WHAT ARE THE FUNCTIONS OF A SCRUB NURSE?

Scrub nurses are specially trained nurses who work with surgeons and assist the medical team inside the operating room. They are highly important members of surgical teams as they provide assistance and support in the operating room and also provide patient care after surgeries. Scrub nurses are also referred to as preoperative nurses. As preoperative nurses, their responsibilities include providing patient care before, during, and after surgeries.

Preparation and General Surgery

One of the primary functions of a scrub nurse is to work with other members of the surgical team to make sure that all that is needed for the surgical procedure is in the operating room and that a sterile room has been established. The scrub nurse is the surgeon's go-to person during the entire operation. The scrub nurse must maintain a sterile setting for the patient and surgeon to decrease the possibility of spreading infection. In particular, the duties of the scrub nurse during an operation are: maintaining a sterile environment throughout the surgery; being aware of the patient's safety; adhering to all policies regarding instrument count, surgical needles, and sponges; and arranging surgical instruments on the mayo table and back table.

Insturments and Assisting the Surgeon

Another duty of the scrub nurse is to identify all instruments to be used in the operating room. She is responsible for passing the appropriate instruments to the surgeons during surgeries and other procedures. The nurse's knowledge and understanding of each instrument's function will help ensure that the procedure will run smoothly and finish on time. It is also part of the scrub nurse's duties to make sure that surgeons can comfortably and efficiently perform their procedures. They must be keen observers and must immediately notice if the surgeon's foreheads must be wiped or if their goggles are foggy.

After Surgery

After surgery, scrub nurses must: count instruments and sponges used, inform surgeons about the count, clear away all equipment, apply dressing on patient, remove drapes, remove gowns, prepare patient for recovery room, and complete all documentation required.

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WHAT ARE THE FUNCTIONS OF A CIRCULATING NURSE?

Circulating nurses work in hospitals and assist with operations and other surgical procedures by serving as an intermediary between the staff working in the operating room and the rest of the hospital. Circulating nurses have a variety of duties relating to this function.

Pre-Surgical Duties

1. Before a procedure, the circulating nurse ensures that all necessary equipment and instruments are readily available. They also assist the surgical team in scrubbing up and donning sterile gowns and gloves.

Assessment

2. Prior to the start of the procedure, circulating nurses evaluate the condition of the patients, including their vital signs and responsiveness. They are responsible for reporting any irregularities to the attending surgeon.

Duties During Surgery

3. Throughout the procedure, circulating nurses monitor the condition of the patient and the needs of the surgical team. When necessary, they leave the room to gather additional supplies or equipment that the team may require.

Post-Surgery Duties

4. After the procedure, the circulating nurse inventories all instruments and supplies that were used during the procedure in order to ensure that nothing was inadvertently left inside of the patient. If an item is missing, the circulating nurse immediately reports this to the attending surgeon.

Other Duties

5. If the surgery resulted in any specimens that require diagnostic testing, the circulating nurse is responsible for transporting them to the laboratory facilities. When the surgical team includes surgical technicians, the circulating nurse may be responsible for supervising their activities.

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WHAT ARE THE FUNCTIONS OF A RECOVERY ROOM NURSE?

The recovery room nurse is the primary patient advocate following surgery. This nurse monitors patients when they are still under the effects of anesthesia, and the area they work in is called the post-anesthesia care unit (PACU). Recovery room nurses must be registered nurses who have been extensively trained in critical care.

Initial Care

1. A recovery room nurse provides constant care to patients immediately following surgery. This may be a time frame anywhere from 30 minutes to a few hours until the patient is stable enough either to be transported to his hospital room or discharged from the facility. The recovery room nurse connects the patient to devices such as cardiac monitoring equipment, and to intravenous therapy for fluids and pain medication.

Patient Monitoring

2. Patient observation is an essential role of the recovery room nurse. On a regular basis, she takes the patient's vital signs, such as blood pressure, pulse and temperature. The nurse ensures that the patient is breathing properly and administers oxygen when needed. Recovery room nurses must react rapidly to signs of negative physical changes, calling for assistance and beginning cardiopulmonary resuscitation if necessary.

Pain Intervention

3. Pain intervention is another important part of the job description of a recovery room nurse. The nurse observes patients to assess their comfort level, asks patients about their level of pain, and administers pain medications that have been prescribed. He notifies the physician if more pain medication appears to be needed. The nurse must be able to use patient-controlled pumps, and intravenous and epidural infusions.

Additional Duties

4. Recovery room nurses make complete notes on the charts, and communicate information in verbal or written form to other PACU nurses and to physicians. They complete any forms required by the facility. Some recovery room nurses supervise supplemental staff members.

Considerations

5. Recovery room nurses can work any type of shift, days or nights, and also can work on a per diem, or as needed, basis. Traveling nurse organizations recruit for recovery room nurses as well. They must be able to communicate effectively with patients of different ages and backgrounds. Recovery room nurses must have excellent observation skills, be able to think critically, and be able to make quick and effective decisions.

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SURGICAL SKIN PREPARATION

The current recommended practices by AORN for skin preparation of patients are as follows:

RECOMMENDED PRACTICE I

The surgical site should be assessed before skin preparation.

1. Skin should be assessed before skin preparation, and the presence of moles, warts, rashes, or other skin conditions at the surgical site should be noted and documented. Inadvertent removal of lesions traumatizes the skin at the surgical site and provides an opportunity for wound colonization by microorganisms.

RECOMMENDED PRACTICE II

Whenever possible, hair should be left at the surgical site. If it is determined that hair should be removed, removal should be performed according to physicians’ orders and/or according to policies and procedures in the practice setting.

