcium
carbonate, or combinations of these substances may be found. All stones removed at operation are
usually subjected to chemical analysis. Stones obtained as surgical specimens are best submitted
in a dry jar. Fixative agents such as FormalinR can obscure the results of the analysis.

c. Stones in the renal pelvis may drop down into the opening of the ureter (the uretero-pelvic
junction) and occlude it, or they may pass into the ureter and lodge at the ureterovesical junction
or where the ureter passes into the bony pelvis at the level of the iliac crest. A stone may lodge in
a renal calyx and continue to enlarge, eventually filling the entire calyx or renal pelvis (staghorn
stone).

d. Hydroureter, hydronephrosis, and fibrosis with destruction of the renal parenchyma can result
from unrelieved obstruction.

8-14. NEPHRECTOMY

a. General. This operation involves the removal of the kidney. It is done to treat some congenital
unilateral abnormalities causing renal obstruction or severe hydronephrosis, tumor of the kidney,
a severely injured kidney, renal tuberculosis, calculous pyelonephrosis, and sometimes cortical
abscess.

b. Patient Preparation. The position of the patient on the operating table will depend on the type
of lesion, the position of the kidney, and the surgical approach selected. The most common
position for kidney operations is the lateral when a lumbar, transpleural, or extra-pleural
transthoracic approach is to be used. A supine or a modified Trendelenburg position is employed
when an abdominal approach is to be used.

c. Approaches to the Kidney.

(1) Lumbar or simple flank incision. This incision begins at the costovertebral angle and parallels
the twelfth rib. It extends, forward and downward between the iliac crest and the thorax.

(2) Nagamatsu incision. This is a modification of the simple flank incision and is made over the
eleventh and twelfth ribs, removing a section of each.

(3) Thoracoabdominal incision. The tenth and eleventh ribs are removed, and the chest cavity is
opened, collapsing the lung. Rib spreaders and approximators and chest drainage are required.


                                                                                                 175
When the lumbar, Nagamatsu, or thoracoabdominal approach is used, the patient is placed in a
lateral position.

(4) Transperitoneal and retroperitoneal incisions. The patient is placed in a supine position. A
vertical incision is made in the epigastric and umbilical region on the affected side. This approach
is used for a large kidney tumor or when the kidney and ureter are extensively involved in the
surgery.

d. Operative Approach (Lumbar Approach).

(1) The incision is carried through the skin, fat, and fascia. Bleeding vessels are clamped with
hemostats and ligated.

(2) The external oblique, the latissimus dorsi, and the internal oblique muscles are exposed. The
required portions of the dorsi, external oblique, posterior inferior serratus, and internal oblique
muscles are split or divided and retracted with a dull rake or Richardson right-angled retractors.
Bleeding is controlled. The transversalis fascia is cut with scissors. Then the iliohypogastric and
ilioinguinal nerves are identified and retracted. The sacrospinal muscle is retracted. The deep
lumbar fascia is separated. The quadratus lumborum muscle may be divided.

(3) The pleura, peritoneum, and twelfth thoracic artery and nerve are identified and retracted.
Laparotomy pads and Deaver retractors are placed to protect the adjacent structure and afford
exposure.

(4) If necessary, a rib or ribs (twelfth, eleventh, or tenth) may be resected to give access to the
kidney. The periosteum is stripped with an Alexander costal periosteotome and Doyen rib
raspatory.

(5) A scalpel and heavy scissors may be used to cut through the lumbocostal ligaments. The rib
is grasped with an ochsner clamp and cut with rib shears, removing the portion necessary to
expose the kidney.

(6) Retractors and pads are placed. Gerota's fascia, the perirenal capsule, is grasped with long
tissue forceps and incised with a scalpel. The incision is extended, using dissecting scissors, and
the kidney and perirenal fat are exposed. The kidney is dissected free, using sharp and blunt
dissection with long tissue forceps, scissors, and sponges on forceps. Crile hemostats are used on
bleeding vessels.

(7) The ureter is identified, separated from its adjacent structures, and retracted. Holding forceps
such as long Babcock or long Allis clamps may be used, or a length of Penrose tubing may be
passed around the ureter to retain and retract it. The ureter is occluded by double clamping and
then divided and ligated (see figures 8-6 A and B).

(8) The kidney pedicle containing the major blood vessels is isolated and doubly clamped by
using long kidney clamps of a size suitable to the structures. The vessels are securely ligated with
heavy chromic gut and transfixed with heavy sutures on Atraumatic needles. The pedicle is
severed and the kidney removed (see figures 8-6 C and D).

(9) The wound is explored for bleeding, hemostasis secured, and the cavity cleansed by
irrigating, sponging, and suctioning as necessary. A drain of Penrose tubing, which may be
wicked with gauze, or a drain made of heavy rubber or plastic tubing is placed if leakage of urine
is likely to occur.

Figure 8-6. Nephrectomy.


                                                                                                  176
A and B-Upper portion of ureter is freed, cut, and ligated. C-Chromic gut ligatures are placed;
kidney clamps are applied between proximal ligature and kidney itself. D-Renal vascular pedicle
is doubly ligated with suture ligatures, and the kidney is removed.

(10) The fascia and muscles are closed in layers with interrupted chromic sutures. If necessary,
retension sutures may be used. The skin edges are approximated with interrupted sutures of silk
or wire or with skin clips.

(11) The drain is secured and the wound dressed with gauze sponges, abdominal pads, and
adhesive strips.

8-15. HEMINEPHRECTOMY

a. General. This procedure involves the partial excision of the kidney, and is otherwise similar to
nephrectomy.

b. Operative Procedure. This procedure is usually indicated when one pole of the kidney has
been destroyed by localized disease, such as an obstructive calculus. The rest of the kidney is
healthy. This condition may be the result of a kidney being formed with two collecting systems.
The capsule is pushed back, and a wedge of kidney tissue is resected, which includes the diseased
or damaged cortex, pelvis, and vessels. The healthy kidney tissue is sutured with gut, the capsule
is replaced and a pad of fat is sutured over the line of closure. A nephropexy will probably be
done also to ensure good position and drainage.

8-16. PROCEDURES FOR OPENING THE KIDNEY a. Definitions.

(1) Nephrotomy is an incision into the kidney. A simple incision and drainage may be required
for hydronephrosis, cyst, or perinephritic abscess.

(2) Pyelotomy is an incision into the renal pelvis.

(3) Pyelostomy is an incision into the renal pelvis to establish drainage or to permit irrigation of
the renal pelvis.

(4) Pyelolithotomy is the removal of a stone or stones through the opening made in the renal
pelvis.

(5) Nephrostomy is an opening into the kidney to maintain temporary or permanent drainage. A
nephrostomy is used to correct an obstruction of the urinary tract, conserve and permit
physiological restoration of renal tissue that has been impaired by disease, provide permanent
drainage when a ureter is unable to function, treat anuria as an emergency measure, or drain a
kidney during the postoperative period following a plastic repair on the kidney or renal pelvis.

(6) Nephrolithotomy and pyelonephrolithotomy are essentially the same, since one is simply an
extension of the incision. This is done in order to remove a large stone intact or to explore a calyx
where a small stone or fragment has slipped. The presence of a staghorn calculus is an indication
for this procedure.

b. Operative Procedure.

(1) For opening. The kidney is approached as described for nephrectomy, using the desired
incision. The renal pedicle is identified; the ureter is identified and retracted as necessary. The
kidney is mobilized to permit approach to the aspect desired.



