CSFA EXAM
TJC Root Cause Analysis Matrix
-What happened? -Why did it happen? -What were the most proximate factors? -What systems & processes underlie those proximate factors?
who would benefit from cemented and non-cemented hip prostheses?
-Young, active individuals with strong healthy bones are ideal candidates for noncemented total hip replacement arthroplasties. -Elderly patients with osteoporosis and poor quality bone are usually candidates for cemented components because their bones may lack the compressive strength to support weightbearing forces.
The transverse rectus abdominis myocutaneous (TRAM) flap is
-a single-stage reconstruction of a postmastectomy breast using the transverse rectus abdominis muscle. -this flap gives the patient and plastic surgeon an alternative to the latissimus dorsi flap by taking excess tissue from the lower abdomen to construct the breast, usually without the need for an implant.
what is a Total knee replacement (arthroplasty)?
-a surgical procedure designed to replace the worn surfaces of the knee joint. -Success depends on patient selection, component design , surgical technique, and rehabilitation.
what are the procedural considerations of a simple retropubic prostatectomy?
-patient is placed in a slight Trendelenburg position with the pelvis elevated and the legs slightly abducted. -Routine skin preparation is carried out. -Electrocoagulation is usually employed . -Although the draping procedure must conform to individual operating room policies, the following procedure is suggested for draping the patient. The first towel , with a cuff, is placed under the scrotum. The next three towels are placed around the lower abdominal incision site, followed by a sterile laparotomy sheet. A fifth towel, folded in half, is placed over the penis and scrotum below the retropubic incision site and secured with two nonperforating towel clamps. -The instrument setup includes a basic laparotomy set and bladder and prostatic instruments . -The following supplies should be readily available : Jackson-Pratt drains, water-soluble lubricant, Toomey and Asepto syringes, a urinary drainage system, a 20 Fr 5 ml Foley catheter, a 22 or 24 Fr 30 ml Foley catheter, 10 and 30 ml syringes, and a self-retaining retractor such as the US200 adjustable urology retractor.
the collateral ligaments do what?
-reinforce the knee capsule medially and laterally. -they resist varus and valgus stresses on the knee.
what are some procedural considerations of a parathyroidectomy?
Because multiple biopsies are often performed to determine the presence or absence of parathyroid tissue, numerous specimen containers may be necessary. Check with the surgeon in regard to any preoperative localization studies and the possibility of a mediastinotomy. Have mediastinotomy instruments available if necessary.
Stage 3 of anesthesia
Begin with the onset of a regular breathing pattern and lasts until cessation of respiration. This stage is known as the operative or surgical phase.
Stage 4 of anesthesia
Begins with the cessation of respirations and must be avoided, or it will necessitate the initiation of cardiopulmonary resuscitation and may lead to death.
Accessory Nerve motor
CN XI, Controls muscles in the neck and larynx
Hypoglossal Nerve motor
CN XII, Motor to tongue muscles
absorbed by water;, Vaporization and coagulation of hemorrhoidal tissue can be accomplished with, most commonly used laser
CO2 Laser
A device that will emit an ultra sonic energy that emulsifies abnormal tissue and then aspirates the tissue is a(n)
CUSA
The talus forms an articulation with which of the following lists of bones: o Navicular, cuneiform, fibula and calcaneus o Tibia, cuboid, fibula, and cuneiform o Fibula, cuneiform, calcaneus, and tibia o Calcaneus, navicular, tibia, and calcaneus
Calcaneus, navicular, tibia, and calcaneus
extends from the occipital of the cerebrum to the occipital fissure
Calcarin's fissure:
found in the mesial surface of the cerebrum.
Callosomarginal fissure:
The anatomic region bordered by the cystic duct, the common hepatic duct, and the cystic artery is referred to as: Tetralogy of Fallot Calot's triangle Circle of Willis Anatomical snuffbox
Calot's triangle
Common hepatic bile duct, cystic duct, & cystic artery
Calots triangle
The cranial vault where the brain is stored is the
Calvaria
Don't Nourishing coat of the eyeball that consists mainly of blood vessels
Choroid
vascular layer beneath the sclera that provides nourishment to the outer portion of the retina, makes aqueous humor
Choroid
Produces spinal fluid
Choroid plexes
a structure within the ventricles that produce CSF
Choroid plexuses:
the cerebral hemisphere are connected by a deep bridge of nerve fibers.
Corpus callosum:
the largest structure of the basal ganglia of the brain
Corpus straitum:
when would a subcutaneous mastectomy be done?
This procedure is recommended for patients who have central tumors of noninvasive origin, chronic cystic mastitis, hyperplastic duct changes, or multiple fibroadenomas, or who have undergone several previous biopsies. Breast reconstruction may be undertaken at the time of mastectomy or at a later date if desired.
pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest;, assoc. peripheral vascular occlusion
claudication
possible treaments for femoral shaft fractures
closed reduction skeletal traction femoral cast bracing.
Treatment method for femoral shaft fractures?
closed reduction, skeletal traction, and femoral cast bracing, internal fixation.
additional accessory instruments or devices may include a sterile drawstring intestinal bag to do what?
confine loops of normal bowel from the operative segment or sterile radiopaque surgical towels
meningies
connective tissue covering the brain & spinal cord and protect it made up of 3 connective tissue membranes, 3 connective tissue membranes Dura mater, Arachnoid mater and Pia mater., The CNS is supported and protected by the meninges, three connective tissue membranes located between the brain and the cranial bones and between the spinal cord and the vertebral column. The meninges are, from external to internal, the dura mater, the arachnoid, and the pia mater.
when using succinylcholine or anectine what is the last muscle to relax?
diaphragm
Contains thalamus and hypothalamus, Lies between the cerebrum and the brain stem and contains relay centers for information entering and exiting the brain
diencephalon
Medical treatment for osteomalacia includes
dietary supplements and exposure to sunlight.
Endoscopic Mucosal Resection or E M R
excision of dysplastic lesions related to Barrett's espophagus uses suction to elevate lesion and snare is used
what is a transverse colectomy?
excision of the transverse colon through an upper midline or transverse incision. Bowel integrity is reestablished by an end-to-end anastomosis.
what is a Roux-en-Y?
a Y shaped surgical connection in which the intestines is detached from it's original origin and reattached so as to bypass a part of the stomach and duodenum.
sites within the prepped area with high concentrations of microorganisms such as ____________________, _____________________, or _______________________ are prepped last
existing stoma draining fistula rectum
This method of fracture management provides rigid fixation and reduction with the ability to manage severe soft-tissue wounds. Because of the increased chance of infection in patients with an open fracture, it is often the preferred treatment.
external fixation
risk factors for unplanned hypothermia include:
extremes of age low body weight open cavity surgery thyroid disorders diabetic neuropathy peripheral vascular disease a cold O.R. infusion of cold fluids irrigating the abdomen with cold N.S. or other solutions
Acute fracture treatment is necessary to
alleviate neurovascular compromise
Epidural anesthesia is administered: o Anterior (deep to) to the lumbar or sacral nerve roots. o Into the space between the spinal canal and the dura mater covering the nerve roots. o Into precisely the same subarachnoid space as spinal anesthesia, but in the sacral area. o Directly into the cerebral spinal fluid at any point from the ventricles in the brain, to the cauda equina.
Into the space between the spinal canal and the dura mater covering the nerve roots
Crohn's disease
Is an auto immune disease, chronic inflammation of the intestinal tract characterized by ulcerations and formation of scar tissue that may lead to intestional obstruction
circle of willis
Is comprised of 9 arteries, the right and left internal carotid arteries, the anterior communicating artery, which serves to link the right and left anterior cerebral arteries, the right and left posterior cerebral arteries and the right and left posterior communicating arteries; most common site for brain aneurysms
What is intracellular fluid?
are liquids within cell membranes that contain dissolved substances essential to fluid and electrolyte balance and metabolism.
National Patient Safety Goals (NPSGs)
areas of patient safety concern identified annually by the Joint Commission that, if rectified, may have the most positive impact on improving patient care and outcomes
What type of laser is used in the middle ear for stapendectomy procedures?, retinal detachment; tears (common), what are the emergent tx's for acute angle closure glaucoma?
argon laser
Glioblastomas
arise fr malignant transformation of astrocytes, high grade, survival is less than twoyears, secrete grwoth factors (VEGF) to stimulate proliferation of blood vessels
Transverse fissure:
found between the cerebrum and the cerebellum
Zygal fissure:
found in the cerebrum.
Collateral fissure
found in the inferior surface of the cerebrum.
recovery
fourth phase of anesthesia
is a break in the continuity of a bone.
fracture
Diarthrotic
freely movable
Stage 1 of anesthesia
from initial administration of anesthetic agents to loss of consciousness
The bone that forms the forehead and nasal cavities
frontal
Biliroth 1
fundus of the stomach is connected to the duodenum, body and pyloric region of the stomach is removed;, gastroduodenostomy
hartmans pouch
gallbladder folds back on itself at neck, forms a pouch, Typical location for stones
Vasodialate & stop arterial spasm during cardiac arterial bypass grafting
Papaverine
what is a parathyroidectomy?
Parathyroidectomy is excision of one or more parathyroid glands. Normal or atrophic glands are generally not removed.
This disease is characterized by the three symptoms tremors, rigid, and bradykinesia
Parkinson
pyloroplasty
gastric drainage procedure that widens the pylorus to allow greater egree of stomach contents into the duodenum
Type 2 hiatal hernia
gastroesophageal junction remains fixed in its abdominal position while the fundus of the stomach migrates into the thoracic cavity
GERD
gastroesophageal reflux disease, a condition where the lower esophageal sphincter is incompetent and allows stomach contents to reflux into the esophagus
Is a drug combined with heparin that causes a postoperative loss of anticoagulant activity
Peroneal sulfate
Superior Mesenteric Artery SMA
blood supply to the distal pancreas,duodenum, cecum, and the ascending and right transverse colon;, what are some medical conditions that may mimic anorexia?, What is the most common vessel blocked with intestinal ischemia?, The inferior pancreaticoduodenal artery branches off which artery?
Osteophytes:
bone spurs
adverse side effects associated with the use of succinycholine
cardiac dysrhythmias hyperkalemia myalgias increases in intraocular, intercranial, and intragastric pressures malignant hyperthermia
negligence
careless neglect, often resulting in injury You can be found negligent and be sued for damages for any of the following reasons: 1) performing procedures you have not been taught 2)failing to report defective or malfunctioning equipment 3) failing to meet established standards of safe care for clients 4) failing to prevent injury to clients, other employees and visitors 5) failing to question a physicians order that seems incorrect
decompression
caused by bulging disk; removing any stenosis
What is an inflammatory response?
causes infected areas to become red and painful, or inflamed can last from days to many weeks depending on level of contamination should not last more than 7-10 days
local anesthesia
causes the loss of sensation in a limited area by injecting an anesthetic solution near that area or by using a topical application
large intestines
cecum, ascending colon, transverse colon descending colon, sigmoid, and rectum; water absorption back into the bloodstream, and eliminates food wastes;
what three types of hip implants are there?
cemented, non-cemented, or hybrid.
the large fissure that separates the frontal lobe from the parietal lobe
central fissure(fissure of Rolando
Collections of blood cells found within each of the 4 ventricles. As blood flows through the choroid plexuses, fluid filters out into the ventricles, and at that point is called CSF
choroid plexuses
delivers oxygenated blood to the left atrium and left ventricle, signs of cardiac ishimia most likely happened during mitral vale replacement if this artery is occluded
circumflex artery
Tourniquet time
Recommended 1 hour on upper extremity, 2hours on thigh
Red blood cells and thawed plasma must be kept at what temp?
Refrigerated at 4 deg Celsius
what are some procedural considerations of the mesh-plug hernia repair?
Regardless of the hernia type, the mesh-plug technique is performed on an ambulatory basis. Repair of the inguinal hernias with mesh-plug technique has provided significant advantages when compared with conventional suture technique. A plug repair requires less overall dissection and ensures tension-free hernioplasty. These factors increase patient comfort, speed rehabilitation, and contribute to a very low recurrence rate, that is, 1%for primary and 2% for recurrent hernias.
What systems regulate the intake, distribution and output of water and electrolytes?
Renal and pulmonary systems
Arterie used to graft during abdominal aortic aneurysm AAA
Renal arterie
(or the thing speaks for itself) is a doctrine that applies to injuries sustained by a patient inside the OR
Res ipsa loquitor
The short gastric arteries are direct branches of which of the following: Splenic Artery Left Gastric Artery Right Gastric Artery Right Gastroepiploic Artery
Splenic Artery
what is a Bassini Repair?
The Bassini repair approach to the hernia and the treatment of the sac is identical to that previously described. The major difference with this repair is that the superior transversalis fascia is sutured to the inguinal ligament with no attempt made to approximate it to the inferior portion of the transversalis fascia or Cooper's ligament (pectineal ligament). Critics of this procedure claim that it is not anatomic because layers that originally are not one (transversalis fascia and inguinal ligament) now are approximated. Nonetheless, this repair is extremely popular and is used successfully by many surgeons.
what are some procedural conditions of a sentinel node biopsy?
This procedure is similar to that for a breast biopsy. Sentinel node identification is accomplished by an injection of either isosulfan blue dye or metastable technetium 99 99 ( mTc), a radioactive material. The procedure is coordinated with the staff of the nuclear medicine department and requires the use of a hand-held detector like a Geiger counter if technetium is used.
retina, retinopathy, treatment, photocoagulation (67228-67229), laser peripheral iridotomy, shorter wavelength
Yag laser
diverticulum
Zenker diverticulum (diagnosed by barium Swallow)oat common disease of the colon , an abnormal side pocket in the gastrointestinal tract usually related to a lack of dietary fiber; , bleeding occurs in descending colon; ruptures in the sigmoid
Opening on the temporal surface of the zygomatic bone
Zygomaticotemporal Foramen
an opening on the temporal surface of the zygomatic bone
Zygomaticotemporal foramen
what are the procedural considerations for a modified radical mastectomy?
The patient is placed supine on the operating room bed with the operative side near the bed edge. The arm on the operative side is extended to less than 90 degrees on a padded armboard. The skin is prepped and draped as previously described.
what are some procedural considerations for a subcutaneous mastectomy?
The patient is positioned as for a biopsy. If reconstruction is to be undertaken, appropriate equipment and supplies are also required.
what are the procedural considerations of a C-Section?
The patient should be in a supine position with elevation of the right side to displace the uterus and prevent aortocaval compression. Bony prominences are padded, and the patient is positioned in good body alignment with a safety strap above the knees. It may be necessary to assist the anesthesia team with the administration of regional anesthesia before placing the patient in the supine position. -maternal vital signs are monitored and recorded according to the institutional protocol. -Fetal heart tones are also monitored and recorded per institutional protocol. The perioperative nurse is caring for two patients. -If a general anesthetic is to be employed, all preparations, including skin prep, bladder drainage, draping, suction connection, counts, and gowning and gloving of all scrubbed personnel, must be done before induction. -In many hospitals, healthcare providers qualified to deliver newborn care and resuscitation are in attendance for the delivery. A radiantwarmer and resuscitative equipment for immediate postdelivery care of the infant are available in the operating room because these infants are considered to be at risk until there is evidence of physiologic stability. -In preparation for delivery, if indicated, the mother's hair is clipped or shaved from the abdomen above the umbilicus to the level of the mons pubis and laterally to above the level of the iliac crests. The skin is prepped for abdominal surgery. The vagina is not prepared. An indwelling urinary catheter is inserted. -Instrumentation includes the basic abdominal gynecologic set, with the addition of Lister bandage scissors, Foerster sponge-holding (ring) forceps, Pennington forceps, cord clamps, Delee retractor, delivery forceps, a head extractor (if desired), laboratory tubes for cord blood,a drain (optional), and a bulb syringe.
why would a parathyroidectomy be performed?
The presence of adenomas (hypersecreting neoplasms), hyperplasia, or carcinomas requires surgical excision. In the last case, resection of lymph nodes is essential, although metastasis may also occur by way of the bloodstream.
what are the reasons for surgical interventions of the thyroid and parathyroid?
The purpose of the surgical intervention relates to the patient's medical diagnosis . Hyperthyroidism (Graves' disease) is associated with diffuse, bilateral enlargement of the thyroid gland. Hashimoto 's thyroiditis is believed to be an autoimmune disease, and nontender enlargement of the gland occurs. Surgery is performed to relieve tracheal obstruction. Nontoxic nodular goiter does not produce an excess of hormones and is noninflammatory in character ; thyroid tissue proliferates in an apparent attempt to produce the minimal hormonal requirement. Surgery may be indicated to relieve tracheal or esophageal obstruction or to rule out a malignant nodule of the thyroid gland. Total thyroidectomy may be done for malignant tumors.
where there are surgical reasons to tuck the arms at the side, what should be done?
pad the elbows to protect the ulnar nerve turn the palms inward maintain wrist in a neutral position
disorder affecting older adults. It is characterized by proliferation of osteoclasts and compensatory increased osteoblastic activity, resulting in rapid, disorganized bone remodeling. The bones are weak and poorly constructed.
paget's disease
what is referred to as "bowel technique" or "GI technique"?
planning for additional drapes, towels, gowns and gloves for the surgical team to implement proper techniques to keep clean and dirty items separate during open bowel procedures
coughing and deep breathing exercises will be necessary after surgery to prevent what?
pneumonia (by opening alveoli and removing pooled excretions)
Presence of air or gas in the pleural space that may occur spontaneously, due to trauma, or deliberately, introduced in a collapsed lung
pneumothorax
haustra
pocketlike sacs in the large intestines
Tensile Strength
point of rupture, relating to the nature of the material rather than its thickness.
The primary goal in treatment of an upper extremity fracture is to
preserve mobility and restore range of motion, enabling the individual to perform skilled and delicate work.
goal of treatment for Barrett's esophagus
prevent progression to dysplasia by minimizing or eliminating acid reflux through diet, lifestyle changes, and anti-reflux medications
what is an antireflux procedure?
prevents reflux of gastric juices into the esophagus, it is also done when hernia is repaired
is a surgical maneuver used in some abdominal operations. A large hemostat is used to clamp the hepatoduodenal ligament interrupting the flow of blood through the hepatic artery and the portal vein and thus helping to control bleeding from the liver.
pringle maneuver
photodynamic therapy
procedure in which cells selectively treated with an agent called a photosensitizer are exposed to light to produce a reaction that destroys the cells
2 advantages to the McBurney's incision
quick and easy to close allows firm wound closure
Crutch palsy is due to direct pressure on what nerve?, What nerve is most commonly injured in a mid- or distal humeral shaft fracture?, What nerve is damaged if a patient presents with "wrist drop"?
radial nerve
general anesthesia
reversible unconscious state characterized by amnesia, analgesia, depression of reflexes, muscle relaxation and homeostasis
ascending colon
right side of the abdomen from the cecum up to the transverse coloncontracts rt. lobe of the liver; secondarily retroperitoneal
pumps deoxygenated blood into the pulmonary artery
right ventricle
closure of a midline incision entails the use of what suturing technique?
running suturing technique (large gauge, delaying absorbing suture about four times longer than the length of the incision)
hernia
rupture
Halsted stitch
same as mattress stitch
Sp02
saturation (pulse) of oxygen or in a pulsating vessel, expressed as a percentage
the fascia located in the subcutaneous fat that must be incorporated for a secure wound closure
scarpus fascia
Appendectomy (open approach)
severance and removal of the appendix from its attachment to the cecum through a right lower quadrant, muscle splitting incision (McBurney) removes an acutely inflamed appendix
ASA P4
severe systemic disease that is a constant threat to life or requires intensive therapy serious limitation of daily activity, major impact on anesthesia and surgery
what medications might a provider use with the total I.V. anesthesia?
short acting meds such a propofol with remifentanil or alfentinil for induction which may be administered by continuous infusion intermediate-acting muscle relaxant like cisatracurium, atlacurium, rocuronium or vecuronium
a partial dislocation , often indicated by ligamentous instability.
subluxation
Anectine, Quelicin, What agent may trigger hyperthermia, Only member of depolarizing neuromuscular blocker, causes fasciculation during induction and muscle pain after use; has short duration of action
succinylcholine
Dermis
supports epidermis thicker than epidermis and composed of collagen larges portion of the skin, providing strength and structure contains blood vessels, lymph ducts, hair roots, nerves, subaceous and sweat glands vascular and innervated
In the case of excessive cup wear or a femoral neck length that is short, what happens when modular components were used?
surgery is minimized with the ability to exchange the modular components without removing the implants fixed to the bone.
Fast heart rate (HR greater than 100 bpm)
tachycardia
rapidly developing tolerance
tachyphylaxis
The facial nerve innervates
taste
what is a gastrojejunostomy?
the establishment of a permanent communication, either between the proximal jejunum and the posterior wall of the stomach, without removing a segment of the G I tract.. It is accomplished through a midline or paramedian abdominal incision May be performed to treat a benign obstruction at the pyloric end of the stomach or an operable lesion of the pylorus when a partial gastrectomy would not be feasible. It also provides a large opening without spincter obstrction.
Latissimus blood suppy, latissimus dorsi flap used in a breast recon. following a mastectomy receives its main blood supply from this artery
thoracodorsal artery
closed fractures
those in which there is no communication between the bone fragments and the skin surface.
instrument/supplies needed for excision of an esophageal diverticulum
thyroid set 2 additional pennington clamps 6 Halsted curved mosquito hemostats 2 5inch adson forceps 2 lateral retractors
recurrent laryngeal must be identified and protected during this procedure;, Semi-Fowler's or Fowler's;, Tetany is a possible postoperative complication
thyroidectomy
goal of myotomy
to relieve the obstruction caused by the contracted LES while preventing postoperative gastric reflux scarring, and subsequent stricture
why is a billroth 2 procedure performed?
to remove a benign or malignant lesion in the stomach or duodenum . this technique and modifications may be selected because the volume of acidic gastric juice will be reduced and the anastamosis can be made along the greater curvature or at any point along the stump of the stomach. after surgery, duodenal and jejunal secretions empty into the remaining gastric pouch. the stomach empties more rapidly because of the larger opening, and a limited amount of gastric juice remains
why is arthroplasty of the joints performed?
to restore motion of the joint and function to the muscles and ligaments.
TIVA
total intravenous anesthesia
Which nerve is protected by putting padding under the arms on an arm board?, What nerve is injured by fracture of the medial epicondyle (at the level of the elbow)? injury to this nerve can cause "claw hand", nerve transposition- relocated to the anterior aspect of the medial epicondyle
ulnar nerve
Two techniques that facilitate continual assessment of cerebral perfusion
use of cervical block anesthesia or electroencephalography. A conscious patient under cervical block anesthesia can be observed for neurologic deficits encountered during the procedure. In addition, the patient under general anesthesia can be monitored with an EEG.
antibiotics
given 1 hour before surgery; cefazolin antibiotic of choice
cranial nerve 9
glossopharyngeal taste, swallow
what must be used as irrigation when using electrical current in tissue dissection during surgical procedures?
glycine, sorbitol, and mannitol
Major organ for homeostasis. Regulates temperature, thirst, hunger, sleep, moods, sex drive., links the nervous system to the endocrine system via the pituitary gland
hypothalmus
how do you measure inspiratory effort and help to encourage deep breathing?
incentive spirometry
what reason would an esophagectomy/intrathoracic esophagogastrostomy be performed?
involve removal of diseased portions of the stomach and esophagus performed to remove strictures in distal esophagus that may develop after trauma, infection, or to remove tumors in the cardia of the stomach or distal esophagus
Thoracotomy
involves an incision in the chest wall through a median sternotomy and a lateral or posterolateral incision for the purpose of operating on the lungs. Intraoperative patient care is similar for various thoracotomy procedures, with consideration of the patient's history and disease process, planned procedure , and individualized patient needs.
femoral shaft fractures are associated with what?
ipsilateral (same-side) trochanteric or condylar fractures .
what is total hip replacement?
is a common orthopedic procedure performed on patients with hip pain caused by degenerative joint disease or rheumatoid arthritis.
Infraorbital foramen
is a passage for the infraorbital nerve and artery.
what is a near-total thyroidectomy?
is a total lobectomy with contralateral subtotal thyroidectomy.
foramen of Vesalius?
is an occasional opening medial to the foramen ovale of the sphenoid, for passage of a vein from the cavernous sinus
what is a radical hysterectomy (Werthiem)?
is en bloc dissection with careful removal of all recognizable lymph nodes in the pelvis, together with wide removal of the uterus, tubes, ovaries, supporting ligaments, and upper vagina. Extensive dissection of the ureters and of the bladder is also involved
Diagnostic arthroscopy
is for patients whose diagnosis cannot be determined by history or physical exam. Or whose CT or MRI finding are inconclusive.
Incisive foramen
is one of the openings of the incisive canals into the incisive fossa of the hard palate.
Laparoscopic Roux-en-Y Gastric Bypass
largely restrictive midly malabsorptive reroutes the passage of ingested food and fluid from a small pouch created with surgical staples or sutures in the proximal stomach to a segment of the proximal jejunum
Ligament of Cooper's
lateral extension of lucuner ligament, surrounds spermatic cord & testies. Cremaster muscle forms a ring around spermatic cord, continuation of internal oblique, Genito femoral intervals cremaster muscle & over middle surface of the thigh
positioning of the patient for esophagectomy
lateral position
where do indirect inguinal hernias occur?
lateral to inferior epigastric vessels
parital pleura
layer that surrounds the walls of the thoracic cavity
common retractor for brain tissue is
layla
pressure injury
localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device
esophagectomy approach depends on what 5 things?
location of tumor size of tumor extent of planned lymph node dissection type of conduit used to replace the esophagus surgeon preference
the deep fissure between the two cerebral hemispheres
longitudinal fissure
fidelity
loyalty
The external carotid artery may be identified by the: o Absence of branches in the neck, inferior to the common carotid bifurcation o Presence of branches in the neck, inferior to the common carotid bifurcation o Presence of branches in the neck, superior to the common carotid bifurcation o Absence of branches in the neck, superior to the common carotid bifurcation sensation to the cheek
o Absence of branches in the neck, superior to the common carotid bifurcation sensation to the cheek
Res ipsa loquitor
"The thing speaks for itself"
The advantages of closed reduction over open reduction and internal fixation are
(1) a lower incidence of infection and (2) absence of additional soft-tissue or vascular damage.
external fixators contain what three components?
(1) bone-anchoring devices (threaded pins, Kirschner wires), (2} longitudinal supporting devices (threaded or smooth rods), and (3} connecting elements (clamps and partial or full rings).
what are the different Intramedullary nail and rod designs?
(1) flexible nails like the Rusch or Enders type , (2) standard rods such as the Sampson and AO rods, and (3) interlocking nails such as the Grosse-Kempf and Russell-Taylor varieties .
Local tissue effects of PMMA may include
(1) tissue protein coagulation caused by polymerization, (2) bone necrosis caused by occlusion of nutrient metaphyseal arteries, and (3) cytotoxic and lipotoxic effects of non-polymerized monomer.
varities of fracture architecture
(1) transverse fracture, in which the fracture line runs at a right angle to the longitudinal axis of the bone; (2) longitudinal fracture, which runs along the length of the bone; (3) oblique fracture and spiral fracture, in which bone is twisted apart (similar exceptthat oblique is shorter than spiral); (4) comminuted fracture, in which the bone fragments splinter into more than two pieces; (5) compression fracture, in which one fragment is driven into the other end and is relatively fixed in that position; and (6) pathologic fracture in which a bone will fracture easily because it is weakened by disease.
what are the steps in the operative procedure of a laminectomy?
(Laminectomy for Herniated Disk-Nucleus Pulposus)- 1. A midline vertical or transverse incision is made at the operative site. 2. Hemostatic forceps may be placed on the underside of the skin edge and everted for hemostasis. Deeper vessels are usually electrocoagulated. 3. Two self-retaining retractors (Cone,Weitlaner, or Adson) are inserted for exposure. 4. The fascia is incised in the midline with Mayo scissors , electrosurgical cutting tip, or a scalpel. 5. One side of the spinous processes is exposed by sharp dissection. 6. The paraspinous muscles and periosteum are stripped off the laminae with a knife and sharp periosteal elevators. Cutting current dissection with the electrosurgical unit may be used. 7. As each area is stripped, a gauze sponge is packed around the bony structures with a periosteal elevator to aid in blunt dissection and to tampon bleeding. The paraspinous muscles are dissected from all the laminae. In disk surgery this may be done only on one side, the side of the lesion. 8. A laminectomy retractor is then placed in position. A Scoville (with a blade on the tissue side and a slightly shorter hook on the bone side), Tower, Crank, or Beckman-Adson retractor can be used. 9. Cottonoid strips or patties are placed in the extremes of the field for hemostasis. 10. The edges of the laminae overlying the interspace with the herniated disk are defined with a curette. A partial hemilaminectomy of these laminal edges extending out into the lateral gutter of the spinal canal is performed with a Schwartz-Kerrison rongeur. The bone edges are waxed. 11. The flavalligament is grasped with vascular bayonet forceps with teeth, and a #15 blade on a #7 knife handle is used to incise it as close to the midline as possible. Cottonoid strips or patties are passed through this incision to protect the underlying dura, and a window is cut into the flaval ligament with a #15 blade on a #7 knife handle. 12. Additional ligaments out in the lateral gutter of the spinal canal may be removed with a large curette or a Cloward punch after first protecting the dural sac and nerve root with a cottonoid strip. 13. A dural elevator and a Love or copper nerve root retractor are used to retract the nerve root and dural sac to expose the disk space. 14. Epidural veins are controlled by packing with narrow cottonoid strips and if necessary by careful coagulation with a bipolar bayonet. 15. Any herniated fragment of disk is removed with a pituitary rongeur. 16. After coagulation of its surface, an opening is cut into the posterior aspect of the interspace with a #11 or 15 blade on a #7 knife handle. 17. Pituitary rongeurs, straight and angled, narrow and wide, are used to remove the disk material from the interspace. 18. Straight and angled Scoville and ring curettes help to further clean out the interspace. Disk material so loosened is removed with the pituitary rongeurs. 19. The area is irrigated with lactated Ringer's or normal saline solution, and the interspace is explored with a suction tip. 20. The nerve roots and extradural space are explored with a blunt nerve hook. 21. If no further specimen is obtained, hemostasis is secured with cottonoid strips or patties. If possible, neither gelatin sponge nor gauze nor other hemostatic material is used. 22. The cottonoid strips are removed from the epidural space, the bed is unflexed, and the area is further irrigated. A change of position sometimes causes more disk material to protrude, and the interspace is re-exposed with a nerve root retractor to rule out this possibility. 23. All cottonoid strips and patties and retractors are removed, and the wound is closed. For cervical or thoracic disks, only the protruding fragment is removed and limited if any exploration of the interspace is performed. The reason is that attempts of adequate interspace exploration require retraction of the dural sac, which contains the spinal cord at these levels. Such retraction would result in cord injury and paralysis. For a thoracic disk a costotransversectomy or transthoracic approach is used.
What is autotransfusion?
(cell salvage), blood is collected during the surgical procedure and reinfused to the patient after it is filtered or washed.
hematocrit
(f) 37-47%; (m) 42-52 % , percentage of blood volume occupied by red blood cells
Procedural complications of tissue expander insertion
-A basic plastic instrument set is used. -The breast-shape expander is supplied in a sterile package from the manufacturer and is available in a variety of sizes. -The care of the tissue expander is the same as that for other implantable devices. -The patient is positioned supine with the arms extended on armboards. -Prepping and draping are carried out in the routine manner to expose both breasts and axilla.
what is internal fixation?
-Internal Fixation is often the treatment of choice for correction of fractures of long bones or those in the hip region. -Application of compression plates and screws and insertion of pins, intramedullary rods, nails, or wiring are methods of internal fixation. -Fractures of most anatomic parts in adults can be repaired using internal fixation.
nipple reconstruction
-This procedure may be done at the time of the original reconstruction, but most surgeons believe that they have a better result if it is done as a secondary procedure after the reconstruction has healed and symmetry is achieved. -Tissue may be harvested from donor sites such as the groin, auricular area, labia, big toe, or contralateral nipple. -Tattooing may complete the reconstruction.
procedural consideration for wedge resection
-Thoracic instrumentation is used. -The patient is positioned to allow access to the operative site with consideration of the area of lung to be removed.
wedge resection
-Wedge resection is removal of a wedge-shaped section of parenchyma that includes the identified lesion, without regard for intersegmental planes. -The resection is used for removal of small, peripherally located benign primary tumors, peripherally located inflammatory disease, and biopsy in chronic diffuse lung disease.
what is a modular hip system?
-allows the orthopedic surgeon to choose from an array of interchangeable components that have been developed. -various femoral head sizes (22, 26, 28, and 32 mm) are available to maintain proper center of rotation. -acetabular cups may be snap fit, low profile, or deep profile, which adds additional thickness to the medial wall, where there may be significant bone loss.
cancellous screws are commonly used when
-fractures occur at the condylar ends of the shaft. -plating of a fracture may occur with or without dynamic compression.
breast augmentation is done for
-hypomastia, to correct breast asymmetry, and to recreate the breast after mastectomy. -A saline-filled prosthesis is inserted to enlarge or form the breast mound. -Placing the implant under the pectoralis muscle contributes to softness.
when is joint arthroplasty recommended?
-in individuals with a painful, disabling arthritic joint that is no longer responsive to conservative therapy. -generally reserved for those with a less active lifestyle. -the younger patient, very active older person, or laborer may better be served with a reconstructive procedure such as arthrodesis or osteotomy.
aneurysmal disease
-is caused by a disruption of the media, which structurally weakens the aortic wall. -Aneurysmal aortas are found to have a significantly decreased amount of collagen and elastin in the vessel wall. -Aneurysms occur most often in the abdominal aorta, thoracic aorta, and the popliteal arteries.
carotid endarterectomy
-is the removal of an atheroma at the carotid artery bifurcation to increase cerebral perfusion and decrease the risk of embolization.
what are the contraindications to breast reconstruction surgery?
-may include metastasis to major organs such as liver, bone, or lung. -The use of chemotherapy and radiation does not preclude reconstruction but may delay it somewhat as a result of the healing processes.
what does the first assistant need to be aware of in AAA repair procedures?
-must be alert to the fact that at the time the aortic clamp is released to permit distal flow "de-clamping shock" or severe hypotension may occur. -This may be attributable to inadequate volume replacement, the sudden reestablishment of flow to vasodilated distal vessels, potassium, or the release of acidic metabolites. -This and hemorrhage have been proposed as the causes of renal failure from acute tubular necrosis.
what might increase a patients' risk of fluid and electrolyte balance?
-preexisting conditions such as diabetes mellitus, liver disease or renal insufficiency -diagnostic procedures that require IV dyes -preoperative steroids or diuretics -preoperative surgical regimens (bowel cleansing) -medical management (gastric suction)
Operative records include
-preoperative diagnosis, -surgery performed, -a description of findings, -specimens removed, -postoperative diagnosis, -and names of all individuals participating in intraoperative care. -positioning and stabilizing devices, -electrosurgical unit number and settings, -medications, and -evidence of ongoing assessment and additional actions taken
reduction mammoplasty is indicated for
-the patient with gigantomastia or macromastia resulting with back pain, intertrigo, or deep grooving in the shoulders from the weight of the breasts. -The procedure may also be performed to achieve symmetry after a mastectomy on the contralateral side. -Excessive breast tissue and its overlying skin are excised, with reconstruction of the breast contour, size, shape, and symmetry. -Preoperatively the patient needs to be aware that the scars will be visible and that she may have a slight degree of asymmetry. -Autologous blood should be available and the patient typed and crossmatched before undergoing anesthesia.
when considering treatment for femoral neck fractures, what things are considered?
-type and location of fracture (location on shaft) -the number of segments involved -the degree of comminution -the activity level of the patient.
what is the Ilizarov device?
-uses principles of tension-stress and distraction to correct bone defects and limb length discrepancies. -limb length may be adjusted with gradual bone distraction of bone ends, stimulating new bone formation.
when is open reduction, internal fixation used?
-when satisfactory reduction of a fracture cannot be obtained or maintained by closed methods, and skeletal traction is not indicated. -the advantage is that anatomic alignment of the fracture can usually be obtained and verified through direct observation.
()ALPHA- FETOPROTEIN (AFP) SERUM
0 44 ng/ mL
WBC: immature polys (BANDS)
0-10%
WBC: basophils (BAS)
0-2%
CK MB
0-3 ng/mL
what is the complication rate of all surgical procedures and what is the cost per infection?
