Transoral Primary Flap Resection
Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (RA-TLH-BSO) · da Vinci hysterectomy · robotic hysterectomy
Through three or four small ports in the neck, and a window is cut out through tiny cuts to find the cause of symptoms that tests could not explain and plan the treatment.
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- Supine
- Anesthesia
- General Anesthesia
- Wound class
- Pro
In 30 seconds
Scan this outside the room.
- Antibiotic before the drapes come off. The dilatorDY-lay-terAn instrument used to stretch or widen an opening, canal or passage in the body.Full entry mark picks the spot. Three 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 , markerMAR-kerSomething that can be measured, such as a substance in the blood, that shows a disease or body process is present.Full entry end first; infusion on the Shea holder; lidocaineLY-doh-kaynA local anesthetic that numbs an area, also given by IV to treat some fast, abnormal heart rhythms.Full entry with epinephrineep-ih-NEF-rinA hormone and drug, also called adrenaline, that raises heart rate and blood pressure and opens the airways.Full entry behind the glans penisGLANZ PEE-nisThe rounded tip of the penis, formed by the end of the corpus spongiosum, where the external urethral meatus opens.Full entry . Five ports: 12 mm working. Groin: #10 blade and electrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry ; incision from under the chest and pelvis, feet hanging free. Spinal needle finds the window; strap muscles parted in the left ventricleLEFT VEN-trih-kulThe heart's lower left chamber, which pumps oxygen-rich blood into the aorta and out to the body.Full entry ; small bleeders controlled at once. 28 to 32 C; vent via the right in moist laps; Deaver and Harrington. Joystick half-pin; 3-in-1 Guide and Positioner, two-finger tight; olive wire and measure the graftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry .
The tray
32 instruments, by what they do. Tap a name for its card.
Allis ForcepsClamping
BabcockClamping
Curved HemostatsClamping
Hemostatic Clip ApplierClamping
Kelly ForcepsClamping
Kocher ForcepsClamping
Right Angle ClampClamping
Rochester Pean ForcepsClampingAll 32 instruments
#3 Knife HandleCutting
Curved Mayo ScissorCutting
Metzenbaum ScissorCutting
Straight Mayo ScissorCutting
Adson ForcepsGrasping
DeBakey ForcepsGrasping
Doyen Intestinal ForcepsGrasping
Ferris Smith Tissue ForcepsGrasping
Foerster Sponge ForcepsGrasping
Toothed ForcepsGrasping
Alexis O Wound Protector-RetractorRetracting
Army-Navy RetractorRetracting
Balfour RetractorRetracting
Bookwalter RetractorRetracting
Deaver RetractorRetracting
Harrington RetractorRetracting
Ribbon RetractorRetracting
Richardson RetractorRetracting
Thompson RetractorRetracting
Bulb SyringeSuctioning
Poole Suction ProbeSuctioning
Yankauer SuctionSuctioning
Mayo-Hegar Needle HolderSuturing
Skin StaplerSuturingClamping & Occluding8
Cutting & Dissecting4
Grasping & Holding6
Retracting9
Suctioning & Aspirating3
Suturing2
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The room
The equipment, the prep and drape, the suture and the medicines.
Electrosurgical Unit
Patient Return Electrode
Suction
Suction Tubing
Smoke Evacuator
Sequential Compression Device
Forced-Air Warming Blanket
Armboard
Laparotomy Sponge
Radiopaque Gauze Sponges
Ligating Clips
Closed Suction Drain
Sterile Basin
Specimen Container
Specimen Tube
Nasogastric Tube
Scalpel Blade
Graduated Pitcher
Incise Drape
Drape with a tube stockinette or glove), a large sheet over the eyes, ears and no sterile drapes. Supine, the table in front and back. A leg holder may hold the leg passes through a pin), and the SCD on; warming. The Foley goes in and is removed and any stool cleaned away; the stoma itself last, a fresh sponge after each wipe of the table, then large sheets or an adhesive plastic drapes over the table tilted to the table.
What closes each layer in this case, by type and size.
See ProEvery medicine in this case, its strength and when it is used.
See ProStep by step
10 steps, one line each.