                                                                                                  177
(2) For pyelotomy or pyelostomy. The pelvis of the kidney is incised with a small blade. Traction
sutures of number 8-0 black silk on French eye or swaged-on needles may be placed at the edges
of the incision to hold it open while the pelvis and calyces are explored. In pyelostomy, the
catheter is placed through the incision directly into the renal pelvis.

(3) For nephrostomy. A curved clamp or stone forceps is passed through a pyelostomy incision
into the renal pelvis and then out through the substance of the renal paren-chyma via a lower pole
minor calyx. The tip of a Malecot or Pezzer catheter is then drawn into the renal pelvis, and the
pyelotomy incision is closed. The distal end of the tube is brought out through the flank incision.
Penrose drains are placed, and the incision is closed in the regular manner.

(4) For pyelolithotomy. The renal pelvis is opened, and the ureter may be probed for stones or
strictures by passing a ureteral catheter and irrigating. Stones are removed. A multieyed catheter--
Pezzer, Malecot, or Foley type--is placed. The catheter is secured with sutures. A purse-string
suture may be placed around the nephrostomy tube. After removal of a staghorn calculus,
mattress sutures are usually tied over a pad of renal fat to support the long parenchymal incision.

(5) For closure. An incision in the renal pelvis may be closed with fine chromic-gut swaged on
needles or left unclosed. The wound is drained and closed, as for nephrectomy. Reinforced
absorbent dressings or special wound decompression apparatus is required for draining wounds.

8-17. NEPHROURETERECTOMY

a. General. This operation involves the removal of a kidney and the entire ureter that drains it. It
is indicated for the presence of hydronephrosis, a hydroureter too damaged to repair, or
carcinoma of the renal pelvis or ureter. This procedure usually requires two separate incisions,
one in the flank and one in abdomen. Two separate instrument sets are not required, but a second
skin preparation setup and set of sterile drapes are required.

b. Operative Procedure.

(1) The patient is placed in a lateral position. The kidney and upper ureter are exposed, as
described for nephrectomy, freed from their supporting structures, and brought out of the wound,
taking as much ureter as possible. The ureter is not cut at this time. The wound is drained and
closed in layers, leaving the kidney and ureter outside the wound, and lightly dressed.

(2) Care must be taken not to contaminate the kidney, exposed ureter, and incision as the patient
is repositioned in a supine manner.

(3) The abdomen is prepped, sterile drapes are applied, and an abdominal incision is made to
expose the lower ureter and bladder. These structures are freed. The ureter and a small cuff from
the bladder are removed.

(4) At this time, the kidney and entire ureter are gently pulled free through the flank incision.

(5) A Penrose-type drain or catheter is placed in the bladder, and it is closed with chromic suture
number 2-0. The abdomen is closed in layers and both wounds are dressed with gauze sponges
and abdominal pads.

8-18. RECONSTRUCTIVE OPERATIONS ON THE KIDNEY

a. General.

(1) Pyeloplasty is a revision or reconstruction of the renal pelvis. It is done to create a better
anatomical relationship between the pelvis of the kidney and the ureter and to relieve pain and

                                                                                                    178
obstruction to the flow of urine from the kidney. It may be necessary to ligate aberrant vessels,
divide fibrous bands, resect stenotic areas, or reconstruct a redundant kidney pelvis to accomplish
this and prevent or relieve hydronephrosis and hydroureter.

(2) Ureteroplasty is a reconstruction of the ureter, usually at the ureteropelvic junction.

(3) A Foley-Y pyelouretero-plasty may combine correction of a redundant kidney pelvis with
resection of a stenotic area of the ureter.

b. Operative Procedure.

(1) The kidney and upper ureter are exposed, as for nephrectomy (refer to paragraph 8-14), using
the desired approach.

(2) The kidney pelvis and ureter are incised, trimmed, and shaped to the desired contour, using
fine forceps and scissors. A caliper and a ruler may be used for establishing more precise
relationships to improve urinary drainage. Anchoring sutures or soft rubber drains may be used
for traction during handling and repair. The repair is completed using fine sutures and needles, as
specified by the surgeon. The technique used is designed to provide a direct funnel- shaped
enlarged outlet. The Foley Y-V

plasty technique may be used for this purpose. It converts a Y-shaped incision into a V-shaped
one by resecting the redundant tissue between the arm and the stem of the Y. Fine, interrupted
stitches are placed to make the repair. Stenotic areas of the ureter are excised as necessary and the
ureter anastomosed with fine, everting stitches (ureteroureterostomy).

(3) A nephrostomy tube may be placed through a stab wound in the renal parenchyma. A
splinting latex catheter 8 or 10 Fr may be placed to extend along the nephrostomy drain through
the kidney pelvis and into the ureter beyond the site of the plastic repair.

(4) The incision is closed in layers and the wound dressed.

8-19. KIDNEY TRANSPLANT

a. General.

(1) This procedure involves the removal of a donor kidney by means of a nephrectomy and
ureterectomy with transplant of the donor's kidney in the recipient's iliac fossa. This is done in an
effort to restore kidney function and thus maintain life in a patient who is succumbing to renal
failure.

(2) The patient selected for kidney transplant is usually young, well advanced in irreversible
uremia, free of other significant disease or infection, and free of obstruction in the lower urinary
tract.

(3) A kidney replacement may be chosen from a living donor or from a cadaver that is without
disease and of the same blood group as the recipient. The ideal living donor is an identical twin,
although family members or other volunteers may be selected.

(4) It is important that the time lapse between donor nephrectomy and trans-plantation of the
organ to the recipient be kept to a minimum. In living donors, hypothermia may be used to reduce
the oxygen requirements of the kidney.

b. Preparation. Two adjacent operating rooms are prepared for the surgery, and the operations on
donor and recipient proceed simultaneously. On a cadaver donor, the supine position is used, and
                                                                                                 179
a disposable drape with a large fenestration is used to provide adequate exposure for bilateral
nephrectomies. For a living donor, either the lateral or supine position may be used. The recipient
lies in the supine position.

c. Donor Operation.

(1) In living donors, angiography assists in selection of the preferred donor kidney.

(2) The donor nephrectomy is done much as the procedure already described in paragraph 8-14,
but the surgeon will do a delicate dissection to prevent trauma to the renal vessels and ureter.

(3) The patient may be given intravenous mannitol before the kidney is excised, and the surgeon
may inject 1 percent lidocaine (Xylocaine®) about the renal pedicle before its dissection to
prevent vasoconstriction. The scrubbed nursing team member should have sterile iced normal
saline available to cool the kidney immediately after it is removed.

(4) If the donor kidney is cooled by intraarterial perfusion, cold (15C) , sterile, lactated Ringer's
solution to which heparin and procaine have been added will be introduced into the vessels by
means of small polyethylene catheters under strict aseptic conditions. The sterile basins and donor
kidney should be covered with a sterile drape and taken to the recipient operation by the surgeon.

d. Recipient Operation.

(1) The incisional approach is carried out.

(2) The donor kidney is placed in the contralateral iliac fossa of the patient and rotated 180~
degrees so that the posterior surface is anterior in the patient. Placing the organ extraperitoneally
may prevent peritonitis if an infection develops.

(3) The renal artery is anastomosed to a branch of the hypogastric artery and the renal vein to the
external iliac vein.

(4) The ureter, depending on its length, may be implanted into the bladder directly by a tunneling
technique, or it may be anastomosed to the recipient ureter. A cystostomy tube may be inserted
into the bladder.