1% to 12% cost is $12,000 to $30,000 per infection
Indications for external fixation include
1) severe open fractures, 2) highly comminuted closed fractures 3} arthrodesis, 4) infected joints, 5) infected nonunion 6) fracture stabilization to protect arterial or nerve anastomoses, 7) major alignment and length deficits 8) congenital deformities 9) static contractures.
steps in the operative procedure for a carotid endarterectomy with shunt
1-5. The first five steps as described for carotid endarterectomy are followed. 6. A piece of tubing (polyethylene or Silastic) with a suture tied around its center or a commercially prepared shunt device is inserted into the common carotid artery and the internal carotid artery to maintain cerebral blood flow and is held with vessel loops or shunt clamps. 7. The plaque is removed as described for carotid endarterectomy. 8. The arteriotomy is closed with or without a patch. 9. Before the arteriotomy closure is completed, the shunt clamp or vessel loop on the internal carotid artery is released, and the shunt is removed. The external carotid occluding clamp is removed, followed by the common carotid artery clamp, and last, the internal carotid artery occluding clamp. 10. The wound is closed in the usual manner.
what are the steps in the thyroidectomy?
1. A transverse incision parallel to the normal skin lines of the neck is made through the skin and first layer of the cervical fascia and platysma muscle, approximately 2 cm above the sternoclavicular junction 2. An upper skin flap is undermined to the level of the cricoid cartilage; straight clamps are placed on the dermis and retracted anteriorly and superiorly to facilitate dissection. A lower flap is then undermined to the sternoclavicular joint. A knife, fine curved scissors, tissue forceps, and gauze sponges are used to undermine the flaps. Bleeding vessels are clamped with hemostats and ligated with fine , nonabsorbable sutures. Lateral retraction with a vein retractor or ArmyNavy retractor helps identify the plane for dissection. 3. Flaps may be held away from the wound with stay sutures inserted through the cervical fascia and platysma muscle or by one of the various self-retaining retractors. 4. The fascia in the midline is incised between the strap (sternohyoid and sternothyroid) muscles with a knife. The sternocleidomastoid muscle may be retracted with a loop retractor. Ordinarily it is not necessary to divide the strap muscles ; however , the strap muscles may be divided between clamps should additional exposure be required as with a very large gland, using Mastin muscle clamps, Kocher clamps, or hemostats and a knife. The divided muscles are retracted from the operative site with retractors , thereby exposing the diseased lobe. 5. The interior and middle thyroid veins are clamped, divided with Metzenbaum scissors, and ligated with fine nonabsorbable sutures . 6. The lobe is rotated medially , and loose aerolar tissue is divided posteriorly and medially toward the tracheoesophageal sulcus with hemostats and Metzenbaum scissors. Small sponges are used for blunt dissection. Bleeding is controlled by hemostats and ligatures , as well as by electrosurgery; the bipolar electrosurgical unit (ESU) may be used. The recurrent laryngeal nerve,which enters the cricothyroid muscle at the level of the cricoid cartilage , is identified and carefully preserved . Electrocoagulation should not be used in the vicinity of the recurrent or superior laryngeal nerve because the spread of the current could damage the nerve. 7. The thyroid lobe is pulled downward, a Lahey goiter or polar retractor is inserted as necessary, and the avascular tissue between the trachea and upper pole of the thyroid is dissected by means of Metzenbaum scissors. 8. The superior thyroid artery is secured with two or three curved hemostats or right-angled clamps; the artery is ligated, divided, and then transfixed with nonabsorbable sutures. Care is taken here to not injure the superior laryngeal nerve. The upper parathyroid gland is often identified at this time. 9. The inferior thyroid artery is identified and ligated by means of fine forceps, sutures, and scissors. The lower parathyroid is identified. The thyroid lobe is then dissected away from the recurrent nerve with Metzenbaum scissors and hemostats. Bleeding vessels are clamped with hemostats and ligated with fine nonabsorbable sutures. 10. The lobe is elevated with Lahey vulsellum clamps ;it is freed from the trachea with fine scissors , forceps, knife, and hemostats. The fibrous bands attached to the trachea and cricoid cartilage are divided. 11. The isthmus of the gland is elevated with fine forceps and divided between hemostats with scissors, removing the lobe and isthmus. If a pyramidal lobe is present, it is removed from its attachment to the gland to its termination in the neck, which may reach the hyoid bone. If it is necessary to transect the hyoid bone, a small bone cutter is used. 12. The cut surface of the opposite lobe requires careful hemostasis. A running suture may be utilized for this purpose as well as to reapproximate it to the pretracheal fascia. 13. The strap muscles, if severed , are approximated with fine interrupted absorbable or nonabsorbable sutures. If necessary, a drain may be inserted into the thyroid bed and brought out between the strap muscles and sternocleidomastoid muscle. Many surgeons prefer to drain the wound laterally through the sternocleidomastoid muscle and the lateral extremity of the incision in the belief that this produces better healing and cosmetic results. 14. The edges of the platysma muscle are approximated. The skin edges are then approximated with subcuticular, fine absorbable sutures. 15. Wound closure tapes (such as Steri-Strips) are applied to the wound edges , and gauze dressings are placed on the wound with minimal tape.
steps in the operative procedure (Cemented Modular Hip System, Anterior Approach)
1. An incision is made 2.5 cm distally and laterally to the anterosuperior iliac spine and curved distally and posteriorly over the lateral aspect of the greater trochanter and lateral surface of the femoral shaft to 5 cm distal to the base of the trochanter. 2. The tensor fasciae latae is divided over the greater trochanter, and this is carried distally to the extent of the incision. Dissection is carried proximally between the interval of the gluteus medius and the tensor fas,ciae latae muscle. 3. The anterior fibers of the gluteus medius tendon are tagged and detached from the trochanter. The capsule is incised longitudinally along the anterosuperior surface of the femoral neck. In the distal part of the incision the origin of the vastus lateralis may either be reflected distally or split longitudinally to expose the base of the trochanter and proximal part of the femoral shaft. 4. Once a capsulotomy is performed, the hip can be dislocated. Adduction and external rotation will present the femoral head anteriorly into the surgical site. 5. The femoral osteotomy guide is placed over the lateral femur. This identifies the point on the femoral neck where the osteotomy should be made. Some femoral osteotomy guides will also gauge the neck length required. The level is marked, and a femoral osteotomy is carried out with a reciprocating saw. 6. The femur is retracted to expose the acetabulum, allow completion of the capsulotomy, and expose the rim of the entire acetabulum. 7. The acetabulum is inspected, any osteophytes are removed, and articular cartilage is reamed with bone-conserving reamers in a circumferential manner. The smallest reamer is progressed in a graduated method 1 or 2 mm at a time until the cartilage is reamed down to expose osteochondral bone. A hemispheric shape and bleeding bone should result. 8. Remaining soft tissue is curetted from the floor of the acetabulum, and systic areas are filled with cancellous bone from the femoral canal and packed with a bone tamp. Any other bone grafting of major bony defects is accomplished using the fixation method of choice (bone screws). 9. Several 6 mm holes are drilled into the floor of the acetabulum, aimed into the ilium, ischium, and pubix. Holes are undercut using curettes. These prepared holes act as anchoring areas for the bone cement. 10. Trial acetabular components are placed on the positioning device and positioned in the socket. The cup is assessed for size, position within the socket, and the relationship of the component compared with the bony margins of the acetabulum. 11. The prepared acetabular socket is given a lavage, dried with wicks, and filled with cement that has been injected and pressurized with an injection gun. The acetabular shell component is positioned and held motionless until the cement polymerizes. Extruded cement is trimmed from around the edge of the component. A polyethylene insert is later snapped into the shell. 12. A sponge is placed in the acetabulum to protect the component from bone debris and subsequent cement as attention is turned to the femur. 13. Dropping the foot toward the floor and internally rotating and pushing the leg proximally exposes the proximal femur. The femoral canal is accessed using a box osteotome or trochanteric reamer followed by the T-handle canal reamer. 14. Beginning with the smallest broach, alternatively impact and extract in the proximal femoral canal. Progressively larger broaches are used to crush and remove cancellous bone until cortical bone is reached. A broach that is not advancing should not be used. This could result in shattering the femur. 15. With the final broach seated to the desired depth in the canal, the neck is prepared with a calcar reamer. The broach remains as the femoral trial component along with the various-sized head, neck, and offset trial components. 16. The trial component is removed, and the canal is given a lavage and brushed to accommodate the PMMA. 17. A cement restricter is inserted into the femoral canal. The femoral components are passed and assembled on the back table. 18. The cement is injected and pressurized within the femoral canal. 19. The femoral component, with the proximal and distal centralizers, is inserted into the canal with or without the femoral head. 20. The appropriate size of femoral head is positioned onto the stem, and reduction is carried out. The joint is taken through a range of motion to check for positioning, stability, and the limit to which dislocation occurs. 21. Depending on the surgeon and the surgical approach, the greater trochanter may or may not have been removed for exposure of the hipjoint. If removed, it is reattached with 18-gauge wire or a cable grip system. 22. The wound is closed in layers over suction drains. The skin is closed with staples, and a sterile dressing is applied to provide compression to the wound. 23. An abduction pillow or splint is placed between the patient's legs postoperatively if stability of the joint is of concern.
what are the steps in the C-Section procedure?
1. An infraumbilical vertical incision or lower transverse Pfannenstiel incision is made. The incision should be long enough to allow the infant to be delivered without difficulty but no longer. Therefore, the length of the incision varies with the estimated size of the fetus. 2. The abdominal wall is opened in layers. The rectus and pyramidalis muscles are separated in the midline by sharp and blunt dissection to expose the underlying transversalis fascia and peritoneum . 3. The peritoneum is elevated with two Crile hemostats about 2 cm apart. The peritoneum between the two clamps is palpated to rule out the inclusion of bowel, omentum, or bladder. The peritoneum is opened and the abdominal cavity entered. 4. Bleeding sites anywhere in the abdominal incision may be clamped but not ligated until later, unless the clamps obstruct exposure. When the patient is under general anesthesia, speed is important to prevent an anesthetized infant. Electrosurgery may be used at this point to stop bleeding, especially if the patient is awake and under regional anesthesia. 5. The uterus is quickly but carefully palpated to determine the size and presenting part of the fetus as well as the direction and degree of rotation of the uterus. 6. The reflection of the peritoneum (serosa) above the upper margin of the bladder and overlying the anterior lower uterine segment is gently separated by sharp and blunt dissection. 7. The developed bladder flap is held downward beneath the symphysis with a bladder retractor such as the Delee. 8. The uterus is opened with a knife through the lower uterine segment about 2 cm above the detached bladder. Once the uterus is opened, the incision can be extended by cutting laterally with a large bandage scissors or by simply spreading the incision by means of lateral pressure applied with each index finger when the lower uterine segment is thin. 9. The presenting membranes are incised. Suction is imperative here, and many surgeons prefer no suction tip (only the large open end of the suction tubing) during the expulsion and suctioning of amniotic fluid. 10. All retractors are removed. The fetal head is gently elevated, either manually or by use of obstetric forceps, through the incision, aided by transabdominal fundal pressure. The pressure helps expel the fetus. 11. As soon as the head is delivered, a bulb syringe or separator tip is used to aspirate the exposed nares and mouth to minimize aspiration of amniotic fluid and its contents . 12. About 20 units of oxytocin per liter of fluid may be administered intravenously as soon as the shoulders are delivered (or after delivery of the infant), so that the uterus contracts. This use of oxytocin minimizes blood loss. 13. On delivery of the entire infant, the cord is clamped and cut, and the infant given to the member of the team who is responsible for resuscitation efforts as needed. A sterile gown or sheet should be provided to the individual receiving the infant to avoid any break in aseptic technique and to maintain universal precautions during transfer of the infant. 14. The edges of the uterine incision are promptly clamped with Pean forceps, ring forceps, or Pennington clamps. 15. The placenta is delivered and placed in a large receptacle provided from the back table. Fundal massage or manual removal may be employed to hasten delivery of the placenta and reduce bleeding. 16. One or two separate layers of suture may be used to close the uterine incision. 17. After determination that there is no further bleeding after closure of the uterine incision, the cut edges of the serosa overlying the uterus and bladder are approximated with a continuous suture. 18. Any blood, blood clots, vernix, and amniotic fluid in the pelvis and peritoneal cavity are removed. The fallopian tubes and ovaries are also inspected. Tubal ligation may be carried out at this point. 19. The peritoneum and each abdominal layer are closed.
what are the steps in a transverse colectomy procedure?
1. The abdomen is opened, and the peritoneal cavity is explored to determine the extent of the pathologic area. 2. Moist packs are used to wall off surrounding structures to expose the hepatic and splenic flexures of the colon. 3. The colon is mobilized by incising the lateral peritoneum on either side and transsecting the transverse mesocolon. Hemostats, a Metzenbaum scissors, and 3-0 nonabsorbable ligatures are used. 4. The operative field is prepared for resection by placing towels or laparotomy sponges around the colon to isolate any contamination from the lumen of the bowel. 5. Two intestinal resection clamps are applied. 6. Transection is completed with a scalpel or mechanical linear stapling device. 7. An end-to-end or side-to-side stapled anastomosis is completed. 8. Contaminated articles are discarded. 9. Approximation of mesentery and lateral peritoneum is completed with 3-0 nonabsorbable sutures. 10. The abdominal wound is closed. Retention sutures may be used. 11. The wound is dressed.
steps in the operative procedure for a TRAM flap
1. The skin from the mastectomy scar is excised. 2. The transverse rectus abdominis muscle is dissected and tunneled subcutaneously to the midline of the abdomen. 3. The flap is brought to the chest wall and sutured medially; the thinnest portion of the flap is superior and medial, and the thickest portion is inferior and lateral. 4. Because of the amount of tissue available, an implant is often unnecessary. There are alternative approaches to the TRAM flap. With the pedicle approach the TRAM flap is elevated on a vascular pedicle and rotated into place. With the free approach the TRAM flap is separated from the superior epigastric vessels and anastomosed to the vessels of the chest. A supercharged flap involves elevating the TRAM flap on its vascular pedicle, rotating it into position on the chest , and anastomosing vessels to augment blood supply to the flap. With the free or supercharged TRAM flap the microscope, microvascular instruments, Wood's lamp, and loupes need to be available .
What are the steps in the operative procedure for repair of perforated peptic ulcer open technique?
1. The surgeon makes an upper midline laparotomy incision. 2. Exploration of the upper abdomen to locate the site of the perforation follows. 3. The surgeon performs a tissue biopsy of the ulcer to rule out malignancy 4. To "close" the perforation, the surgeon places a small pedicle of omentum over the perforation and secures it to the stomach wall with interrupted 3-0 absorbable sutures; the omentum patch is called a Graham patch. 5. The abdomen requires copious irrigation with warm saline. 6. Closure of the abdomen is in two layers. Dressings are applied.
steps in the craniotomy operative procedure
1. The surgeon and the assistant apply digital pressure over folded 4 X 4 inch radiopaque sponges on both sides of the incision line. The skin and galea are incised in segments, with the length of each segment being equal to that over which the finger pressure is applied. The tissue edges are held with 6-inch toothed forceps as scalp clips are placed on the flap edges. Hemostatic clamps are placed on the outside edge of the incision in adults and are grouped in segments and secured together by rubber bands placed around the handles or by a Penrose drain or open 4 X 4 inch sponge threaded through the handles and tied or clamped together with heavy forceps, such as a Pean. Any remaining active arterial bleeding is controlled by electrocoagulation . If the incision extends into the temporal area, bleeding in the temporal muscle is managed by electrocoagulation , hemostats, tamponade , or suture ligature . Mayo scissors can be used to incise temporal muscle and fascia. 2. The soft tissue is peeled off the periosteum by sharp or blunt dissection or by electrodissection. The scalp flap is turned back over folded sponges and retracted by use of small towel clamps and rubber bands or muscle hooks on rubber bands. In either case the traction is maintained by securing the rubber band to the drapes with heavy forceps. The flap may be covered with a moist sponge or Telfa strips and a sterile towel. Bleeding is controlled by electrocoagulation. 3. When a free bone flap is planned, the muscle and periosteum are incised. Muscle and periosteum are elevated with the skin-galea flap, turned back, and retracted as a unit, as described previously . 4. The periosteum and muscle are incised with a scalpel or electrosurgical knife except at the inferior margins, which are left intact to preserve the blood supply to the bone flap. The periosteum is stripped from the bone at the incision line with a periosteal elevator. Bone wax is used to control bleeding. 5. The scalp edges and muscle are retracted from the bone incision line by a Sachs or Cushing retractor. Two or more burr holes are made with either a hand or power cranial drill. As each hole is drilled, the assistant must hold the patient's head to diminish the agitation and prevent displacement from the headrest. A great deal of heat is generated by the friction of the perforator or burr against the bone. The scrub nurse or assistant must irrigate the drilling site to counteract the heat and remove bone dust, which collects as the holes are made. Some surgeons prefer that the scrub nurse collect the bone dust for replacement in the burr holes at closure. The dust is placed in a medicine glass and kept moist with a small amount of normal saline solution. A large-gauge suction tip is used to remove both irrigating solution and debris from the field. As the inner table is perforated and the dura exposed, the burr hole may be temporarily tamponed with bone wax or a cottonoid strip or patty . Each hole is eventually debrided by a #0 or 00 bone curette or small periosteal elevator Uoker). The dura mater is freed at the margins with a #3 Adson elevator, #3 Penfield dissector, or right-angle Frazier elevator or similar instrument. The hole is irrigated and suction applied simultaneously. Active bleeding points in the bone are identified, and bone wax is applied. 6. When all burr holes have been made, the bone flap is cut by sawing between holes after the dura mater has been separated from the bone by a dural separator , such as the Sachs, or by a #3 Penfield dissector. Dural separation is done to prevent tearing of the dura mater, especially over venous sinuses. Using a rongeur, the surgeon may cut channels into the two burr holes at the inferior edge of the planned bone flap under the muscle. When the rest of the bone flap has been sawed, this segment can be easily cracked as the bone is elevated and turned back. If the sawing is done by hand, a dural separator is passed from one hole to the next under the bone. A saw guide-passer with a saw attached is passed from one hole to the next in the same manner. The saw is detached from the guide, saw handles are attached to both ends of the saw, and the bone is incised by sawing in a back-and-forth motion. Friction generates heat, so irrigation and suction must be used during the process. The procedure is repeated until all segments but the one under the muscle have been cut. Usually a new saw is used each time. An air craniotome or Midas Rex drill can also be used for the opening. Irrigation and suction are required as the bone flap is cut. Soft-tissue edges are retracted with Sachs or Cushing retractors. 7. The bone flap with muscle attached is lifted off the dura mater by two periosteal elevators. As it is forced up and back, the bridge of bone under the muscle cracks. Bleeding from the bone is controlled with bone wax. A double-action rongeur is used to remove sharp, irregular edges where the bone cracked. The bone flap is covered with a moist sponge, cottonoid material, or Telfa pads and then a clean sterile towel and is retracted in the same manner as the scalp flap. 8. The dura mater is irrigated. Moist cottonoid strips or patties or Telfa pads may be inserted between the dura mater and bone and folded back to cover the exposed bone edges. Clean sterile towels may be placed around the operative site. 9. The dura mater is opened. A dura hook may be used to elevate the dura mater from the brain, and a small nick is made in the dura mater with a #15 blade on a #3 or #7 knife handle; or a small opening may be made in the dura mater without elevating it, after which the dural edges are grasped with straight mosquito hemostats or two Adson or Cushing forceps with teeth and are elevated. A narrow, moist cottonoid strip is inserted with smooth forceps (bayonet or Cushing) into the opening to protect the brain as the dura mater is incised and elevated. The dural incision can be made with Metzenbaum scissors, special dura scissors, or a Rayport dura knife. Usually traction sutures are placed at the outer edge of the dura mater and are tagged with small bulldog clamps or mosquito hemostats. Sometimes the tag instruments are attached to the drapes to increase traction and keep tension on them . As the dural veins are approached during dural opening, they are ligated or coagulated before cutting . Ligation is done with hemostatic clips such as Week Hemoclips, McKenzie clips, or Ligaclips. The brain surface is protected by moist cottonoid strips. 10. The surgeon places cottonoid strips and brain retractors , self-retaining and manual, appropriately while working toward visualizing the particular pathologic entity. 11. Brain spoons, Cushing pituitary spoons , and Ray curettes as well as pituitary rongeurs or other tumor forceps must be available for tumor removal. Also, a selection of dissectors, Cushing and Gerald forceps, and a bipolar coagulation unit are used. Completely filled irrigating syringes and a full range of moist cottonoid patties and strips must be within easy reach of the surgeon and the assistant. After correction of the pathologic condition and control of bleeding, the brain may be irrigated with an antibiotic solution of the surgeon's choice.. 12. The dura mater is usually closed by running or by interrupted sutures of #4-0 silk,4-0 polyglactin 910 suture, or 4-0 black braided nylon. A drain may or may not be used. Epidural tack-up sutures are usually placed around the edge of the craniotomy defect to close the epidural dead space. This is usually done before the opening of the dura. 13. The bone flap may or may not be replaced. If swelling is anticipated, it is usually not replaced. If the flap is free and replaced, holes may be drilled in it, and the skull and suture material are inserted to secure it in place. Titanium plates and screws are also available for fixation of flaps. The craniotome or Midas Rex can be used for this purpose. During drilling a dura protector is used on the skull side. A brain spoon can serve as a dura protector. 14. Periosteum and muscle are approximated with #2-0 or 3-0 polyglactin 910 synthetic absorbable suture or #2-0 or 3-0 silk or Surgilon. The galea is closed with the same sutures as above. Skin closure can be interrupted or continuous and of silk or synthetic suture material, such as nylon, or skin staples.
what are the steps in performing an excision of an esophageal diverticulum?
1. incision is made over the inner border of the sternocleidomastoid muscle and is extended from the level of the hyoid bone to a point 2cm above the clavicle 2. the sac of diverticulum is freed and ligated 3. the pharyngeal muscle and surrounding tissues are closed 4. esophageal myotomy is often performed distally to the diverticulum. a myotomy seems to lessen the likelihood of recurrence
what are the steps in performing a thoracoabdominal incision?
1. it begins at a point midway between the xiphoid process and umbilicus and extends across to the 7th or 8th interspace and to the midscapular line 2. rectus and oblique muscles are divided in the line of incision down to the peritoneum and pleura 3. costal cartilage and diaphragm are then divided
RETICULOCYTES: NEWBORN
1.1 4.5%
magnesium
1.5-2.5
the normal position of the proximal femur is
10 to 15 degrees of anteversion.
The normal position of the proximal femur
10 to15 deg. Of anterversion
PT
10-15 seconds
BUN
10-20
Normal adult respiratory rate
12 -16 breaths per minute
(-)FERRITIN FEMALE
12-160 ng/mL
HEMOGLOBIN : FEMALE
12.0 15.2 gm/dL
CHOLESTEROL
120-200 mg/dL
HEMOGLOBIN (Hgb): MALE
13.2-16.2 gm/dL
hemoglobin
13.5 to 17.5 in male 12 to 16 and female, Iron- containing protein in red blood cells that transports oxygen from the lungs to the tissues of the body
SODIUM
135 145 mEq/L
sodium
135-145
(-)PLATELET COUNT
140 450 x 10^3/ uL
Platelets
150,000-400,000
(-) FERRITIN MALE
18- 250 ng/mL
In the diagram above, which of the noted incisions is designed for anterior access to the spleen, and avoids the cutaneous nerves and innervation to the rectus muscle? o 5 o 3 o 2 o l
2
WBC: monocytes (MONO)
2-12%
INR (warfarin therapy)
2-3 3.0-4.5 on warfarin
PHOSPHOROUS
2.4 4.5 mg/d L
phosphorus
2.5-4.5
what percentage of patients aquire a HAI?
20%
WBC: lymphocytes ( LYMP)
20-50%
TRASFERRIN
204- 360 mg/dL
Skeletal system is made up of how many bones?
206
BICARBONATE
22 26 mEq/L
PARTIAL THROMBOPLASTIN TIME (PTT)
23 32.5 seconds-also fibrinogen stats
Tourniquet pressure
250-300mmHg for the arm and lower leg, 300-350mmHg for the thigh.
(-)TOTAL SERUM IRON FEMALE
26-170 ug/dL
TOTAL IRON-BINDING CAPACITY (TIBC)
262-474 Hg/dL
In the diagram in question 3.8 above, which of the noted incisions would allow a single-layer fascial closure? o 5 o 3 o 2 o 1
3
The numder of lobes found in the right side of the chest
3
teniae coli
3 bands of longitudinal smooth muscles from the large intestines that fuse to form the rectum
Is the amount of time tha heparin is systemically distributed in an adult
3 minutes
URIC ACID
3.5 8.5 mg/dL
potassium
3.5-5.0
( ALBUMIN
3.5-5.2 g/L
ALBUMIN
3.5-5.2 g/L
The number of pairs of nerves
31
(-)HEMATOCRIT: CHILD
31-43%
WBC polymorphonuclear cells ( POLYS)
35-80%
(-)HEMATOCRIT: FEMALE
37-46%
TOTAL CK (creatine kinase?)
38- 120 ng/mL
ALKALINE PHOSPHATASE (ALP)
38-126 U/L
SSIs are the ________ most commonly reported HAI
3rd
How long should a patient be NPO prior to a surgery?
4-6 hours Clear liquids up to 2 hrs prior to surgery
RBC MALE
4.1 10.9 x 10^3/uL
()HEMATOCRIT (HcT): MALE
40-52%
In the diagram below, which of the noted incisions would avoid contact with the posterior rectus sheath? 1. Subcostal 2 Paramedian 3 Midline 4. McBumey 5. Plannenstiel 6. Transverse o 5 o 3 o 2 o 1
5
wound drains are usually removed within how many days of surgery
5
what are some procedural considerations with the Nissen Fundoplication?
5 stab wounds in abdomen expected discharge on second day post-op post op upper G I series to verify function of newly constructed anti-reflux valve patient discharged after X-rays general anesthesia N G tube and foley after induction and intubation supine or modified lithotomy
WBC
5,000-10,000
()ASPARTATE AMINOTRANSFERASE (AST) 5-35 U/L
5-35 U/L
The percentage accounts for all the deaths in head trauma accidents:
50%
TRIGLYCERIDE
50-199 mg/ dL
TOTAL PROTEIN
6.3-8.2 g/dL
The adult human body is approximately how much water?
60% 45% to 55 % elderly, 70% to 80 % in infants.
GLUCOSE
65-110 mg/dL
UREA NITROGEN (BUN)
7-21 mg/dL
ALANINE AMINOGRANSFERASE (ALT)
7-56 U/L
LIPASE
7-59 U/L
normal ph
7.35-7.45
(-)TOTAL SERUM IRON MALE
76-198 ug/dL
(-)RBC mean cell volume (MCV) FEMALE
78-101 fL
GAMMA-GLUTAMYLTRANSFERASE (GGT)
8-78 U/L
CALCIUM
8.4- 10.2 mg/dL
()RBC mean cell volume ( MCV) MALE
82-102 fL
what is a McBurney's incision?
8mm oblique incision muscle splitting incision use for removal of appendix
calcium
9-11
10. (-)PROTHROMBIN TIME (PT)
9.8-11.9 seconds
Normal adult pulse oximetry
95-100%
Normal Sp02 for a young, healthy individual
98% to 100%
What is a Billroth 1 gastrectomy?
A Billroth I gastrectomy is the resection of the diseased portion of the stomach through a right paramedian or abdominal anastomosis between the stomach and duodenum.
what is a billroth 2 procedure?
A Billroth II gastrectomy is a resection of the distal portion of the stomach through an abdominal incision and the establishment of an anastomosis between the stomach and jejunum
what is a McVay, or Cooper's, Ligament Repair?
A McVay, or Cooper's, ligament repair approximates transversalis fascia superior to the inferior insertion of the transversalis fascia along Cooper's ligament.
what is a cystocele?
A cystocele is a herniation of the bladder that causes the anterior vaginal wall to bulge downward. A defect in the anterior vaginal wall is usually caused by obstetric or surgical trauma, age, or an inherent weakness. A large protrusion may cause a sensation of pressure in the vagina or present a mass at or through the introitus; it may also cause voiding difficulties
Respondeat Superior
A doctrine under which a principal or an employer is held liable for the wrongful acts committed by agents or employees while acting within the course and scope of their agency or employment.
Res Ipsa Loquitur
A doctrine under which negligence may be inferred simply because an event occurred, if it is the type of event that would not occur in the absence of negligence. Literally, the term means "the facts speak for themselves."
moderate sedation analgesia
A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by minimal tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate.
Patient Self-Determination Act (PSDA)
A federal law that mandates that every individual has the right to make decisions regarding medical care, including the right to refuse treatment and the right-to-die
World Health Organization (WHO)
A group within the United Nations responsible for human health, including combating the spread of infectious diseases and health issues related to natural disasters.
procedural considerations for an anterior resection of the sigmoid color and rectosigmoidostomy
A laparotomy set and Gl instrument set are required. Linear stapling instruments as well as the end-to-end curved mechanical stapling instruments (EEA) are used. Long instruments for dissecting into the pelvis may be necessary. A rigid sigmoidoscope is utilized before patient preparation and after the anastomosis. A self-retaining retractor set is required. The patient is placed in a modified lithotomy position with legs extended into Allen universal stirrups. An indwelling urinary catheter is inserted before the abdominal and perineal preps. If there is an assisting surgeon, a table with a basic minor set and rectal instruments should be available to facilitate the end-to-end stapling of the anastomosis. Cross-contamination from the table of instruments utilized on the patient's rectum to the table of laparotomy instruments is prevented. A table with closure instruments may be the surgeon's preference. This should require only a laparotomy set of instruments. Identification of the ureters during extensive deep abdominal procedures may best be achieved by the preoperative placement of ureteral catheters by a transurethral approach. If the tumor is believed to involve the ureters, the surgeon may have consulted a urologist to perform the ureteral catheter placement at the start of the patient's scheduled procedure. Provision of transurethral endoscopes, supplies, and equipment is necessary.
what is a modified radical mastectomy and why is it performed?
A modified radical mastectomy is done to remove the involved area with the hope of decreasing the spread of the malignancy . This surgery's elliptic incision with lateral extension toward the axilla gives a good cosmetic result for plastic surgery reconstruction, provides good arm movement because the pectoralis muscles are not removed, and usually does not require a skin graft.
Indication for endo vascular AAA
A proximal infrarenal neck remnant of 1-2 centimeter
why is a a right hemicolectomy and ileocolostomy performed?
A right hemicolectomy and ileocolostomy are performed to remove a malignant lesion of the right colon and in some cases to remove inflammatory lesions involving the ileum, cecum, or ascending colon.
how is a rod or nail used in internal fixation?
A rod or nail is placed percutaneously in a large bone such as the humerus or femur.
isotonic solution
A solution with the same osmolality as blood plasma
discectomy
A surgical removal of the whole or a part of an intervertebal disc
What is fluid spacing?
A term used to classify distribution of body water
why is a transverse colectomy performed?
A transverse colectomy is performed for malignant lesions of the transverse colon. A more radical procedure may be required when the lesion has perforated the greater curvature of the stomach. If the entire lesion is respectable, a partial gastrectomy may also have to be performed.
why is a vaginal repair done?
A vaginal repair is done to correct a cystocele or a rectocele and to reestablish the support of the anterior and posterior vaginal walls, restoring the bladder and rectum to their normal positions.
Universal Protocol
A written checklist developed by the Joint Commission to prevent errors that can occur when physicians perform the wrong procedure, for example
what is an abdominoperineal resection?
Abdominoperineal resection is the mobilization and division of a diseased segment of the lower bowel through a midline incision. The proximal end of bowel is exteriorized through a separate stab wound as a colostomy . The distal end is pushed into the hollow of the sacrum and removed through the perineal route.
scoliosis
Abnormal lateral curvature of the spine
8th cranial nerve responsible for hearing and balance, also known as the vesstibulocochlear nerve
Acoustic nerve
the eighth cranial nerve responsible for hearing and balance, also known as the vestibulocochlear nerve.
Acoustic nerve:
a benign, slow growing tumor that forms on the sheath of the eighth cranial nerve. This tumor can cause hearing loss, balance problems, and facial paralysis.
Acoustic neuroma:
what is a shouldice repair?
Again, the approach to the hernia is the same as previously described, but in the Shouldice repair a double layer of transversalis fascia is sutured to the inguinal ligament. It is reinforced by a layer of internal oblique muscle and conjoined tendon approximated to the undersurface of the fascia of the external oblique. Proponents of this repair have reported very low recurrence rates in a large series of patients. Although the Shouldice repair is controversial, it remains an alternative for surgeons who have studied the technique.
Colloid solutions include
Albumin Purified protein factors Dextran Hetastarch
used to test blood supply to the hand & evaluate the potency of the radial & ulnar arteries
Allen's
why is an abdominoperineal resection performed?
An abdominoperineal resection is performed for malignant lesions and inflammatory diseases of the lower sigmoid colon, rectum, and anus that are too low for the use of EEA stapling devices.
Root Cause Analysis
An analytical technique used to determine the basic underlying reason that causes a variance or a defect or a risk. A root cause may underlie more than one variance or defect or risk.
what is an enterocele?
An enterocele is a herniation of Douglas's cul-de-sac and almost always contains loops of the small intestine. An enterocele herniates into a weakened area between the anterior and posterior vaginal walls.
A bulge or weakening of an artery wall
Aneurysm
a coil-spring device made of titanium used to treat aneurysms
Aneurysm clip:
A type of xray that takes pictures of blood vessels with the help of dye injected via catheter
Angiogram
tough fibrous outer wall of an intervertebral disc.
Annulus (annulus fibrosis):
a strong fibrous ligament that courses along the anterior surface of the vertebral bodies from the base of the skull to the sacrum
Anterior longitudinal ligament (ALL)
what is an anterior resection of the sigmoid colon and rectosigmoidostomy?
Anterior resection of the sigmoid colon and rectosigmoidostomy involve the removal of the lower sigmoid and rectosigmoid portions of the rectum. This is usually done through a laparotomy incision, and an end-to-end anastomosis is completed.
The most common site of perforation of a peptic ulcer
Anterior surface of the first portion of the duodenum
one of three membranes that surround the brain and spinal cord; the middle web-like membrane
Arachnoid mater:.
Used during retinal surgery
Argon laser
Maintained at less than 90-degree angle to prevent branchial plexus stretch.
Armboards
a congenital disorder in which there is an abnormal connection between arteries and veins without an intervening capillary.
Arteriovenous malformation (AVM):
Most common tumor found in the cerebellum of children and adultson common primary brain tumor
Astrocytoma
a tumor arising from the supportive cells of the brain called astrocytes
Astrocytoma:
Foramen Ovale:
At the base of the skull the foramen ovale is one the larger of the several holes
Warning that a seizure may be eminent, the beginning of a seizure
Aura
Graft material gained from patients own bone (liac common)
Autogenous graft
Bone obtained from a tissue bank
Autograft (Allograft)
parkinsons
Autoimmune disease with depletion of dopamine, what disease is due to a problem with (nucleus)basal ganglia and specifically the substria nigra
Hip fractures
Avascular necrosis and degenerative changes can occur as a result of diminished blood supply to the femoral head.
a long process of the nerve cell (neuron) that carries nerve impulses away from the cell body to other nerve cells.
Axon:
What are the requirements for a patient to be eligible for bariatric surgery?
BMI of 40 or greater if no coexisting medical problems BMI of 35 or greater with comorbidities such as type II diabetes, hypertension, hyperlipidemia, or OSA
Steam sterilization process, with implantable devices should be run with biological indicators should contain
Bacillus stearothermophilus
Neural compression remains the major indication for disk excision.
Back pain
preventing recurrence of dislocation, reducing arthritic changes, restoring joint motion
Bancart procedure
masses of gray matter located deep within the cerebral hemisphere
Basal ganglia:
Fractures in this area of the skull are most common
Base
Stage 2 of anesthesia
Begins with the loss of consciousness and ends with the onset of regular breathing and loss of eyelid reflexes. This is referred to as the excitement of delirium phase because it is often accompanied by involuntary motor activity. The patient must not receive any auditory or physical stimulation during this period because it can stimulate a release of catecholamines, which can raise heart rate and blood pressure.
Implant manipulation
Bending implants to conform to bone should be avoided as it does weaken the implant, if it is, never straighten it. Fixation devices should never be reused.
Non cancerous tumor that grows slowly, does not invade nearby tissues or spread, and has distinct boundaries is considered what?
Benign
BIS
Bispectral Index System (analyzes relationship and frequency of brain signals) (0-100) 40-60 is normal
varus
Bowed leg, force from the inside (medial aspect) the knee, forcing the knee outward (laterally)
Direct inadvertent stimulation of the Vagus nerve auring carotid endarterectomy may have which of the following transient affects: Bradycardia Tachycardia Alkalosis Acidosis
Bradycardia
Direct inadvertent stimulation of the Vagus nerve auring carotid endarterectomy may have which of the following transient affects: Bradycardia Tachycardia Alkalosis Acidosis
Bradycardia
Connects the upper brain to the spinal chord,responsible for autonomic functions such as breathing and heart rate
Brainstem
connects the upper brain to the spinal cord; responsible for autonomic functions such as breathing and heart rate.
