Operating Room Procedures

8/3/2019 Operating Room Procedures

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SURGICAL SCRUBBING

THE SURGICAL SCRUB

The scrub person should perform a scrub in the following instances:

3.12.1 Before the first case in the morning and this scrub will last for 5 minutes.

3.12.2 Subsequent cases when the scrub will last for 3 minutes.

3.12.3 Only the nails are brushed. Brushing other areas of the hands and arms

has been proven to be detrimental to the skin surface causing abrasions.5

PRINCIPLES

The scrub person should follow certain principles when performing the surgical

scrub;

3.13.1 Rinsing time is not to be included in the total scrub time.

3.13.2 Un-sterile objects should not be touched once the scrub procedure has

begun.

3.13.3 The entire scrub procedure must be repeated if an un-sterile object is

touched.

3.13.4 The same scrub procedure should be utilized for every scrub procedure

whether it is the first or last one of the day however subsequent washes

should encompass two thirds of the forearms only to avoid

compromising the hands.

PROCEDURE :

a. Both surgical scrub methods follow an anatomical pattern of scrub. One should

think of the fingers, hands, and arms as having four sides or surfaces. If properly

executed, both methods are effective and each exposes all surfaces of the hands

and forearms to mechanical cleaning and chemical antisepsis.

b. b. In the following paragraphs, the brush-stroke method is described, using a

disposable, prepackaged, pre-sterilized sponge/brush, impregnated with a

surgical detergent.



(1) Regulate the flow and

temperature of the water.

(2) Pretear package containing

brush (see Figure 1-4); lay the

brush on the back of the scrub

sink.

Figure 1-4

(3) Wet hands and arms (see

Figure 1-5) for an initial prescrub

wash. Use several drops of

surgical detergent, work up a

heavy lather, then wash the hands

and arms to a point about two

inches above the elbow.

Figure 1-5

(4) Rinse hands and arms

thoroughly, allowing the water to

run from the hands to the elbows

(see Figure 1-6). Do not retrace or

shake the hands and arms; let the

water drip from them.

Figure 1-6

(5) Remove the sterile brush and

file, moisten brush and work up a

lather. Soap fingertips and clean

the spaces under the fingernails of

both hands under running water

(see Figure 1-7); discard file.

Figure 1-7

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(6) Lather fingertips with sponge-

side of brush; then, using bristle

side of brush, scrub the spaces

under the fingernails of the right or left hand 30 circular strokes(see

Figure 1-8). When scrubbing,

slightly bend forward, hold hands

and arms above the elbow, and

keep arms away from the body.Figure 1-8

(7) Lather digits (see Figure 1-9);

scrub20 circular strokes on all four

sides of each finger.

Figure 1-9

You may begin with the thumb or little finger (see Figure 1-10) or the

right or left hand. Scrub one hand

and arm completely before moving

on to the other hand and arm.

(8) Lather palm, back of hand, heel

of hand, and space between

thumb and index finger. Choosing

either of the surfaces, scrub 20

circular strokes on each surface.

(9) You are now ready to scrub the

forearm. Divide your arm in three

inch increments. The brush should

be approximately three inches

lengthwise. Use the sponge-side of

the brush lengthwise to apply soap

around wrist. Scrub 20 circular

strokes on all four sides; move up

the forearm--lather, then scrub,

ending two inches above the

Figure 1-10






elbow.

(10) Soap and/or water may be

added to the brush at any time

(11) Repeat steps (6) through (9)

above for the other arm.

(12) Discard brush.

(13) Rinse hands and arms without

retracing and/or contaminating.

(14) Allow the water to drip from

your elbows before entering the

operating room.

(15) Slightly bend forward, pick up

the hand towel from the top of the

gown pack and step back from the

table (see Figure 1-11). Grasp the

towel and open it so that it is

folded to double thickness

lengthwise. Do not allow the towel

to touch any unsterile object or

unsterile parts of your body. Hold

your hands and arms above your

elbow, and keep your arms away

from your body.

Figure 1-11

(16) Holding one end of the towel

with one of your hands, dry your

other hand and arm with a blotting,

rotating motion (see Figure 1-12).

Work from your fingertips to the

elbow; DO NOT retrace any area.

Dry all sides of the fingers, the

forearm, and the arms thoroughly

(see Figures 1-13 and 1-14). If moisture is left on your fingers and

hands, donning the surgical gloves

will be difficult. Moisture left on the

arms may seep through surgical

Figure 1-12





cloth gowns, thus contaminating

them. (17) Grasp the other end of

the towel and dry your other hand

and arm in the same manner asabove. Discard the towel into a

linen receptacle (the circulator may

take it from the distal end). Figure 1-13

Figure 1-14

GOWNING

GOWNING FOR THE CLOSED GLOVE TECHNIQUE

PRINCIPLES

Surgical gowns are folded with the inside facing the scrub person. This method of

folding facilitates picking up and donning the gown without touching the outside surface.

