Sutures, needles and supplies

1Why it matters

Every operation ends the same way: something has to hold the tissue together while it heals, and most of the time that something is suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close. Suture is any strand used to sew tissue together; bringing two cut edges back together this way is called approximation. A strand tied around a vessel or duct to close it is a ligature, or tie, and tying it off is called ligating.

The surgeon chooses the suture. Your job is to know what comes next, read a packet in a second, open only what the case needs, load each needle ready to use, and get every needle back.

Suture needles are also the sharps that hurt surgical teams most. In one large study of sharps injuries in surgery, suture needles caused more than four in ten, and surgical technologistssurgical technologistSUR-jih-kul tek-NOL-uh-jistA member of the operating room team who prepares the sterile field and instruments and hands them to the surgeon.Full entry Close were most often hurt while passing sharps, taking them apart or throwing them away.

Sponges, drains, drapes, blades, staplers, syringes and suction tips arrive on your back table too, and each has a right way to be handled. Counting them is in chapters 28 and 29, dressings in chapter 30, electrosurgeryelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close safety in chapter 20, and drugs on the field in chapter 12.

2The words of suture

SuturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close has its own vocabulary, and AST's Core Curriculum expects you to know it.

How a strand is built

• Monofilament: one solid strand. It glides through tissue and gives germs nowhere to hide, but it is stiffer and its knots slip more easily.
• Multifilament: many fine fibers twisted or braided into one strand. It is soft and ties firm knots, but the spaces between its fibers can hold fluid and bacteria.
• Coated: a covering, usually on a braided strand, so it slides more easily and frays less. Some coatings carry an antibacterial agent. An uncoated strand has none.
• Dyed or undyed: a strand may be colored with an approved dye, as violet polyglactin and blue polypropylene are, or left undyed, clear or in its natural color.

What makes a good suture

• Tensile strength: how much pull a strand takes before it breaks. A suture should be about as strong as the tissue it holds.
• Uniform size: a good strand has the same diameter all along its length, because a thin spot is a weak spot.
• Knot security: how well a knot holds without slipping.
• Memory: a strand's habit of springing back into its packet coils. High memory means tangles and knots that loosen. Monofilaments have the most; silk and braided polyester the least.
• Pliability: how easily a strand bends and handles. Silk is the classic soft suture.
• Capillarity, or wicking: soaking up fluid and carrying it along the strand. Braided strands wick most, and wicking can carry bacteria along the suture line.
• Tissue drag: frictionfrictionFRIK-shunThe rubbing of one surface against another, such as skin against bed sheets.Full entry Close as the strand is pulled through tissue, measured as its coefficient of friction. Coating lowers it, though a very slippery strand lets knots loosen.
• Elasticity: stretching and coming back, so a suture line can give a little as tissue swells.
• Plasticity: stretching and keeping the new shape. It helps knots stay secure; polypropylene has high plasticity.
• Tissue reaction (bioactivity): the body treats almost every suture as a foreign body and reacts with inflammation. A suture that causes little reaction is inert. Steel, polypropylene and nylon are among the most inert. Gut causes a strong reaction, and silk the most of the nonabsorbable sutures.

Absorbable and nonabsorbable

• Absorbable suture is broken down by the body. It loses its strength first, usually within weeks, then slowly disappears. Ideally it lasts as long as the tissue needs support.
• Natural absorbable suture (surgical gut) is digested by enzymesenzymeEN-zimeA protein that speeds up a chemical reaction in the body without being used up.Full entry Close from the body's cells. Synthetic absorbable suture is broken down by water in the tissues, called hydrolysis, which is more predictable and causes less inflammation.
• Nonabsorbable suture stays. The body walls it off in fibrousfibrousFY-brusMade of or containing tough threads (fibers), especially of connective tissue.fibr/o fiber-ous full of, relating toFull entry Close tissue, called encapsulation, or it is taken out later, as skin sutures often are.
• Infection speeds up the breakdown. Most sutures, gut among them, break down very quickly in infected tissue, one reason an actively infected wound is not sutured until the infection is treated.

3Suture size

Size is a strand's diameter. In the United States, every suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close needs FDA approval and has to meet the standards of the United States Pharmacopeia (USP), which cover size, tensile strength and sterilitysterilitysteh-RIL-ih-teeThe state of being completely free of living germs, including spores; also, being unable to have children.Full entry Close. Because of the USP standard, a 3-0 strand is the same thickness in silk, nylon or polyglactin. The numbers run two ways from 0:

• Below 0, more zeros mean a finer strand. 2-0 is finer than 0, and 4-0 is finer than 3-0. The finest go down to 11-0 and even 12-0. Size 11-0, used in microsurgery, is light enough to float in the air.
• Above 0, bigger numbers mean a thicker strand. Size 2 is heavier than size 1. The heaviest, size 5, is about as thick as ordinary string.

Finer strands are weaker, so the surgeon uses the finest one that will hold: it does less damage, makes smaller knots and leaves less foreign material. Sizes 0 to 4-0 cover most general surgery. As a rough guide, though each surgeon's preference card has the final word:

• 1 and 0: abdominal fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close and orthopedicorthopedicor-thuh-PEE-dikHaving to do with the bones, joints, muscles, ligaments and tendons, and the branch of medicine that treats them.orth/o straightped/o child (the field began with straightening children's bones)-ic relating toFull entry Close wounds, where the pull is greatest.
• 2-0 and 3-0: most stick ties. Ties from a reel are usually 2-0, 3-0 or 4-0.
• 3-0 and 4-0: most subcuticular skin closures.
• 4-0 and 5-0: joining the aorta; 4-0 also closes the duraduraDOOR-uhThe tough outer layer of the membranes that cover the brain and spinal cord.Full entry Close.
• 6-0 and 7-0: small arteries, such as the coronary and carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close arteries.
• 8-0 to 11-0: microvascular and eye surgery.

Stainless steel wire was long sized by the Brown and Sharpe (B&S) gauge, where a bigger number means thinner wire. Steel now has USP sizes too, but some surgeons still ask for wire by gauge, and the package prints it.

4Suture materials

SuturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close fall into four groups: natural or synthetic, and absorbable or nonabsorbable. Learn the groups first. Trade names differ by company, and most facilities buy most of their suture from one company, so learn its products.

Natural absorbable: surgical gut

• Surgical gut is collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close from the intestines of sheep or cattle, the only natural absorbable suture. Synthetic sutures have largely replaced it, but it still suits fast-healing tissue such as the lining of the mouth.
• Plain gut is untreated. It loses its strength within about 7 to 10 days, is gone in about 70 days, and causes a strong inflammatory reaction.
• Chromic gut is treated with chromium salts, so it reacts less and lasts longer: more than half its strength at 7 to 10 days, some up to 3 weeks, fully absorbedabsorptionub-ZORP-shunThe taking in of a substance, such as a drug or a nutrient, into the bloodstream.Full entry Close in about 90 days.
• Where gut is not used: plain gut is not used in heart, vessel or brain and nerve surgery, chromic gut is kept out of the skin, where its reaction can scar and invite infection, and any gut breaks down fast in an infected wound.
• Gut is packed in an alcohol solution that can catch fire on the field, so open it away from the incision and use it soon. If it has stiffened, dip it in room-temperature saline for a few seconds just before use. Never soak or heat it, and handle it as little as you can.

