SRGT 1542: Final Exam Key Topics (Chapters 16,18-19, 22-24)

Trephine

A cylindrical saw for cutting a circular piece of bone

Lacrimal

A facial bone that, along with the zygomatic bone and palate, helps to form the orbit of the eye

Intracapsular cataract extraction

A method for surgically removing a cataract by injecting alpha chymotrypsin into the posterior chamber to digest the suspensory ligament so that the diseased lens can be removed in its entirety

Extracapsular cataract extraction

A method for surgically removing a cataract through an incision in the side of the cornea and replacing the diseased lens with an intraocular implant

Cataract

A pathological condition in which the crystalline lens has become opaque due to age or trauma

Strabismus

A pathological condition involving a misalignment or deviation of the eyes that prevents them from working simultaneously to track visual objects

Chalazion

A small, red, inflamed lump that can be located on the inner or outer surface of the eyelid; caused by an inflammatory reaction to material trapped inside the meibomian gland in the eyelid

Double Lung Transplant Procedure

A lung transplant is performed for a variety of reasons, including emphysema, COPD, idiopathic pulmonary fibrosis, cystic fibrosis, and primary pulmonary hypertension. The procedure is not performed for patients who have a history of cancer or currently have cancer, who have a history of chronic liver and kidney disease, who currently have an infection such as HIV or hepatitis, who had tobacco use in the last 6 months, or who have a history of alcohol and drug abuse. The patient must be psychologically stable in order to cope with the life-long challenges that a lung transplant presents, including ability to remember medication regimen. Steps 1-5: Removal of Lungs from Recipient 1. A clamshell incision is made in the mammary fold. The incision extends mid-axillary region from right to left with the gentle curve at the sternum. A small skin flap is created with ESU and forceps to the level of the fourth intercostal space and the pectoralis muscle is divided at that level. 2. The fourth intercostal space is entered laterally and the rib spreader is placed to aid in the dissection of the mammary vessels as close to the sternum as possible. The mammary vessels are divided; the vessels are doubly clamped and divided with hemoclips or CCCT with 2-0 silk ties. 3. The tissue posterior to the sternum is dissected and the sternum cut with the sternal saw. The self-retaining sternal retractors are placed bilaterally and slowly opened while the retrosternal mediastinal tissue is incised to provide exposure of the aorta and the right atrium in case CPB becomes necessary. Procedural Consideration: The surgical team must be ready for the surgeon to indicate that CPB must be used. Hypoxia and/or chronic low pH combined with hemodynamic instability are two intraoperative complications that demand the use of CPB. Note: The following steps of the procedure are for transplantation of the right lung. However, the first lung to be transplanted is the one identified as having the lesser perfusion of the two lungs. 4. The anesthesia provider collapses the right lung. The pleura lying over the pulmonary hilum and the inferior pulmonary ligament are incised. The superior pulmonary vein, pulmonary artery, and inferior pulmonary vein are dissected free and divided. The superior division of the right pulmonary artery is CCCT; next, two vascular staplers are used to divide the superior pulmonary vein as close to the lung to be removed as possible in order to preserve the length for anastomosis. The inferior division of the right pulmonary artery and inferior pulmonary vein are also divided with vascular staples as close to the lung as possible. Procedural Consideration: The surgeon is careful to identify and prevent injury to the phrenic nerve during the dissection of the hilum. The nerve supplies the diaphragm, and injury can result in diaphragmatic paralysis. 5. The bronchus is the last structure to be divided and the lung is then removed. Procedural Consideration: The surgeon will exercise great care in achieving hemostasis at this point in the procedure, in particular for patients who have bronchiectasis or cystic fibrosis, as they tend to have enlarged bronchial arteries. Steps 6-9: Preparation for the Donor Lung 6. Before the donor lung can be implanted, the bronchus, pulmonary veins and the pulmonary artery must be prepared for anastomosis. Allis clamps are placed on the corners of the bronchus and held in place by the surgeon. Using a sponge for blunt dissection and the Metzenbaum scissors, the surgeon dissects away the tissue that surrounds the bronchus (called peribronchial tissue) toward the mediastinum. Next, the cartilaginous wall is cut from around the end of the bronchus, but left attached on the posterior side. The surgeon will place 3-0 PDS or Vicryl at the corners of the cartilaginous wall, but the needles are not cut off. Now the membranous wall located behind the cartilaginous wall is cut with valve scissors. 7. Two Judd-Allis clamps are placed on the stumps of the pulmonary vein. The pericardium is incised around the veins in order to obtain as much length as possible of the left atrium in order to apply the atrial clamp when the atrial anastomosis is performed. 8. Two Judd-Allis clamps are placed on the pulmonary artery and the tissue around the artery is removed. Hemostasis is confirmed in the hilar region and a cooling jacket is placed in the pleural cavity. The donor lung will lie on the jacket during the anastomoses. 9. The donor lungs are separated and prepared on a separate sterile back table. The bronchus, pulmonary artery, and atrial cuff are prepared. To separate the lungs, the atrial cuff is divided at the midline. The right and left pulmonary arteries are divided at their attachment to the primary pulmonary artery. The bronchus is divided with a GIA linear stapler and left stapled until implantation to keep the lung inflated. The right pulmonary artery is cut to a short length to avoid kinking at the site of anastomosis. The first branch of the artery is identified and preserved to serve as an anatomical landmark to avoid kinking or twisting at the site of the anastomosis. The left atrium is dissected free from its pericardial attachments. The surgeon will hold the atrial cuff upward with vascular forceps, and a Kelly clamp is applied to the pericardial tissue flap. The surgeon performs the dissection with the Metzenbaum scissors and preserves the flap, which to will be used to help cover the bronchial anastomosis; 5 mm or slightly more of the atrium is left around the pulmonary veins. Steps 10-11: Implantation of the Donor Lung 10. Right before the donor lung is placed in the pleural space on top of the cooling jacket, the surgeon opens the bronchus using a #15 knife blade. 11. The order of the anastomosis is bronchus, pulmonary artery, atrial cuff. Bronchus: The previously placed sutures in the cartilaginous wall of the recipient bronchus are placed at the corners of the donor bronchus, but not tied; Crile clamps are placed on the sutures to provide traction. The membranous wall is anastomosed first with a continuous 4-0 Maxon or PDS suture. When the membranous portion anastomosis is completed, the surgeon gently pulls on the two traction sutures to tighten the membranous wall sutures. Next, the cartilaginous wall is sutured with 3-0 or 4-0 polypropylene. When the diameters of the lumens match up, an end-to-end anastomosis is performed using interrupted suture technique. If the diameters do not match up, a telescoping anastomosis is used; the donor bronchus will be telescoped outside the recipient bronchus. The mediastinal tissue posterior to the pulmonary artery and donor peribronchial tissue is used to cover the bronchus at the site of the anastomosis. Pulmonary artery: The surgical assistant gently pulls on the mediastinum to reveal the pulmonary artery. Two Judd-Allis clamps are placed on the end of the artery stump. A vascular clamp is placed further down the artery to aid in providing as much length as possible for the anastomosis. A 5-0 polypropylene suture is placed in the bottom corner of the artery, but not tied. A suture is placed in the top corner and tied. The back wall of the artery is anastomosed first using a continuous suture. The front wall is then anastomosed; the first continuous suture is from the bottom corner to the middle and the second continuous suture is from the top corner to the middle. Before the surgeon ties the front wall suture, the pulmonary artery is filled with warm normal saline to remove the air; the surgeon will use a 14-gauge angiocatheter attached to a 20-mL syringe filled with the saline solution. Atrial cuff: The pulmonary veins are cut open just below the staple lines. The atrial tissue between the two veins is cut in order to create a single atrial cuff for anastomosis. Two Judd-Allis clamps are placed on the superior and inferior vein stumps. An atrial clamp is placed on the recipient's left atrium to aid in providing as lengthy of an atrial cuff as possible. The posterior wall of the atrium is sutured first; an everting mattress suture technique is used to create an end-to-end anastomosis. The anterior wall is sutured using the same suture technique. The sutures are not immediately tied; a curved Kelly clamp is placed between the suture line into the inferior pulmonary vein to keep the suture line open. While the anesthesia provider inflates the lung, the pulmonary artery clamp is slowly released; the surgeon will take 8 to 10 minutes to remove the clamp in order to provide a controlled reperfusion of the lung. While the clamp is being removed and the lung inflated, blood flow through the suture line is allowed and air is also allowed to escape. Once this is complete, the Kelly clamp is removed and the suture is tied. 12. The surgeon explores the pleural space to confirm there is no air leakage from the anastomoses and to confirm hemostasis. 13. The procedure is performed for the left lung. 14. After the left lung is in place, two 28 Fr chest tubes are inserted in each pleural cavity, one straight tube and the other curved. 15. Four #2 Vicryl sutures are used to close each hemithorax. Three or four #5 steel wires are used to close the sternum. The muscle and subcutaneous layers are sutured with absorbable suture. The skin is closed with suture or staples. 16. The anesthesia provider changes the double-lumen ET tube to a single-lumen ET tube. The surgeon performs a bronchoscopy to aspirate secretions and internally recheck the anastomoses

Embolectomy or Thrombectomy Procedure

A sudden loss of circulation to an extremity is usually an indication of arterial embolism. An embolus can be a blood clot, fat, air, or even a small portion of a tumor that circulates through the cardiovascular system until it eventually becomes lodged in smaller vessels, at which point it is now called a thrombus, blocking the blood flow to an extremity or organ. Morbidity associated with embolism remains high; however, not necessarily because of the ischemic limb, but because of the underlying disease that led to the formation of the embolus. Emboli lodge at bifurcations or the origin of large vessel branches, at sites of anatomical narrowing, and at sites of pathological narrowing, such as an atherosclerotic superficial femoral artery. Approximately 80 percent of peripheral emboli affect the lower limb, with the common femoral bifurcation accounting for approximately 50 percent of cases. Emboli may originate from the left atrium in patients with atrial fibrillation or from the left ventricle when the endocardium is damaged and the ventricle contracts poorly. Emboli may also originate from the aorta to the extremities. Emboli may also be present in patients who have had an arteriovenous shunt inserted for dialysis or prior lower extremity bypass surgery. Using a #10 knife blade, the surgeon makes an incision in the groin and cuts down to expose the femoral artery. Procedural Consideration: Metzenbaum scissors and DeBakey forceps are typically used during this step of the procedure. 2. Vessel loops are placed around the common, deep, and superficial femoral arteries. 3. Vascular clamps are placed proximally on the common and deep femoral arteries. The backflow of blood within the superficial femoral artery is confirmed. 4. Vascular clamps are placed distally on the common and superficial femoral arteries. The clamp is removed from the deep femoral artery and backflow is confirmed. 5. Using the #11 knife blade, an arteriotomy is made into the common femoral artery and extended with the 45 degress Potts-Smith scissors. 6. The surgeon inserts the Fogarty embolectomy catheter into the superficial femoral artery, advances it slightly past the thrombus, and inflates the balloon (Procedural Consideration: A variety of sizes of catheters should be available in the OR. The surgeon will communicate the size to the surgical technologist, who will request the circulator to open the catheter onto the sterile back table. The syringe filled with the correct amount of heparinized saline solution is attached to the catheter. 7. The surgeon slowly pulls the catheter backwards with the balloon inflated in order to dislodge the thrombus, and it is removed as the catheter is taken out of the artery. The thrombus is passed off from the surgical technologist to the circulator as a specimen. Several passes of the catheter may be needed to establish adequate flow. 8. A vascular clamp is placed on the artery because backflow is now reestablished. Procedural Consideration: The surgical technologist must have the vascular clamp ready to quickly hand to the surgeon when the catheter with the thrombus is removed from the artery. 9. The vascular clamp is removed from the common femoral artery and a small-diameter irrigating catheter is inserted. The heparinized saline solution is injected to irrigate the common femoral artery. 10. The surgeon may perform an angioscopy or perform an arteriogram to confirm patency of the artery. A Doppler may also be utilized to confirm the presence of distal pulses. 11. The artery is closed in continuous fashion using polypropylene suture. Occasionally, a patch angioplasty is performed utilizing a xenograft or synthetic patch. The wound is closed in layers and dressings are placed.

Vitrectomy Procedure

A vitrectomy is performed to remove the blood so the surgeon can view whether there is a detachment. Traction retinal detachment is another pathology that involves the vitreous humor. When vitreous humor pulls on scar tissue, the retina may detach. When the detachment involves the macula, central vision is lost. Scar tissue may wrinkle the retina and also cause visual loss. The vitreous humor and scar tissue are removed from the surface of the retina, releasing the traction Intraocular gases: Usually either C3F8 or SF6 ; when mixed with sterile air, these gases have the property of remaining in the eye for extended periods of time (up to two months). The eye's own natural fluid eventually replaces them. Gas is useful for flattening a detached retina and keeping it attached while healing occurs. Gas injection is also used to close macular holes. It is frequently necessary for the patient to maintain a certain head position following surgery when gas is used. Possible complications of intraocular gas include progression of cataracts and elevated IOP. Silicone oil: This is sometimes used instead of gas to keep the retina attached postoperatively. Silicone remains in the eye until it is removed (necessitating a second surgery). The technique is advantageous when long-term support of the retina is required. Unlike what they experience with gas, patients are still able to see through clear silicone oil. Positioning is less critical with silicone oil; therefore, it may be used with patients who are unable to position themselves appropriately postoperatively. Like gas, silicone oil may promote cataracts, cause glaucoma, and damage the cornea. Endophotocoagulation: This technique uses a laser to treat intraocular structures. This modality is often used to treat retinal tears in the setting of retinal detachment and is frequently used to treat proliferative diabetic retinopathy as well. Lensectomy: Lensectomy is the removal of the eye's crystalline lens during a vitrectomy procedure. This is sometimes performed when there is a cataract, which prevents the surgeon from adequately visualizing the internal structures. A lensectomy may also be necessary to gain access to and remove scar tissue during complicated retinal detachment or diabetic retinopathy procedures. The natural lens can be replaced with a clear lens implant at a later date or during the same surgical procedure. Lensectomy is usually performed using high-frequency ultrasound. *An incisable drape is placed over the operative eye. The surgeon incises the drape using small, straight scissors. The eyelids are retracted with a speculum.* A sclerotomy is performed in the pars plana. For a 25-gauge procedure, the sclerotomy is performed with a 25-gauge trocar and canula assembly. If a 20-gauge procedure is to be performed, a small incision is made in the conjunctiva to expose the sclera with Wescott scissors, and a 20-gauge vitrectomy blade used for the sclerotomy. *20-gauge: A 7-0 suture is typically placed in advance to eventually support the infusion cannula.* This sclerotomy is placed 3 to 4 mm from the limbus. The trocar or blade is inserted until it is seen through the pupil; it is withdrawn. For the 25-gauge procedure, the canula remains in the sclerotomy. The infusion cannula is inserted through this sclerotomy. Two more sclerotomies are made, one at the upper border of the lateral rectus muscle and one at the medial sides of the lateral rectus muscle, using the same procedure as the infusion sclerotomy. The endoilluminator is inserted through one of these sclerotomies, and the vitrectomy handpiece or other instrument is inserted through the final sclerotomy. * At this point, the surgical technologist will have tested the suction vacuum and assessed the cutting function of the vitrector, and also ensuring that the unit rates have been set for proper infusion, cutting, and aspiration according to the surgeon's preference.* The vitrectomy is performed using the maximum cutting speed on the instrument. * The surgeon controls the vitrector via a foot switch. Be sure it is in a comfortable, easy-to-access location. Other instruments, such as intraocular scissors or foreign body forceps, may be introduced through the same sclerotomy to accomplish the surgical objective. Prior to removal of instruments from the eye, infusion should be stopped.* When the procedure is complete, the instruments are withdrawn and sclerotomy plugs are inserted if necessary. 25-gauge: the plugs and canulas are removed. The surgeon check for leakage with a Weck-Cell or cotton tip swab. 20-gauge: the plugs are removed and the sclerotomies are closed using 7-0 polyglactin sutures, infusion site last. The conjunctiva is also closed with 7-0 polyglactin suture. A subconjunctival injection of betamethasone and gentamicin may be given. An eyepad, rigid shield, and tape are applied.

Tunic

An investing membrane

Balanced salt solution (BSS)

An irrigant used for the eye during eye procedures

Stainless steel wire/arch bars

Arch bars are used to immobilize the jaw following mandibular and/or maxillary fracture. However, the advances in rigid fixation have decreased the necessity for and/or amount of time that arch bars are required. Arch bar set includes pediatric- and adult-size stainless steel arch bars. Wire used to attach arch bars to the teeth must be precut and prestretched to prevent stretching of the wire intraoperatively and postoperatively, ensuring the security of the arch bars. To prepare the wire, cut segments slightly longer than needed—approximately 10 cm. Place cut ends of wire in jaws of two wire twisters and secure. Twist each instrument half a turn and pull to stretch. Remove the instruments and trim the crimped ends. Time permitting, several wires are prepared in advance. Plan to use at least one wire for each viable tooth. Allow extra in the event that some wires fall to the floor or break. The arch bars are measured, shaped, and cut to size. Procedural Consideration: Have two (one for the mandible and one for the maxilla) appropriate-sized arch bars ready, along with the wire cutter. The wire, probe, cutter sequence will be repeated until the arch bars are secured to each tooth in the mandible and maxilla. Wire or elastic loops can now be placed over the hooks of the arch bars and tightened to immobilize the jaw.

Abdominplasty Procedure

Abdominoplasty is performed to thin the upper abdominal fat, tighten the abdominal muscles, and remove excess subcutaneous fat and skin from the mid- to lower abdomen. The surgeon marks the incision using the marking pen. A low transverse incision in the shape of a "W" is made down to the level of the rectus sheath. A small inferior flap is created. The incision is made low enough so the scar will be hidden by the patient's undergarment or bathing suit as well as by the regrowth of the pubic hair. Bleeding is controlled with cautery. Next, dissection begins on the superior flap that extends beyond the level of the umbilicus. *Much of the initial dissection may be accomplished with the use of electrosurgery in either the cut or blend mode. The surgical technologist should keep the pencil tip clean with the use of a scratch pad and/or position the pad near the surgeon to be used.* A second incision is made around the umbilicus using the sterile template, commonly called the "cookie cutter," to ensure that the incision is a perfect circle. The umbilicus is freed from the skin and subcutaneous tissue, allowing it to remain attached to its pedicle, or base. The flap dissection continues superiorly to the level of the outline of the ribs bilaterally. *A variety of retractors is used as the dissection continues. The fiberoptic retractor may be used according to the surgeon's preference.* The superior flap is retracted to reveal the rectus abdominis muscle. The muscle, along with its fascia, or sheath, is pulled together and sutured to firm the abdominal wall and accentuate the waistline. The skin flap is then pulled down, the new location for the umbilicus is marked, and the excess tissue is removed. An opening is created for the umbilicus using the "cookie cutter" template and the structure is sutured into position. The wound is now closed in layers. One or two closed wound drainage systems may be placed, with the tubing exteriorized through the lateral wound edges. Staples may be used to close the skin layer. A small dressing is placed over the umbilicus and a pressure dressing over the transverse incision. The surgeon may request an abdominal girdle placed on the patient.

