Basic Surgical Techniques

Basic Surgical Techniques - pt. 1

One of the major jobs of a Surgical Technologist is to assist the

surgeon during an operation. As a sterile team member, the

Surgical Technologist may stand directly across from the surgeon

in the role of the first assistant or function in the role of the "scrub

nurse." Some of the duties of the assistant are to sponge and

suction blood from the operative site, hold retractors and other

instruments, and cut suture for the surgeon. An expanded role of a

first assistant may include incising and suturing tissue as directed

by the surgeon. The "scrub nurse" will pass instruments, supplies,

and suture to the surgeon during the procedure. The unsterile

"circulating nurse" will provide for the safety and comfort of the

surgical patient and will be alert to the needs of the other members

of the surgical team. For each role, it is vital for the Surgical

Technologist to know the various steps the surgeon may take

during most surgical procedures. This presentation on "Basic

Surgical Techniques" will show the routines for a basic abdominal

case, however most of these techniques will apply to any type of

surgical procedure.

By using the surgeon's preference card, the supplies are collected

for the surgical case. This may be done in the Operating Room by

surgical personnel or in the Central Supply Department and sent to

the Operating Room on a closed case cart.

Prior to opening the first case of the day, flat surfaces and

overhead lights are cleaned with a damp cloth moistened with a

hospital grade or high level disinfectant.

Both the scrub nurse and circulating nurse assist with opening the

sterile supplies needed for the surgical procedure. Some hospitals

have a set routine on where supplies are opened in the room, for

example, the suture on the left side of the back table and the linen

on the right side. Also unsterile equipment must be obtained.

Teamwork is of utmost importance now, and through out the

surgical procedure. Supplies and equipment should be obtained at

this time because once the patient enters the room, the circulator's

attention must be directed toward the patient.

The scrub nurse opens his/her gown and gloves last, preferably on

a separate field and proceeds to perform the surgical scrub.

Ideally, someone should stay in the room to maintain vigilance

over the sterile field.

Surgery - pt. 2

Following the surgical scrub, the technologist dries his/her hands

using a sterile towel, and dons his/her sterile gown and gloves

using the closed gloving method. The Surgical Technologist

proceeds to set up the surgical case following that hospital's

routine.

The scrub nurse and circulating nurse perform a sponge, needle,

and instrument count before the initial incision is made.

The circulating nurse obtains the patient's x-rays if necessary and

checks on any blood products that may have been ordered.

The circulating nurse greets the patient who is in the pre-op

holding area. The patient's chart is checked for appropriate

information. The nurse verifies the patient's identity, the operative

procedure and site, doctor, pre-op orders and lab work. An IV

may be started at this time by the nurse or a member of the

anesthesia team.

When the surgical team is ready, the patient is brought into the

operating room and moved to the OR bed. The positioning should

be performed by at least two persons, with one standing beside the

locked stretcher and the other beside the OR bed. A safety strap is

placed 2-3 inches above the patient's knees and the patient's arms

are placed on arm boards. Monitoring devices such as blood

pressure cuff, EKG pads, and pulse oxymeter are placed on the

patient by the circulating nurse or a member of the anesthesia

team..

Surgery - pt. 3

When the surgeon is ready to begin the operation, the patient is

anesthetized. The circulating nurse should be readily available to

assist the anesthesia personnel if needed.

Once the anesthesia personnel gives permission, the patient is

placed in the appropriate position for the procedure. Positioning is

the responsibility of the circulating nurse and the anesthesia

personnel. The surgeon often supervises difficult positions.

The circulating nurse may insert a foley catheter, exposes the

operative site, and performs the skin prep. On an abdominal

hysterectomy the circulating nurse will also prep the cervix. If an

electrosurgical unit (ESU) is used, the grounding pad should be

placed on the patient at this time.

The circulator activates the overhead spot lights.

The lights are then moved into position over the operative field by

the circulator.

Surgery - pt. 4

Following the surgical scrub, the surgeon enters the operating

room and is gowned and gloved by the scrub nurse. The surgeon

may ask for a moist towel to wipe the powder from his/her

gloves.

The circulator ties the surgeon's gown in the back.

The surgeon then preps the patient's skin with an antiseptic

solution. If performed on the abdominal area, the umbilicus is

prepped last.