Synthetic absorbable

These polymers break down by hydrolysis at a steady rate with little reaction. Keep them dry: moisture weakens them, so they are never dipped.

• Polyglactin 910 (Vicryl) and polyglycolic acid (Dexon): braided and easy to handle. They hold for about 2 to 3 weeks, for soft tissue, ties and many layers in general and gynecologicgynecologygy-nuh-KOL-uh-jeeThe branch of medicine that cares for the female reproductive organs and breasts.gynec/o woman-logy study ofFull entry Close surgery. An antibacterial version that carries triclosan (Vicryl Plus) is also made.
• Poliglecaprone 25 (Monocryl): a smooth monofilament that loses about half its strength in a week and nearly all by 3 weeks. It is used for buried stitches, such as a subcuticular skin closure, and is not recommended for fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close or other tissue under strain.
• Polydioxanone (PDS) and polyglyconate (Maxon): monofilaments that hold much longer, about half their strength at 4 weeks, a common choice for fascia.
• Fast-absorbing versions, such as polyglactin 910 Rapide, lose most of their strength in a week and suit skin.

Natural nonabsorbable: silk

Silk is spun by silkworms, braided or twisted, and treated to wick less. It handles beautifully and its knots hold, so it is a favorite for ties and for bowel and vessels. It loses strength when wet, and buried silk slowly loses its strength over about a year. As a braided strand, it is a poor choice in a contaminated wound. Cotton is another natural nonabsorbable suture, rarely used now.

Synthetic nonabsorbable

• Nylon (Ethilon): strong and nearly inert. Monofilament nylon is a common skin suture, and its finest sizes, down to 11-0, serve eye surgery and microsurgery. Its knots slip, so surgeons tie extra throws.
• Polypropylene (Prolene): a smooth, very inert monofilament that can be used in the presence of infection, a mainstay of vascular and plastic surgery. High memory makes it springy in larger sizes.
• Polyester (Ethibond, Mersilene): braided and very strong, with little reaction, for heart valves, graftsgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close and fascia.
• Stainless steel: very strong and among the most inert, for bone, tendon and jaw surgery. It kinks, can tear out of tissue, and its barbed ends can damage tissue and gloves. It is never bent before use.
• ePTFE (expanded polytetrafluoroethylene): a nonabsorbable monofilament used in heart surgery, for example to replace the cords that hold the mitral valvemitral valveMY-trul valvThe heart valve between the left atrium and the left ventricle.Full entry Close.

Barbed and antibacterial sutures

Barbed suture has tiny barbs that grip tissue in one direction, so the surgeon can close without knots and the strand does not slide back. It comes in absorbable and nonabsorbable materials. Antibacterial sutures carry an agent such as triclosan in their coating to help prevent infection.

5Choosing a suture

The surgeon chooses, and the choice is on the preference card. It rests on the type of procedure, the tissue, the state of the wound and of the patient, and the surgeon's own experience. Knowing why lets you predict the next request and catch a mistake.

• Healing speed. Mucosamucosamyoo-KOH-suhThe moist lining of body passages that open to the outside, such as the mouth, nose, gut and bladder.Full entry Close, the subcutaneoussubcutaneoussub-kyoo-TAY-nee-usUnder the skin; in the fatty layer between the skin and the muscle.sub- undercutane/o skin-ous relating toFull entry Close layer and other quick-healing tissue can take absorbable suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close. FasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close, tendon and ligament carry heavy loads, and fascia heals slowly, so they need nonabsorbable suture, or a slowly absorbedabsorptionub-ZORP-shunThe taking in of a substance, such as a drug or a nutrient, into the bloodstream.Full entry Close one, in a larger size.
• Critical tissue. The heart and blood vessels get nonabsorbable suture.
• Wound status. An actively infected wound is not sutured. Where the risk of infection is high, because of the wound's class or the patient's condition, the surgeon wants a strong suture line that resists absorption: nonabsorbable suture, or an absorbable one that lasts a long time. Monofilaments are preferred, because braided strands wick germs. A grossly contaminated wound, such as one from a traumatic injury, may be left open to heal by second intention (see First, second and third intention, below).
• The urinary tract. Suture in contact with urine can seed stones, so absorbable suture is used.
• Scarring. For a cosmetic closure of the face and other exposed skin, the surgeon picks an inert suture, usually a monofilament, which does the least injury as it passes through.
• The patient. Age and illness such as diabetes, lung disease or long-term steroidsteroidSTAIR-oydA fat-based chemical built from cholesterol; the group includes hormones such as cortisol and estrogen, and many drugs.ster/o solid-oid likeFull entry Close use slow healing and change the choice.

6The suture packet and its label

SuturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close comes in dispenser boxes of one to three dozen packets. Each packet is two layers: a sterile primary packet of foil or paper, which may hold fluid, sealed inside a peel-open overwrap whose outside is not sterile. A packet stays sterile while it is whole, and some carry an expiration date because the suture itself can break down. Good packaging does three jobs: it keeps the suture sterile, it protects the strand and needle from damage, and it lets the suture reach the field and come out of the packet quickly without tangling.

Boxes and packets are color coded by material, but the colors are not the same at every company, so always read the label.

Suture boxes are kept on carts or racks in a supply area, or in closed cabinets in the OR, and a large facility may have a room just for suture. Suture carts are never brought into the operating room, where blood and body fluids could soil them.

Reading the label

Find the size, the material, and the type and size of the needle first.

• Material, by name, with the strand's color.
• Size: the USP size, often with its metric diameter.
• Needle: a silhouette of its shape, the number of needles, and the maker's needle code.
• Strand length and number of strands.
• Product (reorder) number, lot number and expiration date.

Suture styles

• Pre-cut strands: several needlelessneedlelessNEE-dul-lesWorking without a needle, such as an IV connector that a syringe or tubing attaches to directly.Full entry Close lengths, used as free ties, from about 12 to 60 inches.
• Reels: one long strand, often 54 inches, on a spool for many ties in a row. Reels show on x-ray, and many facilities count them because they are easily lost in a wound. The holes in the side of the reel show its size.
• Single-armed: one needle swaged to one end.
• Double-armed: a needle at each end, for joining vessels and other round structures, sewing from the middle out both ways.
• Multi-strand packs: several needle-and-strand sutures in one packet, for a row of interrupted stitches. They replaced the old way of threading eyed needles one after another (rapid-sequence suturing), but they put more needles and more paper on the field, which raises the risk of a lost needle and the cost.
• Control release (detachable, pop-off): the needle comes off with a straight tug of the needle holder, so many interrupted stitches can be placed quickly, as in an anastomosisanastomosisuh-nas-tuh-MOH-sisA connection between two tube-shaped structures, such as two ends of bowel or two blood vessels, made by surgery or found naturally.Full entry Close. Other multi-strand packs have needles that are cut off with suture scissors.
• Looped: the strand comes as a loop, for a running stitch that is tied to itself. The label says when a suture is looped.
• Barbed and knotless: barbed suture holds without knots (see Barbed and antibacterial sutures above), and its label says so.

7Opening and preparing suture

Open only the suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close the case needs. Leftover packets cannot be sterilizedsterilizationstair-uh-luh-ZAY-shunA process that destroys all microorganisms, including spores, on an item; also a permanent birth control procedure.Full entry Close again, and every extra needle is one more to count.