Repair of Atrial Septal Defect (ASD) Procedure

An ASD is an abnormal opening in the wall between the two atria. There are three types of ASD: ostium secundum, sinus venosus, and ostium primum. The ostium secundum type is in the midatrial septum and is the most common. The sinus venosus type of defect occurs high in the septum near the entrance of the superior vena cava in the right atrium. This type of defect is usually associated with anomalous pulmonary venous drainage, in which one or more pulmonary veins drain into the right atrium rather than the left. The ostium primum is located low in the anterior portion of the septum and is associated with other defects in the AV canal, usually with a cleft of the mitral valve. The ASD results in a shunting of oxygenated blood from the left atrium across the defect into the right atrium. If the defect is large or of the ostium primum type with marked shunting of flow, the workload of the right side of the heart is increased. Pulmonary hypertension, enlargement of the pulmonary artery and its branches, and enlargement of the heart's right side may be a result of this increased workload. In later stages, right-sided heart failure and a reversal of the shunt with subsequent cyanosis may ensue. The primary indication for surgical repair of the ASD is the presence of symptoms. Surgery may also be indicated in the infant who is asymptomatic but has clear echocardiographic evidence of right ventricular volume overload. The child who is asymptomatic for the defect should undergo surgical repair around the age of 4 to 5. If symptoms are present, intervention should come at any age without hesitation. 1. The surgeon makes a median sternotomy and CPB is begun. The patient's core body temperature is established at . The aorta is cross-clamped and the heart is stopped with cardioplegia solution injected into the aortic root. Procedural Consideration: There are two methods of CPB that the surgeon will choose to use. When bicaval cannulation is used, the pediatric patient remains on CPB during the procedure and the blood flow bypasses the right atrium by traveling through the superior and inferior venae cavae cannulas. However, this method of cannulation can block the view of the surgical site. Therefore, single cannulation may be used by placing the cannula into the right atrium. 2. Using a finger inserted into the right atrium through a stab wound, the defect is inspected and a decision is made as to whether primary closure or patch closure is to be performed. If significant tension will be the result of a primary closure, then the patch will be used. Procedural Consideration: If single venous cannulation is used, the venous line is clamped just before the incision is made in the right atrium. Palpation before making the atrial incision eliminates the need to explore the atrium, which decreases the hazards of the formation of an air embolism. 3. Using a #15 knife blade, the right atrium is incised. 4. Small ASDs may be closed directly with polypropylene suture with continuous suture technique. 5. Large defects are closed with a Dacron patch or autologous pericardium. The patch is sutured to the defect with a double-armed 4-0 or 5-0 polypropylene. The suture is begun at the inferior margin of the defect; each end is placed around the sides in continuous fashion to meet at the superior margin and tied. The right atrium is closed with a 4-0 or 5-0 polypropylene suture. Procedural Consideration: Before the atrium is completely closed the right atrium and pulmonary artery are deaired by allowing blood to fill the atrium. Autologous pericardium patches are an excellent choice for the repair because they are resistant to postoperative SSI. 6. The clamp is removed from the aorta in order to allow blood to flow from the left atrium to the right atrium to prevent air embolism. The lungs are ventilated to deair the pulmonary veins and left atrium. CPB is discontinued; suction is applied to the vent in the ascending aorta for a few minutes after the heart is beating. The chest is closed as described for open-heart procedures.

Ventricular Aneurysm Repair Procedure

An aneurysm is a sac formed by localized dilatation of the walls of an artery due to structural weakening. The strength of an arterial wall is in the elastic tissue of the tunica media. Destruction of this layer by any disease diminishes the strength of the vessel wall. Arterial aneurysms may be classified according to cause, shape, location, or structure. There are two types of aneurysm: true aneurysm, in which the wall of the sac consists of one or more of the layers that make up the wall of the blood vessel; and false, or pseudoaneurysms, which are pulsatile hematomas that are not contained by the vessel layers but are confined by a fibrous capsule. Atherosclerotic aneurysms are classified as true aneurysms. False aneurysms are caused by disruption of the vessel wall or of the anastomotic site between graft and vessel, with blood contained by surrounding tissue Left ventricular aneurysms (LVAs) develop in post-MI patients. The aneurysm of the left ventricle is a mural fibrous scar that can cause congestive heart failure. The wall of the aneurysm is thin. The mural thrombus can be a large size and calcify over time. The pericardium overlying the aneurysm may be adhered to the epicardial surface of the aneurysm and also may calcify. The lack of coronary reperfusion after an MI contributes to the development of an LVA. It is thought that reperfusion of the affected coronary artery by drug therapy or angioplasty contributes to a lower incidence of LVA by improving the blood flow, and hence oxygen, to the infarcted portion of the myocardium. The surgeon makes a median sternotomy. The anesthesia provider heparinizes the patient. The ascending aorta and right atrium are cannulated and CPB is begun, including administration of cardioplegia. The aorta is now cross-clamped. Procedural Consideration: Cardioplegia and aortic cross-clamping are first performed to prevent the dislodging of the mural thrombus when the aneurysm is dissected from the pericardial sac. 2. The left ventricle is vented by placing a vent through the junction of the right superior pulmonary vein and left atrium. 3. The pericardial adhesions that overlie the aneurysm are divided by blunt and sharp dissection, freeing the aneurysm from the pericardial sac. 4. The surgeon inspects the left ventricle and confirms the location of the aneurysm. Using the #15 knife blade and Potts-Smith scissors, a ventriculotomy is made on the anterior aneurysm wall 3-4 cm from the left anterior descending (LAD) coronary artery. The heart is slightly elevated from the pericardial sac and the center of the incised wall of the aneurysm is identified. 5. With the left ventricle open, the mural thrombus is carefully dissected from the ventricle. The margins of viable myocardium are identified and the scar tissue is excised. Loose thrombi are removed. Care is taken to preserve the papillary muscles from injury. Procedural Consideration: A wet lap sponge may be placed inside the ventricle to cover the aortic and mitral valves to prevent debris from entering the aorta or left atrium. 6. The remaining portion of the aneurysm is excised, but a 2- to 3-cm rim of scar tissue is left in place for the placement of sutures when the Dacron patch is placed rather than placing the sutures through viable myocardium. The ventricle is inspected and irrigated with warm saline solution to remove any remaining small pieces of thrombus. 7. Inferior and posterior located aneurysms require repair with a circular Dacron patch, but anteriorly located aneurysms can also be repaired with the patch. The following are the steps of the repair: The Dacron patch is cut in circular fashion approximately 2 cm larger in diameter than the ventricular opening. Polypropylene suture with felt pledgets is placed in purse-string fashion through the scar tissue rim and tightened to reduce the size of the ventricular opening. The 2-0 or 3-0 pledgeted polypropylene sutures are placed in interrupted horizontal mattress fashion through the aneurysm fibrous scar tissue located on the ventriculotomy rim and then through the patch. The pledgets are located on the exterior of the ventricle. The sutures are tied bringing the patch into place and covering the ventricular opening. A second layer of 2-0 polypropylene suture is placed in continuous fashion for reinforcement and hemostasis. 8. Air is removed by venting the ascending aorta and left ventricle while allowing the heart to fill and ventilating the lungs. Additionally, the patient is rewarmed. Temporary pacing wires are placed on the right atrium and ventricle. CPB is discontinued and heparinization reversed. 9. The surgical site and median sternotomy are closed in routine fashion.

Angioplasty Procedure

Arterial blood is pumped by the heart through arteries. Arteries are large in size as they leave the heart, but begin dividing into progressively smaller arteries as they move into various regions of the body. Arterial blood refers to blood that is transported away from the heart to the tissues of the body. Artery walls consist of three layers called tunics Tunica adventitia—outer layer consisting of connective tissue. This layer attaches the artery to the surrounding tissues and contains tiny vessels called vasa vasorum that nourish the cells of the arterial wall. Tunica media—middle and thickest layer consisting of elastic fibers and smooth muscle fibers that completely encircle the artery. The smooth muscles are innervated by sympathetic branches of the autonomic nervous system. Impulses from these nerves can cause the smooth muscles to contract, resulting in a narrowing of the lumen of the vessel. This process is called vasoconstriction and results in a rise in blood pressure. The inhibition of the impulses from the autonomic nervous system allows the smooth muscles to relax, resulting in an increase of the diameter of the lumen. This is called vasodilation and results in a decrease in blood pressure. Tunica intima—inner layer composed of a lining of endothelium. This layer is in contact with the blood; the lining of this layer must be smooth so that platelets can flow without being damaged and clotting will be prevented. Arteriosclerosis obliterans is a common disorder of the arteries characterized by thickening and loss of elasticity of the arterial walls. This results in a decreased blood flow to the organs that the arteries supply. A type of arteriosclerosis is atherosclerosis. Atherosclerosis usually occurs with age and is associated with tobacco use, hypertension, obesity, diabetes mellitus, and high levels of low-density lipoprotein cholesterol. Atherosclerosis is characterized by the formation of yellow-colored plaques of cholesterol and lipids called atheromas on the inner layers of the walls of medium-sized and large arteries. The formation of the atheroma is usually segmental. The vessel walls become fibrotic and calcified and the lumen narrows, causing reduced blood flow to the organs the artery supplies. The two main areas of early peripheral involvement are the aortic bifurcation and the distal superficial femoral artery. The disorder may then progress to involve other arteries. The plaque places the patient at risk for thrombosis, coronary heart disease (CHD), angina pectoris, and myocardial infarction. The following procedure describes percutaneous transluminal coronary angioplasty for treating blockage of the coronary artery. 1. Under fluoroscopic guidance, an arterial introducer needle is inserted into the femoral artery. Procedural Consideration: Antegrade percutaneous puncture of the femoral artery is the best approach for most peripheral stenoses. The most common approach is through the ipsilateral femoral artery, but the contralateral approach is occasionally used. 2. A sheath introducer is placed over the needle into the artery to keep it open and control bleeding. The needle is removed. 3. A long, flexible plastic tube called the guiding catheter is placed through the sheath introducer and the tip inserted up to the opening of the affected coronary artery. Procedural Consideration: The placement of the guiding catheter allows for the injection of contrast dye into the coronary artery to allow the surgeon to visualize the location and extent of the lesion under fluoroscopy. 4. With the use of fluoroscopy, the surgeon is able to estimate the diameter of the coronary artery and communicates the size of coronary guidewire and balloon catheter that will be needed to the surgical technologist. Procedural Consideration: The surgical technologist should also be ready to provide heparin to the surgeon for injection through the guiding catheter to prevent the formation of blood clots. 5. The coronary guidewire is inserted through the guiding catheter, advanced into the coronary artery and through the site of stenosis or blockage and past the lesion. Procedural Consideration: Passage of the guidewire through a lesion is the most crucial part of the procedure. Steps to prevent and reverse vessel spasm should be taken during the procedure; the surgical technologist should always have nitroglycerine ready for intra-arterial injection. 6. A balloon-tipped angioplasty catheter is threaded over the guidewire, carefully advanced, and positioned across the coronary artery lesion. 7. The balloon is slowly inflated to compress the atheromatous plaque against the wall of the coronary artery. Procedural Consideration: The surgeon will use fluoroscopy throughout the procedure. 8. An intraluminal expandable wire mesh stent may be placed within the vessel after balloon angioplasty to maintain patency of the vessel lumen. The Palmaz stent is delivered to the site of the lesion with the balloon angioplasty catheter. Once in position, the balloon is inflated and the stent is expanded against the arterial wall and left in place as the balloon is deflated and removed. 9. Fluoroscopy is used to confirm the repair and images are permanently recorded.

Angioscopy Procedure

Arteries grow progressively smaller until they become arterioles, which in turn become capillaries. Capillaries are microscopic vessels designed to exchange nutrients and wastes between the blood and tissue fluid around the cells in specialized areas called capillary beds. After this exchange, capillaries unite to form venules, the smallest of veins (Figure 23-5). These venules unite to form progressively larger blood vessels called veins, which eventually become the superior and inferior vena cava, the largest of veins. Veins, then, are designed to transport blood back to the heart. Angioscopy is an endoscopic visualization of the inner surfaces of blood vessels. Angioscopy has multiple applications, including diagnosing an arterial embolism or used as an adjunct procedure during vascular bypass to visualize valves of the venous system. The vessel to be visualized is exposed through a cut-down incision. 2. The segment of vessel to be viewed is isolated by the placement of two vascular clamps, one distal and the other proximal. 3. A small arteriotomy or venotomy is made with the #11 or #15 knife blade. 4. The blood is flushed from the segment with saline irrigation. 5. The vein-irrigating catheter is inserted and the Ringer's solution allowed to flow into the vessel. Procedural Consideration: A pneumatic pressure cuff is placed around the bag of Ringer's solution and inflated to a pressure between 200 and 300 mm Hg. However, some surgeons may use an irrigation pump that, when turned on, can provide a constant pressure of 200 mm Hg. Additionally, some angioscopes have an irrigation port to attach the irrigating tubing. 6. The angioscope is positioned centrally and inserted into the vessel. The distal vascular clamp is removed. The vein-irrigating catheter is advanced parallel with the angioscope. Procedural Consideration: The surgical technologist may be responsible for helping the surgeon to advance the vein-irrigating catheter. When internally viewing a vein, the force of the irrigation fluid helps to open the valves to facilitate advancing the angioscope. 7. Upon completion of the procedure, the angioscope is carefully withdrawn along with the irrigating catheter. The vessel incision is closed and the proximal vascular clamp removed. Procedural Consideration: The surgeon may use the Doppler ultrasound to confirm the reestablishment of normal blood flow within the vessel.

Transverse Rectus Abdominis Musculocutaneous Flap (TRAM) Procedure

Breast removal due to cancer or other disease may be one of the most psychologically devastating procedures that a woman may have to endure. Along with dealing with the diagnosis of cancer, many women feel that they have been stripped of their womanhood. Reconstruction mammoplasty can help to restore a woman's appearance, positive self-image, and quality of life. For some patients, breast restoration may begin at the same time that the mastectomy is performed. The reconstructive process can involve more than one procedure. The nipple and areolar reconstruction is often the final stage. Some patients may choose to have surgery performed on the otherwise unaffected breast to gain symmetry. For patients with advanced malignancies, reconstruction may not be recommended. A description of the different types of mastectomy can be found in Chapter 14. Several options for breast reconstruction exist, depending on the type of mastectomy that has been performed. These options include: Implant reconstruction: If the patient has enough remaining tissue, the surgeon may insert an implant similar to those used for augmentation mammoplasty under the existing muscle. Otherwise, a temporary device called a tissue expander is inserted in the same location that the final implant will be located. This temporary device allows for fluid to be gradually added at intervals to stretch the existing tissue. When the desired result is achieved, the permanent implant is substituted. Flap reconstruction: Flap reconstruction involves transferring tissue from one part of the body to another. The tissue may be taken from the abdomen, back, buttocks, or thigh. Two types of flap surgery exist: Free flap reconstruction involves totally removing the tissue to be transferred from its original location and transplanting it to the chest. The blood vessels must be microscopically reconnected at the new site. The patient will not experience any sensation to the grafted area. Pedicle flap reconstruction allows the tissue to be transferred to remain attached to its blood supply. It is relocated via a tunnel under the existing skin. The flap consists of the skin (if necessary), fat, and muscle. The flap may be used to create a pocket to accept an implant, or the tissue itself may create the new breast mound. The latissimus dorsi musculocutaneous flap and the TRAM flap techniques are the two most commonly used pedicle flaps (Figure 19-32). Pedicle flap reconstruction using a TRAM flap will be used to illustrate breast reconstruction. Patients who are excessively overweight or those who have previously undergone abdominal surgery may not be good candidates for this type of reconstruction. In addition to the items previously mentioned, the surgical technologist should consider the following: If the reconstruction is to be performed at the same time as the mastectomy, it may be necessary for the sterile surgical team members to use a new set of sterile supplies for the reconstructive portion of the procedure to prevent the spread (seeding) of cancer cells. Tissue repair material such as synthetic mesh may be needed to reinforce the donor site. Closed wound drainage systems may be used at both surgical sites. A Doppler with a sterile probe should be available to identify the location of the major blood vessels serving the flap. Breast reconstruction often immediately follows mastectomy and the patient remains under general anesthesia. The initial prep and draping should be done to accommodate the secondary procedure. Therefore, the entire chest and abdomen should be exposed. The exposed area should include the natural breast to use for comparison. The general surgeon and the plastic surgeon will have collaborated prior to the mastectomy regarding the type of mastectomy to be performed and the planned breast incision. Often, the general and plastic surgeons work together for the entire procedure, changing roles as primary surgeon and assistant as the case progresses. The general surgeon terminates the mastectomy portion of the procedure following removal of the breast and axillary contents. Hemostasis is achieved and the wound is left open and covered with a sterile towel. At this point, the TRAM procedure is performed. Using a #10 blade, the surgeon makes an elliptical incision from iliac crest to the other iliac crest. The superior incision includes the umbilicus and the inferior incision is just above the symphysis pubis. Using blunt dissection and long Metzenbaum scissors, the surgeon creates a subcutaneous tunnel from the abdominal incision to where the mastectomy was performed The surgical technologist should keep clean moist lap sponges on the field at all times during the dissection and tunneling phase of the procedure. The surgeon dissects down to the anterior rectus sheath with the use of electrosurgery and Metzenbaum scissors. *The surgical technologist should also keep the cautery tip clean. Due to the frequency of its use during the procedure, in particular when the surgeon is dissecting down to the anterior rectus sheath and incising the sheath, the tip may become clogged with charred tissue. If it is not kept clean, the effectiveness of the tip will diminish.* A transverse incision is made into the anterior rectus sheath, and the inferior edge of the rectus abdominis muscle is transected. Using the sterile Doppler probe, the superior and inferior epigastric arteries are identified. The superior vessels are preserved in order to provide continual perfusion to the flap. The inferior epigastric artery is double clamped, cut, and ligated with the surgeon's preferred suture. *The surgical technologist should have the sterile Doppler probe available for use throughout the procedure.* Dissection continues superiorly, developing the pedicle of rectus muscle up to the costal level. Using his or her hands, the surgeon passes the flap through the subcutaneous tunnel in a superior direction and positions it on the mastectomy site. The surgeon performs this step of the procedure in such a manner as to preserve the arterial and venous supply to the newly created breast. Any compromise in circulation could cause the flap to become ischemic and slough. Using Metzenbaum scissors and a #15 blade, the surgeon trims excess skin with subcutaneous tissue from the flap. The surgeon shapes the breast, using the nonoperative exposed breast as a template to achieve as much symmetry as possible.*The surgical technologist should save the excess skin because the surgeon can use the subcutaneous tissue as an aid in adding more tissue to the breast mound and shaping it.* The abdominal wound is closed. The anterior rectus sheath is closed with absorbable suture. The skin is closed with a subcuticular closure or skin staples. The first closed wound drainage system is placed. *The surgical technologist should have synthetic mesh available for use in closure of the abdominal wound.* The surgeon visually inspects the vascular status of the flap for color and gently touches it to check for warmth. The surgeon may perform further shaping of the breast. *The surgeon may use the sterile Doppler probe as an aid in assessing the vascular status of the flap prior to closure.* The flap is secured to the chest wall with synthetic absorbable suture, and the skin flaps are closed with a nonabsorbable suture. The second closed wound drainage system is placed in the wound and the distal end of the drain is brought out at the lateral edge through a stab wound. The abdominal wound dressing is placed. A loose, fluff-style dressing is placed on the chest. A postsurgical bra may be used for support.* The fluffs should be carefully applied to the chest to prevent placing any unnecessary pressure on the wound that might compromise the circulation to the flap. A Montgomery strap may be used to keep abdominal dressings in place.* This completes the first stage of reconstruction. Rarely is nipple-areolar reconstruction planned as part of this first stage. If performed at this time, an FTSG is taken from the postauricular area and used to create the areola. An FTSG is taken from the labia to create the nipple (see Procedure 19-19, Nipple Reconstruction).