Draping of the patient follows, according to procedure and the

surgeon's preference. The scrub nurse should know the draping

routine and have all necessary drapes ready in proper order.

For most basic abdominal draping, four towels are placed around

the incision site and held in place with four towel clips. Some

surgeons prefer to use a clear plastic drape over the four towels

after the skin has been blotted dry with a towel.

Surgery - pt. 5

A fenestrated drape is applied as the final drape. A laparotomy

sheet is used for most surgeries on the anterior trunk.

The surgeon steps into position to operate with the assistant

standing across from him/her. The scrub nurse quickly brings up

the mayo stand, back table, and ring stand, and places two lap pads

at the incision site. A magnetic pad, to prevent instruments from

falling from the field, may be placed near the incision site. This

pad also contains a "no pass" area for sharps.

The (ESU) active electrode is secured to the sterile drape followed

by the suction tip and tubing. An ESU tip cleaner may be placed

on the magnetic pad.

The circulator attaches the distal ends of the active electrode and

the grounding pad, applied earlier, to the power unit, and the end

of the suction tubing to the suction canister. These units are then

turned on by the circulator.

The circulator then moves the kick bucket into a convenient

location.

Surgery - pt. 6

When the surgery is ready to begin, the scrub nurse passes the

skin knife to the surgeon. The skin knife is usually the #20 knife

blade attached to the #4 knife handle. The surgeon and first

assistant hold the skin taut as the incision is made.

Bleeders will be encountered as the incision is made into the

subcutaneous layer. The surgeon may elect to coagulate these

blood vessels with the ESU or clamp the bleeders with hemostats

and tie them off with absorbable suture material. A 3-0 Vicryl or

Plain on a ligating reel may be used.

The first assistant is responsible for raising the hemostat so the

surgeon can get the tie around it and then exposing the point so the

knot can be tightened. The hemostat is then removed. Some

surgeons prefer for the assistant not to remove the hemostat until

they verbally request it.

After several additional knots are tied, the first assistant will cut

the suture. Vicryl is a multifilament suture material and should be

cut on the knot. Plain is monofilament and may come untied, so a

3 millimeter tail is left on the suture.

If the surgeon uses the ESU, the hemostat is held away from the

skin edges. The hemostat is touched by the activate electrode and

at the surgeon's request is removed by the first assistant. Care

must be taken, by the first assistant, to activate the coagulation

button on the active electrode instead of the cutting button.

Surgery - pt. 7

The surgeon deepens the incision through the subcutaneous layer

with the ESU cutting element or the inside knife which is the #10

blade attached to the #3 handle. Whenever the surgeon is cutting,

the scrub nurse should be ready to pass a hemostat, in case a blood

vessel is encountered.

The next layer is the fascia. Since the fascia is a tough, white,

fibrous layer, the surgeon may use the curved mayo scissors, the

inside knife, or the ESU to deepen the incision A Goulet retractor

is often used to retract the skin and subcutaneous layer at this time.

The next layer is the abdominal musculature. If a midline

abdominal incision is used, the incision is made between the rectus

abdominal muscles. The surgeon may use the handle of the #3

knife for blunt dissection to separate the muscles.

The next abdominal layer is the peritoneum. It is the thin serous

membrane that lines the abdominal cavity. Since the abdominal

organs are located directly under the peritoneum, the surgeon must

take special precautions to avoid cutting these underlying

structures. To enter the peritoneum, many surgeons grasp it with

two hemostats and elevate the tissue. The surgeon then nicks the

peritoneum with the inside knife.

Surgery - pt. 8

While the surgeon and the first assistant elevate the peritoneum

with their fingers, the surgeon extends the incision with the

metzenbaum scissors. In preparation for entering the peritoneum,

the scrub nurse moistens two lap pads with saline and prepares a

large self retaining retractor such as the Balfour. From this point,

small sponges, if used, must be mounted on an instrument.

With the peritoneal incision complete, the surgeon is now able to

visualize the abdominal contents. Usually most surgeons will

perform a manual examination of the abdominal cavity to check

for abnormalities. At the completion of this exam, the surgeon is

ready to perform the proposed operative procedure.