1. Check each box against the preference card: material, size, needle and length.
2. The circulator peels the overwrap and flips the primary packet onto the field, or holds it for you to lift out. The sealed edge is the line between sterile and non-sterile.
3. Tear the primary packet at the notch near its sealed edge, or unfold it if it comes ready to load.
4. Count multi-needle packets with the circulator as you open them. Your facility's policy says whether they are opened and counted before the incision.
5. Arrange packets in the order the surgeon will use them, with the sharps grouped near the sharps container.

To take out a tie, hold the packet and draw the strand out by its loose end. Take out packet kinks by holding both ends and gently pulling your hands apart. Never strip a braided strand through your gloved fingers, which frays it, and never test it with a sharp jerk.

To make ties from a full-length strand, rest the coil across one hand and draw the loose end out gently until the strand is uncoiled. Then take an end in each hand and pull the middle out into thirds before cutting.

For a suture with a needle, grip the needle with the needle holder first, then draw the strand out without tugging on the swage. To straighten it, hold the strand an inch or two from the needle and pull gently on the far end. Nylon can be drawn gently between gloved fingers to take out its memory. Straighten a control-release suture with care, or the needle pops off and the suture is wasted.

Too long a strand drags below the field; too short is hard to tie. As a guide, a running suture is about 24 inches, an interrupted stitch 12 to 14 inches, and a tie for a deep vessel 24 to 30 inches.

Rules for handling suture

• Never wet a synthetic absorbable, and never soak or heat gut.
• Never crush a strand with an instrument. A damaged monofilament can look fine and still break after surgery.
• Never bend steel wire.
• Empty packets and used ties go in the suture bag on the side of the Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close away from the wound, never in the kick bucket, where a needle could hide among the sponges.

8Needles

Surgical needles are made of high-grade steel alloy. Every suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close needle has three parts: the eye or swage, where the strand attaches; the body, which the needle holder grips; and the point.

Swaged and eyed needles

Nearly all suture today is swaged: the strand is sealed into the hollow end of the needle at the factory. A single strand follows the needle and fills the hole, so the tissue is barely torn. That is why a swaged needle is called atraumatic. Eyed needles are rare today, but you still need to know them:

• A closed-eye needle is threaded by hand like a sewing needle, so a double strand passes through the tissue and tears it more.
• A French-eye (spring-eye) needle has a slit above the eye. The strand is pulled down over the slit until it snaps in. Never pull the strand through the eye once it is set: that strips the strand and can break it.

Most scrubs never thread a needle, but learn how in case you must. Pass the strand through the eye from the inside of the needle's curve to the outside, which keeps the short end from slipping back out. Leave a short end of about 3 to 4 inches on a 24-inch running suture, or 2 to 3 inches on a 12- to 14-inch interrupted stitch; one reference leaves about a third of the strand. Before passing it, lay both ends between the tips of the needle holder's jaws so the strand cannot back out of the eye. In heart valve surgery, keep French-eye needles ready in case the surgeon must place a suture again after its needles were cut off.

Shape and size

A straight needle, such as a Keith needle, is used by hand, with no needle holder. Curved needles are named for the part of a circle they make: 1/4, 3/8, 1/2 or 5/8 circle. A compound curve changes its curve along its length, for delicate work such as the eye. The deeper and tighter the space, the more curve the surgeon needs. A needle's size is its length and the diameter of its body: fine needles for microsurgery, very heavy ones for closing the sternum. Each maker codes its needles by size and shape, and you learn your surgeons' codes by working with them.

Point

• Taper: a round body narrowing to a sharp point that pierces and spreads tissue without cutting. The most used point, for soft tissue such as bowel, vessels, peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close, muscle, fat and duraduraDOOR-uhThe tough outer layer of the membranes that cover the brain and spinal cord.Full entry Close.
• Conventional cutting: a triangular point with its third cutting edge on the inside of the curve, facing the wound edge, for tough tissue such as skin, tendon and joint capsule.
• Reverse cutting: the third edge is on the outside of the curve, away from the wound edge, so the stitch is less likely to tear out. Stronger than conventional cutting, and a common skin needle.
• Taper-cut: a cutting tip on a round body, for dense fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close, tendon and periosteum.
• Side-cutting (spatula): flat on top and bottom, cutting at the sides, to split thin layers of the eye without diving deep.
• Blunt: a rounded tip that pushes between tissue fibers. Used for friable organs such as the liver and kidney, and now recommended for fascia and muscle because it greatly cuts needlestick injuries.

9Loading and passing the needle

Choose a needle holder whose length suits the depth of the wound and whose jaws suit the needle: fine for fine, heavy for heavy. Chapter 24 covers the needle holders themselves.

3D Mayo-Hegar Needle HolderOn 256 setups

Loading

1. Load the needle while it is still in the packet, using the packet to steady it. Never set a needle in place with your fingers.
2. Grip the needle with the tips of the jaws, set square (at a right angle) to them, about one-third of the way back from the swage; anywhere from one-third to one-half is acceptable. Tough tissue may call for a grip nearer the middle, and the surgeon asks when another angle is wanted.
3. Never clamp the swage. It weakens the join and puts the needle holder too far back for good balance.
4. Draw the strand out gently, without pulling on the needle, and straighten it.

On a needle holder with curved jaws, such as a Heaney, load the needle so the angled tip of the jaws points toward the swage, not toward the needle point. A locking micro needle holder, such as a Castroviejo, opens with a gentle squeeze on its bowed handles, takes the needle, and locks again with another squeeze. Some have no lock; keep light pressure on their handles as you pass them so the needle cannot drop.

The neutral zone

A neutral zone is a set spot on the field, such as a magnetic pad, an instrument mat or a basin, where sharps are put down and picked up, so two people never hold the same sharp at once. AST recommends it for every operation, and AORN and the American College of Surgeons recommend it too. Agree on its place with the surgeon before the incision, say "sharp" each time you place one, and take your hand completely away. Lay the needle holder so it can be picked up by the handle without turning it, and keep only one sharp in the zone at a time.

The surgeon puts the used needle holder back in the zone; never pull a loaded one out of the surgeon's hand. When the surgeon cannot use the zone, for example under a microscope, say each pass out loud and say when your hand is out of the way. A surgeon who is not using the zone turns the needle with forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close toward the box lock of the needle holder before setting it down.

Passing

• Load and present the needle holder so the surgeon can use it without shifting it or looking up: needle point up, on the surgeon's thumb side, and aimed back toward the surgeon. When it is handed directly, as when the neutral zone cannot be used, place it firmly in the surgeon's palm.
• Hold the free end of the strand, or lay it over the back of your hand, so it does not tangle in the surgeon's hand or slide off the field.
• A right-handed surgeon drives the needle clockwise and a left-handed surgeon counterclockwise, so load it as a mirror image for the left hand. A backhand stitch reverses the direction. Where the surgeon stands, across from you or beside you, also changes how you hold it out, so practice both, with either hand.
• Hand tissue forceps to the surgeon's other hand with the needle holder. The surgeon uses them to steady the tissue and to pull the needle through and reposition it, so the needle is moved with instruments, never fingers. Choose them for the tissue: forceps with teeth for skin, tendon and fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close; smooth forceps for mucosamucosamyoo-KOH-suhThe moist lining of body passages that open to the outside, such as the mouth, nose, gut and bladder.Full entry Close, organs and any tissue that bleeds easily; and vascular forceps, whose scored tips grip without puncturing, for vessels.