1. An assessment of the amount and degree of hair at the site should be performed. The necessity of hair removal depends on the amount of hair, location of the incision, and type of surgical procedure to be performed. Inappropriate hair removal techniques can traumatize skin and provide an opportunity for colonization of microorganisms at the surgical site.

2. If hair is to be removed at the surgical site, these guidelines should be followed:

Personnel skilled in hair removal techniques should perform the removal. Hair removal should be performed as close to the time of surgery as possible, except

when a depilatory is to be used (see number four). Hair removal should be performed in an area outside of the room where the procedure

will be performed. Hair removal should be performed in a manner that preserves skin integrity.

3. Microscopic exudative rashes and skin abrasions can occur during hair removal. These rashes and skin abrasions can provide a portal of entry for microorganisms. When hair removal is necessary, an electric or battery-powered clipper with a disposable or reusable head that can be disinfected between patients should be used, if possible. This is the simplest and least irritating method of hair removal. If hair is removed, removal should take place away from the sterile field, preferably in an area outside of the room where the procedure will be performed. The dispersal of loose hair has the potential to contaminate the surgical site and sterile field.

4. Depilatories have caused skin reactions in some individuals, causing surgeries to be cancelled. If a depilatory is to be used, manufacturers’ written instructions regarding pre-application skin testing should be followed. Depending on the manufacturers’ instructions, some depilatories may require use before the patient’s arrival in the practice setting.

5. Hair removal with a razor can disrupt skin integrity. If the physician orders shaving with a razor, hair and skin should be wet before shaving. Wetting hair with soapy water makes it softer and easier to remove and results in fewer microabrasions to the skin’s surface. Wet shaving also controls dispersal of loose hair.

6. All items used in hair removal should be disposed of or disinfected between surgical procedures.

RECOMMENDED PRACTICE III

The surgical site and surrounding areas should be clean.

1. The skin around the surgical site should be free of soil and debris. Removal of superficial soil, debris, and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.

2. Cleansing should be accomplished before surgical skin preparation by any of the following methods:

patient showering and/or shampooing before arrival in the practice setting, washing the surgical site before arrival in the practice setting, or washing the surgical site immediately before applying the antiseptic agent in the

practice setting.

RECOMMENDED PRACTICE IV

When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent.

1. Antiseptic agent(s) should be selected according to AORN’s “Recommended practices for the evaluation and selection of products and medical devices used in perioperative practice settings” and used in accordance with the manufacturers’ written instructions. Antiseptic agent(s) should have a broad range of germicidal action.

2. Data from current research, manufacturers’ literature, the Association for Professionals in Infection Control and Epidemiology (APIC), and the US Food and Drug Administration should be consulted when selecting an antiseptic agent for skin preparation.

3. Products for skin antisepsis should be chosen carefully according to the patient’s condition. Antiseptic agents used on the skin of patients with known hypersensitivity reactions may cause adverse outcomes (e.g., blisters, rashes). Some antiseptic agents may be absorbed by the skin or mucous membranes and become neurotoxic or ototoxic. Certain antiseptic agents are believed to be potentially harmful to fetuses or neonates if used on pregnant women and/or nursing mothers.

4. Antiseptic agents used for skin preparation should be applied using sterile supplies. Infection can occur due to a high microbial count at the incision site; therefore, skin preparation should progress from the incision site to the periphery using a sponge/applicator, which should be discarded after the periphery has been reached.

The use of sterile supplies alone does not reduce microbial counts and rebound microbial activity. Friction during the cleansing process and application of antimicrobial agents are the primary methods for removing soil and transient organisms. Data from one limited study suggest that a clean prep kit may be as effective as a sterile kit for disinfecting skin. Additional research is needed to establish definitive patient outcomes and/or support for a change in practice. Antiseptic products that are marketed with applicators may be applied with clean gloves per the manufacturers’ written recommendations; however, there presently are no published data that support the use of clean, as opposed to sterile, gloves.

5. The prepared area of skin and the drape fenestration should be large enough to accommodate extension of the incision, the need for additional incisions, and all potential drain sites. Enlarging the drape fenestration or inadvertent shifting of the drapes can result in contamination, as an unprepared area may be exposed.

RECOMMENDED PRACTICE V

Personnel who are knowledgeable about the patient and skilled in skin preparation techniques should prepare the surgical site in a manner that preserves skin integrity and prevents injury to the skin.

1. When preparing the skin for a surgical procedure, special considerations should include:

preparing areas of high microbial counts (e.g., umbilicus, pubis, open wounds) within the prepared areas last;

isolating the colostomy site(s) from the prepared area, covering the site(s) with an antiseptic-soaked sponge, and preparing the colostomy site(s) last;

using normal saline to prepare burned, denuded, or traumatized skin; avoiding the use of chlorhexidine gluconate and/or alcohol or alcohol-based products on

mucous membranes; using gentle preparation techniques when preparing skin of patients with certain

medical conditions (e.g., diabetes, skin ulcerations); allowing sufficient contact time of antiseptic agents before applying sterile drapes to

achieve maximum effectiveness of the agent; allowing sufficient time for complete evaporation of any flammable antiseptic agent

(e.g., alcohol, alcohol-based preparations) to reduce the possibility of fire; and preventing antiseptic agent pooling beneath patients, pneumatic tourniquet cuffs,

electrodes, or electrosurgical unit dispersive pads to reduce the risk of chemical burns.

TYPES OF SUTURES

Suture Material and Structure

Natural sutures

Natural sutures can be made of collagen from mammal intestines or from synthetic collagen

(polymers). Tissue reaction and suture antigenicity lead to inflammatory reactions, especially

with natural materials.