Bronchoscopy Procedure

Bronchoscopy is an invasive diagnostic and/or therapeutic procedure for the evaluation of hemoptysis, infection, carcinoma of the lung, and damage to the lungs due to smoke inhalation. It is useful for retrieving foreign objects lodged in an airway and for laser treatment of endobronchial tumors. Brochoscopy is also useful for postoperative evaluation of the transplanted lung. Carcinoma of the lung is the leading cause of death due to cancer in the United States. Patients usually present with a persistent cough, hemoptysis, and shortness of breath. Other signs and symptoms include pleural effusion, pain on inspiration, and/or clubbing of fingers if the cancer has invaded the pleural space. One of two methods is used for applying the topical anesthetic. In the first method, the anesthesia provider or surgeon sprays the local anesthetic to numb the tongue, palate, pharynx, larynx, and trachea. The second method involves the surgeon or anesthesia provider using a straight or curved metal cannula that is attached to a laryngeal syringe. The topical anesthetic is squirted onto the surface of the vocal cords and then through the glottis and onto the surface of the trachea. Flexible: The surgeon inserts the flexible bronchoscope through the endotracheal adaptor and endotracheal tube. Rigid: If not using a scapular roll, the head of the OR table is slightly lowered after the patient has been administered general anesthesia. A plastic tooth guard is placed over the upper teeth for protection. The surgeon inserts the rigid bronchoscope into the mouth and over the anterior surface of the tongue. The surgical technologist may be asked to retract the upper lip slightly upward or the surgeon will do it himself or herself. The surgeon identifies the epiglottis and moves it upward using the tip of the bronchoscope. *When setting up for the procedure, the circulator should squirt lubricant onto a 4 × 4 sponge on the back table or Mayo stand. The surgical technologist should lubricate 2-3 in. of the end of either type of scope just prior to insertion.* When positioning the patient for a rigid bronchoscopy, the head is slightly tilted to the left when the surgeon wants to view the right bronchi and slightly tilted to the right to view the left bronchi. Flexible: The surgeon advances the scope through the vocal cord and into the trachea to view the tracheal rings and tissues. Next, the surgeon advances the scope into the right or left bronchi. Using the tissue-biting forceps, the surgeon may take tissue specimens as well as take fluid specimens and use the biopsy brush. *The surgical technologist will be responsible for assisting the surgeon in taking fluid specimens. The suction tube with specimen container is positioned for collecting bronchial washings; the specimen container must be held upright and not tipped to prevent the specimen from going through the suction. When the surgeon gives the order, the surgical technologist connects the suction tubing to the bronchoscope. The suction tubing is disconnected and the surgical technologist injects 5 mL of saline solution into the channel of the scope and quickly reconnects the suction to take additional fluid specimen; the surgical technologist must be familiar with the brand/type of bronchoscope being used and know the correct channel in which to inject the saline solution. The surgeon may have the procedure repeated several times.* When a brush biopsy is taken, the surgical technologist must complete two actions along with the circulator. First, the surgical technologist will take the brush and rub it on a microscope slide that the circulator is holding. The circulator will then "fix" the specimen to the slide by spraying it with 95% ethanol alcohol. Next, the surgical technologist will use the wire-cutting scissors to cut the brush off the end of the forceps while holding it over the specimen container the circulator is holding. Rigid: The surgeon advances the scope through the vocal cords and into the trachea to view the tracheal tissues. The patient's head is moved slightly to the left and the scope advanced to view the right bronchi. The right-angle telescope is inserted into the bronchoscope to view the right bronchial branches and upper lobe. The surgeon may take fluid and tissue specimens at this time. The straight aspirating tube is used to take cytology specimens from the pharynx, larynx, and esophagus. The curved aspirating tubes are used to remove cytology specimens from the upper portions of the bronchi. The surgical technologist must communicate where the specimen was obtained to the circulator so he or she can correctly label the specimen container. Flexible: The surgeon withdraws the flexible bronchoscope and reinserts in the opposite bronchi to view and remove tissue and fluid-washing specimens. Rigid: The surgeon withdraws the bronchoscope and telescope into the trachea, the patient's head is straightened and the scope advanced to view the middle lobes. Rigid: The scope is withdrawn again, the patient's head is slightly turned to the right, and the left bronchi and upper lobe are inspected. Additional fluid and tissue specimens may be taken. Flexible and rigid: The bronchoscope is removed. The smaller-diameter flexible fiberoptic bronchoscope allows for visualization of the upper, middle, and lower lobe bronchi and may have a video camera attached for viewing on a monitor. Transbronchial lung biopsy for examination of pulmonary infiltrate is also performed through the flexible bronchoscope.

Dacryo

Combining form referring to the lacrimal apparatus of the eye

Rhytidectomy Procedure

Commonly called a facelift, the procedure is purely cosmetic to remove excessive facial skin folds and subcutaneous tissue to eliminate wrinkles and fatty deposits. Incision is initiated within the hairline in the temporal region of the scalp, approximately 5 cm above the earProcedural Consideration: The surgeon uses a #15 scalpel blade for the initial incision. The incision is continued to just below the earlobe and then back up and around the ear. *Incision follows natural creases in the skin to camouflage scarring.* The subcutaneous tissue in the preauricular area is undermined.* Tenotomy scissors are used.* Moving inferiorly to the jaw line and superiorly to the lateral aspect of the nose, the subcutaneous tissue is dissected from the platysma below. * The surgical technologist uses double-prong skin hooks and progresses to larger retractors, as the situation allows, to hold tension along the wound edges and facilitate dissection.* Wound edges of the developed flap are pulled taut to determine the amount of redundant skin to be excised. The opposite side of the face will be referred to during this stage to maintain symmetry and create a natural appearance. *"Tacking" sutures may be placed temporarily to hold the skin in place until the desired level of tension is achieved.* Redundant tissue is excised and wound is closed using suture of surgeon's choice. A Jackson-Pratt drain may be placed to help eliminate dead space and reduce the risk of hematoma. * Excision is done with new #15 scalpel blade* This process is duplicated contralaterally. * Reorganize and repeat steps.*

Orthotopic Heart Transplant Procedure

Cardiomyopathy is a general term designating primary disease of the myocardium, often of obscure and unknown etiology. In response to injury, the heart often enlarges, restricting its normal function. Cardiomyopathy can appear in many forms, including alcoholic, congestive, hypertrophic, infiltrative, and restrictive cardiomyopathies. Alcoholic cardiomyopathy may occur in the individual who consumes large amounts of ethanol over a long period. Ethanol has a toxic effect on cardiac tissue, and eventually results in cardiac enlargement and low cardiac output. The onset of alcoholic cardiomyopathy is gradual with fatigue and dyspnea on exertion as the first symptoms. Physical examination usually reveals a cardiac murmur, edema, hypertension, and an increasing central venous pressure. Congestive cardiomyopathy is characterized by cardiac enlargement, especially of the left ventricle, myocardial dysfunction, and congestive heart failure. Hypertrophic cardiomyopathy is characterized by an extensive thickening of the left ventricular myocardium and septum. Blood flow from the atria to the ventricles may be affected as well. Young males are most often affected, but the disease can also occur in a familial form that affects males and females equally. Infiltrative cardiomyopathy results in the deposition of abnormal substances in the myocardium, as may occur in amyloidosis. The foreign material results in restrictive cardiomyopathy because the heart cannot expand adequately to receive the inflowing blood. The ventricular walls become excessively rigid, impeding ventricular filling. Restrictive cardiomyopathy is marked by normal systolic function of the heart but abnormal diastolic function. Cardiomyopathies are incurable. Currently, the best treatment is heart transplantation. Heart transplants are also indicated for patients with severe myocardial damage caused by coronary artery disease, heart valve disease with congestive heart failure, and severe congenital heart disease. Harvest of Donor Heart 1. The surgeon exposes the donor heart through a median sternotomy. 2. The aorta and pulmonary artery are mobilized superiorly to the level of the aortic arch and bifurcation to provide as long of a length as possible for the anastomosis. 3. The superior vena cava is mobilized superiorly to the level of the azygos vein. Two ties are placed around the vena cava, but left in place and the strands left uncut. 4. The inferior vena cava is mobilized from the pericardium. The patient is now systemically heparinized. A cardioplegia cannula is inserted in the ascending aorta. 5. The superior vena cava is now divided between the two ties, which is followed by CCCT of the inferior vena cava at the level of the diaphragm. 6. Using an aortic clamp, the aorta is cross-clamped at the level of the innominate artery and cold cardioplegia is administered (Figure 22-28A). An incision is made in the right superior pulmonary vein to vent the left atrium. Cold cardioplegia is administered to this area. 8. The heart is slightly lifted out of the pericardium to allow the surgeon to CCCT the pulmonary veins. 9. The pulmonary artery is CCCT at the bifurcation and the aorta CCCT at the origin of the innominate artery. 10. The heart is removed and placed in a basin of cold slush saline solution and transported to the recipient OR (Figure 22-28B). Orthotopic Heart Transplantation 1. The surgeon exposes the recipient's heart through a median sternotomy and CPB is begun by inserting a superior vena cava cannula and a cannula in the right atrium. 2. Using an aortic clamp, the aorta is cross-clamped above the aortic valve and proximal to the innominate artery. The heart is removed by incising the atria next to the AV groove and cutting the great arteries distal to the aortic and pulmonary valves. 3. The donor heart is brought up onto the surgical field. The first anastomosis is the left atrium of the donor heart to the left atrium of the recipient heart. The surgeon uses a 3-0 double-armed polypropylene suture to accomplish the anastomosis A curved left heart catheter (also called a vent) is inserted through the left atrial appendage and advanced into the left ventricle of the donor heart. The catheter aids in air removal at the end of the procedure when the aortic cross-clamp is removed. 5. The right atrium is incised; the incision extends superiorly from the inferior vena cava and is angled away from the junction of the superior vena cava and right atrium of the donor heart. This incision protects and preserves the SA node. 6. The right atrial anastomosis is accomplished using a double-armed 3-0 polypropylene suture in continuous fashion. 7. The lateral and inferior edges of the donor right atrium are anastomosed with the placement of sutures through the atrial septal region of the previous left atrial anastomosis. 8. The pulmonary anastomosis is completed using 4-0 double-armed polypropylene in continuous fashion. The posterior wall is sutured first and then the anterior wall. 9. The last anastomosis is the aortic anastomosis, which is completed in the same manner as the pulmonary artery. During this step the patient's body temperature is slowly increased (Figure 22-29B). 10. The patient is placed in slight Trendelenburg position and air is removed from the heart and aorta by lowering the bypass flow, and the air bubbles are released through the ventricular and ascending aortic vents. Although the venting continues, the aortic cross-clamp is slowly removed over a 5- to 10-minute period. 11. When the air has been removed the heart is defibrillated and after adequate reperfusion of the new heart has been achieved, the CPB is stopped. 12. The cavity and heart are checked one last time for bleeding and the anastomosis for leaks (Figure 22-29C). 13. The surgical site is closed in layers in routine fashion.

Repair of Coarctation of the Aorta Procedure

Coarctation of the aorta is a localized narrowing of the aorta in an otherwise normal vessel. In the adult form, the narrowing is usually distal to the left subclavian artery or just distal to the ligamentum arteriosum. In infantile aortic coarctation, the obstruction is proximal to the ductus arteriosus. A posterolateral incision is made in the fourth intercostal space. In adult patients, the fourth rib will be stripped and resected. Procedural Consideration: The collateral circulation that formed may have contributed to the enlargement of the arteries in the muscle layer and intercostal space. Controlling bleeding is essential to maintaining normal hemodynamic stability in the patient. The surgical technologist should be prepared for the surgeon to frequently use the ESU and have a large number of ties. 2. The lung is retracted anteriorly and inferiorly, and the coarctation is exposed by incising the mediastinal pleura over the aortic isthmus. Using a vessel loop, the vagus nerve will be retracted medially Procedural Consideration: The aortic isthmus is a small area of the aortic arch just distal to the left subclavian artery and right before the aorta that is termed the descending aorta. To keep bleeding at a minimum, the surgeon is meticulous in the dissection of tissue surrounding the aorta and intercostals vessels. The dissection will be carried out in blunt fashion; the surgical technologist should provide the surgeon with an unfolded 4 × 4 radiopaque sponge that he or she will place around the fingers to facilitate the blunt dissection. 3. The supreme intercostal vein (most superior vein in the line of intercostal veins) crosses over the aortic isthmus; it is CCCT to expose the coarctation. Procedural Consideration: The intercostal vessels have thin walls and therefore must be carefully handled throughout the procedure. 4. The intercostal arteries distal to the supreme intercostals vein are ligated; however, it is not necessary to cut the arteries. They are retracted inferiorly and medially with vessel loops. 5. In the event heavy bleeding occurs, the surgeon places large-gauge silk sutures or vessel loops around the subclavian artery and aorta; Crile clamps are placed on the ends of the sutures or vessel loops. 6. The aorta is mobilized almost up to the diaphragm. 7. The surgeon now determines the length of aorta to be excised above and below the coarctation. Usually, the aortic lumen proximal to the coarctation is narrower than the lumen distal to the coarctation, demanding the excision of a long segment in order to achieve lumens that are matching in size (Figure 22-36B). Procedural Consideration: In adults, usually primary anastomosis cannot be performed even with extensive mobilization of the aorta due to excessive tension placed on the anastomosis. In this case, a Dacron tubular graft will be placed. 8. Arterial clamps are placed on the aorta above and below the area of dissection, and a clamp is placed on the left subclavian artery. 9. Using the #15 knife blade, an incision is made either above or below the area of constriction and, with the Potts-Smith scissors, is carried circumferentially. The procedure is performed on the opposite end. The aortic specimen with constriction is removed. 10. The end-to-end anastomosis is begun by suturing the posterior wall of the aorta with 5-0 or 6-0 absorbable monofilament suture placed in continuous fashion (Figure 22-36C, D). 11. The anterior wall is anastomosed with either the continuous suture or with simple interrupted sutures (Figure 22-36E). Procedural Consideration: When using a Dacron tubular graft after the coarctation has been excised, the synthetic graft is positioned between the two aortic segments and sutured into place with a 4-0 continuous polypropylene suture. 12. The lower arterial clamp is removed first and the upper clamp is removed slowly. The surgical technologist should be ready to quickly hand the clamps back to the surgeon if bleeding occurs and quickly provide sutures to be placed to control the bleeding. 13. The pleura is closed with a continuous absorbable suture. 14. Before the chest is closed in layers, the surgeon ensures that hemostasis has been achieved.

Aortic Valve Replacement Procedure

Disease of the semilunar or AV valves of the heart can lead to stenosis of the valves, a condition that can obstruct the normal flow of blood from one region of the heart to another, or to valvular insufficiency, which can cause a reflux of blood into the area from which the blood was ejected during systole. This reverse flow, usually involving the mitral and tricuspid valves, is known as regurgitation. As the valvular disease progresses, the myocardium enlarges to compensate for insufficient flow, and, unless treated surgically with prosthetic valve replacements, congestive heart failure is bound to ensue. Aortic valve dysfunction may result from rheumatic disease, acute infection, atherosclerotic heart disease, or congenital defects. Stenotic valves are often due to the aging process. Rheumatic fever may cause calcium deposition and fibrous tissue formation on the leaflets of the mitral valve. This results in an immobile valve, and the AV orifice between the left atrium and left ventricle becomes progressively narrower. Half of the patients with the disease will develop atrial fibrillation and blood flow from the atria to the ventricles is not ejected normally because the contraction is eliminated. Blood stagnated in the atria may form thromboses that could result in arterial embolization. Aortic valve stenosis is less common than mitral valve disease and usually affects males. It can be caused by rheumatic fever, but atherosclerosis can be responsible for the condition in the elderly. Congenital valvular malformation is the predominant factor in aortic stenosis, causing the patient to become more susceptible to endocarditis or rheumatic fever. Aortic stenosis impedes the flow from the left ventricle into the aorta, resulting in hypertrophy of the left ventricle as the ventricle struggles to overcome the increased resistance of its outflow tract. As the hypertrophied ventricle becomes dysfunctional, cardiac output is decreased; backflow to the left atrium and pulmonary circulation results in left atrial and pulmonary hypertension. The enlarged ventricle may also compress the coronary arteries at a pressure exceeding coronary perfusion pressure, resulting in myocardial ischemia and angina, exacerbated by the increased oxygen demands of the hypertrophied ventricle's myocardium. Eventually, heart failure will ensue. Aortic regurgitation, like aortic stenosis, is frequently caused by rheumatic fever, which damages the leaflets of the valve and results in an incomplete closure. Marfan syndrome is another etiologic factor. This disease, which affects connective tissue systemically, results in necrosis and aneurysm formation of the ascending aorta. The dilation of the aortic annulus pulls the leaflets apart, resulting in valvular insufficiency. Congenital malformation of the valve results in susceptibility to bacterial endocarditis and rheumatic fever; aortic regurgitation is therefore imminent. When the leaflets of the aortic valve close improperly, the outlet between the left ventricle and the aorta remains open to a degree, and blood that has been expelled into the aorta across the aortic valve flows back into the left ventricle during diastole. The ventricle hypertrophies and must contract more forcefully to expel this increased volume of blood. Aortic valves are the most frequently replaced valves in cardiac surgery. There are basically two types of valves used for replacement: biologic (tissue) and mechanical. A valve that combines synthetic material with animal tissue is also frequently used. The tissue valves may be harvested from a pig or a human cadaver, and may also be constructed from the pericardium of a cow. Unlike mechanical valves that have a tendency to form blood clots, placement of a tissue valve does not require anticoagulant therapy for the recipient. Porcine (pig) and human donor valves usually wear out after a period of 10 to 15 years, and so are not suitable for implantation in younger patients. Mechanical valves are constructed from modern ceramics, and are usually implanted into patients under the age of 65 because of their longer life span. These valves require the use of anticoagulant therapy because of their tendency to form blood clots. Other risks associated with the use of the mechanical valves are hemorrhage and endocarditis. A valve that combines bovine pericardium with polyester and plastic, such as the Carpentier-Edwards bioprosthesis valve, lasts approximately 14 years and is another option for patients over the age of 65. The leaflets of the valve are constructed from pericardial tissue, while the supporting structure is made from polyester and plastic. In certain instances, a diseased aortic valve can be replaced with the patient's own healthy pulmonary semilunar valve. The pulmonary valve is then replaced with a human donor valve. The benefit to this type of valve replacement is that no foreign synthetic substance or animal tissue is introduced into the body, so there is little risk of rejection or clot formation. Room-temperature saline should be used up to the point of aortic cross-clamping; thereafter, cold saline is to be used until the rewarming period. Warm saline should be used after rewarming begins. There should never be water on the back table. It would be too easy to accidentally use water instead of saline when filling the cannulas. Water will cause lysing of RBCs. Be ready to go back on the pump at a moment's notice. Do not discard cannulas after removal, and keep cannulation sutures ready after the patient is removed from CPB. Keep wire cutters and the sternal retractor sterile until the patient is safely out of the OR. Pass off defibrillation cables at the same time as the ESU cords. The surgeon will not want to wait for the defibrillation paddles if suddenly needed. Keep the field clear of instruments, blood-soaked sponges, and other materials. Wring out blood from laparotomy sponges into a bowl specifically labeled for blood from the sponges and suction with the pump sucker. The surgical technologist should ensure the valve sizers are for the valve being replaced. Do not use aortic valve sizers for mitral valves and vice versa. Do not open the valve prosthesis until you have confirmed with the surgeon that it is the one he or she needs. The surgical technologist should not break scrub and should maintain the sterility of the Mayo stand and back table until the patient has safely left the OR. Wire cutters, sternal retractor, cannulation stitches loaded on needle holders, and cannulas should be available in case the patient must be placed back on CPB. A median sternotomy is performed and CPB is initiated. Procedural Consideration: Bone wax is used to seal off bleeders from the sternal walls. The 2-0 silk pericardial stays retract the pericardium and are often secured to the sternal retractor. 2. For the maintenance of a bloodless field, a left ventricular vent is placed through the right superior pulmonary vein and into the left ventricle. Procedural Consideration: Follow sequence for cannulation previously outlined. Cardioplegia solution is prepared in advance of need. 3. The aorta is cross-clamped and cardioplegia is infused in a retrograde fashion through the coronary sinus. If the aortic valve is incompetent, cardioplegia may be infused through the ascending aorta. Procedural Consideration: A large Fogarty aortic cross-clamp with plastic, atraumatic inserts is frequently used to occlude the aorta. 4. An incision is made into the aorta, the edges are retracted with sutures, and the exposed aortic valve is inspected. Procedural Consideration: Retraction sutures are ready. Prepare valve retractors and scissors for use. 5. Leaflets are resected and calcium deposits are carefully removed from the annulus for eventual placement of sutures. Procedural Consideration: The surgical technologist should ready the valve sizers at this point and the circulator should be ready to open the proper valve. Be sure the prosthesis holder is readily available. 6. The annulus is sized and the prosthesis is selected. The prosthesis is delivered to the annulus on a prosthesis holder. Procedural Consideration: Tissue prosthetics must be rinsed in saline according to protocol. Follow the manufacturer's instructions for rinsing porcine valves, typically, 2 to 3 minutes in three different bowls. 7. Interrupted, nonabsorbable, multifilament sutures of alternating colors are placed into the annulus and through the skirt of the valve, and the valve is carefully pushed down into place (Figure 22-31A). Procedural Consideration: The surgical technologist should keep close track of the sutures to be loaded and of the needles that are returned by the surgeon. Wet valve and sutures with saline when placing valve into annulus. 8. The sutures are tied and the motion of the prosthetic leaflets is tested (Figure 22-31B). Procedural Consideration: The surgical technologist should have a French-eyed needle available in case the surgeon needs to place another suture through the annulus after the needles have been cut off. 9. The aortic incision is closed with nonabsorbable sutures and the cross-clamp is removed (Figure 22-31C). Procedural Consideration: Polyester is the suture of choice for aortic incision closure. 10. Air is removed from the left ventricle, the cross-clamp is removed, and CPB is discontinued. Chest tubes are placed for the evacuation of fluid and air, and the chest is closed in the usual manner. Procedural Consideration: Patient is warmed, the heart is restarted, and the cannulas are removed. Prepare chest tubes and closing suture. Count as needed.