Brainstem:
spinal tumors
Breast, lung, prostate, renal, gastrointestinal, and thyroid carcinomas, lymphomas, and multiple myelomas frequently metastasize to the lumbar spine.
The fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis is known as the: o Pelvic ligament. o Round ligament. o Broad ligament. o Poupart's ligament.
Broad ligament
area that usually occurs in the left cerebral hemisphere and coordinates the complex muscular movements assoc. with speech.
Broca's area:
found in the third left frontal fold of the brain
Broca's fissure:
is a soft tissue or bony mass at the medial side of the first head
Bunion (Hallux valgus)
connects the brain's insula and the inner surface of the operculum
Burdach's fissure:
a small dime-sized hole made in the skull.
Burr hole:
a capnometer measures what?
C02 concentration
what does a capnograph provide a continuous display of?
C02 concentration of gases from the airways
Computerized axial tomography, xray beam that moves back and forth across the bodyto project sross sectional images
CAT Scan
imaging method that uses x-rays, same as an "x- ray" image but x-rays are directed from many different angles through a cross-section of the body, also called CT scan, x-rays of the brain from many different angles; only shows structure, not activity
CAT scan
Optic Nerve sensory
CN II, Either of the pair of sensory nerves that comprise the second pair of cranial nerves, arise from the ventral part of the diencephalon, form an optic chiasma before passing to the eye and spreading over the anterior surface of the retina, and conduct visual stimuli to the brain.
Trochlear Nerve motor
CN IV, efferent, voluntary motor: Superior oblique muscle of eyeball. test: downward and lateral gaze; smallest cranial nerve
Glossopharyngeal Nerve both Facial
CN IX, Motor to pharynx; sensory from taste buds
Oculomotor Nerve motor
CN IlII: (motor) controls eye movement; raises eye lids, Levator palpebrae superioris- innervation
Trigeminal Nerve both
CN V, sensory for the face, motor fibers for chewing muscles, the chief nerve of sensation for the face and the motor nerve controlling the muscles for chewing., *3 divisions ophthalmic, maxillary, and mandibular
Abducens Nerve motor
CN VI, mixed (mainly motor), sensory function: proprioception, somatic motor function: movement of the eyeball, which supplies the lateral rectus muscle of each eyeball, responsible for turning the eye outwards.
Facial Nerve both
CN VII, What supplies taste to the anterior 2/3 of the tongue?, Controls muscles of facial expression; carries sensation of taste; stimulates small salivary glands and the lacrimal (tear) gland
Vestibulocochlear Nerve(Acoustic Nerve) sensory
CN VII, sensory for balance and hearing, Ear nerve that splits into two smaller nerves
Intervates the heart
CN X
Vagus Nerve both
CN X, The cranial nerve with sensory and motor functions controlling the heart, blood, vessels, and organs of the viscera is the
Forms the soft spongy marrow
Cancellous Bone
Threads are broader and run half the length of the screw.
Cancellous bone screw
what are some procedural considerations of the radical hysterectomy?
Careful estimation of blood loss and calculation of urinary output are needed throughout the operative procedure. The patient is prepped as described for total abdominal hysterectomy. An indwelling urinary catheter is inserted. The basic abdominal gynecologic instrument set is required, plus long and deep instrumentation and a self-retaining retractor may be used.
Results from entrapment of the median nerve on the volar surface of the wrist
Carpal tunnel syndrome
A layer of elastic tissue that forms at the ends of bones. It is anueral, alymphatic, and avascular, but high is water content
Cartilage
the bundle of nerves at the end of the spinal cord that supply the muscles of the legs, bladder, bowel and genitals.
Cauda equina:
neuroglia
Cells that support, insulate, and protect neurons. These cells are able to divide and are usually involved in brain tumors., Cells that *nourish, support, insulate, and protect* neurons
neurons
Cells that transmit electrical message from one area of the body to another area., A nerve cell; the basic building block of the nervous system.
A lysis of bone around the prosthesis casuing early loosening. Porous coating is an attempt to stop it.
Cement disease
part of the brain responsible for balance and muscle control for movement
Cerebellum:
is a narrow channel in the midbrain connecting the third and fourth ventricles.
Cerebral aqueduct
an operation in which a surgeon creates a new pathway for the movement of fluids and/or other substances in the brain.
Cerebral bypass:
a clear fluid produced by the choroid plexus in the ventricles of the brain.
Cerebrospinal fluid (CSF):
an insufficient blood flow to the brain.
Cerebrovascular insufficiency:
the neck portion of the spine made up of seven vertebrae.
Cervical:
Is a displacement and herniation into the cervical canal of the cerebellum
Chiari malformation
The primary ECF anion is
Chloride
a rare, slow growing, benign tumor arising at the base of the skull, especially in the area near the pituitary gland.
Chondroma:
a rare, malignant bone tumor that grows from cartilage cells.
Chondrosarcoma:
a rare, bone tumor arising from primitive notochord cells; usually occurs at the base of the spine (sacrum) or at the skull base (clivus).
Chordoma:
digested food and enzymes are turned into this before entering the small intestines
Chyme
An important anastomosis of four arteries that supply blood to the brain
Circle of Willis
Symptoms is cramping
Claudication
An injury to the ulnar nerve could cause
Claw hand
found in the inferior temporal lobe of the brain
Clevenger's fissure:
brain injury from an external impact that does not break the skull
Closed head injury:
Patients who developed fever,abdominal pain and, profuse diarrhea, most frequent antibiotics associated enterecolitis
Clostridium difficile
a procedure, performed during an angiogram, in which platinum coils are inserted into an aneurysm.
Coiling:
found in the inferior surface of the cerebrum.
Collateral fissure
a state of unconsciousness from which the person cannot be aroused;
Coma:
balanced anesthesia
Combination of IV drugs and inhalation agents used to obtain specific effects
Antibiotic irrigation
Common anitbiotics include polymyxin and bacitracin
Contraindications for tourniquet use
Compartment syndrome, McArdle disease, hypertension, or other vascular problems.
Desired effect of cancellous screw
Compression
widespread injury to the brain caused by a hard blow or violent shaking,
Concussion:
"Surgical neck" of the Humerous
Constriction below the greater and lesser tuberosities
what are the contraindications of vaginal hysterectomy?
Contraindications to a vaginal approach are (1) when a large uterine tumor is present, (2} in pelvic malignancy because of an associated inflammatory process involving the fallopian tubes and ovaries , and (3} the possibility of missing metastatic disease that might be present.
somatic nervous system
Controls voluntary muscle movements. Motor cortex of the brain sends impulses to here, which controls the muscles that allow us to move. skeletal nervous system
Purpose is to supply oxygen and nutrients and removes metabolic waste from the myocardium
Coronary circulation
The cerebral hemispheres are connected by a deep bridge of nerve fibers called what?
Corpus Collosum
Forms the hard outer shell of bone
Cortical Bone
Have threads that are closer together, narrow, and run the entire length of the screw.
Cortical bone screws
Drug that paralyzes the spincter muscle of the iris
Cycloplegics
problems associated with fluid and electrolyte imbalance during surgery
DFV deficient fluid volume, water imbalance, and potassium imbalance
Subluxation
Defined as partial or incomplete dislocation
Healing has not occurred within the average time
Delayed Union
Muscles that stabilize the shoulder joint?
Deltoid, pectoralis major, teres major, and lattissimus dorsi
what anesthetic agent is unique, in that, it boils at 22.8 degree Celcius, near room temperature and its vapor pressure approximates atmospheric pressure?
Desflurane (Suprane)
is patients whose diagnosis cannot be determined by history or physical exam. Or whose CT or MRI finding are inconclusive.
Diagnostic arthroscopy
Shaft long bones
Diaphysis
This is the central part of the brain, (contains the hypo-thalamus)
Diencephalon
Common fuel source for surgical fires.
Disposable drapes
Type-A extra-articular, Type-B single condyle fracture, Type-C combination of both
Distal femoral fractures
bilroth 2 or gastrojejunostomy
Distal gastrectomy combined with GI reconstruction to connect the gastric remnant to the jejunum via end-to-side or an end-to-end anastomosis Addresses gastric lesions extending proximal to the antrum
steps in the operative procedure for mitral valve replacement
Double venous cannulation is used. 1. The aorta is cross-clamped, and cardioplegic solution is infused through the aortic root or, more commonly, retrograde through the coronary sinus. 2. The left atrium is incised along the interatrial groove to expose the mitral valve. 3. The valve is assessed, and the anterior leaflet is excised. The posterior leaflet is often retained to enhance the ventricular configuration and postoperative function. Occasionally the anterior leaflet is retained. Rongeurs may be used to debride heavy calcification; loose debris is removed. A margin of the valve annulus is retained to insert fixation sutures to the prosthesis. 4. A valve sizer is used to determine the correct size of the prosthesis, which is delivered to the field. 5. Nonabsorbable cardiovascular sutures (15 to 20) are placed in the retained margin of the valve and then placed into the sewing ring of the prosthesis. 6. The sutures are held taut (and moistened) as the prosthesis is guided into position and secured, and the sutures are tied and cut. 7. Continuous nonabsorbable sutures are used to partially close the atriotomy. The patient is placed in reverse Trendelenburg's position, and the lungs are inflated to remove air from the pulmonary veins and atrium. Air is aspirated from the left ventricle through a hypodermic needle or vent catheter, and the atrial closure is completed.
A choledoco-duodenostomy refers to the surgical anastomosis of which of the following two structures: o Gall bladder with the common bile duct o Common bile duct and fundus of the stomach o Duodenum and common bile duct o Pancreatic duct and antrum of the stomach
Duodenum and common bile duct
the outermost layer of the meninges
Dura:
4 procedures to diagnose GERD
EGD barium swallow 24 hr esophageal PH monitoring esophageal manometry to rule out other causes of gastric reflux such as esophageal motility disorders
spica cast
Encircles the waist and extends to the ankles or toes
active transport
Energy-requiring process that moves material across a cell membrane against a concentration difference
cerebral spinal fluid
Ependymal cells, Cushions brain & spinal cor, Your body produces 2 cups a day, replaced every 8 hours. Functions as a cushion, diffusion of gases, waste, and nutrients, and your brain floats in this fluid.
An uncontrolled discharge of neurons within the brain would define
Epilepsy
Separates epiphysis and diaphysis of long bones. Is considered the growth plate in children and can cause malformation if fractured as a kid.
Epiphyseal Plate
4 complications of GERD
Esophagitis, ulceration, Barrett's esophagus, respiratory issues such as asthma and bronchitis, pneumonia dental erosion
What is second spacing?
Excess accumulation of interstitial fluid (edema)
Back surgery caution
Excessive ECU should be avoided to decrease the risk of injury to the sympathetic nerves.
How does the blood bank know if blood is safe to re-issue?
External blood bag thermometers
Most common causes of Bell's Palsy damage to this nerve
Facial
The Chief artery of the face (arises from the carotid) is
Facial
Fluids and electrolytes move between ICF and ECF spaces to
Facilitate body processes such as: acid-base balance tissue oxygenation response to drug therapies response to illness
Zenker's diverticulum
False diverticulum . Herniation of mucosal tissue at Killian's triangle between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor
The cranium is thinner in these patients
Females
Healing occurs when tissue is clearly incised and reapproximated and repair occurs without complication in
First intention
Anatomical landmark that separates the frontal and parietal lobes and is clinically important because its anterior convolution contains the center for ipsilateral motor control
Fissure of Rolando
separates the frontal and parietal lobes of the brain from the temporal lobe.
Fissure of Sylvius:
a deep groove in the brain
Fissure:
Dye used in opthalmic surgery to diagnose corneal abrasion
Floresium sodium
The most common ovarian cyst
Follicular
The medulla oblongata passes through what opening in the skull.
Foramen magnum
The medulla oblongata passes through what opening the skull.
Foramen magnum
is a large opening in the occipital bone of the cranium. It is one of the several oval or circular apertures in the base of the skull (the foramina),
Foramen magnum:
one of several foramina located in the base of the skull, on the sphenoid bone, situated lateral to the foramen ovale, in a posterior angle.
Foramen spinosum
Applies to the doctrine which provides proximate cause in negligence, which states that something similar was likely to happen in a different situation under similar circumstances
Forseeability
forseeability
Forseeability of harm is central to the issue of whether a person's conduct breached the standard of reasonable care. An actor is negligent only if his conduct created a forseeable risk and the actor recognized, or a reasonable person would have recognized, that risk. Where a reasonable person in the defendants circumstances would not forsee any danger, then the defendant is simply not negligent.
are more common than in any other major bone. Presence of proximal and distal hinge joints allow no adjustment for rotational deformity so care need to be taken in repair. Closed IM nail is treatment of choice
Fractures of tibia
what fractures can be more effectively treated using the open reduction internal fixation method?
Fractures that are comminuted or difficult to reduce
If coagulopathy is an issue what should be considered?
Fresh frozen plasma (FFP) platelets Cryoprecipitate
This skull bone has a lobe of the brain underneath with the same name
Frontal, Temporal, occipital
Potts fx
Fx of thr fibula near the ankle
most common complications of Meckel's diverticulum
GI bleeding intussusception obstruction strangulation diverticulitis volvulus
most common complications of a Meckel's diverticulum
GI bleeding, followed by intussusception, obstruction, strangulation, diverticulitis, and volvulus
instruments that deliver double or triple rows of closely spaced, staggered insert staples, and are designed for both open or laparoscopic use designed to approximate tissue while preserving blood supply to tissue edges
GI linear and circular stapling devices
GERD
Gastro esophageal reflux disease, A condition causing a backflow of stomach acid through an incompetent esophageal sphincter is called
Fracture bed
Generally used for femoral neck and shaft fixation
This fossa contain the hypophysis or pituitary
Glabella
What is the standard procedure for operative management of a perforated peptic ulcer?
Graham patch closure
standard procedure for operative management of a perforated peptic ulcer
Graham patch closure
Fracture of c3 to c5 can increase what?
Great risk of respiratory difficulties
Torus fx
Greenstick fx
Replacement of adrenal steroid therapy is usually required, diabetes may result, cessation of menses may result
HYPOPHYSECTOMY
an abnormal flexion posture of the proximal interphalangeal joint of one of the four lesser toes.
Hammer toe
Nonunion
Healing has ended without producing a bony union. Bone growth stimulators can be used in patient that have a high risk of nonunion.
Normal adult heart rate
Heart Rate: 60-99 beats per minute
Symptoms of GERD
Heartburn, regurgitation, and dysphagia. less common symptoms are chest pain, hypersalivation, painful swallowing
Radiation, evaporation, and conduction
Heat loss from body
most common technique of pyloroplasty
Heineke-Mikulicz pyloroplasty
Most commonly performed technique of pyloroplasty
Heineke-Mikulicz pylroplasty
Bone healing process
Hematoma formation, Fibrin plug formation, invasion of osteoblasts, callus formation, then remodeling.
What are the serious complications of Roux-en-Y gastric bypass surgery?
Hemorrhage, anastomotic leaks, pulmonary embolism, pneumonia, infection, small bowel obstructions or stenosis, and incisional hernia.
During lap chole it is important to isolate the following ligaments, comon bile duct, hepatic artery, portal vein (porta hepatis.)
Hepatoduodenal
Direct hernia occurs
Hesselbachs triangle
what is an esophageal hiatal hernia repair and anti-reflux procedure?
Hiatal herniorraphy performed to restore cardio esophageal junction in its correct anatomic position in the abdomen, to secure it firmly in place, and to correct gastroesophageal reflux
where the pons is located
Hindbrain:
a fissure that extends from the brain's corpus callosum to the tip of the temporal lobe.
Hippocampal fissure:
Hodgkins
Hodgkin's disease= cancer of lymph is very curable in early stage.
Increase amount of CSF
Hydrocephalus
Abnormally large magnesium content of the blood plasma
Hypermagnesemia
Signs of blood transfusion reaction
Hyperthermia Increased intraoperative bleeding Weak pulse Hypotension Visible hemoglobinuria Vasomotor instability Greatly decreased or no urinary output
deficient calcium in the blood, Positive Trousseau (tetany, seen most often) & chovtek Signs (hyperactivity of muscles), Hypoparathyroidism, lack of vitamin D; chronic renal failure;, treated with gluconate, Tums, intravenous calcium
Hypocalcemia
plays a key role in maintaining hemostasis
Hypothalamus:
The optic nerve is listed as
I
3 types of general anesthesia
I.V. technique inhalation technique with a volatile anesthetic agent combination of I.V. and inhalation technique
Name the 4 routes of administration of pre-op medications
IM IV Intranasal P.O. (oral)
Why would whole blood be given?
If the patient has an acute, massive loss (1/3 of circulating volume or 1500 mL for an adult)
Fires and explosions can and have happened in the OR. What are the typical components that precipitate such an event?
Ignition source/heat Fuel Oxygen
Alloys used most frequently include stainless steel, cobalt-chromium, and titanium-vanadium aluminum
Implant material
what is the difference between a congenital hernia and an acquired hernia?
In a congenital hernia, the hernia sac has a small neck , is thin walled, and is closely bound to the cord structures. In an acquired indirect hernia the neck is wide, and the sac is both short and thick walled.
Putting a patient into Trendelenberg position has the effect of: o Decreasing blood flow to the brain o Decreasing blood flow to the coronary arteries o Increasing blood flow to the brain o Increasing blood flow to the coronary arteries
Increasing blood flow to the brain
where are indirect hernias located?
Indirect hernias leave the abdominal cavity at the internal inguinal ring and pass with the cord structures down the inguinal canal. Consequently the indirect hernia sac may be found in the scrotum. Indirect hernias may be either congenital, representing a persistence of the processus vaginalis ,or acquired .
Bone healing sequence
Inflammation, cellular proliferation, callus formation, ossification, remodeling
Tourniquet intervals
Inflation and deflation should be 5min every 30min to minimize effects on muscles and nerves.
Lapx inguinal hernia landmarks
Inguinal ring, inferior epigastric vessel and spermatic vessels
Intentionaly causing harm
Intentional tort
The uterine artery is a most commonly a direct branch of the: o Internal iliac artery o External iliac artery o Common iliac artery o Gonadal artery
Internal iliac artery
is a communication between the lateral and third ventricles.
Interventricular foramen
Preferred fixation device of femoral shaft fracture
Intramedullary Rod (IM)
what is the preferred method of treatment for femoral shaft fractures and why?
Intramedullary fixation devices Intramedullary nails and rods increase the load sharing of the bone, making the implant less likely to fracture. Bone healing requires a load across the fracture site to promote osteosynthesis and prevent refracture.
CUSA
Irrigation and aspiration instrument that uses variable ultrasonic energy to remove tumor tissue without disrupting normal structures
Splenomegaly
Is the most common physical identifiable pathology of portal hypertension
what is a total gastrectomy?
It is the complete removal of the stomach and establishment of an anastomosis between the jejunum and the esophagus. It may include an enteroenterostomy, if indicated
is an opening formed by the jugular notches on the temporal and occipital bones.
Jugular foramen
valgus
Knock Knees
Dissection of the lateral peritoneal attachments of the duodenum to allow inspection of the duodenum, pancreas and other structures
Kocher Manuever
The level spinal cord terminate
L1-L2
what solution can help correct intraoperative third space fluid losses?
Lactated ringers
what three approaches are used to reach the spinal cord and its adjacent structures to treat compression fracture , dislocation , herniated nucleus pulposus, and cord tumor, as well as for spinal cord stimulation and insertion of infusion pumps for pain control?
Laminectomy, hemi-laminectomy , and the interlaminar approach Laminectomy is also done to insert subarachnoid shunts for hydrocephalus or pseudotumor cerebri.
Where is Thoracodorsal nerve located and what does it innervate?
Lateral to the long thoracic nerve and intervates the latissimus dorsi muscle
Position used for total hip arthroplasty?
Lateral. Pad anterior and posterior at umbilicus and lumbar regions. Use bean bag if preferred
Position used for total hip arthroplasty?
Lateral. Pad anterior and posterior at umbilicus and lumbar regions. Use bean bag if preferred.
Fx between the maxillary & orbital floors & may involve the medial & lateral walls of the maxillary sinuses & the pterygoid process of the sphenoid
Le Fort I
A horizontal fracture of the maxillae is termed
Le fort I
Normal adult blood pressure
Less than 120mmHg systolic and less 80mmHg diastolic
what is a major concern during carotid endarterectomy?
Lessening the likelihood of any transient or permanent neurologic deficit
Bands of connective tissue that hold bone to bone. Provide stability to a joint.
Ligaments
Ligament that connects femoral head to acetablum
Ligamentum teres
it is responsible for distinguishing between favorable or unfavorable outside stimuli
Limbic system:
Surgical position where obturator nerve can be injured if the legs are improperly fixed
Lithotomy position
lobectomy
Lobectomy is excision of one or more lobes of the lung. -It is performed to remove metastatic involvement when the tumor is peripherally located and hilar nodes are not involved. -Other conditions affecting the lung and resulting in lobectomy might be bronchiectasis, giant emphysematous blebs or bullae, large centrally located benign tumor, fungal infections, and congenital anomalies. -Lesser consideration is given for lobectomy of the middle lobe because of bronchial division involvement.
When opening the aneurysmsal sack during resection of abdominal aortic aneurysm (AAA) the artery ligated
Lumbar
MRI
Magnetic resonance imaging, a technique that uses magnetic fields and radio waves to produce computer-generated images of soft tissue
Fracture healed with a deformity that may cause impairment of function, and possibly angulation.
Malunion
Triangle of Calot
Margins: edge of the liver, hepatic duct and cystic duct; cystic artery can be found here; nice of Lund is also found here
Cancellous grafts
May be taken from the ilium, olecranon, or distal radius
Cortical grafts
May be taken from the tibia, fibula, iliac crest, or ribs.
Muscle splitting incision used for removal of appendix tri
Mcburney
Midazolam (Versed)
Medication administered pre-operatively to relieve apprehension and to provide amnesia
the structure that extends from the level of the foramen magnum to the pons
Medulla oblongata:
HCT (hematocrit)
Men: 42-52% Women: 36-48% Volume of packed cells in whole blood
The smallest part of the brain
Midbrain
the corpora quadrigemina is located on the dorsal side of this
Midbrain:
what can greatly decrease the amount of surgery needed in the case of some revisions of total hip replacements?
Modular components, such as a polyethylene cup that snaps into a metal acetabular shell
Somatosensory Evoked Potentials (SEPs)
Monitoring that may be used during some neurosurgery to assess the integrit of the spinal cord during surgery in which the spinal cord is manipulated
Femoral neck fx occurs just below the ball and socket hip joint
Monteggia fx
ASA P5
Moribund, not expected to survive 24 hrs with or without operation (surgery done as a last recourse or resuscitative effort)
Osmosis
Movement of a fluid through a semi-permeable membrane from a solution that has a lower solute concentration to one that has a higher solute concentration
Diffusion
Movement of molecules from an area of higher concentration to an area of lower concentration.
Drugs used to facilitate intubation and provide good operating conditions at lighter planes of anesthesia
Muscle relaxants NMBD's or neuromuscular blocking drugs
a defect of the CNS which contains a hernial sac containing a portion of spinal cord, meninges and CSF fluid.
Myelomeningocele:
Condition characterized by dead tissue areas in the myocardium
Myocardial infarction
Crystalloid solutions include
NS and LR
Pressure injuries include what?
Nerve compression (peroneal and lunar nerves) Nerve stretching (brachial plexus) Pressure ulcers (coccyx, back of head, heels)
NMS
Neuroleptic malignant syndrome
what are the three most frequently performed anti-reflux procedures?
Nissen Hill Belsey Mark 4
what procedures other than the Nissen Fundoplication has been developed for the management of GERD?
Nissen Rosetti fundoplication Toupet operation Lind technique Thai fundoplication Belsey Mark 4 procedure Watson technique
What is first spacing?
Normal distribution of fluid in extracellular and intracellular compartments
What gas hoses are attached to the anesthesia machine (by color)?
O2 (green) N2O (blue) medical air (yellow) connectors are specific so they cannot be cross-connected
anesthesia machines have what two cylinders on them?
O2 and N2O
The bone at the inferior base of the skull is
Occipital
found between the occipital and parietal lobes of the brain.
Occipitoparietal fissure:
Signs of cardiac ischimia most likely happened during mitral valve replacement
Oclusion of the circumflex arter y
12 cranial nerves Ohh, Ohh, Ohh, To Touch And Feel Vaginas Gives Victor A Harden
Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear (Auditory), Glossopharyngeal, Vagus, Accessory, Hypoglossal
is for patients presenting with an intra-articular abnormality ligamentous injury.
Operative arthroscopy
PREMIUM NON NOCERE
Or first do no harm
AORN association of perioperative registered nurses
Organization that facilitates the management, teaching, and practice of perioperative nursing.
make sure patients have discontinued all anti inflammatories 2 weeks prior to surgery.
Ortho pre-op evaluation
Pelvic girdle is composed of ilium, ischium, and pubis
Os coxae, or innominate bone
Pelvic girdle is composed of ilium, ischium, pubis
Os coxae, or innominate bone
Bone cells that initiate bone formation
Osteoblasts
Bone cells that break down bone.
Osteoclasts
Bone cells that make up 90% of all cells in the body, and maintain bone.
Osteocytes
Metabolic bone disease that results in inadequate mineralization of bone as a result of Vitamin D deficiencies.
Osteomalacia
Metabolic disease characterized by excessive loss of calcified matrix bone mineral (calcium or VitaminD) causing reduction in bone mass. Its the most common and accounts for 2mil fractures a year.
Osteoporosis
Usual oxygenation source for fires in surgery
Oxygen or oxygen-nitrogen composition such as nitrous oxide administered by prong or mask.
what method of pain relief provides consistent pain control for the first !-3 days after surgery?
PCA (patient controlled analgesia)
Measurement of the amount of bicarbonate in arterial blood
PaCo3
Tucking arms at the sides
Pad the elbows to protect from ulnar nerve damage
Rapid disorganized bone remodeling from osteoclast and blast activity.
Paget Disease
The superior mesenteric artery provides primary blood supply for which of the following structures: o Esophagus o Pancreas o Stomach o Spleen
Pancreas
The defect when both direct and indrect hernias are present
Pantaloon Hernia
The connective tissue between the patella and the tibial tuberosity in the knee facilitates quadriceps muscle contraction across the knee joint. What is this structure? o Patellar Ligament o Quadriceps Tendon o Vastis Lateralis o Vastis Medialis
Patellar Ligament
Most common autogenous graft used in ACL repair.
Patellar tendon
ASA P6
Patient declared brain dead whose organs are being removed for donor purposes
ASA P3
Patient with severe systemic disease that limits activity, but is not incapacitating
who should receive a total knee replacement?
Patients with severe destruction of the knee joint resulting from degenerative rheumatoid or traumatic arthritis or destruction of only the medial or lateral compartments of the knee joint as a result of extreme varus or valgus deformity complain of pain and instability.
Type A- stable, Type B-rotationally unstable, but vertically stable, Type-C- Both rotationally unstable and vertically unstable.
Pelvic fracture classifications
The craniotome uses this attachment to drill bone.
Perforator
The layer of connective tissue that covers all bone. Contains arteries for nourishment of bone cells.
Periosteum
A "foot drop" results from insufficiency of the extensor muscles the foot, and may be caused by lumbar disc herniation (damage to nerve root in the lumbar spine), or damage to/compression of the nerve as it courses superficial to the fibular head. peroneal pudendal posterior tibial sural
Peroneal
The primary ICF anion is
Phosphate
The muscle serving as a valve to prevent regurgitation of blood from the intestine back into the stomach
Piloric sphincter
how are pins used in internal fixation?
Pins can be placed percutaneously to fix fractures involving the digits, wrist, elbow, and foot.
what is used for fixation of femoral neck fractures?
Pins of various designs, such as Knowles and Hagie pins and universal cannulated screws
sacral plexus
Piriformi, sciatic nerve, supplies the buttocks, perineum, and lower limbs
During aposterelateral approach for intravascular hip fx, is released along with the short external rotators & capsule from the femur a single muscucapsular flap
Piriformis
How is an upper inverted U abdominal incision closed?
Placement of interrupted sutures in the peritoneum and anterior and posterior rectus sheaths muscle and fat need not be sutured skin edges are approximated and closed using suture or mechanical staple applier according to surgeon preference
Most likely etiology of pulmonary infections in a patient with Aids
Pneumocystis carini
What are the modifications of the Billroth 2 procedure?
Polya and Hofmeister operations, which also establish G I continuity through bypassing the duodenum
Bone Cement
Polymethylmethacrylate (PMMA) Used in total joints
The junction of the superior mesenteric and splenic veins forms
Portal vein
Physiologic consequences of an RSI
Possible infection Obstruction Fistula formation Perforation Consequent pain, suffering or death Need for additional surgery
Treatment of Scoliosis
Posterior spinal fusion with Harrington rods. Luque segmental spinal rod procedure, Cotrel-Dubousset system procdure, and Texas scottish rite hospital crosslink system
The primary ICF cation is
Potassium
Anticholinergic (atropine or glycopyrrolate)
Pre-operative med used to prevent bradycardia in pediatric patients to control secretions in patients undergoing oropharyngeal procedures or to control cardiac reflex that may cause bradycardia
(Or first do no harm) is a statement that guides a physician in the care of a patient
Premium non nocere
normal saline or lactated ringers administered intravenously does what?
Prevents the shift of fluid and electrolytes from intracellular compartments.
Best method of managing blood loss during a traumatic liver injury or hepatic resection, via intermittent vascular occlusion of the portal triad
Pringle Maneuver
what can happen if femoral shaft fractures are not managed appropriately?
Prolonged immobility ,with its attendant complications , and disability can result
The sphincter at the junction of the small and large intestines
Pyloric sphincter
Gastric drainage procedure that widens the pylorus to allow greater egress of stomach contents into the duodenum
Pyloroplasty
Location to repair a fx of distal radius
Radial
why is a radical hysterectomy done?
Radical abdominal hysterectomy is performed in the presence of cervical carcinoma, with or without attendant radiation therapy. Abdominal exploration determines lymph node involvement. With no lymph node involvement, a wide-cuff hysterectomy is performed. The uterus, tubes, and ovaries, together with most of the parametrial tissues and the upper portion of the vagina, are dissected en bloc. Dissection of the ureters from the paracervical structures takes place so that the ligaments supporting the uterus and vagina can be removed. Radical abdominal hysterectomy can also be used in certain cases of endometrial carcinoma.
what is a right hemicolectomy and ileocolostomy?
Right hemicolectomy and ileocolostomy involve the resection of the right half of the colon-including a portion of the transverse colon, the ascending colon, and the cecum-and a segment of the terminal ileum and mesentery. An end-to-end, side-to-side, or end-to-side anastomosis is done between the transverse colon and the ileum.
Chamber of the heart ejects deoxygenated blood into the pulmonary artery for oxygenation by the lungs
Right ventricle
thawed cryo and platelets must be maintained at what temp?
Room temp 22 deg Celsius
Most occur through the insertion of the tendenious fibers of the supraspinatus muscle that attaches to the greater tuberosity.
Rotator cuff tears
What is a Laparoscopic Roux-en-Y Gastric Bypass surgery?
Roux-en-Y gastric bypass (RYGB) is a largely restrictive and mildly malabsorptive procedure that reroutes the passage of ingested food and fluid from a small pouch created with surgical staples or sutures in the proximal stomach to a segment of the proximal jejunum.
Removal of diseased portion of rt colon, bowel continuity is reestablished by anastamosis between colon and ileum, ileum anastamosed to transverse colon
Rt Hemicolectomy
Hernia
Rupture
What is SBAR?
S: Situation B: Background A: Assessment R: Recommendation
steps in the operative procedure for femoral shaft fractures
Russell-Taylor Rod with or without Locking Screws 1. An incision is made over the tip of the greater trochanter and continued proximally and medially for 6 to 8 cm. The fascia of the gluteus is incised, and the piriformis fossa is palpated. 2. With a threaded guide pin followed by cannulated reamers or by use of an awl, the trochanteric fossa is identified , and the cortex is penetrated. A 3.2 mm guide rod is inserted to the level of the fracture . A curved guide pin is available for more severely displaced fractures. 3. Under fluoroscopy, the guide wire is advanced across the fracture site and into the distal fragment until the ball tip of the guide wire reaches the level of the epiphyseal scar. A second guide wire is held against the portion of the guide wire extending out of the proximal femur, and the length is measured. That measurement is subtracted from 900 mm (total guide wire length) to determine the length of the intramedullary nail required. 4. The cannulated reamers are placed sequentially over the guide wire. The entire femur is reamed at 0.5 mm increments. The entire shaft, and especially the fracture site, should be visualized with fluoroscopy as the reamers pass. 5. The final reamer size should be verified with the reamer gauge. The femur is reamed 1 mm over the selected nail diameter. Inserting a nail in an inadequately reamed femur or inserting a nail that is too large can cause severe bone splitting and comminution. 6. The proximal screw guide/slap hammer is assembled onto the nail. The nail is oriented to match the curve of the femur. 7. Using the handle of the inserter, the rotation of the nail is controlled, and the nail is driven into the femur. The nail is fully seated when the proximal screw guide is flush with the greater trochanter. The inserter is disengaged from the slap hammer. 8. Using the power drill and correct drill sleeves, a 4.8 mm hole is drilled through both cortices, and the depth is measured directly off the bit. 9. Through the appropriate drill sleeve, a 6.4 mm self-tapping locking screw is inserted, and the drill sleeve is removed. 10. By fluoroscopy the distal screw holes are confirmed as perfect circles on the screen. The distal targeting device is mounted on the nail followed by the left or right adapter block. The adapter block is adjusted until the calibration reads the length of the nail. The cross hairs are aligned in the adapter to the holes in the distal nail, with confirmation by fluoroscopy. 11. An incision is made through the adapter block over the distal femur to the lateral cortex. After the same steps as those for placing the proximal screw, one or two distal locking screws are inserted. There are various free-hand techniques for inserting distal locking screws. NOTE: Many errors and complications, some disastrous, can occur when proceeding with intramedullary fixation . -Late nailings (12 hours) can lead to complications related to difficulties in reduction. -Traction should be used if a delay is expected. -Reamers and nail guides can perforate the cortex. -Some surgeons may use an un-reamed technique in large femoral canals, which alleviates the potential for reaming injuries but increases the chance for femoral fracture. -Nails that insert with great difficulty may be too large for the canal and become incarcerated in the bone, requiring bone resection for removal. -Nails inserted that are undersized can bend and eventually break with weight-bearing. -Infection in the open or closed nailing is a serious complication. The literature reports infection rates from 1.5%to 10% after open reduction and 1% in closed nailings. Safe, efficacious intramedullary nailing requires proper technique and attention to detail.
Overall focus of AHRQ activities
Safety and quality Effectiveness Efficiency
Sv02
Saturation of mixed venous oxygen in percentage, measurement made from a special pulmonary artery catheter
Most commonly fractured carpal bone
Scaphoid bone
The Joint Commission
Sets quality standards for accreditation of health care facilities
what is a repair of an inguinal hernia and why is it done?
Several operative procedures for repair of inguinal hernias are currently used. Approaches that reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor are favored. A surgical repair in which transversalis fascia is sewn to transversalis fascia accomplishes this goal.
what symptoms of a AAA indicate rupture and a need for immediate medical attention?
Severe back pain, along with symptoms of hypotension, shock, and distal vascular insufficiency
what is a simple mastectomy and why is it done?
Simple mastectomy is removal of the entire involved breast without lymph node dissection. A simple mastectomy is performed to remove extensive benign disease, if malignancy is believed to be confined only to the breast tissue, or as a palliative measure to remove an ulcerated advanced malignancy.
Removal of just the affected lung
Simple pnumectomy
what is a Simple Retropubic Prostatectomy?
Simple retropubic prostatectomy is the enucleation of hypertrophic prostatic tissue through an incision in the anterior prostatic capsule by an extravesical approach. The retropubic approach offers excellent exposure of the prostate bed and vesical neck and readily controllable intraoperative and postoperative bleeding.
bradycardia
Slow heart-rate (HR less than 60bpm)
The primary ECF cation is
Sodium
Key sources of heat and ignition in surgery
Sparks from static electricity ESUs Lasers
The casting method used to manage a pelvic
Spica cast
Hernia through the linea semilunaris, or a spontaneous lateral ventral hernia
Spigelian hernia
What should happen if signs of blood transfusion reaction occur?