Every needle comes back

• Pass on an exchange basis: a loaded needle holder goes out as the used one comes back, so you always know where every needle is.
• Look at each returned needle: it must be whole. A broken or missing needle is reported to the surgeon and the circulator at once. Every piece is found and accounted for, then kept in the sharps container or passed off to the circulator.
• Used needles go straight onto the magnetic pad or into the needle counter. A needle is never loose: it is on a needle holder, in its packet or in the counter.
• Load needles just before they are needed, so no bare needle waits on the Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close or back table. In a trauma case, holders may be loaded early with the needle tips still tucked in the packet.

• Before the surgeon ties, cut the needle off or use a control-release suture, so no needle swings free during the knot.
• Keep the second needle of a double-armed suture in sight, for example on a rubber-shod hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close, so it does not snag the drapes.
• Pick up a needle dropped on the field with a needle holder, never fingers. One on the floor is the circulator's to pick up the same way.
• After the case: once the skin is closed and the dressing is on, look over the field for any loose sharp before the drapes come off. Needles and blades go into the small sharps container you set up on the back table, never overfilled so it closes tight, and that whole container goes into the room's large puncture-resistant sharps container.

10How suture is used

Halsted's principles

More than 100 years ago, the Johns Hopkins surgeon William Halsted set out rules for treating tissue that still shape good surgery:

1. Handle tissue gently.
2. Control bleeding (hemostasishemostasishee-moh-STAY-sisThe stopping of bleeding, either by the body's own clotting process or by medical or surgical methods.hem/o blood-stasis stopping, standing stillFull entry Close).
3. Keep the blood supply.
4. Keep tissue moist.
5. Keep strict sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close.
6. Keep tension off the tissue.
7. Close dead space, the gaps between layers where blood and serumserumSEER-umThe clear, yellow liquid left from blood after it clots and the cells are removed.Full entry Close can pool.

Halsted also favored fine suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close placed close together, which is why surgeons still use the finest strand that will hold.

How the team exposes and holds tissue during the case, with retractionretractionrih-TRAK-shunA drawing back or pulling in of tissue; in breathing, the skin sinking in between, below or above the ribs with each breath.Full entry Close, tractiontractionTRAK-shunA steady pulling force applied to a body part with weights, ropes and pulleys.Full entry Close and countertraction, is taught in chapter 29.

Stitches

• Continuous (running): one strand, tied only at the start and end. Quick, with tension spread evenly, but a break anywhere can loosen the whole line. It suits layers with little tension that need a tight seal, such as the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close or a vessel.
• Locking running: each pass goes under the loop before it, for extra strength and better control of bleeding. The person following the suture keeps light tension on the strand.
• Interrupted: each stitch placed, tied and cut on its own. Slower but strongest: if one knot fails, the rest hold, and an infection is less able to travel along the line. Used for bowel and vessel joins. Interrupted stitches may be simple, figure-of-eight, vertical or horizontal mattress, or buried; buried and mattress stitches add security to the line.
• Subcuticular: a running stitch inside the dermisdermisDER-misThe thick layer of skin under the epidermis that holds blood vessels, nerves, hair roots and glands.derm/o skinFull entry Close, just under the epidermisepidermisep-ih-DER-misThe thin outer layer of the skin.epi- on, uponderm/o skinFull entry Close, for a neat closure with few marks, usually absorbable so nothing needs taking out.
• Purse-string: a running stitch in a circle around an opening, drawn tight like a drawstring, as around the base of the appendixappendixuh-PEN-diksA small, finger-shaped pouch attached to the first part of the large intestine, in the lower right abdomen.Full entry Close or around a tube.

Ties and ligatures

• Free tie: a pre-cut strand placed in the surgeon's open hand to tie around a clamped vessel.
• Reel: the whole reel goes into the palm with 2 or 3 inches of strand pulled free, then back to its place; a loose reel can fall into the wound.
• Tie on a passer: for a deep vessel, the end of a tie is clamped in the tip of a curved or right-angle clamp so the surgeon can pass it around the vessel. Lay the strand over the back of your hand as you pass it.
• Suture ligature (stick tie): a needle and strand on a needle holder. The needle passes through the vessel before the tie, so the tie cannot slip off a large vessel.
• Tag: a hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close on the ends of a suture, to hold it for later or pull on it. Traction (stay) sutures hold tissue out of the way.
• Drain stitch: a nonabsorbable stitch, such as nylon, that holds a drain to the skin so it stays in place.

Suturing through a scope

In laparoscopiclaparoscopiclap-uh-roh-SKOP-ikDone through a few small cuts in the abdomen with a thin camera and long instruments, instead of one large opening.lapar/o abdomen-scopic viewingFull entry Close and robotic surgery, the surgeon sutures through ports. In extracorporeal suturing the knot is tied outside the body and pushed down the port to the tissue; in intracorporeal suturing it is tied inside with instruments. Endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close suture devices help: a pre-tied loop on a long plastic pusher (such as the Endoloop) slips over a pediclepediclePED-ih-kulA narrow stem or stalk that attaches a structure, such as a tumor or a skin flap, to the body.Full entry Close and is cinched tight, and a stitching device (such as the Endo Stitch) passes its needle between two jaws and doubles as a knot pusher. A port closure device (such as the Carter-Thomason) can close the fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close at a port site. Chapter 21 covers the scope and ports themselves.

Retention sutures and other helpers

Retention sutures are heavy, nonabsorbable, interrupted sutures through all layers of the abdominal wall, a few centimeters out from the incision. They take strain off a wound at risk of splitting open (dehiscencedehiscencedee-HIS-ensThe splitting open of the edges of a wound that had been closed, such as a surgical incision.Full entry Close) or of the bowel pushing through (eviscerationeviscerationih-vis-er-AY-shunThe pushing out of internal organs, usually loops of bowel, through a surgical wound that has come open.e- outviscer/o internal organs-ation processFull entry Close). Where they cross the skin, they run through bolsters of rubber or plastic tubing, or tie over an adjustable bridge, so they do not cut in. A pledget, a small square of felt on a stitch, keeps it from cutting through a fragile vessel wall. A tendon suture may be tied over a button for the same reason, and a suture anchor, a small device of metal or absorbable material (such as a screw) set into bone, holds a suture that fixes tendon or ligament to the bone.

PTFE Felt PledgetOn 25 setups

Cutting suture

Use suture scissors, never tissue scissors. Steady the blades with your index finger, open them slightly, slide the tips down to the knot and turn them to about a 45-degree angle, which leaves a short tail. When you can, keep the strand and knot in view so you cut nothing else. Leave the tail the surgeon wants: long enough that the knot holds, short enough to leave little foreign material. Monofilament knots slip more easily, so their tails are usually left a little longer. Cut too short, and you may cut the knot itself; then the stitch has to come out and be placed again.

When you must cut while doing other tasks, you can palm the scissors. Pick cut ends out of the wound area so they cannot fall in. To take a stitch out, lift it with a straight clamp, cut it below the knot on one side only, and pull it through; cut both sides, and the strand can be drawn into the wound, where it may not be found without opening the wound. A straight hemostat, such as a Crile or Kelly, is the best tool for pulling out the remains of a cut suture. When the surgeon removes old sutures from an earlier operation, often buried in scar, a fine straight hemostat works best: lay a folded towel on the field to hold the pieces so none drop back into the wound, then take the towel off the field.