Monofilament versus multifilament sutures

Monofilament suture is made of a single strand. This structure is relatively more resistant to

harboring microorganisms. The monofilament sutures exhibit less resistance to passage

through tissue than multifilament suture. Great care must be taken in handling and tying

monofilament suture because crushing or crimping of this suture can nick or weaken the suture

and lead to undesirable and premature suture failure.

Multifilament suture is composed of several filaments twisted or braided together. These

materials are less stiff but have a higher coefficient of friction. Multifilament suture generally

has greater tensile strength and better pliability and flexibility than monofilament suture. This

type of suture handles and ties well. Because multifilament materials have increased capillarity,

the increased absorption of fluid may act as a tract for the introduction of pathogens.

Absorbable versus nonabsorbable sutures

Absorbable sutures provide temporary wound support, until the wound heals well enough to

withstand normal stress. Absorption occurs by enzymatic degradation in natural materials and

by hydrolysis in synthetic materials. Hydrolysis causes less tissue reaction than enzymatic

degradation.

The first stage of absorption has a linear rate, lasting for several days to weeks. The second

stage is characterized by loss of suture mass and overlaps the first stage. Loss of suture mass

occurs as a result of leukocytic cellular responses that remove cellular debris and suture

material from the line of tissue approximation. Chemical treatments, such as chromic salts,

lengthen the absorption time.

Importantly, note that loss of tensile strength and the rate of absorption are separate

phenomena. The surgeon must recognize that accelerated absorption may occur in patients

with fever, infection, or protein deficiency and may lead to an excessively rapid decline in

tensile strength. Accelerated absorption may also occur in a body cavity that is moist or filled

with fluid or if sutures become wet or moist during handling prior to implantation.

Nonabsorbable sutures elicit a tissue reaction that results in encapsulation of the suture

material by fibroblasts.

The United States Pharmacopeia classification is as follows:

Class I - Silk or synthetic fibers of monofilament, twisted, or braided construction

Class II - Cotton or linen fibers or coated natural or synthetic fibers in which the coating

contributes to suture thickness without adding strength

Class III - Metal wire of monofilament or multifilament construction

Suture Characteristics

Absorbable Sutures

The absorbable surgical sutures are made from either "natural" or synthetic polymers.

Natural

Collagen: The collagen sutures are derived from the submucosal layer of ovine small

intestine or the serosal layer bovine small intestine "gut." This collagenous tissue is

treated with an aldehyde solution, which cross-links and strengthens the suture and

makes it more resistant to enzymatic degradation. Suture materials treated in this way

are called plain gut.

Surgical gut, plain: Tensile strength is maintained for 7-10 days postimplantation

(variable with individual patient characteristics), and absorption is complete within 70

days. This type of suture is used for (1) repairing rapidly healing tissues that require

minimal support and (2) ligating superficial blood vessels. Surgical gut, fast-absorbing:

This type of suture is indicated for epidermal use (required only for 5-7 d) and is not

recommended for internal use.

Surgical gut, chromic (treated with chromium salt):

o Tensile strength is maintained for 10-14 days. The absorption rate is slowed by

chromium salt (90 d). Tissue reaction is due to the noncollagenous material

present in these sutures. Also, patient factors affect rates of absorption and

make tensile strength somewhat unpredictable.

o Salthouse and colleagues demonstrated that the mechanism by which gut

reabsorbs is the result of sequential attacks by lysosomal enzymes.3 Natural fiber

absorbable sutures have several distinct disadvantages. First, these natural fiber

absorbable sutures have a tendency to fray during knot construction. Second,

there is considerably more variability in their retention of tensile strength than is

found with the synthetic absorbable sutures. A search for a synthetic substitute

for collagen sutures began in the 1960s. Soon, procedures were perfected for

the synthesis of high molecular weight polyglycolic acid, which led to the

development of the polyglycolic acid sutures.3

Synthetic

Chemical polymers are absorbed by hydrolysis and cause a lesser degree of tissue reaction

following placement.

Polyglactin 910 (Vicryl): This synthetic suture is a braided multifilament suture coated

with a copolymer of lactide and glycolide (polyglactin 370). The water-repelling quality

of lactide slows loss of tensile strength, and the bulkiness of lactide leads to rapid

absorption of suture mass once tensile strength is lost. The suture is also coated with

calcium stearate, which permits easy tissue passage, precise knot placement, and

smooth tie-down. Tensile strength is approximately 65% at 14 days postimplantation.

Absorption is minimal for 40 days and complete in 56-70 days. These sutures cause only

minimal tissue reaction. Vicryl sutures are used in general soft tissue approximation and

vessel ligation. Another similar suture material is made from polyglycolic acid and

coated with Polycaprolate (Dexon II). This material has a similar tensile strength and

absorption profile.

Poliglecaprone 25 (Monocryl): This synthetic suture is a monofilament suture that is a

copolymer of glycolide and e-caprolactone. The suture has superior pliability, leading to

ease in handling and tying. Tensile strength is high initially, 50-60% at 7 days, and is lost

at 21 days. Absorption is complete at 91-119 days. Poliglecaprone 25 sutures are used

for subcuticular closure and soft tissue approximations and ligations.

Polysorb

o Copolymers of glycolide and lactide were synthesized to produce a Lactomer

copolymer that is used to produce a new braided absorbable suture, Polysorb.

The glycolide and lactide behaved differently when exposed to tissue hydrolysis.