Stop transfusion, infuse NS Report reaction Possible order for antihistamines Return unused portion of blood Send urine sample Monitor reaction Complete incident report
Cerebrospinal spinal fluid circulates freely
Subarachnoid space
Lethargy, confusion, and other neural deficitis are symptoms of
Subdural hematoma
The only depolorizing muscle relaxant in clinical use
Succinylcholine (Anectine)
a shallow groove on the brain
Sulcus:
With patient in the prone position, the dorsal roots of the spinal nerves are oriented: o Deep to its corresponding ventral roots o Superficial to its corresponding ventral roots o Cranial to its corresponding ventral roots o Caudal to its corresponding medial roots
Superficial to its corresponding ventral roots
The nerve that is tested by the anesthesiologist to check for depth of anesthesia is
Supraorbital
Rotator cuff muscles
Supraspinatus & teres minor, infraspinatus & subscapularis
Muscles of the rotator cuff
Supraspinatus, infraspinatus, teres minor, and subscapularis
Abnormally rapid heartbeat
Tachycardia
When a drug loses its effectiveness in a patient the patient isaid to have developed
Tachyphylaxis
Normal adult temperature
Temperature (oral): 97.8F 99'F
The bone that forms the lateral sides of the head are
Temporal
The mastoid is part of this bone
Temporal
regional anesthesia
Temporary interruption of nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked.
Tough long strands of fibers that form the ends of muscles.
Tendons
is an extension of the Dura mater that separates the cerebellum from the inferior portion of the occipital lobes.
Tentorium cerebelli
Include Ventricular septal defect, pulmonary valve stenosis, right ventricular hypertrophy and transposition of the aorta are the four anamolies
Tetralogy of Fallot
Serves as a relay station
Thalamus
serves as a relay station
Thalamus:
vertebrae
The 33 bones that make up the spinal column. the lower nine are infused sacral-5 & coccyx-4, The 26 small bones that make up the backbone;
most popular classifications for grading femoral neck fractures
The Garden and AO nomenclature
The inferior mesenteric artery serves as principal blood supply to which of the following structures: The Ileocecal Valve The Caecum The Hepatic Flexure of the colon The Splenic Flexure of the colon
The Splenic Flexure of the colon
Burst Strength
The amount of pressure needed to rupture a viscus, or large interior organ.
intercostal nerves
The anterior rami of spinal nerves T1-T11 form the intercostal nerves. Nerve T12 is called a subcostal nerve.
what are some procedural considerations of an abdominoperineal resection surgery?
The choice of patient position depends on the surgeon. Some surgeons prefer to start with the patient in the supine position and move the patient to the lithotomy position for the perineal portion of the operation. Others initially place the patient in a modified lithotomy position; this surgery may be performed simultaneously by two teams ,which may require two scrub nurses with two different setups. An indwelling urinary catheter is inserted after induction. A nasogastric tube will be inserted by the anesthesiologist following intubation. A Gl set and an ostomy appliance are required for the abdominal portion of the procedure. A perineal set is used for the perineal portion of the procedure. Identification of the ureters during extensive deep abdominal procedures may best be achieved by the preoperative placement of ureteral catheters via transurethral approach. If the tumor is believed to involve the ureters, the surgeon will have consulted a urologist to perform the ureteral catheter placement at the start of the patient's scheduled procedure. Preparation and assembly of transurethral endoscopes, supplies, and equipment are necessary.
what is the closed method of internal fixation?
The fracture is reduced using closed reduction methods of manipulation and traction and then aligned with percutaneous insertion of pins, intramedullary nails, or rods.
In addition to being a chemical irritant, prep solutions can be what?
The fuel component in the fire triangle.
Procedural considerations for a total gastrectomy
The incision may be bilateral subcostal, long transrectus, long midline, or thoracoabdominal. A basic thoracotomy set, a Gl set, and a laparotomy set are necessary. Mechanical linear stapling devices should be available. In addition, two long, blunt, nerve hooks and two 10-inch needle holders are used. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
procedural considerations for a vaginal hysterectomy
The instrumentation includes the basic vaginal instrument set with the addition of 2 22-gauge needles, 1-1/2 or 3 inches, and 2 10 ml syringes. An abdominal gynecologic instrument set should be available in case laparotomy is indicated. To facilitate dissection and decrease bleeding, the vaginal walls may be infiltrated with normal saline or a local anesthetic (vasoconstrictors are optional).
In Submandibular gland removal, what must be identified?
The lingual branch of the trigeminal nervemust be identified and preserved
Breaking Strength
The load required to break a wound regardless of its dimension, the more clinically significant measurement
what is a Mesh-Plug repair?
The mesh-plug technique has been recommended for the treatment of primary and recurrent direct and indirect inguinal hernias. The various hernia types as classified by Gilbert have a corresponding relationship to the use of mesh plugs. Types I, II, and Ill are indirect hernias.
Ulnar nerve transposition
The nerve is relocated to the anterior aspect of the medial epicondile
Which of the flowing statements are true regarding total thyroidectomy procedures? o Potential post-op complications are relatively minor o The presence of hyperparathyroidism should be carefully monitored postoperatively o The open approach generally utilizes a low transverse collar incision o Most complications are immediately apparent through intra-operative diagnostic testing
The open approach generally utilizes a low transverse collar incision
autonomic nervous system
The part of the nervous system responsible for control of the bodily functions that are not consciously directed, such as breathing, the heartbeat, and digestive processes.
procedural concerns for inguinal hernia repair
The patient is in the supine position for abdominal wall and inguinal or femoral hernia repairs. The patient's skin surface area from above the umbilicus to midthigh is exposed , prepped with antimicrobial solutions, and draped with sterile drapes. A sterile drape should be placed under the scrotum if it becomes necessary to enter the scrotum.
what are some procedural considerations of an axillary node dissection?
The patient is placed supine on the OR bed with the operative side near the bed edge. The arm on the operative side is extended to less than 90 degrees on an armboard. The skin is prepped and draped as previously described.
Crossmatching refers to
The test for compatibility of the recipient's serum and the donor's red blood cells.
Screen blood test refers to
The test for unexpected antibodies
Arachnoid mater
The web-like middle layer of the three meninges., middle layer of meninges; cerebrospinal fluid and blood vessels found here;
Meyer-Overton Theory
Theory that suggests that anesthesia is produced by the volume of anesthetic molecules present (dissolved) at the site, not by the type of inhaled agent present
what are the procedural considerations of thyroid and parathyroid surgery?
These patients need an environment that is calm and quiet to reduce the risk of overstimulation , which could result in thyroid crisis, as well as to make the overall experience more tolerable .
visceral pleura
Thin membrane that covers the lungs.
what are the procedural considerations of a modified neck dissection?
This modified type of neck dissection facilitates removal of a tumor and lymph nodes suspected of metastases and allows the patient a minimal defect and minimally impaired shoulder function. With radical and modified neck dissection , the surgeon and radiologist may decide on a course of postoperative radiation therapy or chemotherapy. The decision depends on the type and location of tumor, stage of disease, and condition of the patient.
why is an anterior resection of the sigmoid colon and rectosigmoidostomy performed?
This operation is selected to treat lesions in the lower portion of the sigmoid and rectum that permit excision with a wide margin of safety and still retain sufficient tissues with adequate blood supply for a viable rectosigmoid end-to-end anastomosis.
why is a radical neck dissection performed?
This procedure is done to remove the tumor and metastatic cervical nodes present in malignant lesions as well as all nonvital structures of the neck. Metastasis occurs through the lymphatic channels by way of the bloodstream. Diseases of the oral cavity, lips, and thyroid gland may spread slowly to the neck. Radical neck surgery is done in the presence of cervical node metastasis from a cancer of the head and neck that has a reasonable chance of being controlled. A prophylactic neck dissection implies elective radical neck surgery when there is no clinical evidence of metastatic cervical cancer.
Packed Red Blood Cells (PRBCs)
To increase oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume
Why is whole blood used?
To replace large volumes of blood loss because it increases volume and improves the oxygen-carrying capacity of the blood.
A brain tumor on the hypoglossal nerve will cause loss of use of the :
Tongue
The hypoglossal nerve innervates
Tongue
why is a total gastrectomy done?
Total gastrectomy is done as a potentially curative or palliative procedure to remove a malignant lesion of the stomach and metastases in the adjacent lymph nodes.
Used preoperatively, intraoperatively, and postoperatively for prevention or reduction of muscle spasm, immobilization of a joint or body part, or reduction of a fracture or dislocation.
Traction
Pulling on the wrist to reduce a radius fx
Traction& counter traction
Involves freeing the nerve from a groove at the back of the medial epicondyle of the humerous and bringing it to the front of the condyle.
Transposition of ulnar nerve
naloxone
Treatment for opioid overdose.
What is Hesselbach's triangle?
Triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially.
Ophthalmic, maxillary, mandibular
Trigeminal nerve branches
Fracture of the ankle bones, which consist of medial malleolus (tibia), lateral malleolus (fibula), and posterior malleolus(posterior tibia)
Trimalleolar fracture
Smallest nerve
Trochlear nerve
Layers of artery
Tunica media, tunica intima, tunica adventia
what is a type 1 hernia?
Type I is characterized by a tight internal ring through which any size peritoneal sac can pass. The sac, when surgically reduced, is held within the abdominal cavity by the intact internal ring.
what is a type 2 hernia?
Type II hernias have a moderately enlarged internal ring, 4 cm or smaller.
what are type 4-7 hernias?
Type IV and Type V hernias are direct hernias. In Type IV hernias, the defect involves virtually the entire flow of the inguinal canal. Type V is a diverticular defect of the floor and is generally in a suprapubic position, resembling a punched-out recurrent hernia. Type VI includes components of both indirect and direct hernias. Femoral hernias are classified as Type VII.
what is a type 3 hernia?
Type Ill hernias have a patulous internal ring greater than 4 cm. In this type, the sac can have a sliding component that impinges upon the direct space.
tricompartmental knees are divided into what three categories?
Unconstrained prostheses semi-constrained prosthesis, Fully constrained prostheses
Total knee implants may be classified into three different categories
Unicompartmental implants Bicompartmental designs Tricompartmental implants
what are the surgical interventions of the thyroid and parathyroid?
Unilateral Thyroid Lobectomy Subtotal Lobectomy Bilateral Subtotal Lobectomy Near-Total Thyroidectomy Total Thyroidectomy
What is a midabdominal transverse incision?
Used on left or right side for a retroperitoneal approach slightly above or below umbilicus on either side carried laterally to the lumbar region at an angle between the rib and crest of the ileum
Nissen fundiplication
Used to treat refractory GERD and/or Barrett's Reinforces closing function of lower esophageal sphincter. Wrap stomach around esophagus., Surgical treatment for a hiatal hernia
The recurrent laryngeal nerve is a branch of the: Phrenic Nerve Facial Nerve Brachial Plexus Vagus Nerve
Vagus Nerve
Knee scope acces to view medial meniscus, manuever
Valgus
what can be used to replace or augment the cruciate ligaments?
Various types of ligament grafts Autografts, allografts, and artificial substitutes are available
where the proximal end of the VP shunt is placed.
Ventricle:
The brain contains four fluid filled spaces called what?
Ventricles
the cerebellar hemisphere are joined in the midline by a structure
Vermis:
The outer covering of the lung
Visceral pleura
A brain tumor on the optic nerve will cause loss of the use of:
Vision
The bone in the base of the nasal cavity is
Vomer
Co2 laser beams is absorbed by
Water
epilepsy
What disorder is characterized by seizures due to uncontrolled neuron activity?
procedural considerations for a right hemicolectomy and ileocolostomy
When a side-to-side anastomosis is carried out, the transsected stumps of the ileum and the transverse colon are closed before the anastomosis is done. It is completed between the side portions of the ileum and the transverse colon. A side-to-side anastomosis can also be performed by inserting the GIA stapler into both colon segments and firing the device. The stumps are then closed using a TA linear stapling device. When an end-to-end anastomosis is performed, the layers of the transsected stumps of the ileum and the transverse colon are sutured together. Circular linear stapling devices such as an EEA may be used for anastomosis. A laparotomy set and Gl instrument set are required. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
What is third spacing?
When fluid accumulates in areas that normally have no fluid or only a minimal amount of fluid This fluid accumulation occurs with burns, ascites, peritonitis or small bowel obstruction
when would a semi-constrained prosthesis be used?
Where there is significant deformity and the need for soft-tissue release, the surgeon may decide to use a semi-constrained prosthesis, which lends itself to more inherent stability necessitated by ligamentous deficiency.
basal artery
Which area affected by ischemic stroke tends to be the most fatal?
nephroblastomas
Wilm's tumor(commonly found in children), cause obstruction of the vena cava, hepatic veins or renal veins
clean wound
Wound edges can be approximated and secured. A clean wound is expected to heal by first intention
The vagus nerve is listed as:
X
The Hypoglossal nerve is listed as
XII
Yag Laser used to vaporize a portion of the residual lens capsule after cataract surgery
Yag laser
The cheekbones in the face are called the
Zygomatic arch
A dislocation (luxation) is
a complete displacement of one articular surface from another. This injury can disrupt neurovascular structures , requiring immediate attention.
Criminal Negligence
a degree of carelessness amounting to a culpable disregard of rights and safety of others
what drug is given 3 to 5 minutes before administering the intubating dose of succinylcholine to help make the onset of paralysis faster and duration of action shorter?
a dose of non-depolarizing relaxant such as rocuronium
AHRQ (Agency for Healthcare Research and Quality)
a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans
Centers for Medicare and Medicaid Services (CMS)
a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities.
Gerotas Fascia
a fibrous capsule that encircles the kidney to aid in keeping the kidney in the correct anatomical position and to cushion it from injury, kidneys live retroperitoneal with the ureters
what is a subtotal lobectomy?
a lobectomy that spares the posterior capsule and may or may not spare a portion of the adjacent thyroid tissue.
what is an adjustable gastric banding?
a restrictive procedure in which the opening from the esophagus to the stomach is reduced by a hollow gastric band placed around top of the stomach fold of the stomach is wrapped around band to secure it in place band has a port inflated with saline 4 weeks post-op restricts amount of ingested food
the femoral component design is what?
a symmetric design that can be used on either the left or the right knee.
common law
a system of law based on precedent and customs
what is tissue expansion?
a technique used to stretch normal tissue that is adjacent to a defect, mechanically creating redundancy of normal tissue to correct the defect.
Acetabular cups come with what?
a textured back for cement fixation and may have standoff pegs to allow an appropriate cement mantle.
Gamma Knife
a type of radiation treatment for brain tumors
cranial nerve 6
abducens moves eye
accountability
ability to answer for one's own actions
signs and symptoms of prolonged ileus
absence of bowel sounds abdominal distention diffuse abdominal pain nausea vomiting
jejunum
absorption of digested foods, vitamins,& electrolytes; thick wall with larger lumen in diameter and more vascularity compared to ileum; color; deep red
Key elements in planning the location and length of the surgical incision are:
access preserving abdominal wall function ability to securely close the wound
cranial nerve 11
accessory moves head
When does the small intestine, stomach, and large intestine return to normal function after surgery?
activity/motility of small intestine returns to normal within a few hours after surgery stomach motility returns to normal within 24-48 hours large intestine returns to normal within 48-72 hours
an optimally placed incision provides
adequate access to the targeted pathology provides sufficient visualization room to complete the procedure without undue trauma to surrounding structures can be extended if unexpected findings required additional exposure to complete the procedure can be closed securely with minimal risks for disruption
3 benefits of adjustable gastric band surgery
adjustable reversible improves long-term health, including risks of cardiovascular disease and T2D
Degenerative musculoskeletal conditions are associated with
aging
commonly used anesthetic inhalation gases
air oxygen nitrous oxide desflurane or suprane isoflurane or forane sevoflurane or ultane
Orthopedic implants
all implants must be of the same metallic composition to prevent galvanic corrosion.
tests for patency of radial and ulnar artery
allen's test
what is a temporary carotid artery shunt, or Javid shunt used for and what are the disadvantages to using it?
allows for a continuous blood flow through the carotid artery and to the brain. Some disadvantages in using this temporary device are the additional dissection necessary for its placement and the possibility of dislodging debris when the shunt is inserted as well as a difficult view of the endarterectomy end point and increased difficulty in suturing a patch.
what is supraspinatus syndrome?
also known as impingement syndrome, can involve multiple pathologic conditions such as calcium deposits ,bicipital tendonitis, subacromial bursitis,tenosynovitis ,and other non-articular lesions along with a cuff tear. The approach to diagnosis and treatment is similar for both.
what is the hepatopancreatic ampulla also known as?, distal common bile duct
ampulla of vator
tort
an act or failure to act which causes an injury or wrong to someone else
what is a craniotomy?
an incision into the skull to expose and surgically treat intracranial disease.
A combination of a torn anterior cruciate ligament, medial meniscus, and medial collateral ligament often indicates the need for what?
an open procedure (arthrotomy).
record of a vessel, radiograph obtained after injection of radiopaque contrast material into blood vessels
angiogram
Cimetidine (Tagamet), Ranitidine (Zantac), Famotidine (Pepcid)
antacid or an H20 receptor-blocking medication used to decrease gastric acid production or the acidity of the gastric contents or both part of safe airway management
lateral to the linea alba, what covers the rectus muscles?
anterior and posterior rectus sheaths
ALIF
anterior lumbar inter fusion
most common site of perforated peptic ulcer
anterior surface of the first portion of the duodenum
The artery which leaves the left ventricle and gives rise to the brachiocephalic trunk, left common carotid, and left subclavian artery,
aortic arch
Radiofrequency
application of radiofrequency energy to the abnormal cells using the HALO 360 or HALO 90 systems
Btween the 3rd and 4th ventricles., NTD/Congenital causes: Hydrocephaly: Obstruction of the passage of fluid through a narrowed (most common cause)
aquaduct of sylvius cerebral aqueduct
the third ventricle connect to the fourth ventricle via what?
aqueduct of sylvius
a landmark on the lower abdominal wall located about one third of the distance between the umbilicus and the symphysis pubis
arcuate line
fluid management during significant blood loss may require:
arterial montoring frequent intraoperative sampling of hemoglobin and hematocrit (H&H), arterial blood gases (ABG's), electrolytes, and coagulation studies
augmentation
as by the patient's own iliotibial band, protects the graft initially after repair of a partial tear.
when does bowel technique begin? end?
as soon as GI tract is clamped and transected proceeds through wound irrigation, before wound closure
nerve of Grassi
associated with the stomach
Glial cell
astrocytes, cells of the central nervous system that provide structural support, promote efficient communication between neurons, and serve as scavengers, removing cellular debris
commonly used non-depolarizing muscle relaxants with intermediate onset and duration
atracurium or tracurium cisatracurium or nimbex rocurinium or zemuron vecuronium or norcuron
Reconstruction of the breast can be accomplished in three ways:
available tissue and an implant, tissue expanders, or flaps.
AWR
awareness with recall
A fracture of the surgical neck of the humerus will most likely damage what nerve?, Deltoid, teres minor, Anterior shoulder dislocation
axillary nerve
steam sterilization process ,biological indicators
bacillus stearother mophilus
aerobes
bacteria that thrive in oxygen
Which area affected by ischemic stroke tends to be the most fatal?
basal artery
what instruments and supplies are needed for a nissen fundoplication?
basic laparotomy set laparoscope laparoscopic camera two 5 millimeter trocars one 10 millimeter trocar two 11 millimeter trocars light cord insufflation tubing electrosurgery cord laparoscopic instruments such as grasping forceps, endo scissors, endo babcock, endo dissecting forceps, endo clip appliers, and endo suturing device endo retractors should be available suction and suction irrigator penrose drain or a 12 french red rubber is used to assist in isolating and retracting distal esophagus bougie dilators size 40 to 60 french
what instrumentation is needed for a hiatal hernia repair?
basic laparotomy set maloney or hurst dilators in 32 to 42 french self retaining retractor system 1 inch penrose drain If transthoracic approach is used, a basic thoracic set would be required
instruments needed for esophagectomy/intrathoracic esophagogastrostomy
basic thoracotomy set basic laparotomy set GI set Have linear staplers and vascular clips available
why is internal fixation anatomic reduction necessary before internal fixation of femoral neck fracture?
because of the high incidence of associated complications, such as nonunion and avascular necrosis of the femoral head.
how do you make a subcostal incision?
begins in epigastrium extends laterally and obliquely downward, just below the lower costal margin muscles contain veins and arteries which must be ligated if more exposure is needed, incision is extended across rectus muscle of the other side rectus muscles are either retracted or transversely divided. vessels must be ligated
How is a McBurney's incision made?
begins well below umbilicus and goes through McBurney's point and extends upward toward the right flank external oblique muscle and fascia are split in direction of their fibers and are retracted internal oblique, transversalis muscle and fascia are split and retracted peritoneum incised transversely
Induction
begins with administration of anesthetic agents and continues until the patient is readt for positioning or surgical prepping, manipulation or incision
Extreme positions of the head and arm can cause injury to the, Trauma to a nerve of this plexus may cause wrist drop., A network of nerves formed by cervical and thoracic spinal nerves and supplying the arm and parts of the shoulder. 1 per side of the body.;
brachial plexus
oldest part of the brain, beginning where the spinal cord swells upon entering the skull; controls fundamental survival processes like heartrate and breathing, the oldest part and central core of the brain, beginning where the spinal cord swells as it enters the skull; It is responsible for automatic survival functions.
brainstem
commonly used local anesthetics
bupivacaine or marcaine or sensorcaine chloroprocaine or nesecaine lidocaine or xylocaine ropivacane or naropin tetracaine or pontoca
Paralysis causes by non-depolarizing relaxants. May be antagonized or reversed by what?
by I.V. anticholinesterases, such as edrophonium, neostigmine, or rarely pyridostigmine.
Upper part of cranium or skull
calavaria
2. fracturing of c3 to c5
can cause respiratory difficulties
what are the advantages of a midthoracic epidural placed preoperatively prior to general anesthesia
can decrease postoperative pain increase adherence to pulmomary exercises promote early ambulation
steps in the operative procedure for femoral neck fractures
cannulated screw fixation for nondisplaced femoral neck fractures - 1. The fracture is exposed through a 5 cm lateral incision over the greater trochanter. 2. The dissection is carried through the subcutaneous and fascial layers; the vastus lateralis is detached anteriorly and retracted, exposing the femoral neck. 3. Two guide pins are driven into the middle of the femoral head, one anterior and one posterior, within 5 mm of subchondral bone; a third pin is placed adjacent to the medial cortex at a 135- degree angle. Care must be taken to not violate the articular surface. 4. The guide pins are measured for correct screw length, and the cannulated screws are inserted over the guide pin without applying compression until all are seated. 5. Compression of the anterior screws is completed first and the posterior screws last to avoid collapse of the posterior aspect of the neck. 6. Traction is released, and the fracture site visualized with fluoroscopy while the hip is rotated through a full range of motion. 7. Radiographs are taken to verify the position of the screws; the wound is irrigated and closed. NOTE: Screw protrusion into the joint space can be disastrous to the articular surface. Radiopaque dye can be injected to rule out communication with the joint.
This artery supplies the scalp with blood
carotid
consists of the brain and the spinal cord
central nervous system
a cleft separating the frontal from the parietal lobes of the brain. Also called central fissure, fissure of Rolando
central sulcus
Control of finely coordinated movements. Coordination center, voluntary movement and balance. "Small brain."
cerebellum
Largest part of the brain, Higher level brain functions; thoughts, emotions, memory, reasoning, language, and processing of sensory information.
cerebrum
A nerve plexus formed by the ventral branches of the first four cervical spinal nerves and supplying the structures in the region of the neck. One important branch is the phrenic nerve, which supplies the diaphragm.; c3,4,5
cervical plexus
endogenous endorphins
chemicals similar to narcotics that are produced by the body and cause euphoria and depress pain
part cerbellum herniates down through foramen magnum
chiari malformation
Type of horrible wound but has some bacterial contamination to it, a laceration obtained outside surgical area, Some bacterial contamination
clean contaminated
skeletonizing
clean up
controlled entries into the GI tract without spillage of gastric or bowel contents are classified as:
clean-contaminated
fractures are classified according to what two groups?
closed fractures and open or compound fractures
how is the thoracoabdominal incision closed?
closed in layers with interrupted sutures absorbable sutures may be used for peritoneum and intercostals muscles non-absorbable suture may be used for the muscle and fascial layers skin layers approximated with staples or nonabsorbable suture
RED CELL DISTRIBUTION WIDTH (RDW)
coefficient of variation: 11.5-14.5 % , Standard Deviation: 35-47 fL
by the 3rd day postoperatively, what begins to form
collagen
Femoral neck and intertrocanteric fractures
commonly require ORIF
main concern with orthopedics, injury caused when tissues such as blood vessels and nerves are constricted within a space as from swelling or from a tight dressing or cast, PAIN WITHOUT MOVEMENT under a cast, BAD
compartment syndrome
what is a total gastrectomy?
complete stomach resection reestablishment of GI continuity is with a Roux-en-Y anastomosis between the jejunum and esophagus esophagojejunostomy
what medical complications can occur in total joint arthoplasty?
complications include but are not limited to cardiac dysrhythmias, myocardial infarction, hemorrhage, and pulmonary emboli.
what is the tibial component?
composed entirely of UHMWPE (ultra high molecular weight polyethylene), thereby lowering manufacturing costs.
moral conflict
conflicts of your personal and religious beliefs
what type of anesthesia is appropriate for outpatient endoscopic procedures?
conscious sedation
gross contamination from the GI tract, major breaks in sterile technique, or visible presence of acute infection
contaminated
maintenance
continues until near completion of the procedure this phase is achieved either with inhalation agents with I.V. meds given in titrated doses, or by continuous infusion
peristalis
contraction of smooth muscle that keep digested food moving downward
the cruciate ligaments do what?
control AP stability.
the large band of neural fibers connecting two brain hemispheres and carrying messages between them
corpus collosum
what are the types of screws used in internal fixation?
cortical, cancellous, lag, pre-tapped, and self-tapping.
Before prepping, what do you do with a stoma?
cover and protect existing stomas with an occlusive sterile clear plastic dressing or a collection appliance or isolate them with a plastic drape secured with adhesive strips
statistics on skin
covers about 3000 sq inches weighs 6 lbs receives 1/3rd of the body's circulating blood
Olfactory Nerve sensory
cranial nerve I, transmits impulses that convey sense of smell
the degree to which people are responsible for their actions
culpability
what is the Pfannenstiel's Incision and what is it used for?
curved transverse incision of the lower abdomen used for pelvic surgery
insertion of a primary catheter does what?
decompress the bladder provides accurate measurement of urinary output and renal function
GI patients are at an increased risk for venous thromboembolism (VTE) events such as :
deep vein thrombosis pulmonary embolism
Type 3 hiatal hernia
defect continues to enlarge and the GEJ itself begins to migrate into chest along with the rest of the stomach
aneurysm
defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect;, 5.5cm is the size when surgery is recommended;, atherischlerosis /95%
When a wound is allowed to heal open for 5 days and then it is closed is called
delayed closure
How are muscle relaxants classified?
depolarizing or non-depolarizing
culpable
deserving blame
hemolysis
destruction of red blood cells
blood type test
determine blood type and compatibility
obese patients typically present with what 7 serious co-existing health conditions?
diabetes cardiopulmonary disease obstructive sleep apnea (OSA) gallstone disease hypertension hyperlipidemia joint disease
8 symptoms of achalasia
difficulty swallowing regurgitation heartburn difficulty burping hiccups choking after meals nighttime cough weight loss
what are hernias that occur within Hesselbach's triangle?
direct inguinal hernias
Metabolic diseases are
disorders of bone remodeling.
open gallbladder laparoscopic
dissected anti-grade, dissected retrograde
Bilroth 1 (gastroduodenostomy)
distal gastrectomy with GI reconstruction to connect gastric remnant to the duodenum via an end-to-side or end-to-end anastomosis (gastroduodenostomy)
Umbilical Hernia
due to developmental deficiencies congenital umbilical hernia or weakness in linea alba in area of umbilicus
Biliroth 2
duidenum is closed or removed and the fundus is connected to the jejunem, body and pyloris also removed;, gastrojejunostomy
what equipment is needed for a laparoscopic nissen fundoplication?
electrosurgical unit, insufflation unit with C O 2 gas, two video monitors placed on each side
What connects the veins in and outside the scalp?
emmisary vein
ETCO2
end-tidal carbon dioxide
If patient is unresponsive to medications and they don't want surgery, the next option is
endoscopic procedures
what is the EsophyX
endoscopic stapling system that treats GERD
what is the EndoCinch?
endoscopically place sutures in mucosal folds at a distal location
Ivor Lewis Esophagectomy also known as transthoracic esophagectomy requires what two incisions
entails both an upper midline abdominal incision and a right thoracotomy incision
End ileostomy
entails bringing a transected portion of the ileum through the abdominal wall to divert small bowel content away from the GI tract distal to the ileostomy can be temporary or permanent
What supporting cells, found only in the ventricles are responsible for creation and circulation of CSF?, The type of neuroglia which formal layer of supporting epithelial cells that line brain ventricular and Central canal of spinal cord is called
ependyma
key structure of skin
epidermis dermis sub-q
8 symptoms of hiatal hernia
epigastric or chest pain chronic cough heartburn regurgitation of undigested food dysphagia early satiety vomiting aspiration
What disorder is characterized by seizures due to uncontrolled neuron activity?
epilepsy
Modified Heller Myotomy also know as laparoscopic esophageal myotomy is what?
esophageal myotomy that treat achalasia
7 possible complications of paraesophageal hernia
esophageal reflux gastritis gastric volvulus with risk of strangulation necrosis perforation gastric outlet destruction hemorrhage pneumonia
complications associated with GERD
esophagitis and Barrett's esophagus due to prolonged exposure to gastric acid
Gastrojejunostomy which is also called Biliroth 2
establishes permanent communication between the proximal jejunum and stomach to bypass an obstruction of the distal stomach or proximal duodenum resulting from a gastric tumor or severe stenosis of the pylorus
commonly used intravenous anesthetics
etomidate or amidate diazepam or valium ketamine or ketalar midazolam or versed propofol or diprivan sodium methonexittal or brevital sodium
Osteoporosis is characterized by
excessive loss of calcified matrix, bone mineral, and collagenous fibers, causing a reduction of total bone mass.
cranial nerve 7
facial moves face, salivate
Achalasia
failure of the lower esophagus sphincter muscle to relax if untreated, the risk of esophageal cancer increases
the two hemispheres are separated by a layer of Dura mater.
falx cerebri.
why is the midline incision the standard for exploratory laparotomy?
fast entry into the abdomen provides excellent exposure to any part of the abdominal cavity can be closed securely and rapidly
What are 5 major patient concerns?
fear of the unknown relinquishing control being awake not awakening from anesthesia concerns related to surgery (ie, diagnosis, prognosis)
What nerve is injured during an abdominal hysterectomy?, that distributes to anterior muscles of thigh, flexors and adductors of hip, and skinover anteromedial surface of thigh and medial surface of leg and foot
femoral nerve
largest principal load-bearing bone in the body
femur
ileum
final portion of small intestines,connects to the cecum; absorbs nutrients the jejunum doesn't; Meckel's Diverticulum found here color;pale pink Peyer's patches
premium non nocere
first do no harm
duodenum
first of small intestines where all food digestion is complete; associated with Brunner's gland; connects the pylori of the stomach to the jejunum
Motion of the knee occurs in three planes
flexion and extension, abduction and adduction , and rotation.
dye used in ophthalmic surgery to diagnose corneal abrasion
floresium sodium
Treatment for benzodiazepine overdose.
flumazenil
In what three instances would local anesthesia be used?
for minor procedures if the patient's cooperation if necessary if the patient's physical condition warrants its use
Bankart Procedure
for restoration of shoulder stability
laparoscopic appendectomy
for uncomplicated appendicitis in the presence of perforation, conversion to open will likely be necessary
connection between lateral ventricles to the third ventricle?
foramen monroe
the small opening (on both the right and left sides) that connects the third ventricle in the diencephalon with the lateral ventricle in the cerebral hemisphere
foramen of monro
What is a Meckel diverticulum?
forms when the vitelline duct fails to close completely by birth. The diverticulum includes all layers of the intestinal wall, and ileal, gastric, or pancreatic mucosa can line it.
Meckel's diverticulum
forms when vitelline duct fails to close completely by birth the diverticulum includes all layers of the intestinal wall ileal, gastric or pancreatic mucosa can line it uncommon in most cases does not cause symptoms
Fissure of Bichat:
found below the corpus callosum in the cerebellum of the brain.
hypertonic solution
has a greater concentration of solutes than that of plasma and moves water out of the cells (5% dextrose in NS or in LR)
Hypotonic IV solutions
has a lower concentration of solutes than that found in plasma and moves water into the cells (0.45% saline or 2.5% dextrose)
what is an unconstrained prostheses
have very little constraint built in between the femoral and tibial components and depend on the integrity of soft tissues to provide stability of the reconstructed joint.
The accessory nerve innervates
head movement
How do closed wounds heal?
heal by primary intention precise incision that is reapproximated quickly, usually within hours or less
How does an Open wound heal?
heals by secondary intention defect is larger than closed wound, but decreases in size as granulation process takes over
The vestibulocochlear nerve innervates
hearing
symptoms of hiatal hernia
heartburn reflux (backward flow) regurgitation dysphagia
what are the benefits of early ambulation?
helps regain overall muscle tone and strength supports cardiac and pulmonary function reduces or prevents the risk of deep vein thrombosis in lower extremities boosts a sense of well-being
Inguinal Hernia
hernia occuring in the groin area, more common in males, *landmarks inguinal ring, inferior epigastric vessels, and spermatic vessels
What is a pantaloon hernia?
hernia sac exists as both direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring
Aneurysm, dissecting. Association?, Chronically high blood pressure
hypertension
factors that create optimal anesthesia and good surgical conditions:
hypnosis analgesia amnesia appropriate surgical conditions, including muscle relaxation and patient positioning continued homeostasis of the patient's vital signs
cranial nerve 12
hypoglossal moves tongue
Factors that can affect the pulse ox reading
hypoperfusion hypotension hypovolemia vasoconstriction hypothermia electrosurgery motion ambient light IV dyes nail polish
removal of the pituitary gland, the removal of abnormal glandular tissue performed through the nasal passages
hypophysectomy
closure of subcostal incision
includes approximation and closure of the falciform ligament, peritoneum posterior rectus sheath and anterior rectus sheath with interrupted , nonabsorbable suture Sub Q and skin are closed the same way as vertical incision Absorbable suture may be used with staples
those in which the whole thickness of the bone is not broken but is bent or buckled, as in greenstick fractures, which commonly occur in prepubertal children.
incomplete closed fractures
3 phases of anesthesia
induction maintenance emergence
leaving sutures or staples in too long promotes what two things
infection negative effects on scarring
what is a catastrophic complication of total joint surgery and what additional issues can it cause?
infection usually requires additional surgery, prolonged hospitalization, and a greater economic burden.
bone healing sequence
inflammation;cellular proliferation;callus formation;ossification; remodeling
depending on the kind of surgical procedure, maintenance of anesthesia may be accomplished with only what?
inhalation agents and spontaneous, assisted or controlled ventilation
when is antibiotic coverage administered for total joint arthroplasty?
initiated pre-operatively, continued during lengthy procedures, and administered for 24 to 48 hours postoperatively.
kyphoplasty
injection of bone cement into collapsed vertebra
A deliberate act that causes harm to another for which the victim may sue the wrongdoer for damages.
intentional tort
non depolarizing agents can be subdivided by duration of action into two groups:
intermediate acting long acting
blood supply to the brain via
internal carotid and vertebral artery
what suturing technique is used for skin closure on a midline incision and how are the sutures placed?
interrupted suturing technique stitches placed 1cm from wound edge with at least 1cm between sutures
what is a total thyroidectomy?
is removal of both lobes of the thyroid and attempted removal of all thyroid tissue present.
The prime surgical consideration when a rupture occurs
is the control of hemorrhage by occlusion of the aorta proximal to the point of rupture.
the primary function of the femoral component in hip replacement surgery is
is the replacement of the femoral head and femoral neck after resection. -The femoral head should ultimately sit where it reproduces the center of rotation of the hip. -The neck length is variable and is built into several different heights of femoral heads that are eventually seated onto the Morse taper of the femoral stem. -The version (implant rotation within the canal) is very important; too much anteversion or retroversion leaves the hip prone to dislocation.
Femoral-popliteal bypass
is the restoration of blood flow to the leg with a graft bypassing the occluded section of the femoral artery. -The bypass may be a saphenous vein or straight synthetic graft. -The patency of an outflow artery must be demonstrated for a successful bypass procedure. -If popliteal patency is doubtful, artery exploration is necessary as the first procedure. -Involvement of the popliteal artery may necessitate the exposure and use of the tibial vessels for the lower anastomosis. If this occurs, the procedure could require the use of microvascular instruments and technique.
descending colon
left colic flexure down from the transverse to the sigmoid; secondarily retroperitoneal
avulsion fracture results in
ligamentous attachment remaining intact on a separated bone fragment. This may occur after joint dislocation or rotational injury, such as the femoral condyle separating from the tibial plateau.
disadvantage of the subcostal incision
limited exposure
Triple arthrodesis
limits the motion of the foot and ankle to plantar flexion and dorsiflexion
at the midline, the anterior and posterior rectus sheaths fuse together to form what?
linea alba (an avascular nerve free structure that vertically divides the right and left rectus muscles from the xiphoid process to the symphysis pubis
MAJOR ARTERIES THAT SUPPLY THE INTESTINES
lliocolic artery, right colic artery, middle colic artery, left colic artery, and the superior rectal artery
Connects the ilium to the femur
lliofemoral Ligament
Situation Ethics
making a decision with good ethical judgement based on the current situation
Risk factors for development of osteomalacia include
malabsorption problems, vitamin D and calcium deficiencies, chronic renal failure, and inadequate exposure to sunlight.
