Wednesday, October 17, 2012

The World Health Organization Surgical Checklist

How important is the World Health Organization (WHO) Surgical Checklist?

It will take a couple of minutes and a few excruciating heartbeats (depending on the surgeon and the anesthesiologist) to complete this very short and comprehensive list of things to remember before starting and ending the operation. This can reduce surgical errors not just during the operation but also after. We also practice this in our institution, except during REAL emergency cases. It may not be this ideal, but it has all the necessary things needed in order to provide safety to our patients inside the operating room.


If WHO Surgical Checklist is not done:


Here is a sample of our WHO Surgical Checklist in our institution:

 



 

Does your institution have the same?

Tuesday, August 21, 2012

Arteriovenous Fistula (AVF) Creation

arteriovenous fistula (AVF) creation

 

I remembered the first day I was back inside the operating room, our head nurse asked me to scrub for the arteriovenous fistula (AVF) creation. I would have been excited if not for the fact that I was out of OR for more than a year and I forgot some of the instruments name inside the AVF Set we have. Well, happy to say I survived the operation, and still living to tell the tale. Thank God the surgeon was nice, and fast. It only took less than an hour for him to finish the task. If you ask me the longest I have ever scrubbed for an AVF Creation: 4 hours. This reminds me of an exploratory laparotomy or a TAHBSO with Peritoneal Fluid Cytology and Bilateral Lymph Node Dissection.

So far, AVF proved to be the best kind of vascular hemodialysis access for people whose veins are big enough, not just because this could last for a longer period of time but it is also less likely than other types of access to form clots or become infected. However, if the veins aren’t large enough, a graft or catheter is always an option.

Arteriovenous Fistula is an abnormal connection or passageway between an artery and a vein surgically created for hemodialysis treatment (in this case). However, some AVF can be congenital or can be acquired because of a pathologic process such as trauma or erosion of an arterial aneurysm.

The purpose of this surgery is to provide a long-lasting site through which blood can be removed and returned during hemodialysis. The fistula is prepared weeks or months prior to the start of the dialysis. When the artery and vein are joined, the vein would steadily becomes larger and stronger, making the fistula last long with fewer complications compare to other hemodialysis access.

Usually, the surgery is done using a local anesthetic injected at the site of the proposed fistula. Typically, surgeons would prefer to do the fistula in the patient’s non-dominant arm. The procedure can be performed as an out-patient basis, if the patient is not currently admitted for any other reason. Skin prepping depends upon the surgeon – in our case, one surgeon can be okay with paint while others wanted thorough skin prepping which extends from the armpit down to the fingertips. After this, surgeon will infiltrate the local anesthesia and make a small incision in the forearm just enough to allow the permanent fusion of the vein and artery in the arm. Blood vessels will be appropriately clamped and ligated to stop blood flow for the procedure. Silk sutures (Silk 3/0 or 4/0 Multi strands – still depends on your surgeon’s preferences) will be utilized. In our hospital, our surgeons used Prolene 6/0 for the operation and closed the incise area with a cutting Vicryl 4/0. But prior to closing, surgeons check for the patency of their work. They palpate for a thrill (a quick powerful beat that suddenly collapses) and later when the field is not sterile anymore, they would auscultate for a bruit (soft & low-pitched sound). A pressure dressing is then applied. Once joined, blood flow will likely increase as vein will become thicker. In the coming months, connection will become strong and develop into the fistula that will allow permanent vascular access.

After the Operation

It is important that the patient should be reminded to take care of their vascular access. Some important reminders are:

  • No BP taking on the AVF site

  • Checking of Pulse every day

  • Keeping the access clean all the time

  • Using the site for the sole purpose of dialysis

  • Not wearing any tight jewelry or clothing near or over the access site

  • Not putting any pressure or lifting heavy objects on the access arm

  • Sleeping with access arm free, not under the head or body


Some common instruments used during AVF Creation:

  • Minor Set (which includes the usual: hemostats, metz, suture scissor, crile retractor)

  • Pott's Scissor

  • Weitlaner Retractor

  • Ragnel Retractor

  • Vascular Loops

  • Tenotomy Scissor


AVF Creation

 

Thursday, August 2, 2012

New Uniforms :)


What's new today: It's the first day I get to wear my uniform!

Yes, the Operating Room complex decided to have a uniform that can separate the staff nurses from the surgeons, the volunteer nurses and well - the other people inside the complex. I sorta love it except for the pants that is ill-fitted.



This picture was taken the minute I stepped outside our locker room and inside the operating room lobby. These two good looking men are my seniors: Sir Romy & our head nurse, Sir Roger - one of the best OR nurses I have ever seen and encountered (and I am not just saying this to get into his good graces).