If the scrub person touches the outside of the gown whilst donning it, the gown must beconsidered to be contaminated. If this occurs discard the gown, as only the inside of the

gown should be touched while putting it on.

The scrub person’s hands and arms are contaminated if they are allowed to fall

below waist level or to touch the body therefore hands and arms should be kept above





the waist and away from the body at an angle of about 20 to 30 degrees above the

elbows.

After donning the surgical gown, the only parts of the gown that are considered

sterile are the sleeves (except for the axillary area) and the front from waist level to a

few inches below the neck opening. If the gown is touched or brushed by an un-sterile

object the gown is then considered contaminated. The contaminated gown must be

removed using the proper technique and then a new sterile gown should be donned.

PROCEDURE:

a. With one hand, pick up the entirefolded gown from the wrapper by

grasping the gown through alllayers, being careful to touch onlythe inside top layer, which isexposed (see Figure 1-15). Stepback from the table to allow other team members room to maneuver.

Figure 1-15

b. Hold the gown in the manner shown in Figure 1-16, near thegown's neck, and allow it to unfold,being careful that it does not toucheither your body or other unsterileobjects.

c. Grasp the inside shoulder seamsand open the gown with thearmholes facing you.

Figure 1-16

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d. Slide your arms part way into thesleeves of the gown, keeping your hands at shoulder level away fromthe body (see Figure 1-17).

Figure 1-17

e. With the assistance of your circulator, slide your arms further into the gown sleeves; when your fingertips are even with the proximaledge of the cuff, grasp the insideseam at the juncture of gown sleeveand cuff using your thumb andindex finger. Be careful that no partof your hand protrudes from the

sleeve cuff (see Figure 1-18).

Figure 1-18

f. The circulator must continue toassist at this point. He positions the

gown over your shoulders (seeFigure 1-19) by grasping the insidesurface of the gown at the shoulder seams.

1. The Circulator adjusts the gownover the Scrub's shoulders.

2. Note that the Circulator's handsare in contact with only the insidesurface of the gown.

Figure 1-19.1

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Figure 1-19.2

NOTE: For the reusable cloth gown (which is rarely used), use theprocedures given in steps a through f. The circulator then prepares to tie thegown. The neck and back ties are tied in an up-and-down motion. He thenties the belt by grasping the gown at the back as the scrub leans forward.The circulator leans down and grasps the distal end of one belt tie; thisenables the circulator to handle the belt without touching any part of the gown

that should remain sterile. The circulator then brings the belt tie to the back of the gown. The scrub then swings toward the opposite side so that thecirculator can grasp the other belt in the same manner. The circulator willthen tie the belt in an up-and-down motion; this reduces the area of contamination on the gown. The circulator will then tuck the ends of the beltinside the gown at the back. Then the scrub; proceeds to the glovingprocedure.

g. The circulator then prepares tosecure the gown. The neck andback may be secured with aVelcro® tab or ties (see Figure 1-20). The circulator then ties thegown at waist level at the back. Thistechnique prevents thecontaminated surfaces at the backof the gown from coming intocontact with the front of the gown.

Figure 1-20

The scrub person will proceed to the Glove Technique before completing the finalgown tie.

GLOVING

SURGICAL GLOVE TECHNIQUE

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Gloves are packaged so that the scrub person may don the gloves without

contaminating the outer surfaces and each pair of gloves is packaged in an individual

sterile wrapper. The closed cuff method of gloving is preferable to the open cuff method

as it eliminates potential hazards in the glove procedure as indicated:

• The danger of contamination of gloves caused by the glove cuffs rolling on skin is

eliminated because the skin surface is not exposed.

• The gown cuffs can be anchored securely by the gloves without the danger of

contamination that exists when gloves are donned by the open cuff method.

PROCEDURE:

(1) Take a tuck in each gown cuff if thecuffs are loose. Make the tuck bymanipulating the fingers inside thegown sleeve; do not expose the barehands while tucking the gown cuffs.

(2) The circulator opens the outer wrapper of the glove package and flipsthem onto the sterile field.

Figure 1-21

(3) Open the inner package containingthe gloves and pick up one glove bythe folded cuff edge with the sleeve-covered hand (see Figure 1-21).

(4) Place the glove on the oppositegown sleeve, palm down, with theglove fingers pointing toward your shoulder (see Figure 1-22). The palmof your hand inside the gown sleevemust be facing upward toward the palmof the glove.