NOTE:

Bilateral nephrectomies and splenectomy may be performed on the recipient at the time of
transplant or at another time, depending on the patient's general condition and the surgeon's
program of management. This is done to prevent hypertension or urinary tract infection.

8-20. RECONSTRUCTIVE OPERATIONS ON THE URETER

a. General. Reconstructive operations may be indicated because of a pathological condition of the
urinary bladder or lower ureter that interferes with normal drainage. Conditions requiring urinary
diversion or reconstruction of the urinary tract include malignancy, cystitis, stricture, trauma, or
congenital malformations such as ureteral reflux. Pelvic malignancy or an anomaly requiring
removal of the bladder necessitates urinary diversion.

b. Definitions and Purposes.

(1) Ureterostomy (ureterotomy). The opening of the ureter for continued drainage from it into
another part.

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(2) Cutaneou-sureterostomy (anastomosis or transplant). The diversion of the flow of urine from
the kidney via the ureter away from the bladder onto the skin, usually on the abdomen.

(3) Ureterectomy. The complete removal of the ureter. This procedure includes hephrectomy, as
well as the excision of a cuff of the bladder.

(4) Uretero-lithotomy. An incision into the ureter and removal of a stone.

(5) Ureterou-reterostomy. The division of the ureter and reconstruction in continuity with another
ureteral segment (see figure 8-7).

(6) Ureteroileostomy (ileal conduit) or ureterosigmoidostomy (anastomosis). The diversion of the
ureter into a segment of the ileum or into the sigmoid colon.

(7) Ureteroneocystostomy (ureterovesical anastomosis). The division of the ureter from the
urinary bladder and reimplantation of the ureter into the bladder at another site.

c. Patient Preparation. The site of incision and position of the patient will depend on the
indications for surgery and the nature of the proposed reconstruction or anastomosis. The patient
may be placed in a supine position for an abdominal approach or in a modified Trendelenburg
position for a low abdominal or pelvic incision. The patient may also be placed in a lateral
position for high ureteral stones.

d. Operative Procedure for Ureteral Anastomosis.

(1) The ureter is exposed through the desired incision. A ureteral catheter, passed retrograde,
may be used to facilitate identification and isolation of the ureter. The ureter is identified and
dissected free, using long forceps and scissors.

(2) The ureter is picked up with fine traction sutures, freed from the surrounding tissues, and
severed at the desired level.

(3) The distal end of the ureter is ligated, and the proximal stoma is transferred to the site of
anastomosis. The anastomosis is accomplished with fine dissection instruments and fine swaged-
on sutures.



F igure 8-7. Technique of reimplantation of ureter at kidney pelvis. Correction of ureteral
obstruction by aberrant vessels that cannot be divided without producing muscular renal damage.

A-Outline of proposed pelvic (ureteral) cuff and extent of redundant pelvic wall resection.

B-Ureter, with its funneled end, is brought approximated to dependent part of resected pelvic wall
(al to aa and bl to b).

C and D-Anastomosis completed. Nephrostomy drainage and ureteral splint may be inserted.

(4) A soft splinting catheter is usually left in place until healing has taken place and free drainage
is assured.

(5) The wound is closed in layers and dressed in the routine manner.

e. Operative Procedure for Ureterolithotomy.

                                                                                                     181
(1) The patient usually has a kidney, ureter, and bladder X-ray examination immediately before
surgery to determine the exact location of the stone. The surgeon may also schedule a cystoscopic
examination preoperatively and may attempt to manipulate the stone through the ureter.

(2) The position of the stone determines the surgical approach. A stone high in the ureter will
require a flank incision, whereas one closer to the bladder will require an abdominal incision.
Both of these have been described previously. The incision into the ureter is made with a small
surgical blade above the stone. The Randall stone forceps will be used to locate and remove the
stone. The ureter may be closed with fine chromic gut sutures number 4-0, or it may be left open
and the site drained well. Either approach requires minimal routine closure.

(3) Ureterocutaneous transplant, ureterosigmoid anastomosis, and ileal segment are all urinary
diversion procedures performed when the bladder no longer serves as a proper urine reservoir.
The cause may be a congenital disorder (as in the neurogenic bladder), exstroptiy, trauma, or
tumor.

f. Operative Procedure for Ureterocutaneous Transplant (Anastomosis). The surgical approach is
the same as for a low ureterolithotomy, and the ureter is severed from the bladder. The severed
ureter is passed through a stab wound in the flank and sewn to the skin with an everting suture-of
number 4-0 chromic gut on an Atraumatic needle to form a stoma. The structures are handled
with plastic instruments, fixation forceps, and iris scissors. A small catheter is passed into the
ureter and irrigated for patency. The patient must have a urine collecting bag postoperatively.

g. Operative Procedure for Ureterosigmoid Anastomosis.

(1) The abdomen and peritoneal cavity are entered in the routine manner through a left rectus
incision. A portion of the large bowel is protected with pads. Deep retractors are placed, and with
long forceps and scissors the posterior peritoneum is incised.

(2) The ureters are severed close to the bladder. The ureter is brought through the posterior
peritoneal incision to the sigmoid. Traction sutures and smooth tissue forceps are used to retain
and handle the severed ureters.

(3) The sigmoid colon is immobilized to prevent traction and tension on the ureter by securing
the former to the pelvic peritoneum at a point where the ureter falls easily on the bowel, and a silk
number 8-0 traction stitch is taken. Using a scalpel with blade number 15, an incision is made
through the taenia of the sigmoid muscle layer separating it from the mucosal layer. A tunnel is
created by blunt dissection.

(4) The ureter is laid on top of the mucosa, and a small-slit is made in the mucosa, using a scalpel
with a number 11 blade.

(5) With fixation forceps and iris scissors, the ureter is slit to match the bowel incision. The
ureter is anchored to the bowel with number 4-0 chromic ureteral sutures on Atraumatic needles.
The other ureter is anastomosed in the same manner in a position slightly above the first.

(6) The posterior peritoneum is closed with fine silk sutures. Drainage is established. The
abdominal wound is closed in layers.

h. Operative Procedure for Ileal Conduit.

(1) A urethral catheter is inserted to decompress the bladder, and a rectal tube is placed in the
rectum. Before the incision is made, the stoma site is marked on the skin. Through a midline
abdominal incision, the peritoneum is incised and the abdomen is entered in the routine manner;
abdominal retractors are placed.

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(2) The ureters are mobilized and brought through the retroperitoneum.

(3) The distal ileum and mesentery are inspected to identify the blood supply. A Penrose drain is
passed through the mesentery midway between the two main arterial arcades adjacent to the
ileum at the proximal and distal ends of the selected segment. This segment usually comprises 6
to 10 inches of the terminal ileum, a few inches from the ileocecal valve.

(4) The vessels of the mesentery are ligated. Care is exercised to preserve the ileocecal artery and
adequate circulation to the isolated ileal segment. The peritoneum is incised over the proposed
line of division of the mesentery. Allen or other intestinal clamps are placed across the ileum, and
the bowel is divided flush with the clamps. Using gastrointestinal technique, the proximal end of
the conduit is closed with a chromic layer of sutures followed by a second layer of interrupted
silk sutures. The remaining ileum is reanastomosed end-to-end.

(5) The mesentery is closed with interrupted silk sutures.

