Sequence of Passing Instruments

8/13/2019 Sequence of Passing Instruments

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Sequence of passing instruments

All nurses

If you see them starting to dissect around a vessel/nerve then have a mixter or lahey handy

because they may want to put a neoloop around it. When you hand up a neoloop also give

them an artery clip because they'll clip the ends of the loop together.

When they are tying off vessels it's usually clip, clip, cut, tie, cut. So you hand up an artery clip,

another clip, metz scissors then a tie of some sort then your straight mayo scissors.

Another thing is if they are doing a laparotomy, when they go deeper into the abdomen you

need longer instruments. Instead of handing up say a 7 inch pair of metz, go for a longer pair.

Same with forceps, needleholders etc.

My biggest piece of advice is to really just watch what they are doing, what instrument they use

and when. If you have some idea on what the surgeon is trying to achieve then you can start

anticipating instruments.

I'm not a pro in the O.R., i'm also same like you 1 year ago... which reminds me that i also want

to learn too much that i ask anyboy on how to know which i will give next, but my advice maybe

is not too much help but i hope it will give you small hints....

if you see that there is a bleeding in the fats, in the muscles..they might use artery forceps andligate it with suture or another is they will use adson tooth forceps and use coagulation

cautery... if they prefer ligation then u will need to give artery forcep and tie( it also depend if

they want it to put the tip with an artery or simply give the tie/ suture) and scissors to cut...

which scissors to use, if you previously give a suture- give suture scissors

if they will cut a tissue, give metz or tissue scissor..

nontooth is usually use on delicate tissues usually inside already.. while tooth forcep is usually

outside (skin and fats)unless preferred by the surgeons...

When suturing give the surgeon need needle with the needle holder and tooth or non tooth

forceps, and give the assistant an artery clamp and scissors.if they are suturing inside or about to expose an organ, give a retractor... this is needed esp.

during laparotomy... to expose the organs inside...

You just need to observe and keep in mind the preferences of surgeons also because different

surgeons have different approach...

just keep in contact.. and let me know your progress...

i am just interested in persons who are also willing to learn...


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Learning about SuturesFirst and foremost, allow me to disclose that my place of employ utilizes Ethicon suture (as have other

ORs in which Ive worked), therefore I will do my best to generalize where possible. I will also try to

keep it simple. I can ramble for hours about suture.....it's a problem. And you know what they say,

acknowledging a problem is the first step to recovery.

And away we go:

What the devil is the difference between the sutures?

Well, sutures are comprised into three different varieties: Natural, braided (multifilament) and non-

braided (monofilament).

Natural sutures:

Plain gut

Chromic gut

Examples of multifilament:

Nurolon

Vicryl

Cotton

SilkEthibond

Monofilament:

Nylon

PDS

Prolene

Monocryl

Sutures are then further categorized by whether each is absorbable or non-absorbable.

Absorbable:

VicrylChromic gut

Plain gut


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PDS

Monocryl

Nurolon

Non absorbable:

Nylon

Prolene

Silk

Ethibond

Okay, before we get too far into our discussion, let's pause and break this all down as far as what this

means to you as a circulator.

~~ When a patient has an infection, most doctors will not use a multifilament suture when closing an

infected wound. Why? Because the braid in a multifilament suture is a lovely little breeding ground

riddled with nooks and crannies that allow the bacteria to breed like crack riddled bunnies.

Sub point: Monofilament lacks these nooks and crannies and therefore tends to be favored. Infected

patient? Think monofilament sutures.

~~ When a patient is "spitting suture" it tends to be a non absorbable or slow absorbing suture (we will

get to that in just a sec. Hang with me).

So, let's talk absorption info, shall we?

Plain gut: 70 days

Chromic gut: 90 days

Vicryl: 55-70 days

Monocryl: 90 - 120 days

PDS: 180 - 210 days

Nurolon: loses something like 20% of it's mass, if you will, per year, if I remember correctly. ::nudges

sleeping brain::

What this means to you: Well....honestly? Not too terribly much. Just some good info to know. I've only

used this piece of info twice in my career and both times it was in answer to a surgeon who then stared

at me as if I had three heads.

Well, Ms. Potato, you say, that's all find and dandy, but where on the body are the various sutures used?