Figure 1-22

(5) Place the glove's rolled cuff edge atthe seam that connects the sleeve tothe gown cuff (see Figure 1-23). Graspthe bottom rolled cuff edge of the glovewith your thumb and index finger.

Figure 1-23



(6) While holding the glove's cuff edgewith one hand, grasp the uppermostedge of the glove's cuff with theopposite hand (see Figure 1-24). Takecare not to expose the bare fingers

while doing this.

Figure 1-24

(7) Continuing to grasp the glove (seeFigure 1-24); stretch the cuff of theglove over the hand (see Figure 1-25).

Figure 1-25

(8) Using the opposite sleeve- coveredhand, grasp both the glove cuff andsleeve cuff seam and pull the gloveonto the hand (see Figure 1-26). Pullany excessive amount of gown sleevefrom underneath the cuff of the glove.

Figure 1-26

(9) Using the hand that is now gloved,put on the second glove in the samemanner. When gloving is completed,no part of the skin has touched theoutside surface of the gloves. Check tomake sure that each gown cuff issecured and covered completely by thecuff of the glove (see Figure 1-27).

Adjust the fingers of the glove asnecessary so that they fit snugly.

Figure 1-27

While the scrub person is wearing a sterile gown and gloves they must take particular care toavoid contaminating these as this could potentially result in the transfer of pathogenic micro-organisms to the patient's wound. The following rules should therefore be observed:

• Never drop hands below the level at which they are working and never below

waist level.• Never tuck gloved hands under armpits as the axillary region of the gown is

considered contaminated. Never put hands behind the back, they must be kept infull view at all times.

• Never reach across an un-sterile area for an item.

• Never touch an unsterile item with gloved hands unless asked to do so by thesurgeon (e.g. in the event of an emergency such as cardiac arrest).



FINAL TIE OF GOWN

Once the sterile gloves are on the scrub person is ready to secure their gown

with assistance of the circulating person.

PROCEDURE:

a. The scrub will take hold of the paper tab

that holds the belt and belt tie located at

waist level (see Figure 1-28) and pull the

tab away from the belt tie.

Figure 1-28

b. The scrub will pass the paper tab that

holds the belt to the circulator (see Figure

1-29).

Figure 1-29

c. The circulator will take hold of the paper

tab, being very careful not to touch the belt,

and will move to the side or behind the

scrub (see Figure 1-30).

Figure 1-30



d. When the circulator is properly

positioned (to the side or behind the scrub),

the scrub will then take hold of the belt

only being careful not to touch the paper tab and pull on the belt leaving the

circulator with only the paper tab in his

hand (see Figure 1-31).

NOTE: The circulator must hold on tight to

the paper tab so that when the scrub pulls

on the belt the tab doesn't come with the

belt and contaminates the scrub.

Figure 1-31

e. Now the scrub will take hold of the belt tie that is at waist level and tie the belt to

it (see Figures 1-32 and 1-33).

Figure 1-32

Figure 1-33

ADJUSTMENT OF GOWN

Now that the gloves are on and final tie of the gown is done, the circulator

completes his adjustment of the gown by stooping down, grasping the outside of the



side seams at the bottom of the gown, and gently pulling down (see Figure 1-34) in

accordance with local SOP.

Figure 1-34

REMOVING THE GOWN AND GLOVES BETWEEN CASES

On completion of a surgical case the outer part of the gown and gloves are

considered to be contaminated by bacteria from the procedure and the scrub person

must remove them very carefully to avoid contamination to their forearms and hands.

The gloves should be removed after the gown.

PROCEDURE:

a. After the circulator unties theneck and back ties, the teammembers perform the followingprocedure by themselves. Graspthe gown at the shoulders andpull the gown forward and downover the arms and gloved hands.

Figure 1-41

b. Holding the arms away fromthe body (see Figure 1-41), foldthe gown so that the outside of the gown is folded in (see Figure

1-42); discard it into the linenhamper.

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Figure 1-42

c. Grasp the outer surface of oneglove with the other gloved hand

"rubber to rubber" (see Figure 1-43) and pull off the glove.Discard the glove into thedesignated receptacle.

Figure 1-43

d. Place the fingers inside thecuff of the glove "skin to skin"(see Figure 1-44); discard theglove.e. After exiting the "sterile area,"remove the mask and discard itinto the proper receptacle.

Figure 1-44

SERVING OF GOWNS AND GLOVES

Occasionally it may be necessary for the scrub person to assist another member

of the scrub team to don or change their gown / gloves e.g. if they have become

contaminated. Their gown and gloves should be removed as described in the above

procedure and the outer wrap of a new gown pack is opened by the circulating person.

PROCEDURE:

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Grasp the gown near the neckbandusing the thumb and index finger of each hand and roll the gown so thatthe outside surface is over (protecting)your gloved hands (see Figure 1-35).