Coronary Artery Bypass with Grafting (CABG) Procedure

Due to the amount of information about coronary artery disease, it is presented in paragraph format. Coronary atherosclerotic heart disease is the most common type of coronary artery disease and is recognized as the leading cause of death in the industrialized Western world. Each year, approximately 1 million Americans die from the disease, and the annual economic costs are staggering, averaging in the tens of billions of dollars. Risk factors for coronary atherosclerosis include: Age: Older people are far more likely to be affected. Gender: The disease affects more males than females. Female sex hormones are thought to play a role, and estrogen therapy for postmenopausal women is currently being studied. Race: There is a higher mortality rate among non-whites. Genetics: A familial disposition is thought to have both genetic and environmental origins. Hypertension: High blood pressure will accelerate the development of atherosclerosis, particularly if it develops at an early age. Cigarette smoking: This is one of the most important risk factors associated with the disease. The negative effects on the cardiovascular system are partially related to nicotine, tar, carbon monoxide, and other harmful components of cigarette smoke. Diet: A diet rich in saturated fats, especially animal fats contributes to the development of the disease. Obesity: Overall, obese people develop atherosclerosis at an earlier age and have more significant lesions than do those who weigh less. Elevated serum levels of lipids, such as cholesterol, lipoproteins, and triglycerides, directly correlate with the extent and severity of the atherosclerosis. Obese individuals are also more prone to hypertension, diabetes, and glucose intolerance; it is these associated factors that may be the link between obesity and atherosclerosis. Clotting factors: Soluble clotting factors, such as thrombin, fibrin, and platelets, play a role in the formation of atherosclerotic lesions. Psychosocial influences: Individuals in lower socioeconomic positions are more likely to smoke, are more obese, and have higher rates of hypertension than those in positions of higher economic status. Individuals who are under constant pressure to perform, or who can be labeled "overachievers," are more likely to develop atherosclerosis. The term atherosclerosis describes a condition that involves the formation of an atheroma in the intima of medium and large arteries. The first step in the formation of the atheroma (Figure 22-21) is believed to be an injury to the endothelial lining of the arterial wall. Blood platelets and lipoproteins are deposited into the injury as a repair mechanism, and growth factors released from the platelets stimulate the growth of new smooth muscle tissue in the arterial wall. Changes in the metabolism of the smooth muscle cells promote the accumulation of cholesterol and other lipids within the cells' cytoplasm, which, when leaked across the cell membrane into the interstitial spaces, attract scavenger macrophages. The macrophages secrete biologically active substances that cause further damage to the arterial wall. Eventually, collagen is deposited into the lesion and scar tissue begins to form, narrowing the lumen of the artery. An incision is made extending from the sternal notch to the xiphoid process and vessels are coagulated Procedural Consideration: Prepare the sternal saw and the sternal retractor. For repeat sternotomies, an oscillating saw is used so that a ventricle that may be adhered to the chest wall is not cut. 2. The sternum is opened with a sternal saw, and a self-retaining sternal retractor is inserted (Plate 22-2). Procedural Consideration: If the IMA is dissected for coronary artery anastomosis, a mammary retractor is placed instead of the sternal retractor. 3. The pericardium is incised and retracted with sutures. Procedural Consideration: Retraction sutures are prepared in advance as their use is anticipated. 4. If the left IMA is to be used for left anterior descending artery anastomosis, the IMA is dissected as a pedicle graft proximally from the level of the subclavian artery and distally to the costal margin. Side branches are occluded with small clips. Procedural Consideration: The pedicle graft is soaked in a papaverine solution to prevent vasospasm. A papaverine-soaked 4 × 4 gauze is usually wrapped around the graft. 5. The saphenous vein is harvested from one or both legs by a separate team at the same time that the chest is opened. Tributaries are ligated during dissection with small hemoclips and 4-0 silk ties Procedural Consideration: If the saphenous vein is not taken endoscopically, then dissection is carried out with a #10 blade on a #3 handle, Metzenbaum scissors, and DeBakey forceps. Hemoclip appliers must be reloaded for immediate reuse. 6. The vein is flushed with heparinized saline to identify any branches that may have been missed, and the vein is stored in a heparin/saline solution until needed. Procedural Consideration: Flushing is facilitated by a saphenous vein cannula inserted into the vein and secured with a silk tie. Tributaries are tied off with a 4-0 silk tie. 7. CPB is initiated utilizing techniques discussed previously Procedural Consideration: The pump lines should be easily accessible and ready to hook up to the cannulas. An Asepto filled with warm saline should be ready to displace air bubbles during hookup. 8. Coronary artery stenoses are identified, and an arteriotomy is made just distal to the stenosis. Procedural Consideration: A #64 Beaver blade and handle are useful for the arteriotomy. Tenotomy scissors and Diethrich angled coronary scissors should be available. 9. The internal mammary artery or saphenous vein is anastomosed to the affected coronary artery with 6-0- or 7-0-gauge polypropylene sutures Procedural Consideration: A disposable bulldog vascular clamp is used to occlude the distal end of the IMA. 10. A Satinsky partial-occlusion clamp is applied to the ascending aorta, and a 4.5-mm hole is made in the isolated section of the aorta with an aortic punch. Procedural Consideration: Pass vascular clamp of appropriate size as needed. Prepare aortic punch and sutures if saphenous vein graft is used. 11. The proximal saphenous vein is anastomosed to the aorta in an end-to-side fashion with size 6-0 polypropylene sutures Procedural Consideration: No proximal anastomosis is necessary for the IMA because only the distal end of the artery is transected. The proximal portion remains intact at its origin of the subclavian artery. 12. The Satinsky partial-occlusion clamp is removed and needle aspiration of the graft is performed to remove air. Procedural Consideration: Needle aspiration is carried out with a 25-gauge, -in. needle on a 10-mL syringe. 13. CPB is discontinued, chest tubes are placed for the evacuation of fluid and air, and the sternum is closed with heavy-gauge stainless steel wire. The chest is closed in the usual manner. Procedural Consideration: Use caution when passing wire to avoid puncture of gloves. Have wire twisters, cutters, and closing suture ready. Count as necessary. Chest tubes are secured to the skin with 0 silk on a cutting needle.

Ablation of Radial Thumb and Collateral Ligament Procedure

Duplication of the digits is referred to as polydactyly. This can be a partial or complete additional digit or digits; it may affect the hands and/or feet and it may be unilateral (more common) or bilateral. The condition usually involves just the phalangeal bones. Fifth-finger duplications are the most common type The procedure described here is for treating duplication of the thumb called bifid thumb. The duplication can be complete or partial. The cause of bifid thumb is unknown. The Wassel classification of bifid thumb is the most commonly used classification (Figure 19-29): Type I: partial duplication of the distal phalanx and same epiphysis Type II: complete duplication including epiphysis of distal phalanx Type III: duplication of distal phalanx and bifurcation of the proximal phalanx Type IV: most common type; complete duplication of the distal and proximal phalanges Type V: Type IV with bifurcation of the metacarpal Type VI: Type IV with duplication of metacarpal Type VII: Varying degrees of duplication associated with triphalangeal thumb There is usually some hypoplasia of both thumbs, commonly worse in the thumb on the radial side, which is desired because this allows for preserving the all-important ulnar collateral ligament when the radial-side thumb is removed. The nail may be one conjoined nail or each thumb has a nail. The surgeon marks the incision with the marking pen. Using the #15 knife blade, the surgeon makes the skin incision over the dorsal aspect of the radialmost thumb. The incision exposes the abductor pollicis brevis tendon where it inserts into the proximal phalanx of the radialmost thumb; this tendon must be preserved. The incision also exposes the intrinsic tendon and radial and ulnar collateral ligaments The radial collateral ligament is detached distally from the phalanx that will be excised (Figure 19-30B). The radialmost thumb is removed with part of the metacarpal. The remaining thumb is centralized over the articular surface and the radial collateral ligament and intrinsic tendon are sutured to the base of the proximal phalanx (Figure 19-30C). A K-wire is placed across the joint to hold the alignment in place (Figure 19-30D). The positions of the extensor and flexor tendons are confirmed to ensure they are in a central position along the thumb. If the position is not correct, the surgeon will resect and move the distal ends of the tendons to establish centralization and stability of the thumb. *The abductor pollicis brevis tendon can be advanced to the level of the extensor tendon and sutured in place with 5-0 Vicryl to achieve centralization and stability of the thumb.* The wound is thoroughly irrigated and the skin closed with 6-0 nylon interrupted sutures. A short arm thumb spica cast is applied.

Enucleation

En bloc removal of a structure; usually refers to the removal of the eye

Anesthesia methods for ophthalmology cases include _____.

General or local anesthesia= Surgical Repair of Chalazion and Surgical Repair of Entropion Retrobulbar block or general anesthesia= Iridectomy, Vitrectomy, and Enucleation Retrobulbar bloack with sedation or general=Scleral Buckle and Keratoplasty (Corneal Transplant) General or hypotensive anesthesia (to minimize bleeding)= Dacryocystorhinostomy (DCR) Anesthetic for retrobulbar block: lidocaine 2% with epinephrine, Local with sedation; retro or peribulbarblock may be used= Extracapsular Cataract Extraction Local or general (Local anesthesia will include instillation of tetracaine drops).= Repair of Traumatic Eyelid Laceration General anesthesia (sometimes local in adults)= Strabismus Correction: Recession/Resection

Subtotal Palmar Fasciectomy for Dupuytren's Contracture Procedure

Dupuytren's contracture may present itself in one of three ways: a nonpainful nodule in the palm of the hand near the fourth or fifth digit; a dimpling or pit in locations just described; or finally as a longitudinal fibrous band or cord extending from the palm toward the fingers All of these primary signs are caused by contraction of the palmar fascia. The contraction causes deformity and contractures of the dermis and/or digits. Occasionally, the patient may experience tenderness over an existing nodule. When the contracture causes restricted movement and impaired function, surgery is indicated. The surgery is variable, depending on the extent of the pathology; it can range from simple nodule excision to very complex in which restoration of full function and normal appearance may not be possible. The surgeon may or may not use the lead hand to keep the hand in place. If not used, the surgical technologist will be responsible for holding the hand and digits in place. The surgeon marks the incision(s) with the marking pen. If a free skin graft will be used it is first taken. *The graft is often taken from the medial region of the arm. The surgical technologist must keep the graft moist by wrapping saline-soaked sponges around it until needed.* Using the #15 knife blade, the surgeon will make one or more incisions on the volar or palmar surface of the hand according to the extent of the disease (Figure 19-23). For extensive contractures, a Z-plasty incision may be used so that the existing tissue can be used to cover the palm.* The surgeon may use several #15 knife blades; make sure to frequently change the blades to avoid the surgeon using a dull blade.* The incision is carried down to the palmar fascia, taking care to avoid injury to digital nerves and tendons. Using Adson tissue forceps and curved tenotomy scissors, the surgeon dissects the contracted fascia away from the underlying nerves, blood vessels, and tendons. *This dissection can be very tedious and time consuming if the contracture is advanced. The surgical technologist must remain alert throughout the procedure.* If being used, the skin graft is placed at this point of the procedure. Wound closure may be performed as primary closure. Numerous stitches may be required to successfully stretch the existing skin to add the length necessary for closure. *If a skin graft cannot be taken to cover a small surface of the palm, the wound may be left open to heal by second intention.* Nonadherent dressing such as petrolatum gauze is placed with fluffs and an elastic bandage to hold the dressing in place for several days. A splint may be placed, depending on surgeon's preference.

Glaucoma

Glaucoma- Angle closure glaucoma refers to the inability of the aqueous fluid to exit the eye at the correct angle due to blockage by the iris. This raises the intraocular pressure (IOP), creating the condition known as glaucoma. If not treated promptly, acute closure glaucoma can damage the optic nerve and retinal blood supply, resulting in loss of vision. Three types of iridectomy procedures are performed: peripheral, radial, and sector. The procedure is often performed at the same time as a trabeculectomy; A laser iridectomy can be performed for treating angle closure glaucoma. The laser beam creates a small hole in the peripheral portion of the iris to connect the posterior and anterior chambers of the eye. This permits the iris to fall back away from the trabecular meshwork, opening the angle of the anterior chamber to allow the outflow of the aqueous fluid through the Schlemm canal; Common side effects of laser iridectomy are increased intraocular pressure (IOP) and anterior uveitis.

Upper Lobectomy Procedure

If a neoplasm is confined to a particular lobe of the lung and hilar nodes are not involved, a lobe of the lung can be removed without disturbing other portions of the lung. After the patient has been prepped and draped, an incision is made into the fourth intercostal space (fifth or sixth interspace incision is made for the right middle lobe and lower lobe dissections). * Incision is made with a #10 blade on a #3 handle.* A rib spreader is placed, and the pleura is incised. The anterosuperior portion of the hilar pleura is incised and separated. *Once the thorax is opened, it is unlikely that the rib instruments will be reused. Remove them from the Mayo stand* The fissure between the upper and lower lobes is opened, and dissection of the pulmonary artery is begun. *During the thoracic procedure, the surgical technologist should keep a calculation of the amount of irrigation used because of the potential for blood replacement. If sponges are to be weighed, throw off sponges only after they are completely soaked with blood.* Pulmonary artery and pulmonary vein lobar branches are identified, isolated, doubly ligated, and divided. * Thoracic procedures require the surgical technologist to always think a few steps ahead of the surgeon so that the surgeon never has to wait for a loaded suture or instrument. Time is of the essence during an injury to a major vessel of the thorax, and it requires the surgical technologist to move quickly and think clearly.* The upper lobe bronchus is freed by blunt dissection, and a bronchus clamp or staple gun is placed at least 1.5 to 2 cm from the main bronchial trunk. *Have stapler loaded and sutures prepared. The bronchus is divided quickly. Entry of the bronchial tree will change the wound classification and may result in contaminated instruments. Be prepared to isolate any contaminated instruments or supplies.* The bronchus is divided and closed with nonabsorbable sutures or staples fired from the autosuture device. *Be aware of the surgeon's and surgical assistant's moves at all times. Closely listening and watching during the procedure allows for anticipation. During an emergency, this is vital because the procedure may quickly deviate from normal.* A pleural flap is placed over the bronchial stump and secured with sutures. The remaining lobes are checked for air leaks, and the wound is closed after placement of chest tubes. The surgeon may inject 0.25% Marcaine during skin closure for postoperative pain control. *Body-temperature irrigation will be needed to fill the thorax to check for leaks. The anesthesia provider will perform the Valsalva maneuver (forcible exhalation or induced cough). Prepare for chest tube placement, wound closure, and appropriate counts. The lines from the chest tubes must be hooked up to the closed suction drainage unit and suction immediately turned on to prevent clotting within the chest tubes. The surgical technologist should not break scrub and keep the Mayo stand and back table sterile until the patient has left the OR.*

Full-Thickness and Split-Thickness Skin Grafts Procedure

If necessary the recipient site may need to be readied by excision of a benign or malignant lesion, or irrigation and debridement (I & D). The excision is carried out using a #15 scalpel blade, Adson tissue forceps and tenotomy or iris scissors. * I & D is the removal of foreign bodies or necrotic and infected tissue from the wound. This prepares the wound bed to accept the graft. Minimal capillary bleeding is desirable because it shows viability of the underlying tissue.8 If the specimen is considered a malignant lesion it is immediately sent to the pathology lab to be examined for margins to ascertain that all of the malignant tissue has been excised, along with a "buffer" of normal tissue. *While waiting for the pathologist's report, it is advisable to place saline-moistened 4 × 4 sponges on the open wound to protect the tissues from drying out.* At this time, the sterile team members will change their gloves and the surgical technologist will switch to the "clean" instruments.*Have the second set of gloves in correct sizes for all team members readily available.* FTSG: The next step is to excise the FTSG from the donor site using technique similar to that used for preparing the recipient site. The surgeon will use either the #15 knife blade or knife dermatome. Remember, FTSGs tend to be much smaller than STSGs. *Following removal, the graft is wrapped in moistened gauze and stored in a safe place on the back table.* STSG: Prior to removing the tissue from the donor site, the area may be lubricated with sterile mineral oil or chlorhexidine gluconate (surgeon's preference). This serves to reduce friction and helps to provide a smooth surface. While the surgical technologist provides traction on the skin to be harvested, the surgeon activates the dermatome and guides it along the skin surface area. Using two smooth Adson forceps, a second surgeon or surgical technologist will grab the edges of the harvested skin as it comes through the dermatome and keep slight tension on the skin to keep it from curling up. Once the graft is taken the surgeon will use a #15 knife blade to sever the skin from the patient. Depending on the size of the recipient site, this may be performed multiple times in order to acquire the amount of tissue needed. It may be necessary for the surgical technologist to change the dermatome blade if it becomes dull. The harvested skin should be placed in body-temperature saline while awaiting meshing or application to the recipient site. FTSG: If necessary to decrease tension on the wound edges, the subcutaneous tissue immediately surrounding the incision may be undermined using Metzenbaum or tenotomy scissors.*Again, the instruments should be from the second setup.* FTSG: The donor site is sutured closed and the sterile dressings are applied.* Suture and dressings of surgeon's choice are used.* STSG: Following removal of the graft, topical epinephrine, thrombin, or phenylephrine is often applied to the donor site to aid in hemostasis. Once hemostasis is established, the donor site dressing is placed. FTSG: The graft and recipient site may each be modified in shape for proper "fit." If any subcutaneous tissue is present on the graft it is removed with tenotomy or iris scissors. The graft is positioned and secured with suture or stapled in place.* Any dressing used here must be dry.* STSG: If meshing of the graft is performed, the skin is placed on the derma-carrier and inserted into the mesh graft device. After the graft has been meshed, it is applied to the recipient site and sutured or stapled into position. If the graft is sutured in place, the sutures are left long in order to tie over a stent dressing. A dry sterile dressing is applied to aid in preventing movement of the newly applied skin graft.* If a meshed graft will not be immediately used, it must be kept on the derma-carrier to keep the graft from rolling up and kept moist by placing a saline-soaked sponge over the graft. If more than one graft is taken and meshed, each graft should be placed on a new derma-carrier. The newly applied skin will receive its blood supply from the capillary ingrowth from the recipient site; any disruption may cause the graft to be shed (sloughed off); therefore, careful placement of the dressing is important.*

Z-Plasty Scar Revision Procedure

Individuals with scars, acquired through a traumatic accident or surgically, can opt to have a plastic surgeon perform the scar revision procedure. The goal of the procedure is to reduce the scar, realign the wound edges, and perform a closure, which will have an improved cosmetic appearance once healed. Using the marking pen, the surgeon marks the Z-plasty incision. As previously described for a simple scar revision, the scar is excised. *The scar tissue may possibly be sent to pathology for further testing.* The Z incision is made with the primary angled incision directly over the previous scar. The straight top and bottom incisions are made in equal length (just like when writing the letter Z) and are at right angles to the primary incision The two skin flaps are slightly rotated (transposed), thus reversing the flaps, and are sutured into place The surgeon may or may not apply a dressing depending on the extent of the procedure.

Evisceration

Interruption of a closed wound or traumatic injury that exposes the viscera.

Ventricular Assist Device (VAD) Insertion Procedure

Insertion of a VAD is performed for two reasons: Serve as a temporary device that maintains circulation in patients who need a heart transplant. Temporarily support an open-heart patient who cannot yet be removed from the CPB. A VAD is used to support the circulation from the left, right, or both ventricles. For patients who require a heart transplant, a left ventricular assist device (LVAD) is placed. The device decreases the workload of the heart by diverting the blood from the ventricle to a pump that pushes the blood into the systemic circulation. The VAD helps to keep the patient ambulatory and to lead as normal of a life as possible while waiting for a donor heart. The surgeon makes a median sternotomy with the sternaI saw and extends the incision to the umbilicus with the #10 knife blade. 2. Using blunt and sharp dissection (Metzenbaum scissors, ESU), the surgeon creates a round preperitoneal pouch. The top of the pouch is just below the mammary line and the bottom at the level of the umbilicus, extending laterally to the line with the axilla and medially in line with the umbilicus. The VAD is inserted into the pouch. 3. CPB is established and the aorta is cross-clamped. 4. A Dacron graft is anastomosed to the aorta in end-to-side fashion. 5. Using a device that is part of the VAD instrumentation called a core-cutting device, the surgeon makes a round opening in the apex of the left ventricle. 6. The surgeon inserts the apex connector into the opening of the left ventricle. The connector has a flange with small holes for suture. Pledgets are used; suture is placed through the holes in the flange and sutured to the myocardium of the left ventricle in interrupted fashion. 7. The inflow conduit is connected to the apex connector. 8. A round opening is made in the diaphragm that is just large enough to accommodate inserting the inflow conduit through the opening and attaching it to the VAD. 9. The Dacron graft that was anastomosed to the aorta is attached to the outflow conduit, which is then attached to the VAD. 10. The driveline (or what we would refer to in layperson's terms as the electrical or power cord) is subcutaneously tunneled from the VAD and exteriorized through a small incision in the groin to be connected to the battery pack. Procedural Consideration: The flow of blood is from the left ventricular apex to the VAD through the aortic conduit and into the circulatory system. 11. The surgeon confirms that hemostasis has been achieved. CPB is discontinued, and the surgical site is closed in routine fashion.

