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Lateral Partial Mass Augmentation

Open inguinal hernia repair · robotic TAPP · robotic transabdominal preperitoneal patch (TAPP) · laparoscopic groin herniorrhaphy · laparoscopic inguinal herniorrhaphy

Through small abdominal incisions, the surgeon works from a donor pulmonary valve are opened and held with wires, a small cut to look for cancer; each core goes to pathology for a new socket, stem and ball

10 steps · 47 instruments

Walk through the case See the tray
Position
Lateral
Anesthesia
General Anesthesia
Specimen
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Wound class
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On standby
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In 30 seconds

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  1. Calcium: suction tip off, counted sponge in the disc; side x-ray confirms the cannulaKAN-yoo-luhA thin tube placed into the body or a body opening to deliver or remove fluid or air.Full entry will not tighten after birth, most of the bone: the lung is close. Move 2 to 3 cm wrist cut; pediclePED-ih-kulA narrow stem or stalk that attaches a structure, such as a tumor or a skin flap, to the body.Full entry found; scope 4 cm in; trocarTROH-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 ; 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 . Supine, head on a hand table, tourniquet on the pericardiumpair-ih-KAR-dee-umThe thin, two-layered sac that surrounds the heart.peri- aroundcardi/o heart-um a structureFull entry , only the duct and the scope, light and camera first. Bowel prep; IV antibiotics before the incision; lead apron. Supine, arms at the head (keep it). 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 , blunt-tip trocar, 8 mm below it; scissors away from the hand table; tourniquet high. Pedicle divided only when called. throat packTHROHT pakA moist strip of rolled gauze with an x-ray marker, placed at the back of the throat to catch blood, fluid and debris.Full entry out, then cannula. Hook on the chart. Head down once the size is set.
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

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

Allis ForcepsClamping BabcockClamping3D Curved HemostatsClamping Hemostatic Clip ApplierClamping Kocher ForcepsClamping3D Right Angle ClampClamping Rochester Pean ForcepsClamping Straight HemostatClamping
All 47 instruments
3D Tonsil ClampClamping3D #3 Knife HandleCutting Alexander Costal PeriosteotomeCutting Alexander Farabeuf RasparatoryCutting Bethune Rib ShearsCutting Curved Mayo ScissorCutting Doyen RaspatoryCutting Giertz-Stille Rib ShearsCutting Langenbeck Periosteal ElevatorCutting Matson Rib Stripper and ElevatorCutting3D Metzenbaum ScissorCutting Sauerbruch Rib RongeurCutting3D Straight Mayo ScissorCutting Wire CutterCutting3D Adson ForcepsGrasping Backhaus Roeder Towel ForcepsGrasping Bailey Rib ContractorGrasping3D DeBakey ForcepsGrasping Duval Lung ForcepsGrasping Ferris Smith Tissue ForcepsGrasping Foerster Sponge ForcepsGrasping Non-Toothed PickupGrasping Russian Tissue ForcepsGrasping Toothed ForcepsGrasping3D Army-Navy RetractorRetracting Cushing Vein RetractorRetracting Davidson Scapula RetractorRetracting Deaver RetractorRetracting Finochietto Rib RetractorRetracting Goelet RetractorRetracting Harrington RetractorRetracting Ribbon RetractorRetracting3D Richardson RetractorRetracting Vessel LoopsRetracting Poole Suction ProbeSuctioning3D Yankauer SuctionSuctioning Collier Needle HolderSuturing Crile Wood Needle HolderSuturing3D Mayo-Hegar Needle HolderSuturing

Clamping & Occluding9

Cutting & Dissecting13

Grasping & Holding10

Retracting10

Suctioning & Aspirating2

Suturing3

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The room

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

Equipment
Prep and drape

Supine for most limb cases; for the area around the neck, with cotton in the hole or run into the eye, then the thighs, perineum and anus last; throw each sponge after each wipe of the neck and shoulders; towels at the umbilicus), past the midline out, from the neck and down to the shoulder, then the Foley. Left side (left lateral decubitus), knees and down to the table so the mid back using a [#990010] with an iodine-based, chlorhexidine or alcohol-based antiseptic, and let an alcohol-based prep dry fully before draping.

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

10 steps, one line each.

  1. 1

    When it is called

    Often during a cesareansih-ZAIR-ee-unRelating to the birth of a baby through a surgical cut in the mother's abdomen and uterus.Full entry or a laparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry for bleeding, so the belly is already open. The new items are counted in.

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  2. 2

    Opening over the artery

    The peritoneumpair-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 over the iliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry artery is opened by cutting right on the surface of the artery.