The arm holes of the gown are facingthe team member being gowned. Offer the inside of the gown to the scrubbedteam member and allow him to slip hisarms into the gown sleeves (seeFigure 1-35).

Figure 1-35

b. The scrub pulls the gown over theteam member's shoulders (see Figure

1-36). The circulator then secures theneck of the gown and ties the insidewaist tie.

Figure 1-36

c. Grasp the right glove firmly at waistlevel. Keeping your thumbs extendedand covered by the glove cuff, stretchthe cuff so that he can introduce hishand without touching your gloves (seeFigure 1-37).

1 Assisting the team member indonning the first glove. Note that thescrub has spread the cuff wide topermit the team member to introducehis hand without touching the scrub'sgloves.

2 Note also that the scrub protects hisgloved fingers by holding them

beneath the cuff of the glove, and histhumbs by holding them away from thepartly-gloved hand.

Figure 1-37.1

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Figure 1-37.2

While you are stretching the gloveopen, stand with one foot forward and

one foot to the rear (see Figure 1-38).This stance will help you from beingthrown off balance. (DO NOT snap theglove; bring it upward gently over thecuff of the gown.)

NOTE: Always offer the right glovefirst. Be careful that you do not getthrown off balance while the other team member introduces his hand intothe glove (see Figure 1-38).

Figure 1-38

d. Repeat the technique described inparagraph c above for the left hand.The team member can assist withdonning this glove (see Figure 1-39).Give the team member a moistenedsaline sponge so that he can removeexcess powder from his gloves if thegloves are powdered.

NOTE: The scrub should remove thepowder from his gloves again.

Figure 1-39

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e. The circulator will readjust the neckfastener if needed and assist scrubbedteam member with tying the outsidewaist tie of the gown. After the tie issecured, the gown is adjusted at the

bottom (see Figure 1-34). Figure 1-40shows a gloved and gowned teammember.

Figure 1-40

ROLES AND FUNCTIONS OF SCRUB NURSE, CIRCULATING,RECOVERY NURSE

∞ SCRUB NURSE

Before an operation

Ensures that the circulating nurse has checked the equipment

Ensures that the theater has been cleaned before the trolley is set

Prepares the instruments and equipment needed in the operation

Uses sterile technique for scrubbing, gowning and gloving

Receives sterile equipment via circulating nurse using sterile technique

Performs initial sponges, instruments and needle count, checks with circulating nurse

When surgeon arrives after scrubbing

Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon

as they enter the operation suite

Assemble the drapes according to use. Start with towel, towel clips, draw sheet and

then lap sheet. Then, assist in draping the patient aseptically according to routine

procedure

Place blade on the knife handle using needle holder, assemble suction tip and

suction tube

Bring mayo stand and back table near the draped patient after draping is completed

Secure suction tube and cautery cord with towel clips or allis

Prepares sutures and needles according to use

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During an operation

Maintain sterility throughout the procedure

Awareness of the patient’s safety

Adhere to the policy regarding sponge/ instruments count/ surgical needles

Arrange the instrument on the mayo table and on the back table

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision

Passes the 1st knife for the skin to the surgeon with blade facing downward and a

hemostat to the assistant surgeon

Hand the retractor to the assistant surgeon

Watch the field/ procedure and anticipate the surgeon’s needs

Pass the instrument in a decisive and positive manner

Watch out for hand signals to ask for instruments and keep instrument as clean as

possible by wiping instrument with moist sponge

Always remove charred tissue from the cautery tip

Notify circulating nurse if you need additional instruments as clear as possible

Keep 2 sponges on the field

Save and care for tissue specimen according to the hospital policy

Remove excess instrument from the sterile field

Adhere and maintain sterile technique and watch for any breaks

End of Operation

Undertake count of sponges and instruments with circulating nurse

Informs the surgeon of count result

Clears away instrument and equipment

After operation: helps to apply dressing

Removes and siposes of drapes

De-gown

Prepares the patient for recovery room

Completes documentation

Hand patient over to recover room



∞ CIRCULATING NURSE

Before an operation

• Checks all equipment for proper functioning such as cautery machine, suction

machine, OR light and OR table

• Make sure theater is clean

• Arrange furniture according to use

• Place a clean sheet, arm board (arm strap) and a pillow on the OR table

• Provide a clean kick bucket and pail

• Collect necessary stock and equipment

• Turn on aircon unit

• Help scrub nurse with setting up the theater

• Assist with counts and records

During the Induction of Anesthesia

• Turn on OR light

• Assist the anesthesiologist in positioning the patient

• Assist the patient in assuming the position for anesthesia

• Anticipate the anesthesiologist’s needs

• If spinal anesthesia is contemplated:

Place the patient in quasi fetal position and provide pillow

Perform lumbar preparation aseptically

Anticipate anesthesiologist’s needs

After the patient is anesthetized

• Reposition the patient per anesthesiologist’s instruction

• Attached anesthesia screen and place the patient’s arm on the arm boards

• Apply restraints on the patient

• Expose the area for skin preparation

• Catheterize the patient as indicated by the anesthesiologist

• Perform skin preparation

During Operation

• Remain in theater throughout operation

• Focus the OR light every now and then

• Connect diatherapy, suction, etc.