Dantrolene, What is the diagnoses for rapid increase in body temperature, unstable blood pressure, muscle rigidity, tachycardia, tachypnea
malignant hyperthermia
appendix
mass of lymphatic tissue that helps contribute to immunity; connects to the cecum;possible cause of appendictis in adults-fecal matter blocking the lumen; appendisitis in youth- hyperplasia of lyphatic follicles in appendix occludes the lumen
what are the three types of complications in total joint arthroplasty?
medical complications, mechanical complications, and infections.
Part of the brainstem that controls vital life- sustaining functions such as heartbeat, breathing, blood pressure, and digestion.
medulla oblongata
creatinine
men 0.6-1.2 women 0.5-1.1
what is a bicompartmental design for a total knee implant?
mentioned only to demonstrate the progression of total knee design, replaced both the medial and lateral surfaces of the femur and tibia. This implant design is almost completely rejected as a technique for knee replacement.
the middle part of the brain between the diencephalon and the pons; also called the midbrain
mesencephalon
Diabetic ketoacidosis;, Addition of large amounts of fixed acids to body fluids; caused by lactic acidosis (circulatory failure), ketoacidosis (diabetes, starvation), phosphates and sulfates (renal disease), acid ingestions, secondary to respiratory alkalosis, adrenal insufficiency
metabolic acidosis
Bone diseases can be
metabolic, infectious, or degenerative.
moderate sedation/analgesia (conscious sedation)
method of anesthesia that is administered for specific short term surgical diagnostic and therapeutic procedures
McVays Repair
method used to repair femoral hernias (transverse fascia &conjoined tendon to cooper's lagament(pectenial ligament)
capnography
monitor that measures end tidal carbon dioxide levels
pulse oximetry
monitor that measures oxygen saturation in a pulsating vessel
cultural/individual relativism
moral standards and accepted lifestyle practices which vary widely from individual to individual, and even more so from culture to culture
commonly used anesthetic opioid analgesics
morphine sulfate alfentanil or alfenta fentanyl or sublimaze remifentanil or ultiva sufentanil or sufenta hydromorphine or dilaudid morphine liposomal or depo dur
sigmoid colon
most common site for diverticula; S shaped part the colon between the ascending and rectum;suseptible to volvulus because greatest range of motion, easy to twist on itself
pharyngoesophageal diverticula
most common type of esophageal diverticula
En Bloc esophagectomy
most radical approach to esophagectomy esophagectomy with radical lymph node dissection
what is the leading cause of death after AAA repair?
myocardial infarction Patient should have a thorough preoperative cardiac assessment
patients with peripheral vascular disease are at risk for what?
myocardial ischemia, myocardial infarction, hypotension, and hypertension.
Malpractice
negligence by a professional in the performance of a professional act
commonly used cholinergic agent
neostigmine or prostigmine
causes of prolonged ileus vary and can arise from:
neurogenic inflammatory hormonal pharmacologic mechnical effects of surgery (including over-manipulation of the intestines during surgery)
N20
nitrous oxide
Which lymphoma type is most dangerous?, a caner of the lymphocytes(usually B cells)) and killer cells. Older adults(more than 65 years) with night sweats, fever, wt loss, generalized lymphadenopathy (poor prognosis)
non-hodgkins
ASA P1
normal healthy patient
2 disadvantages to the McBurney's incision
not good exposure difficult to extend. to extend medially, inferior epigastric vessels are ligated and the rectus sheath is incised transversely
Cranial Bones
occipital bone, 2 parietal bones, frontal bone, 2 temporal bones, sphenoid bone, and ethmoid bone
cranial nerve 3
oculomotor moves eye, pupil
Inferior Mesenteric Artery IMA
oirgin: abdominal aorta; Supplies the left half of the transverse colon, the descending/iliac/and sigmoid colon, and part of the rectum; often sacrificed during AAA REPAIR, COLONIC ISHEMIA CAN OCCUR
cranial nerve 1
olfactory smell
peripheral nervous system
once nerves leave the intervertebral foramen; 31 pairs of spinal nerves and 12 pair of cranial nerves, All the other nerves in the body, all the nerves not encased in bone. Divided into two categories: Somatic and Autonomic.
ethical dilemma
one that would ask you to do something that might be legal, but may appear underhanded or "shady"
wounds regain tensile strength for up to how long after surgery
one year
what two ways are wounds classified?
open or closed
Pyloric Sphincter
opening from the stomach to small intestines; regulates chymes from the stomach to the duodenum
esophageal hiatus
opening in the diaphragm through which the esophagus enters the abdominal cavity
cranial nerve 2
optic Sight
most common degenerative change in bone
osteoarthritis
metabolic bone disease characterized by inadequate mineralization of bone as a result of vitamin D deficiency, which leads to reduced absorption of calcium and phosphorus
osteomalacia
The most common infectious process in bone
osteomyelitis.
one of the most common and serious of bone diseases.
osteoporosis
The most common metabolic bone diseases are
osteoporosis, osteomalacia, and Paget's disease, all of which may result in bone fractures.
Epidermis
outermost layer of skin composed of several layers consisting of keratin and lipids
replacement fluids include:
packed red blood cells albumin platelets fresh frozen plasma electrolytes colloids and crystalloids
Vasodialates stops arterial spasm during cardiac bypass
papverine
type 1, 2, and 4 hiatal hernia
paraesophageal hernias which have a true hernia sack
After local excision of a parathyroid, a cut metastatic site may secrete what?
parathormone , causing hypercalcemia and its attendant problems.
transverse colon
part of the colon that extends across the abdomen, blood supply from the SMA and IMA; vitamin K is produced here; most movable part of lg. intestines; intraperotoneal, *structures that hold transverse colon are transverse mesocolic,hepatic flexure, and splenic flexure
Procedure combined with a Heller myotomy to treat achalasia
partial gastric fundoplication
Lap Nissen Fundoplication
performed when recurrent or persistent reflux or gastric contents into the esophagus or mouth, defective or incompetent LES. This procedure is performed when changes such as dietary changes, weight loss, and meds don't work
what are the 4 steps in closing a vertical midline incision?
peritoneum and posterior fascia are usually sutured as a single layer sometimes the incision site is supported by retention sutures extending through most or all layers anterior fascia, sub Q, and skin are closed as layers alternative closure includes figure of eight, monofilament, non-absorbable sutures for one layer closure of peritoneum and fascia
A "foot drop" results from insufficiency of the extensor muscles in the foot, and may be caused by lumbar disc herniation (damage to a nerve root in the lumbar spine), or damage to/compression of the nerve as courses superficial to the fibular head. peroneal pudendal posterior tibial sural
peroneal
A "foot drop" results from insufficiency of the extensor muscles in the foot, and may be caused by lumbar disc herniation (damage to a nerve root in the lumbar spine), or damage to/compression of the nerve as it courses superficial to the fibular head. peroneal pudendal posterior tibial sural
peroneal
7 Symptoms of Zenker's diverticulum
persistent cough excessive salivation regurgitation of undigested foods halitosis voice changes retrosternal pain intermittent dysphagia
Which muscle might be a source of sciatic pain by entrapping the sciatic nerve?, originates on anterior surface of pelvis, inserts on greater trochanter, rotates hip laterally and abducts flexed thigh at hip
piriformis
Released hormones that affect your growth as well as influencing activities of other glands. "Master Gland", secretes many hormones, thyroid and parathyroid glands promote growth of brain, bones, and muscle, and adrenal gland produces hormones and aldosterone
pituitary glands
4 stages of cancer
polyp removal(biopsy);radiation(chemo);lymphatic cancer; organ cancer
A portion of the brainstem that relays information between the cortex and medulla, regulates sleep, and carries some motor and sensory information from the head and neck., Controls breathing, Connects the brain with the cerebellum, hence Its name which means "bridge." Along with the medulla oblongata, the pons also controls respiratory rate.
pons
a temporary decrease in bowel activity for 3 days after GI surgery
postoperative ileus
autotransfusion may not be appropriate in GI surgery because:
potential contamination from bowel contents or from malignant GI tumors
Fluid and electrolyte imbalances may occur rapidly in the surgical patient, and can be caused by factors, including
preoperative fluid and food restrictions, intraoperative fluid loss, of the stress of surgery.
Designs of total knees should allow what?
preservation of the normal ligaments whenever possible while providing soft-tissue balance when necessary to maintain stability.
Malpractice
professional negligence
what rapid-acting medication is injected intravenously to take the patient rapidly to stage 3 of anesthesia?
propofol (diprivan)
In cases of severe comminution or avascular necrosis of the femoral head the patient may require what?
prosthetic placement
stents
protect the joint from excessive stress while the permanent ligament substitute is healing.
what three things does skin provide?
protection and sensation regulates fluid balance and temperature produces vitamins and immune system components
Theory of general anesthesia that proposes that hydrophobic areas of the specific proteins in the CNS act as receptor sites
protein receptor therapy
An indwelling urinary catheter is frequently inserted for what reason?
provide a useful indication of renal function and hemodynamic status
5 advantages of the subcostal incision
provides good cosmetic results nerve damage is limited. most commonly is the 8th intercostal nerve less tension on the edges than a vertical incision it is readily extended less respiratory impairment
In knee arthroscopy, the antero-medial portal is placed: o on the same side of the patella as the Ilio-tibial band. o on the opposite side of the patella from the pes anserinus. o superior to the quadriceps insertion on the patella. o proximal and anterior to the pes anserinus, medial to the patellar ligament.
proximal and anterior to the pes anserinus, medial to the patellar ligament.
4 endosopic procedures to treat GERD
radiofrequency ablation, intraluminal endoscopic sewing devices, transmural fasteners, staplers
what is a rectocele?
rectocele is formed by a protrusion of the anterior rectal wall (posterior vaginal wall) into the vagina. In general, the anterior rectal wall forms a bulging mass beneath the posterior vaginal mucosa. As the mass pushes downward into the lower vaginal canal, the rectum may be torn from the fascial and muscular wall. The levator ani muscles become stretched or torn. The symptomatic signs are a mass protruding into the vagina, difficulty in evacuating the lower bowel, hemorrhoids, and a feeling of pressure. An enterocele is a herniation of Douglas's cul-de-sac and almost always contains loops of the small intestine.
what can be used as a jejunostomy tube to deliver postoperative enteral nutrition?
red rubber catheter
Malabsorptive bariatric surgery
reduces absorptive capacity of the small intestine with a bypass of a segment or segments of the proximal small bowel
what is restrictive bariatric surgery?
reduces the size of the stomach, gives a feeling of fullness so the patient eats less
what is a vaginal hysterectomy?
removal of the uterus through an incision made in the vaginal wall and the pelvic cavity.
Small bowel resection
removes a segment of diseased, obstructed, or necrotic small intestine When possible, connecting the distal and proximal segments of the remaining small bowel restores continuity
an artery originating from the abdominal aorta and supplying the kidneys and adrenal glands and ureters
renal artery
what are tricompartmental implants?
replace not only the opposing femorotibial joint, but also the patellofemoral joint. Most of the total knee replacements completed today are of this variety.
injuries resulting from RSIs are all subject to legal doctrine, called
res ispsa loquitur (the thing that speaks for itself) because these injuries ordinarily do not occur in the absence of some form of negligence
partial gastrectomy
resection of the distal stomach for treatment of malignant gastric tumors and complications of peptic ulcer disease such as bleeding, perforation, and obstruction
Transhiatal Esophagectomy
resection of the esophagus by blunt dissection from a cervical incision from above and transhiatal approach through an abdominal incision. This technique decreases risk of injury to the recurrent laryngeal nerve
hyperventilation, Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.
respiratory alkalosis
Largest nerve in the body that starts at the sacrum and goes down the back of both thighs, What lower extremity nerve is described by the following motor loss? Loss of flexion of the knee and all function below the knee, weakened extension of the thigh, Longest and thickest nerve of the body
sciatic nerve
what is the upper inverted U abdominal incision?
seldom used incision that has been used for gastrectomy, transverse colon resection, transverse colostomy, biliary and pancreatic procedures incision extends from a point below the costal margin on one side in the anterior axillary line to the same point on the opposite side curved incision, with the midpoint lying midway between the xiphoid process and the umbilicus intercostal nerves are preserved
Rolando's fissure:
separates the brain's frontal and parietal lobes.
Wernicke's fissure:
separates the brain's temporal and parietal lobes from the occipital lobe.
layers of the stomach and intestines
serosa, mucosa, and submucosa
what happens once an implant has been inserted with bone cement that has hardened?
significant bone resection and loss would result if correction were necessary.
common suture materials used in GI procedures (and what they are used for)
silk vicryl pds 3-0 4-0 on taper needle for intestinal tissues 3-0 4-0 suture for small vessels 0 or 2-0 for larger vessels closure of enterotomies or hand sewn anastomosis of the bowel 3-0 4-0 absorbable for the mucosa and seromuscular layers
What are the 5 advantages to a vertical midline incision?
simplest incision offers good exposure to the abdominal cavity preferred type of incision hemostasis easily achieved few layers are transversed
Corporate Liability
since the corporation is itself a legal entity, it is the corporation which is legally responsible for its acts and its debts-not the people who own it
what is the largest organ in the body?
skin
layers of the abdominal wall in the midline
skin sub Q fat linea alba preperitoneal fat peritoneum
what are the two types of hiatal hernias?
sliding and paraesophageal
Amphiarthrotic
slightly movable
The latin term glabellus refer to
smooth and hairless
The vagus nerve will innervate
smooth muscles
What is a hiatal hernia?
special type of hernia in which a defect, either congenital or accidental in the diaphragm permits a portion of the stomach to enter the thoracic cavity
What controls the release of bile?, what's another name for the hepatopancreatic sphincter?, The ampulla of Vater empties its contents into the duodenum thru the structure called the?
sphincter of oddi
common types of regional anesthesia
spinal (subarachnoid block or SAB) epidural caudal major peripheral nerve block
abnormal spleen enlargement, identifiable pathology of portal hypertension
splenomegaly
bacteria can be found as common flora of the skin, hair, and nose;, most common pathogen in wound infections
staph aureus
Astrocytoma
star-shaped tumor that usually develops in the cerebrum; frequently in people younger than 20 years old, MC primary brain tumor; frontal lobe MC site in adult; cerebellum MC site in children, most common tumor in the brain
what are the 4 steps in creating a vertical midline incision?
starts below sternal notch extends distally around umbilicus and back to midline peritoneum is incised round ligament of liver may be divided
most common conduit to replace the esophagus
stomach
surgical wound have the potential for infection from
strains of antibiotic resistant bacteria, such as MRSA and VRE
preferred med for rapid sequence induction
succinylcholine
what is the standard depolarizing agent and what does it depolarize?
succinylcholine or anectine postjunctional neuromuscular membrane
a selective relaxant binding agent SRBA that encapsulates the steroidal neuromuscular agents and is excreted in the urine
sugammadex (bridion)
common positions for patients undergoing GI procedures
supine low modified lithotomy jacknife position
what is the patient positioning of a patient having a hiatal hernia repair?
supine may be repositioned to lateral if the gastroesophageal sphincter cannot be accessed through a high midline position foley is inserted after induction of general anesthesia
what position is the patient placed in for an excision of an esophageal diverticulum?
supine with a shoulder roll placed to assist with hyperextension of the patient's neck patient's head may be turned to the side and held in place with padded headrest or donut
scaffolds
support the soft tissue initially to allow ingrowth of the host tissue.
SGA
supraglottic airway device
The lines of the skull where bones fuse are
sutures
primary, secondary, or tertiary; 3', What type of prevention is diabetes management?
tertiary
condition affecting nerves causing muscle spasms as a result of low amounts of calcium in the blood caused by a deficiency of the parathyroid hormone
tetany
Pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertropophy make up what syanotic heart defect?, Boot-shaped heart, Cyanotic heart disease
tetralogy of fallot
Relay station for sensory information
thalamus
to be successful in a malpractice case, the injured patient must prove what?
that the members of the surgical team departed from the standards of care applicable to their profession and that this breach caused the injury
aura
the beginning of a seizure
Open fractures exist when
the break in the bone communicates with a wound in the skin. These fractures are usually considered contaminated, requiring measures to control potential infection.
Deontology
the ethics dealing with duty, moral obligation, and right action
personal liability
the legal responsibility for one's own actions or failure to act appropriately. Responsibility often means financial restitution for harms resulting from negligent acts
Garden and AO nomenclatures
the most popular classification for grading fractures
Aeger primo
the patient first
The choice of implant and method of fixation in a total knee replacement depend on what?
the predisposition of the bone, patient age and activity level, and surgeon comfort with a particular technique.
how is the pfannenstiel incision performed and what is the advantage to this incision?
the rectus muscles are separated in the midline and peritoneum is entered through midline vertical incision since the rectus muscles contract, there is minimal strain on fascial sutures enables a strong closure
what is an axillary node dissection?
the removal of the axillary nodes through an incision in the axilla. An axillary dissection is usually done through an incision separate from that for other breast operations. The removal and examination of the axillary nodes allow staging of the disease. Adjunct treatment can be more accurately planned when the pathologic stage is determined.
Statutory Law
the state constitutions and the statutes, or laws, enacted by state legislatures comprise state laws and are found in the various state codes
If either method demonstrates reduced cerebral perfusion, what will the surgeon do?
the surgeon may decide to use a temporary carotid artery shunt.
dura mater
the thick, tough, outermost membrane of the meninges
Pia Mater
the third layer of the meninges, located nearest to the brain and spinal cord
what is a radical neck dissection?
the tumor, all soft tissue from the inferior aspect of the mandible to the midline of the neck to the clavicle end posterior to the trapezius muscle, and lymph nodes are removed en bloc in the affected side of the neck.
what is an alternative approach to a traditional suture anastomosis?
the use of a mechanical stapling device. The device allows the surgeon to perform an end-to-end, end-to-side, or side-to-side anastomosis. An enterotomy is made close to the anastomosis site. The stapler is inserted, and the distal bowel is secured between the anvil and the head of the stapler. The anvil is then inserted into the proximal loop of bowel and secured to the center rod. The gap is closed, and the stapler is fired. The stapler is extracted through the enterotomy. The integrity of the anastomosis is verified, and the enterotomy is closed with sutures.
mechanical VTE prevention includes what?
the use of graduated compression stockings intermittent pneumatic compression devices on the lower extremities
all the fresh gas moving from the anesthesia machine to the patient flows through what?
the vaporizer
muscle relaxants affect what muscles? what muscles do they have little effect on?
they affect skeletal muscle they have little effect on cardiac or smooth muscle
surgery of esophagus involves what type of incision?
thoracoabdominal incision in the left chest resection of the 7th, 8th, and 9th rib or separation of the two appropriate ribs establishment of an anastomosis between esophagus and stomach
What nerve innervates the Latissimus dorsi muscle?
thoracodorsal nerve
3 open approaches used for esophagectomy
transhiatal esophagectomy T H E transthoracic esophagectomy T T E or Ivor Lewis En Bloc or tri-incisional esophagectomy
Defects in this can cause direct and indirect hernias
transverse fascia
Cranial nerve 5
trigeminal face sensation
cranial nerve 4
trochlear moves eye
veracity
truthfulness
percutaneous endoscopic gastrostomy or PEG tube
tube inserted into the stomach for long-term feeding
layers of arteries
tunica intima, thick tunica media, tunica adventitia
volvulus
twisting of the bowel can cut off blood supply and lead to gangrene; can be corrected by peristalsis
four most reliable sites for core monitoring of temperature
tympanic membrane distal esophagus nasopharynx pulmonary artery
preoperatively a physician may order what in anticipation of intraoperative blood/blood component transfusion?
type and scree type and crossmatch
I.V. technique
type of anesthesia that traditionally includes an induction agent such as propofol, combined with 30% to 40% oxygen and nitrous oxide, an amnesia/anxiolytic such as midazolam or diazepam, an analgesic such as fentanyl or morphine sulfate and a muscle relaxant
MAC (monitored anesthesia care)
type of anesthesia where a patient is very relaxed, but typically still aware
Inhalation technique
type of general anesthesia that may use propofol to facilitate rapid induction or patients may "breathe themselves down" with a potent agent such as sevoflurane, plus nitrogen and oxygen used with children to avoid inserting an I.V. catheter while they're awake
sentinel event
unexpected occurrence involving death or serious injury
Abduction pillow
used after total joint replacement for immobilization
Body exhaust suits
used as a defense against airborne bacteria
what is a thoracoabdominal incision?
used for operations on proximal portions of stomach and distal section of esophagus abdominal part usually made first for exploration, then extended across costal margin into chest if necessary
Arthroscopy
used on the shoulder, wrist, and knee often, and elbow, hip, and and ankle not often.
what is dynamic compression?
uses screw and plate configurations to apply forces through the fracture site.
What are acetabular non-cemented cups?
usually are porous coated and may have screw holes present to aid in anchoring the less than stable cup
Why do direct inguinal hernias occur?
usually from heavy lifting or other strenuous activity they protrude into the inguinal canal, but not into the cord and therefore rarely into the scrotum
what is the subcostal incision and why would it be used?
usually on right side used for gall bladder, common duct or pancreas left side is used for splenectomy
cranial nerve 10
vagus heart rate, digestion
a variety of what are inserted into the stomach as a gastrostomy tube, decompressing the stomach until normal bowel peristalsis returns
variety of catheters, examples are malecot, pezzer
two lateral ventricles, a third and fourth ventricle, reservoirs inside the brain that contain cerebral spinal fluid, The two lateral ventricles are in the cerebral hemispheres, the diencephalon is in the third ventricle, the midbrain holds the cerebral aqueduct and the fourth ventricle is the pons and medulla
ventricles of the brain
This radiographic study is done to locate tumors of the brain
ventriculography, encephalography, tomography
cranial nerve 8
vestibulocochlear hearing, balance
Broca's area
what is the most common site of lesion in AOS speech formation, portion of the left frontal lobe of the human brain that is specialized for language production
An epiphyseal separation occurs
when a fracture passes through or lies within the growth plate of a bone. When this occurs in a child with immature bone, retardation of limb length and growth may occur. These injuries require immediate and expert treatment.
Pantaloon Hernia
when direct & indirect hernia are present
type 4 hiatal hernia
when other organs such as the colon, spleen and pancreas and small bowel enter the hernia sac
ligament of trietz
when surgically running the bowel, you would start here;, connects from the diaphragm to the duodenal jejeunal flexure and helps mark the transition from duodenum to jejunum, divides upper and lower Gl
when is a surgical hiatal hernia performed?
when symptoms are severe it is usually done through a transabdominal approach
Type I hiatal hernia or sliding hiatal hernia is
widening of the esophageal hiatus and relaxation of the phrenoesophageal membrane allows the G E J to migrate into the thoracic cavity, often resulting in the development of GERD
cecum
widest and smallest part of the colon; first part of the large intestines; appendix is attached ;where the distal ilium enters and forms the ileocecal valve; intraperitoneal covered by mesocecum
Hb (Hemoglobin)
women 12-16 men 14-18
early removal of suture or staples invites what two things
wound dehiscence scar widening
In the presence of open fractures involving soft tissues, several associated conditions may arise, including
{1) secondary hemorrhage, (2) infection, (3) severe damage to soft tissues , (4) damage to blood vessels and nerves, and (5) Volkmann 's contracture (ischemic paralysis).
The surgical team should consider the following principles when providing care for the patient with fractures:
{1) the patient (extremity , fracture site) must be handled gently ; {2) initial general medical treatment must be provided; {3) equipment and personnel must be readily available to treat impending or existing shock and control hemorrhage ; ( 4) principles of aseptic technique must be maintained; (5) positioning must allow adequate circulatory and respiratory function with adequate exposure; and (6) patient comfort must be considered.
procedural considerations for breast reduction mammoplasty
-A basic plastic instrument set is used with the addition of a "cookie cutter" areola marker or a "keyhole" pattern marker, a marking pen, skin stapler, tape measure, ESU, and two closed-wound suction systems. -A scale for weighing specimens should also be available, and tissue from each side should be carefully weighed and marked appropriately. -The patient is placed in a supine position with arms slightly extended on padded armboards. -The hips should be positioned at the break in the OR bed so that the patient may be raised to a sitting position if necessary. -Standard prepping and draping are done. -Care should be taken not to remove the preoperative markings.
procedural considerations for breast augmentation mammoplasty
-A basic plastic instrument set is used, plus lighted fiberoptic retractors. -The breast implants are packaged in sterile containers from the manufacturer and given to the scrub nurse when breast size is determined. -The patient is placed in a supine position. The arms may be extended on armboards to approximately 60 degrees. -Alternatively, the hands may be placed over the lower abdomen, the elbows protected with foam padding, and the arms gently secured with adhesive tape to the OR bed. -Prepping and draping are carried out in the routine manner to expose the operative site.
Procedural considerations of Laparoscopic Roux-en-Y Gastric Bypass surgery
-All patients undergoing bariatric surgery need special consideration because they usually have associated serious comorbidities that place them at risk during the procedure. -A special OR bed that heightened risk can accommodate patients who weigh more than 350 pounds (159 kg) is required. -In addition to laparoscopic instrumentation and accessory supplies, extra-large blood pressure cuffs and extra- long trocars are necessary. -Positioning requires additional padded safety restraints, pressure-reduction devices to reduce the risk of pressure injury, and properly fitting IPCDS. -The perioperative nurse anticipates the potential for anesthesia assistance during intubation and airway management.
procedural considerations for mitral valve replacement
-Although the surgeon may intend to implant a specific type of prosthesis, patient-related factors or prosthetic valve complications may modify the plan. -A complete range of valves should be available as well as saline to rinse the glutaraldehyde storage solution from biologic prostheses, should they be used. -Pledgeted sutures of alternating colors are used. -Venting catheters and aspirating needles are used to remove air from the heart and ascending aorta. A small dental mirror may subvalvular structures.
what are the chances of aneurysm rupture?
-An aneurysm with a diameter of 6 cm or more (2 cm is considered normal) has a 42% chance to rupture in 5 years. -Rupture carries a 50% mortality.
what is the operative procedure for breast augmentation mammoplasty?
-Augmentation mammoplasty is done through circumareolar, inframammary, or axillary incisions. Either the underlying breast tissue or the pectoralis muscle from the chest wall is elevated. A pocket is dissected, and the implant is placed in the pocket. Electrocoagulation is used to achieve hemostasis. The pocket may be irrigated with an antibiotic solution before placement of the implant. The wound is closed in layers, and a light gauze dressing is applied. A bra or an Ace wrap may be used for support.
procedural considerations for thoracotomy
-Basic thoracic instrumentation is used and may include a sternal saw and stapling devices. -Preparation by the anesthesia care provider with careful monitoring of the patient is a priority. -Insertions of a double-lumen endotracheal tube, an arterial line for monitoring arterial blood gas samples, and a central venous line to ensure patient access for fluids are procedures performed by the anesthesia care provider. -An epidural catheter may be inserted for intraoperative and postoperative pain management. -Patient preparation by the surgical team includes positioning, placement of devices for prevention of complications (such as sequential compression stockings, a thermal blanket, and a dispersive pad), insertion of a urinary catheter, and on-going evaluation of patient care.
procedural considerations for lobectomy
-Basic thoracic instrumentation is used. -The patient is placed in a lateral position for a posterolateral incision; the supine position may be used for upper and middle lobe resections. -The procedure varies with the specific lobe to be removed depending on the anatomic structure.
procedural considerations for segmental resection
-Basic thoracotomy instrumentation is used. -The patient is placed in a lateral position for an incision appropriate for the area of tissue to be removed.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
-Conduct a preprocedure verification process to ensure all relevant documents and imaging studies are available before the start of the procedure -Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. -Mark the correct place on the patient's body where the surgery is to be done. -perform time out before the procedure start or or making surgical incision.
what are the causes of osteoporosis?
-Decreasing levels of estrogen and testosterone in the older adult -Inadequate intake of calcium or vitamin D -lack of weight-bearing activities, exercise, and physical inactivity -smoking; and caffeine intake
procedural considerations for a craniotomy
-Depending on the location of the pathologic condition , a craniotomy may be frontal, parietal, occipital, temporal, or a combination of two or more of these . -When turning a scalp flap for a craniotomy, the surgeon may peel the scalp back off the pericranium ; the bone flap is then elevated with the overlying muscles still attached (osteoplastic) , or the periosteum may be stripped off the skull before the bone flap (free flap) is turned. -The bone plate may be separated from the soft tissues, removed from the skull, and set aside for replacement at the end of the procedure. It may be placed in an antibiotic solution or an iodophor solution or wrapped in a saline-moistened sponge or one that has been saturated with an antibiotic solution or an iodophor solution. The bone plate is not removed from the sterile field. If it is not replaced, it may be frozen in a sterile container or saved and stored in a marked, unsterile container to use as a template for forming a cranioplastic plate at a later date. -The defect can be repaired without use of this template , however. If the bone is not separated from the soft tissues, it is turned back with the temporal muscle and soft tissues.
what are the procedural considerations of the external fixation surgery?
-External factors are applied using sterile technique with the patient under general or regional anesthesia. -Radiographic imaging ensures fracture reduction after closed manipulation, and proper pin placement. --Because the incision site is small to allow introduction of pins, a soft-tissue set appropriate to the site will be necessary. -Many different external fixators are available for use. -Irrigation and debridement at the fracture site and surrounding soft-tissue may be necessary if there is soft tissue damage, so pulsatile lavage with 3000 ml normal saline solution should be available. -A power drill will be used at the pin sites, and a periosteal elevator should be available for blunt or sharp dissection. An appropriate-sized pin cutter should also be available to shorten the pins if the need arises. -The dressing consists of povidone-iodine complex ointment, antibiotic impregnated-gauze, or Telfa with a gauze overwrap.
what is a non-cemented hip reconstruction?
-Fixation with a non-cemented prosthesis is initially accomplished by a tight fit and intimate contact of the implants within bone of substantial strength. -As with all prosthetic designs, it is essential to fill the medullary canal and wedge the prosthesis in as tightly as possible to provide temporary press-fit fixation. -These prostheses closely follow normal anatomic shape. -Only the instrumentation corresponding to the implant should be used. -Precise machining of the femoral canal must be ensured. -Acetabular components are usually press fitted, but many systems provide holes for screw fixation if stability of the prosthesis is in doubt. -Sufficient time is then allowed for the cancellous bone to heal by growing into the porous portions of the prosthesis. -The healing process requires the same amount of time as a long bone cortical fracture (approximately 3 months). -Extreme caution is taken postoperatively to protect the operative hip from excessive compression, rotation, and shear stresses.
procedural considerations for femoral shaft fractures
-General or epidural anesthetics are used. -The patient is placed on the fracture table in the supine position, traction applied, and the fracture manually reduced and confirmed with fluoroscopy. -If the fracture is profoundly unstable, care must be taken during manipulation to prevent neurovascular complications. -For open intramedullary fixation , extra retractors and bone instruments may be required. -For a percutaneous reduction, a soft-tissue set and large-bone set are required in addition to the intramedullary nail implants and associated instruments , a power reamer and drill,and long guide wires for reamers. -This procedure requires the use of fluoroscopy. -A skeletal traction tray with Steinman pins may be necessary.
what is hybrid hip arthroplasty?
-Hybrids involve cementing one component, usually the femoral stem, and then inserting a metal-backed, porous-coated acetabular component in a press-fit state. -Hybrid arthroplasty was very popular for a time but two factors have made this a controversial procedure. -The first relates to research that demonstrates that wear debris is increased with the larger metal to polyethylene interface present in the metal-backed, porous-coated acetabular component. -The second relates to cost. The metal-backed, porous-coated acetabular component is significantly more expensive than the all polyethylene component. -Consequently, patient selection is very important in determining which type of component is best.
what is a sentinel node biopsy and why is it performed?
-Identification and microscopic examination of the sentinel nodes, the first lymph nodes along the lymphatic channel from the primary tumor site, will help in determining the need for additional or more extensive surgeries and treatments and potentially adverse outcomes for the patient. -The sentinel node is not located in the same site in every patient. -This procedure helps to focus pathologic attention in more detail on a small amount of tissue to determine the evidence of micrometastatic disease. -Patients with histogically negative lymph nodes can have a greater likelihood of survival than patients with metastatic lymph nodes. Evidence of a positive node results in an axillary node dissection and adjunct therapy.
Procedural considerations for a pyloroplasty
-Instrumentation and supplies include laparotomy set and a self-retaining retractor. -If closure of the pylorus is to be hand sewn, a long 3-0 absorbable suture on a tapered GI needle and several 3-0 silk sutures on the same type of needle are available. -If the pyloric closure will be with a stapler, linear stapler is available. -The procedure requires general anesthesia with endotracheal intubation. -Patient placement is supine. -The abdomen is prepped. -Unless gastric distention is present, no insertion of an NG tube. -A urinary bladder catheter may not be needed because the time needed to complete this procedure is relatively short.
what are intertrochanteric fractures and who is most likely to suffer them?
-Intertrochanteric fractures most frequently occur in older patients . -The fractures usually unite without difficulty . -However, because the lower extremity is externally rotated at the fracture site , internal fixation is necessary to prevent malunion. -Internal fixation allows patients to be mobilized earlier, thereby decreasing mortality and morbidity.
procedural considerations for a laminectomy
-Laminectomy can be done with the patient in the prone, lateral, knee-chest, or sitting position. -It is performed on the cervical, thoracic , or lumbar spine. -Laminectomy instruments include the basic neurosurgical set, the back retractor of the surgeon 's choice , and an assortment of specialty rongeurs.
Procedural considerations for Meckel diverticulectomy
-Laparotomy and GI sets are required. -Linear stapling devices should be available. -Patient positioning is supine, and general anesthesia is administered. -The anesthesia provider may insert an NG tube after intubation. -Insertion of an indwelling urinary catheter precedes abdominal skin prep.
procedural considerations for a TRAM flap
-Markings on the patient are made preoperatively with the patient in an upright position. -A basic plastic instrument set is used as for the latissimus dorsi flap. The patient is positioned supine with arms extended on armboards. -Positioning the patient for this procedure is particularly difficult because of the need to promote closure of the abdominal wound, support circulation to the flap, and protect the patient from injury. -The OR bed is often flexed ; additional padding of the lower extremities may be required. -The chest and abdomen are prepped and draped simultaneously .
what is a rotator cuff tear?
-Most rotator cuff tears occur through the insertion of the tendinous fibers of the supraspinatus muscle that attaches onto the greater tuberosity of the proximal humerus. -In severe tears , the remaining tendons of the cuff, the subscapularis, infraspinatus, and teres minor, may also be involved.
what are the advantages and disadvantages of a suprapubic prostatectomy?
-One advantage of the suprapubic approach is that it allows access for surgical correction of any existing bladder condition such as vesical calculi or vesical diverticula . -Control of bleeding is a major consideration in any prostatectomy and is one disadvantage of the suprapubic approach . -Because the prostate is located beneath the symphysis pubis, ligation of bleeding capsular vessels is difficult. -However, control of hemorrhage and replacement of blood loss, coupled with skilled perioperative nursing care and early mobilization of the patient, have greatly minimized complications.
what are the features of PMMA cement?
-PMMA adheres to the polyethylene and metal but not to the bone. -It fills the cavity and interstices of the bone and forms a mechanical bond. -PMMA is manufactured as a liquid monomer and a powder and is mixed under sterile conditions by the scrub nurse in the operating room at the time of implantation. -It usually takes 10 to 12 minutes to harden. -Because of the potentially harmful effects of PMMA fumes to the nasal epithelium, an exhaust system should be used during the mixing process.
what groups of people are usually affected by partial rotator cuff repairs and complete rotator cuff repairs?
-Partial rotator cuff tears and impingement usually affect people in the middle decades of life or later and are often attributable to a long-term degenerative process. -Complete tears of the rotator cuff occur after accidental injury of younger patients such as pitchers and football quarterbacks.
Nonreimbursable claims most relevant to perioperative patient include the following
-Pressure ulcers, stages III and IV Falls trauma -Surgical site infections (SSIS) after bariatric surgery, certain orthopedic procedures, and coronary artery bypass surgery (mediastinitis) -Vascular catheter-associated infections -Catheter-associated urinary tract infections (CAUTIS) -Administration of incompatible blood -Air embolism -Foreign objects unintentionally retained after surgery -Wrong patient, wrong procedure, or wrong site surgeries -Deep vein thrombosis (DVT) -Pulmonary emboli associated with knee and hip replacements -High readmission rates to facility within 30 days of discharge
pulse lavage and routine irrigation serves what purpose during total joint surgery?