Plate and Screw Fixation of Mandibular Fracture Procedure

Local anesthetic with epinephrine is injected. *Local anesthetic of choice is preloaded in syringe with needle attached. Follow facility policy for passing sharps. Refill the syringe in anticipation of use on contralateral side. Notify anesthesia provider of epinephrine use* An incision is made anterior to the angle of the mandible and any bleeding is controlled.* A #15 blade will be needed. Anticipate use of electrosurgical pencil.* Wound edges are retracted. *Retractor(s) of choice will be needed. Provide suction as needed.* Periosteum is stripped from the bone.* Periosteal elevator such as a Freer will be used.* Bone edges are manipulated into position and steadied by the surgical assistant or with a bone-holding clamp. *Stabilize patient's head during manipulation. Be sure breathing tube does not become crimped or dislocated. Bone clamp may be needed.* A plate of appropriate thickness, length, and design is chosen and customized for the patient. *Provide a variety of plates for selection. Plates can be customized to the area by curving the plate, using bending irons.* The plate is placed against the bone, bridging the fracture site, and secured in position. *Provide plate-holding clamp to secure plate to bone. Load drill with correct size bit.* A hole is drilled with the correct-diameter drill bit. *A drill guide may be used. Have depth gauge ready.* The depth of the hole is measured and tapped if necessary.* Present correct-size tap. Retrieve requested-size screw and load onto insertion device.* The proper screw is placed into the predrilled hole. *Reset the drill and organize insertion tools for reuse.* The sequence is repeated until the plate is firmly affixed to the bone.* Record the pertinent information about the implants for the patient's permanent operative record.* The procedure is repeated on the contralateral side, if necessary.* Reorganize tools for reuse.* Proper reduction/fixation is ensured by visual inspection of the area. Intraoperative X-rays may be useful. * Prepare to accept X-ray cassette into sterile field if requested. Prepare irrigation fluid and suture for closing.* The wound is irrigated and closed. *Count.*

Mastopexy: Anchor Technique Procedure

Mastopexy is performed to correct breast ptosis. The ptosis can be severe enough to cause lower back problems as well as cause the straps of braziers to indent the skin, causing chronic discomfort. The surgeon marks the planned incision with the marking pen on both breasts. The incision may have been marked in the preoperative holding area. Using the #15 knife blade, the surgeon makes an anchor-shaped incision that starts at the base of the areola and extends at an angle vertically on both sides and upward to form the boundaries of where the nipple will be relocated. The nipple is removed and relocated when performing a full mastopexy. The excess dermal tissue is excised from within the borders of the incision including removal of the nipple. The skin is drawn together and reapproximated, lifting the breast to a new position, and the nipple repositioned (Figure 19-37B). * If augmentation mammoplasty is indicated, it is now performed.* Fluffs are used for the dressing and a postsurgical bra is used to hold the dressings and breasts in position while healing takes place.

Draping Oral and Maxillofacial Surgeries

Patient is supine, with head tilted back to provide exposure; a roll towel may be placed to aid in slightly extending the neck. A donut or foam headrest may be used for stabilization. Tuck arms at patient's sides; protect ulnar nerves. Patient prep may not be required for oral procedures. Facial procedures may require prep with mild antiseptic; the eyes and ears should be protected from contact with the prep solution. Brush teeth or swab inside of mouth with an oral antiseptic. Draping may not be necessary. A half-sheet may be placed across the patient's body to provide a clean surface on which to rest equipment and supplies. A turban-style head wrap may be used to restrain the hair. The throat pack is dampened rolled gauze that contains a radiopaque marker. It is included in the formal count. It is used to prevent oral secretions, irrigation fluid, blood, and bone or tooth fragments from becoming lodged in the pharynx. It must be removed prior to extubation.

Tooth Extraction/Odontectomy Procedure

Odontectomy involves resection of the soft tissue and excision of the bone surrounding the tooth prior to removal of the tooth. The teeth lie in each jaw in a semicircular fashion. The side of the tooth that lies closest to the lips is referred to as the labial; the tongue side is lingual; cheek side is buccal. Each tooth is imbedded in a socket of the alveolar process; the alveolar maxillary process contains the upper teeth and the mandibular process contains the lower teeth. Incisors—four front teeth used to tear food; cuspids—lateral to the incisors, used to grasp and shred food; bicuspids—distal to the cuspids, used to break up food into smaller portions; molars—flat-topped teeth also used to break up food. Three regions of a tooth: crown—portion above the gumline; root—portion below the gumline; neck—junction of the crown and root. The crown is covered by enamel, which is the hardest part of the tooth. Dentin forms the majority of the crown; it is harder than bone and encases the pulp. The pulp contains the blood vessels, nerves, and connective tissue. The root is held in place by the periodontal ligament, which is made of collagenous fibers and connects the bony alveolar process and cementum of each tooth. The cementum is a bone-like substance that covers the tooth from the termination of the enamel at the neck to the thickest region at the apex of the root. Extraction of teeth involves the removal of a tooth or teeth that cannot be salvaged by restoration, or those that interfere with occlusion. Simple extraction is removal of the tooth from the alveolar socket with extraction forceps. Insert mouth prop. *rovide suction with Yankauer tip as needed.* A throat pack may be placed.* Prepare throat pack for use. A dressing forceps or McGill may be used to aid in the insertion of the throat pack.* *Anticipate the use of the Minnesota retractor, plastic cheek retractor, or mirror for cheek/tongue retraction. Precoat mirror with antifog solution.* The site may be injected with a local anesthetic using a control syringe. * Local anesthetic should be prepared in advance according to surgeon's preference. Inform anesthesia provider of epinephrine use.* To determine the amount of damage to the surrounding gingiva, a probe with graduated marks is inserted into the gumline. *Switch suction tip to Frazier* The gingiva is removed from the surface of the tooth with an elevator. *Periosteal elevator of surgeon's preference will be needed for gingival dissection.* The tooth is removed from the alveolar socket; the socket may be packed with gauze. *Choose extraction forceps according to the type of tooth to be removed and surgeon's preference. 2 × 2 gauze may be used to temporarily pack the socket.* The alveolar socket is inspected and irrigated to ensure that no debris remains. Direct pressure may be applied to the site for a short time and plain or chromic gut sutures may be placed as needed. *Irrigation fluid should be preloaded in the syringe with the blunt needle attached. Provide two irrigation systems so that one can be refilled while the other is in use. Provide suction as needed. Suture of choice is loaded on needle holder in anticipation of use. Count.* If the tooth scheduled for extraction is impacted, odontectomy is performed. The gumline is incised with a #15 blade.*A #15 blade is loaded on the #7 knife handle.* The soft tissue is dissected to expose the impacted tooth.* Provide periosteal elevator of choice* A dental drill may be required to remove any bone preventing exposure of the tooth. The tooth may be removed as a whole or require splitting with the drill or an osteotome so that it can be removed in sections *Provide extraction forceps of choice. Change drill bit if necessary and provide suction and irrigation. An osteotome must be accompanied by a mallet for use.* The area is inspected for debris, rinsed, and closed with a 4-0 chromic or silk on a cutting needle. *Provide suction and irrigation if needed. Suture of choice is loaded and passed. Count.* Pharynx is suctioned and throat pack removed. *Switch suction tip to Yankauer. Provide Wieder retractor. The instrument that was used to insert the throat pack will be needed again for extraction.*

Closure of Patent Ductus Arteriosus (PDA) Procedure

PDA is a failure of that fetal structure to completely close after birth. In fetal life, the ductus arteriosus connects the pulmonary artery to the aorta in order to shunt oxygenated blood directly into the systemic circulation by bypassing the lungs. It usually extends from the origin of the left pulmonary artery to just distal to the origin of the left subclavian artery. PDA may coexist with other anomalies, such as VSD, coarctation of the aorta, and pulmonary stenosis. Once the diagnosis of PDA is established, surgical intervention should be planned because it is highly unlikely that spontaneous closure will occur in the few weeks after birth, especially if the PDA is large. If symptoms are present, surgery should be performed immediately. The ductus should be divided after 1 year of age or earlier if there is congestive heart failure. If the patient is asymptomatic, an elective procedure should be performed within 3 months of diagnosis. If a ductus is found late in life and there is a small shunt, surgery is usually not recommended. Surgery in the adult can present problems because the ductus is usually calcified, brittle, and aneurysmal. Because the defect is outside the heart chamber, CPB is not required. Infants: Surgeon makes incision through the third intercostal space. Children: Incision is through the fourth intercostal space. The incision through either space is short and spares the serratus anterior muscle The apex of the lung is retracted downward and anteriorly. The mediastinal pleura is opened over the aorta and retracted with retention sutures; mosquito clamps are placed on the ends of the sutures. The incision is extended upward along the proximal side of the left subclavian artery. The left superior intercostal vein is identified and CCCT. 3. The dissection continues over the anterior surface of the aorta up to and across the PDA toward the pulmonary artery. The direction of the dissection prevents injury to the recurrent laryngeal nerve. 4. The aorta, main pulmonary artery, vagus and recurrent laryngeal nerves, and thoracic duct are identified. Intraoperative injury to these structures must be prevented. 5. The parietal pleura and pericardium are incised over the anterior surface of the PDA, dissected free, and retracted medially with retention sutures. The PDA is now exposed (Figure 22-35B). 6. Dissection of the posterior wall of the PDA is critical. First, the aorta must be prepared for possible occlusion in the event of hemorrhage. Two umbilical tapes are placed around the aorta above and below the PDA, and two tapes are placed around the left subclavian artery; the tapes are loosely clamped. The aorta is retracted superiorly and anteriorly to expose the posterior wall of the PDA. 7. The PDA clamps are placed as close to the aorta and pulmonary artery as possible (Figure 22-35C). 8. There are three methods of closing the PDA: Any additional tissue surrounding the ductus is dissected to allow a small right-angle clamp to be passed underneath the lower margin of the ductus. A silk tie is placed in the tip of the right-angle clamp and the tie brought around the ductus and tied. The PDA is divided as close to each clamp as possible and a continuous suture is placed to close the lumen of each stump (Figure 22-35D). Four or five metal clips are placed to close the PDA. Procedural Consideration: The placement of metal clips avoids having to place the right-angle clamp behind the thin, friable ductus and possibly tearing it, causing life-threatening hemorrhage. Second, the placement of metal clips shortens the surgical time. Last, using metal clips decreases the amount of time the left lung must be retracted, thus decreasing the intraoperative complications with ventilation that can arise. 9. After ligation or division, the pleura is left open, and a small drainage catheter is placed into the left pleural space for the drainage of fluid and air for 24 hours. The ribs are approximated and the wound is closed in two layers with running sutures.

Keratoconus

Progressive eye disease that causes the normally round cornea shape to become irregular and cone-shaped

Inferior Vena Cava Filter Placement—Jugular Vein Access Procedure

Placing an inferior vena cava (IVC) filter is indicated for preventing pulmonary embolism (PE) due to deep vein thrombosis (DVT). DVT is a disorder involving a thrombus in one of the deep veins of the body. The deep veins most commonly affected are the iliac and femoral veins. It is a life-threatening disorder; if the thrombus becomes an embolus, it is likely it will enter the lungs, causing a PE. Symptoms include tenderness, claudication, swelling, and discoloration of the skin. IVC filter placement is performed when medical therapy, including bed rest and anticoagulant drugs, does not resolve the disorder. The surgeon palpates for the jugular vein and injects 3-5 mL of lidocaine 1%. 2. Using the #15 knife blade, the surgeon makes a small horizontal skin incision. 3. Depending on the surgeon's preference, an 18-gauge needle or ultrasound-guided micropuncture device is used to enter the jugular vein. The surgeon may use a Modified Seldinger technique to obtain entry into the vessel. Venous blood is aspirated to verify entry into the vein. 4. The course for inserting the guidewire is viewed on fluoroscopy. If the surgeon is using the micropuncture device, the 0.035-in. wire will be used. 5. The 0.035- or 0.038-in. guidewire is advanced into the IVC. The sheath is placed over the guidewire and then the catheter is inserted through the sheath and over the guidewire. 6. The guidewire is removed and a small amount of contrast medium is injected to verify location of the catheter. Procedural Consideration: The surgeon will perform a cavogram. The cavogram is performed to measure the diameter of the IVC, verify the anatomical location of the renal veins, rule out that an IVC does not exist on the left side of the body, and make sure the IVC is patent. 7. The catheter is removed and replaced with the introducer sheath. Procedural Consideration: When placing the IVC filter through the jugular vein, a 7F introducer sheath will be used; femoral vein is entered and an 8.5F sheath is used. 8. The sheath is advanced to the spot where the IVC filter will be placed. 9. The inner dilator is removed, and the deployment catheter with the preattached filter is inserted. Procedural Consideration: The surgeon is careful not to push the filter all the way out of the sheath, but just to the end so it is ready for deployment. 10. The sheath and filter are advanced to the position of deployment distal to the lowest renal vein. 11. The sheath is drawn back and the filter is uncovered and opens, but it is still attached to the sheath. If the filter is not in the correct position or incorrectly angled, it can be resheathed and fluoroscopy continued so the surgeon can reposition the sheath and filter. When the correct position is achieved, the filter hook is released and the filter is positioned. 12. The surgeon will perform another cavogram to verify IVC filter position. 13. The sheath is removed and the incision closed with interrupted sutures, and small dressing is placed.

Pulmonary Thromboendarterectomy Procedure

Pulmonary embolism obstructs the pulmonary artery, resulting in life-threatening chronic pulmonary hypertension and its associated complications. Patients are often asymptomatic until the disease has progressed and right heart failure is occurring. The earliest sign is severe pulmonary hypertension when exercising; however, the patient may not consider the symptoms abnormal and not report to the physician. Other signs and symptoms include enlarged pulmonary arteries, septal hypertrophy, tricuspid regurgitation, chronic cough, syncope, palpitations, and hemoptysis. The disease is always bilateral. The surgeon may insert an inferior vena cava filter prior to the start of the primary procedure. * Based on the surgeon's preference, the filter may be inserted preoperatively in a separately scheduled procedure, before the median sternotomy incision is made, or within 24 hours postoperatively.* The surgeon performs a median sternotomy with the powered sternal saw. The pericardial sac is opened (called a pericardiotomy) and CPB is established by venous cannulation and ascending aortic cannulation. *Refer to the CABG procedure for details concerning cannulation.* The body of the patient is cooled followed by circulatory arrest. While the body is cooling the surgeon will dissect free and mobilize the superior vena cava in order to gain access to the right pulmonary artery.* The surgeon will identify and preserve the phrenic nerves during this step of the procedure.* Beginning with the right pulmonary artery, the surgeon makes an arteriotomy using the #11 knife blade and extends the incision with the Potts-Smith scissors. (a)Due to the increased bronchial blood flow, the surgeon may call for intermittent periods of circulatory arrest and reperfusion in order to obtain exposure of the surgical site; or, (b)The surgeon will work on the right pulmonary artery, reperfuse, and repeat the procedure on the left pulmonary artery. Using smooth vascular forceps, Freer elevator, and Jamieson dissector, the plaque is raised and excised from the right pulmonary artery. Dissection begins on the posterior wall of the artery and continues in a circumferential manner. The surgeon continues the removal of the plaque from the segmental and subsegmental arterial branches using a combination of suction and dissection.*The surgeon may use a choledochoscope to first identify the location of the plaque in the arterial branches.* The surgeon closes the right pulmonary artery arteriotomy and performs the procedure on the left pulmonary artery. Upon completion of the endarterectomy, CPB is resumed and the patient is re-warmed. *This is when the surgical technologist will need to request warm saline to be poured into a basin by the circulator for use by the surgeon.* The median sternotomy is closed and the dressings are applied.

Rhinoplasty: External Technique Procedure

Rhinoplasty is reshaping of the nose. It is considered a plastic surgery procedure because no functional changes are made to the interior nasal passageways. However, it may be performed in conjunction with other nasal procedures to repair the nose in the post-trauma patient. The nose packing is removed. Using a #15 blade, the surgeon makes the skin incision along the base of the columella and upward along the outside of one nostrilProcedural Consideration: Minor bleeding is controlled with the use of suction ESU. A double-pronged skin hook is used to retract the skin upward at the apex of the nose.*The surgical technologist will be responsible for holding the skin prong retractors.* The skin is undermined using the Freer or Cottle elevators and tenotomy scissors. *The surgical technologist will be responsible for suctioning blood from the nose and incision site with a Frazier suction tip*. The periosteum and perichondrium are elevated and freed with the use of the elevators, scissors, and chisel. Using the #15 blade and tenotomy scissors, the upper lateral cartilage is trimmed. If a hump is present, it is removed with a chisel and hammer and then smoothed with a rasp. Bony spurs can be removed in the same manner. * While the surgeon holds the chisel in place, he or she may have the surgical technologist tap the chisel with the mallet.* At this point, the surgeon may perform a septoplasty. Once the septoplasty is done, if necessary, the edges of the cartilage are trimmed with the tenotomy scissors. Using his or her fingers, the surgeon molds the cartilage and bone, and, if necessary, places a cartilage or bone graft to mold the nasal tip. As a final step, the surgeon performs lateral osteotomies using the chisel and mallet to further straighten the nose. The skin is closed with a 4-0 absorbable suture (Figure 19-9B). A metal or fiberglass nasal splint is placed and a small piece of gauze may be carefully taped over the nares to absorb any drainage.* The surgical technologist should make sure to have the correct type of nasal splint available according to the surgeon's preference.*