Glycolide provides for high initial tensile strength, but hydrolyzes rapidly in

tissue.4 Lactide has a slower and controlled rate of hydrolysis, or tensile strength

loss, and provides for prolonged tensile strength in tissue.4

o The Lactomer copolymer consists of glycolide and lactide in a 9:1 ratio. The

handling characteristics of the Polysorb sutures were found to be superior to

those of the Polyglactin 910 suture.4 Using comparable knot construction and

suture sizes, the knot breaking strength Polysorb sutures was significantly

greater than that encountered by Polyglactin 910 sutures. In addition, the mean

maximum knot rundown force encountered with the Polysorb sutures was

significantly lower than that noted with the Polyglactin 910 sutures, facilitating

knot construction.

o The surfaces of the Polysorb sutures have been coated to decrease their

coefficient friction.5 The Polysorb suture is coated with an absorbable mixture of

caprolactone/glycolide copolymer and calcium stearyl lactylate. At 14 days

postimplantation, nearly 80% of the United States Pharmacopeia (USP) tensile

strength of these braided sutures remains. Approximately 30% of their USP

tensile strength is retained at 21 days. Absorption is essentially complete

between days 56 and 70.

o Drake et al studied the determinants of suture extrusion following subcuticular

closure by synthetic braided absorbable sutures in dermal skin wounds.6

Miniature swine were used to develop a model for studying suture extrusion.

Standard, full-thickness skin incisions were made on each leg and abdomen. The

wounds were closed with either sized 4-0 Polysorbor Vicryl sutures. Each incision

was closed with 5 interrupted, subcuticular, vertical, loops secured with a

surgeon’s knot. The loops were secured with 3-throw knots in one pig, 4-throw

knots in the second pig, and 5-throw knots in the third pig. The swine model

reproduced the human clinical experience and suture extrusion, wound

dehiscence, stitch abscess, and granuloma formation were all observed. The

cumulative incidence of suture extrusion over 5 weeks ranged from 10-33%.

Vicryl sutures had a higher cumulative incidence of suture extrusion than that of

the Polysorb sutures (31%vs 19%). With Polysorbsutures,the5-

throwsurgeon’sknothad a higher cumulative incidence of suture extrusion than

the 3-throw or 4-throw surgeon’s knot square, 30% versus 17% and 10%,

respectively. This swine model offers an opportunity to study the parameters

that influence suture extrusion.

Polydioxanone (PDS II): This is a polyester monofilament suture made of

polydioxanone. This suture provides extended wound support and elicits only a slight

tissue reaction. Tensile strength is 70% at 14 days and 25% at 42 days. Wound support

remains for up to 6 weeks. Absorption is minimal for the first 90 days and essentially

complete within 6 months. This material has a low affinity for microorganisms (like

other monofilament). PDS II suture is used for soft tissue approximation, especially in

pediatric, cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic)

situations. Another similar suture material is made from polytrimethylene carbonate

(Maxon). This material has a similar tensile strength and absorption profile.

A barbed suture (V-Loc, Covidien Inc) was developed that is self-anchoring with no knots

required for wound closure. The elimination of knot tying may reduce many of the

challenges of knot construction.

o The barbed suture is manufactured from a size O polydioxanone that reabsorbs

within 26 weeks. This suture consists of axially barbed segments on each side of

a mid point at which the barbs change direction. The tensile strength of the

barbed suture decreases over time. Each suture is attached to a Premium Cutting

and Taper Point needle with NuCoating technology.7

o The unique performance of the barbed suture was confirmed for gastrointestinal

wound closure in a randomized control study. The V-Loc wound closure device

appeared to offer comparable gastrointestinal closure as compared to 3-O

Maxon, while being significantly faster. However, further studies with V-Loc are

required to evaluate its use in laparoscopic surgery.8

Sanz et al randomized 210 rats into one of five study groups to compare three

absorbable sutures with a new synthetic absorbable suture, Maxon. They evaluated

Maxon, Vicryl, chromic catgut and PDS II with respect to tissue inflammatory reaction,

knot security, suture tensile strength, and suture absorption. The results indicated that

Maxon and PDS II elicited a lower degree of chronic inflammation when compared with

Vicryl and chromic catgut. The tensile strengths of Maxon and Vicryl significantly

exceeded those of PDS II and chromic catgut during the critical period of wound healing.

Maxon and PDS II retained a larger percentage of tensile strength during the long

postoperative period, whereas Vicryl and chromic catgut were mostly absorbed. The

authors concluded that Maxon was an excellent addition to the armamentarium of the

surgeon.9

Caprosyn

o The latest innovation in the development of monofilament absorbable sutures

has been the rapidly absorbing Caprosyn suture. Caprosynmonofilament

synthetic absorbable sutures are prepared from Polyglytone 621 synthetic

polyester, which is composed of glycolide, caprolactone, trimethylene

carbonate, and lactide. Implantation studies in animals indicate that Caprosyn

suture retains a minimum of 50-60% USP knot strength at 5 days

postimplantation, and a minimum of 20-30% of knot strength at 10 days

postimplantation. All of its tensile strength is essentially lost by 21 days

postimplantation.

o Pineros-Fernandez et al recently have compared the biomechanical performance

of Caprosyn suture with that of chromic gut suture.10 The biomechanical

performance studies included quantitative measurements of wound security,

strength loss, mass loss, potentiation of infection, tissue drag, knot security, knot

rundown, as well as suture stiffness. Both Caprosyn and chromic gut sutures

provided comparable resistance to wound disruption. Prior to implantation,

suture loops of Caprosyn had significantly greater mean breaking strength than

suture loops of chromic gut. Three weeks after implantation of these absorbable

suture loops, the sutures had no appreciable strength. The rate loss of suture

mass of these 2 sutures was similar.

o As expected, chromic gut sutures potentiated significantly more infection than

did the Caprosyn sutures. The handling properties of the Caprosyn sutures were

far superior to those of the chromic gut sutures. The smooth surface of the

Caprosyn sutures encountered lower drag forces than did the chromic gut

sutures. Furthermore, it was much easier to reposition the Caprosyn knotted

sutures than the knotted chromic gut sutures. In the case of chromic gut sutures,

it was not possible to reposition a two-throw granny knot. These biomechanical

performance studies demonstrated the superior performance of the synthetic

Caprosyn sutures compared with chromic gut sutures and provide compelling

evidence of why Caprosyn sutures are an excellent alternative to chromic gut

sutures.