-Pulsatile lavage systems or routine irrigation may be used to keep tissues moist, remove debris, and dilute bacteria, which may be present. -Additional antibiotics are added to the physiologic saline solutions used for irrigation and to PMMA
what are the procedural considerations for a suprapubic prostatectomy?
-Spinal, epidural,and general anesthesia may be equally acceptable types of anesthesia for patients having a suprapubic prostatectomy, depending on their medical condition. -The patient is placed in a slight Trendelenburg position with the umbilicus elevated and the legs slightly abducted. -skin preparation, draping, and instrumentation are as described for retropubic prostatectomy.
what is a suprapubic prostatectomy?
-Suprapubic prostatectomy is the removal, through a transvesical approach, of benign periurethral glandular tissue obstructing the outlet of the urinary tract. -A low midline, or Pfannenstiel , incision may be used.
procedural considerations for pneumonectomy
-The basic thoracic instrumentation is used. -The patient is placed in the lateral position for a posterolateral incision.
procedural considerations in closed reduction fracture surgery
-The choice of anesthesia depends on the site of fracture and patient condition. -A closed reduction can be performed with {1) infiltration of local anesthetic agent into the fracture sit (hematoma block), {2) intravenous regional anesthesia (Bier block), (3) regional or spinal nerve block, or (4) general anesthesia -Closed reduction may take place before an open procedure to reduce the fracture site. -Skeletal traction may also be applied to the fracture site, requiring a surgical skin prep and application of drapes. The appropriate casting or brace materials should be readily available to prevent loss of fracture reduction. Supplies should be available in the event it is necessary to open the fracture site and apply fixation.
what is the common goal of rotator cuff tear treatments?
-The common goal is to restore joint stability, alleviate pain, and allow the patient to return to normal activities. -In some instances a significant reduction in preinjury activity may be permanent.
steps in the closed fracture surgery
-The fragments are manipulated into alignment by the surgeon, using manual traction. -Reduction is confirmed using radiography (x-ray or fluoroscopy). After reduction has been obtained, the fracture is immobilized with casting material or bracing technique.
procedural considerations for a femoral-popliteal bypass
-The patient is placed in a supine position. -The hip is externally rotated and abducted with the knee flexed -Prepping and draping include the entire groin and leg. -The instrument setup includes the basic minor and vascular sets, plus the following: Gelpi retractors, Garrett or Weitlaner retractors, a tunneler, and supplies and equipment for operative arteriograms.
what are some procedural considerations of intertrochanteric fracture surgery?
-The patient is placed in the supine position on the fracture table, and the fracture is reduced by manipulating the extremity and confirming with fluoroscopy. -Various internal fixation devices, including Ambi , Free lock, DHS hip screws, and medullary fixation may be used. -Success of the procedure is determined by bone quality, fragment configuration, ability to reduce adequately, implant design, and implant-insertion technique . -Intraoperative blood loss is minimized because the hip joint is not opened. -A soft-tissue and large bone set are required, in addition to the compression hip screw instrumentation and implants, bone-reduction and plate-holding clamps , and a power drill and reamer.
procedural considerations for Repair of collateral or cruciate ligament tears
-The patient is placed in the supine position with a tourniquet applied to the upper area of the thigh. -A surgical prep is done from the upper area of the thigh down to and including the foot. -Soft-tissue instruments, arthroscopy instruments, ACL reconstruction instruments such as Steinman pins and reconstruction guides, and a tension isometer are required. -A power drill, microsagittal saw, and burrs are essential. -The fixation device of choice should also be available. Meniscal repair instruments should be in the room.
what are the procedural considerations in the anterior cervical disk with fusion?
-The patient is placed in the supine position, with the head turned very slightly to the left and with the right hip elevated for exposure of the iliac crest (if the bone dowel is to be taken from the iliac crest). -The basic minor dissecting set is used.
procedural considerations for AAA repair
-The patient is placed in the supine position. -The skin is prepped for a midline abdominal incision,and draping is completed to permit access to the groin region for possible exploration of femoral arteries . -The pedal pulses should be marked before the beginning of the procedure so that they may be located immediately if the surgeon requests a check of the pulses. -This assessment of pulses can be done manually or with an ultrasonic instrument (Doppler probe)
procedural considerations for a total knee replacement
-The patient is placed in the supine position. A tourniquet is applied to the upper thigh. -The surgical prep is completed. -A soft-tissue set, large-bone set, the total knee instruments, trials, and implants of choice, a power drill and saw, PMMA and cement supplies, and a pulse lavage will be required.
procedural considerations of femoral neck fractures
-The patient is placed on a fracture table under general or regional anesthesia (spinal or epidural). -Slight traction and external rotation are adjusted on the affected side. -A soft-tissue set and large-bone set are required as well as the fixation device of choice with instrumentation, Kirschner wires, Cobra retractors, a power drill, and fluoroscopy.
what are some procedural considerations of a radical neck dissection?
-The patient is placed on the OR bed in a supine position. General endotracheal anesthesia is administered before the patient is positioned for surgery . A shoulder roll may be placed to slightly hyperextend the neck with the head slightly turned to the contralateral side. The head of the bed may be slightly elevated to reduce venous bleeding. -During the operation the anesthesia provider works behind a sterile barrier at the patient's unaffected side. -The preoperative skin prep is extensive, including the neck, lower face, and upper chest. The patient's neck is draped so as to leave a wide operative field. -For the rare occasion when a dermal graft is to be harvested to cover and protect the carotid artery (as when a patient has received extensive previous radiation therapy), the thigh area is also prepped and draped with sterile towels in readiness for obtaining a dermal graft before closure of the neck wound. It is usually more convenient to use the thigh on the same side as the neck dissection. -Patient and family education includes tracheostomy care (if applicable), pain management,care of the surgical incision, reportable signs and symptoms, healthful behaviors, and review of physical therapy exercises. These include range-of-motion exercises for the neck, shoulder , and arm muscles on the affected side.
procedural considerations for a carotid endarterectomy
-The patient is placed on the operating room bed in a supine position with the head supported on a head support. -The head is turned away from the operative side, and the neck may be slightly hyperextended. -A roll may be placed between the scapulae.
procedural considerations for a cemented hip reconstruction
-The patient is positioned in the lateral decubitus position and secured in place with anterior and posterior bolsters. This position is essential to ensure correct anatomic placement of the acetabular cup. -Bony prominences should be adequately padded. -A surgical preparation is completed from the level of the umbilicus down to and including the foot, and the patient is draped. -The radiographs are overlaid with the implant templates. -A soft-tissue set and large-bone set are required. -In addition, the total hip implants and corresponding instrumentation, acetabular reamers, hip retractor set, power reamer driver and saw, and pulse lavage with a 3-liter bag of NS will be needed. -If PMMA is used, femoral canal suction wicks, a cement restricter and its inserter, and PMMA and supplies used to mix it will be needed. -If a trochanteric osteotomy is performed, the equipment of choice for its reattachment will be needed. -Revision of total hip arthroplasties require the same instrumentation as cemented total hip in addition to cement removal instrumentation, fluoroscopy, and the revision implants and their corresponding instrumentation.
procedural considerations for latissimus dorsi flap
-The skin island and area of dissection for the latissimus dorsi flap are drawn on the patient's back before prepping and draping. -The patient is placed in a lateral position with the arm on the operative side extended and elevated on a sling support. -Pressure points are padded and protected by the use of pillows and sheet rolls, and the patient is stabilized on the OR bed. -The patient is prepped and draped to expose the affected breast area and muscle and the donor site. -A basic plastic instrument set is used, plus long Metzenbaum scissors, long DeBakey forceps, vascular instruments, Deaver retractors, Freeman areolar markers, lighted breast retractors or a headlight, a Doppler probe, and a second ESU. -Two surgical teams may work simultaneously, one freeing the muscle flap and the other preparing the recipient site.
what is a Removal of Anterior Cervical Disk with Fusion (Cloward Technique)?
-This procedure is done to relieve pain in the neck, shoulder, and arm caused by cervical spondylosis or a herniated disk. -It entails removal of the disk and fusion of the vertebral bodies. Bone dowels for the fusion are obtained from the patient's iliac crest or from a bone bank.
the latissimus dorsi muscle is
-a wide, flat muscle extending over the midthoracic portion of the back and inserting into the humerus -its blood supply comes from the thoracodorsal artery and perforators from the upper lumbar arteries and the intercostals vessels -this rich vascularity allows the surgeon flexibility in orienting and positioning the flap to the pattern of the deficit on the anterior chest wall.
what are two methods of fixation in total joint arthroplasty?
-application of a precoat of PMMA to the femoral stem to enhance prosthesis-to-cement-mantle bonding. -attachment of a porous metal surface to parts of the femoral stem and the entire outer surface of the acetabular component
what are semi-tubular plates?
-are less rigid and do not have the ability to produce dynamic compression. -this type of plate is used in the forearm and fibula, where weight bearing, which could break the plate, is not a factor.
what are fully constrained prostheses?
-are linked together with pure hinges, rotating hinges, and nonhinged designs. -They are used in the presence of considerable bone loss, instability, deformity, and revision surgery where there has been significant bone loss. -Fully constrained prostheses do not provide a normal range of motion, and such a lack leads to excessive wear and implant loosening and breakage.
what are unicompartmental implants?
-are used to replace just one opposing articular surface (medial or lateral) of the femur and tibia. -These implants, however, lost popularity as a result of biomechanical and technical pitfalls. -They account for less than 10% of all total knee replacements performed in the United States.
closed reduction fractures may be treated by
-closed reduction, or manipulating the fragments into position without incising the skin. This is the treatment of choice when possible to decrease the opportunity for infection, improve results (including bone union of the fracture) , and minimize the recovery period. -Significant bone comminution, periosteal damage, or soft tissue entrapped within the fracture site may result in complications .
what are the two types of femoral stems?
-collarless or have collars that sit down on the resected femur. -Collars will produce forces upon the bone and may be desired in cases of osteoporotic bone, where bone genesis may be diminished because of the disease process.
what are cancellous bone screws?
-screws that feature threads that are broader and farther apart than those of cortical screws. -Cancellous screws are used in cancellous bone, which is less dense than cortical bone; then bone accumulates within the threads to provide the purchase for fixation -like cortical screws, cancellous screws can traverse fracture sites and hold plates onto bone. The screw threads do not completely traverse the bone through the opposite cortex.
what are cortical bone screws?
-screws that have threads that are close together and narrower than other types of threads. -These threads run along the entire length of the screw and transfix bone, gaining purchase (grab) of bone cortex.
why is closed reduction considered a misnomer?
-since small openings in the soft tissue and bone are made to facilitate introduction of the devices. -these incisions are considerably smaller than those created when repairing the fracture using open reduction.
Procedural considerations for a graham patch closure
-standard laparotomy instrument set is needed for open approach. -The laparoscopic technique requires basic laparoscopy instruments and equipment including four trocars, laparoscopic needle holders, dissectors, graspers, and scissors. -The technique for closure of the perforated ulcer is the same for laparotomy and laparoscopy with the exception of using intra- corporeal suturing techniques for the laparoscopic approach.
Abdominal aortic aneurysmectomy is
-surgical obliteration of the aneurysm, which may or may not include the iliac arteries, with insertion of a synthetic prosthesis to reestablish functional continuity. - AAAs are usually asymptomatic and found on routine physical examination. They occur more frequently in men than in women.
advantages of external fixation
-the absence of casting material -fracture stabilization at a distance from the injury site -ability to perform subsequent procedures such as skin grafts or vascularized grafts -minimal joint interference -early mobilization -the ability to use internal fixation or other skeleton-fixation devices at the same time or sequentially.
what can affect the blood supply to the femoral head and contribute to death of the femoral head and failed fixation?
-the degree of displacement tamponade pressure from intracapsular bleeding -delays in reduction and fixation
Mitral valve replacement (MVR) is
-the excision of the mitral valve leaflets and replacement with a mechanical or biologic prosthesis. -Generally, the mural (posterior) leaflet and associated chordae and papillary muscles are retained to maintain ventricular configuration, thereby enhancing postoperative ventricular function. -If possible, the anterior leaflet is also retained if it is not too heavily calcified. -Median sternotomy is performed in most cases, but right thoracotomy incisions are useful in selected cases. -Minimally invasive procedures on the mitral valve can also utilize right thoracotomy incisions or ports.
the most reliable autogenous tissue is
-the middle third of the patellar tendon and a block of patella. -To minimize necrosis and maintain graft strength, the fat pad with its blood supply may be preserved along with the patellar tendon.
Elective surgery patients have a pretransfusion blood sample taken when?
1-7 days before surgery
WBC: eosinophils (EOS)
0-7%
BILIRUBIN: TOTAL
0.2 -1.3 mg/ dL
RETICULOCYTES: ADULT
0.5 1.5%
RETICULOCYTES: INFANT
0.5 3.1%
CREATININE
0.5-1.4 mg/ dL
steps in operative procedure for carotid endarterectomy
1. A longitudinal incision is made over the area of the carotid bifurcation. The Weitlanr self-retaining retractor may be placed for exposure. 2. With Metzenbaum scissors, the soft tissue is dissected for exposure of the carotid artery and its bifurcation. 3. A moistened umbilical tape or vessel loop is passed around the vessel for ease of handling. The patient is systemically heparinized. 4. The external, common, and internal carotid arteries are clamped. 5. With a #11 scalpel blade, an arteriotomy is made over the stenotic area. The incision is lengthened with a Potts angulated scissors to expose the full extent of the occluding plaque. 6. With a blunt dissector, the plaque or plaques are dissected free from the arterial wall. Heparin solution is used as an irrigant to clean the intima. 7. The arteriotomy is closed with fine vascular sutures . A synthetic (polyester or polytetrafluoroethylene) or autogenous (vein) patch graft may be used to restore the arterial lumen if it is small. Before complete closure, blood flow is temporarily restored through the arteries to wash away any free plaques, air, or thrombi. For this to be done, the occluding clamps are opened and closed individually, with flushing of any debris away from the internal carotid artery. 8. The occluding clamps are removed from the external and common carotid arteries; the internal carotid artery clamp is removed last. This sequence ensures that any minor debris missed will be flushed harmlessly into the external rather than the internal carotid artery. 9. Additional interrupted sutures may be needed to control leakage. 10. A drain is inserted via a separate stab incision. 11. The wound closure is accomplished inthe usual manner, and dressings are applied.
operative procedure for CABG with Arterial and Venous Conduits
1. A median sternotomy is performed as described. 2. Conduit preparation a. IMA - The IMA is dissected free from its retrosternal bed. A special retractor can be used to expose the IMA until the necessary length is obtained. Occasionall , both right and left IMAs are used. Heparin is given before arterial grafts are clamped and cut to prevent intraluminal thrombosis. Minimally invasive IMA dissection is performed with a special retractor inserted into the left anterior thoracic incision at the level of the fourth intercostals space. A light source is usually required to visualize the proximal IMA. Ligation of arterial branches and venous tributaries is performed with hemostatic clips and electrocoagulation. 3. Radial artery. A longitudinal incision is made 3 cm distally to the elbow crease lateral to the biceps tendon, ending 1 cm before the wrist crease. The artery is exposed and mobilized with a vessel loop and harvested as a pedicle with adjacent veins and fatty tissue. The artery is ligated proximally and distally after systemic heparinization. Papaverine may be injected into the lumen to reduce spasm. The arm is closed over a small suction drain. 4. Gastroepiploic artery. When an additional arterial conduit is required, the gastroepiploic artery may be used. 5. Saphenous vein. The necessary length of saphenous vein is harvested from one or both legs, and tributaries are ligated. The distal end of the vein is identified to place the vein in a reversed position so that the semilunar valves do not interfere with the flow of blood. The vein is flushed with heparinized blood or saline and kept moist until needed. Minimally invasive saphenous vein harvesting is performed through one to three incisions over the vein at the knee and at the ankle and the groin if necessary. The vein is located under direct vision; the remaining length of vein is excised by means of video-assisted endoscopy and endoscopic scissors. An endoscopic clip applier is used to clip tributaries on the leg side; tributaries on the vein side may be clipped or ligated with suture after removal from the leg. To reduce postoperative tunnel dead space and minimize fluid accumulation, the leg is wrapped with a pressure bandage. 3. Cardiopulmonary bypass with mild hypothermia is instituted. If CABG is performed without CPB, the patient is not cooled. CPB standby is usually available. Antegrade-retrograde cardioplegic solution is infused after the aorta is cross-clamped. 4. Coronary anastomoses. Anastomoses using saphenous vein, free arterial grafts, and in situ arterial grafts (such as IMA and gastroepiploic artery) are performed. e. The affected coronary artery is identified, and a small incision is made into the artery. The graft conduit is beveled to approximate the incision (side-to-side jump grafts may be performed as well). f. The anastomosis is made with fine cardiovascular sutures. Before the anastomosis is completed, the distal coronary artery may be probed to ensure patency. g. Steps a and bare repeated for each subsequent anastomosis. 5. The distal anastomosis of the IMA to the coronary artery is done as described for the anastomosis of the saphenous vein graft to the coronary artery. No aortic (proximal) anastomosis is required because the IMA remains intact at its takeoff from the subclavian artery. 6. Aortic anastomoses h. Aortic anastomoses may be performed while the aorta is cross- clamped; or the aortic clamp is removed, the heart is defibrillated, and the anastomoses are completed after each distal (coronary) anastomosis. When the proximal (aortic) anastomoses are performed on a beating heart, the aorta is partially occluded with an angled vascular clamp, and a small segment is resected, approximately the diameter of the vein graft. An aortic punch may be used for this. i. The conduit is anastomosed, end to side, to the aorta with fine vascular sutures. The partial occlusion clamp is removed, so that the proximal portion of the vein can fill with blood. Needle aspiration of the vein graft is performed to prevent air from entering the coronary circulation. j. When proximal anastomoses are performed during a single period of cross clamping, air is aspirated from the grafts before the cross-clamp is removed. 7. The aortic anastomoses of the vein grafts are usually marked with clips or rings for future identification. 8. Cardiopulmonary bypass is discontinued , and the sternum is closed. 9. Minimally invasive procedures A. These are indicated in patients with lesions easily accessible through an anterior thoracotomy, such as narrowings in the left anterior descending (LAD) and diagonal coronary arteries. When endovascular CPB and cardioplegic solution is used, more lateral and posterior arteries (obtuse marginal and right coronary arteries) may be grafted because ventricular fibrillation secondary to stimulation of the heart is obviated with induced cardioplegic arrest. A double-lumen endotracheal tube may be inserted so that the left lung can be hypoventilated to enhance visualization of the LAD (and the IMA). B. In a beating heart CABG, cardiac contraction poses a technical difficulty for the surgeon in creating a precise anastomosis. Various coronary stabilizers are available to reduce the motion of the heart in the vicinity of the anastomosis. These are often attached to the retractor, thereby freeing the hands of the surgeon to sew. Pharmacologic cardiac motion reduction may be employed; beta-blockerdrugs and adenosine have been used by some surgeons. The anastomosis of the IMA to the LAD is performed under direct, albeit limited, vision. m. In arrested heart procedures, the IMA-to-LAD anastomosis is constructed on a quiet heart. Access to the graft site is through one or more left anterior thoracic ports.
what are the steps in the abdominoperineal resection surgery?
1. A midline incision is made. 2. After thorough exploration of the abdominal cavity, the surgeon determines the extent and operability of the lesion. 3. If a resection is to be done, the surgeon retracts the sigmoid colon to the right side. 4. The peritoneum on the left of the mesocolon is divided. The incision into the peritoneum is made opposite the main branches of the inferior mesenteric vessels and extended into the pelvis and around anterior to the rectum. 5. The pelvic peritoneum is mobilized by blunt dissection to form the left side of the new pelvic floor and permit early visualization of the left ureter. 6. The peritoneum is incised on the right side until the incision connects with that made on the left. 7. The right ureter is identified and protected. 8. The blood supply of the portion of intestine to be removed is isolated and ligated. 9. Care must be taken not to damage the left colic artery, which will supply the blood to the colostomy. 10. The mesentery is tied to permit greater exposure in the operative field. 11. The surgeon frees the rectum, usually as low as the sacrococcygeal junction . Care is taken to avoid injury to the presacral nerves, which could result in sexual and bladder dysfunction. 12. After the bowel is freed, the distal segment is transsected with a linear stapling instrument. 13. The proximal margin of resection is examined and transsected. The bowel and mesentery are removed from the abdominal cavity. 14. The surgeon prepares the permanent colostomy by extending the stump through the abdominal wall. 15. The colostomy will be "matured" (sutured externally to the abdominal wall tissues so that the mucosa is everted into a raised and secured ostomy) after abdominal closure. 16. The combined excision and perineal dissection is initiated when the lesion is determined to be respectable. 17. To prevent contamination, the anus is often closed with a purse-string suture. 18. An incision is made around the anus in an elliptical manner outside of the sphincter muscles with a generous margin of perianal skin. 19. The anus is grasped with an Allis or Ochsner forceps and tipped upward to enable its attachment to the coccyx to be severed more readily. 20. Electrodissection is used. The levator ani muscle is exposed; while the finger of the surgeon is held beneath it, it is divided as far from the rectum as possible. 21. . All bleeding points are clamped and tied. 22. The Foley catheter allows the surgeon to get as close to the bladder as possible without damaging it. 23. After the anococcygeal raphe is divided, the surgeon's hand is thrust up into the hollow sacrum to free the rectum by blunt dissection, grasp the upper end of the distal fragment, and deliver the stump through the perineum. 24. Drains may be placed into the pelvic cavity and exteriorized through stab wounds in the buttocks. 25. The surgeon is regowned and gloved before returning to the abdominal wound. 26. When all bleeding is controlled, the incision is closed. If two teams are not available for synchronous excision of the perineum, the perineal portion of the operation is performed after the abdominal resection is complete. In this case the abdomen is closed and the remaining rectosigmoid stump is excised perineally. If two teams are not available for synchronous excision of the perineum, the perineal portion of the operation is performed after the abdominal resection is complete. In this case, the abdomen is closed and the remaining rectosigmoid stump is excised perineally.
what are the steps in the operative procedure to insert tissue expanders?
1. A submuscular pocket is created for the temporary expander. In addition, a tunnel and pocket are created at an adjacent site from the main pocket for the placement of the injection dome and the connecting tube. 2. The tissue expander is tested before insertion for watertight integrity. 3. The expander is then inserted, the reservoir positioned subcutaneously and connected, the wound closed, and the expander filled with sterile saline solution until slight blanching of the skin is achieved. The amount is recorded on the patient record. On occasion, the surgeon may choose to instill 3 to 5 ml of methylene blue into the expander, which can help to identify the proper location of the fill tube postoperatively. 4. Additional inflation of the tissue expander usually begins 2 to 3 weeks after initial placement when healing of the incision line has started and thereafter on an average of every 7 days. The time from implant insertion until complete fill varies according to the desired maximum stretch. 5. After the desired expansion has occurred, the temporary expander is exchanged for a permanent prosthesis.
what are the steps in the operative procedure of an anterior cervical disk with fusion?
1. A transverse skin incision is made on one side of the neck (usually the right) directly over the involved disk space; curved mosquito hemostats or Michel clips are placed on the skin edges for hemostasis. 2. A Weitlander retractor is placed, and the platysma muscle is divided with Metzenbaum scissors and tissue forceps with teeth or with the electrosurgical cutting blade. 3. The medial edge of the sternocleidomastoid muscle is defined with the scissors by blunt and sharp dissection. 4. A vertical plane of dissection between the carotid sheath laterally and the trachea and esophagus medially is created by blunt finger dissection. This plane is held open with Cloward hand retractors, Meyerding finger retractors, or U.S. Army retractors. 5. The anterior surface of the spine is identified, and the long muscles of the neck are peeled off the anterior surface of the spine with periosteal elevators. Bleeders are coagulated with a dural elevator or bayonet forceps. 6. A 20-gauge spinal needle is inserted a short distance into the disk space, and a lateral x-ray examination is taken to determine the level of the exposure. At this time a C-arm may be brought in to give instantaneous localization of the desired level. 7. While x-ray films are being developed, the neck incision is covered, an incision is made over the iliac crest, and straight hemostats are applied and retracted. 8. Soft tissue is dissected until the crest is reached using Mayo scissors, tissue forceps , electrosurgical cutting blade, and Richardson retractors for exposure . 9. A Hudson brace with the Cloward dowel cutter is used to remove the bone graft. (Care must be exercised to use dowel cutter, Cloward guide, and cervical drill guards matched for size.) The dowel should have cortex at both ends. The dowel hole is inspected and waxed if needed. The incision is packed with gauze sponges and covered. 10. The Cloward self-retaining retractors (two long and two short blades) are inserted into the neck incision. The right blade should be slightly longer than the left. Care is used to protect the carotid artery and the esophagus. A combination of sharp and dull blades is used to acquire the best retraction. If a toothed blade is used, the teeth are carefully hooked beneath the long muscle of the neck. 11. A #15 or 11 blade on a #7 knife handle is used to cut into the disk space; a fine pituitary rongeur is used to remove the disk material, which is saved and weighed as a specimen. A vertebral spreader is inserted into the vertebral space to widen the area, and further disk material is removed with the rongeur or small curettes (angled or straight, nos. 0 to 4-0) until the entire surface of both vertebrae are clean. A Surgairtome with small burr may also be used. 12. The Cloward bone guide is inserted into the disk space to measure its depth. 13. After the drill guard is adjusted so that the drill can protrude no farther than the measured depth of the interspace , the cervical drill guard is inserted around the disk space, with the aid of a mallet, until the points catch the vertebral bodies above and below the interspace. 14. After the guard is in place, the vertebral spreader is removed or spread to a more limited degree. 15. The Cloward drill on a Hudson brace is inserted into the guard, and the hole is drilled. (The bone dust on the drill point is inspected and saved in a medicine glass .) Cottonoid strips or topical hemostatics are used for active bleeders. Bone wax should not be used on the walls of the disk hole. Thrombin-soaked cottonoid pledgets may help control bleeding. 16. The bottom of the hole is checked for further disk or cartilaginous material, which is removed. The guide may be removed and replaced, and drilling may be done several times until the desired depth is reached. The drill and guide are then removed. 17. Further bone is removed by use of the Cloward cervical punch or curettes until complete anterior decompression of the nerve root or dural sac is obtained. Nerve hooks may be used here for demonstration of adequate dissection. The Surgitome 200 or Midas Rex may also be used. 18. The depth of the hole is measured and compared with the dowel. The dowel may be trimmed with a drill, rongeur, or rasp. The shaped dowel attached to the impactor is inserted into the hole and tapped into place. The double-edged impactor is used to drive the dowel in deeper if necessary. The spreader is removed, and bone dust may be applied. 19. Hemostasis is obtained and the wound irrigated; the vertebral spreader and retractors are removed, and both incisions are closed. Other instrumentation designs and techniques have been developed for the anterior approach to cervical disk disease. The first assistant needs to be aware of these to accommodate the neurosurgeon's preference.
operative procedure in Exploration of Above-Knee Popliteal Artery
1. A vertical incision is made along the medial aspect of the lower area of the thigh. If the popliteal artery is diseased, an incision below the knee is necessary to expose the distal popliteal artery. 2. A Weitlaner retractor is used to retract the muscles and expose the artery. 3. The knee is flexed, the popliteal artery is dissected free, and a moist umbilical tape is passed around the popliteal artery. It may be desirable at this time to perform arteriograms if doubt exists about the patency of the popliteal artery or distal arterial tree. 4. The saphenous vein is exposed when the femoral and popliteal incisions the length of the thigh are joined or through multiple short incisions along the medial area of the thigh. If the vein is suitable, the necessary length is resected or prepared for in situ grafting. If a prosthesis is used, the length and size are determined, and the graft may be preclotted as previously described. 5. The saphenous vein is prepared for use by carefully ligating side branches with fine silk. Finally, because of venous valves, the vein is reversed so that the end originally in the groin is anastomosed to the popliteal artery. 6. For a synthetic graft, the tunneler is passed beneath the sartorius muscle from the popliteal fossa to the groin. 7. The graft is carefully pulled through the tunnel and positioned to prevent kinks or twists. 8. An incision is made into the femoral artery with a #11 knife blade and extended with a Potts angulated scissors. 9. The graft is anastomosed to the artery with fine vascular sutures. 10. The knee is flexed, and vascular clamps are placed on the popliteal artery at the site of the distal anastomosis. 11. An incision is made into the popliteal artery as explained for the femoral arteriotomy. 12. The graft is sutured to the popliteal (or tibial) artery, and before completion the femoral occluding clamp is momentarily opened to eliminate air and debris. 13. All occluding clamps are removed, and the graft is assessed for anastomotic leaks. 14. The incision is closed as described previously.
operative procedure in Exploration of Common Femoral Artery
1. A vertical incision, extending downward about 3 to 5 inches along the medial aspect of the thigh, is made over the femoral artery below the inguinal area, and a self-retaining retractor is inserted. 2. The common femoral artery is located, and the artery is dissected in both directions for complete exposure. 3. Moist umbilical tapes or vessel loops are passed around the common femoral, the superficial femoral, and the deep femoral arteries.
steps in the operative procedure for a non-cemented hip reconstruction
1. After the incision is made the capsule is entered, and the femoral head is dislocated. 2. A pilot hole is established in the trochanteric fossa as an intramedullary reference point. 3. Reaming of the intramedullary canal is then performed in a progressive manner with fully fluted rigid reamers. 4. A femoral neck osteotomy is achieved by positioning an osteotomy template along the axis of the femur and cutting at the level of the collar. 5. Attention is directed to the acetabulum, which is cleared of soft tissue and reamed with hemispheric reamers. 6. Trial acetabular sizers are placedto determine the correct position and size of the prosthetic component. 7. A hollow osteotome is used in the femoral canal to connect the pilot hole to the osteotomy site. 8. Femoral broaches are then inserted to enlarge the intramedullary space for trial insertion. 9. A power calcar planer may be placed over the trunnion of the broach and used to contour the femoral neck. 10. A trial head and neck component is positioned onto the fitted broach, and a trial reduction is carried out. 11. If trial reduction is satisfactory, all trial components are removed. 12. The appropriate-sized acetabular component is inserted into the acetabulum, and a polyethylene insert is locked into place. 13. The femoral component is placed into the canal, and the modular head is seated on the trunnion. 14. Reduction of the hip is followed by standard closure with drains. 15. Abduction of the hip is maintained postoperatively with a foam abduction pillow, if necessary.
what are the steps involved in rotator cuff surgery?
1. An anterosuperior deltoid incision is made. 2. The coracoacromialligament is divided at the acromial attachment. 3. A subacromioplasty (resection of the undersurface of the acromion) is completed. This is also primary treatment for impingement syndrome. 4. Small, simple tears can be repaired by suturing the torn edges with heavy, nonabsorbable sutures. 5. Massive tears may require attaching the torn edges to the greater tuberosity using boneanchoring devices. 6. If the defect cannot be bridged, a flap from the subscapularis tendon can be transposed and sutured to the supraspinatus and infraspinatus muscles. 7. If impingement is involved or solely the cause of a rotator pathologic condition,other measures involving the same approach are taken. 8. Calcium deposits encased in tendon are excised to alleviate mechanical obstruction, or acromioplasty is performed. 9. After closure a sling is applied. Patients with small tears may begin motion on the third to fourth postoperative day. Larger tears may be immobilized for 2 to 8 weeks .
what are the steps in the axillary node dissection procedure?
1. An incision is made slightly posterior and parallel to the upper lateral border of the pectoralis major muscle, or transversely across the axilla. 2. The fascia is incised over the pectoralis muscle. The pectoralis minor muscle is exposed. Major blood and lymphatic vessels are clamped and ligated. The use of electrosurgery is avoided around the axillary vessels and nerves to reduce the risk of inadvertent injury and subsequent impaired muscle function. 3. The tissue over the axillary vein is incised. 4. The lymph nodes between the pectoralis major and pectoralis minor muscles are removed. Care is taken not to injure the medial and lateral nerves of the pectoralis major muscle. 5. The axillary fat and lymph nodes are freed from the axillary vein and chest wall. The long thoracic nerve is identified along the chest wall near the axillary vein, and the thoracodorsal nerve posteriorly is dissected free from the specimen. 6. The fat and nodes are removed. The incision is closed with sutures and staples,and a dressing is applied. A suction drain is usually placed through a separate stab incision for lymphatic drainage .
what are the steps in the subcutaneous mastectomy?
1. An incision is usually begun in the inframammary crease and may be made on the medial or the lateral aspect of the breast. Some surgeons initially remove and preserve the nipple areola complex by employing lateral extensions of wide circumareolar incisions. 2. Blunt dissection is performed to elevate the breast from the pectoral fascia. 3. The breast tissue is separated from the skin with an attempt made to remain in a plane between the subcutaneous tissue and the breast. Dissection is carried out toward the axilla. With care, 90% or more of the breast tissue, including the tail of Spence, can be removed. Some lymph nodes in the axillary area also may be removed. Bleeding vessels are clamped and ligated. 4. If a perioperative decision was made for immediate reconstruction,that procedure follows atthis time. Provided that the subareolar tissue shows no signs of tumor, as verified by a pathologist, the salvaged areolar complex is placed on a deepithelialized dermal bed. 5. A closed-wound suction catheter typically is inserted. The wound is closed, and a light pressure dressing is applied.
what are the steps in the modified radical mastectomy procedure?
1. An oblique elliptic incision with a lateral extension toward the axilla is made through the subcutaneous tissue. The bleeding points are controlled with hemostats and ligatures or electrocoagulation. 2. The skin is undercut in all directions to the limits of the dissection by means of a #3 knife handle with a #10 blade and curved scissors . Knife blades need to be changed frequently to ensure precise dissection. 3. The margins of the skin flaps are covered with warm, moist laparotomy pads and held away with retractors. The fascia and breast are resected from the pectoralis major muscle starting near the clavicle and extending down to the midportion of the sternum. The pectoralis muscle is left intact. 4. The intercostal arteries and veins are clamped and ligated. 5. The axillary flap is retracted for a complete dissection of the axilla. Careful attention is directed to preventing injury to the axillary vein and medial and lateral nerves of the pectoralis major muscle. 6. The fascia is dissected from the lateral edge of the pectoralis muscle. Ligation of the vessels is preferred in the axilla and adjacent to the sternum. The fascia is then dissected from the serratus anterior muscle. The thoracic and thoracodorsal nerves are preserved. 7. The breast and axillary fascia are freed from the latissimus dorsi muscle and suspensory ligaments. The specimen is then passed off the field. 8. The surgical area is inspected for bleeding sites, which are ligated and electrocoagulated . wound is irrigated with normal saline. Closed-wound suction catheters are inserted into the wound through stab wounds and secured to the skin with a nonabsorbable suture on a cutting needle. 9. A few absorbable sutures may be used in the subcutaneous tissue to approximate the skin edges. The incision is closed with interrupted nonabsorbable sutures or staples. 10. The dressing can be a simple gauze dressing, a bulky dressing held in place by a Surgi-Bra, or a gauze or elastic bandage wrap.
what are the steps in the McVay or Cooper's ligament repair?
1. An oblique incision is made parallel to the inguinal ligament,ending two fingerbreadths lateral to the public tubercle. 2. The incision is carried through the superficial and deep (Scarpa's) fascia to the external oblique aponeurosis. Hemostasis is maintained with fine ties or electrocoagulation. 3. The external oblique aponeurosis is opened in the direction of its fibers to the external ring, and the aponeurotic flaps are reflected back along the iliohypogastric and ilioinguinal nerves, which are identified and preserved from injury. The ilioinguinal nerve is a sensory nerve that innervates the medial thigh and the scrotum. 4. The cremaster muscles that form an envelope around the spermatic cord and represent the continuation of the internal oblique muscles are opened and the cord is exposed. The medial fibrous portion of the internal oblique is called the conjoined tendon. 5. By gentle dissection the spermatic vessels and the vas deferens are separated. A moistened Penrose drain is then used to gently retract the vessels and vas deferens. The cord is then examined for an indirect hernia, which arises from the internal ring lateral to the inferior epigastric vessels, and is initially adherent to the cord. 6. If an indirect sac is identified, it is carefully dissected away from the cord until the neck of the hernia is clearly delineated. 7. The sac is opened, and any abdominal contents are returned to the peritoneal cavity. 8. A suture ligature or purse-string suture is placed high in the neck of the sac, and the excess peritoneum of the hernia is excised. The ligated stump quickly retracts into the peritoneal cavity. The inguinal floor is then inspected for evidence of a direct hernia. If only a direct sac is present, usually no resection of the hernia is done because the sac easily returns to the abdominal cavity. 9. If the transversalis fascia is present on both sides of the hernia defect, it is sutured together. Suturing begins at the symphysis pubis and continues laterally to the internal ring. If the inferior transversalis fascia is weak or not present, the superior portion is sutured to Cooper's ligament, the site of insertion of the transversalis fascia. In this case, suturing again begins at the public tubercle and is continued laterally along Cooper's ligament to the medial border of the femoral sheath, where a transition stitch is placed. The repair is then carried laterally, approximating transversalis fascia to inguinal ligament. 10. When the transversalis fascia is pulled down to Cooper's ligament, a relaxing incision in the rectus sheath is sometimes necessary to relieve excess tension. Essentially this incision is 5 to 7 cm long in the anterior rectus sheath. The incision begins immediately above the public crest, approximately 1 cm from the midline, and extends cephalad, following the line of fusion of the external oblique aponeurosis with the rectus sheath. The posterior rectus sheath and the rectus muscle itself guard against later herniation at the point where the relaxing incision is made. If too much tension makes direct approximation undesirable, a synthetic surgical mesh may be sutured in place as the new inguinal floor ("tension-free" mesh repair). 11. After the integrity of the posterior inguinal floor has been reestablished, the cremaster muscles are reapproximated around the cord. Repair is completed with the approximation of the external oblique aponeurosis, Scarpa's fascia, and the skin.
what are the steps in the PerFix hernia Plug procedure?