A self retaining retractor such as the Balfour may be used. Large

moistened lap pads may be used to protect the tissue edges under

the blades of the retractor and to pack the abdominal contents

away from the operative site. Usually the first organ observed is

the omentum. The omentum is attached to the transverse colon

and hangs loosely over the abdominal organs.

During the case, the first assistant is responsible for adequate

exposure of the field. This includes manipulating retractors and

other instruments and requires the knowledge of the proper

techniques in tissue handling.

The first assistant also keeps the wound free from blood and other

body fluids by using the suction and lap sponges. An expanded

role of the first assistant would include maintaining hemostasis by

clamping bleeders or using the ESU to coagulate bleeders.

Surgery - pt. 9

When the surgeon is placing a continuous stitch, the first assistant

"follows" the suture by grasping the end and keeping it taut.

The first assistant must also be ready to cut the suture or "tag" it

with a hemostat at the appropriate time.

The surgeon may ask the first assistant to "flash" a clamp. This

technique requires releasing the clamp slowly and just enough for

the surgeon to get the suture around the tissue. The clamp is then

closed while the surgeon ties the suture around the clamp.

With additional training, the first assistant role may include the

manipulation and suturing of tissue.

The scrub nurse assists by observing the operative procedure and

passing the appropriate instruments to the surgeon and first

assistant. The general rule for passing instruments is to pass in a

firm manner in the direction of use. The surgeon should not have

to readjust an instrument once it is in his/her hand. Always pass

the curve of the instrument toward the surgeon's other hand.

When the surgeon is beside the scrub nurse, in an effort to avoid

bumping arms, it is generally best to pass with the hand opposite

from where the surgeon is standing. It is usually easier to pass

instruments when the scrub nurse is standing across the table from

the surgeon.

Surgery - pt. 10

Most clamps are used in pairs. A basic maneuver used repeatedly

during an operative procedure is clamp, clamp, cut, tie, tie. For

example, if the surgeon is dissecting he/she will double clamp

with hemostats to prevent the spillage of contents from the vessel

or organ.

The surgeon will then cut in between the two clamps with

scissors. For delicate tissues such as blood vessels, ovaries, and

intestines, metzenbaum scissors are used. For tougher tissue such

as the muscle, uterus, or breast, the curved mayo scissors will be

used.

The surgeon will then tie what was cut using the appropriate

suture , frequently on a ligating reel.

Other common surgical techniques include: When the surgeon is

cutting, the scrub nurse should have hemostats or the appropriate

size clamp ready to pass to the surgeon or first assistant to clamp

bleeders.

When the surgeon is tying off bleeders, the scrub nurse should

have the suture scissors ready to pass to the first assistant, or a

hemostat to "tag" the end of the suture.

When passing suture to the surgeon or first assistant, pass it with

the tip of the needle pointing toward his/her chin. This is the

position in which he/she will use the suture and will also help

avoid a dangerous needle stick. The surgeon will usually want a

pair of tissue forceps for his/her other hand.

Surgery - pt. 11

If the surgeon nicks the scrub nurse's glove with a needle, tell

him/her before they pass the needle through the patient's tissues.

The needle should be discarded from the sterile field. The

circulating nurse will retain the needle for the final count. The

scrub nurse will turn away from the field and the circulating nurse

will remove his/her contaminated glove. A new glove is donned

using the open method of gloving. Remember, the closed method

of gloving can not be used once the hand has passed through the

cuff.

To avoid the loss of a needle, they should always be passed to the

surgeon on an exchange basis. NEVER take back an empty needle

holder.

Once the needle is returned to the scrub nurse, it is placed in the

needle counter in the appropriate space. This is best done with

one hand to avoid sticking the finger of the hand holding the

counter.

The scrub nurse needs to keep clean lap pads on the field at all

times. He/she should discard used sponges in the kick bucket as

necessary. Small sponges such as peanuts or probangs should

remain on the field to avoid loss.

The circulating nurse should retrieve the used sponges from the

kick bucket by using a sponge stick or his/her gloved hand. The

used sponges should be placed in a clear sponge counting bag..

The anesthesia personnel and the surgeon will need to view the

sponges to determine the patient's estimated blood loss (EBL).

Surgery - pt. 12

If the surgeon asks for a "tie on a passer" he/she wants a

strand of suture on a right angle clamp. This is used to tie a

structure deep in a cavity where the surgeon's hands can't

reach.