• Position kick buckets on the operating side

• Replenishes and records sponge/ sutures

• Ensure the theater door remain closed and patient’ s dignity is upheld

• Watch out for any break in aseptic technique

End of Operation

• Assist with final sponge and instruments count

• Signs the theater register

• Ensures specimen are properly labeled and signed

After an Operation

• Hands dressing to the scrub nurse

• Helps remove and dispose of drapes

• Helps to prepare the patient for the recovery room

• Assist the scrub nurse, taking the instrumentations to the service (washroom)

• Ensures that the theater is ready for the next case

∞ RECOVERY NURSE

• Coordinate planned nursing care with other health care team members

• Assist in proper preparation of supplies, medications, and equipment involved in

patient care.

• Participate in patient care and education conferences.

• Assist with preoperative patient assessment and teaching.

• Assist in organizing and developing policies and procedures.

• Develop effective communication and interpersonal relationship skills.

• Maintain good physical and mental health.

• Prepare postanesthesia areas for patients.

• Monitor patients' vital signs, breathing, alertness, awareness following the

surgical procedure.

• Administer medications as needed and/or ordered

• Record all appropriate information on the patient chart.

• Assist patients with transfer from cart to the recliner.

•Provide verbal and written discharge instructions.

• Coordinate with Physical Therapy for services as required.

• Coordinate with the pre-op nurse, the post-op calling of patients.

• Assist patients to vehicles upon discharge.





• Other duties as assigned.

DRAPING

What is DRAPING?

Draping is a procedure of covering a patient and surrounding the areas with a sterile

barrier to create and maintain an adequate sterile field during operation.

It is part of the job description of a peri-operative nurse to provide not just the correct

instruments but as well as the correct drapes prior to a procedure. The OR nurse should

first understand the fundamental principles of Draping:

1. Isolate. You need to isolate dirty from the clean and vice versa (for example: groin,

colostomy and equipment from the area to be prepped). Isolation is done utilizing an

impermeable drape, usually fabricated from a plastic material.

2. Barrier. This provides an impervious layer and must have a plastic film to prevent a

strike-through.

3. Sterile Field. The creation of a sterile field is through sterile presentation of the drape

and aseptic application technique. If the drape used is not impervious, an additional

impervious layer needs to be added.

4. Sterile Surface. Since the skin could not be sterilized, it is needed to apply an incise

drape to create a sterile surface. Only an incise drape can create a sterile surface.

5. Equipment Cover. Sterile drapes cover nonsterile equipment used on sterile field. This

helps to protect the patient from the equipment as well as to protect and prolong the life

of the equipment.

6. Fluid Control. Collection of fluid keeps the patient dry, decreases healthcare worker

exposure and lessens clean up. A fluid control system should be used anytime the

procedure is known to include large amounts of body fluids or irrigating solution such as

TURP.

Draping materials are selected to make and maintain an effective barrier that lessens

the passage of microorganisms between nonsterile and sterile areas. There are also

basic characteristics of surgical drapes, all surgical drape materials should posses

these traits regardless of which materials are utilized:

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• Abrasion resistance

• Barrier properties

• Biocompatibility

• Drapeability. The ability of a material to conform to the shape of the object over which it

is placed

• Electrostatic properties

• Nonflammability

• Nonlinting. Materials for draping should not contain or generate with normal use, free

fiber particles.

• Tensile strength

TYPES OF DRAPES

• Reusable Drapes

The main concern about reusable drapes is the fluid impermeability under the

conditions of use. Steam Sterilizing and laundering swells the fabric whereas drying and

ironing shrinks the fibers. This cycle increases the propensity for loosened fibers that

alter the fabric structure. Most manufacturers report a loss of barrier quality

after 75 laundry or sterilization cycles.

•Disposable Drapes

The problem with Disposable Drapes is the collection, transportation and storage of

waste material. Burning or Incineration is a method for destroying waste disposables but

must be properly managed to prevent environmental contamination.

• Plastic Incisional Drapes

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Impermeable polyvinyl sheeting are available in the form of sterile prepacked surgical

drapes. The incision is directly made through the adherent plastic drape. This type

facilitates draping of irregular body surfaces as neck and ear regions, extremities and

joints.