1. An oblique incision, 6 cm in length, is made and the external oblique fascia is opened through the external ring. Exposure is obtained by use of a self-retaining retractor (such as a Beckmann); a hand-held retractor such as Gauley may also be required. Hemostasis is usually achieved with the use of electrocoagulation . 2. The spermatic cord is mobilized, as previously described in the McVay repair. The ilioinguinal and genital femoral neNes are identified and preseNed. The medial external oblique fascia is separated from the underlying transversus abdominis aponeurosis with a sweeping motion of the index finger . 3. An indirect sac and any lipoma of the cord are dissected free. The sac and lipoma are allowed to drop back through the internal ring and into the abdominal cavity. Rarely is the sac opened except for incarcerated hernias. 4. Using the Gilbert classification, the internal ring is sized and the tapered end of the mesh plug is inserted through the internal ring and positioned just beneath the crura. The plug is designed such that its fluted outer layer, combined with its inside configuration of eight mesh petals, maintains its overall contour while allowing it to conform tension-free to the configuration of the internal ring. 5. Repair of indirect hernias. Type I indirect hernias require 1-2 synthetic , absorbable sutures ; in Type II and Ill hernias, more sutures are required due to the increased size of the internal ring. Repair of direct hernias. In direct hernias, the fusiform or saccular defect is circumscribed near its base with an electrosurgical device and the hernia is reduced, providing a surrounding margin of intact tissue for securing the plug. The plug is then inserted through the floor of the defect. With Type IV and V (direct) hernias, the mesh plug is routinely secured with up to 8-10 interrupted sutures of synthetic, absorbable . Where there are both indirect and direct hernias (Type VI) two mesh plugs may be needed. Type VII defects are treated similarly with mesh plugs. 6. Repair of femoral hernias. In femoral hernias, a small or medium-sized plug is secured in position after the sac has been reduced. 7. In most types of mesh-plug hernia repairs , a second piece of flat mesh is used for reinforcement. The piece is cut to match the shape of the inguinal canal and then placed without sutures on the anterior surface of the posterior wall of inguinal canal. The proximal portion is split to provide an opening for the spermatic cord, and the mesh tails are brought together with sutures to form a new internal ring. 8. With the spermatic cord structures placed on top of this flat mesh, the external oblique fascia is reapproximated over the structures with a running, synthetic, nonabsorbable suture. 9. An interrupted suture of a similar size is used to bring the subcutaneous tissue together, and the skin is closed with a subcuticular stitch. A transparent dressing is used to cover the wound site.
steps in the operative procedure for latissimus dorsi flap
1. Initially the island of skin is incised transversely across the back, with care being taken so that the resulting scar will be covered by a bra or bathing suit. 2. The muscle, subcuticular fat, and fascia are then freed from the overlying skin by undermining so that part or all of the muscle may be mobilized. 3. The skin island and the muscle are then tunneled under the axilla to the chest wall. The insertion of the muscle on the humerus and accompanying blood vessels are left undisturbed. The latissimus dorsi muscle fills the space left by the missing pectoralis muscle. 4. The island of skin is oriented to the recipient site, and both are sutured into place. 5. A saline-filled implant is placed under the muscle before suturing to reconstruct the breast mound. 6. The wound is drained by closed-wound suction catheters. 7. The nipple-areola complex may also be reconstructed by sharing the nipple on the unaffected side or by using groin or auricular tissue. It can be done at the time of reconstruction or at a later date as a minor procedure under local anesthesia.
Mnemonic for cranial nerves: Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly
1. Olfactory: smell 2. Optic: sight 3. Oculomotor: moves eye, pupil (superior oblique muscle) 4. Trochlear: moves eye 5. Trigeminal: face sensation 6. Abducens: moves eye 7. Facial: moves face, salivate 8. Vestibulocochlear: hearing/balance 9. Glossopharyngeal: taste/swallow 10. Vagus: heart rate/digestion 11. Accessory: moves head 12. Hypoglossal: moves tongue
what are the steps in the radical neck dissection procedure?
1. One of several types of incisions may be used, including the Y-shaped,H-shaped, or trifurcate incision, all of which aim for complete lymphadenectomy while preserving good, viable skin flaps. 2. The upper curved incision is made through the skin and platysma with a knife, tissue forceps, and fine hemostats; ligatures are used for bleeding vessels. The upper flap is retracted; then the vertical portion of the incision is made, and the skin flaps are retracted anteriorly and posteriorly with retractors. The anterior margin of the trapezius muscle is exposed by means of curved scissors . The flaps are retracted to expose the entire lateral aspect of the neck. Branches of the jugular veins are clamped, ligated, and divided. 3. The sternal and clavicular attachments of the sternocleidomastoid muscle are clamped with curved Pean forceps and then divided with a knife. The superficial layer of deep fascia is incised. The omohyoid muscle is severed between clamps just above its scapular attachment. 4. By sharp and blunt dissection, the carotid sheath is opened. The internal jugular vein is isolated by blunt dissection and then doubly clamped, doubly ligated with medium silk, and divided with Metzenbaum scissors. A transfixion suture is placed on the lower end of the vein. 5. The common carotid artery and vagus nerve are identified and protected. The fatty areolar tissue and fascia are dissected away using Metzenbaum scissors and fine tissue forceps. Branches of the thyrocervical artery are clamped, divided, and ligated. 6. The tissues and fascia of the posterior triangle are dissected, beginning at the anterior margin of the trapezius muscle and continuing near the brachial plexus and the levator scapulae and the scalene muscles. During the dissection ,branches of the cervical and suprascapular arteries are clamped, ligated, and divided. 7. The anterior portion of the block dissection is completed. The omohyoid muscle is severed at its attachment to the hyoid bone. Bleeding is controlled. All hemostats are removed, and the operative site may be covered with warm, moist laparotomy packs. 8. The sternocleidomastoid muscle is severed and retracted. The submental space is dissected free of fatty areolar tissue and lymph nodes from above downward. 9. The deep fascia on the lower edge of the mandible is incised; the facial vessels are divided and ligated. 10. The submandibular triangle is entered . The submandibular duct is divided and ligated. The submandibular glands with surrounding fatty areolar tissue and lymph nodes are dissected toward the digastric muscle. The facial branch of the external carotid artery is divided. Portions of the digastric and stylohyoid muscles are severed from their attachments to the hyoid bone and on the mastoid. The upper end of the internal jugular vein is elevated and divided. The surgical specimen is removed. 11. Theentirefieldisexaminedforbleeding andthenirrigatedwithwarm salinesolution.Although rarely necessary , a skin graft may be placed to cover the bifurcation of the carotid artery, extending down approximately 4 inches, and sutured with 4-0 absorbable suture on a very small cutting needle. 12. Closed wound suction drains are placed into the wound. 13. The flaps are carefully approximated with interrupted, fine nonabsorbable sutures or with skin staples . A bulky pressure dressing may be applied to the neck, depending on surgeon preference.
steps in the anterior resection of the sigmoid colon and rectosigmoidostomy
1. The abdomen is entered through a laparotmy incision. 2. The peritoneal cavity is explored for metastasis and respectability of the lesion. 3. Before the colon is mobilized, the tumor-bearing segment is isolated by ligatures to the lymphovenous drainage (that is, provided that these structures are accessible). 4. A loop of sigmoid colon is elevated as the small intestines are walled off with moist packs; retractors are placed. 5. The peritoneum on the left side of the colon is incised with a long scalpel, scissors, hemostats, and sponge forceps . 6. Traction sutures of 2-0 nonabsorbable may be used as the peritoneum is reflected. 7. Bleeding vessels are ligated with 2-0 or 3-0 nonabsorbable ligatures. 8. The pelvic peritoneum is exposed and dissected free to form the left side of the reconstructed pelvic floor. Long dissecting instruments are used. 9. Vessels are ligated with 30-inch nonabsorbable ligatures. 10. Extreme care must be exercised throughout to protect the ureters from injury. 11. The sigmoid colon is turned toward the left, and incision and dissection of the peritoneum is performed on the right side of the pelvis. 12. The two incisions are then curved and joined in front of the rectum. 13. The rectum is freed anteriorly and posteriorly from the adjacent structures. 14. The sigmoid colon is clamped with intestinal clamps after mobilization of the proximal portion. A right-angled intestinal clamp or a reticulating linear stapling device may be commonly used to clamp the distal portion of the rectosigmoid. 15. As the sigmoid colon is divided distally to the clamp, the transsected rectal edges are grasped with Allis or Ochsner forceps, and the rectal opening is exposed. 16. The diseased portion is removed, and the soiled instruments are discarded into a separate basin. 17. Continuity is established by an end-to-end anastomosis of the proximal colon and the rectum using a curved mechanical stapling instrument (EEA). 18. "Donuts" of tissue removed from the EEA stapling device are examined closely for thickness and continuity and then set as separate specimens to the pathology laboratory. 19. The assisting surgeon passes a rigid sigmoidoscope into the lumen of the bowel transanally . 20. Warm irrigating solution is poured into the peritoneal cavity, and the lumen of the bowel is insufflated. 21. The surgeon observes for air leak from the anastomosis and oversews the site if indicated. 22. The pelvic floor is reperitonealized, and drains may be placed. 23. The abdominal wound is closed in the routine manner, and a dressing is applied.
operative procedure for AAA repair
1. The abdomen is opened through a midline incision from the xiphoid process to the symphysis pubis. Hemostasis is accomplished, and exploration is completed as described for laparotomy. 2. An abdominal self-retaining retractor is inserted into the wound. If necessary for exposure, a portion of the small bowel can be placed outside the abdomen and covered with moist laparotomy packs. 3. The parietal peritoneum is incised over the aorta and extended superiorly to expose the aneurysm and also inferiorly over the bifurcation and beyond the iliac arteries. Metzenbaum scissors, smooth forceps, and hemostats are used. 4. Careful blunt and sharp dissection is continued to expose the aorta above the aneurysm to permit placement of an aortic clamp. The renal artery and ureters are avoided. The iliac vessels and bifurcation are inspected for evidence of small aneurysms, thrombosis, and calcification. 5. An aortic clamp such as a DeBakey, Fogarty, or Satinsky is applied and closed. Opening of the aneurysm is undertaken with a scalpel or electrosurgical blade and heavy scissors. 6. The aneurysm is completely opened, and all atheromatous and thrombotic material is removed. The aneurysm walls may be excised but usually are left in place for eventual coverage of the prosthesis . In either case the posterior aspect of the aorta is left intact. Bleeding is controlled, especially from the lumbar vessels, which enter posteriorly. 7. A prosthetic graft of appropriate size is prepared for insertion. If the aneurysm does not involve the aortic bifurcation, a straight tubular graft is used; otherwise a bifurcated or Y-shaped graft is necessary. Pre-clotting of a knitted graft may be accomplished by immersing the graft into a small quantity of the patient's own blood before systemic heparinization. 8. The aortic cuff is prepared for anastomosis by irrigating it with heparinized saline solution and by removing all fibrotic plaques. One or two vascular sutures (double armed) are used to accomplish the anastomosis by a through-and -through continuous suture . Additional interrupted sutures may be needed if the anastomosis leaks on completion. 9. The distal vessels are opened and inspected for backbleeding, and heparinized saline solution may be injected to prevent clotting. 10. Each limb of the graft is anastomosed to the iliac artery, using a smaller vascular suture and similar technique. After the first side of the anastomosis has been completed, blood is permitted to circulate, and the remaining limb of the graft is clamped to prevent leaking during the last part of the anastomosis. 11. The aneurysm is closed over the graft. 12. The abdominal wound is closed.
steps in the procedure for a right hemicolectomy and ileocolostomy
1. The abdomen is opened, and the peritoneal cavity is retracted and packed with warm, moist sponges. 2. The mesentery of the transverse colon and the terminal ileum is incised at the points where the resection is to be done. 3. Moist packs are placed to isolate the viscera to be resected. A Metzenbaum scissors, hemostats, and 3-0 nonabsorbable ligatures are used to clamp, cut and ligate mesentery vessels. 4. The lateral peritoneal fold along the lateral side of the right colon is incised, and the right colon is mobilized medially. Metzenbaum scissors, hemostats, and sponges on holders are used. 5. The ureter and duodenum are carefully identified. 6. The same procedure is carried out on the terminal ileum. The mesenteric vessels are clamped and ligated with 2-0 nonabsorbable ligatures. 7. The operative field is prepared for anastomosis. 8. Intestinal clamps are placed on the transverse colon and ileum. 9. Division is completed with a scalpel, and the specimen is removed. 10. An end-to-end anastomosis is completed between the severed ends of the terminal ileum and the transverse colon. 11. Instruments and supplies that have come into contact with bowel mucosa are discarded. 12. The mesentery and posterior peritoneum are closed with interrupted 3-0 nonabsorbable sutures. 13. The abdominal wound is closed. A dressing is applied.
what are the steps in the resection of the small intestine procedure?
1. The abdominal wall is incised through a midline incision and retracted. 2. The peritoneal cavity is explored and protected with moist, warm saline packs. 3. Intestinal clamps are placed above and below the diseased segment of the small bowel and mesentery. 4. The involved area is removed with a linear stapling instrument such as a GIA, electrosurgical blade, or a scalpel. 5. The continuity of the Gl tract is established by an end-to-end, end-to-side, or side-to-side anastomosis. 6. The wound is closed and dressed.
What are the steps in a Billroth 1 procedure?
1. The abdominal wall is incised, and the peritoneal cavity is opened and explored. 2. Bleeding vessels are clamped and ligated or coagulated. 3. The abdominal wound is retracted, and the surrounding organs are protected with warm, moist packs. 4. The gastrocolic omentum is freed from the colon mesentery to prevent injury to the middle colic artery. 5. With hemostats and Metzenbaum scissors, the right and left gastroepiploic arteries and veins are clamped, divided, and ligated with 2-0 nonabsorbable sutures and 2-0 and 3-0 suture ligatures thereby freeing the greater curvature of the stomach. 6. The gastric vessels are also clamped, divided, and ligated to free completely the diseased portion of the stomach. 7. The operative field is prepared for open anastomosis 8. After sectioning of the stomach from the greater to lesser curvature, two Allen intestinal anastomosis clamps or other suitable clamps are placed on the upper portion of the duodenum just distal to the pylorus. 9. Division of the duodenum is accomplished by scalpel or electrosurgery, as preferred. A linear cutting and stapling device (such as GIA) may be used to divide the tissues. 10. Additional moist packs are placed for protection, and two sets of anastomosis clamps are placed across the stomach. 11. Division of the stomach is completed by the surgeon's preferred method. 12. At the lower margin the opened stomach is approximated to the duodenum by a series of interrupted sutures placed in the serosa layers. 3-0 nonabsorbable suture on an atraumatic intestinal needle is used. Suture ends are held with hemostats, and the intestinal clamps are removed. 13. Stumps of the stomach and duodenum are cleansed with moist sponges, and bleeding vessels are ligated with fine suture or coagulated. 14. During the anastomosis of the stomach and remaining duodenum, the involved segments may be held with rubber-shod clamps. The excess of the lesser curvature of the stomach is closed on completion of the anastomosis. 15. Soiled instruments are discarded into a separate basin. 16. Routine laparotomy closure is completed
what are the steps in the Billroth 2 procedure?
1. The abdominal wall is incised, and the peritoneal cavity opened and explored. 2. Bleeding vessels are clamped and ligated or coagulated. 3. The abdominal wound is retracted, and the surrounding organs are protected with warm, moist packs. 4. The gastrocolic omentum is freed from the colon mesentery to prevent injury to the middle colic artery. 5. With hemostats and Metzenbaum scissors, the right and left gastroepiploic arteries and veins are clamped, divided, and ligated with 2-0 nonabsorbable suture and 2-0 and 3-0 suture ligatures, thereby freeing the greater curvature of the stomach. 6. The distal portion of the stomach is isolated. 7. Moist packs are placed for protection of the viscera, and two sets of anastomosis clamps are placed across the distal stomach. 8. The stomach is resected just distal to the pylorus using a scalpel, electrocautery, or a linear stapling and cutting device (GIA). Meridian Institute of Surgical Assisting © 2005 All Rights Reserved All content on this page is the property of Meridian Institute of Surgical Assisting. Unauthorized use or reproduction is strictly prohibited. 9. A proximal loop of jejunum is positioned for anastomosis to the posterior wall of the remaining stomach. 10. An anastomosis is established between the stomach and jejunum using mechanical linear stapling devices (GIA and TA instruments) . 11. The abdomen is closed
steps in the operative procedure for anterior repair
1. The bladder may be drained , or an indwelling urinary catheter or suprapubic systostomy catheter may be inserted (surgeon's preference). Aerolar tissue between the bladder and vagina at the bladder reflection is exposed. The full thickness of the vaginal wall is separated up to the bladder neck by a knife, curved scissors , tissue forceps , Allis-Adair or Allis forceps , and gauze sponges. Bleeding vessels are clamped andtied with ligatures or electrocoagulated. 2. The urethra and bladder neck are mobilized with a knife, gauze sponges, and curved scissors. 3. Sutures are placed adjacent to the urethra and bladder neck in such a manner that, after they have been tied,a narrowing of the bladder neck and a delineating of the posterior urethrovesical angle occur. 4. The connective tissue on the lateral aspects of the cervix is sutured into the cervix to shorten the cardinal ligaments. 5. Allis-Adair forceps are applied to the edges of the incision, and the left flap of the vaginal wall is drawn across the midline. Edges are trimmed according to the size of the cystocele . This process is repeated on the right flap of the vaginal incision. 6. The anterior vaginal wall is closed in a manner resulting in reconstruction of an anterior vaginal fornix
what are the steps in the intertrochanteric fracture surgery? (Freelock compression plate and lag screw)
1. The fracture is reduced by closed reduction and maintained by adjusting the table traction. 2. Reduction is checked in both the AP and lateral views with fluoroscopy . 3. An incision is made from the greater trochanter distally to accommodate the length of the implant. 4. The dissection is completed through the fascia lata and the vastus lateralis is exposed. 5. The reduction is visually confirmed;the guide pin is inserted after determining the angle of plate to be used. A 135-degree angle plate is commonly used. 6. The pin should be centralized in the femoral head approximately 1 cm short of the femoral articular surface. Care must be taken to not enter the joint space , since this might result in arthritic changes. Further penetration of the pin through the acetabulum and into the pelvis can potentially damage large vessels or bowel. A second pin can be used to control rotation in high neck or unstable fractures. 7. The lateral cortex is opened with the conical cannulated drill bit over the guide pin. 8. The depth gauge is placed over the guide pin. The size of the required lag screw is determined from the guide . 9. A double-barrel reamer is adjusted to correspond to the depth of the guide pin. The cortex is reamed over the guide pin to create a channel tor the lag screw and barrel of the compression plate. 10. The lag screw channel is tapped to the full distance of reaming to allow proper seating of the lag screw, particularly in young patients with firm bone. Reaming depth of osteoporotic bone is reduced 5 mm. and the tap depth is reduced approximately 1 to 2 cm to allow sufficient screw purchase. 11. The plate angle can be confirmed with a trial; the implants (plate and lag screw) are then delivered to the back table. 12. The plate, lag screw , and insertion wrench with centering sleeve are assembled. A screw stabilizer is passed through the center of the insertion wrench and threaded into the lag screw. 13. The entire assembly is placed over the guide pin and the lag screw is advanced to the desired depth, with periodic verification with fluoroscopy. Penetration of the lag screw through the femoral articular surface must be avoided. 14. The insertion wrench is disassembled, and the barrel of the compression plate is placed over the lag screw. The barrel of the plate should fully cover the lag screw. The plate is seated on the lateral femoral shaft. 15. The plate is secured to the shaft of the femur with plate-holding forceps. The guide pin is removed. At this point traction can be released to allow compression of the fracture site. 16. Screw holes are made using the drill guide and a 3.5 mm drill bit. The length is determined, and cortical screws are inserted through the screw hole on the plate with sufficient purchase on the opposite cortex of the shaft. The top screw hole on the plate can accept a 6.5 mm cancellous screw, which can be angled for better purchase in comminuted fractures. 17. Traction is released if not done previously. A compression screw is inserted into the barrel of the screw and threaded into the back of the lag screw, compressing the fracture site. The compression screw exerts a powerful force. The amount of compression applied should correlate with the quality of the bone. 18. The wound is irrigated and closed. Two suction drains may be inserted during closure. Weight bearing may begin as early as the first postoperative day depending on reduction and quality of bone. NOTE: Many of the same techniques and principles of long bone fracture fixation are used in treatment of various types of hip fractures.
what are the steps in the application of a unilateral frame?
1. The fracture is reduced manually. 2. The skin is incised over an area free from neurovascular structures. 3. Blunt dissection to the bone or with the elevator may be necessary. 4. A drill sheath is used to protect surrounding soft tissue while predrilling the cortex. 5. Hand or low-speed power drilling is used to insert the half pins above and below the fracture. 6. Universal joints are slipped over the pins and joined with a connecting rod. 7. The frame is tightened using the appropriate wrenches. 8. Radiography or fluoroscopy is used to confirm reduction and alignment. 9. The pin sites are covered with an antibacterial agent and dressed with sterile gauze.
steps in the operative procedure for vaginal hysterectomy
1. The labia may be retracted with sutures. A vaginal retractor is inserted to retract the vaginal wall. 2. Dilatation and curettage may be performed, as previously described. 3. A Jacobs vulsellum, tenaculum, or suture ligature is placed through the cervical lips to permit traction on the cervix. 4. The vaginal wall is incised with a knife anteriorly through the full thickness of the wall. The bladder is freed from the anterior surface of the cervix by sharp and blunt dissection. The bladder is then elevated to expose the peritoneum of the anterior cul-de-sac, which is entered by sharp dissection. 5. The peritoneum of the posterior cul-de-sac is identified and incised. 6. The uterosacral ligaments containing blood vessels are clamped, cut, and ligated. The ends of the ligatures are left long and are tagged with a clamp. 7. The uterus is drawn downward, and the bladder is held aside with retractors and moist, small laparotomy packs. 8. The cardinal ligament on each side is clamped, cut, and ligated. The uterine arteries are doubly clamped, cut, and ligated. 9. The fundus is delivered with the aid of a uterine tenaculum. 10. When the ovaries are to be left, the round ligament, the uterovarian ligament, and the fallopian tube on each side are clamped together and cut, and the uterus is removed. These pedicles are then ligated. 11. The peritoneum between the rectum and vagina is approximated with a continuous suture. The retroperitoneal obliteration of the cul-de-sac is done by sutures that pass from the vaginal wall through the infundibulopelvic ligament and round ligament, through the cardinal ligament, and out the vaginal wall. The sutures are tied on the vaginal aspect of the new vault. The round, cardinal, and ureterosacralligaments may be individually approximated for additional support. 12. Any existing cystocele and rectocele and the perineum are repaired, as described for vaginal plastic repair. In the presence of prolapse, reconstruction of the pelvic floor may be required.
steps in the radical hysterectomy procedure
1. The skin is incised, and the abdominal layers are opened, as described for laparotomy. 2. The peritoneum is cut at its reflection on the anterior surface of the uterus between the round ligaments. By blunt dissection, the bladder surface is freed from the cervix and vagina . 3. The right round and infundibulopelvic ligaments are clamped, cut with a knife or Metzenbaum scissors , and ligated with sutures to expose the external iliac artery. The ureter is identified and retracted with a vein retractor. 4. The lymph and aerolar tissues are dissected from the iliac artery, obturator fossa, and ureter with Lahey forceps, Kitner sponges, and Metzenbaum scissors . A complete lymph gland dissection removes the tissue from Cloquet's node to the bifurcation of the iliac arteries bilaterally . The uterine artery and vein are clamped, cut, and doubly ligated. 5. The uterus is elevated, the cul-de-sac is opened, and the uterosacral and cardinal ligaments are clamped, cut with scissors, and doubly ligated with suture ligatures. The pararectal and paravesical areolar tissues are dissected free to skeletonize the upper vagina, and the paraurethral tissues are removed as near to the pelvic walls as possible. 6. The upper third of the vagina is cross-clamped with Heaney forceps and divided with a long #4 knife handle and #20 blade. The uterus and surrounding tissues are removed. Electrocoagulation is useful in minimizing venous oozing from small venules and capillaries. Lowering the head of the operating bed 15 degrees is also helpful in reducing the oozing of blood and serum . Careful apposition of the skin edges with interrupted mattress sutures must take place to prevent overlapping of the skin edges and a resulting delay in healing. 7. The vagina is sutured open with a running locked stitch, and closed sound drainage is provided from above. The pelvis is peritonealized with a continuous suture. 8. The abdominal wound is closed (retention sutures may be used) and dressed in the usual manner. Vaginal packing and drains may be used. A suprapubic indwelling catheter may be placed. The catheter helps prevent postoperative bladder spasm and allows for bladder drainage if the patient is unable to void after removal of the urinary catheter.
operative procedure for breast reduction mammoplasty
1. The skin to be excised, as well as the new site for the nipple, is marked. 2. The skin between the new and the old nipple sites is incised and removed, with the nipple remaining attached to the underlying breast tissue. On patients with very large breasts the nipples are removed and then reapplied as free grafts when the reduction is complete. 3. The redundant segment of breast tissue inferior to the nipple is excised through an inverted-T incision. Tissue from each breast is measured and kept separately. 4. The nipple and adjacent tissue are mobilized and sutured in place. 5. The medial and lateral skin edges are approximated in a vertical suture line inferior to the nipple. 6. The inframammary elliptical incision is trimmed and closed transversely. Closed-wound suction catheters may be placed. The wound is dressed.
operative procedure for pneumonectomy
1. The skin, subcutaneous tissue , and muscle are incised by scalpel, suction, and electrodissection. Hemostasis is attained. If a rib is to be excised, the procedure discussed later is implemented. 2. The ribs and tissue are protected with moist sponges; the rib retractor is placed and opened slowly. 3. The lung is mobilized when peripheral adhesions are freed and the pulmonary ligament is divided. Dissection to the hilum of the involved lobe is carried out. 4. The superior pulmonary vein is gently retracted, and the pulmonary artery is dissected. 5. The branches of the pulmonary artery and vein of the involved lobe are clamped,doubly ligated, and divided with fine right-angled vascular clamps , scissors , and nonabsorbable suture. 6. The inferior pulmonary vein is exposed by incising the hilar pleura and retracting the lung anteriorly. The inferior pulmonary vein is clamped, doubly ligated, and divided. 7. The bronchus clamp is applied, and the bronchus near the tracheal bifurcation is divided. The stump is closed with atraumatic nonabsorbable mattress sutures or bronchus staples. If staples are applied,the scalpel is used to complete division of the bronchus . The lung is removed from the chest. 8. The pleural space is irrigated with normal saline to check for hemostasis and air leaks during positive pressure inspiration. 9. A pleural flap is created and sutured over the bronchial stump. Other methods of securing the bronchus might be used. 10. Hemostasis is ensured in the pleural space. 11. Chest tubes (28 to 30 Fr) are inserted into the pleural space and brought through a stab wound at the eighth or ninth interspace near the anterior axillary line. An upper tube is inserted through a second stab wound if indicated to evaluate leaking air. The tubes are secured with heavy sutures and connected to water-seal drainage after closure of the pleural space. 12. The rib approximator is placed, and closure is begun with interrupted sutures. 13. The muscle, subcutaneous tissue, and skin are closed. Drains are anchored to the chest wall with suture. 14. The dressing is applied. 15. Chest tube connections are secured with Parnham bands or tape and labeled (anterior or posterior).
operative procedure for wedge resection
1. The skin, subcutaneous tissue, and muscle are incised using a scalpel, suction, and electrodissection. 2. The rib retractor is placed. 3. Bleeding is controlled, and small bronchi are secured with clamps and ligature. Large bronchi are ligated or sutured to prevent persistent air leak. 4. a. The wedge is outlined for excision, with a margin of normal tissue left, using one of the following techniques. b. Long hemostatic clamps are applied in three rows to outline the wedge. Excision is accomplished with a scalpel. The tissue is sutured with a running absorbable suture behind the clamps before removal. The edges of the tissue are oversewn with a continuous or interrupted suture. c. The lobe is grasped with a lung clamp, and the thoracic stapling instrument is applied to the parenchymal portion of the lung. Staples are applied, and the wedge is excised with the scalpel. Staples are reapplied to the opposite side of the lesion adjoining the staple lines. The specimen is removed. Air leaks are checked by irrigation and inspection. Bleeding is controlled with ligation or hemoclips. The procedure is completed as for pneumonectomy.
operative procedure for lobectomy
1. The skin, subcutaneous tissue, and muscle are incised using scalpel , suction, and electrodissection. Hemostasis is attained . If a rib is to be excised, the procedure already discussed is implemented. 2. The ribs and tissue are protected with sponges. The rib retractor is placed and opened slowly. 3. The pleura is entered, and peripheral adhesions are freed with scissors , blunt dissection, or a sponge on a sponge-holding forceps. 4. The hilar pleura is incised and separated. 5. The branches of the pulmonary arteries and veins are isolated, clamped, double ligated, and divided with fine, right-angled vascular clamps, scissors, and nonabsorbable suture. 6. The main trunk of the pulmonary artery is identified as is the fissure between the lobes. 7. The bronchus clamp is applied. The remaining lung is inflated to identify the line of demarcation. The bronchus is divided with a scalpel or heavy scissors . 8. Bronchial secretions are suctioned. 9. The bronchus is closed with atraumatic, nonabsorbable mattress sutures or bronchus staples. If staples are applied, the scalpel is used to complete division of the bronchus . 10. Incomplete fissures are divided between hemostats with fine Metzenbaum scissors. Edges may be sutured closed. 11. A pleural flap is created and sutured over the bronchial stump. Other methods of securing the bronchus might be used. 12. The pleural cavity is thoroughly irrigated with normal saline, and hemostasis is ensured. The remaining lobes are inflated to check for air leaks, and the degree of expansion of the remaining lobes is assessed. 13. The pleural space is irrigated, and the procedure is completed as for a pneumonectomy.
operative procedure for segmental resection
1. The skin, subcutaneous tissue, and muscle are incised with scalpel, suction, and electrodissection. 2. The parietal pleura is incised with a scalpel and scissors. Adhesions are divided with sharp or blunt dissection. 3. The segmental artery is identified to provide accurate identification of the bronchus of the diseased segment. 4. The segmental pulmonary vein and branches are ligated. 5. The bronchus is clamped with the bronchus clamp, and the remaining lung is inflated. The intersegmental boundary is confirmed, and proper placement of the clamp is ensured. 6. The visceral pleura is incised around the diseased segment, beginning anterior to the hilum and progressing toward the periphery. Exposure is facilitated with malleable or other type of retractors. The intersegmental vessels are clamped with thoracic hemostats and ligated. 7. The segmental bronchus is transsected. The stump is closed with atraumatic, nonabsorbable mattress sutures or bronchus staples. 8. Dissection is continued to separate segmental surfaces, and vessels are ligated as needed. The segment of the lung is removed. 9. A pleural flap is created and sutured over the bronchial stump. Other methods of securing the bronchus may be used. 10. The lung is reinflated and irrigated with normal saline. Bleeding is controlled with ligatures or hemoclips. 11. The procedure is completed as for pneumonectomy.
Steps in midabdominal transverse incision
1. skin and sub-Q are incised 2. anterior rectus sheath is split 3. rectus muscle is divided 4. vessels withint rectus are clamped and ligated 5. posterior rectus sheath and peritoneum are cut in the direction of fibers, preserving the intercostals nerve 6. peritoneum is incised near the midline and incision is extended laterally to the oblique muscle 7. lateral muscles are incised to provide wide exposure
What are the steps in the operative procedure of a Meckel diverticulectomy?
1. The surgeon opens the abdomen through a low midline or right lower quadrant incision and identifies the diverticulum. 2. If the diverticulum is long and narrow with a narrow base, it is double-clamped and divided at its base. 3. Closure of the bowel beneath the clamp is with full-thickness 3-0 absorbable sutures. 4. A row of inverting sutures using 3-0 or 4-0 nonabsorbable suture is used to close the outer layer. 5. Alternatively, a linear GI stapler may be used to resect diverticulum. If the base is broad, The surgeon they isolate the loop of bowel containing the diverticulum from the mesentery and perform a limited small bowel resection. Completion of anastomosis of the divided ends is with an inner continuous layer of 3-0 synthetic absorbable sutures and an interrupted outer layer of 4-0 nonabsorbable sutures. Closure of the abdominal wound follows. This procedure can also be performed laparoscopically using an endoscopic G.I. linear stapling device.
What are the steps in the operative procedure of laparoscopic Roux-en-Y gastric bypass?
1. This surgery requires placement of five trochars above the umbilicus. Two on the midline, two in the left upper quadrant, and one in the right upper quadrant. The surgeon makes an incision for the liver retractor. 2. The surgeon mobilizes the omentum and identifies the ligament of treitz 3. Using a vascular stapler the surgeon divides the jejunum 40 cm distal to the ligament of treitz. 4. While the proximal jejunum is left to lie in the patient's right side, the surgeon lifts the Roux limb superiorly and passes it through the transverse colon mesentery 5. With several loads of a linear stapler, the surgeon creates a gastric pouch. 6. The surgeon next anastomoses the Roux limb to the proximal gastric pouch. Methylene blue is instilled to check for leaks. The surgeon may perform the gastrojejunostomy with either traditional suturing techniques or a circular EEA stapler. 7. The surgeon closes any mesenteric defects, inspects the abdomen, and directs closure of the port sites.
what are the steps in the simple retropubic prostatectomy procedure?
1. Through a Pfannenstiel or low vertical midline incision the anterior rectus sheath is incised along with portions of the internal and external oblique muscles. 2. The rectus abdominis muscles are retracted laterally to expose the space of Retzius. 3. After placement of traction sutures, the anterior portion of the prostatic capsule is incised transversely . 4. The prostatic adenoma may be dissected or finger-enucleated from the surgical capsule. 5. Care is taken to place hemostatic sutures at the 5 and 7 o'clock positions, encompassing the vesical neck and prostatic capsule, to ligate the primary blood supply to the prostate. Other bleeding points within the capsule may be suture ligated with 2-0 absorbable sutures. 6. A Foley catheter is inserted in the urethra and through the bladder neck and inflated within the bladder. Frequently, a three-way catheter is used for continuous bladder irrigation. 7. The prostatic capsule incision is closed with either a continuous or an interrupted 0 absorbable suture. 8. A drain is placed in the space of Retzius and brought out through the fascia and skin through a separate stab incision. 9. The abdominal incision is then closed in layers, and the wound is dressed. 10. If continuous bladder irrigation is to be used, normal saline solution irrigation is initiated through a 4-liter closed irrigation system.
what are the steps in a simple mastectomy surgery?
1. Through a transverse elliptical incision, using a knife and curved scissors , the skin edges are freed from the fascia. Bleeding vessels are clamped with hemostats and ligated with sutures or electrocoagulated. 2. The skin edges of the wound can be protected with warm, moist laparotomy pads; the breast tissue is grasped with Allis forceps and is dissected free from the underlying pectoral fascia with curved scissors and a knife. 3. The tumor and all breast tissue are removed. Bleeding vessels are clamped and ligated or electrocoagulated. 4. A closed-wound drainage catheter is inserted and anchored to the skin with a fine suture. The wound is closed with fine sutures or staples; a dressing is applied. Modified Radical Mastectomy: Modified radical mastectomy is performed after a tissue biopsy with a positive diagnosis of malignancy and involves removal of the involved breast and all axillary contents (all three levels of nodes-axillary , pectoral, and superior apical) . The underlying pectoral muscles are not removed before or after removal of axillary nodes.
what are the steps in a total gastrectomy procedure?