The examples listed above represent only some of the available synthetic absorbable sutures.

Depending on the anatomic site, surgeon's preference, and the required suture characteristics,

other types of synthetic absorbable suture are available.

Nonabsorbable Sutures

Natural

Surgical silk: This suture is made of raw silk spun by silkworms. The suture may be

coated with beeswax or silicone. Many surgeons consider silk suture the standard of

performance (superior handling characteristics). Although classified as a nonabsorbable

material, silk suture becomes absorbed by proteolysis and is often undetectable in the

wound site by 2 years. Tensile strength decreases with moisture absorption and is lost

by 1 year. The problem with silk suture is the acute inflammatory reaction triggered by

this material. Host reaction leads to encapsulation by fibrous connective tissue.

Surgical cotton: This is made of twisted, long, staple cotton fibers. Tensile strength is

50% in 6 months and 30-40% by 2 years. Surgical cotton is nonabsorbable and becomes

encapsulated within body tissues.

Surgical steel: This is made of stainless steel (iron-chromium-nickel-molybdenum alloy)

as a monofilament and twisted multifilament. It can be made with flexibility, fine size,

and the absence of toxic elements. Surgical steel demonstrates high tensile strength

with little loss over time and low tissue reactivity. The material also holds knots well.

Surgical steel suture is used primarily in orthopedic, neurosurgical, and thoracic

applications. This type of suture also may be used in abdominal wall closure, sternum

closure, and retention. This material can be difficult to handle because of kinking,

fragmentation, and barbing, which renders the wire useless and may present a risk to

the surgeon's safety.11

The cutting, tearing, or pulling of other patient tissues is also a risk. Surgical steel in the

presence of other metals or alloys may cause electrolytic reactions and, therefore, is not a safe

choice in these circumstances. The size of the steel wires is classified by the Brown and Sharpe

gauge, ie, 18 (largest diameter) to 40 (smallest diameter). The standard United States

Pharmacopeia classification is also used to denote wire diameter.

Synthetic

Nylon: This is a polyamide polymer suture material available in monofilament

(Ethilon/Monosof) and braided (Nurolon/Surgilon) forms. The elasticity of this material

makes it useful in retention and skin closure. Nylon is quite pliable, especially when

moist. Of note, a premoistened form is available for cosmetic plastic surgery. The

braided forms are coated with silicone. Nylon suture has good handling characteristics,

although its memory tends to return the material to its original straight form. Nylon has

81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years. The material is

stronger than silk suture and elicits minimal acute inflammatory reaction. Nylon is

hydrolyzed slowly, but remaining suture material is stable at 2 years, due to gradual

encapsulation by fibrous connective tissue.

Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]): This

suture material is formed from polyester, a polymer of polyethylene terephthalate. The

multifilament braided suture also comes coated with polybutilate (Ethibond) or silicone

(Ti-cron). The coating reduces friction for ease of tissue passage and improved suture

pliability and tie-down. The suture elicits minimal tissue reaction and lasts indefinitely in

the body. Polyester fiber sutures are stronger than natural fibers and do not weaken

with moistening. The material provides precise consistent suture tension and retains

tensile strength. This suture is commonly used for vessel anastomosis and the

placement of prosthetic materials.

Polybutester Suture (Novafil): The polybutester is a block copolymer that contains

butylene terephthalate and polytetramethylene ether glycol. The polybutester suture

has unique performance characteristics that may be advantageous for wound closure.12

This monofilament synthetic nonabsorbable suture exhibits distinct differences in

elongation compared with other sutures. With the polybutester suture, low forces yield

significantly greater elongation than is seen in the other sutures. In addition, its

elasticity is superior to the other sutures, allowing the suture to return to its original

length once the load is removed.

Coated Polybutester Suture (Vascufil): The clinical performance of polybutester suture

has been enhanced by coating its surface with a unique absorbable polymer (Vascufil).13

The coating is a polytribolate polymer that is composed of 3 compounds: gylcolide, ε-

caprolactone, and poloxamer 188. Coating the polybutester suture markedly reduces its

drag force in musculoaponeurotic, colonic, and vascular tissue.

Polypropylene (Prolene): This monofilament suture is an isostatic crystalline

stereoisomer of a linear propylene polymer, permitting little or no saturation. The

material does not adhere to tissues and is useful as a pull-out suture (eg, subcuticular

closure). Polypropylene also holds knots better than other monofilament synthetic

materials. This material is biologically inert and elicits minimal tissue reaction. Prolene is

not subject to degradation or weakening and maintains tensile strength for up to 2

years. This material is useful in contaminated and infected wounds, minimizing later

sinus formation and suture extrusion.

Surgipro II: A polypropylene suture has been developed that has increased resistance to

fraying during knot rundown, especially with smaller diameter sutures. These sutures

are extremely inert in tissue and have been found to retain tensile strength in tissues for

as long as 2 years. These sutures are widely used in plastic, cardiovascular, general, and

orthopedic surgery. They exhibit a lower drag coefficient in tissue than nylon sutures,

making them ideal for use in continuous suture closure.