• Standard Drapes

Standard Drapes are whole, or plain sheet used to cover instrument tables, operating

tables and body regions. The sheet should be large enough to provide enough margin

of safety between the surrounding physical environment and the prepared operative

field. Fenestrated or Slit Sheets are used for draping patients. They leave the

operative site exposed for (laparotomy draping) abdomen, chest, flank, back and other

size for limb, head and neck.• Aperineal Drape

Aperineal drapes are for operations on the perineum and genitalia with the patient in

lithotomy position. This consists of a fenestrated sheet and two triangular leggings.

Draping Procedure

• Drapping is always done from sterile area to an unsterile areaand by drapping nearest

first

• The scub nurse should never reach across an unsterile area to drape

• When the opposite side of the operating room bed must be draped , the scrub nurse

must go around the bed to drape

• Do not flip, fan or shake drapes. Rapid movement of drapes creates air currents on

which dust, lint and droplet nuclei may migrate

•

Shaking a drape causes uncontrolled motion of the drape which may cause it to come incontactwith an unsterile surface or object

• A drape should be carefully unfolded and allowed to fall gently into position by gravity

• The low portion of a sheet that falls bellow the safe working level should never be raised

or lifted back onto the sterile area

• Drape the incisional area first and then the periphery

• Use nonperforating towel clamps or devices to secure tubing and other items on a

sterile field

• When sterility of a drape is questionable, consider it contaminated

OPERATING ROOMINSTRUMENTS



Allis Forcep

• Interdigitating short teeth to grasp

and hold bowel or tissue.

• Slightly traumatic, use to hold

intestine, fascia and skin.

Babcock Forcep

• More delicate that Allis, less directly

traumatic.

• Broad, flared ends with smooth tips.

• Used to atraumatically hold viscera

(bowel and bladder).

Towel clips

• Secure drapes to a patient's skin.

They may also be used to hold tissue.

Kocher clamps straight &

curved

• is used to grasp heavy tissue. May

also be used as a clamp. The jawsmay be straight or curved. Other

names: Ochsner.



Metzenbaum scissors

• Used to cut delicate tissue.

Available in regular and long sizes.

Army navy retractors

• is used to retract shallow or superficial incisions. Other names:

USA, US Army.

Richardson retractor (manual)

• is used to retract deep abdominal or

chest incisions.

Pean staright and curve

Forceps

• a clamp for hemostasis.



Tissue Forceps

• An instrument with one or more fine

teeth at the tip of each blade for

controlling tissues during surgery,

especially during suturing.

Thumb forceps

•

to grasp soft tissue, especially while

suturing.

Straight and Curve Kelly

Forceps

• Kelly forceps are a type of hemostatusually made of stainless steel. They

resemble a pair of scissors with the

blade replaced by a blunted grip.

They also feature a locking

mechanism to allow them to act as

clamps.

• used for occluding blood vessels,

manipulating [tissues], or for assorted

other purposes.

Ovum Forceps

• Ovum forceps are commonly used to

remove placental fragments inside

the uterus. It is also used as a

hemostat or a clamping instrument.



Bandage scissors

• It is used to cut the gauze and the

bandages while dressing the wound

or surgical incision.

Mosquito forceps straight and

curved

•

A small, straight or curved forceps

used in general surgery that has a

locking grip with 3–5 teeth to allow

rachet clamping at various pressures.

Mosquitos are used to retract in small

fields, hold delicate tissue, and

compress bleeding vessels, among

other things

Mixter forcep

• Deal for occluding blood vessels,

assisting in dissection and passing

sutures around structures.

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Tenaculum forceps

•

used to graps the cervix and apply

traction to the uterus during GYN

procedures

Adsons forceps with or without teeth

•

Adson Forcep with or without teeth-

adsons with teeth are frequently used

at the end of a case to close ski

• Adson-brown forceps- tips have a

miltiple-tooth pattern (plastics & fool)

Mayo scissors

•

Used to cut thick or tough tissuel

width of jaws are thicker than metz

curved or straight (suture scissors)

Suture scissors

• Remove sutures through the design

of the tip.

Needle holder

• a surgical forceps used to hold and

pass a suturing needle through tissue



#3 #4

Blade holder 4&3

• #3 most frequently used handle.

holds 10, 11, 12, & 15

• #4 knife handle-holds only the 20

blade.

Bladder retractors

• used to facilitate dissection of the

vascular pedicles during laparoscopic

radical cystectomy in a female

patient.

PACKING OF INSTRUMENTS

Surgical instruments are placed in specialized packaging to keep them sterile.

After each use, surgical instruments must be repackaged in either a sterilization bag or

woven wrapping intended for use in an autoclave, or sterilization machine. Packaging

surgical instruments is a precise procedure which requires knowledge of proper

technique. Always follow your facility's instrument packaging protocol.