First, second and third intention

Surgical wounds are also named by how they are closed, which decides how they heal. How the body heals a wound is taught in chapter 11.

• First intention (primary): a clean wound sutured closed, so its cut edges touch and heal together.
• Second intention (granulation): a wound left open, such as an infected or badly contaminated one. It fills in slowly from its base with granulation tissuegranulation tissuegran-yuh-LAY-shun TISH-ooNew, moist, red tissue that fills a healing wound from the bottom up.Full entry Close and leaves a larger scar, and a large one may need a skin graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close.
• Third intention (delayed primary closure): an infected or contaminated wound is treated and packed open first, then sutured once enough granulation tissue has grown.

11Blades

Scalpel blades fit handles by number: #10, #11, #12 and #15 fit the #3 and #7 handles, and #20 and up fit the #4 handle.

• #10: a curved edge, for skin incisions.
• #11: for small puncture (stab) incisions, such as port sites.
• #12: curved, cutting on the inside of its curve, for tonsiltonsilTON-sulOne of the masses of lymph tissue at the back of the throat that help fight germs entering the mouth and nose.Full entry Close and palate surgery.
• #15: for short, delicate cuts: small vessels, plastic surgery skin incisions and the hand.
• #20 and #22: larger versions of the #10; the #20 for orthopedic surgeryorthopedic surgeryor-thuh-PEE-dik SUR-juh-reeSurgery on the bones, joints, ligaments, tendons and muscles.ortho- straightped child (the specialty began with straightening children's bones)-ic relating toFull entry Close, the #22 for chest and heart incisions.

Scalpel BladeOn 294 setups

Never load or remove a blade with your fingers. To load one, grip the blade's dull side with a hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close or a needle holder and fit it into the handle's slots. Skip any needle holder whose jaws are lined with diamond dust or special metal: loading blades can knock its jaws out of line. To take a blade off, use a single-handed blade remover, or use a safety scalpel instead, such as one with a retractable blade or a single-use handle that is never taken apart.

With a safety scalpel, AST suggests the scrub uncovers the blade, places the scalpel in the neutral zone, and covers it again when it returns. Pass every knife through the neutral zone, drop used blades straight into the sharps container, and pick up a blade dropped on the field with forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close.

12Sponges

Sponges soak up blood, cushion tissue under retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close, hold bowel aside and help separate tissue. Every sponge used in a wound has a radiopaqueradiopaqueray-dee-oh-PAYKBlocking x-rays, so the material shows up white on an x-ray image.radi/o radiation, x-rayopaque not letting throughFull entry Close markermarkerMAR-kerSomething that can be measured, such as a substance in the blood, that shows a disease or body process is present.Full entry Close that shows on x-ray, and gauze without one never goes in. AST and AORN guidance say sponges are never cut or altered.

• Raytec (4 by 4): woven gauze folded into a 4-inch square, for shallow wounds. In a deep wound or body cavity, it is always mounted on sponge forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close as a sponge stick: fold it in thirds one way and in half the other, with the folded edge at the tip. Any loose Raytec comes off the field before the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close is opened.

Radiopaque Gauze SpongesOn 156 setups

• Laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close sponge (lap): a large pad with a loop of tape and a radiopaque marker at one corner, for the abdomen and chest. Wet it in warm saline and wring it out before passing, unless the surgeon wants it soaking wet or dry.

Laparotomy SpongeOn 92 setups

• Dissectors (peanuts, Kittners, cherries, pushers): small, tightly rolled sponges for blunt dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close, always passed on a clamp. Spares stay in their holder, never loose on the field.

Peanut and Kittner SpongesOn 38 setups

• TonsiltonsilTON-sulOne of the masses of lymph tissue at the back of the throat that help fight germs entering the mouth and nose.Full entry Close sponges: gauze-covered balls on a string, for the throat. The string stays outside the mouth so a sponge cannot fall into the airway; check it is still attached when the sponge comes back.
• Cottonoids (patties): flat squares of pressed cotton or rayon with a string, for brain, spine, ear and vascular surgery. They are usually wet with saline or a drug such as thrombinthrombinTHROM-binAn enzyme in the blood that turns fibrinogen into fibrin, the threads that hold a blood clot together.thromb/o clot-in substanceFull entry Close, kept moist the whole case, and offered from a basin or on a flat ribbon retractor, and they can sit between a suction tip and delicate tissue. Every one comes back with its string; never cut the strings.

CottonoidOn 25 setups

• Cellulose spears (such as Weck-Cel): small cellulose sponges used in eye and eyelid surgery to dab tiny bleeders, so the surgeon has a dry view and can find each bleeder to cauterize.
• Dental sponges: small 2 by 2 gauze sponges, with cotton rolls or dental pellets, for mouth and tooth surgery. A gauze throat pack with a radiopaque thread is moistened and placed in the throat; it is counted, and it must come out before the breathing tube does.

Keep one basin of saline just for wetting sponges, because lint comes off them. Drop used sponges, never throw them, into the kick bucket for the circulator to count.

13Drains

Blood and serumserumSEER-umThe clear, yellow liquid left from blood after it clots and the cells are removed.Full entry Close that collect in a wound give germs a place to grow, and a drain gives that fluid, or air, a way out. Most drains leave through a small stab wound beside the incision and are stitched to the skin with nonabsorbable suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close. They are made of PVCpremature ventricular contractionpree-muh-CHOOR ven-TRIK-yuh-ler kun-TRAK-shunAn extra heartbeat that starts early from a ventricle instead of from the heart's normal pacemaker.Full entry Close, silicone (Silastic is a silicone rubber), rubber or latexlatexLAY-teksNatural rubber made from the sap of the rubber tree, used in some gloves, catheters and other medical supplies.Full entry Close, so check for a latex allergylatex allergyLAY-teks AL-er-jeeAn allergic reaction to proteins in natural rubber latex, found in some gloves, catheters and other products.Full entry Close. Before a drain goes in, look it over and make sure it is open all the way through, because a faulty drain can leave a piece behind when it is pulled.

All but the simplest drains empty into a reservoirreservoirREZ-er-vwarA place where germs live and multiply, such as a person, animal, water or soil.Full entry Close, which keeps the fluid contained so infection does not spread and lets the team measure it. Keep every drain's collection unit below the level where its tube leaves the body, so fluid cannot run back in.

Drains are flat or tube-shaped, with or without a reservoir, and they are open or closed. An open drain, such as a Penrose, lets outside air reach the wound. A closed drain is sealed from the air and works by suction or a pressure difference.

Passive drains

Passive drains work by gravity and capillarycapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close action.

• Penrose: a soft, flat, thin-walled tube that lets fluid run out into the dressing, with no reservoir. A Penrose is also looped around a structure, such as the esophagusesophagusih-SOF-uh-gusThe muscular tube that carries food and liquid from the throat to the stomach.esophag/o esophagusFull entry Close, to lift and hold it.