Aortofemoral Bypass Procedure

See previous procedure for abdominal aortic artery and iliac artery anatomy. The external iliac arteries become the femoral arteries as they exit the pelvic cavity and cross the inguinal ligament. The femoral arteries, which pass fairly close to the anterior surface of the upper thigh, send branches back into the pelvic region to supply the genitals and lower abdominal wall. Branches include the medial and lateral femoral circumflex arteries, which supply muscles of the proximal thigh and encircle the femur; and the deep femoral artery (profundus femoris), which is the largest branch of the femoral artery and serves the hip joint and hamstring muscles of the thigh. Arterial obstructions due to atherosclerosis occur most frequently in the aortoiliac segment of the arterial system causing claudication. Results of arterial bypass in this region are good because of its high flow rate and large-diameter vessels. Incisions are made in each groin lateral to the vascular axis with dissection of the profunda femoris down to the first perforating branch or beyond. Procedural Consideration: Dissection is accomplished using Metzenbaum scissors and tissue forceps. The surgical technologist should have Weitlaner retractors ready for placement. 2. The inguinal ligament is partially excised at the upper limit of the incision for unlimited passage of the Dacron graft from the abdomen. The deep circumflex iliac vein is divided to make way for eventual tunnelling. Procedural Consideration: Dissection will continue with the electrocautery and sharp and blunt techniques. Suction may be used intermittently. 3. The abdomen is opened from the xiphoid to the pubis, and the transverse colon and omentum are reflected superiorly. The small bowel is displaced over the right-hand wound margin and covered with warm, moist packs. Procedural Consideration: Incision is made with #10 knife blade. The surgical technologist should have bowel bag or warm moist packs completely wrung and ready for coverage of small bowel. 4. The posterior peritoneum is incised and extended toward the aortic bifurcation. Procedural Consideration: The surgical technologist should be prepared for sudden hemorrhage. 5. The portion of the aorta just below the renal arteries is isolated and cleared, and the left renal vein is mobilized. Procedural Consideration: The 18-in. silk ties of 3-0 or 4-0 gauge are good for ligating small superficial vessels. For ligation of larger, deeper vessels, 2-0 or 3-0 silk ties of 30-in. length on carriers are necessary. Typical carriers are Schnidt tonsil clamps or Sarot clamps for deeper ligation. 6. A retroperitoneal tunnel is developed with a tunneling device or long clamp lateral to the vascular axis and behind the ureter. Procedural Consideration: A device for tunneling may be a Sarot clamp, uterine dressing forceps, or a specialty CV tunneler with a bullet tip that the graft end can be tied onto with heavy silk ties and pulled through the tunnel. If a clamp is used to create the tunnel, it can also be used to grasp the graft end and pull it through. 7. Blood is drawn from the vena cava, and a knitted Dacron graft is selected and preclotted. Procedural Consideration: Have various graft sizes available (but unopened) for the surgeon to choose. (Note: PTFE grafts do not require preclotting.) 8. The patient is heparinized systemically, and a large vascular clamp is applied to the aorta just below the left renal vein. A 2- to 3-cm section of aorta is excised and the distal aortic stump is oversewn. Procedural Consideration: Make sure the vascular clamps chosen are the proper size and angle for the vessel being repaired or bypassed. The aorta is typically occluded with a large Fogarty or DeBakey aortic clamp. 9. The proximal stump of the aorta is prepared for anastomosis, and the Dacron graft is sewn to the aorta in an end-to-end fashion with a continuous 4-0 Prolene suture. Procedural Consideration: If the aorta is friable, Teflon-coated pledgets may be used with the suture to reinforce the anastomosis, preventing the suture from tearing the tissue. The pledget is loaded by carefully folding the pledget in half with one hand, and placing the needle (loaded on a needle holder) through the top half of the fold. A vascular clamp is applied to the common femoral artery. (Note: If the anastomosis site is further distal, clamps are applied to the superficial and deep femoral vessels.) Procedural Consideration: Angled vascular or Potts vascular clamps are frequently used for femoral artery occlusion. The superficial and deep femoral vessels are frequently occluded with bulldog vascular clamps. 11. An incision is made into the common femoral artery, and the graft is cut to the correct length and its end beveled. Procedural Consideration: Arteriotomy is begun with a #11 blade on a #7 knife handle and completed with a Potts-Smith scissors. The Dacron graft is cut with straight Mayo scissors. A PTFE should be cut with a fresh #15 knife blade. 12. The graft limb is anastomosed to the femoral artery using a continuous, double-armed 5-0 or 6-0 Prolene suture. Just before the completion of anastomosis, the proximal and distal clamps are released to flush the graft, and the femoral suture line is flushed with heparinized saline. Procedural Consideration: The surgical technologist should be familiar with the art of "running" polypropylene suture. A small basin may be useful to contain blood when the graft is flushed to remove clotted blood and air. Heparin solution is prepared in advance of need. 13. The suture line is completed for the right side, and the same process is repeated for the left. The posterior peritoneum and preaortic fascia are closed over the graft, and the abdomen and groin incisions are closed in layers. A three-layer dressing is placed for each incision. Procedural Consideration: Be prepared for an intraoperative arteriogram. Supplies needed are arterial needle (or butterfly needle), 20-mL syringe, X-ray cassette or C-arm drape, injectable saline, and contrast solution. Make sure that bubbles are completely removed from the syringe and tubing. Glass syringes are preferred over plastic for intra-arterial injection because they do not retain air bubbles as much as plastic. Three incisions are used. Doppler ultrasound may be used to assess the blood flow. Be sure the appropriate number of counts is completed.

Suction Lipectomy Procedure

Suction lipectomy is performed for the removal of subcutaneous fat deposits to provide the patient with a pleasing cosmetic appearance. It provides a means of contouring those areas of the body that have not responded to changes in diet and exercise. The procedure may be performed on virtually any area of the body. The surgeon marks the area to be suctioned with a nonerasable marker (Sharpie). Procedural Consideration: This may be done in the preoperative holding area. The surgeon injects the tumescent solution and waits a few seconds for it to take effect.*The surgical technologist must keep close track of the amount of solution that is injected.* Using the #15 knife blade, the surgeon makes the smallest possible incision in the lower abdomen following a crease and skin lines. The smallest-diameter cannula is inserted and maneuvered forward. The liposuction machine is turned on and the surgeon begins to suction out the adipose tissue by making several jabbing passes parallel to the skin. * This blunt dissection technique contributes to further loosening the fat globules, which are then removed by the suction through the openings at the distal end of the cannula. Depending on the situation, the surgeon may request a larger suction cannula as the procedure progresses.* If using laser liposuction, the laser probe is inserted through the cannula and vaporizes rather than extracts the adipose tissue. Ultrasonic liposuction uses ultrasound waves applied with a titanium probe to break down the walls of the fat cells, liquefying them for easier removal with the suction. Both of these methods may decrease the patient's risk for hemorrhage and reduce postoperative pain, swelling, and bruising. When the surgeon is satisfied with the amount of tissue that has been removed, the cannula is removed and the wound closed. *The suctioned material is collected in a graduated canister. Close monitoring of the volume of adipose extracted is very important because excessive suctioning (greater than 1000 mL) can cause hypovolemia and other fluid/hemodynamic complications.* According to the amount of tissue that has been removed, the dressing may be as simple as a self-adherent bandage. A more complex pressure dressing may be applied to reduce dead space and decrease postoperative edema. *The surgeon may want the patient to wear an abdominal girdle over the dressings to provide additional pressure. The girdle is opened on the stretcher and the patient transferred from the OR table onto it. The girdle is then wrapped around the patient and hooked or snapped together.*

Repair of Tetralogy of Fallot (TOF) Procedure

TOF is the most common cyanotic heart defect in children. The classic form, of which there are several variations, includes the following four defects: VSD Infundibular or pulmonary valve stenosis An aorta that overrides the VSD Right ventricular hypertrophy The first three defects are congenital and the fourth is acquired as a result of the increased pressure within the right ventricle. Older children with this disease often give a history of squatting after exercise and are subject to hypoxic spells. Squatting relieves the symptoms of dyspnea and faintness that can occur after exertion by causing a rise in the common ventricular pressure. Pulmonary artery flow is enhanced as a result of the increased ventricular pressure, and more oxygenated blood enters the left side of the heart. TOF results in cyanosis, which may appear soon after birth, in infancy, or later in childhood. These "blue babies" may have sudden episodes of severe cyanosis with rapid breathing and may even lose consciousness. Other complications of the disease include infective endocarditis, blood clotting problems, cerebral infarction or embolism, cerebral abscess, and, rarely, right ventricular failure. Therefore, early total surgical correction should be done for all cases to avoid these complications. Infants with severe TOF may require a shunt between the aorta or subclavian artery and the pulmonary artery to increase blood flow to the lungs. This shunt allows for more blood flow to the lungs for increased oxygen saturation, which reduces cyanosis and allows the child to grow and develop until a total repair can be done when the child is older. A median sternotomy is performed. At this time, a small pericardial patch is excised for later use in reconstruction of the right ventricular outflow tract. If the surgeon uses a synthetic graft, this step will not be performed. 2. CPB and cooling are initiated in the usual manner. 3. The pulmonary trunk is dissected away from the right and left pulmonary branches and the ascending aorta, and the aorta is cross-clamped for cardioplegia infusion. Circulation is stopped and the right atrial cannula is removed for exposure. 4. Using a #15 blade and Metzenbaum scissors, the surgeon makes a right vertical ventriculotomy over the infundibular area. 5. Self-retaining retractors are positioned and a small portion of the hypertrophied infundibular muscle is excised from the right ventricular outflow tract using smooth forceps and Metzenbaum scissors. 6. The VSD is identified and incised. Hypertrophied septal and parietal bands on each side of the defect are excised. In the majority of cases the closure of the VSD requires the use of an intracardiac patch; the patch is either synthetic (Dacron) or a piece of excised pericardium. Interrupted horizontal mattress sutures reinforced with Teflon patches are used for placement of the patch. 7. If the pulmonary annulus is determined to be small, it is also enlarged with use of a Gore-Tex patch or other synthetic material of the surgeon's preference. 8. If the pulmonary valve leaflets are fused, a pulmonary valvulotomy is performed by blunt and sharp dissection. Using two clamps or smooth forceps, the edges of the valve are grasped and inverted. Using a #15 blade, the surgeon incises the fused leaflets to release them and also inserts a finger gently through the valve opening to ensure patency. 9. The right ventricular outflow patch is placed to enlarge the right ventricular outflow tract located inferior to the pulmonary valve. The patch will be either synthetic (Dacron or Teflon) or pericardial homograft. The right side of the heart is filled with saline. CPB is reinstated with a single cannula placed into the right atrium, just below the opening of the superior vena cava. While the patient is warming, the patch is sewn to the right ventricular outflow tract with a continuous 5-0 Prolene suture. A 19-gauge catheter is pushed through a purse-string suture into the epicardium of the right ventricle for postoperative monitoring. 10. Air is withdrawn from the left ventricle by inserting a needle into the ascending aorta. 11. Air is removed from the pulmonary veins by inflating the lungs. 12. The pressures of the pulmonary artery and right ventricle are taken to ensure success of the procedure. If the pressures are not normal, the procedure may continue to achieve the desired results. 13. CPB is discontinued; chest tubes are inserted; the chest is closed in the usual manner and dressings are applied. The patient is transported to the pediatric ICU.

Posterior chamber

The area behind the iris, but in front of and behind the lens

Anterior chamber

The cavity of the eye located anterior to the iris and containing the aqueous humor

Globe

The eyeball in its entirety

Abdominal Aortic Aneurysm with Graft Procedure

The aorta, the largest artery in the body, begins at the ascending aorta, ascending from the left ventricle of the heart. From the abdominal aorta, branches serve the abdominal wall and abdominal viscera. The visceral branches include the celiac artery, which is a thick, short artery that immediately divides into three arteries: the left gastric, splenic, and common hepatic arteries. The superior mesenteric artery is an unpaired vessel arising anteriorly from the abdominal aorta. This vessel branches to supply numerous abdominal organs. Renal arteries pass laterally from the aorta to each kidney and also serve a small portion of the adrenal glands. The inferior mesenteric artery is an unpaired vessel arising anteriorly from the abdominal aorta, just above the bifurcation of the aorta. This vessel supplies the lower abdominal organs. The abdominal aorta bifurcates into the left and right common iliac arteries at the level of the fourth lumbar vertebra. These divide inferiorly into two main branches—the right and left external iliac arteries, and the right and left internal iliac arteries. The majority of patients with abdominal aortic aneurysm (AAA) are diagnosed while the patient is still asymptomatic. AAAs are generally fusiform. The majority occur below the origin of the renal arteries and terminate at the bifurcation of the aorta or common iliac arteries. Rarely one or both renal arteries may arise from an AAA without involving the superior mesenteric artery or extend beyond the bifurcation of the common iliac arteries into the external or internal iliac arteries. Aneurysms may also occur in the smaller peripheral arteries. Atherosclerotic aneurysms of the femoral and popliteal arteries are likely to shed emboli and finally thrombose rather than rupture. The patient typically complains of foot or calf pain. Examination reveals a pulsating mass in the groin or behind the knee and irregular red-blue patches of skin on the foot. Continued embolization and loss of the extremity are inevitable in the untreated patient. Iliac artery aneurysm rupture is more likely than aneurysms of the popliteal and femoral arteries. These aneurysms are generally not detected on physical examination or routine X-rays, and so they progress until they rupture. Severe abdominal and back pain with a pulsatile abdominal mass signifies aneurysm rupture. The aneurysm may rupture into the peritoneal cavity with rapid exsanguination, but it more commonly ruptures into the retroperitoneal space, where it is briefly contained before fatal hemorrhage occurs. Hypertension increases the likelihood of rupture for any given size of aneurysm. Operative mortality is very low (2 to 3 percent) for the elective procedure, but once rupture has occurred, operative mortality rises steeply and may exceed 80 percent for the patient in shock. Therefore, elective surgical correction is highly advisable. An incision is made from the xiphoid to the pubis. Layers of the abdominal wall are dissected, and the aorta is exposed. Procedural Consideration: The surgical technologist should prepare a large self-retaining retractor (Balfour or Bookwalter) for the abdominal wall and large Deaver and Harrington retractors for the bowel. 2. The inferior mesenteric artery is isolated at the left border of the aneurysm with a vessel loop. The peritoneal incision is extended to the area over the common iliac arteries. 3. The external and internal iliac arteries are isolated for eventual vascular clamp placement. However, if the common iliac artery is aneurysmal, only the external iliac artery is mobilized. Often only one vascular clamp is applied to the distal portion of the common iliac artery bilaterally. Procedural Consideration: Atraumatic Potts vascular or angled DeBakey clamps are frequently used to occlude the iliac artery. 4. The aorta is mobilized proximal to the aneurysm up to the level of the renal arteries and cleared for eventual placement of a vascular clamp. Procedural Consideration: A large right angle may be useful to mobilize the aorta. 5. A bifurcated knitted Dacron graft is selected after sizing, and blood is drawn from the vena cava for preclotting. (If a PTFE or woven polyester is used as graft material, preclotting is not necessary.) Procedural Consideration: A 20-mL syringe with a 20- to 23-gauge hypodermic needle is used to draw venous blood for preclotting. The surgical technologist should have the graft in a metal bowl for saturation with blood. 6. The patient is given intravenous heparin, and vascular clamps are applied to the external and internal iliac arteries bilaterally (or to the common iliac arteries). Procedural Consideration: Note the time that the heparin is administered and the time of placement of proximal and distal vascular clamps. 7. A Satinsky aortic vascular clamp is carefully applied to the aorta above the aneurysm. Procedural Consideration: The surgical technologist should ensure that all anastomosis sutures are loaded and ready. 8. The aneurysm is opened longitudinally along the anterolateral wall and stopped just short of the aortic bifurcation. Thrombus material is removed from the interior of the aorta, and lumbar vessels are oversewn with nonabsorbable synthetic suture of surgeon's preference from within the aneurysm sac Procedural Consideration: The aneurysm is opened with #11 blade on #7 knife handle and completed with Mayo scissors. Thrombus material should be saved for specimen. 9. A T-shaped extension is cut into the proximal border of the aneurysm, and the anterior aneurysm wall is opened for copious irrigation with heparinized saline. Procedural Consideration: The jet action of the 20-mL syringe/heparin needle combination with heparinized saline forces small pieces of thrombus from the aortic wall. 10. The proximal anastomosis is begun with a continuous, double-armed 4-0 Prolene suture on a taper-cut needle. Procedural Consideration: The 4-0 Prolene should be loaded onto a long, vascular needle holder with a narrow diamond jaw. 11. A Fogarty clamp is placed across the graft immediately distal to the anastomosis, the aortic vascular clamp is released, and the two ends of the Prolene suture are tied together, completing the anastomosis. Procedural Consideration: Any leaks in the proximal anastomosis are patched with interrupted, pledgeted Prolene sutures. Most patch sutures are single-armed, so the surgeon may ask the surgical technologist to cut a double-armed Prolene suture in half. 12. The right limb of the graft is aspirated, brought down to the common iliac bifurcation, and cut to the correct length. Procedural Consideration: Prepare to cut the graft to the appropriate size. An additional vascular clamp may be placed on the distal graft. 13. An arteriotomy is performed on the right common iliac vessel, and the graft limb is anastomosed in an end-to-side fashion with a double-armed 5-0 or 6-0 Prolene. Procedural Consideration: Do not try to remove knots from Prolene sutures. If a knot is found while loading the suture, simply discard the knotted Prolene and load another. 14. Before completion of the iliac anastomosis, the distal and proximal clamps are opened for flushing. The suture ends are tied, and circulation is opened. Procedural Consideration: Wet the hands of the surgeon with saline before the tying of polypropylene sutures. Note time blood flow is restored to limb. Patch sutures may be needed. 15. The same process is repeated for the left side. The anterior wall of the aneurysm sac is sutured over the proximal aortic graft. The abdominal wound is closed in layers. A three-layer dressing is placed. Procedural Consideration: Prepare closure suture. Note number of laps removed from abdominal cavity. Routine closure including counts is carried out.

Orbital Floor Fracture Repair Procedure

The bones of the orbit support and protect the eyes. Each orbit consists of the following seven craniofacial bones: frontal, lacrimal, ethmoid, maxilla, zygomatic, sphenoid, palatine. Two classifications of orbital fractures—floor fractures or orbital blowouts—involve one or more of the numerous bones of the orbit (Figure 18-10). Trauma caused by auto accidents, fights, and falls commonly results in these fractures. The orbit contains fat to protect the eye from shock and connective structures to retain the eyeball and allow for its motion, blood vessels, and the optic nerve (second cranial nerve). Orbital fractures may appear alone, unilaterally, bilaterally, or in conjunction with other facial fractures. Characteristics of orbital fractures: diplopia; enophthalmos; periorbital fat and muscles pinched in the fracture line or herniated into the maxillary antrum; swelling and bruising. The orbital floor separates the eye from the maxillary sinus. The floor is a thin extension of the maxillary and zygomatic bones. The planned incision is marked and injected with a local anesthetic containing epinephrine.* Provide sterile marking pen. Medication is obtained and drawn into the syringe in advance. Notify anesthesia provider of epinephrine use.* Incision is made with a #15 blade underneath the lower eyelid on the affected side and hemostasis is achieved.*Cotton swabs or Weck-Cel sponges are used to blot away blood and irrigation solution around the incision. Keep an ample supply readily available. Present electrosurgical pencil, if needed. Provide suction as needed.* A traction stitch may be placed between the lower eyelashes and incision site to aid in exposure. *Traction stitch is preloaded on needle holder. It may either be tied and cut or secured with a hemostat. Dull Senn or vein retractors may be needed to provide additional exposure.* Curved tenotomy scissors and Adson tissue forceps are used for dissection through the infraorbital fat to expose the infraorbital rim. * Pass scissors to surgeon's dominant hand and tissue forceps to the opposite. Electrosurgical pencil may be used intermittently.* The periosteum is incised with a #15 blade and elevated with the use of a Freer. *A new #15 blade will be needed. Pass Freer elevator. Be sure to present sharp or dull end as specified by surgeon*. A moistened orbital retractor or Teflon-coated malleable brain spatula may be placed to gently retract the eye, superiorly exposing the orbital floor. *Have premoistened retractor of choice available.* The periorbital fat and any other entrapped tissues are released and retracted.* Freer elevator or scissors and tissue forceps may be needed repeatedly.* The fracture site is exposed and bone fragments are manipulated into position. *Be sure eye is protected during reduction of bone fragments.* Any loose bone fragments are repositioned and the wound is irrigated. *Irrigation fluid of surgeon's choice is preloaded in syringe with blunt needle. Pass irrigation fluid along with Frazier tip suction. A kidney basin placed at the side of the face may be useful in containing excess irrigation fluid.* If the reduction is stable, Silastic sheeting may be inserted over the fracture site to prevent entrapment of the orbital contents in the fracture and support the globe. *Sheeting must be prepared and sterilized according to manufacturer's instructions. Sheeting will be customized—have straight scissors ready.* If the reduction is not stable, a rigid fixation device may be implanted, followed by the insertion of Silastic sheeting. * Communicate additional needs with other team members. Secure any necessary additional supplies.* Reduction may be verified radiographically. *Provide necessary supplies to facilitate X-ray.* Once adequate stable reduction is achieved, the traction suture is removed and the wound is closed.* Provide closing suture of surgeon's choice. Count.* If used, the corneal protector is removed and the dressing is applied.* Provide dressing materials. Ice may be needed.*

Pneumonectomy Procedure

The chief indication for pneumonectomy is bronchogenic carcinoma. Less common indications include multiple lung abscesses, bronchiectasis, and extensive unilateral tuberculosis. Using the #10 knife blade, the surgeon makes a posterolateral incision in the skin and carries it through the subcutaneous and muscle layer with the knife and ESU. If necessary, a rib is stripped and resected. The rib retractor is placed and opened to expose the lung in the thoracic cavity. The surgeon explores the cavity to determine if metastasis is present. If extensive metastasis is confirmed, the surgeon will terminate the procedure; two chest tubes will be inserted, and the wound will be closed. Using long Metzenbaum scissors, vascular forceps, and blunt dissection, the surgeon dissects cavity adhesions and the mediastinal pleura to completely free up the lung. In the process of dissection the pulmonary ligament is doubly clamped, cut, and tied (CCCT). Using a vessel loop, the superior pulmonary vein is retracted laterally to expose the pulmonary artery. The artery is CCCT.*When dividing the arteries and veins, the surgeon takes care to identify and preserve the vagus nerve. The surgeon may use a vessel loop to gently and slightly retract the nerve from the area of dissection; the vessel loop may be moved several times according to where the dissection is taking place.* The superior pulmonary vein is CCCT. Branches of the superior pulmonary vein and pulmonary artery are isolated and CCCT. * The division of branches can be tedious and time consuming, but it is necessary to prevent postoperative hemorrhage in the thoracic cavity. The surgical technologist must remain focused and anticipate each time the surgeon needs clamps by keeping one or two clamps in the hand ready to be passed. Additionally, the surgeon will use a large number of ties; the surgical technologist must make sure not to run out of ties to pass to the surgeon.* The lung is retracted anteriorly using an Allison lung retractor. Using the Metzenbaum scissors and vascular forceps, the surgeon incises the hilar pleura to expose the inferior pulmonary vein. The vein is CCCT. The bronchus clamp is placed on the bronchus near the bifurcation of the trachea. The bronchus is divided and the stump closed with nonabsorbable sutures using a mattress suture technique, or with the clamp still in place the bronchus is divided with the bronchial stapler. If staples are used, the surgeon will use a #15 knife blade on a long knife handle to divide the bronchus. The lung is removed and given to the surgical technologist. *The surgical technologist may need an extra-large basin to place the lung and hand off to the circulator. Confirm with the circulator whether it is right or left lung.* The thoracic cavity is thoroughly irrigated with warm normal saline solution. The cavity is inspected for hemorrhage and the bronchial stump is checked for air leakages. The empty pleural space must be thoroughly suctioned to prevent the irrigation solution and blood, if present, from entering the opposite lung. *The surgical technologist should anticipate when the surgeon will want the saline irrigation and ask the circulator to pour it just before it is needed in order to prevent it from becoming cold.* The surgeon excises the peripheral lymph nodes within the thoracic cavity, including the mediastinal space. Using the pleura, the surgeon creates a flap that is sutured over the bronchial stump using nonabsorbable suture. Two chest tubes are placed and the pleural space is closed. After the space is closed the chest tubes are connected to the closed water-seal drainage unit. The rib retractor is removed and the Bailey rib contractor is placed. The thoracic cavity is closed with nonabsorbable suture using interrupted suture technique. The muscle and subcutaneous layers are closed. The skin is closed with skin staples or subcuticular closure and skin closure tapes. The dressing is applied. Chest tubes are sutured to the skin with large-diameter nonabsorbable suture.