Well, my friend, before I can answer that question honestly, I must introduce you to one more of two

additional determining factors that marks where in the body a suture goes: needle type.


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Right then.

There are then six types of needles: Cutting, reverse cutting, taper, trocar, blunt, and side cutting.

Don't panic. Here's the breakdown of each and what they are typically used for:

~~ Cutting: Triangular shaped needle (if you were to stare down the tip) with the cutting or sharpened

edge found to the inside. (more superficial closing sutures. Needle call letters or code example: CR)

~~ Reverse cutting: Triangular shaped needle with sharpened edge found to the outside. (also more

superficial closing sutures. Needle call letters or code examples: FS, PS, M, LR, KP-3)

~~ Taper: round needle tapering to a point (this is the most atraumatic needle type, hence it is used in

deep fascia closure as well as on bowel, vessels, nerves, tendons, etc. Needle call letters or code: CT, CT-

1, SH, UR, BB, BV)

~~ Trocar: rounded needle ending in a cutting point. My facility does not use these needles. Alas, I am

unable to provide further info. I apologize.

~~ Blunt:....yeah....blunt. Um...we don't use blunt needles at my facility. Ever.

~~ Side cutting: Flat needle with cutting edge to front. (eye surgery only). I'd be lying to say I know. The

last eye case I worked on was an enucleation. So. Um. Yeah. We didn't fix the eye.

Moving on! So whats the last determining factor (other than surgeon preference) that determines what

we hand them?

Why, size of course. After all, it always comes back to size.

And Im not just talking needle size. Pause.

Although that is a factor. If Im working on a finger, giving me a veritable harpoon to use isnt going to

work so well, ya know? Its all aboutcommon sense with this one. If the work is delicate--think eyes,

plastics and the like-- are you going to offer the surgeon the biggest, gnarliest needle in your arsenal? I

would hope not. Small and delicate for wellsmall and delicate. Mmhm.

And go.

Size is also a reference to the density of the suture or what is called tensile strength.

Its written on the outside of each box and you have heard it since the day you started. Its that pesky


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numeric coding in big bold letters: 0, 1, 2-0, etc.

So what in the devil does that mean?

Heres how it works: think of it like learning negative numbers in school. The Higher the positive

number, the bigger the suture. The Higher the negative number, the smaller the suture. Example: Which

is bigger: 3 or -8.

Also, sutures that do not have a 0 to follow are commonly referred to as a number XX.

In practicum:

A number 5 Ethibond is going to be the suture world equivalent of twine rope where as a 10-0 Nurolon

is as fine if not finer than a human hair.

Any suture that is a positive or high number without an 0 to follow is thick. Anything with an 0 to follow

is fine. As the front number rises, the thickness of the suture grows more fine.

More examples, in case I completely lost you:

Number 2 Nylon: thick

2-0 Vicryl: Fine

2-0 Nylon: Still fine.

2-0 Monocryl: .you guessed it. Still fine.

Number 1 PDS: thick

3-0 Vicryl: More fine than a 2-0 Vicryl. Thicker than a 4-0 Vicryl.

Make sense?

Okay! Time out to put this together before we get to putting it all into the working world:

Just like needles size, suture thickness is a matter of common sense: You do not use a 10-0 Nylon to hold

together the fascia of an abdomen or sew together the muscles in a knee. Kinda wouldnt work.

So where do you find the thick suture? In the deep parts of the wound and where there is going to be

natural resistance and pulling put on the suture by the living body.

Exceptions: nerves and vessels. Again, common sense. To sew the little walls of an artery in a bypass, are

you going to use a Number 2 suture? God no. Think more along the lines of a 7-0. Fine suture for fine

work. Big suture for big work.

So when the doc is sewing deep, hes going to ask for that Number 1 suture or an 0 (typically called an

o in our little corner of the OR globe). When the doc is sewing the shoulder closed and is working on


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sub-scap or cuff, is he going to want a 5-0? Nope. Those muscles are going to PULL on that suture.

Number 2 it is then.

Now a quick note: remember, the number is not only an indicator of size but of tensile strength. Higher

the number: stronger the suture. Higher the number with an 0 to follow: weaker the suture.

Now comes the fun part:

Lets put it all together. With some practical application discussion. Heheh.