Penrose DrainOn 37 setups

• T-tube: drains bilebilebileA yellow-green fluid made by the liver and stored in the gallbladder that helps digest fats.chol/e bileFull entry Close from the bile ductbile ductbyle duktOne of the tubes that carry bile from the liver and gallbladder to the small intestine.Full entry Close into a bag.
• Catheters such as the Foleyindwelling urinary catheterin-DWEL-ing YUR-ih-nair-ee KATH-uh-terA tube passed through the urethra into the bladder and left in place to drain urine into a bag.Full entry Close, Malecot and Pezzer also drain passively, as after genitourinarygenitourinaryjen-ih-toh-YOOR-ih-nair-eeRelating to the genital (reproductive) organs and the urinary organs together.genit/o reproductive organsurin/o urine-ary relating toFull entry Close surgery (chapter 34). Drains such as the Pezzer, Malecot and Penrose are usually set in place in the wound with a blunt clamp, such as a Mayo or Pean.
• Sump drain: a tube inside a tube. Fluid seeps into the outer tube, which has many holes, and is drawn off through the inner one, a design that keeps the holes from clogging. It handles large amounts of fluid deep in the abdomen. AST's Core Curriculum groups it with the passive drains, though it works best on low suction.

Active drains

• Closed suction drains, such as the Jackson-Pratt (a soft bulb) and the Hemovac (a canister that is pressed flat): perforatedperforationper-fuh-RAY-shunA hole that goes all the way through the wall of an organ or tissue.per- throughforat bored (a hole)-ion processFull entry Close tubing in the wound connects to a reservoir. Once the wound is closed, squeezing the reservoir flat and closing its plug creates suction that draws fluid out as it slowly opens up. As the dressing is taped, the circulator connects the drains' nonsterile ends (dressings are in chapter 30).

Closed Suction DrainOn 79 setups

• The tubing leaves the skin on a sharp trocartrocarTROH-karA sharp or bladed instrument inside a tube (cannula), used to pierce a body wall and leave the tube in place as a port.Full entry Close. Take off its guard with an instrument, pass it through the neutral zone, and put the cut-off trocar straight into the sharps container.
• Negative pressure wound therapywound vacuum-assisted closurewoond VAK-yoom uh-SIS-tid KLOH-zhurA wound treatment that uses a sealed dressing connected to a suction pump to draw fluid out and help the wound heal.Full entry Close (a wound VAC): foam in the wound, sealed under film and connected to a pump that keeps up steady suction. It removes fluid, keeps the wound moist and reduces swelling.

Negative Pressure Wound Therapy SystemOn 2 setups

• A stomastomaSTOH-muhAn opening on the surface of the body made by surgery, such as the end of bowel brought out through the belly wall.stoma mouth, openingFull entry Close pouch, which collects drainage from an opening made onto the skin in surgery, goes on with the dressings (chapter 30).

Chest drainage

The space around the lungs normally holds a negative pressurenegative pressureNEG-uh-tiv PRESH-erPressure that is lower than the pressure around it, so air or fluid is drawn in.Full entry Close that keeps them open. After chest surgery or injury, a chest tubechest tubechest toobA tube placed through the chest wall into the space around the lung to drain air, blood or fluid.Full entry Close connects to a chest drainage unit (the Pleur-evac is one brand) with three chambers: one collects drainage, one holds a water seal that keeps air from being drawn back into the chest, and one controls suction. Keep the unit upright and below the chest at all times, because fluid running back can collapse the lung. Chest tubes are stiff Silastic or PVC tubes with many holes near the tip, sewn to the skin with heavy nonabsorbable suture and dressed with petroleum gauze, fluffs and flat gauze; two tubes may be joined with a Y-connector to one unit. Connections are secured with bands or tape, and each tube is labeled, such as anterior and posterior. If a tube comes out, cover the hole at once with sterile petroleum gauze, so air cannot rush in. Tubes come out when the air leak has stopped and the drainage has stayed low for 24 hours.

Chest TubeOn 45 setups Chest Drainage UnitOn 45 setups

14Drapes

Drapes form a barrier between the prepped incision site and everything that is not sterile. Draping itself comes in chapters 26 and 28; these are the materials.

• Nonwoven disposable drapes are impervious or nearly so. Woven cloth drapes are treated to resist moisture but are not waterproof, so they need extra layers where fluid will be. AST calls for impervious, fluid-resistant drapes, especially around the opening.
• Towels square off the incision site as the first layer.
• Adhesive barrier drapes: plastic towel drapes (such as the Steri-Drape) with a strip of adhesive along one edge, used to wall off an area, such as the eyes, nose and mouth in ear surgery.
• Fenestrated drapes have a window (fenestration) over the incision, made for each area: laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close, thyroid, eye, extremity and more.

Fenestrated DrapeOn 58 setups

• Plain sheets (half, three-quarter or full), also called utility drapes, cover large areas, and split or U-drapes wrap around a limb or the hip. Universal drapes are used with towels in place of a fenestrated sheet on some cases.
• Fluid-collection pouch: a pouch, built into a drape or added to it, that catches and channels large amounts of irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close and blood, with ports to drain it during the case, as in orthopedicorthopedicor-thuh-PEE-dikHaving to do with the bones, joints, muscles, ligaments and tendons, and the branch of medicine that treats them.orth/o straightped/o child (the field began with straightening children's bones)-ic relating toFull entry Close, brain, gynecologicgynecologygy-nuh-KOL-uh-jeeThe branch of medicine that cares for the female reproductive organs and breasts.gynec/o woman-logy study ofFull entry Close and urologic surgery.
• Incise drapes: clear adhesive plastic pressed onto the prepped skin over the incision, plain or impregnated with an iodineiodineEYE-uh-dyneA mineral the thyroid gland uses to make thyroid hormone; it is also used to kill germs on the skin and in some contrast dyes.Full entry Close antiseptic. The CDC finds them not necessary to prevent infection, so whether one is used follows the surgeon and your facility's policy. When one is used, some guidelines call for the iodine type, except for a patient allergic to iodine.

Incise DrapeOn 82 setups

• Stockinette: a fabric tube, impervious or not, rolled up over an arm or leg. Coban, a stretchy wrap that sticks to itself, may be wound over it.
• Equipment covers: sterile plastic sleeves shaped for the microscope, C-arm, cameras, probes and robot.

15Electrosurgical supplies

Chapter 20 explains electrosurgeryelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close and its safety. These are the supplies you set up.

• Active electrode: the handheld pencil, often called the Bovie, with changeable tips: blade, needle, ball, loop and extended, some insulated or coated. Check the cord and insulation, and seat the tip firmly. The tip counts as a sharp: it is part of the sharps count and goes into the sharps container at the end.

Electrosurgical Electrode TipsOn 34 setups

• Safety holster: a nonconductive holder on the drapes, in plain sight and within the surgeon's reach, preferably fastened with a clamp that is not metal. The pencil goes back in it after every use, never onto the patient or drapes.
• Scratch pad: an abrasive pad for cleaning char (escharescharES-karThick, dry, dark dead tissue that covers part or all of a wound.Full entry Close) off the tip, kept handy for the surgeon but away from the wound. A coated, nonstick tip is wiped with a wet sponge instead, because the pad ruins the coating. Never scrape a tip with a blade; it pits the tip and risks a cut.
• Patient return electrode: the adhesive, gel-coated pad that carries current back to the generator in monopolar electrosurgery. Check its expiration date, pick the right size, never cut it, and place it on clean, dry skin over a large muscle near the surgical site. Bipolarbipolarby-POH-lerHaving two poles or two opposite ends; most often used as a short form of bipolar disorder.bi- twopolar having polesFull entry Close instruments need no pad.