- 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 . heparinized salineHEP-uh-rih-nyzd SAY-leenSaline with heparin added, used on the field to flush vessels, grafts, shunts and devices so blood does not clot in them.Full entry (dilutedy-LOOTTo make a liquid weaker by adding more liquid, as when a diluent is added to a drug; as an adjective, weakened or watery.Full entry to the surgeon's preference) is labeled, and the vessel loopVES-ul LOOPA thin, stretchy silicone strip looped around a vessel, nerve or duct to lift it, hold it aside or briefly block a vessel.Full entry and umbilical tapeum-BIL-ih-kul TAYPA narrow, flat cotton tape passed around a vessel, duct or other structure to lift it and hold it aside.Full entry are wet. The graftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry plan is confirmed with the surgeon: reversed vein, vein left in place, or synthetic. Assorted vascular graftVAS-kyuh-ler GRAFTA tube or patch, synthetic or biologic, sewn in to replace a section of blood vessel, carry blood around a blockage, patch a vessel or make dialysis access.Full entry and Fogarty catheters are in the room, unopened.
Next up · Pro - 2
Exposing the common femoral artery
Most often the groin is opened first; some surgeons start at the knee to check the popliteal arterypop-LIT-ee-ul AR-ter-eeThe artery behind the knee, the continuation of the femoral artery, which divides into the anterior and posterior tibial arteries.Full entry . A #10 blade on the #3 Knife Handle makes a vertical cut over the femoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry below the groin crease, and a Weitlaner Retractor or Gelpi Retractor holds it open. The common femoral artery is freed in both directions, and wet tapes or vessel loopVES-ul LOOPA thin, stretchy silicone strip looped around a vessel, nerve or duct to lift it, hold it aside or briefly block a vessel.Full entry go around the common, superficial and deep femoral arteries, each brought behind the vessel with the Right Angle Clamp.
Next up · Pro - 3
Exposing the popliteal artery
A cut is made along the inside of the lower thigh, or just below the knee, depending on where the bypass will end. A Weitlaner Retractor holds the muscles back; Army-Navy Retractor, Richardson Retractor or Cushing Vein Retractor retractors are used deeper. The knee is flexed and the popliteal arterypop-LIT-ee-ul AR-ter-eeThe artery behind the knee, the continuation of the femoral artery, which divides into the anterior and posterior tibial arteries.Full entry is freed and encircled with a wet umbilical tapeum-BIL-ih-kul TAYPA narrow, flat cotton tape passed around a vessel, duct or other structure to lift it and hold it aside.Full entry or vessel loopVES-ul LOOPA thin, stretchy silicone strip looped around a vessel, nerve or duct to lift it, hold it aside or briefly block a vessel.Full entry .
Next up · Pro - 4
Harvesting the saphenous vein
The 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 is exposed through one long cut or several short ones along the inner thigh, with the Metzenbaum Scissor and the DeBakey Forceps. Its side branches are tied with 4-0 or 5-0 silk or closed with small clips, then divided. The vein is flushed with heparinized salineHEP-uh-rih-nyzd SAY-leenSaline with heparin added, used on the field to flush vessels, grafts, shunts and devices so blood does not clot in them.Full entry through the Heparin Flushing Needle, tested for leaks, and set aside in a basin.
Next up · Pro - 5
Tunneling the graft
The Crawford Cooley Tunneler is passed under the sartorius muscle between the knee and groin cuts. The vein is marked along one side with the Sterile Skin Marker so it is not twisted, and pulled through the tunnel without kinks or tension. Reversed, the end that was in the groin is sewn to the popliteal arterypop-LIT-ee-ul AR-ter-eeThe artery behind the knee, the continuation of the femoral artery, which divides into the anterior and posterior tibial arteries.Full entry .
Next up · Pro - 6
Heparin, clamping and the femoral arteriotomy
anesthesiaan-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 gives IV heparinHEP-uh-rinAn anticoagulant drug, given by injection or IV, that keeps blood clots from forming or growing.Full entry . The common femoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry is clamped with an angled vascular clampVAS-kyuh-ler KLAMPA clamp with light, finely ridged jaws that stops or slows blood flow in a vessel without crushing or tearing its wall.Full entry (Debakey Peripheral Vascular Clamp), and the superficial and deep femoral arteries are controlled with the vessel loopVES-ul LOOPA thin, stretchy silicone strip looped around a vessel, nerve or duct to lift it, hold it aside or briefly block a vessel.Full entry or bulldogs (Bulldog Clamp, Glover Bulldog Clamp). A #11 blade on the #7 Knife Handle opens the artery, and the Potts-Smith Scissors lengthens the cut.
Next up · Pro - 7
The proximal anastomosis
The vein is sewn end to side to the common femoral arteryFEM-er-ul AR-ter-eeThe large artery that carries blood to the leg, running through the groin and down the thigh.Full entry with a running 6-0 Prolene on the Castroviejo Needle Holder. Shods hold the sutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry ends, and heparinized salineHEP-uh-rih-nyzd SAY-leenSaline with heparin added, used on the field to flush vessels, grafts, shunts and devices so blood does not clot in them.Full entry irrigates. Before the joint is finished, blood is let through to flush it.