PROCEDURE:

1. Choose the packaging for your surgical instruments. Gather sterilization bags or

double-layer woven wrapping, sterilization tape and sterilization indicator tabs.

Ensure all instruments have been pre-cleaned and are free of body fluids and

debris.



2. Place the instruments in an appropriate-sized sterilization bag. Cover the ends of

sharp instruments with plastic, autoclave-approved tip protectors to prevent

puncture of the bag. Insert a sterilization indicator strip into the package, and seal

the package by removing the adhesive strip protector on the flap. Close the flap

over the open end of the bag.

3. Place two square sterilization sheets on a large, flat surface and arrange in a

square position. Place a single layer of gauze in the middle of the top sheet.

Arrange instruments over the gauze in a single layer, if possible. Open any

closed instruments. Cover the tips of sharp instruments with tip protectors, or

place the tips slightly into the gauze for protection. Add a sterilization strip with

the instruments.

4. Fold the top sterilization sheet appropriately in a square fold. Fold the outer

sterilization sheet over the other in a square-fold. Consult your facility's

guidelines for proper folding technique. Secure the outside sheet with sterilization

tape.

THINGS YOU’LL NEED:

∞ Sterilization packaging

∞ Sterilization indicator strips∞ Sterilization tape∞ Gauze∞ Tip protector

Wrap Surgical Instruments

Surgical instruments are wrapped in double layers of woven fabric specifically designed

for sterilization in an autoclave (sterilization machine). The procedure of wrapping

surgical instruments is precise and must be performed accurately to ensure sterileresults. Wrapping surgical instruments incorrectly can lead to instrument contamination.

Always follow your facility's guidelines for safe instrument wrapping, and do not perform

the task if you are not experienced.

PROCEDURE:

1. Determine if you are wrapping single instruments, sets or trays. Gather single

instrument sterilization bags for single instruments, or autoclave wraps to prepare

instrument sets or trays. Ensure all instruments are free of body fluids or debris and

have been soaked in an approved solution for pre-cleaning.

2. Place a single instrument in an appropriate size sterilization bag. Cover the sharp or

blunt end of the instrument with a small gauze pad to prevent puncture of the bag.

Insert a sterilization indicator strip into the package, and then seal the package.



3. Place two square sterilization sheets on a large, flat surface. Arrange one in a

square position and the other in a diamond position on top of the first. Arrange

gauze in the middle of the diamond-shaped sheet if applicable. Arrange the

appropriate instruments over the gauze, ensuring all lie as flat as possible. Open any

closed instruments. Place the tips of sharp instruments slightly into the gauze for

protection, or use tip covers if available. Add a sterilization strip with the instruments.

4. Fold the diamond-shaped sheet appropriately in an envelope fold. Fold the square-

shaped sheet over the other in a square-fold. Consult your facility's guidelines for

proper folding technique. Tape the outside sheet with approved sterilization indicator

tape.

THINGS YOU’LL NEED:

∞ Sterilization sheets

∞ Sterilization indicator strips

∞ Sterilization tape

∞ Gauze

∞ Instrument tip covers

∞ Sterilization instrument bag

Wrapped pan being weighed

Sequential double-wrapping: envelope fold

Simultaneous double-wrapping:envelope fold



Towel as cushion to decrease chance for tears

Example of single- and double-packagingwith paper-plastic pouches

ABDOMINAL LAYERS

Why does an operating room nurse need to know this?

Assisting is a process of anticipation. The scrub nurse needs to know the layers of the

tissue to hand in the correct instrument and suture at hand. Circulating nurses must also

know for them to gauge the process of the operation and call in for the next patient or

count sponges at the correct time.

There are five main layers of the abdominal tissue:

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line extending from umbilicus towards the anterior superior iliac spine. It's

commonly places obliquely and has the potential to be expended in case the

need arise.

4. Groin incision

• Groin incisions may be oblique or within the skin lines and nearly transverse.

Generally, they end medially at the level of the external ring, usually 1 to 2 finger

breadths above the external ring. Laterally, these incisions usually extend for 10-

12 cm, depending on the size of the patient, the size of the hernia, and prior

surgery. Staying out of the inguinal crease reduces the risk of infection. Such

incisions are closed in layers. The oblique inguinal incision may be on the right or

left side and is used for hernia repair. The superficial epigastric vein is usually

encountered in the subcutaneous tissue. It is ligated and divided.

5. Lanz incisions

• Appendectomy. A better cosmetic result than McBurney

1. Paramedian incisions

• Paramedian incisions are also used when the need arise to access certain

organs towards a particular site.