TYPES OF SURGERY What is surgical diagnosis? You and your child's physician will discuss surgery as a way to correct your child's health problem. This decision will be based on careful evaluation of your child's medical history and medical tests, such as blood tests, x-rays, MRI, CT scan, electrocardiogram, or other laboratory work performed to determine the exact diagnosis. What are the different types of surgery? Surgery can be classified as major or minor, depending on the seriousness of the illness, the parts of the body affected the complexity of the operation, and the expected recovery time.

Major surgery: These are surgeries of the head, neck, chest, and abdomen. The recovery time can be lengthy and may involve a stay in intensive care or several days in the hospital. There is a higher risk of complications after such surgeries. In children, types of major surgery may include, but are not limited to, the following:

o Removal of brain tumors.o Correction of bone malformations of the skull and face.o Repair of congenital heart disease, transplantation of organs, and repair of

intestinal malformations.o Correction of spinal abnormalities and treatment of injuries sustained from

major blunt trauma.o Correction of problems in fetal development of the lungs, intestines, diaphragm,

or anus.

Minor surgery: Some surgeries that children undergo are considered minor. The recovery time is short and children return to their usual activities rapidly. These surgeries are most often done as an outpatient, and children can return home the same day. Complications from these types of surgeries are rare. Examples of the most common types of minor surgeries may include, but are not limited to, the following:

o Placement of ear tubes. o Hernia repairs. o Correction of bone fractures. o Removal of skin lesions. o Biopsy of growths.

Elective surgery: These are procedures you decide your child should undergo, which may be helpful, but are not necessarily essential. An example might be to have a birthmark removed, or to circumcise your male infant.

Required surgery: These are procedures that need to be done to ensure the quality of your child's life in the future. An example might be having a spinal fusion to correct severe curvature of the spine. Required surgery, unlike emergency surgery, does not necessarily have to be done immediately and can allow you time to prepare your child for the experience.

Urgent or emergency surgery: This type of surgery is done in response to an urgent medical need, such as the correction of a life-threatening congenital heart malformation or the repair of injured internal organs after an automobile accident.

TYPES OF ANESTHESIA

Anesthesia is medicine to make you comfortable during surgery or a procedure. There are many types of anesthesia. The anesthesia medicine may be given in your IV, through a face mask, or through a tube in your nose or throat. It can also be given as a shot in your back or as a shot in the area where you will have surgery. The type of anesthesia you may have depends on the type of surgery or procedure you are having. You and your caregiver will decide which type of anesthesia is best for you. Following are some of the types of anesthesia.

General Anesthesia:

o This medicine is used to keep you completely asleep during surgery. General anesthesia can be used for most procedures or surgeries. The medicine may be given as a liquid in your IV. It may also be given as a gas through a face mask, endotracheal (end-o-tra-kee-ull) tube, or a laryngeal (luh-rin-g-ull) mask airway.

o An endotracheal tube or "ET" tube is put into your mouth or nose and down your throat into your lungs. The ET tube helps protect your windpipe during surgery. The laryngeal mask airway is also known as LMA. This is a tube with a small mask on the end that fits into the back of your throat instead of down your windpipe. The small mask is filled with air. The ET tube and the LMA allow you to breathe in oxygen or anesthesia gas during surgery.

Epidural Anesthesia: This is medicine used to numb you from about the nipple line to the waist and down. While lying on your side or sitting up, a catheter (tiny tube) is put into your back through a needle. The needle is then taken out but the catheter is left in place to give you more medicine if needed. You are awake during surgery but may be given medicine in your IV so that you are sleepy. Your lower body is numb and you may be able to move your legs but should not feel pain. Feeling returns to your legs when caregivers stop putting medicine in the catheter and when the medicine wears off. Epidural anesthesia is good for procedures below the waist. Epidural anesthesia can give longer lasting pain relief than spinal anesthesia.

Interscalene (in-ter-ska-lene) Block: This medicine is given as a shot in your neck to numb your shoulder and arm. You are awake during surgery but may be given medicine in your IV so that you are sleepy. This kind of anesthesia may be given in addition to medicine to keep you completely asleep during surgery. You may still feel pressure or pushing during surgery but should not feel pain. Feeling returns when the medicine wears off.

Intravenous (IV) Regional Anesthesia: This is medicine put into an IV in the injured arm or leg. A pressure cuff is put on your upper arm or leg. The pressure cuff is tightened after caregivers tightly wrap your arm or leg with a stretchy bandage. This cuff keeps the medicine in the arm or leg so you do not have pain. You are awake (but may be sleepy) during surgery. You may also be given medicine in your IV so that you are sleepy. This type of anesthesia may be called a Bier block if done on your arm. IV regional anesthesia can be used for many kinds of surgeries or procedures on your arm or leg.

Local Anesthesia: This is medicine given before a procedure or surgery to dull the pain. It is usually given as a shot in several places in and around the surgery area. The shot helps to numb the nerves in that area. This medicine can sometimes be given as an ointment or spray. Tell your caregiver if you are allergic to any numbing medicine, such as "novocaine" or "lidocaine." You are awake during the surgery or procedure. Local anesthesia is best used for tests, procedures, or surgeries where a lot of pain is not expected.

Peripheral Nerve Block: This type of anesthesia is medicine put into your arm or leg through a shot. Your arm or leg will be numb for 4 to 18 hours depending on the type of medicine used. You are awake (but may be sleepy) during surgery. You may also be given medicine in your IV so that you are sleepy. This type of block is also called an axillary block if the anesthesia is given in your armpit. This anesthesia can be used for many types of surgery on the arms or legs.