(6) The closed proximal end of the conduit segment is fixed to the posterior peritoneum. The
ureters are implanted in the ileal segment using plastic technique, with fine instruments and
ureteral sutures of chromic number 4-0 catgut on Atraumatic needles. The peritoneum and muscle
of the abdominal wall lateral to the original incision are separated by blunt dissection. The distal
opening of the ileal conduit is drawn through and sewn to the skin with fine chromic or silk
sutures. The wound is drained, closed, and dressed. An ileostomy bag is placed over the stoma.

NOTE:

The surgeon may do a cystectomy either before or after this procedure. In some cases, he may
choose to leave the bladder rather than subject a debilitated patient to further surgery.

8-21. ADRENALECTOMY

a. General. This operation involves the partial or total excision of one or both adrenal glands.
This procedure may be done to treat hyperfunction of the adrenals, remove tumors of the glands
themselves, or treat tumors elsewhere in the body that are affected by adrenal hormonal
secretions, such as carcinoma of the prostate or breast.

b. Patient Preparation. For unilateral adrenalectomy, the patient may be placed in the lateral
kidney or supine position. More often, however, both glands are explored, and the supine position
is selected.

c. Operative Procedure--Lateral Approach.

(1) An incision curving from the midline and extending from the rib cage to the iliac crest is
made with the scalpel through the skin, fat, and muscle. The lumbodorsal fascia is cut to reveal
the sacrospinal muscle. This muscle is detached from the ribs, using forceps and dissecting
scissors.

(2) The rib is resected.

(3) An opening is made through the transverse fascia with scissors. The pleura and diaphragm
are protected with wet pads, and Gerota's capsule is incised to expose the kidney and adrenal
gland.

(4) The gland is dissected free, using scissors and Babcock forceps. The blood supply of the
gland is identified, clamped or clipped, and divided. Bleeding vessels are ligated. To release the
glands, the left adrenal vein, a branch of the left renal vein, is separated by clamping and cutting.

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The right adrenal vein, a tributary of the vena cava, is also divided. Fine vascular sutures may be
required to repair inadvertent injury to the vena cava.

(5) When hemostasis has been assured, the wound is closed in layers--muscle, fascia,
subcutaneous tissue, and skin.

d. Operative Procedure--Abdominal Approach.

(1) The abdominal wall is incised, and the peritoneal cavity is opened and explored. Bleeding
vessels are clamped and ligated.

(2) The abdominal wound is retracted, and the surrounding organs protected with laparotomy
pads, using instruments and sutures as for routine laparotomy.

(3) The retroperitoneal area near the diaphragm is opened on the left side, exposing the renal
fascia.

(4) The renal fascia is opened to reveal the left kidney and adrenal gland.

(5) The adrenal gland is freed from the kidney by sharp and blunt dissection, clamping and
ligating all bleeding vessels with silk sutures number 8-0 or vascular clips.

(6) After all bleeding is controlled, the kidney is gently replaced in the renal fascia, and closed
with interrupted chromic sutures number O.

(7) The peritoneum is closed over the left kidney and renal fascia.

(8) The abdominal retractors are rearranged to give access to the peritoneum over the right
kidney and adrenal gland. Care must be taken here to avoid trauma to the liver.

(9) The right retroperitoneal space is opened to reveal the renal fascia.

(10) The renal fascia is opened, exposing the right kidney and adrenal gland.

(11) The adrenal gland is freed in the same manner as the left one and excised.

(12) The right kidney is replaced in the renal fascia, which is sutured closed.

(13) The right retroperitoneal area is closed with chromic sutures #0.

(14) The abdomen is inspected for bleeding vessels, which are ligated.

(15) The wound is closed in the routine laparotomy fashion.


                 8 PROCEDURES IN GENITOURINARY SURGERY
            LESSON 8-4 OPERATIONS ON THE BLADDER AND PROSTATE

After completing this lesson, you should be able:

       Identify terms and definitions that are related to genitourinary surgery.
       Identify the anatomy and physiology of the genitourinary organs.
       Identify general considerations in genitourinary surgery.
       Identify operations on the kidney, ureter, and adrenal glands.
       Identify operations on the bladder and prostate.
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       Identify operations on the scrotum, penis, and urethra.

8-22. OPEN OPERATIONS ON THE BLADDER

a. General. The urinary bladder may be opened to remedy acute retention; relieve obstruction and
distention; control hemorrhage; remove stones, tumors, or foreign bodies; or repair congenital or
traumatic defects. Other radical procedures are performed to treat cancer. Total cystectomy
requires permanent urinary diversion.

b. Definitions.

(1) Cystotomy. A procedure in which the bladder is cut open.

(2) Cystolithotomy. A procedure in which the bladder is opened to remove stones.

(3) Cystostomy. A procedure in which an opening is made into the bladder for continuous
drainage.

(4) Cystectomy (total). A procedure in which the bladder and adjacent structures are excised.

c. Patient Preparation.

(1) To facilitate identification and dissection, the bladder is usually drained of urine and filled
with a sterile irrigating or antiseptic solution as a part of the preoperative preparation. Equipment
and instruments for catheterization and irrigation should be prepared, in addition to the surgical
setup. Irrigating solutions should be sterile, isotonic, and at body temperature.

(2) The patient lies in the supine position for most open operations of the bladder. The
Trendelenburg position may be desired, since it tilts the pelvis high and offers good visualization
of the pelvic organs, including the bladder. The patient may be draped with a nonabsorbent
disposable skin drape and a fenestrated laparotomy sheet.

d. Sterile System for Bladder Irrigation.

(1) Each hospital has its own system for bladder irrigation. Suitable solutions should be specified
by the surgeon.

(2) The system may consist of prepackaged irrigating solutions and sterile sets of connecting
tubing, or it may be a flask, rubber tubing, and connector set such as the Valentine irrigator,
which is prepared and sterilized by the operating room personnel as part of the instrument setup.
With the Cotter system, the irrigating fluids are usually mixed and poured by the operating room
personnel. Sterile pitchers or other containers for mixing and pouring will then be needed.

e. Operative Procedure (Suprapubic Cystotomy and Cystostomy).

(1) The bladder is distended preoperatively with the prescribed irrigating solution instilled via
catheter. A vertical or transverse suprapubic incision is made through the skin and subcutaneous
layers to the muscle using a scalpel, thumb forceps, and scissors. Bleeding vessels are controlled
with hemostats and ligated. Wound towels and retractors are placed. The rectus muscle is incised
or split by blunt dissection and retracted. The prevesical fat and peritoneum are retracted upward
with Deaver retractors.

(2) The top of the bladder is dissected free, using thumb forceps and Metzenbaum scissors. The
wall of the bladder is grasped on either side of the midline with Allis forceps. Two traction
sutures of number 0 chromic gut may be placed through the bladder wall and held with straight
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Halsted hemostats. The muscle of the bladder is spread by blunt dissection with the tip of a clamp
or scissors until the mucosa is seen. Two Allis clamps are placed, and the bladder is incised with
a sharp blade. At this point the distended bladder may be emptied via the urethral catheter, which
is unclamped under the drapes by the circulating member of the team, or a suction tube may be
introduced through the stab wound to remove the fluid as the bladder mucosa is incised.

(3) The bladder opening is extended with scissors. Bladder retractors are placed, and the bladder
is explored for diverticula, calculi, or tumor. Removal of the pathological area or other corrective
procedure is carried out and wound closure begun. A Malecot catheter may be used to drain the
bladder suprapubically and a Foley retention catheter to drain through the urethra. The prevesical
space may be drained with Penrose tubing.