Otoplasty Procedure

The pinna (external ear) is a framework of cartilage that is covered by a thin layer of skin that consists of the auricle and external auditory meatus. The auricular sulcus is the depression behind the ear next to the scalp. The outer edge of the pinna is called the helix and it arises from the crus that is just superior to the tragus; the crus extends horizontally right above the auditory canal. At the superior portion of the helix, it is folded over and, as it travels downward, is no longer folded over, leading into the cauda helices (tail of the helix) and ending in the lobule (earlobe). The antihelix gives form to a large part of the external ear. It is a symmetric Y-shaped structure in which the folded crest of the bottom portion of the antihelix continues upward and separates into the superior crus and inferior crus ("Y" portion of the antihelix). The bottom portion (root) of the antihelix forms the lateral edge or rim of the concha. The right "Y" or inferior crux forms the superior rim of the concha as well as separates the concha from the triangular fossa. The superior crux is the branch of the "Y" that is to the left of the triangular fossa. Therefore, the triangular fossa is the space located between the branches of the Y-shaped antihelix. The scapha is the elongated depression that lies between the helix and antihelix. The concha is a slight depression located next to the ear canal. The narrow superior portion is called the cymba conchae and the larger inferior portion is called the cavum conchae. The last three structures are the tragus (auditory canal lobule), intertragal notch, and antitragus. The tragus is a small projection that is located medial to the ear canal. It is separated from the antitragus by a depression called the intertragal notch. The antitragus is the small curved portion that is connected to and superior to the lobule. There are many ear defects and deformities that are corrected by surgery. The pathology to be corrected determines the otoplasty procedure to be performed. The two pathologies being addressed are microtia and prominent ears: Microtia is the congenital absence of part or all of the ear. Prominent ears is a term used to describe pinnae that abnormally protrude from the sides of the head most often due to an inadequate folding or absence of the antihelix. This causes the scapha and helical rim to protrude. Otoplasty for Microtia Using a marking pen, the site for taking the costal cartilage graft is marked at the sixth, seventh, eighth, or ninth intercostal space. Using a #15 knife blade the surgeon makes an incision over the intercostal space. Using the template, the rib segment is removed while the perichondrium is preserved. The pleura is assessed to make sure it is intact. *The surgical technologist provides the surgeon with a bulb syringe filled with saline that is instilled into the wound. If bubbles appear the surgical technologist must immediately receive a chest tube of the size requested by the surgeon for insertion and attachment to a chest drainage system. If no bubbles appear, the wound is closed.* The surgeon uses the template to form the graft with the power drill and burs. *The graft will not be immediately used. To keep it from drying out, the surgical technologist should wrap it in saline-soaked sponges and put on the back table in a safe place until needed.* Using the #15 knife blade, the surgeon makes a postauricular incision. The temporoparietal fascia is elevated and the graft is inserted. The flap is pulled over the graft and sutured in place. *Throughout the procedure hemostasis is achieved with the use of ESU, topical thrombin, and injection of local anesthetic with epinephrine.* A bulky dressing is placed. *The dressing will consist of petrolatum gauze and several fluffs held in place with rolled gauze.* Otoplasty for Prominent Ears Due to Absence of Antihelical Fold The surgeon will use a finger to bend the ear backward, which creates an antihelical fold The antihelical fold position is marked by placing the 25-gauge needle through the ear, anterior to posterior, marking the tip of the needle with methyelene blue, and withdrawing the needle to stain the cartilage. This is performed three or four times.*The surgical technologist may be responsible for marking the tip of the needle by dipping a cotton-tipped applicator in the methylene blue (Figure 19-8B, C).* Using the #15 knife blade, the surgeon excises an elliptical portion of skin from the posterior of the ear. The cartilage is incised near what will be the new antihelical fold and the anterior surface is scored to allow the cartilage to bend backward (Figure 19-8D). The surgeon places several sutures to hold the cartilage in its new anatomical position (Figure 19-8D). The posterior skin incision is closed with suture and a bulky dressing is placed over the incision (Figure 19-8E). *The dressing will consist of petrolatum gauze and several fluffs held in place with rolled gauze.*

Extrinsic muscles

The six muscles of the eye that come from the bones of the orbit and function to move the eye in various directions

Diathermy

The use of high-frequency electromagnetic currents to cauterize blood vessels and destroy neoplasms

Malar Implants Procedure

The zygomatic bones (also called the malar bones) form the prominences of the cheeks and form the lateral walls and floors of the orbits. They join with the frontal, sphenoid, temporal, and maxillary bones. Each zygomatic bone has a temporal process that articulates posteriorly with the zygomatic process of the temporal bone called the zygomatic arch. The masseter muscle is one of the primary muscles of mastication. It is a thick, flat muscle of which the origin is the zygomatic arch and the ramus of the mandible is the insertion. The masseter closes the jaw. Submalar augmentation is performed in patients who have a deficient bone structure or severe atrophy of overlying soft tissue. The deficiency can also be due to trauma or facial surgical procedures, such as cancer of the mandible. Submalar augmentation is usually performed before and in conjunction with rhytidectomy. A small gingivobuccal sulcus incision over the canine fossae is made. The periosteum is incised and elevated, superiorly off the anterior surface of the maxilla. The infraorbital nerve is identified in order to preserve. Using the Joseph's elevator and periosteal elevator, a pocket is created to expose the entire anterior surface of the maxilla to the lateral portion of the zygoma. The inferior surface of the zygoma, including the tendinous insertion of the masseter, is also exposed. *The tendinous insertions of the masseter muscle are left in place and not incised. The pocket is made large enough to prevent compression of soft tissues on the implant.* The implant sizers are inserted to decide on the correct-size submalar implant. When the correct implant size is chosen, it is placed on the anterior skin surface, and, using the marking pen, the surgeon outlines the implant to indicate the position for the permanent implant. The positions of the two medial fenestrations of the implant are also marked on the skin. The permanent implant is inserted into the pocket over the anterior surface of the maxilla and manipulated into the desired position.*The surgical technologist should confirm the size of implant with the surgeon and communicate the information to the circulator, who will open the sterile implant to facilitate transfer to the sterile field. The central portion of the implant is positioned over the anterior surface of the maxilla and the tapered lateral extension fits around the zygomatic arch and rests on the superior tendinous attachments of the masseter muscle.* The implant is removed and 2-0 or 3-0 nonabsorbable suture is placed around the posterior surface and through the openings of the implant. The surgeon places the suture through the pocket and exits at the external markings on the skin. Although placing the suture, the implant is "pulled" into the pocket and again manipulated into the correct anatomical position. *The surgical technologist will be responsible for controlling and guiding the implant into the pocket while the surgeon places the suture.* The implant is held in position when the surgeon ties the sutures externally over a bolster (dental roll). The steps of the procedure are repeated on the opposite side of the face. The wounds are gently irrigated and checked for hemostasis. The incisions are closed in two layers; the first layer is closed with absorbable suture and the skin with nonabsorbable suture. 4 × 4 compression dressing is placed to further stabilize the implants.

Toe-to-Hand Transfer Procedure

Toe-to-hand transfer is performed due to trauma to the hand in which the patient's thumb was traumatically amputated or injured beyond use. Toe Procedure A lateral triangular incision is made on the foot as far back as the dorsal medial aspect to expose the saphenous vein, dorsalis pedis artery and branches, and short extensor muscle. Using the Metzenbaum scissors, the short extensor muscle is divided. The dorsalis pedis artery and its branch, the communicating artery, and communicating vein from the saphenous vein are mobilized from the dorsum of the foot distally into the toe. The long extensor tendon is dissected free from its attachment back to the dorsum of the foot to provide an excellent length of tendon. The deep peroneal nerve is identified and dissected free; it will be used to anastomose to the superficial radial nerve in the hand to provide sensation to the dorsum of the transplanted toe. The proximal communicating vein and artery at the base of the first web space are clamped, cut, and ligated to complete freeing up the dorsalis pedis artery. On the medial side, the long flexor tendon and medial digital nerves are isolated, dissected free, and transected. * The white vessel loop is used to gently retract the deep peroneal nerve superiorly out of the surgical site, the red vessel loop is used to superiorly retract the dorsalis pedis artery, and the blue vessel loop is used to medially retract the saphenous vein.* 8. The toe is placed in an angulated medial position and, using the #15 knife blade, the joint capsule is incised and disarticulated through the metatarsal joint.* The long flexor tendon must be distally retracted to protect it from injury.* All structures except for the arteries and veins have been divided. The tourniquet is released and bleeders are cauterized or ligated. Microvascular vessel clamps are placed on the dorsalis pedis artery and saphenous vein and the vessels are tied and divided, freeing the toe from the foot. *At this point the vessels, tendons, and nerves that are included with the transplant are dorsalis pedis artery, saphenous vein, extensor hallucis longus tendon, flexor hallucis longus tendon, lateral digital nerve, and medial digital nerve.* The skin flaps are positioned and sutured over the donor defect of the foot. *During the surgical amputation of the toe, the surgeon ensures that there is an adequate amount of skin tissue left to cover the defect. Closure of the donor defect can create serious postoperative problems such as delayed healing if too much tissue is transferred with the toe. It is advised to take less tissue from the foot and, if necessary, cover open areas on the hand with a split-thickness skin graft (STSG).* Hand Dissection and Implantation of Toe Transplant A dorsal coronal incision is made in the midline of the amputated area of the stump of the thumb, exposing the median nerve and its branches. The flexor pollicis longus tendon is identified at the base of the metacarpal, which will be used as a bone peg for insertion into the proximal phalanx of the toe transplant. *This creates an adequate web space in order to restore an adequate grip and pinch to the patient's hand.* The toe is fixed into position with the use of a Kirschner wire and the use of a bone peg on the hand fitted into a hole that has been created in the proximal toe phalanx. A screw from the mini-fragment set is transversely positioned. The metacarpophalangeal joint of the thumb is reconstructed to provide additional movement to the transplant. The extensor pollicis longus tendon and extensor hallucis longus are sutured together. The flexor hallucis longus tendon and flexor pollicis longus tendon are anastomosed in the wrist.*The surgeon uses a figure-of-eight suture technique to anastomose the tendons.* The dorsalis pedis artery is anastomosed end-to-end to the dorsal radial artery. The saphenous vein is anastomosed end-to-end to the cephalic vein. The digital nerves from the toe are anastomosed to the digital nerves in the thumb.* The microscope is brought up to the surgical field to be used by the surgeon when anastomosing the arteries, veins, and nerves.* The skin flaps are sutured into place on the lateral and medial aspects of the thumb. If the skin flaps cannot be sutured in place without creating tension, an STSG will be placed directly over the anastomosis.*The surgical technologist must make sure there are plenty of sutures of the correct size available. Interrupted suture technique is used by the surgeon to secure the skin flaps.* A nonadherent bulky dressing is placed that allows for exposure of the fingertips.

Video-Assisted Thoracic Surgery (VATS) Procedure

VATS evolved from thoracoscopy as well as the advances made in minimally invasive surgical techniques and instrumentation. VATS is used for the diagnosis and treatment of several thoracic diseases and disorders of the esophagus, lungs, mediastinum, pericardium, and pleura. Pleural disorders that can be treated include blebs (irregular bulge) and cysts as well as tissue biopsy of mediastinal masses. Procedures that have been performed through VATS include lung wedge resection, lobectomy, lung volume reduction, creation of a pericardial window, pericardiectomy, and thymectomy. VATS is also indicated when the patient has impaired pulmonary functions and the risk of performing open surgery is outweighed by the pathology The following is a description of a VATS wedge resection: Lidocaine or Marcaine is injected into incision site. Using the #15 knife blade, the surgeon makes a 1.5- to 3-cm incision between the fourth and seventh intercostal space at the posterior axillary line. A digital examination is completed to verify the entrance into the pleural cavity. The anesthesia provider deflates the lung. The first 10/12-mm trocar is inserted and removed, leaving the sheath in place. The 10-mm endoscope is inserted and camera and light cords are attached Under endoscopic visualization, the second incision is made between the fourth and seventh intercostal space at the anterior axillary line. The 10/11-mm trocar is inserted and removed, leaving the sheath in place. The third incision is made at the upper posterior axillary line and the second 10/11-mm trocar is inserted. The surgeon may replace the scope with the scope.* The second and third ports are for the insertion of endoscopic instruments (Figure 22-12B, C).* A fourth incision is made; it is a 6-cm submammary incision that will be used for removing the tissue specimen. An atraumatic endoscopic grasper is inserted; the lung is grabbed and retracted downward and anterior. The surgeon identifies the blood vessels that will need to be divided (Figure 22-12D). An endoscopic vascular clamp is placed on the vessel proximal to where the endoscopic staples will be placed. The endoscopic stapler is inserted and fired to divide the vessel. This process will be repeated several times until all major vessels have been divided. *The surgical technologist will need to quickly refill the stapler when it is empty in order to avoid delays. The surgical technologist should have at least two endoscopic staplers available; when one is empty, the full stapler can be handed to the surgeon to allow the surgical technologist time to fill the first stapler.* Using graspers and scissors, the lymph nodes that are situated around the bronchus are removed. *The lymph nodes are considered tissue specimens; the surgical technologist should ask the surgeon if they are to be sent to pathology together or as separate specimens. If to be sent as separate specimens, the surgical technologist should communicate the location from where each one is excised in order for the specimen container label to have the correct information.* The wedge of lung tissue to be removed is identified by the surgeon. A grasper is placed on the lower part of the wedge. An endoscopic stapler is placed across the lung and fired (Figure 22-12E, F). A tissue specimen bag is rolled up and inserted. The wedge is placed inside the bag and brought out through the submammary incision. * If the specimen is infected or has a malignant tumor, the bag prevents the spread of infectious fluid or seeding of malignant cells. Routine, nonendoscopic instrumentation may be inserted through the submammary incision to grasp the specimen bag and remove.* The surgical site is inspected for hemorrhage and the staple line is viewed to verify closure. The surgeon places a chest tube though the lower posterior incision site and it is connected to the Pleur-evac. The sheaths are removed and the incisions closed. The chest tube is secured to the skin with a suture. Small dressings are placed over the incisions.

Blepharoplasty Procedure

When a blepharoplasty is performed, the anatomical structures of importance are the muscles. The muscle that closes the eyelids is the orbicularis muscle that encircles each eye. The primary muscle that opens the eyelids is the levator muscle. It begins deep in the eye socket and continues over the top of the eye. Its tendon, the levator aponeurosis, connects the muscle to the eyelid. Posterior to the skin and orbicularis muscles is the thin cartilage called tarsus or tarsal plate that gives shape to the eyelid. The tarsal plate is connected to the orbital rim by a tendon on each side called the medial canthal tendon and the lateral canthal tendon. This eyelid support system is called the tarsoligamentous sling. The orbital septum is a fibrous membrane that cushions the eyeball; in the upper eyelid, it connects at the top of the tarsal plate and extends to the rim of bone superior to the eye. Posterior to the orbital septum is the upper orbital fat that lies in front of the levator aponeurosis. Dermachalasis is relaxation and hypertrophy of the eyelid skin. Often in association with dermachalasis is the relaxation of the fascial bands that connect the skin to the orbicularis muscle, causing a "bag." This disorder has been linked to sun exposure and age. It can be the cause of restricted vision or the patient may just want a cosmetically improved appearance. Signs of aging are seen throughout all body systems but are externally noticeable primarily on the skin and especially on the face. As the patient ages, elastic fibers decrease in number and adipose tissue is lost, causing wrinkling and sagging; collagen fibers are lost, slowing healing; the mitotic activity of the stratum basale slows and the skin becomes thinner; and glandular production of sweat and sebum decreases, causing drying. Patients complain of several problems. The four main complaints are loose skin, fine lines, exaggeration of normal features, and bagginess around the eyes. The word blepharoplasty means surgical repair of the eyelid; the procedure is performed to remove excess skin or fat deposits of either the upper or lower eyelids and is usually a bilateral procedure. The eyes must be kept from drying out; ointment may be instilled into the eyes prior to the start of the procedure. Surgeon uses a marking pen to indicate the incision lines prior to the injection of the local anesthetic. *If the anesthetic were injected first the anatomy would be distorted.* Using the #15 knife blade an elliptical incision is made along the ciliary margin following the natural curve of the eyelid. Using the jeweler's forceps and Westcott scissors, a skin flap is developed and any redundant tissue, including the medial and central fat pads, is removed. *Great care is used to prevent damage to the levator muscle.* Hemostasis is achieved with the use of cauterization. *The surgical technologist is responsible for gently dabbing the small bleeders in the incision with the use of the Weck-Cel spears, providing the surgeon with a dry visual field, and ability to identify the bleeders to cauterize.* A second incision is made to create a wedge of skin to be excised. It is arched above the primary incision and connected at the medial and lateral edges. *A caliper may be used to ensure that the incisions on both eyelids are equal in length and size and to prevent removal of too much tissue, which could cause a permanent inability for the patient to close the eyelids* Using the Castroviejo needle holder, the surgeon closes the wound. The wound edges are brought together and sutured. The underlying tissue will be sutured with absorbable suture. The skin is closed with monofilament nonabsorbable suture; Prolene is frequently used because its blue color differentiates it from the eyelashes at the time of removal. The procedure is repeated on the opposite eye. No dressing is applied, but antibiotic ointment may be applied.