Next up · Pro - 8
The distal anastomosis
The knee is flexed and the popliteal arterypop-LIT-ee-ul AR-ter-eeThe artery behind the knee, the continuation of the femoral artery, which divides into the anterior and posterior tibial arteries.Full entry is closed off with small bulldogs or by tightening the vessel loopVES-ul LOOPA thin, stretchy silicone strip looped around a vessel, nerve or duct to lift it, hold it aside or briefly block a vessel.Full entry . It is opened the same way, and the end of the vein is trimmed and sewn to it with a running 6-0 or 7-0 Prolene. Before the last stitches, the clamps are released to flush and the inside is washed with heparinized salineHEP-uh-rih-nyzd SAY-leenSaline with heparin added, used on the field to flush vessels, grafts, shunts and devices so blood does not clot in them.Full entry .
Next up · Pro - 9
Checking the bypass
The ends are tied and blood flows through the bypass. The surgeon checks it with the Doppler ultrasoundDOP-ler UL-truh-soundAn ultrasound that uses sound waves to hear or show blood flowing through vessels or the fetal heartbeat.Full entry and may do an angiographyan-jee-OG-ruh-feeAn imaging test that shows blood vessels by injecting a contrast dye and taking x-ray, CT or MRI pictures.angi/o vessel-graphy process of recordingFull entry on the table (contrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry , syringes and an arterial needle or catheter).
Next up · Pro - 10
Closing
Each cut is closed in layers and dressings go on each.
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What to grab, before anyone asks.
What to grab for this case if it bleeds, spills or has to be opened.
See ProThe case
A femoropopliteal (fem-pop) bypass treats peripheral arterial disease when the superficial femoral artery, the main artery of the thigh, is narrowed or blocked and the leg is no longer getting enough blood. Patients usually come in with pain when walking, pain at rest, or wounds on the foot that will not heal. The surgeon builds a new path for blood: one end of a graft is attached to the femoral artery in the groin and the other to the popliteal artery above or below the knee. Before surgery, ultrasound and an x-ray of the arteries show where the blockage is and whether the artery below it is open.
The patient's own great saphenous vein is the preferred graft, especially when the bypass ends below the knee. It is either removed and turned end to end (reversed) so its one-way valves do not block arterial flow, or left in place and the valves are cut (in situ bypass). When the vein is too small or has already been used, a synthetic graft such as PTFE or Dacron is used instead. If the popliteal artery is also diseased, the graft is carried further down to an artery in the lower leg (femorotibial bypass).
The operation is done under general, spinal or epidural anesthesia, through cuts in the groin, along the inner thigh and near the knee. Patients stay in hospital several days, until they are stable and walking without help, and blood thinners are often given afterward to keep clots from forming. Risks include bleeding, wound infection, heart attack, stroke, a clot in the lungs, and a graft that clots or fails; if the bypass fails, an amputation may become necessary.
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Kenneth ZimmermanReviewer
Angel PenaReviewer
Checked against 10 textbooks, AST standards and other references.
All 10 sources
- Association of Surgical Technologists. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 4th ed. Chapter 23 (Peripheral Vascular Surgery), Table 23-1 Typical Peripheral Vascular Instrument Set, p. 1097
- Procedure 23-6 Abdominal Aortic Aneurysm with Graft, p. 1118
- Procedure 23-8 Unilateral Femoropopliteal Bypass, p. 1124-1127.
- Goldman MA. Pocket Guide to the Operating Room. 3rd ed. Chapter 21 (Vascular Surgery), Carotid Endarterectomy Special Notes, p. 489
- Femoropopliteal Bypass, p. 496-500
- Chapter 36 (Cardiovascular Procedures Instrument Trays), Peripheral Vascular Procedures Tray, p. 1127-1128.
- Rothrock JC, ed. Alexander's Care of the Patient in Surgery. 17th ed. Chapter 24 (Vascular Surgery), Femoropopliteal and Femorotibial Bypass and Femoropopliteal Bypass In Situ, p. 899-900.
- Fuller JK. Surgical Technology: Principles and Practice. 8th ed. Chapter 18 (Surgical Skills I), Counts, p. 381.
- Nemitz R. Surgical Instrumentation: An Interactive Approach. 3rd ed. p. 35, 38, 81.
- Association of Surgical Technologists. Guidelines for Best Practices for Safe Medication Practices. p. 3.
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