(4) The bladder is sutured in two layers. A continuous suture of catgut is used on the mucosa and
interrupted stitches of chromic catgut on the muscle layer. The abdominal muscle fascia and
subcutaneous tissue are closed with catgut. Tension sutures of nylon or silver wire may be needed
for some patients. A suture is placed around the cystostomy tube and affixed to the skin. The skin
may be closed with silk or stainless steel wire.

(5) The wound is dressed with bulky dressings. The wound and cystostomy tube are held in place
by adhesive tape strips.

8-23. TROCAR CYSTOSTOMY

a. General. This operation consists of opening the bladder, drainage by blind puncture using
needles or trocar, and insertion of a catheter.

b. Operative Procedure. The skin at the site of the puncture is nicked with the scalpel, and the
trocar is inserted into the bladder (see figure 8-8). The trocar obturator is withdrawn, and a
catheter is passed into the bladder over the catheter guide. The cannula is withdrawn, and the
catheter is sutured to the wound edges. The wound is dressed.



Figure 8-8. Trocar cystostomy.

8-24. PARTIAL CYSTECTOMY

a. General. This procedure involves the resection of a portion of the bladder having a lesion.

b. Operative Procedure.

(1) The bladder and lesion are exposed via suprapubic abdominal, perineal, or vaginal approach.
Usually the bladder is opened suprapubically, as described in paragraph 8-22e.

(2) The ureteral orifices are identified and ureteral catheters passed.

(3) The diseased portion of the bladder is excised, using clamps and ligatures of the type required
for the organs and tissues involved. Vessels are tied with number 2-0 plain gut.

(a) For vesicointestinal fistula, bowel resection with colostomy or ileostomy may be indicated.
For vesicovaginal fistula, a vaginal plastic repair is done.

(b) For diverticulum, excision of the defect is done intravesically or extravesically.

(4) The incision in the bladder is sutured in two layers, as described in paragraph 8-22e(4).
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(5) The bladder is drained suprapubically, as well as by an indwelling urethral catheter. Penrose
drains may also be placed in the wounds.

8-25. CYSTECTOMY

a. General. This operation involves the total or radical excision of the urinary bladder. The extent
and nature of the excision depends on the extent and nature of the pathological area. Total
excision is usually carried out if the malignancy has not infiltrated the entire bladder or shown
evidence of extension or distant metastasis and if the patient is in condition to withstand the
procedure with hope of an appreciable period of relief. More conservative measures may be taken
when the tumor is hopelessly advanced or when the pathological area is limited. If a radical
procedure is to be done, combined abdominal and perineal approaches may be made.

b. Operative Procedure (Suprapubic Approach).

(1) The bladder is approached as for cystostomy.

(2) Deep retractors and laparotomy pads are used to retract the peritoneum. Long tissue forceps,
stick sponges, and long scissors are used for dissection. Long hemostats or right-angled clamps
are placed across the major vessels and ureters. Suture ligatures number 2-0 chromic gut are
placed and the structures divided. Large pedicle or intestinal clamps are placed across the urachus
and its vessels anterior to the bladder. The structures are ligated and divided by sharp dissection.

(3) In the male, the bladder is lifted up, using long Allis forceps. The peritoneum is dissected free
from the bladder. The bladder is retracted to expose the vesicle neck. The bladder is dissected
from the prostate and the vas deferens ligated. A large pedicle or intestinal clamp is placed across
the urethra which is ligated with number 2-0 chromic sutures. The urethra is divided and the
specimen removed.

(4) The seminal vesicles are removed with the bladder. Ureteral transplant is performed if not
done previously.

(5) Penrose drains are placed in the suprapubic wound, which is closed in layers with #0 chromic
interrupted sutures. Silver wire or nylon tension sutures may be placed. The skin is sutured with
silk number 8-0 or steel wire gauge 35. The abdominal and perineal wounds are dressed.

NOTE: In the female, cystectomy will depend on the extent and nature of the pathological lesion.
A vaginal approach may be used and then, via the abdominal approach, lymphadenectomy and
pelvic exenteration completed.

8-26. BLADDER NECK OPERATION (Y-V-PLASTY)

a. General. This operation involves the plastic repair of the bladder neck. It is done to overcome
contracture of the bladder neck due to primary or secondary stricture.

b. Operative Procedure.

(1) The bladder is approached as for cystostomy. The prevesical fat is removed, using long
forceps and dissecting scissors. The vessels over the bladder neck are occluded with right-angled
clamp, ligated with number 2-0 plain gut, and divided. The self-retaining bladder retractor is
placed.

(2) Traction sutures of fine silk on small, fine, cutting-edge needles (cleft palate-type) are placed
at the base and on either side of the urethra to start the pattern for the plastic dissection.


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(3) With the aid of the traction sutures and an Allis forceps, the Y is incised through all layers as
evenly as possible, using sharp-pointed scissors. Bleeding vessels in the wall of the bladder and
bladder neck are ligated with plain number 2-0 gut on small Ferguson needles. The V flap is
folded free, and the length of the Y arm is determined with a caliper and ruler.

(4) The apex of the V is brought to the neck of the bladder to overcome the stricture and broaden
the outlet. A catheter is placed in the urethra to guide the needle and prevent the suture from
penetrating the urethral mucosa. A stitch of chromic number 2-0 suture is taken through the apex
of the V under the urethra to the base of the Y and tied. The closure of the plastic repair is
completed with mattress suture of number 2-0 chromic on Atraumatic needles.

(5) A cystostomy tube is placed in the bladder, and the bladder and abdominal wall are closed in
the usual manner for cystostomy.

8-27. VISICAL-URETHRAL SUSPENSION (MARSHALL-MARCHETTI OPERATION)

a. General. This operation involves the suspension of the bladder neck to the posterior surface of
the pubis in the female patient for treatment of stress incontinence.

b. Patient Preparation. The patient is usually placed in a supine position with Trendelenburg
modification, but the surgeon may prefer a frogleg modification and vaginal preparation with the
insertion of a Foley catheter.

c. Operative Procedure.

(1) A suprapubic incision is made to expose the prevesical space of Retzius. The bladder and
urethra are separated from the posterior surface of the rectus muscles and pubis by gentle, blunt
dissection.

(2) Heavy chromic sutures are placed on each side of the urethra and sewn to the periosteum and
cartilage on the posterior side of the pubis.

(3) The outside of the bladder wall is then sutured with chromic gut suture to the rectus muscle to
further suspend the urethra and bladder.

(4) The area is drained, and the wound is closed in layers.

8-28. SUPRAPUBIC PROSTATECTOMY WITH CYSTOSTOMY

a. General. This procedure involves enucleation of the prostatic adenomas or hypertrophied
masses via a suprapubic approach. It is required because as the male ages, the prostate gland
enlarges and gradually obstructs the urethra, giving rise to symptoms of urinary obstruction. The
enlargement may be benign or malignant. In benign hypertrophy, only the periurethral portion of
the gland is removed. When malignancy is involved, however, total or radical prostatectomy is
done. This may involve excision of the entire gland and its capsule, together with associated
structures, a portion of the trigone of the bladder, and the seminal vesicles.

b. Patient Preparation. The patient is placed in the supine or modified Trendelenburg position,
with the legs apart and the weight of the torso supported by shoulder braces. An O'Connor drape
may be fanfolded at the pubis, with the penis exposed through the fenestration and the finger cot
in the rectum. A towel folded lengthwise is placed over the fanfolded drape at the pubic level, and
a fenestrated disposable drape is used at the site of the suprapubic incision.

c. Operative Procedure.