If the surgeon asks for a "stick tie", "suture ligature", or

"transfixion suture" they want a strand of suture on a needle.

Since this is usually used to tie off a blood vessel, it may be a

nonabsorbable suture, size 3-0 on a small gastrointestinal

needle.

There are a number of hand signals used by surgeons. This

is the signal for a hemostat or other appropriately sized

clamp. This is the position of the surgeon's hand when

accepting most instruments. If the surgeon makes this signal

and you are unsure what he/she needs, the safest instrument

to place in his/her hand is a hemostat.

This is the hand signal for scissors. When the surgeon needs

dissecting scissors the Surgical Technologist must be aware

of the strength of the tissue. For tougher tissue (fascia,

breast, muscle, uterus) the surgeon needs the curved mayo

scissors. For delicate tissue (ovaries, bowel) and for most

general dissection, the surgeon uses the metzenbaum

scissors. The length of the scissors depends on the depth of

the wound. Specialty scissors are used on certain tissues.

For example, Jorgenson scissors are used to cut across the

cervix during an abdominal hysterectomy.

This is the hand signal for the knife or scalpel. The scrub

nurse passes this with the blade down and the handle pointed

toward the surgeon. Care must be taken to avoid injury

when passing the scalpel. A "no pass" zone should be

established on the field.

Surgery - pt. 13

This is the hand signal for forceps. Pick ups with teeth are used on

tougher tissue and smooth forceps are used in delicate areas.

This is the signal for a suture on a needle. The surgeon will make

a fist and simulate the motion used when suturing. Suture is

passed with the needle pointing toward the surgeon's chin.

This is the hand signal for a free tie. The scrub nurse grasps the

strand of suture by its ends and places the suture in the surgeon's

palm.

Other general duties while scrubbed include keeping the field clear

of instruments. If instruments are extremely bloody, they should

be wiped with a sponge moistened with sterile water. Saline

should never be used to clean instruments as it could cause rust to

form on the instrument.

The overhead lights may need to be readjusted during the case.

The scrub nurse uses the sterile light handle for this maneuver.

Surgery - pt. 14

The active electrode of the electrosurgical unit (ESU) should be

kept clean. A special "scratch" pad is available for this purpose.

The ESU tip should stay in its plastic holder to avoid

inadvertently activating the tip and causing a burn.

The mayo stand must never rest on the patient's feet or legs.

When the patient is placed in the trendelenburg position, the scrub

nurse should check the level of the mayo stand.

The scrub and circulating nurses work together to observe the

sterile field, at all times, for possible contamination. If the scrub

nurse's gown becomes contaminated, the circulating nurse should

don unsterile gloves, untie the gown in the back, and assist in

removing the gown and then the gloves. The scrub nurse should

don a new gown and gloves using the closed method. A rescrub

would be unnecessary. The scrub nurse and the circulating nurse

should watch the surgeon and the progress of the procedure, listen,

and try to anticipate the needs of the surgical team. The

circulating nurse should control traffic and noise in the room.

Other duties of the circulating nurse include keeping accurate

records of the case. This may be done with the help of a

computer.

The circulating nurse maintains communication with other areas

of the operating room suite and may be responsible for sending for

the next patient. He/she may need to communicate with other

hospital departments such as pathology. Also the circulating nurse

may be responsible for answering the surgeon's pages and relaying

messages.

Surgery - pt. 16

If the surgeon is concerned about wound disruption he/she may

elect to insert several retention sutures to reinforce the incision.

These sutures are also called "through and through", "tension", or

"stay" sutures and are placed in a secondary suture line. A

nonabsorbable monofilament such as Ethilon or Prolene size 2 is

frequently used. Since this suture passes through all tissue layers

except the peritoneum, the needle swaged on to this suture is

extremely large. To prevent the suture from having a sawing

effect on the skin, rubber bolsters or plastic bridges are used.

To prepare a retention suture the scrub nurse places the bolster on

the suture, tags the end with a hemostat, and places the needle on a

needle holder.

The next layer is the muscle. Suture, when placed in this layer, is

usually of the same material used on the peritoneum. Most

surgeons choose not to close this layer.