Saddle Block or Caudal (kaw-dull) Anesthesia: This is medicine used to numb you below the waist. You may lie on your abdomen (belly) while your caregiver puts a shot of medicine in the lowest part of your spine. You may lie on your back with your legs up in leg holders (stirrups). You are awake during the surgery but may be given medicine in your IV so that you are sleepy. Saddle block or caudal anesthesia is used for procedures or surgeries of the rear end or legs.

Spinal Anesthesia: This is medicine put into your back through a shot while lying on your side or sitting up. You are awake during surgery but may be given medicine in your IV so that you are sleepy. You are numb from about the nipple line to the waist and down. How high the numbness goes depends on where your surgery will be. You are not able to move your legs when the medicine starts to work. You can move your legs in 1 to 4 hours when the medicine wears off. Spinal anesthesia is best for surgeries below the waist.

Care:

Before the surgery or procedure, you may also get medicine in an IV to make you feel sleepy and more relaxed. If you are awake during the surgery or procedure, you may still feel pressure and pushing. Tell your caregiver if you have pain so you can be given more pain medicine.

Informed Consent:

You have the right to understand your health condition in words that your know. You should be told what tests, treatments, or procedures may be done to treat your condition. Your caregiver should also tell you about the risks and benefits of each treatment. You may be asked to sign a consent form that gives caregivers permission to do certain tests, treatments, or procedures. If you are unable to give your consent, someone who has permission can sign this form for you. A consent form is a legal piece of paper that tells exactly what will be done to you. This consent also gives permission for anesthesia. Before giving your consent, make sure all your questions have been answered so that you understand what may happen.

Risks:

There are risks with anesthesia and your caregivers will watch you closely to treat any problems. Some surgeries cannot be done at all if you choose not to have anesthesia. Call your caregiver if you are worried or have questions about your care.

You could have a bad reaction to the medicine.

You could feel sick to your stomach after surgery.

It may take a while for the medicine to wear off.

You may have a sore throat after general anesthesia. Ask your caregiver about using throat lozenges or gargle with warm salt water. The sore throat is usually gone in 1 to 2 days.

You could have a seizure or heart attack.

Your temperature could go very high and you might die.

You could have long-lasting numbness, dolor, or loss of function of body parts after block types of anesthesia.

Do not make important decisions for 24 hours after having anesthesia because anesthesia medicine may make your thinking unclear.

Care Agreement

You have the right to help plan your care. To help with this plan, you must learn about your health condition and how it may be treated. You can then discuss treatment options with your caregivers. Work with them to decide what care may be used to treat you. You always have the right to refuse treatment.

COMMON POST-OPERATIVE COMPLICATIONS

Post-operative complications may either be general or specific to the type of surgery undertaken, and should be managed with the patient's history in mind. Common general post-operative complications include post-operative fever, atelectasis, wound infection, embolism and deep vein thrombosis.

The highest incidence of post-operative complications is between 1 and 3 days after the operation. However, specific complications occur in the following distinct temporal patterns: early post-operative, several days after the operation, throughout the post-operative period, and in the late post-operative period.1

General post-operative complications

Immediate:o Primary haemorrhage: either starting during surgery or following post-operative

increase in blood pressure - replace blood loss and may require return to theatre to re-explore wound.

o Basal atelectasis: minor lung collapse.o Shock: blood loss, acute myocardial infarction, pulmonary embolism or

septicaemia.o Low urine output: inadequate fluid replacement intra- and post-operatively.

Early:o Acute confusion: exclude dehydration and sepsiso Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileuso Fever (see below)o Secondary haemorrhage: often as a result of infectiono Pneumoniao Wound or anastomosis dehiscenceo Deep vein thrombosis (DVT)o Acute urinary retentiono Urinary tract infection (UTI)o Post-operative wound infectiono Bowel obstruction due to fibrinous adhesionso Paralytic Ileus

Late:o Bowel obstruction due to fibrous adhesionso Incisional herniao Persistent sinuso Recurrence of reason for surgery, e.g. malignancy

Post-operative fever

Days 0 to 2:o Mild fever (T <38 °C) (Common)o Tissue damage and necrosis at operation siteo Haematomao Persistent fever (T >38 °C)o Atelectasis: the collapsed lung may become secondarily infectedo Specific infections related to the surgery, e.g. biliary infection post biliary

surgery, UTI post-urological surgery

o Blood transfusion or drug reaction Days 3-5:

o Bronchopneumoniao Sepsiso Wound infectiono Drip site infection or phlebitiso Abscess formation, e.g. subphrenic or pelvic, depending on the surgery involvedo DVT

After 5 days:o Specific complications related to surgery, e.g. bowel anastomosis breakdown,

fistula formationo After the first weeko Wound infectiono Distant sites of infection, e.g. UTIo DVT, pulmonary embolus (PE)

Haemorrhage

If large volumes of blood have been transfused, then haemorrhage may be exacerbated by consumption coagulopathy. May also be due to pre-operative anticoagulants or unrecognised bleeding diathesis.

Perform clotting screen and platelet count, ensure good intravenous access and insert central venous pressure (CVP) catheter. Give protamine if heparin has been used. Order cross-matched blood. If clotting screen abnormal, give fresh frozen plasma (FFP) or platelet concentrates. Consider surgical re-exploration at all times.

Late post-operative haemorrhage occurs several days after surgery and is usually due to infection damaging vessels at the operation site. Treat infection and consider exploratory surgery.

Infection

Infectious complications are the main causes of post-operative morbidity in abdominal surgery.2

Wound infection: most common form is superficial wound infection occurring within the first week presenting as localised pain, redness and slight discharge usually caused by skin staphylococci.