1. Through an incision of choice, the abdomen is opened. 2. The wound edges are protected and retracted. 3. Careful and complete exploration for the extent of metastasis is performed. 4. The omentum is freed from the colon, using sharp dissection; vessels are ligated with 2-0 nonabsorbable suture. 5. The splenic vessels are ligated and transfixed with 2-0 and 3-0 nonabsorbable suture at the tail of the pancreas; the spleen is left attached to the omentum. 6. The duodenum is mobilized, intestinal clamps are applied, and the operative field is protected for transaction and closure of the distal duodenum. 7. The right gastric artery is ligated and transfixed with 2-0 and 3-0 nonabsorbable suture, and the gastrohepatic omentum is separated from the liver. 8. After ligation of the left gastric artery, the mobilized stomach, spleen, omentum, and lesser and greater curvature ligamentous attachments are delivered into the wound. 9. Division of the coronary ligament of the left lobe of the liver permits exposure of the diaphragmatic peritoneum over the esophagogastric junction. 10. The liver is protected by moist packs, and gentle retraction is maintained with a Harrington, Deaver, or malleable retractor. 11. A flap of peritoneum is freed from the diaphragm, and branches of the vagus nerves are divided. 12. A loop of jejunum is selected and delivered antecolic to the esophagogastric junction for anastomosis . 13. With the specimen for traction, the posterior layer of interrupted 3-0 nonabsorbable sutures is inserted or stapling devices are utilized. 14. As the jejunum and the esophagus are incised, bleeding is controlled by mosquito or Crile hemostats and ligatures of 3-0 synthetic absorbable suture. 15. The posterior layer is reinforced with 3-0 intestinal, synthetic absorbable sutures or a linear staple line. 16. Division of the esophagus is completed, and the entire specimen is removed. 17. 4-0 interrupted, synthetic absorbable sutures also are usedto approximate the mucosal anterior wall of the anastomosis . An end-to-end anastomosis circular stapling device may be used to complete the anastomosis between the esophagus and jejunum. 18. A second layer of sutures, 3-0 nonabsorbable or synthetic absorbable, is placed anteriorly in the seromuscular and muscular coat of the intestine. 19. A flap of the peritoneum is attached to the jejunum with interrupted 3-0 nonabsorbable sutures to relieve traction on the anastomosis. 20. A lateral jejunojejunal anastomosis is completed to permit irritating bile and pancreatic fluids to bypass the anastomosis line, thereby preventing esophageal regurgitation. 21. The alternative to using suture materials is the use of mechanical stapling devices. Another method of establishing continuity is a combination of a Rouxen-Y jejunojejunostomy and a jeju noesophagostomy. 22. The abdominal wound is closed in layers. If retention sutures are used, they must be placed extraperitoneally because of the absence of omentum to protect the small bowel.
What are the steps in the gastrojejunostomy procedure?
1. Through an upper midline or paramedian abdominal incision exploration of the peritoneal cavity is completed, as described for routine laparotomy. 2. The pathologic condition is confirmed 3. Warm, moist packs are placed, and the self-retaining retractor is positioned. 4. A loop of proximal jejunum is grasped with a Babcock forceps and freed from the mesentery. 5. The loop of jejunum is approximated to either the anterior or posterior stomach wall several centimeters from the greater curvature of the stomach. 6. 2-0 nonabsorbable traction sutures are placed through the serosal layers at each end of the selected portion of the jejunum and stomach. 7. Gastroenterostomy clamps may be placed before insertion of the posterior interrupted 3-0 or 2-0 nonabsorbable serosal sutures. 8. The field is draped for open anastomosis. 9. The jejunum and stomach are opened. 10. Bleeding points are clamped with mosquito or Crile hemostats and ligated with 3-0 synthetic absorbable sutures. 11. The inner posterior row of sutures is placed, using continuous 2-0 or 3-0 synthetic absorbable suture with atraumatic intestinal needles, and continued for the first anterior row. 12. The anastomosis is completed with anterior serosal sutures of 3-0 or 2-0 nonabsorbable material. 13. Traction sutures are removed 14. Interrupted 4-0 nonabsorbable sutures may be used for reinforcement. 15. The contaminated instruments are discarded into a basin. 16. The abdominal wound is closed in layers and a dressing applied
steps in the sentinel node biopsy procedure
1. With isosulfan blue dye: a. The area of the breast mass is exposed as part of a breast biopsy. After identification of the tumor mass, the surgeon injects the dye directly into the tumor mass or the previous biopsy site. b. The sentinel nodes stained with the blue dye are identified and excised. The node is sent to the pathology department for examination. Based upon the results, the surgeon proceeds with the planned surgery or may elect breast conservation. 2. With technetium: c. The patient's tumor or previous biopsy site is injected with a small amount of radioactive material in the nuclear medicine department on the morning of surgery. d. A hand-held detector is passed over the top of the patient's chest to identify the area of the sentinel node through a positive reading. e. The surgeon marks the skin with a skin scribe to indicate the reactive area. The area is prepped and the surgeon proceeds with the planned procedure for excisional biopsy.
Steps in the operative procedure for a LCS Total Knee replacement
1. With the knee slightly flexed, a straight midline incision is made from 3 to 4 inches above the patella, ending at the patellar tubercle. 2. The capsule is entered medially for a neutral or fixed varus knee, or laterally for a valgus knee. After a median parapatellar incision is made, the patella is reflected laterally to expose the entire tibiofemoral joint. 3. Hypertrophic synovium, a portion of the infrapatellar fat pad, and osteophytes are excised to allow easy access to the medial, lateral, and intercondylar spaces and to facilitate soft-tissue releases, should the need arise. 4. The knee is flexed to 90 degrees and retractors are placed deep to the collateral ligaments and anterior to the posterior capsule to protect these structures during resection of the proximal tibia. 5. The long spike of the alignment guide is sunk into the proximal tibial spines. The ankle clamp is attached by wrapping the spring around the ankle. Proper rotational alignment is established by positioning the appropriate malleoli wings parallel to the trans malleolar axis. The alignment rod is proximally placed just slightly medially to the tibial tubercle. When the rod is parallel to the intramedullary axis of the tibia as viewed laterally, the second spike is impaled into the proximal end of the tibia. 6. The stylus is attached to the tibial cutting block on the side of the lower tibial compartment. The cutting block and stylus are lowered until the tip of the stylus contacts the tibial plateau. After predrilling, two 3-inch-long 1/8-inch fixation pins are placed in the marked row of holes. The stylus and alignment rod are removed, taking care not to misalign the cutting block. Alignment is checked by attaching the alignment tower and rod to the tibial cutting block. If alignment is found to be in variance, the cutting block can be removed from the pins, and the special 2- degree varus-valgus block is applied to the pins for correction. 7. The saw capture is applied, and the proximal tibia is resected. 8. Before proceeding further, the surgeon assures that the extremity can be brought into normal mediolateral (ML) alignment in extension. If not, additional soft-tissue balancing is performed until the normal mechanical axis is obtained. 9. A template is made for the femur, and the appropriate AP femoral resection guide is selected. The guide yoke is attached to the AP block and the yoke is slipped under the muscle anteriorly on the periosteum. The ML centerpoint is found, and a 9mm hole is drilled into the femoral canal. The yoke is removed and the 7-inch, 9 mm rod is inserted into the femoral canal. 10. The femoral guide positioner is placed into the joint space, engaging the slot of the femoral AP resection guide. Tibial shims are placed to equalize collateral ligament tension, if necessary. The AP resection guide is pinned into place, the femoral guide positioner and intramedullary (IM) rod are removed, and the anterior and posterior femoral cuts are made. 11. A distal femoral cutting block is chosen, based on the patient's height, and it is attached to the distal femoral cutting guide. The 8 mm femoral 1M rod is inserted into the distal femoral cutting guide assembly, and that, in turn, is slowly advanced into the femoral canal. The cutting guide should abut the intercondylar notch. The cutting block is pinned into place, the saw capture is applied, and the distal femoral cut is made after removal of the IM rod and cutting guide assembly. 12. The appropriate spacer block is then used to assure equal tension in flexion and extension. If flexion is tighter than extension, additional bone must be resected from the distal femur. 13. The knee is placed in flexion; the femoral finishing guide is centered between the epicondyles and impacted until fully seated. Two anterior fixation pins secure the guide to the femur. Two %-inch holes are drilled into the distal end of the femur, and the anterior and posterior chamfers are cut with the oscillating saw. An osteotome is used to make the recessing cut from the proximal end of the finishing guide. A power saw is used to resect the posterior femoral condyle remnants to assure adequate flexion clearance. 14. The tibial size is reassessed using the tibial templates. The selected tibial template is then positioned rotationally, and the appropriate-sized centering punch is used to cut through the subchondral bone. The bone is compressed into the tibia with the tibial impaction punch. 15. The patellar cutting guide is placed onto the patella, and the appropriate resection is performed. The patellar template is placed over the resected surface, and the cruciate channels are created using the patellar burr through the slot in the template. 16. A trial reduction is performed, seating the tibial tray first, the tibial insert, the femoral component, and finally the patella. If this reduction proves satisfactory with regard to alignment and ligament laxity, the trial components are removed, the bone surfaces are irrigated with a pulsatile lavage, and the permanent components are placed. These can be inserted without bone cement, with bone cement, or a combination of both. 17. Drains are placed in the joint depending on surgeon preference. The joint is closed in the usual fashion, and a compressive dressing is applied to the leg. The tourniquet can be released before closure or after the dressing has been applied. Aftercare consists in rapid mobilization and strengthening, with a target discharge of 3 to 4 days postoperatively.
what are the steps in the parathyroidectomy surgery?
1. With the thyroid gland visible, a thorough exploration of the "normal" locations of the four parathyroid glands is conducted . Meticulous hemostasis by means of mosquito hemostats and fine ligatures is a prerequisite to location and identification of these small glands. 2. The thyroid gland is gently rotated anteriorly to provide access to the posterior thyroid sulcus, where the parathyroid glands are almost always found. Identification of the parathyroid vascular pedicle as it leaves the superior thyroid artery is an excellent means of locating the upper glands. Metzenbaum scissors, mosquito hemostats, and Kitner (peanut) sponges are used in the dissection. 3. Attention is directed toward the posterior lateral surface of the thyroid lobe or just beneath the lower thyroid pole, where the lower parathyroid glands are frequently found. Finding the vascular pedicle from the inferior thyroid artery may aid in identification. Occasionally the lower pair is found in the thymic capsule or tissue, in which case a portion of the thymus is resected. In only 1% of patients is a mediastinotomy indicated. It has been reported that thoracoscopy is a successful minimally invasive technique to remove parathyroid tumors situated deep in the mediastinum. 4. Should one of the parathyroid glands show evidence of disease, the surgeon resects it by clamping the vascular pedicle with mosquito hemostats, dividing with small scissors or knife, and ligating with a fine nonabsorbable suture. The question of how much parathyroid tissue to remove is controversial and relates to whether single or multiple glands are involved, regardless of their size and appearance. A portion of one gland must remain to prevent hypocalcemia and its complications. NOTE: A current concept or alternative for multiple gland involvement is to excise all four glands, transplanting a portion of one in an accessible site such as the neck or forearm for later removal if hypercalcemia recurs. This eliminates reexploration and potential injury to the recurrent laryngeal nerve. 5. The neck region is explored for aberrant parathyroid tissue, which is also resected. 6. The remainder of the operation is the same as that described for the thyroid gland.
what are the steps involved in a laparoscopic nissen fundoplication?
1. incision in infraumbilical fold with 11 blade 2. 11 millimeter trocar placed , insufflation achieved. Verres needle may be used first. 3. scope is put in 4. the 5 millimeter trocars are placed below xiphoid process, lateral to midline in upper right quadrant of the abdomen. 10 millimeter trocar placed on lateral plane to the midline in left abdomen. Second 11 millimeter trocar placed in lateral abdominal wall for use by assistant 5. fan retractor put in 11 millimeter trocar. used to retract left lobe of liver for exposure of G E junction 6. endo babcock inserted through 10 millimeter port and used to grasp upper aspect of fundus of stomach. stomach retracted laterally and downward 7. surgeon mobilizes distal esophagus by opening the hiatus and employs an endodissector forceps to bluntly dissect tissue along right and left crura 8. endoclips are used to ligate the most distal portion of the pericardiophrenic vessel before it is divided 9. posterior vagus is identified by left intact 10. dissection is continued to expose posterior esophagus 11. upper aspect of the greater curvature of the stomach is mobilized, and dissection is continued to the posterior esophagus 12. penrose or robinson catheter is inserted through a sheath and is passed behind the gastroesophageal junction. the catheter and penrose drain ends are brought together and secured with a an endoclamp that is then locked. Cath and penrose used as traction retractor 13. another grasping forcep is used to grasp the apex of the of the gastric fundusand retract it downward to expose the short gastric vessels. the vessels are ligated with endoclips and divided with endoscissors 14. upper portion of the mobilized greater curvature is grasped and passed through the opening that has been created at the hiatus 15. tension and adequate mobilization of the greater curvature of the stomach are assessed. the portion of the greater curvature of the stomach that has been brought around the posterior esophagus at the proximal part of the gastroesophageal junction is then manipulated over the anterior distal esophagus 16. a non-absorbable endosuture is passed through a 5 millimeter port and used to place a row of interrupted sutures to join the aspects of the greater curvature of the stomach in a 2 to 3 centimeter wrap around the esophagus 17. a large bougie is passed down the lumen of the esophagus by the anesthesiologist. the sutures are secured with the bougie in place 18. the catheter and penrose drain are removed. the bougie is removed. the abdomen is deflated 19. closure of the trocar sites is performed. dressing are applied
steps in an esophagectomy and intrathoracic esophagogastrostomy
1. incision is carried midway between vertebral border of scapula and spinous process to the 8th rib nd then forward along this rib to the costochondral junction. The extent of the vertical portion of the incision depends on location of the tumor 2. wound is retracted, bleeding vessels are ligated or coagulated 3. chest cavity is opened, and rib spreader is placed. Moist packs are placed, and lung is retracted with a deaver or harrington 4. Mediastinal pleura is incised with long metz and long plain forceps in line with esophagus and lesion 5. esophagus dissected free from aorta with dry dissectors 6. suture ligatures of 2-0 and 3-0 non-absorbable material are used for controlling bleeding vessels 7. Diaphragm is opened, series of traction sutures are attached 8. stomach is mobilized by dissection of its ligamental attachment with long scissors and curved thoracic clamps 9. left gastric artery is clamped, cut, and doubly ligated with 2-0 non-absorbable suture and suture ligature of 3-0 non-absorbable material. sterile field is prepared for the open method of anastomosis 10. stomach is transected well below the lesion with selection resection instruments 11. closure of stomach is completed with two rows of intestinal sutures of 2-0 synthetic absorbable suture and sometimes with an additional row of 3-0 non-absorbable sutures for reinforcement 12. a separate circular opening is usually made in the upper portion of the stomach for anastomosis to the esophagus 13. two allen clamps or a staples type of clamp are applied above the stricture, and the freed esophagus is divided 14. circular opening in stomach and the transected end of the esophagus are anastomosed. mucosal layers are approximated. the muscular layers of the esophagus and stomach are closed by two row of interrupted suture. a mechanical end-to-end anastomosing surgical stapling device may also be used to accomplish the gastroesophageal anastomosis 15. the stomach is anchored to the pleura, and the edges of the diaphragm are sutured to the wall of the stomach with interrupted sutures of 3-0 or 2-0 non-absorbable material 16. the pleura is cleansed with warm, normal, saline irrigation that is suction off 17. thoracic catheter is inserted for closed drainage. chest wall is closed like a thoracotomy
what are the steps in the hiatal hernia repair procedure?
1. transabdominal incision is made, hernia is located, crural repair is done 2. fundus of stomach is wrapped around lower 4-6 cm of the esophagus and is sutured in place which is called a Nissen fundoplication. The upper part of the lesser curvature of the cardioesophageal junction are sutured to the median arcuate ligament which is called the Hill procedure. Or the stomach is plicated around approximately 270 degrees of esophageal circumference which is called the Belsey Mark 4 procedure. 3. vagotomy, pyloroplasty, or both may be performed at the same time 4. wound is closed
MEAN CELL HEMOGLOBIN CONCENTRATION (MCHC)
3-35 gm/dL
POTASSIUM
3.6-5.0 mEq/L
What is extracellular fluid?
30% of the body fluids fluid in compartments outside the cells of the body including plasma, intravascular fluids, fluids in the gastrointestinal tract ,and cerebrospinal fluid
AMYLASE
30-110 U/L
aPTT
30-40 seconds
what are the procedural considerations in a transverse colectomy?
A laparotomy set and Gl instrument set are required. Linear stapling instruments should be available. A self-retaining retractor system is an asset. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
Procedural considerations for a Billroth 2 surgery
A laparotomy set and Gl instrument set are required. Linear stapling instruments should be available. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
What are some procedural considerations for a Billroth 1 surgery?
A laparotomy set and Gl instrument set are required. Linear stapling instruments should be available. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
procedural consideration of resection of the small intestine
A laparotomy set and Gl instrument set are required. Linear stapling instruments should be available. The patient is positioned supine under general anesthesia. A nasogastric tube is inserted by the anesthesiologist after intubation. An indwelling urinary catheter is inserted before the abdominal skin prep.
steps in the operative procedure for ruptured anterior cruciate repair
An examination under anesthesia (EUA) is performed immediately after induction, when the ligaments are completely lax, to evaluate the severity of the injury. 1. A straight midline or slightly medial incision is made across the knee. 2. Meniscus tears inthe vascular zone (peripheral) are repaired with arthoroscopic meniscal repair instruments or cutting needles with a heavy absorbable suture to repair the meniscofemoral and meniscotibialligaments. If the meniscus is not repairable, partial meniscectomy is performed. 3. The middle third of the patellar tendon with patellar and tibial bone plugs is harvested using a power saw and osteotome. 4. A notchplasty is then performed, debriding and smoothing the lateral intercondylar wall with a burr and curette. 5. The femoral and tibial osseous tunnels are developed using the ligament guide to pass guide wires from the lateral area of the femoral condyle and tibial tubercle into the intercondylar notch at isometric points near the anatomic attachment site of the anterior cruciate ligament. 6. The pins are then overdrilled with cannulated drills as close to the size of the patellar tendon graft as possible. The tunnels are smoothed with a curette. 7. Sutures are placed through drill holes at both ends of the graft to pass the graft through the tunnels. 8. Once the graft is passed through the femoral and tibial osseous tunnels, it is fixed at both ends with interference screws, staples, or polyethylene buttons. 9. The medial collateral ligament and posterior oblique ligament are then individually repaired at their insertion sites with bone screws and spiked washers. 10. Additional extra-articular repair is done if necessary. 11. The wound is closed over intraarticular and subcutaneous drains, and a locking knee brace or knee immobilizer is applied.
what are the steps in the suprapubic prostatectomy?
Bilateral vasectomy may be performed to decrease the postoperative incidence of epididymoorchitis. A meatotomy may also be required if the penile meatus is too small to accommodate a Foley catheter. 1. A Foley catheter is inserted through the urethra into the bladder, and the bladder is inflated with a preferred irrigating fluid. This maneuver facilitates identification of the bladder. 2. A transverse or midline lower abdominal incision is made through the skin and the two layers of superficial fascia. 3. The external and internal oblique muscles are cut along the lines of the original incision. 4. Bleeding vessels are clamped, coagulated, or tied with fine absorbable ties. 5. The rectus muscles are separated in the midline and retracted laterally. 6. After the placement of traction sutures, the bladder is opened at the dome with a scalpel. Liquid contents are aspirated, and the bladder incision is enlarged. 7. The bladder is visually and manually explored for calculi, a tumor, or diverticula. 8. The tip of the index finger of the operating hand is inserted through the vesical neck into the prostatic urethra, and the adenomatous tissue is enucleated. If difficulty is experienced with the enucleation, a finger may be placed into the rectum to elevate the prostate gland. Aseptic technique is maintained during enucleation with the use of a sterile second glove on the hand used in the rectum. 9. After enucleation is completed, attention is directed to maintaining good hemostasis by suture ligation of the vesical neck at the 5 and 7 o'clock positions. Other significant bleeding points may also be ligated. 10. A suprapubic catheter of the urologist's choice is placed into the bladder lumen through a small stab incision. 11. A 22 or 24 Fr two- or three-way Foley catheter with a 30 ml balloon is inserted into the urethra, and the balloon is inflated to a size that prevents the catheter from falling or being pulled into the prostatic fossa. 12. The cystotomy incision is then closed with interrupted 2-0 absorbable sutures. 13. A drain is left along the cystotomy incision, brought out through a separate stab wound, and secured to the skin with a silk suture. 14. The muscles, fascia, and subcutaneous tissues are closed in layers, and a dressing is applied. 15. Normal saline irrigation solution may be connected to the Foley catheter to provide continuous irrigation to the bladder to reduce clot formation and maintain catheter patency. Continuous irrigation may be initiated during closure.
Emissary vein
Drains the intracranial venous sinuses to veins on the outside of the skull
hepatoduodenal
During a lap whole it is important to identify;, this a thicker region of the lesser omentum extending between the liver and the duodenum the right edge is free and contains the portal triad:common bile duct, proper hepatic artery and the portal vein
what procedural considerations are there for rotator cuff surgery?
If surgery is necessary , -the patient is placed in the supine or semi-sitting position with a sandbag or folded towel under the affected shoulder. -The head is turned to the opposite side, taking care to avoid undue stretch to the brachial plexus. -A shoulder positioner can be used if intraoperative mobility of the arm is not a factor. -In addition to a bone and soft-tissue set, shoulder instruments will be required. -The remaining equipment needs will depend on the severity of the tear. -Minor tears may require no more than heavy nonabsorbable suture. - Major tears will require a power drill and burr and possibly a microsagittal saw. -Fixation may be gained with bone-anchoring devices . Free needles will be necessary if these are used.
what is a resection of the small intestine and why is it performed?
Resection of the small intestine involves excision of the diseased intestine through an abdominal incision and frequently includes some type of bowel reanastomosis. It is performed to remove certain tumors, a gangrenous portion of the intestine caused by strangulation from bands of adhesions, a herniation of the intestine, or a volvulus.
A latissimus dorsi flap used in breast reconstruction following a mastectomy resives its main blood supply from. this artery
Thoracodorsal
Stretta procedure
Threads a catheter with a balloon on the end down the esophagus. The balloon is inflated, exposing four sharp probes on the outside of the balloon. The probes then discharge high-frequency radio waves into the LES.
Direct hernia
Through the inguinal canal, behind the spermatic cord
The surgeon asks you to first gently supinate, then gently pronate the operative wrist of a 14-year old patient in supine position. The operative extremity is positioned at 80 degrees to the torso. Which of the following most accurately describes the movement of the operative thumb (which direction it points) as you carry out the instructions? o Thumb lateral, then back to medial. o Thumb medial, then back to lateral. o Thumb superior, then back inferior o Thumb inferior, then back to superior
Thumb inferior, then back to superior
what is open reduction, internal fixation?
a method of providing exposure of the fracture site and using pins, wire, screws, a plate and screw combination, rods, or nails to correct the fracture.
neuromuscular blockade of muscle relaxants can be monitored by what?
a peripheral nerve stimulation
commonly used anticholinergics
atropine glycopyrrolate or robinul
symptomatic bradycardi, What drug is contraindicated in the treatment of glaucoma, What is the drug for an anticholinergic?
atropine sulfate
direct and indirect hernias represent what?
attenuations or tears in the transversalis fascia
emergence
begins with the patient starting to emerge from anesthesia and visually ends with the patient being ready to leaving the O.R.
The majority of abdominal aortic aneurysms begin
below the renal arteries, and many extend to involve the bifurcation and common iliac arteries.
Why is a Billroth 1 procedure performed?
between stomach performed to remove a benign or malignant lesion located in the pylorus, or upper half of the stomach. One of several techniques may be followed to establish Gl continuity, including the Schoemaker, the von Haberer-Finney, and other modifications of the Billroth Iprocedure.
after verifying various patient info, what does anesthesia do with the patient?
connects monitors to patients pre-oxygenate the patient with a mask with 100% O2 for 3.5 minutes administer opioids and benzodiazepenes If succ is to be used, a small pretreatment of muscle relaxantis administered If a patient can be ventilated with a mask, anes. may opt to avoid succ and use a non-depolarizing muscle relaxant to intubate the patient
Utilitarianism
idea that the goal of society should be to bring about the greatest happiness for the greatest number of people
what must an anesthesiologist do before administering any meds?
identify the patient verify consent or securea signed operative permit review current lab tests, diagnostic studies, and pertinent medical history confirms there have been no interval changes in the patient's status
Returned blood can be reissued under what circumstances?
if ithas not been allowed to warm to a temperature greater than 10° C.
SSIs are a significant cause of what three things
illness death excessive healthcare costs
Synarthrotic
immovable
what are the mechnical complications in total joint arthroplasty?
implant breakage, loosening, and wear.
HIPPA (Health Insurance Portability and Accountability Act)
imposes privacy and security rules that limit use or disclosure of protected health information in order to ensure patient privacy rights with respect to this information
Three benefits of endoscopic procedures for GERD
improve gastroesophageal flap valve, improving function of the lower esophageal sphincter or tightening tissue at the GE junction
steps for closure of a midabdominal transverse incision
in layers with interrupted suture sub-Q tissue and skin are closed as for laparotomy rectus muscles cannot be closed because its fibers run vertically approximation of rectus sheath brings edges of muscle into excellent apposition, thus eliminating the need to suture the muscle itself
what are the steps of a midline incision?
incision starts above the umbilicus and is carried down through the subcutaneous layer to the linea alba at the umbilicus the surgeon diverts the incision around the umbilicus incision of linea alba exposes the peritoneum use hemostat or forcep to lift peritoneum away from intestines to prevent injury to underlying structures surgeon lifts abdominal wall to protect structures and extends peritoneal incision
potential complications of the use of tissue expanders
include infection, extrusion, deflation, flipped ports, and hematoma formation.
risks of AAA surgery
include massive hemorrhage, injury to the ureters, renal failure, spinal cord ischemia, and death.
Injury called "terrible triad"
includes a torn ACL, torn medial meniscus, and torn MCL
the injury know as the "terrible triad" involves what?
includes a torn anterior cruciate ligament, torn medial meniscus, and torn medial collateral ligament
what is the transthoracic approach for a hiatal hernia?
it is used in patients who have had left upper quadrant surgery, is obese, or if a Belsey Mark 4 procedure is selected lap nissen fundoplication is the procedure if it is performed laparoscopically
Hesselbacks Triangle
landmarks;medial rectus abdominas, lateral inferior epigastric vessels,and Inferior inguinal ligaments- Direct hernias occur here
what are some procedural considerations of a gastrojejunostomy?
laparotomy and G I instrument set are required. linear stapling instruments should be available. the patient is positioned supine under general anesthesia. a nasogastric tube is inserted by the anesthesiologist after intubation. an indwelling catheter is placed into the urinary bladder before abdominal skin prep
Body fluids and electrolytes are important why?
maintaining homeostasis, transporting necessary oxygen and nourishment to the cells, removing waste products of cellular metabolism, and helping to maintain body temperature. Electrolytes are also essential to transmission of nerve impulses, regulation of water distribution, contraction of muscles, generation of adenosine triphosphate (ATP, needed for cellular energy), regulation of acid-base balance, hemostasis (clotting blood).
duodenum, jejunum, ileum
make up small intestines
how do tissue expanders work?
may have a metal-backed, self-sealing silicone valve at its dome or a small, dome-shaped reservoir with a fill tube that is positioned subcutaneously at a distance from the expander but connected to it. In either case, weekly percutaneous injections of normal saline are placed in the expander until the tissue has reached the desired maximum stretch, usually based on a 3:1 ratio. When the desired stretch has been accomplished, the temporary tissue expander is removed, and a permanent implant is placed.
Metoclopramide (Reglan)
med given to empty stomach to reduce nausea and vomiting and decrease the risk of aspiration
what nerve damage causes carpal tunnel syndrome?, Severing which nerve could paralyze the thumb?
median nerve
Which of the following are true statements regarding the pancreas? mixed exocrine and endocrine organ. o The pancreas o The pancreas lies in direct relation to the portal vasculature, the biliary vena cava, the celiac ganglia, and the spleen its vasculature. o Endocrine and exocrine function are distributed throughout the head, neck, body, and tail sections. o All of the above are true statements.
o All of the above are true statements.
The passage of urine from the kidney into the urinary bladder follows which of the following pathways: o Renal calyx, collecting tubules, renal pelvis, Bowman's capsule, and urethra. o Collecting ducts, renal pelvis, urethra, Bowman's capsule, and ureters o Bowman's capsule, collecting ducts, renal calyx, renal pelvis, and ureter o Collecting ducts, renal pelvis, renal calyx, Bowman's capsule, and ureter
o Bowman's capsule, collecting ducts, renal calyx, renal pelvis, and ureter
Following anesthesia, the speed of emergence is directly related to alveolar ventilation (an excretory function of the lung) and inversely related to blood gas solubility. Which of the following statements is also likely true? o Hypoventilation lengthens the time taken to exhale the anesthetic agent and delays recovery. o Hyperventilation lengthens the time taken to exhale the anesthetic agent and delays recovery. o Hypoventilation shortens the time taken to exhale the anesthetic agent and delays recovery. o Hypoventilation lengthens the time taken to exhale the anesthetic agent and speeds up recovery
o Hyperventilation lengthens the time taken to exhale the anesthetic agent and delays recovery.
Putting a patient into Trendelenberg position has the effect of: o Decreasing blood flow to the brain o Decreasing blood flow to the coronary arteries o Increasing blood flow to the brain o Increasing blood flow to the coronary arteries
o Increasing blood flow to the brain
Primary superficial sensation to the cheek and nose derives from: o Mandibular branch of CNV (Trigeminal) o Maxillary branch of CN V (Trigeminal) o Ophthalmic branch of CN V (Trigeminal) o Geniculate branch of CN VII (Facial)
o Maxillary branch of CN V (Trigeminal)
After what percent of total blood volume may arterial pressure AND cardiac output begin to significantly (and precipitously) drop? o More than about 5% o More than about 10% o More than about 20% o More than about 25%
o More than about 10%
QUESTION After what percent of total blood volume may arterial pressure AND cardiac output begin to significantly (and precipitously) drop? o More than about 5% o More than about 10% o More than about 20% o More than about 25%
o More than about 10%
All but which one of the following may cause acute kidney failure: o Hypovolemia due to hemorrhage o Obstruction of urinary flow o Suprarenal cross-clamping of the aorta o Optimized cardiac output
o Optimized cardiac output
The acetabulum, or hip socket, is comprised of the fusion of which of the three bone choices below? o Ilium, sacrum, and pubis. o Pubis, sacrum, and ischium. o Pubis, ischium, and ilium. o Sacrum, ischium, and ilium.
o Pubis, ischium, and ilium.
Innervation to the external genitalia are supplied by the: o Inferior hypogastric plexus o Pudendal nerve and its branches o Pelvic splanchnic nerves o Inferior gluteal nerve and its branches
o Pudendal nerve and its branches
A lymph node dissection near a cancerous tumor may confirms may the presence of cancer cells. Removal of the entire downstream chain of lymph nodes may be performed to eliminate further lymphatic spread. Which of the following statement most accurately describes a "Sentinel" lymph node biopsy? o Removal and biopsy of successive lymph nodes starting at the known tumor site along the lymphatic pathway until all nodes in a region are resected. o Needle biopsy of all regional nodes and removal of only the "affected" ones. o Biopsy and removal of the single most affected node. o Removal and biopsy of successive lymph nodes starting at the known tumor site along the lymphatic pathway until a "negative" node is discovered.
o Removal and biopsy of successive lymph nodes starting at the known tumor site along the lymphatic pathway until a "negative" node is discovered.
Internal mammary arteries are direct branches of which of the following? o Common Carotid artery/s o Aorta o Thyrocervical trunk o Subclavian artery/s
o Subclavian artery/s
Contents of the thoracic outlet, which may be affected by thoracic outlet syndrome, include which of the following lists of structures? o Brachial artery and vein, and brachial plexus. o Subclavian vein and artery, and brachial plexus. o Thoracic duct, brachial plexus, and superior vena cava. o Ascending aorta, brachial plexus, and thoracic duct.
o Subclavian vein and artery, and brachial plexus.
Which anatomical triangle has the following boundaries: Superior: Posterior belly of the digastric muscle. Lateral: Medial border of the sternocleidomastoid muscle. Inferior: Superior belly of the omohyoid muscle. o The carotid triangle o The suboccipital triangle o The anterior triangle o The submental triangle
o The carotid triangle
The tricuspid valve of the heart lies between the: o Left atrium and left ventricle o Left ventricle and the aorta o The right ventricle and the pulmonary artery o The right atrium and the right ventricle
o The right atrium and the right ventricle
Which of the following structures are considered entirely within the peritoneal cavity? o Kidneys o Urinary bladder o Transverse colon o Pancreas
o Transverse colon
Which of the following is cranial nerve #10: o Hypoglossal nerve. o Vagus nerve. o Acoustic nerve. o Facial nerve.
o Vagus nerve.
During total nephrectomy and/or adrenalectomy, which of the following poses the greatest intra-operative risk from a systemic perspective, during the manipulation of the adrenal gland? o Rapidly dropping blood glucose levels. o Rapidly elevating blood glucose levels. oRapid blood pressure change. o Disseminated intravascular coagulopathy (DIC).
oRapid blood pressure change.
McBurneys Incision
oblique RLQ incision appendix removal
What lower extremity nerve is described by the following motor loss? Loss of adduction of the thigh, can be injured if the legs are improperly fixed
obturator nerve
PaCO2
partial pressure of carbon dioxide in arterial blood
PaO2
partial pressure of oxygen in arterial blood
ASA P2
patient with mild sytemic disease -hypertension -asthma -chronic bronchitis -obesity -diabetes mellitus -tobacco abuse -cvd (minimal restrictions)
other factors considered when planning a surgical incision:
patient's condition and need for fast abdominal entry uncertainty of diagnosis and need for flexibility previous surgical scars potential need for future abdominal surgery or ostomy body habitus (physique) risk for bleeding post operative pain cosmetic results
in what situations besides the operating room might total I.V. anesthesia be used?
pediatrics uncooperative patients trauma patients MRI suite radiology laser suites
3 techniques of PEG tube insertion
pull method also known as Ponsky mehod, push method also known as Sacks-Vine technique, and the sheath method or Russell technique, which is rarely used
The purpose of fracture treatment is to
reestablish the length, shape, and alignment of the fractured bones of joints and restore anatomic function.
what is an excision of an esophageal diverticulum?
referred to ask Zenker's diverticulum removal of a weakening in the wall of the esophagus that collects small amounts of food and causes a sensation of fullness in the neck excision gives complete relief of symptoms
ileocecal valve
regulates discharge of small intestinal contents into large intestines; permits movement of fecal matter and gas in either direction which helps prevent obstructions
what is a subcutaneous mastectomy (adenomammectomy)?
removal of all breast tissue with the overlying skin and nipple left intact.
esophagectomy
removal of all or part of the esophagus, which is indicated for cancer, dysplastic mucosal changes, and stricture of the esophagus due to injury or benign disease
pneumonectomy
removal of an entire lung, usually to treat malignant neoplasms. -Other reasons for removal include an extensive unilateral bronchiectasis involving the greater part of one lung, drainage of an extensive chronic pulmonary abscess involving portions of one or more lobes, selected benign tumors , and treatment of any extensive unilateral lesion. -Other resections are often combined with pneumonectomy , such as resection of mediastinal lymph nodes, resections of portions of the chest wall or diaphragm, and removal of parietal pleura.
what is a bilateral subtotal thyroidectomy?
removal of both lobes of the thyroid in the fashion stated for subtotal thyroidectomy.
what is a modified neck dissection?
removal of neck contents , except for the sternocleidomastoid muscle, internal jugular vein, and eleventh cranial nerve.
segmental resection is
removal of one or more anatomic subdivisions of the pulmonary lobe. -It conserves healthy, functioning pulmonary tissue by sparing remaining segments. -Segmental resection is indicated for any benign lesion with segmental distribution or diseased tissue affecting only one segment of the lung with compromised cardiorespiratory reserve. -The most common cause for removal is bronchiectasis. -Other conditions requiring removal include chronic, localized inflammation and congenital cysts or blebs.
what is a laminectomy?
removal of one or more of the vertebral laminae to expose the spinal canal.
what is a unilateral thyroid lobectomy?
removal of one thyroid lobe with division at the isthmus
In fractures of a lower extremity the objectives of surgery are to
restore alignment and length and provide stability of the extremity for weight bearing.
3 categories of bariatric procedures
restrictive (banding) malabsorptive (sleeve gastrectomy) combination of both
Breast Flaps are described by what features?
the types of tissue they contain, their blood supply, and the method by which they are moved from the donor to the recipient site.