Following the muscle is the fascial layer, which is the toughest

layer that prevents a hernia from occurring. Suture for this layer

varies greatly from a 0 to 2-0 nonabsorbable such as Surgilon

using an interrupted stitch, to 0 to 1 Prolene using a continuous

stitch. If an interrupted suturing technique is used, the scrub nurse

must prepare these sutures rapidly and keep an accurate count of

the many needles.

Interrupted suture may be tied after each stitch but cut all at the

same time. A short pair of tissue forceps with teeth is used on this

layer and medium needle holders are used.

Surgery - pt. 17

After the fascia is the subcutaneous layer. Subcutaneous fat does

not tolerate sutures particularly well. However, if the layer of fat

is thick, it is often necessary to place a few interrupted stitches to

hold the wound edges together to prevent dead space. A dead

space may allow tissue fluids to accumulate, delay healing, and

predispose the wound to infection. Absorbable suture is used in

this layer, usually size 3-0 Plain or Vicryl placed on a short needle

holder.

The skin is the next layer. Suture technique in skin closure varies

greatly among surgeons. A nonabsorbable monofilament suture

on a curved cutting or straight keith needle, size 3-0 or 4-0

Prolene or Ethilon may be used. The curved cutting needle is

placed on a short needle holder and the keith needle is held by

hand. A subcuticular stitch using an absorbable suture may also

be used. Special adson or dura forceps are used during skin

closure. The retention sutures are now tied.

Some surgeons prefer to close the skin using skin staples. The

surgeon usually uses two adson forceps to evert the skin edges

while the skin staples are applied by the first assistant.

The final sponge, needle, and instrument count is performed

during the skin closure by the scrub and circulating nurses.

The circulating nurse opens the dressing material after the final

count is complete. For most abdominal wounds, plain 4x4s are

used and are prepared by the scrub nurse.

Surgery - pt. 18

Following skin closure, the surgeon will want a wet lap pad to

cleanse the skin and then a dry one. Note a penrose drain has been

inserted through a separate stab wound.

The surgeon is now ready for the dressing. If drainage is

expected, a bulky dressing such as an ABD pad may be applied

after the gauze sponges.

The operation is now complete. The scrub nurse pushes the mayo

stand away from the table. In many hospitals, it is policy to keep

the mayo stand sterile until the patient leaves the room. This

facilitates reopening of the wound in case of an emergency.

The scrub nurse checks the drapes for stray instruments and rolls

the drapes off of the field. The circulating nurse tapes the dressing

in place.

Surgery - pt. 19

When the anesthesia personnel gives permission, the patient is

moved to the recovery room bed. A minimum of four people are

needed to accomplish this effectively. A devise such as a Davis

roller or a mechanical mover may be used to facilitate the move.

The suction should remain functional until the patient leaves the

room in case it is needed by anesthesia personnel to suction the

patient's airway. The entire surgical team should stay in the room

until the patient leaves the room.

The circulating nurse and anesthesia personnel accompany the

patient to the PACU. A verbal report is given to the nurse who

will be taking care of the patient and the circulating nurse

completes the patient's records.

The scrub nurse is responsible for the care of the instruments and

supplies following the case. All trash is placed in impervious

biohazard bags. Knife blades are removed from their handles by

using a needle holder. The blades are placed in puncture proof

containers such as the needle counter for proper disposal.

Surgery - pt. 20

All instruments must be prepared for terminal sterilization. Used

instruments are soaked in water, opened, and placed in a mesh

bottom tray. Heavy instruments are placed on the bottom. The

tray is then placed in a closed case cart or placed in a plastic bag

for transportation down the hall.

All sharps are placed in an appropriate sharps container.

All linen is placed in an impervious bag and sent to the laundry to

be washed, which rehydrates the fabric prior to sterilization.

The scrub nurse removes his/her gown and gloves after all contact

with soiled instruments and supplies is completed.

Cleaning of the room is next. Walls are not considered

contaminated and require no cleaning unless they have been

splashed with blood. Flat surfaces of the mayo stand, back table,

and OR table are cleaned with a hospital grade disinfectant.

Surgery - pt. 21

The floor is terminally cleaned with either a wet vacuum or a

clean mop head wet with a hospital grade disinfectant . Wheels of

furniture should be pushed through the disinfectant.

Suction contents may either be flushed down a hopper or treated

with a special solution and discarded in the proper receptacle.

The room is now ready for the next surgical procedure.