Cellulitis and abscesses:o Usually occur after bowel-related surgeryo Most present within first week but can be seen as late as third post-operative

week, even after leaving hospitalo Present with pyrexia and spreading cellulitis or abscesso Cellulitis is treated with antibioticso Abscess requires suture removal and probing of wound but deeper abscess may

require surgical re-exploration. The wound is left open in both cases to heal by secondary intention

Gas gangrene is uncommon and life-threatening. Wound sinus is a late infectious complication from a deep chronic abscess that can

occur after apparently normal healing. Usually needs re-exploration to remove non-absorbable suture or mesh, which is often the underlying cause.

Disordered wound healing

Most wounds heal without complications and healing is not impaired in the elderly unless there are specific adverse factors or complications. Factors which may affect healing rate are:

Poor blood supply. Excess suture tension. Long term steroids. Immunosuppressive therapy. Radiotherapy. Severe rheumatoid disease. Malnutrition and vitamin deficiency.

Wound dehiscence

Affects about 2% of mid-line laparotomy wounds. Serious complication with a mortality of up to 30%. Due to failure of wound closure technique. Usually occurs between 7 and 10 days post-operatively. Often heralded by serosanguinous discharge from wound. Should be assumed that the defect involves the whole of the wound. Initial management includes opiate analgesia, sterile dressing to wound, fluid

resuscitation and early return to theatre for resuture under general anaesthesia.

Incisional hernia

Occurs in 10-15% of abdominal wounds usually appearing within first year but can be delayed by up to 15 years after surgery.

Risk factors include obesity, distension and poor muscle tone, wound infection and multiple use of same incision site.

Presents as bulge in abdominal wall close to previous wound. Usually asymptomatic but there may be pain, especially if strangulation occurs. Tends to enlarge over time and become a nuisance.

Management: surgical repair where there is pain, strangulation or nuisance.

Surgical injury

Unavoidable tissue damage to nerves may occur during many types of surgery, e.g. facial nerve damage during total parotidectomy, impotence following prostate surgery or recurrent laryngeal nerve damage during thyroidectomy.

There is also a risk of injury while being transported and handled in the theatre under general anaesthetic. These include injuries due to falls from trolley, damage to diseased bones and joints during positioning, nerve palsies, and diathermy burns.

Respiratory complications

Occur in up to 15% of general anaesthetic and major surgery and include: Atelectasis (alveolar collapse):

o Caused when airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed

o Symptoms are slow recovery from operations, poor colour, mild tachypnoea, tachycardia and low-grade fever

o Prevention is by pre-and post-operative physiotherapyo In severe cases, positive pressure ventilation may be required

Pneumonia: requires antibiotics, physiotherapy. Aspiration pneumonitis:

o Sterile inflammation of the lungs from inhaling gastric contentso Presents with history of vomiting or regurgitation with rapid onset of

breathlessness and wheezing. Non-starved patient undergoing emergency surgery is particularly at risk

o May help avoid this by crash induction technique and use of oral antacids or metoclopramide

o Mortality is nearly 50% and requires urgent treatment with bronchial suction, positive pressure ventilation, prophylactic antibiotics and IV steroids

Acute respiratory distress syndrome:o Rapid, shallow breathing, severe hypoxaemia with scattered crepitations but no

cough, chest pains or haemoptysis, appearing 24-48 hours after surgeryo Occurs in many conditions where there is direct or systemic insult to the lung,

e.g. multiple trauma with shocko Requires intensive care with mechanical ventilation with positive-end pressure

Thrombo-embolism

Major cause of complications and death after surgery. DVT is very commonly related to grade of surgery.3

Many cases are silent but present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot.

Diagnosis is by venography or Doppler ultrasound. Pulmonary embolism:

o Classically presents with sudden dyspnoea and cardiovascular collapse with pleuritic chest pain, pleural rub and haemoptysis. However, smaller PEs are more common and present with confusion, breathlessness and chest pain

o Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT

Management: intravenous heparin or subcutaneous low molecular weight heparin for 5 days plus oral warfarin.

Common urinary problems

Urinary retention: common immediate post-operative complication that can often be dealt with conservatively with adequate analgesia. If this fails may need catheterisation.

UTI: very common, especially in women, and may not present with typical symptoms. Treat with antibiotics and adequate fluid intake.

Acute renal failure:o May be caused by antibiotics, obstructive jaundice and surgery to the aortao Often due to episode of severe or prolonged hypotensiono Presents as low urine output with adequate hydrationo Mild cases may be treated with fluid restriction until tubular function recovers.

However it is essential to differentiate from pre-renal failure due to hypovolaemia which requires rehydration

o In severe cases may need haemofiltration or dialysis while function gradually recovers over weeks or months

Complications of bowel surgery

Delayed return of function:2

o Temporary disruption of peristalsis: may complain of nausea, anorexia and vomiting and usually appears with the re-introduction of fluids. Often described as ileus

o More prolonged extensive form with vomiting and intolerance to oral intake called adynamic obstruction and needs to be distinguished from mechanical obstruction. If involves large bowel usually described as pseudo-obstruction. Diagnosed by instant barium enema

Early mechanical obstruction: may be caused by twisted or trapped loop of bowel or adhesions occurring approximately 1 week after surgery. May settle with nasogastric aspiration plus IV fluids or progress and require surgery.

Late mechanical obstruction: adhesions can organise and persist, commonly causing isolated episodes of small bowel obstruction months or years after surgery. Treat as for early form.

Anastomotic leakage or breakdown: small leaks are common causing small localised abscesses with delayed recovery of bowel function. Usually resolves with IV fluids and delayed oral intake but may need surgery.

Major breakdown causes generalised peritonitis and progressive sepsis needing surgery for peritoneal toilet, and antibiotics. Local abscess can develop into a fistula.