A O R N J O U R N A L JUNE 1984. VOL 39, NO 7

Ambulatory Surgery Arthroscopy instrumentation and time-savers

icture yourself working in an operating room suite where seven arthroscopies are P scheduled, each averaging about one

hour. Subtract from this hour the six minutes you use to turn over the room. You will use a 17- pound leg holder, video equipment, power equipment, and other sophisticated instrumenta- tion. Multiply this by six surgeons, two of whom each “block-book’’ seven cases one day each week. This is how our freestanding surgical cen- ter works. We succeed because of exceptional team spirit and time-savers.

You may remember when (about three years ago) scrubbing or circulating for an arthroscopy meant preparing and assisting with a tourniquet, inserting a scope, and possibly using a probe. If a meniscus was torn, it was removed by ar- thrototny. Today all those techniques have changed. In the past three to four years, there has been an enormous increase in available in- strumentation and technology. Advances in the field now warrant use of sophisticated video equipment, specialized leg holders, power equipment, and an array of specially designed knives, scissors, and baskets.

This article focuses on two areas-the latest instrumentation and time-saving techniques necessary to be an effective team member.

Chciriges in Iristrumeritcition

rrigation system. One of the first changes we made was with the irrigation system. I Without a good irrigation system, it is dif-

ficult for the surgeon to get a good view of the

joint space. We use 3,000 to 5,0001iter irrigation bags with y-type imgation tubing. We connect two bags to the system. This is convenient, be- cause as one bag empties, the second can be turned on, and as this is running, the next bag hung. The two-bag system does not interrupt the progression of surgery, whereas a one-bag sys- tem could stop the irrigation for a short time.

The tubing is attached to a 6 mm cannula, which is inserted into the medial aspect of the knee through a small stab incision. The outflow suction tubing is connected to the metal sheath of the arthroscope and attached to low wall suction.

Instruments. We still use scissors and baskets for cutting the meniscus. A variety of knives and rotary baskets have also been developed. We like to use a pencil-like knife with disposable blades. Most often we use the 2 cm by % cm double- edged and the retrograde disposable blades. A Swedish knife, with disposable blade and anon- disposable double-edged blade, is also frequent- ly used.

Surgeons use high-speed power equipment. Our arthroplasty system consists of a 4.5 mm and 5.5 mm synovial resector and a 4.0 mm and 5 . 5 mm abrader, which connect to a power pack unit operated by a foot pedal. Each operating room has a power pack assembly, which is plugged into a charger outside the room. This makes the power packs readily available when cutters or resectors are used.

Video sysrern. The video camera is vital be- cause it magnifies and projects a clear view of the inside of the knee onto a television screen. Our video camera is housed in a portable metal cab-

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inet and contains a television monitor, a xenon light source, and a micro-video color unit. The 6-ounce camera attaches to the end of the scope and is encased in a sterile, disposable plastic cover. Using the video camera is a good teaching method for those learning about arthroscopy.

Leg holder. Our surgeons sought better posi- tioning of the leg to manipulate it during surgery.

With the use of a leg holder, the patient is positioned supine with the femoral piece of the table removed and the patient's feet resting on a padded stool. The patient must be positioned at a point where his knees are beyond the break of the table.

After the patient is anesthetized, a tourniquet is applied to the upper thigh and wrapped with an esmarc. After removing the esmarc, the leg holder is applied. A pillow is placed under the knee of the unaffected leg, and a shoulder post is applied on the lateral side to prevent the leg from moving laterally off the table during the proce- dure.

Storcrge. With approximately 70 pieces of in- strumentation, a concise and safe method of storage had to be devised. We purchased a mov- able, metal three-drawer cart to keep the equip- ment organized and locked when not in use. A

Cathleen Harrison Kathleen Upson

Cathleen Harrison. R N . i s ( i i i O R sti!jf nurse (it

HiirlJi)rtl (Crtttii) S i q y i c d Certter. She rec~eived her diplrttii(ijkoitt St Friirtcis Ho.spitc.il School o f N i m i i i g iti Hitrtjiirtl.

Kathleen Upson. R N . is m i OR .sr~!ftiitrsc~ (it H(iri$)rtl Siirgictil Crritrr. She r e c e i w l her tliploniri frorii Htir!fi)rcl Hospitril Sihoo l of Nursirig .

sterilizing tray rests on top of the cart. It can be filled with cold sterilization solution for steriliz- ing the arthroscope, light cord, and power unit.