Anyway, I was hoping to have a great week because my duty ended with a blast the prior week with a double table of tube vent and exploratory laparotomy because of a stab wound.  Instead, I got a blast circulating for a Urology case - Cysto RGP with surgical exploration of the ureters. Three positions for one patient: one in lithotomy, then he was turned to his side and finally supine. We had to change our field a couple of times- which makes it more tasking. Nevertheless, the uro-case was a nice experience and it made me realize one thing: If you want to learn: you don't chose the easy way out, you should be ready to make mistakes because it is through hardship and mishaps that learning grows. 

Saturday, July 28, 2012

Finally, back from Hiatus

Here we go...

What happen?

I got stuck between a writer's block, a little bit of health problem that involves a lot of therapy from friends (no it's not depression) and of course, WORK. YES! Finally - after years of waiting, they hired me! Good thing I am doing the thing I love (besides drinking caffeine and reading books). It's stressful, it makes me go over the edge sometimes (makes me question my sanity, as well as the sanity of the surgical team), my surgical conscience is bugging me, and of course I'm losing weight (or I'd like to think so) in going to and fro the central supply room.

 

What made me write again?

Let's just say there was this one girl who told me she was following my blog - then suddenly this tick in the vain part of me that blushed with embarrassment knowing I haven't been able to update this blog in eons!

 

Anyway, thanks to you dear, you finally gave me this push to starting typing on my keyboard once again and share what's going on inside the operating room. Not to the extent I'm going to enumerate every mishaps - no, I love my license. Just some common and weird stuffs that OR nurses like me as well as students who are aspiring to be OR nurses would appreciate.

Sunday, January 22, 2012

Thyroidectomy

Thyroidectomy

Thyroidectomy is a surgical operation in which all or some parts of the thyroid gland is removed. The thyroid gland is located in the anterior part of the neck just beneath the skin and right in front of the Adam’s apple.  The thyroid gland is one of the body’s endocrine glands that secrete its products inside the body, into the blood stream or lymph. The thyroid creates numerous hormones that have two main functions: (1) they increase the synthesis of proteins in most of the body’s tissues and (2) increase the level of the body’s oxygen consumption.

 

Who needs to undergo a thyroidectomy procedure?

  1. Malignancy

  2. Cosmetic purposes

  3. Goiter which remains untreated by medications

  4. Severe hyperthyroidism

  5. Orbitopathy in Grave’s Disease

  6. Removal and Evaluation of a thyroid nodule whose FNAC results are not clear.


 

Kinds of thyroidectomy

1.       Total Thyroidectomy

The whole gland is taken out. This is done in the case of follicular carcinoma of thyroid, medullary cancer of the thyroid

2.   Partial thyroidectomy

The removal of the gland in front of the trachea after mobilization. This is done in non toxic MNG

3.       Hemithyroidectomy

The whole isthmus is taken out along with one lobe. This is done in benign diseases of a single lobe

4.       Subtotal thyroidectomy

This is done with toxic thyroid.

5.       Hartley Dunhill Operation

This is the removal of the whole lateral lobe with isthmus and partial/subtotal removal of opposite lateral lobe

 

Risks & Complications

There are a lot of risks related with thyroidectomy. The thyroid gland should only be taken out if there is a real reason or an underlying medical condition that necessitates it.

 

  • People who are at risk: obese, smokers, poor nutrition (greater risk for developing complications secondary to the general anesthetic)

  • Voice loss or hoarseness can develop if the recurrent laryngeal nerve is destroyed or damage in the course of the procedure. This damage usually happens in people who have large goiters or cancerous tumors.

  • Hypoparathyroidism can happen if parathyroid glands are either removed or damaged at the time of the operation. This is characterized by a drop in the serum calcium levels which in turn results to muscle cramps and twitching.

  • Hypothyroidism occurs if all or nearly all of the thyroid gland is taken out. Complete removal, on the other hand, can be intentional when the patient is diagnosed with cancer.  If a person’s thyroid levels stays low, it may be required that he or she undergo thyroid replacement medications for the rest of his or her life.

  • Hematoma is the most common complication after the thyroidectomy procedure. This is a collection of blood in an organ or tissue, caused by a break in the wall of a blood vessel. The neck area have an ample supply of blood vessels and bleeding in this area can be difficult to control and can be life threatening. As the hematoma enlarges it can obstruct the airway and cause a person to stop breathing. If a hematoma forms in the neck, the surgeon may need to do a drainage to clear the airway.

  • Wound infection like any other operation, infection can occur.