Patient Return ElectrodeOn 306 setups

• Other energy handpieces you will set up: bipolar forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close, some with an irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close channel at the tips; vessel-sealing devices (such as LigaSure); the harmonic (ultrasonic) scalpel, which coagulatescoagulationkoh-ag-yuh-LAY-shunThe process by which blood changes from a liquid into a gel, forming a clot.coagul clot-ation processFull entry Close and divides tissue between its jaws; the argon beam coagulator; radiofrequency ablationablationab-LAY-shunA procedure that destroys a small area of tissue, often with heat or cold, to stop it from causing a problem.Full entry Close probes; and suction coagulators. Chapter 20 explains how each kind of energy works.

16Staplers and clips

Staplers close or join tissue quickly with staples of stainless steel, titanium or absorbable material. Each staple closes into a B shape that does not crush, so blood still reaches the tissue edges. Staplers come disposable or reusable, for open or minimally invasive surgery, and most take color-coded reloads. A reusable stapler is put together by the scrub during setup; a disposable one comes assembled and sterile, and new cartridges load into it so one stapler can fire again. Each company's stapler works differently, so learn each one through the maker's training. Chapter 32 shows them at work.

Stapling is faster than suturing, with less blood loss and less time under anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, but it costs more, and a misplaced staple line is much harder to fix than a stitch. Besides the open and endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close kinds, staplers come powered (batterybatteryBAT-uh-reeIn law, touching a person on purpose without their consent.Full entry Close driven), robotic (fired from the robot's arm) and for skin and subcuticular closure.

• Linear stapler: straight, staggered rows that close tissue without cutting it.

Linear StaplerOn 14 setups

• Linear cutter: two double rows with a knife between them, sealing and dividing in one firing, as in bowel surgery.
• Circular (intraluminal) stapler: a double ring of staples with a circle trimmed inside it, to join two ends of bowel, often low in the colon.

Intraluminal StaplerOn 6 setups

• Staple line reinforcement: strips of absorbable synthetic or biologic material (a buttress) fitted to the stapler's jaws, a glue, or stitches sewn over the line, used to cut bleeding and leaks along a staple line, as in a sleeve gastrectomy.
• Skin stapler: one staple per squeeze, the arrow on the stapler head lined up on the skin edges while the surgeon turns them outward with toothed forcepsforcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry Close. Quick, low in tissue reaction and even in tension, though it leaves more marks than a subcuticular closure and the staples must be taken out later. AST's position is that a CSTCSTsee-es-tee (said as letters)Certified Surgical Technologist, a credential for surgical technologists; in maternity care, contraction stress test.Full entry Close has the training to run the skin stapler while the surgeon or assistant everts the edges.

Skin StaplerOn 57 setups

Staplers can misfire, fail to fire or form staples badly. When you reload a linear cutter, wipe off the other side of its jaws so no staple from the last firing is left behind, because a leftover staple can make it misfire or not fire at all. The FDA asks teams to read the maker's instructions, keep a range of staple sizes on hand, use the cartridge that matches the tissue's type and thickness, and, if a stapler fails on tissue, clamp or tie the vessels before it is released.

Ligating clips close a vessel or duct in place of a tie. They are stainless steel, titanium or absorbable, come in sizes from micro to large, each matched to its own applier, and are usually placed on both sides before the structure is cut between them. Appliers come disposable and preloaded, or reusable and loaded one clip at a time, with long versions for laparoscopylaparoscopylap-uh-ROS-kuh-peeSurgery or an exam done through small cuts in the belly, using a thin, lighted tube with a camera.lapar/o abdomen-scopy looking with an instrumentFull entry Close.

Ligating ClipsOn 74 setups Hemostatic Clip ApplierOn 88 setups

17Syringes and injection needles

• Fittings: a Luer-lock tip twists on and locks, so a needle or tubing cannot pop off. A slip tip pushes on and pulls off, for low-pressure uses. Both ends of a connection must match.
• Sizes: 1 mL to 60 mL, each marked along the barrel in milliliters. The 1 mL tuberculin syringe measures tiny doses; never confuse it with an insulininsulinIN-suh-linA hormone made by the pancreas that lets the body's cells take in glucose, also made as a medicine.Full entry Close syringe, which is marked in units. A 60 mL syringe is for flushing and irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close, not measuring. Most syringes are plastic; glass ones are used when a very smooth injection matters, such as injecting local anestheticlocal anestheticLOH-kul an-es-THET-ikA drug that blocks feeling in one part of the body without making the person unconscious.Full entry Close into tissue.
• Control syringe: rings for the thumb and fingers, for better control while injecting, such as local anesthetic.
• Prefilled cartridges: some drugs come in a ready-filled cartridge that fits a holder with a plunger. The older Tubex system was replaced by the Carpuject.
• Irrigation: the Asepto, a bulb on a barrel holding about 120 mL, is the usual irrigator in open cases. The bulb syringe has no barrel, for small areas and an infant's mouth and nose. The Toomey is a large syringe, often used through a catheter to irrigate the bladder. Keep track of the irrigation you use, because it mixes with blood in the suction canister and the team needs it to estimate blood loss.

Bulb SyringeOn 103 setups

• Needles: hypodermic needles are sized by gauge and length. The higher the gauge, the thinner the needle: an 18-gauge is wider than a 22-gauge. A blunt needle draws a drug from the circulator's vial without risk of a stick, and a filter needle keeps glass out when drawing from an ampule. Spinal needles are 3 to 4 inches long with a stylet. An angiocatheter (such as the Angio-Cath) uses a needle to place a plastic tube that stays in a vein or artery. Chapter 12 covers drawing up and labeling drugs on the field.

Hypodermic NeedleOn 144 setups

• Recapping: never with two hands. If the same needle will be used again on the same patient, scoop the cap up from the Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close one-handed and leave it loose.

18Containers and field items

• Basins: one for irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close and a second only for wetting sponges, placed so the circulator can pour without reaching over the field.
• Medicine cups: set at the edge of the back table to be filled, then moved in. Label every cup, basin and syringe that holds a solution or drug.

Medicine CupOn 138 setups

• Specimen cups: hold tissue in a safe spot on the back table until it goes off the field.
• Pitchers, trays and petri dishes: sterile containers come in many shapes, and many carry graduated marks for measuring. A graduated pitcher sits at the edge of the back table to be filled, like a medicine cup, and a petri (culture) dish can hold a small piece of tissue, such as a donor corneacorneaKOR-nee-uhThe clear, dome-shaped layer at the front of the eye, over the iris and pupil.Full entry Close.
• Light handle covers: sterile covers that let the sterile team move and focus the overhead lights.
• Magnetic mat or needle counter: holds used needles and small sharps where you can see and count them.
• Sterile marking pen, ruler and labels: for marking the skin and labeling drugs and solutions.

Sterile Skin MarkerOn 106 setups

• SuturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close bag: a paper bag from the back table pack for empty packets and used ties.