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(1) The bladder is distended via catheter irrigation, as for cystotomy. Vasectomy is frequently
done as a preliminary procedure to prevent postoperative epididymitis.

(2) The bladder is approached through the routine cystotomy incision, and the top of the bladder
is dissected free, using long thumb forceps and Metzenbaum scissors.

(3) The wall of the bladder is grasped on each side of the midline with Allis forceps. Two
traction sutures of chromic gut number 0 on Ferguson number 12 needles may be placed through
the wall of the bladder at this point and retained on straight hemostats.

(4) The muscle layers of the bladder are spread by blunt dissection with a hemostat until the
mucosa is exposed. Allis forceps are placed on either side, and the bladder is incised, using a
scalpel with a number 10 blade. The opening is extended with scissors. Bladder retractors--either
long-bladed loops or self-retaining type--are placed, and the bladder is explored.

(5) The surgeon places the forefinger of one hand into the rectum via the finger cot in the
O'Connor drape and pushes the prostate gland forward. With the forefinger of the operating hand,
the lobes of the gland are enucleated from the capsule (see figure 8-9). Bleeding is controlled
with hemostats and ligatures, sutures, or electrocoagulation. Long forceps, half-length sutures,
and long needle holders are required for placing sutures.

(6) Following removal of the prostate and control of bleeding, a hemostatic catheter with an
inflatable bag--Foley 24 Fr with a 30-ml bag may be placed in the fossa; the balloon is adjusted
under direct vision and inflated, using sterile water in a 30-ml syringe with an adapter. A
hemostatic cone of Gelfoam may be used if preferred.

(7) The bladder is closed as for suprapubic cystostomy with a Malecot catheter in place. One or
two wide Penrose drains may be placed in the prevesical space of Retzius. The wound is closed in
layers and dressed.



Figure 8-9. Enucleation of prostate by suprapubic approach.

8-29. RETROPUBIC PROSTATECTOMY.

a. General. This operation involves enucleation of the prostatic hypertrophied lobes directly
through a capsular incision in the upper surface of the prostate rather than through the bladder.

b. Operative Procedure. See Figure 8-9.

(1) Through a vertical or transverse suprapubic incision, the abdominal wall is opened to expose
the space of Retzius. The bladder is not directly opened. The precystic fat is extracted using long,
smooth tissue forceps. Large vessels are ligated, using 18-inch transfixion sutures of chromic gut
number 0 threaded on small Mayo needles.

(2) The prostatic capsule is incised transversely, using number 7 scalpel with a number 10 blade.
The prostate is freed and enucleated, employing scissors and Allis forceps. Deep bleeding vessels
are clamped with long hemostats and ligated with long plain gut number 2-0 or number 8-0
sutures with medium curved taper point Atraumatic needles.

(3) A wedge excision of the posterior bladder neck is made, using long Allis forceps, a long
scalpel, and scissors. A wedge of tissue may be sutured over the defect in the bladder neck after
removal of the prostate. In radical prostatectomy, a V-shaped portion of the bladder mucosa may
be sutured over the defect in the bladder neck.

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(4) A multieyed Robinson or Foley retention catheter is placed via the urethra. A Malecot
cystostomy tube may be placed in the bladder if the surgeon desires.

(5) The incision in the prostatic capsule is closed with a continuous suture of chromic gut
number 0. Penrose drains are placed in the retropubic space, the abdominal incision is closed in
layers, and the wound is dressed.

8-30. PERINEAL PROSTATECTOMY

a. General. Either enucleation of adenomas or radical prostatectomy may be carried out through a
perineal exposure.

b. Patient Preparation. The patient is placed on the operating table in an extreme lithotomy
position. The buttocks are elevated on pads sufficient to tilt the pelvis and flatten the perineum on
the vertical plane. The thighs are fully flexed with the knees to the chest and the feet are
supported in stirrups. The arms are extended on armboards and shoulder braces applied with the
usual precautions. Measures must be taken to reduce strain on the muscles and nerves of the back
and legs and also prevent respiratory embarrassment from compression of the abdomen and chest.
Draping is with an O'Connor drape and perineal sheet.

c. Operative Procedure.

(1) Through a curved incision made just above the anal margin, the skin, fat, and subcutaneous
fascia are divided. Straight hemostats are used for bleeding vessels in the superficial tissues and
curved hemostats for deeper tissues. The tissue on either side of the central tendon is dissected,
using Metzenbaun scissors and forceps. McBurney retractors followed by Young bifurcated
prostatectomy retractors are placed as dissection progresses. The levator ani muscles are exposed
and retracted.

(2) The gland is exposed and enucleated. The surgeon manipulates the gland with a finger in the
rectum via the O'Connor drape finger cot or with the hand protected by a second glove.

(3) Bleeding is controlled with sutures and electrocautery. A multieyed Robinson or Foley
retention catheter is inserted into the urethra. In radical prostatectomy, the bladder neck is
approximated to the urethra to cover the defect of the excision.

(4) A Penrose drain is placed in the wound. The wound is closed in layers with chromic number
0 gut sutures swaged on medium Ferguson number 14 needles. The skin edges are approximated
with interrupted sutures on straight needles.

Section V. OPERATIONS ON THE SCROTUM, PENIS, AND URETHRA

8-31. HYDROCELECTOMY

a. General. This operation (see figure 8-10) involves the excision of the tunica vaginalis of the
testis in order to remove a hydrocele. This is abnormal accumulation of fluid within the scrotum
around the capsule of the testis and within the tunica vaginalism. Excessive secretion or
accumulation may be due to infection or trauma.



Figure 8-10. Hydrocelectomy.

A-Incision through anterior scrotum, exposing hydrocele sac. Characteristic dark blue shiny
appearance of tunica vaginalis (which is sac wall) is due to deep shadow within sac.
                                                                                                 190
B-Hydrocele sac enucleated and removed from scrotum. It is left attached to groin by spermatic
cord.

C-Sac opened and excised from testis.

D-Skin edges and subcuticular tissues approximated with single mattress sutures of no. 8-0 plain
catgut.



b. Patient Preparation. The patient is placed in supine position and draped with fenestrated sheet.

c. Operative Procedure.

(1) An anterolateral incision is made in the skin of the scrotum over the hydrocele mass, using a
scalpel with a number 2-0 blade. Bleeding is controlled with Crile hemostats and vessels ligated
with number 2-0 plain gut ligatures.

(2) Small retractors may be placed (see figure 8-10 A), and then the fascial layers are incised to
expose the testis and tunica vaginalis. With fine scissors and forceps, the sac is delivered and
dissected free (see figures 8-10 B and C). The hydrocele may be aspirated. The adherent tunica
vaginalis is separated from the internal fascia layers and the sac opened. When the tunica
vaginalis has been trimmed as desired, the testis is returned to the scrotal sac.

(3) A Penrose drain is placed, and the wound is closed (see figure 8-10 D) in layers with
Atraumatic sutures plain gut number 2-0 on curved cutting needles. The wound is dressed, and a
supportive sling dressing or suspensory is usually applied.

8-32. VASECTOMY

a. General. This operation involves the excision of a section of the vas deferens. This is done
electively as a permanent method of sterilization or birth control and also prior to prostatectomy
to prevent spread of infection from the urethra to the epididymis.

b. Patient Preparation. The patient usually lies in the dorsal supine position, although the
operation can be done in the lithotomy position prior to transurethral surgery. The procedure may
be done with either local or general anesthesia.

c. Operative Procedure.