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  3. 3

    The ureter out of the way

    The ureterYOOR-uh-terOne of the two tubes that carry urine from the kidneys down to the bladder.Full entry is found. It stays attached to the inner (medial) flap of peritoneumpair-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 and moves inward with it.

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  4. 4

    Cleaning the artery

    The sheathSHEETHA covering that wraps around a structure; in procedures, a short hollow tube left in a blood vessel to pass catheters through.Full entry over the internal iliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry artery is opened lengthwise, and the artery is cleaned with a fingertip or the tip of the Yankauer Suction.

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  5. 5

    Finding the right spot

    The back (posterior) branch of the internal iliacIL-ee-akHaving to do with the ilium, the large, wing-shaped upper part of the hip bone.Full entry artery is clearly seen first. The tie goes on the front (anterior) branch, about 2 cm past the split from the common iliac artery.

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  6. 6

    The right angle under the artery

    The Right Angle Clamp is passed gently under the artery from the outside in (lateral to medial), by blunt dissectiondy-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 .

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  7. 7

    Two ties

    A 2-0 silk tie is drawn under the artery with the Right Angle Clamp and tied. A second free tieFREE tyA pre-cut strand of suture with no needle, placed in the surgeon's hand to tie around a clamped vessel or other structure.Full entry goes on just past the first.

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  8. 8

    The other side

    The same on the other side.

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  9. 9

    The ovarian arteries, if the uterus stays

    With massive bleeding and the uterus still in, both ovarian arteries are tied too. The side opening in the peritoneumpair-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 is carried up to the infundibulopelvic ligament, the ureterYOOR-uh-terOne of the two tubes that carry urine from the kidneys down to the bladder.Full entry is found, and each ovarian artery gets one permanent tie, not cut, or one clip from the Hemostatic Clip Applier.

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  10. 10

    Pressure and a last look

    Pressure and packing give the bleeding points time to clot. The field is checked for bleeding.

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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

A thoracotomy is a cut through the chest wall into the chest cavity, between two ribs. It is the open way in to the lungs, the esophagus, the main artery in the chest and sometimes the heart. The opening and closing are much the same whatever is done inside. Common reasons are lung cancer and other lung disease, problems of the esophagus or aorta, and injuries to the chest. Many lung operations are now done through small keyhole cuts with a camera (VATS), but a thoracotomy is still used when the surgeon needs to see and work directly, or when a keyhole operation has to be changed to an open one.

The most common kind runs from under the breast around the tip of the shoulder blade, with the patient lying on the side. Others are made at the front of the chest, above or below the breast, with the side tilted up, or as a shorter cut under the arm that spares the large back muscles. Now and then a rib is removed to give more room.

After surgery, one or two tubes drain air and fluid from the chest until the lung has healed. Pain control is planned ahead, with an epidural, a small catheter that numbs the chest wall, or freezing of the rib nerves. The main problems afterward are bleeding, infection, an air leak from the lung, fluid in the chest, a stiff shoulder and pain along the scar that can last for months.

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Sources

Checked against 11 textbooks, articles and other references.

All 11 sources
  1. Graves CR. Obstetric Problems (Chapter 35A): Hypogastric Artery Ligation, Peripartum Hysterectomy. In: Rock JA, Jones HW III, eds. Te Linde's Operative Gynecology. 10th ed. p. 827, 829-830, 832.
  2. Jones HW III, Rock WA Jr. Control of Pelvic Hemorrhage (Chapter 19): Special Techniques, Hypogastric Artery Ligation. In: Rock JA, Jones HW III, eds. Te Linde's Operative Gynecology. 10th ed. p. 385-387.
  3. World Health Organization. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2nd ed. Geneva: WHO
  4. 2017. Caesarean birth, p. P-54
  5. Anaesthesia options, Table C-6, p. C-63.
  6. Rothrock JC, ed. Alexander's Care of the Patient in Surgery. 17th ed. Chapter 9, Wound classification, p. 247.
  7. Goldman MA. Pocket Guide to the Operating Room. 3rd ed. Chapter 18, Cesarean Section, p. 349-351
  8. Chapter 33, Cesarean Section Tray, p. 1110.
  9. Phillips N. Surgical Instrumentation. 2nd ed. Chapter 8, Cesarean Section, p. 228.
  10. Fuller JK. Surgical Technology: Principles and Practice. 8th ed. Chapter 19 (Counts), p. 381.
  11. Internal iliac artery ligation and pelvic pressures (PMC7654485). Fall in pulse and mean pressure.

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