 

Procedure

Instruments

(Usual) Surgical Instruments List for the Thyroidectomy procedure:

  • Major Set

  • nylon needle holder

  • short needle holders

  • fine iris scissors

  • #3 knife handles (1Calibrated)Senn Rake

  • #7 knife handle

  • #10 & 15 blades

  • short plain forceps

  • short multitoothed forceps

  • vascular forceps

  • fine Cushing forceps

  • Senn rakes

  • pairs of double skin hooks

  • pair of single skin hooks

  • pair vein retraction

  • adenoid suction

  • double-ended medium-small Richardson retractors

  • McCabe nerve dissector

  • Peanuts

  • fiberoptic headlight unit

  • bipolar cautery unit

  • Penrose drain

Sunday, December 18, 2011

Caesarean Section

Caesarean Section

Caesarean Section (also referred to as C-Section or Cesarean Section) is a type or surgery which one or more incisions are done through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies or remove a dead fetus. This is usually done when a vaginal delivery would put the mother’s or the baby’s life or health at risk. In 1881, Ferdinand Adolf, a German gynecologist, performed the first modern Caesarean Section.

There are many kinds of Caesarean Section. The difference lies in the type of incision whether it is longitudinal or latitudinal done on the uterus, apart from the skin incision.

  1. Classical Caesarean Section involves a midline longitudinal incision which allows a larger space for the baby to be delivered. However, due to complication issues, it is rarely performed today.

  2. The Lower Uterine Segment Caesarean Section is most commonly used nowadays, it involves a transverse cut just above the edge of the bladder and results in lesser blood loss and is easier to repair.

  3. Unplanned Caesarean Section is performed once labor has started due to unexpected labor complications.

  4. Emergency Caesarean Section is done where complications of pregnancy onset is sudden during the process of labor and immediate action is required to prevent the deaths of child, mother or both.

  5. Caesarean Hysterectomy involves a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

  6. Repeat Caesarean Section is done when a patient had a previous caesarean section. Typically it is performed through an old scar.


 

Indications

Caesarean Section is recommended when the usual vaginal delivery may pose a risk to the mother, baby or both. These are some indications for C-Section:

Complications of labor and factors impending vaginal delivery:

  • Prolonged labor or failure to progress (dystocia)

  • Fetal distress

  • Cord Prolapse

  • Uterine Rupture

  • Increased heart rate (mother/baby) after amniotic rupture

  • Increased BP (mother/baby) after amniotic rupture

  • Placental problems (placenta previa/abruptio placenta/placenta accreta)

  • Abnormal presentation (breech/transverse)

  • Failed labor induction

  • Failed instrument-aided delivery (forceps)

  • Overly large baby (macrosomia)

  • Umbilical cord abnormalities

  • Contracted Pelvis


Other complications of pregnancy, preexisting conditions and concomitant disease

  • Pre-eclampsia (a medical condition in which hypertension arises in pregnancy in association with significant amounts of protein in urine

  • Hypertension

  • Multiple births (twins)

  • High-risk fetus

  • HIV infection

  • STI such as genital herpes

  • Previous problems with the healing of the perineum from previous childbirth or Crohn’s Disease

  • Bicornuate Uterus (commonly referred to as “heart-shaped” uterus, this is a type of uterine malformation where two “horns” form at the upper part of the uterus)


 

Contraindications

  • Compromised maternal status (severe pulmonary disease)

  • Karyotypic abnormality (trisomy 13 or 18). Karyotype is the number an appearance of chromosomes in the nucleus of a eukaryotic cell. This term is also used for the complete set of chromosomes in a species, or an individual organism.

  • Known congenital anomaly that may lead to fetal death (anencephaly)


 

Anesthesia

  • Regional Anesthesia (most common) – spinal, epidural or combined spinal/epidural. This is preferred because it allows the mother to be conscious during the surgery and can interact immediately with her baby.

  • General Anesthesia can be necessary because of specific risks to either mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the effects of regional anesthesia. This is also preferred in very urgent cases such as severe fetal distress where there is no enough time to perform the regional anesthesia.


Caesarean Section

Risks

For the Mother

  • Fluid Retention in the wound – 2 weeks post C-Section. Incision had to be opened to use a negative pressure wound therapy unit to drain body fluids to avoid or infection

  • Post-op adhesions

  • Incisional hernias

  • Wound infection


For the Child

  • Fetal injury during uterine incision and extraction

  • Neonatal depression due to anesthesia given to the mother causing a period of inactivity or sluggishness after delivery

  • Breathing problems

  • Breastfeeding problems

  • Potential for early delivery and complications especially if a repeat C-Section is performed even a few days prior to 39 weeks.


Studies have shown that mothers who have their babies delivered by Caesarean Section may take longer to first interact with their child compared with mothers who had their babies vaginally.