:: poof!:: I am now a doctor. Not just any doctor--the one in your OR. And Im bored so Im working on a

belly case. Im rooting around in the bowel and I want to suture some bowel together.

Suture of choice? 2-0 (delicate suture for delicate work. Not too weak, not too strong) Silk (non

absorbable). On an SH (Taper needle: atraumatic. Wont do me a lick of good Im slashing my bowel to

bits to try to sew it together, ya know? P.S. This needle is also called a GI needle by some scrubs)

And this is how the scrub will ask for it, I need a 2-0 silk on an GI. Some scrubs have the actual suture

catalog numbers memorized, which is fine, but I prefer to know my needles and suture types. I digress.

Great! So my bowel sewing has gone wonderful and I think Im done because Im hardcore like that. So I

want to close. Im just starting to close so Im going to be sewing deep.

Suture of choice? 0 (Strong! Those belly muscles tend to pull.) PDS (I want this suture to hang around for

a looooooooong time to be sure the wound closes well) on a CT-1 (again, taper needle. I dont want to

cause undo trauma if I can prevent it. Quick note: some scrubs refer to a CT needle as a general

closure, as in, Ill take an 0 PDS general closure ).

Whats that? Youre out of 0 PDS? Well drat. I guess Ill take a 0 Vicryl on a CT-1.

Okay, so thats done. Im going to close my next layer of fascia.

Ill take a 2-0 Vicryl on a CT-1. (The tissues are getting more delicate as I work towards the surface, and

therefore my suture should follow suit).

You know what? Im going to put a drain in my patient. What should I use as a drain stitch?

How about a 2-0 silk on a FS (Non absorbable so it will still be there in good shape later and reverse

cutting as Im going to go through skin and cutting/reverse cutting makes it smooth like silk).

Wow. Almost done. Lets close skin.


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I would like a 4-0 Monocryl on a reverse cutter or whatever you got like that. Yeah, that will do. Skin is

delicate and Im going to do a lovely plastics closure so my patient doesnt scar as badly. I need

something fine and sharp with a capital S.

Things to take away from practical discussion and various other sidebar comments:

~~ All boxes/suture packets are labeled with all the information that you need: needle type (including

picture as well as written description), number of size and type of suture.

~~ As you work deep to superficial, suture tends to be come more fine. Remember the exceptions

mentioned before.

~~ Popular drain stitch tends to be silk or Nylon. Depends on doctor preference/specialty. Where I come

from General/Neuro/Cardiovascular surgeons tend to use silk. Ortho uses Nylon.

~~ Ortho tends to use more cutting needles as what they are working on is less delicate.

~~ Ortho tends to also use Nylon to close skin. Again, surgeon preference.

~~ When in doubt of needle type (you will be surprised how many doctors dont really know the

difference), grab one of each and bring them close to show the field/surgeon. Let him choose. Choices

are good.

~~ Always read/consult surgeon preference cards/confirmation sheets as any good circulator should.

Know what your doctor tends to favor normally so you know what to offer when he throws you a curve

ball.

~~ Some suture does not have a needle. Umbilical tapes and tie sutures do not. Ties come mostly as

either Silk or Vicryl. In spite of this, they follow the other rules listed above: I would like 0 silk ties .

These sutures tend to be used in the tying off of vessels to large to be bovied into submission.

~~ There is such a thing as a straight needle called a Keith needle. Can be found on Silk and Prolene,

just as examples, and is a straight traditional looking needle. Looks just like what you think of when

you think of sewing. Why is it used? Mostly used in the securing of central lines and art lines superficial

through the skin.

~~ Some sutures come double armed (meaning there are two needles connected to one suture):

Prolene, especially. How to know? The box as well as the package will show an image of two needles

with a fine line between them.


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We've also got some needles that are blunt on the leading edge for things such as livers, that don't like

sharp things being poked into them!:chuckle

There's a lot more detail on suture and suture needles out there, and this was my worth,,,,hope I

didn't mislead you. I'm sure allnurses nation will help you out!

Mike

2-0 (delicate suture for delicate work. Not too weak, not too strong) Silk (non absorbable). On an SH

(Taper needle: atraumatic. Wont do me a lick of good Im slashing my bowel to bits to

try to sew it together, ya know? P.S. This needle is also called a GI needle by some scrubs)

Sequence of Passing Instruments

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