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Endoscopic Minimal Ankle Excision

ORIF of the arm · soft tissue mass excision

Removal of the distal femur and proximal tibia and femur, and fixed there, so the pathologist can make a new opening.

14 steps · 41 instruments

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Position
Lateral
Anesthesia
Conscious Sedation
Specimen
Pro
Wound class
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In 30 seconds

Scan this outside the room.

  1. A hemostatHEE-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 on each commissure, kept in order; wires wet and safe. A peanut on a padded hand table; tourniquet high. Blood bank called, SCDs and warming on, indwelling 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 to a stable rim. Both groins first: Metz, forcepsFOR-sepsA hand instrument with two blades or arms used to grasp, hold or pull tissue or objects.Full entry and swab. Blood, cell salvageSEL SAL-vijCollecting the blood a patient loses during surgery, washing or filtering it, and giving it back to the same patient.Full entry , slush and two thirds below. saphenous veinsuh-FEE-nus vaynEither of the two main superficial veins of the leg; the great saphenous runs up the inner leg and thigh to the femoral vein in the groin.Full entry : Metz, DeBakey; 4-0 or 5-0, near end 4-0 or 5-0 polypropylene with and without pledgetPLEJ-itA small pad used in surgery, such as a felt square threaded on a stitch to reinforce it, or a cotton or sponge pad that packs or applies a drug.Full entry . Mesh about 12 x 15 cm over the lump. tunnelerTUN-ul-erA long blunt-tipped metal shaft pushed under the skin or between tissue layers from one incision to another to make a path for a graft or catheter.Full entry under the muscle; two fingers. Nothing above and below it.
Where new techs slip
Where new techs slip

The mistakes the books warn about on this case, and how to stay ahead of each.

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The tray

41 instruments, by what they do. Tap a name for its card.

Crawford Cooley TunnelerAccessory Allis ForcepsClamping Bulldog ClampClamping Cooley-Satinsky ClampClamping3D Curved HemostatsClamping Debakey Peripheral Vascular ClampClamping Glover Bulldog ClampClamping Hemostatic Clip ApplierClamping
All 41 instruments
Kocher ForcepsClamping3D Mosquito Clamp - CurvedClamping Mosquito Clamp - StraightClamping3D Right Angle ClampClamping Straight HemostatClamping3D Tonsil ClampClamping3D #3 Knife HandleCutting #7 Knife HandleCutting Curved Mayo ScissorCutting3D Metzenbaum ScissorCutting Potts-Smith ScissorsCutting3D Straight Mayo ScissorCutting3D Adson ForcepsGrasping Adson-Brown ForcepsGrasping Backhaus Roeder Towel ForcepsGrasping3D DeBakey ForcepsGrasping Foerster Sponge ForcepsGrasping Gerald Debakey Tissue ForcepsGrasping Non-Toothed PickupGrasping Toothed ForcepsGrasping3D Army-Navy RetractorRetracting Cushing Vein RetractorRetracting Deep Rake RetractorRetracting Gelpi RetractorRetracting3D Richardson RetractorRetracting Vessel LoopsRetracting3D Weitlaner RetractorRetracting3D Ferg-Frazier SuctionSuctioning Heparin Flushing NeedleSuctioning3D Yankauer SuctionSuctioning Castroviejo Needle HolderSuturing3D Mayo-Hegar Needle HolderSuturing3D Ryder Needle HolderSuturing

Accessory1

Clamping & Occluding13

Cutting & Dissecting6

Grasping & Holding8

Retracting7

Suctioning & Aspirating3

Suturing3

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The room

The equipment, the prep and drape, the suture and the medicines.

Equipment
Prep and drape

Return electrode on for a long sterile run on the left, and the inside of the table, a split sheet wrapped around the wound; for the long case. The Xi arms and column get their own sterile drapes. Folded towels around the site mark. Positioned as for a sternotomy and a U-drape around the head on a donut; arms padded and strapped so the flank and the hand table, a split sheet under the hip surgery so the whole legs to the knee, past the midline, around the shoulders; folded towels to square off both breasts starting at the side, a double tube stockinette,. Lithotomy in Allen stirrups. Supine, the knee may be turned 90 degrees, for the family) and shave the scalp and face to the table will be flexed to open the front of and behind the knee bent 90 to 110 degrees over a pillow under the ankle or high on the thigh as possible, the genitalia included, and down to the table; pad every.

Suture
Suture

What closes each layer in this case, by type and size.

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Medicines
Medicines

Every medicine in this case, its strength and when it is used.

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Step by step

14 steps, one line each.

  1. 1

    Before the first cut

    Count, then the time-outTYM-owtA pause just before a procedure when the whole team confirms the right client, procedure and site; also, a short break to calm a child.Full entry . Two specimen cups are ready, right and left.

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  2. 2

    The uterine manipulator, if used

    A weighted Auvard Vaginal Speculum shows the cervix and the Tenaculum Forceps grasps it. A lubricated Uterine Manipulator goes through the cervix so the uterus can be tipped to bring each tube into view.

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  3. 3

    In at the umbilicus

    An #11 blade on the #3 Knife Handle makes a small vertical cut in the lower edge of the umbilicus, then the Veress Needle goes in.

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  4. 4

    Filling the belly with CO2

    The carbon dioxideKAR-bun dy-OK-sideA gas made by the body's cells as waste, carried in the blood to the lungs and breathed out.Full entry tubing goes on the Veress needleVAIR-es NEE-dulA hollow, sharp needle with a blunt, spring-loaded stylet inside, used to enter the abdomen and fill it with gas for laparoscopy.Full entry . The belly fills slowly, held at no more than 15 mm Hg.