(1) The vas is located by palpation in the upper part of the scrotum. A small incision is made in
the skin over the vas (see figure 8-11 A).

(2) An Allis forceps is inserted to grasp the vas and bring it to the surface of the wound (see
figure 8-11 B). The vas is denuded of surrounding tissues of the cord, and straight clamps are
placed on either side of the Allis to crush the vas.

(3) The vas is cut between the clamps and a section removed (see figure 8-11 C). The cut ends
are doubled back and ligated with silk-or cotton number 8-0.

(4) The clamps are removed, and the skin incision is closed with plain gut #8-0 on a needle.
Acollodion dressing and scrotal suspensory may be applied.




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Figure 8-11. . Vasectomy (vas ligation)

.A-Vas grasped between thumb in front and first and second fingers behind. Incision 2 cm long is
made over vas.

B-Vas grasped with Allis clamp and incision deepened into it. C-Vas clamped with two
hemostats and incised between them.

8-33. EPIDIDYMECTOMY

a. General. This is the excision of the epididymis from the testis. It is rarely done but may be
indicated in the treatment of persistent infection.

b. Operative Procedure. Incision is made over the testis in the scrotum to expose the tunica
vaginalis. This is incised to expose the testis and overlying epididymis. An incision is made
between the upper pole of the epididymis, which is then carefully freed from the testis. Bleeding
is controlled and the wound closed with fine sutures and small drain.

8-34. SPERMATOCELECTOMY

a. General. This operation involves the removal of a spermatocele, which usually appears as a
lobulated cystic mass within the scrotum attached to the upper pole of the epididymis. This
condition is usually caused by an obstruction of the tubular system that conveys the sperm. An
epididymovasostomy may be attempted after excision of the mass to maintain the system.

b. Operative Procedure.

(1) The mass is approached through a scrotal incision as for hydrocelectomy or varicocelectomy.

(2) The structures of the testis and spermatic cord are identified, and the cyst is dissected free.
Bleeding is controlled with clamps and ligatures in routine fashion.

(3) The wound is closed and dressed as for hydrocelectomy refer to paragraph 8-31c(3).

8-35. VARICOCELECTOMY

a. General. This procedure involves ligation and partial excision of dilated veins in the scrotum.
It is done to reduce congestion of the testes and to improve spermatogenic function. The
condition occurs more frequently on the left, since the vein of the left testis is connected to the
renal vein and is under greater pressure. The veins of the pampiniform plexus of the spermatic
cord become tortuous and engorged, causing a bag of redundant veins.

b. Operative Procedure.

(1) The incision may be made low in the inguinal canal or in the upper portion of the scrotum.
The structures of the spermatic cord are identified and the vessels dissected free from the vas
deferens.

(2) The abnormal vessels in the inguinal canal are clamped and ligated. The redundant portions
are excised. The remaining structures are sutured to the external oblique fascia above the external
inguinal ring to support the testicle.

(3) A Penrose drain may be placed. The incision is closed in layers.

8-36. ORCHIECTOMY
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a. General. This operation involves the removal of the testis or testes. Removal of both testes is
castration and renders the patient both sterile and deficient in male hormones. Because of the
social implications, this operation, like vasectomy, requires particular attention to legal
permission. Bilateral orchiectomy is usually performed to control carcinoma of the prostate. A
unilateral orchiectomy may be indicated because of cancer, trauma, or infection of the testis. In
benign conditions, a prosthesis may be implanted for cosmetic or psychological reasons.
Prostheses are usually made of silicone rubber.

b. Operative Procedure.

(1) The upper anterior surface of the scrotum is incised over the testicle. The incision is carried
through the skin and fascial layers to expose the tunica vaginalis. Retractors are placed and
bleeding vessels clamped and tied.

(2) The tunica vaginalis is grasped and mobilized. The spermatic cord is dissected free up to the
external abdominal ring, clamped, and ligated. The testis is removed. Bleeding is controlled. A
small Penrose drain may be placed in the wound. Fine sutures of plain gut number 8-0 or nylon
number 4-0 are used to close the wound.

8-37. ORCHIOPEXY

a. General. This operation involves the suspension of the testis within the scrotum. An
undescended (cryptorchid) testis is one that has failed to move properly into the normal
intrascrotal position. A retractile testis is one that has descended through the inguinal canal but
lies either within or superficial to the external ring. An ectopic testis is one that has descended
through the canal and rests in an abnormal position (the perineal femoral area or lateral to the
canal). When this operation is done on young boys, the primary goal is to obtain adequate length
of the spermatic vessels and the vas to allow the testis to lie in the scrotum.

b. Operative Procedure (Transverse Inguinal Approach).

(1) An incision is made at the internal inguinal ring, the inguinal canal is opened, and the testis
and cord freed. Another incision is made at the external inguinal ring and the testis is brought
through the incision and into the scrotum to the proper side.

(2) The reconstruction of the muscle closure of both the internal ring and the external oblique is
accomplished, using fine interrupted silk or chromic sutures.

(3) The subcutaneous tissue and skin are closed with fine sutures, as desired.

8-38. HYPOSPADIAS REPAIR

a. General. This surgery involves penile straightening and urethral reconstruction. Because the
deformities are usually multiple, correction is usually accomplished in several stages, allowing
several months to elapse between operations. The various techniques employed are for the
purpose of providing a straight penis and establishing an effective urethral orifice.

b. Definitions.

(1) Hypospadias. A deformity of the penis and malformation of the urethral wall in which the
urinary meatus is located on the underside of the penis, either short of its normal position at the
tip of the glans or on the perineum or scrotum. This condition is often associated with chordee.

(2) Chordee. A downward bowing of the penis due to the congenital malformation of
hypospadias with fibrous bands.

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(3) Epispadias. A condition in which the urethral meatus is situated in an abnormal position on
the upper side of the penis.

c. Operative Procedures.

(1) Chordee repair (Fraser or Nesbit technique).

(a) A transverse incision is made across the penis. Restricted fibrous tissue is dissected off the
undersurface of the penis. Fine plastic scissors, a scalpel with blade number 10, and fine plastic
tissue forceps are needed.

(b) With the penis held forward and the prepuce retracted, the skin is incised, and a dorsal
quadrilateral flap is freed from the body of the penis.

(c) On each side, a narrow penile band of skin is divided.

(d) A transverse buttonhole is made to accommodate the head of the penis, which is threaded
through it.

(e) The proximal edge of the buttonhole is sutured to the mucosa behind the corona. The
preputial flap is trimmed and sutured to the raw area on the undersurface of the penis.

(f) An indwelling catheter is placed, and the wound is dressed.

(2) Urethral reconstruction.

(a) The urethra is dilated, and a Malecot catheter number 14 or number 16 Fr over a sound
number 8 Fr is used to accomplish a perineal urethrostomy.

(b) On the ventral side of the penis, the Duplay flap is made to create the urethra. The edges of
the flap are inverted and united over a catheter number 8 or number 10 Fr with interrupted
chromic gut sutures number 5 - 0 or number 6-0 on Atraumatic needles.

(3) Penile reformation.

(a) The scrotal flaps are made prior to lifting the penis from the scrotum. A catheter is placed in
the penile urethra. By dissection, the penis with its established new urethra is lifted off the
scrotum.

(b) The flaps are sutured, providing the proper penoscrotal angle.

(c) The scrotal fascia of the flap may be sutured.

(d) A catheter may be placed. The wound is dressed.

8-39. CIRCUMCISION

a. General.