Caesarean SectionOR Memoirs

This is one of the first operations I have assisted all by myself. I remember it vividly – I was on my night duty and I was the only scrub nurse available to assist. Panic attack is an understatement. It was a private patient and the consultant was not really nice. Good thing my staffs (the stuff nurses) were there to instruct me as well as a fellow volunteer who had spent so much time giving his free services in the hospital. (I am not sure if I have to mention names here, but if HE reads this, he has my never-ending gratitude for settling my nerves and teaching me). The instruments are the usual major instruments you get to use in the usual abdominal operations, plus a balfour retractor.



Things to remember during assisting a CS*

  • This is a fast operation – so better pay attention to your consultant

  • The sutures needed in order:



  1. Chromic 1 (2 pcs)

  2. Chromic 2

  3. Vicryl 1

  4. Plain 2/0

  5. Vicryl 3/0 Cutting (or any skin suture your consultant prefers) – OB people rarely go for staples due to aesthetic purposes.



  •  (Order of the shears) After the scalpel: mayo scissors, metz, second knife, bandage scissor (but I have this one consultant who prefers mayo scissors in opening the uterus)

  • When the bag of water is ruptured, prepare the suction bulb, two straights and the bandage scissor to cut the umbilical cord. Once the umbilical cord is cut, and the placenta is out, and removal of clots (or etc), the first suture (chromic 1) will be asked. So in between the handling of the instruments and before the baby is out, the suture should be prepared.


Why I like to assist a C-Section:

  • It’s fast. One consultant could do it in 10 minutes – he amazes me!!!

  • It’s standard procedure – once you have mastered it, you can close your eyes and do it.


But

  • Caesarean Section is BLOODY messy (it’s not a Brit curse, it’s literally bloody, and messy)


 

I hope I helped :)


ChuCha


* Base on my hospital experience

Thursday, December 8, 2011

Mastectomy



Mastectomy is a surgical removal of a breast. This is usually indicated to treat or prevent breast cancer. There are four main types of Mastectomy:

Simple Mastectomy




  • Total Mastectomy or Simple Mastectomy is the removal of the entire breast tissues, but the axillary contents are remains untouched. This type of procedure is sometimes done on both breasts on patients who wanted to undergo mastectomy as a prophylactic measure against cancer. Most of the time, a Jackson-Pratt drainage tube is inserted during surgery in their chest but usually removed several days after surgery as drainage decrease to less than 20-30 ml/day.


[caption id="attachment_484" align="aligncenter" width="199" caption="In handling the drain to the surgeon, it goes with a suture and a suture scissor."]Mastectomy[/caption]

  • Modified Radical Mastectomy (MRM) is the removal of the entire breast tissue including the axillary contents which is composed of fatty tissue and lymph nodes. The difference between MRM and Radical mastectomy is that the pectoral muscles are spared.


Radical Mastectomy




  • Radical Mastectomy also referred to as Halsted Mastectomy was first performed in 1882. This includes the removal of the entire breast, axillary lymph nodes and the pectoralis major and minor muscles behind the breast. This operations is now intended for tumors involving the pectoralis major muscles or recurrent breast CA involving the chest wall.

  • Lumpectomy is the surgical removal of a tumor and a small amount of normal tissue surrounding it.


After the operation is done, the skin is closed with either sutures or staples that are to be removed within 7 to 10 days after the procedure. Usually, a tube is inserted to drain blood and fluid from the operative site. A pressure dressing is placed over the operative site to minimize post-operative bleeding.

Indications:

  • Mastectomy for breast cancer treatment
    Mastectomy may be a treatment option for many types of breast cancer, including:

  • Ductal carcinoma in situ (DCIS), or noninvasive breast cancer

  • Stages 1 and 2 (early-stage) breast cancer

  • Stage 3 (locally advanced) breast cancer — most often after chemotherapy to shrink the tumor

  • Inflammatory breast cancer — most often after chemotherapy

  • Paget's disease of the breast

  • Locally recurrent breast cancer


Risks:

  • Bleeding

  • Infection

  • Pain

  • Lymphedema or swelling in the arm

  • Formation of hard scar tissue at surgical site

  • Shoulder pain and stiffness

  • Hematoma in the surgical site

  • Numbness, particularly under the arm, from lymph node removal


I so hate Mastectomy. It gives me a creepy feeling actually, being a girl. This is one of the operations I do not want to be in – given any choice. It’s like watching yourself there instead of the patient, it would take me minutes before I could have my concentration back. The incision is so big, and the moment they (the surgeons) hand the specimen to you – it’s priceless. The whole operation would pass with me in a daze. Don’t misunderstand me, I still follow operating room protocol and the aseptic technique. Good thing, I don’t easily faint!

[caption id="attachment_485" align="aligncenter" width="300" caption="Special Instrument Used During Mastectomy"]Lahey Clamp[/caption]