19Suction

Tubing joins the tip on the field to a canister. Set it up with the tip attached, and draw sterile water through it now and then so blood does not clot inside. Firm, large-bore tubing is used with high-power suction, as in liposuction.

• Yankauer (tonsiltonsilTON-sulOne of the masses of lymph tissue at the back of the throat that help fight germs entering the mouth and nose.Full entry Close suction): a rigid, angled tube with a rounded tip, the most used tip, which suctions without grabbing tissue.

3D Yankauer SuctionOn 227 setups Suction TubingOn 312 setups

• Frazier: a thin, angled tip with a thumb hole; covering the hole increases the pull. For small spaces such as the nose, spine and skull, with a wire stylet to clear it.
• Poole: an outer sheathsheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry Close with many holes over an inner tube, for large amounts of fluid in the abdomen. The holes spread the suction so bowel is not drawn against the tip.

Poole Suction CannulaOn 6 setups

• Smoke evacuation: electrosurgeryelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close and lasers make a smoke plume that carries chemicals, cells and germs. A smoke evacuator with a filter removes it. Hold the wand as close as you can to where the tip meets the tissue, always within 2 inches (5 cm), without blocking the surgeon's view.

Smoke EvacuatorOn 39 setups

• Cell salvage: a cell saver suctions the patient's own blood, washes and filters it, and returns it, reducing the need for donor blood. Topical hemostatic agentshemostatichee-moh-STAT-ikStopping bleeding; also, a product or agent used to stop bleeding.hem/o blood-stasis stopping, standing still-ic relating toFull entry Close and some antibiotics should not be suctionedsuctioningSUK-shun-ingRemoving mucus, saliva or other secretions from the mouth, nose or airway with a tube connected to a suction source.Full entry Close into it, and amniotic fluidamniotic fluidam-nee-OT-ik FLOO-idThe fluid inside the amniotic sac that surrounds and protects the baby during pregnancy.Full entry Close needs its own separate suction.

20Tissue repair and replacement

Closing skin without suture

• Skin closure tapes (such as Steri-Strips): adhesive strips that hold small wounds closed or support a subcuticular closure. They need dry skin, and a liquid adhesive such as benzoin helps them stick.
• Skin adhesive (a cyanoacrylate glue, such as Dermabond; the Core Curriculum also names Cavilon): painted in layers over skin edges held together. It seals out germs, needs no removal and wears off on its own in about 5 to 10 days. Only for wounds not under tension, and never on an infected wound or for a patient allergic to cyanoacrylate or formaldehyde.
• Wound zipper: two adhesive strips joined by a zipper. The strips go on clean, dry skin on each side of the incision, and closing the zipper pulls the edges together, with no needle holes and no needles to stick anyone.

Mesh

Mesh bridges or strengthens tissue that cannot be closed without tension, most often in herniaherniaHER-nee-uhA bulge of an organ or tissue through a weak spot in the muscle or tissue wall that normally holds it in.Full entry Close repair. Synthetic meshes include polypropylene, which tolerates infection; polyester, which does not; PTFE; and absorbable polyglactin 910 for temporary support. Biologic meshes, made from animal tissue, let the patient's own tissue grow in.

Surgical MeshOn 18 setups

Grafts

• Autograft: tissue moved within the same patient, such as skin, bone, cartilagecartilageKAR-tih-lijFirm, smooth, rubbery tissue that cushions joints and gives shape to parts such as the ear, nose and windpipe.chondr/o cartilageFull entry Close or fat.
• Allograft (homograft): tissue from another person, kept by a tissue bank, such as skin, bone or cartilage.
• Xenograft: tissue from another species, such as pig or cow skin.

Protect an autograft: keep it moist in saline unless the surgeon says otherwise, never on a dry, absorbent surface, in a safe spot on the back table, and point it out when you hand off to another scrub. Implants such as mesh are opened only once the surgeon confirms the exact type and size, and, as with any sterile package, the wrapper is checked for damage and the expiration date confirmed first. Each one goes in the facility's implant log with its lot number and expiration date.

21Other supplies

• Vessel loops: colored silicone loops that lift and hold vessels, nerves and ducts; red usually marks arteries, blue veins, and white or yellow nerves and ducts. Umbilical tape, a cotton tape used wet on a hemostathemostatHEE-moe-statA clamp with finger rings and a locking ratchet used in surgery to grasp and close off bleeding vessels.hem/o blood-stat stopping, standing stillFull entry Close, does the same job.

Vessel LoopsOn 38 setups Umbilical TapeOn 45 setups

• Pain pumps: a small catheter left in the wound or joint and a disposable pump that delivers local anestheticlocal anestheticLOH-kul an-es-THET-ikA drug that blocks feeling in one part of the body without making the person unconscious.Full entry Close for 2 or 4 days, depending on the pump.
• LatexlatexLAY-teksNatural rubber made from the sap of the rubber tree, used in some gloves, catheters and other medical supplies.Full entry Close-free supplies: for a patient with a latex allergylatex allergyLAY-teks AL-er-jeeAn allergic reaction to proteins in natural rubber latex, found in some gloves, catheters and other products.Full entry Close, every item must be latex-free, ideally from a dedicated latex allergy cart, and the patient goes first in the day.
• Emergency supplies: know where the malignant hyperthermiamalignant hyperthermiamuh-LIG-nunt hy-per-THER-mee-uhA rare inherited reaction to certain general anesthesia drugs in which the muscles' metabolism speeds up out of control.mal- badhyper- above normaltherm heat-ia conditionFull entry Close cart and the other emergency carts are and what they hold, so you can fetch them without stopping to think.

Specialty supplies

Each specialty has supplies of its own, and you meet them with the procedures that use them: general surgery (chapter 32), laparoscopiclaparoscopiclap-uh-roh-SKOP-ikDone through a few small cuts in the abdomen with a thin camera and long instruments, instead of one large opening.lapar/o abdomen-scopic viewingFull entry Close and robotic surgery (chapter 21), obstetrics and gynecologygynecologygy-nuh-KOL-uh-jeeThe branch of medicine that cares for the female reproductive organs and breasts.gynec/o woman-logy study ofFull entry Close (33), urology, with its many catheters and stentsstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close (34), eye (35), ear, nose and throat (36), oral and maxillofacial (37), plastic and reconstructive (38), orthopedicorthopedicor-thuh-PEE-dikHaving to do with the bones, joints, muscles, ligaments and tendons, and the branch of medicine that treats them.orth/o straightped/o child (the field began with straightening children's bones)-ic relating toFull entry Close (39), heart, chest and vascular surgery (40 and 41) and neurosurgery (42). Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close supplies are in chapter 13.

22Handling any supply

The same habits apply to every item on this page. Know whether it is disposable or reusable and what it does well or poorly. Inspect it before it goes on the field, because a single-use item can be damaged too: check the package is whole and the date is good. For a device such as a stapler, learn from the maker's training how to prepare, load, reload and unload it. Keep track of what is used, in the count, the implant log and the record.

Know how each device can fail and what to do about it, as with a stapler that misfires (see Staplers and clips). At the end, dispose of each item by its type and your facility's policy: sharps go into the sharps container, and soiled drapes, gowns and gloves are placed, never thrown, into the impervious biohazard bag. Breaking down the field is in chapter 30.

Check yourself5 quick questions

Free for everyone. Pick an answer for each, then check them all at once.

In the ORWhere you'll use this