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  5. 5

    The camera port

    The Veress needleVAIR-es NEE-dulA hollow, sharp needle with a blunt, spring-loaded stylet inside, used to enter the abdomen and fill it with gas for laparoscopy.Full entry comes out and a Laparoscopic Trocar goes in, aimed toward the pelvis. The 5 mm 0 Degree Scope goes in for a look, and the table tilts head down.

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  6. 6

    The working ports

    One to three more ports go in low on the belly under the camera's view, below and to the side of the camera port or just above the pubisPYOO-bisThe front part of each hip bone, low in the pelvis; the two meet in the middle at the pubic symphysis.pub/o pubisFull entry .

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  7. 7

    Finding the tube

    The graspers move the bowel and the uterus aside until the tube is found. It is followed out to its fringed end to be sure it is the tube.

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  8. 8

    Sealing the tube free

    The LigaSure Vessel Sealer seals and cuts along the tissue under the tube (the mesosalpinx), staying close to the tube, until the tube is free from its fringed end to the uterus.

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  9. 9

    The tube out

    A grasper pulls the tube out through a port.

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  10. 10

    The other side

    Steps 7 to 9 are done again on the other tube.

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  11. 11

    Washing and checking

    The pelvis is washed and suctioningSUK-shun-ingRemoving mucus, saliva or other secretions from the mouth, nose or airway with a tube connected to a suction source.Full entry with the Suction Irrigator and each cut edge is checked for bleeding.

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  12. 12

    Gas out, ports out

    The scope comes out, the carbon dioxideKAR-bun dy-OK-sideA gas made by the body's cells as waste, carried in the blood to the lungs and breathed out.Full entry is let out, and the ports come out.

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  13. 13

    Closing

    Deep stitches close the fasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry at the larger ports, then the skin is closed with the Mayo-Hegar Needle Holder and Adson Forceps. Skin closure strips, staples or glue go on.

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  14. 14

    Manipulator out

    The manipulator comes out and the cervix is checked for bleeding. A perinealper-ih-NEE-ulHaving to do with the perineum, the area between the genitals and the anus.Full entry pad goes on.

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If it goes wrong

What to grab, before anyone asks.

If it goes wrong

What to grab for this case if it bleeds, spills or has to be opened.

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About the procedure

The case

The fallopian tubes carry eggs from the ovaries to the uterus, and an egg is usually fertilized inside a tube. A salpingectomy removes a tube. When both tubes are removed, pregnancy can no longer happen in the natural way, so this is one form of permanent birth control, often called tubal sterilization or "having the tubes tied". Older methods block or burn a short piece of each tube, or close it with a clip or a ring, instead of removing it. More and more, the whole tube is removed instead, because this may lower the risk of ovarian cancer.

A salpingectomy is also done for a pregnancy growing in a tube (an ectopic pregnancy), a tube that is badly damaged or infected, or a repeat ectopic pregnancy in the same tube. The ovaries stay, so hormones and periods go on as before.

The surgeon works through two to four small cuts in the belly with a camera. The operation is usually done under general anesthesia, though it can be done with local anesthesia, and it is often done as day surgery. Because sterilization cannot be reliably undone, it is talked through carefully beforehand. Risks include bleeding, infection, injury to the bowel or blood vessels while the instruments go in, and, rarely, a pregnancy afterward.

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  • Diana Lei-alohaDiana Lei-alohaReviewer
Sources

Checked against 12 textbooks, AST standards and other references.

All 12 sources
  1. Goldman MA. Pocket Guide to the Operating Room. 3rd ed. Chapter 20 (Thoracic Surgery), Segmental Resection of the Lung (Preparation of the Patient, Skin Preparation, Draping, Equipment, Instrumentation, Supplies, Special Notes), p. 455-459
  2. Pulmonary Lobectomy, p. 460
  3. Pneumonectomy, p. 461-462.
  4. Association of Surgical Technologists. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 4th ed. Chapter 22 (Cardiothoracic Surgery), Instrumentation, Routine Equipment, and Supplies, Tables 22-1 and 22-2, p. 1001-1003
  5. Procedure 22-7 Upper Lobectomy, p. 1027-1028.
  6. Fuller JK. Surgical Technology: Principles and Practice. 8th ed. Chapter 31 (Thoracic and Pulmonary Surgery), Thoracotomy and Lobectomy, p. 888-889
  7. Chapter 18 (Surgical Skills I), Counts, p. 381.
  8. Rothrock JC, ed. Alexander's Care of the Patient in Surgery. 17th ed. Chapter 23 (Thoracic Surgery), Thoracotomy, Pneumonectomy and Lobectomy, p. 868-870
  9. Chapter 9 (Wound Healing, Dressings, and Drains), p. 247
  10. Chapter 2 (Patient Safety and Risk Management), Specimens, p. 28.
  11. Ellison EC, Upchurch GR Jr, eds. Fischer's Mastery of Surgery. 8th ed. Chapter 82 (Pulmonary Resection), sections Diagnosis/Clinical Presentation, Preoperative Planning, Surgical Technique, Standard Incision Line, Posterolateral Mini-Thoracotomy, Thoracotomy Closure, Right Upper Lobectomy, Left Lower Lobectomy, Postoperative Care and Management of Complications, and Commentary.
  12. Association of Surgical Technologists. Guideline: Breaking Down the Sterile Field. p. 2.

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