(1) This procedure is the excision of the foreskin (prepuce) of the glans penis. It is done
prophylactically in infancy and is commonly performed in the newborn period. For Jewish
patients, this may be a religious rite performed by a rabbi. Provision should be made in a hospital
to observe the religious needs and preferences of parents in this regard.


                                                                                                194
(2) Circumcision is done for the relief of phimosis, a condition in which the orifice of the
prepuce is too small to permit easy retraction behind the glans. Circumcision may be done to
relieve paraphimosis, a condition in which the prepuce cannot be reduced from a retracted
position.

b. Patient Preparation. Newborn infants are generally positioned on specially constructed boards
that facilitate restraint by immobilizing the limbs and exposing the genitalia. No anesthesia is
used for newborn infants. Older patients may be given a general or local anesthetic.

c. Operative Procedure.

(1) If the foreskin is adherent, a probe or hemostat may be used to break up adhesions. The
foreskin is grasped with an Allis forceps and stretched taut over the glans. A superficial,
circumferential incision is made in the skin at the level of the coronal sulcus at the base of the
glans. A straight hemostat may be placed at the medial dorsal aspect and the foreskin cut from the
meatus to the sulcus with a straight scissors or scalpel. The foreskin is then completely excised at
the level of the sulcus. Bleeding vessels are clamped with mosquito hemostats and tied with fine
number 2-0 plain gut ligatures.

(2) The raw edges of the skin incision are approximated along the corona with fine number 4-0
chromic sutures on Atraumatic needles. The wound may be dressed with petrolatum or
hemostatic gauze, if desired.

(3) The plastibell method for infants is done in a somewhat different way. A dorsal slit is made,
adhesions freed, and the bell placed over the glans inside the foreskin. A suture is tied lightly
around the bell, compressing the foreskin into the groove. The free skin is trimmed and the bell
handle is broken off.

8-40. URETHRAL MEATOTOMY

a. General. This involves incisional enlargement of the external urethral meatus. The procedure
is done to relieve stenosis or stricture.

b. Patient Preparation. For the male, a supine position is generally used, and the penis is elevated
on a small folded sheet. For the female, the lithotomy position is used. Either general or topical
anesthesia may be used. Cocaine 5 percent is used for the meatus and 2 percent procaine with
bulb syringe is used for instillation into the urethra.

c. Operative Procedure. A straight hemostat is applied to the ventral surface of the meatus. An
incision is made along the frenulum to enlarge the opening and overcome the stricture. Bleeding
vessels are clamped and ligated with fine plain surgical gut sutures. The mucosal layer is sutured
up to the skin with fine plain gut sutures. A dressing of petrolatum gauze may be applied.

8-41. EXCISION OF URETHRAL CARUNCLE

a. General. This procedure involves the removal of papillary or sessile tumors of the urethra. It is
done to rectify an inflammatory prolapse from the lower lip of the female urinary meatus.

b. Operative Procedure for the Removal of Papillary Growth. The growth is exposed, clamped at
its base with curved hemostats, and excised. A urethral indwelling catheter is inserted into the
bladder. The wound is closed.

c. Operative Procedure for Removal of Sessile Growth. A circular skin incision is made around
the meatus and carried through the submucosal layer. The urethra is freed from the caruncle, the
meatus is dissected back to the healthy tissue, and the diseased portion of the urethra is excised.

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The mucocutaneous junction is approximated with fine chromic gut sutures. An indwelling
urethral catheter is introduced and is kept in the bladder for at least 5 days.

8-42. URETHRAL DILATATION AND INTERNAL URETHROTOMY

a. General. This procedure involves the gradual dilatation and removal of a urethral stricture to
provide for adequate urinary drainage of the kidney.

b. Operative Procedure for Gradual Dilatation. The urethra is lubricated and anesthetized. In the
male patient, the penis is clamped and the urethra anesthetized. A filiform bougie is passed
through the urethral stricture into the bladder. Sounds or followers of desired type attached to
filiform bougies are then passed into the bladder.

c. Operative Procedure for Internal Urethrotomy. The filiform bougie is passed into the bladder;
the urethrotome is connected and inserted. The Otis urethrotome consists of a curved sound with
a groove on its upper side, along which is a triangular knife. Its sides are sharp and its apex blunt.
The urethrotome is inserted, and then the blade is released to cut the stricture. Electrosurgical
cutting and coagulating electrodes may be used.

8-43. CYSTOSCOPY

a. General. This procedure is the visual inspection of the interior of the bladder and examination
of adjacent structures by means of an instrument (cystoscope) introduced via the urethra into the
bladder. The examination may be done as an end in itself, or may be the first step in a series of
examinations or treatments that may be accomplished transurethrally.

b. Patient Preparation. The patient is placed in the lithotomy position perineal, preparation is
carried out, and the patient is draped with a lithotomy fenestrated sheet and leggings. Surgical
jelly is required to lubricate instruments passed into the urethra. A local or general anesthetic may
be administered. The surgeon will require a circulator, but probably not a scrub assistant.

c. Operative Procedure.

(1) The surgeon assembles the cystoscope, fitting the obturator into the sheath. The light is
tested, and the circulating team member adjusts the current to the proper brightness.

(2) The instrument is lubricated and inserted into the patient's urethra. The obturator is removed
and the telescope inserted into the sheath. The surgeon puts his eye to the eyepiece and makes his
examination. The bladder is distended with irrigating fluid. The surgeon adjust the flow and
volume with the stopcock. Then the obturator or telescope is removed, the irrigating fluid flows
out.

(3) Other procedures such as catheterization, biopsy, or stone removal are carried out by
exchanging or supplementing the cystoscope lens with the appropriate accessory instrument.

(4) Kidney function studies, cystometry, and X-ray examinations may be performed and various
specimens of urine collected. When the examination is concluded, the instrument is removed. A
urethral catheter may be inserted as required.

8-44. TRANSURETHRAL SURGERY

a. General. By means of a resectoscope passed into the bladder via the urethra, piecemeal
resection of the prostate gland and of tumors of the bladder and bladder neck may be carried out,
and bleeding vessels and tumors may be fulgurated.


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b. Operative Procedure. See Figure 8-12.

(1) The resectoscope is assembled. The sheath is fitted with its obturator. The electrode and
telescope are attached to the working element. The irrigating system is connected to the sheath.
The lamp cord or fiberoptic bundle is fitted to the telescope. The electrode is attached to the
electrosurgical unit. The currents are adjusted as the surgeon directs.

(2) The surgeon lubricates the sheath containing the obturator and inserts it into the urethra and
bladder. The obturator is removed, and the operating element is introduced through the sheath.

(3) Viewing the anatomy through the telescope, the surgeon begins the electro-dissection,
alternately cutting and coagulating. The bladder is permitted to drain--washing out blood tissue
and clots--and refill at intervals. The operating element may be removed and evacuating devices
such as the Ellik applied, to flush out the bladder.

(4) When the stones are present, they are trapped or crushed with dislodgers or lithotrites, and
copious irrigations are done.

Figure 8-12. Transurethral resection of bladder tumor.

(5) When resection of the lesion is completed and bleeding controlled, the operating instrument is
removed. A Foley catheter is introduced. A catheter stylet may be employed. The bag of the
catheter is filled, using a 30-ml syringe and adapter. The catheter may be a self-inflating type or
have a valve that requires no clamp to retain the fluid in the hemostatic bag. The catheter is
flushed for patency, irrigating with an Asepto syringe. When the surgeon is satisfied that the
patient's condition is good, the patient is transferred from the operating table.




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