1. Transverse incisions

• The transverse incision is made just above the umbilicus and divides one or both

sides of the rectus muscle as necessary. Transverse incisions are most

commonly used for access to the right colon (when placed on the right),

duodenum, and access to the pancreas where the incision is carried across the

midline. They provide excellent exposure to the subhepatic space and upper

gastrointestinal tract, reportedly with less pain than a midline incision. However,

in the current era, many surgeons have entirely replaced transverse incisions

with midline incisions extended as necessary to gain lateral access to the

abdominal and retroperitoneal viscera.

1. Rutherford Morison incision

• Access to sigmoid colon and pelvis, particularly if the midline is very scarred from

previous surgery.

1. Pfannenstiel incisions

• The incision is the usual procedure adopted for surgical access towards pelvic

organs and mainly for cesarean sections. The incision is placed horizontally

about 5 cm above the pubic symphysis and is about 12 cm in length.



TYPES OF SUTURING

Surgical suture is a medical device utilized to hold body tissue together either

after suffering from an injury or surgery. It is usually consists of a thread attached to a

needle. There are numerous shapes, sizes and thread materials that have been

developed over the years.

An ideal surgical suture should have the following characteristics: (1) sterile (2)

universal (its material can be used in any surgical procedure) (3) causes less tissueinjury or reaction (4) easy to handle (5) high tensile strength (6) holds securely when

knotted (7) good absorption profile and (8) resistant to infection. However, at the

moment, no single material possesses all the mentioned characteristics.

Every surgical suture should be made to assure a number of important

characteristics: (1) sterility (2) same size and diameter (3) elasticity for easy handling

and securing of knot (4) uniform tensile strength of suture size and type (5) freedom

from irritants or impurities that would cause tissue reaction.

Suture Size

The surgical suture size is the diameter of the suture strand. It is denotes as zeroes.

The more zeroes it has, the smaller the diameter strand is (for example, 1-0 or 0 is

bigger than 2-0 or 00). The smaller the suture, the lesser is the tensile strength of the

strand.

Types of Surgical Suture

The different kinds of surgical sutures used differ on the operation, with the major

criteria being the demands of the location and environment and on the discretion and

professional experiences of Surgeons.

• Absorbable Suture & Non-Absorbable Sutures

✔ Absorbable Suture

These are surgical sutures that are absorbable and will break down safely in the body

over time without intervention. Utilized internally because it would require a re-opening if

they were to be removed.

NATURAL

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• Collagen

• Surgical Gut, Plain

• Surgical Gut, Chromic

SYNTHETIC

• Polyglactin 910 (Vicryl)

• Poliglecaprone 25 (Monocryl)

• Polysorb

• Polydioxanone (PDS II)

• A barbed suture (V-Loc, Covidien Inc)

• Caprosyn

• Maxon

✔ Non-Absorbable Suture

These are surgical sutures that must be removed manually if they are not left for an

indefinite period of time. Often used in sutures located in a stressful environment, for

instance the heart since there is a steady movement and pressure or the bladder

because of adverse chemical presence. It may require specialized or stronger materials

hold it together. Usually, these types of non-absorbable surgical sutures are specially

treated or made of special materials to lessen the risk of degradation. Used externally

and can be removed within minutes without reopening the wound.

NATURAL

• Surgical Silk

• Surgical Cotton

• Surgical Steel

SYNTHETIC

• Nylon

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

• Polybutester Suture (Novafil)

• Coated Polybutester Suture (Vascufil)

• Polypropylene (Prolene)

• Surgipro II



✔ Monofilament and Multifilament Sutures

Surgical sutures can also be divided into two kind’s base on the material structure.

Monofilament

This type of surgical suture allows a better passage through the tissues because it is

made up of a single strand. This kind of structure is more resistant to harbouring

microbes. Usually, Monofilament sutures bring out lower tissue reaction than braided

sutures.

• · Polypropylene sutures

• · Catgut

• · Nylon

• · PVDF

• · Stainless steel

• · Poliglecaprone

• Polydioxanone sutures

Multifilament or Braided Sutures

This type of suture provides a better knot security since it is composed of numerous

filaments twisted or braided together. It is less stiff but has a higher coefficient of friction.

Since its materials have increased capillarity, the increased absorption of fluid may

cause introduction of pathogens.

• · PGA sutures

• · Polyglactin 910

• · Silk

• Polyester sutures

Selecting surgical sutures depends on the training and preference of the surgeon.

Many suture materials are available individual surgical location and surgical

requirement. Usually, the surgeon chooses the smallest surgical suture that effectively

holds the healing wound edges. The tensile strength of the suture should never surpass

the tensile strength of the tissue. As the operative site heals, the relative loss of surgical

suture strength over time should be slower than the gain of tissue tensile strength.

Operating Room Procedures

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