Time - s a ving Tec hn i y ues

reoperritive. A typical arthroscopy day begins at 7 am with setting up the operat- P ing room. Cases begin at 7:30 am.

Usually three nurses are assigned to the operating room suite-two circulators and one scrub. Each nurse has a specific function, and good team work aids our efficiency.

As one nurse gathers all disposable goods, another assembles and sets up the tables. We use one prep table and one 40 X 17 inch back table. The femoral piece is removed, and the stool is positioned at the end of the table for the patient to rest his feet.

The video cabinet is pushed into position and unlocked. Irrigation bags are hung on an IV pole. The other nurse places arthroscopes, light cords, and power units in cold sterilization solution. She gathers a tourniquet. esmarc, leg holder, and the scissors, baskets, and a grasping clamp from the cart. All three nurses open supplies onto the back table after they have completed their other assignments. Using this system, we have been able to decrease our time per set up to approxi- mately ten minutes.

ltitruoperutive. As a patient enters the room, he is greeted by the operating room staff and is positioned on the table by one circulator. This nurse's responsibilities include verifying with the patient which knee is to be operated on, careful positioning of the patient with attention to protecting and cushioning pressure points, and application of the tourniquet and leg holder. The circulating nurse stays with the patient through- out the anesthetic induction to offer support and answer questions.

The second circulator works with the scrub nurse. The second circulator is responsible for pouring solutions, tying gowns, completing pa- perwork, and opening additional sterile equip- ment.

After the patient is anesthetized, the circula- tors apply the tourniquet and leg holder while the

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surgeon scrubs. The circulators prep the opera- tive site, and the scrub nurse applies the sterile drapes.

The scrub nurse hands off the light cord, irri- gation tubing, and suction tubing. A circulator plugs in the light and holds the camera so the scrub nurse can apply the sterile plastic cover. The other circulator connects the suction tubing to wall suction and connects the irrigation tubing to the 3.000 cc bags. When power equipment is used during a case, a circulator gets the power pack and the foot pedal ready for the surgeon.

During the procedure, irrigation bags are re- placed as needed, and suction bottles are emptied as they become full . Specimen tags are filled out, and the local anesthesia solution is drawn by the scrub nurse. The solution is injected into the joint space at the end of the procedure. As the case progresses, sterile items are gathered and assem- bled into groups for subsequent cases.

Because of the high volume of cases each day, the three nurses rotate scrubbing and circulating duties after each case. Each nurse is proficient in the skills necessary for scrubbing and circulat- ing.

Postopercrtive. At the end of the case, the scrub nurse applies a dry sterile dressing. This dressing consists of 4 x 4 inch gauze bandages, a 6-inch rolled gauze, and an elastic bandage. The instruments are cleaned and sterilized.

After the scrub nurse has applied the sterile dressing, one circulator assists in removing the leg holder and applying the ace bandage on topof the dressing. The other circulator washes the arthroscope, light cord, and power unit, and submerges them in cold sterilization solution for ten minutes. After the patient is brought to the recovery room, the ancillary staff cleans the room, and the next case is set up. The whole process takes about six minutes, compared to the usual hospital turnover time of 45 minutes.

The average recovery room stay for an ar- throscopy patient is 90 minutes. During this time, vital signs are monitored, the operative site observed, pedal pulse checked, and pain medica- tion administered as needed.

When the patient is ready for discharge, post- operative instructions are given to the patient and

family members. Many surgeons provide a sheet with their specific instructions to the patient. These instructions include permissible activity, exercise, medications, bandages, and follow-up care. Most patients are able and encouraged to walk out of the facility with a nurse when dis- charged.

Aclvcriitcrges of Ambulcrron Surgery for Putieiit

here are four advantages to patients in having an arthroscopy performed on an T ambulatory basis. These include psycho-

logical/emotional, physiological, economic, and financial benefits .

Patients can spend most of the preoperative and postoperative period at home. When patients are properly prepared to manage their own care and avoid hospitalization, they perceive the sur- gical event as less threatening and are better equipped emotionally to deal with the recovery process. Physiologically, the patient benefits from a greatly reduced risk of nosocomial infec- t ion.

Economic advantages, in addition to the min- imal disruption of normal life routines, include no additional child care expenses or transporta- tion arrangements, and fewer missed days of work. Patients who schedule procedures for a weekend or vacation period can reduce absen- teeism at their jobs. And financially, the proce- dure performed in an ambulatory surgical setting costs one-third to one-half less than the same procedure inhospital, even before the addition of room and board charges.

CATHLEEN HARRISON, RN KATHLEEN UPSON, RN

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