Surgical Repair of Entropion Procedure

_____ is an abnormal inversion of the lower lid margins, causes the eyelashes to rub against the cornea, resulting in irritation, pain, and chronic tears. ______ is due to the aging process, but it can also be caused by trauma. The eyelids consist of several layers: skin, subcutaneous tissue, orbicularis oculi muscle, tarsal plates, and palpebral conjunctiva. Additionally, there are two subunits: medial and lateral canthus tendons. The medial canthus contains the lacrimal drainage ducts and the medial canthal tendon, which is a fibrous extension of the tarsus and surrounds the lacrimal sac. The lateral canthus contains the lateral canthal tendon, which is formed by fibrous extensions of the upper and lower tarsal plates. _____ :This is the most common type and occurs when the canthal tendons retain their normal rigidity but atrophy of the tarsus and orbital fat, as well as hypotonia of the subcutaneous tissues and skin, results in the inversion of the lower eyelid _____: This is due to hypertrophy of the oculi muscle, which causes the eyelid margin to be pushed superiorly and against the globe. A sterile marking pen is used to mark the incision to be made in the lateral canthus. Using a small-gauge angled needle, local anesthetic (usually 1% xylocaine with epinephrine) is injected into the lower lid of the eye through the conjunctiva The lateral canthotomy is made with straight tenotomy scissors or #15 blade. The surgical technologist must be ready to hold pressure and blot with Weck-Cel or Ray-Tec sponge while the surgeon uses electrocautery. The orbicularis oculi muscle is dissected off the orbital septum with the use of the scissors. Using smooth tissue forceps, the lower lid is gently pulled laterally toward the incision that was made in the lateral canthus to shorten the lid and correct the entropion. The tarsus of the eyelid is reattached to the lateral canthal tendon with 4-0 or 5-0 nonabsorbable suture, and the lower lid fascia is reattached to the orbicularis using the same type of suture. Excess skin is grasped with the smooth forceps, pulled upward, and excised with the tenotomy scissors or scalpel. The skin incision is closed with 6-0 or 7-0 nonabsorbable suture.

Vein Ligation and Stripping (Unilateral) Procedure

aricose veins are veins that have become elongated, dilated, and tortuous. Varicose veins are characteristic of a disorder that is progressive and there is no cure. Incompetent valves are one primary cause of varicose veins, causing blood to pool within the vein causing distention of the vessel. They are categorized as primary and secondary. Primary varicose veins are the result of dilated, visible protrusions of superficial veins. Secondary varicose veins are the result of deep venous disorders such as DVT. Veins in the legs are more frequently affected, in particular, the saphenous vein and its branches. Risk factors include heredity, female gender, hormones (particularly progesterone), constricted clothing, long periods of standing, obesity, incompetent venous valves, pregnancy, physical inactivity, smoking, and hypertension. Varicose veins can result in venous stasis, which can lead to stasis ulcers. Symptoms include aching and heaviness of the lower extremity that worsens during the day, nighttime leg cramping, edema, fatigue, visible protrusions of the veins, skin pigmentation, ulceration, eczema, tenderness, and internal and external bleeding. Indications for therapy and/or surgery include pain, easy fatigability, recurrent thrombophlebitis, external bleeding, external appearance of the leg(s), and complications of varicose veins such as dermal atrophy, hemorrhage, ulceration, and cellulitis. Contraindications to treatment include pregnancy during the first and second trimesters, significant leg edema, arterial occlusive disease, and immobility. Using the #15 knife blade, the surgeon makes a small transverse incision in the upper thigh above the location of the proximal portion of the saphenous vein. 2. The incision is carried down to the saphenous vein. Bleeders are cauterized or clamped and tied with silk ties. A Weitlaner self-retaining retractor is placed. 3. The proximal end of the vein is mobilized with sharp and blunt dissection. While dissecting upward, the surgeon ligates vein branches by double clamping, cutting, and tying with silk ties and/or with hemoclips. 4. At the junction with the femoral artery, the saphenous vein end is double clamped and cut, but not tied. One clamp is removed. 5. The surgeon moves to the distal saphenous vein in the ankle region and makes a transverse incision over the saphenous vein. Procedural Consideration: A new #15 knife blade should be loaded on the knife handle for the surgeon to use. Another Weitlaner retractor is placed to expose the surgical site. 6. The incision is carried down to the saphenous vein, which is double clamped and cut but not tied. 7. The clamps are removed and the vein stripper is inserted into distal opening of the saphenous vein at the ankle and advanced to the proximal end. Just before the stripper comes through the opening at the proximal end, the clamp that was left in place is removed (Figure 23-18). The surgeon or surgical technologist screws the acorn onto the exteriorized end of the stripper. The surgeon tightly ties a large-diameter silk tie around the vein and stripper just below the acorn. 9. The surgeon pulls the stripper back toward the ankle, which inverts and strips the ankle from the leg. Procedural Consideration: As the surgeon is pulling the stripper, he or she may have the surgical technologist follow along and apply external pressure to keep the stripper and vein from excessive movement within the leg. 10. The surgeon pulls the stripper back toward the ankle, which inverts and strips the vein from the leg. The proximal saphenous vein remnant is either tied off with a heavy silk tie or stick-tied with a 5-0 polypropylene suture. 11. Both surgical sites are closed in layers, sterile dressings applied, and either a compression stocking or elastic wrap is applied to the entire leg.

Nuss Pectus Excavatum Repair by VATS Procedure

e most common congenital deformity of the chest is a funnel-shaped, asymmetrical depression due to a posterior displacement of the sternal body, referred to as pectus excavatum (funnel chest). The deformity usually affects 4 to 5 ribs on each side of the sternum. In extreme cases, the sternum may even reach the vertebral column. The cause of the abnormal growth of the costal cartilage and sternum is not known, but its occurrence along with Marfan's syndrome and/or kyphosis is common. Symptoms include bronchospasm, exercise intolerance, dysrhythmias, chest pain, and dyspnea. Surgical repair before the age of 5 years produces the best results. Treatment is for aesthetic and psychological reasons as well as restoration of normal respiratory functions in extreme cases. After draping the patient, the surgeon will place a template on the chest of the patient and bend it to the desired shape. The pectus bar is placed on the template, and in the pectus bar bender to bend the pectus bar to match the shape of the template. *The surgical technologist should place the bended pectus bar in a safe place on the back table until needed. If the pectus bar were to fall on the floor, the surgeon will most likely want a new bar to bend because the bar that fell on the floor could have scratches.* Using a #15 knife blade, two bilateral 2.5-cm incisions are made at the previous skin marks A tunnel is made just below the skin from both incisions toward the marks that were made on each rectus ridge. The anesthesia provider collapses the right lung and the thoracoscope is inserted two intercostal spaces below the right lateral incision. The thoracoscope is advanced subcutaneously to the pectus ridge. The pectus bar introducer is inserted through the right-side incision and advanced across the mediastinum until the tip appears through the left-side incision. The umbilical tape is tied to the introducer and it is slowly pulled back, out left to right. *The umbilical tape will be used to guide the pectus bar through the tunnel.* The umbilical tape is untied from the introducer and tied to the pectus bar on the right side. The pectus bar is advanced through the tunnel right to left under the sternum.*The pectus bar is inserted with the convexity facing posteriorly.* The umbilical tape is untied from the pectus bar. The pectus bar plate flipper is used to turn the pectus bar into position, which raises the sternum and anterior chest wall into the desired anatomic position. The distal ends of the pectus bar lie along the lateral sides of the chest wall (Figure 22-13B). Stabilizer plates are placed to secure the pectus bar to the chest and prevent migration. The plates are either sutured together with a large-diameter nonabsorbable suture, #2 or #3 steel wire, or with the use of a metal bar lock that is placed in a distal hole of the plates. The stabilizer is further secured to the lateral chest wall muscles with several sutures placed through the holes. The pectus bar stabilization is further achieved by the surgeon placing a suture around the bar and ribs. The surgeon performs a final examination of the thorax with the thoracoscope to verify no injury to the pericardium, lungs, and mediastinal structures, as well as no bleeding. Two chest tubes are inserted and the right lung is reexpanded. The thoracoscope is removed. Lateral incisions are closed in layers, including a subcuticular closure. Small dressings are placed.

Carpal Tunnel Release Procedure

Carpal tunnel syndrome is a condition of the hand in which the median nerve is compressed by the transverse carpal ligament. Decompression of the nerve is achieved by incising part of the fibrous sheath of the ligament. A small incision is made on the palmar surface of the hand with a #15 blade on #7 knife handle. 2. Hemostasis is achieved and the transverse carpal ligament is either stretched or cut to release the pressure being exerted on the median nerve. 3. The wound is irrigated and a simple closure is performed. 4. The wound is dressed with initial contact layer and bulky dressing.

Anterior Cervical Discectomy and Fusion (ACDF): Cloward Technique Procedure

Certain spondylitic lesions, some fractures, and procedures for correction of spinal stenosis may require an anterior approach to the spine. Extreme cases require an anterior approach followed by a posterior approach. The anterior approach is especially useful for treatment of spinal stenosis at the cervical and thoracic levels. With cervical disc extrusion, symptoms may be chronic or acute (due to some injury). The patient may experience neck stiffness, soreness, and limited mobility, along with radicular symptoms. Some tenderness may occur over the brachial plexus. The normal curvature of the neck tends to be straightened somewhat in these patients When osteophytes have formed in the foramen, cervical discomfort may occur in episodes over a period of months or years before radicular symptoms become evident. In some instances, radiographs will show narrowing in the disc space, indicating extruded disc, or disc degeneration. Radiographs will also show osteophytes that have formed. There are two primary surgical treatments for cervical disc disease: Decompression of the nerve roots and/or spinal cord with a posterior cervical laminectomy and discectomy. Anterior cervical discectomy and fusion. The anterior approach offers the advantage of a direct approach to the disc space without the removal of the lamina. After the disc is removed, the disc space is filled with cancellous and cortical bone (fusion), usually from the iliac crest. An incision is made over the cervical disc space at the medial border of the sternocleidomastoid muscle with a #10 blade on #3 knife handle, and hemostasis is obtained with electrocautery. 2. The esophagus, carotid artery, and trachea are retracted medially. The periosteum of the anterior cervical vertebral bodies is stripped with a periosteal elevator, and a spinal needle is inserted into the vertebral space. 3. A lateral C-spine X-ray is taken to identify the proper level. 4. An incision is made over the iliac crest, and a bone graft is procured with a Hudson brace and dowel cutter or osteotome and mallet. 5. Blades are chosen for the Cloward self-retaining retractor, and the retractor is placed. 6. An incision is made into the disc space with a #15 blade loaded on a #7 knife handle, and disc material is removed with the pituitary rongeur and sent for specimen. 7. The vertebral spreader is placed into the disc space and opened to the desired width. Additional disc material is removed with small curettes, angled and straight. Procedural Consideration: A caliper may be used to ensure the vertebrae are distracted to the proper distance. 8. The depth of the intervertebral space is measured, and the cervical drill guard is inserted into the space. A hole is drilled into the guide with the Cloward drill on Hudson brace, and the drill and guide are removed. 9. The bone dowel is trimmed for size with the air drill and rongeur and placed into the disc space. The vertebral spreader is removed, and the bone graft is inspected for proper positioning. Procedural Consideration: An impactor and mallet are typically necessary to properly place the bone graft within the disc space. 10. The retractors are removed, and the wound is irrigated and closed in layers. Procedural Consideration: A lateral cervical X-ray may be obtained before closure to ensure proper bone graft placement. 11. The incisions are dressed with inner contact layers, 4 × 4 pads, and an ABD for the iliac crest.

Anterior Thoracic Decompression Procedure

A thoracotomy approach is popular for discectomies in the thoracic region because of the small diameter of the thoracic spinal canal. An alternative approach is the removal of the medial segment of a rib and transverse process to expose the intervertebral disc. For these procedures, the rib is often used as autograft bone material and is packed into the disc space after the disc and cartilage plates have been removed and the vertebral bodies have been curetted. An anterior/posterior thoracic approach may be utilized for the placement of rods and pedicle screws. The patient is first placed in a lateral thoracic position for the anterior approach, and a thoracic surgeon exposes the vertebral bodies through a thoracotomy. Screws and rods or fusion material is placed and secured, and the wound is closed in layers in the usual manner. The patient is then turned onto the Wilson frame to a prone position, prepped, and redraped. The posterior thoracic spine is exposed in the usual manner. A thoracotomy incision is made and the latissimus dorsi and other muscles are transected. Procedural Consideration: A rib may be resected with a rib cutter to gain exposure. 2. The parietal pleura is opened and a thoracotomy retractor is placed. 3. A localization X-ray is taken to verify correct level. 4. The parietal pleura is cleared with blunt dissection. 5. Segmental vessels are ligated as necessary with hemoclips and transected to mobilize the aorta. 6. Discectomy, decompression, or fusion is performed. 7. The wound is irrigated and a chest tube is placed. The ribs are reapproximated with a Bailey and sutured with heavy absorbable suture. 8. The fascia and subcuticular layers are closed in routine fashion.

Craniotomy for Aneurysm Repair Procedure

Aneurysms are weak spots in the walls of arteries that over time will balloon out from the arterial wall, causing them to thin sufficiently. They can rupture, causing severe bleeding in and around the brain. Patients with cerebral aneurysm are generally asymptomatic until rupture unless the defect is large enough to press on surrounding structures, such as the optic chiasma or optic nerves. If the aneurysm ruptures, the patient will typically present with signs of meningeal irritation, focal signs of cerebral damage, and uniformly bloody spinal fluid. Cerebral aneurysms are typically found at points of bifurcation in the arteries of the circle of Willis. More than 85 percent of aneurysms occur in the carotid circulation, 30 percent of these arising from the internal carotid near the origin of the posterior communicating artery. Others arise from the anterior communicating artery, and some are positioned at the first major branch point of the middle cerebral artery. They often occur in multiples, and vary in size from a small pea to a plum. The goal of surgical treatment for cerebral aneurysm is to isolate the aneurysm from the parent vessel by placing a specially designed clip across the neck of the aneurysm. If the aneurysm cannot be clipped in such a manner, the sac of the defect may be reinforced with synthetic materials such as polymethyl methacrylate or mesh gauze, or one of the feeding vessels may be ligated. The scalp and bone flaps are turned, and the dura is opened and retracted with dural sutures. Procedural Consideration: Follow the steps listed for craniotomy for entry into the cranium. 2. The Sylvian fissure is split by bipolar cautery dissection for separation of the frontal and temporal lobes. 3. Brain spoons are placed and secured to the Leyla-Yasargil or Greenberg self-retaining retractor. The optic nerves and optic chiasma are visualized. 4. The operating microscope is brought in and positioned, and the feeding vessels and the neck of the aneurysm are exposed with microsurgical dissection of surrounding structures. Procedural Consideration: Aneurysm clip appliers should be ready for loading and temporary clips should be available for use. Aneurysm clips will be selected at this time. 5. A temporary aneurysm clip may be utilized to test eventual placement of a permanent clip or to occlude the parent vessel if rupture occurs and the neck of the aneurysm cannot be visualized for clip placement Procedural Consideration: Papaverine may be necessary to prevent vasospasm. 6. After the patient's blood pressure has been lowered by the anesthesiologist, an angled, curved, or straight aneurysm clip is applied across the neck of the defect. Procedural Consideration: Once an aneurysm clip has been opened, it cannot be closed and used again. 7. The blood pressure is slowly raised, and the clip is checked for proper positioning and leakage. If necessary, an intraoperative angiogram can be performed with a C-arm. 8. The dura is closed, a drain is placed, and the bone flap and scalp flaps are secured in the usual manner. Procedural Consideration: Follow closure steps for craniotomy.

Arteriovenous Fistula and Shunt Procedure

As the axillary artery enters the brachial region of the arm, it becomes the brachial artery, which continues along the medial side of the humerus. The major branch of the brachial artery is the deep brachial artery, which serves the triceps muscle. At the end of the elbow, the brachial artery divides into the medial ulnar and lateral radius arteries. The largest branch of the radial artery is the radial recurrent artery, which supplies the elbow. The branches of the ulnar artery are the anterior and posterior ulnar recurrent arteries. The ulnar and radial arteries pass anteriorly to the palm, where branches fuse to form palmar arches. From these arise palmar digit arteries, which supply the fingers and thumb. The superficial tissues of the upper extremities are drained by the cephalic and basilic veins. The cephalic vein courses along the lateral side of the arm from the hand to the shoulder, eventually emptying into the axillary vein. Arteriovenous fistula and shunt is established for vascular access for patients who require long-term renal dialysis. This is commonly accomplished by utilizing the radial artery and cephalic vein. Using a #15 knife blade, the surgeon makes the incision over the radial artery and cephalic vein in the forearm. 2. The incision is carried down to the vessels, which are identified. The vessels are mobilized for the length of the anastomosis and vessel loops are placed. 3. Small vascular clamps or bulldog clamps are placed proximally and distally on each vessel. 4. Branches that are near the site of anastomosis in both vessels are identified, doubly clamped, cut, and tied. 5. Using the #11 knife blade, the surgeon makes an arteriotomy in the radial artery, which is slightly extended with the 45 degrees Potts-Smith scissors. 6. The radial artery is dilated with the DeBakey or Garrett vascular dilators. Procedural Consideration: The surgical technologist should have the dilators lined up in order of size (smallest to largest diameter) and communicate the size of the dilator to the surgeon when handing to him or her. 7. The cephalic vein is doubly clamped, cut, and tied distally. 8. Using the #11 knife blade, a venotomy is made in the cephalic vein. 9. Using continuous suture technique, the radial artery is anastomosed to the cephalic vein (Figure 23-19). Procedural Consideration: Just before the last 2 to 3 stitches are placed, the surgeon will inject a small amount of heparin into the area of the anastomosis. 10. The area is thoroughly irrigated with antibiotic irrigation solution and the anastomosis checked for bleeding. 11. The wound is closed in layers and dressing placed. The area of the anastomosis is gently palpated to confirm blood flow.

Ulnar Nerve Transposition Procedure

At the elbow, the ulnar nerve travels through a tunnel of tissue (the cubital tunnel) that runs under the medial epicondyle of the elbow. This is commonly referred to as the "funny bone." Beyond the elbow, the ulnar nerve travels under muscles in relation to the ulna. As the nerve enters the hand, it travels through another tunnel (Guyon's canal). The ulnar nerve gives feeling to the little finger and half of the ring finger. It also controls most of the little muscles in the hand that help with fine movements, and some of the bigger muscles in the forearm that create a strong grip. Ulnar nerve pain can be relieved with surgical intervention from two different surgical procedures. Ulnar nerve decompression is accomplished by cutting the ligament of Osborne where the nerve passes through the medial aspect of the elbow. Ulnar nerve transposition is an actual relocation of the ulnar nerve to a slightly more anterior location in the elbow. A long incision is made over the ulnar nerve. 2. The nerve is dissected free from the surrounding soft tissues with Metzenbaum scissors and hemostatic forceps. 3. Moist umbilical tapes, vessel loops, or Penrose tubing is passed around the freed segment of the nerve to aid in handling it for further dissection until the satisfactory length of nerve has been freed. 4. The muscle and fascia entered by the nerve at each end may be slit with scissors to prevent kinking of the nerve at these points. 5. A fascial flap overlying the medial epicondyle of the humerus is cut and elevated. The nerve is transposed beneath it. 6. The fascia is loosely reapproximated to the fascial edge remaining on the epicondyle. 7. The wound is closed in layers.

Augmentation Mammoplasty Procedure

Augmentation mammoplasty is performed to increase the size of the breast or create a new breast post-mastectomy. The surgeon marks the circumferential incision with the marking pen. The local anesthetic is injected. The incision is made along the inferior border of the areola with the #15 knife blade. The subcutaneous tissue is dissected toward the inferior border of the breast. The pocket for the implant is created just under the existing breast tissue or beneath the pectoralis muscle. The subpectoral pocket may provide better long-term support of the prosthesis (Figure 19-31). *The surgeon may use the fiberoptic retractor during this step of the procedure. Steps 1 to 5 are repeated on the opposite breast.* The implant sizers are inserted into the pockets and inflated with saline to determine the final size of implants. The circulator will elevate the OR bed to raise the patient into a sitting position to allow the surgeon to evaluate the appearance and identify adjustments that should be made to the implants and/or pocket. The implant sizers are removed and pocket adjustments made if necessary. The surgical technologist confirms the size of implants with the surgeon and communicates the information to the circulator, who facilitates transfer of the implants to the sterile field with the surgical technologist. *While the implants are being transferred to the sterile field, the surgeon will irrigate the pocket with the saline-antibiotic irrigation solution using the bulb syringe.* The surgeon rolls up the implant, inserts into the pocket, unrolls, and positions it. The surgical technologist provides the surgeon with a saline-filled syringe to fill the implant. The inferior border of the breast tissue is sutured to the pectoralis fascia and the periareolar incision is closed using a subcuticular running stitch. 4 × 4 dressing sponges are placed and postsurgical bra is used to provide support.

Craniectomy for Steriotactic Procedures

Craniectomy is the permanent removal of a section of the cranium using a burr hole to gain access to underlying structures. Allows for the precise localization of subcortical targets without creating large scalp and bone flaps. Intracranial masses (tumor, hematoma, abscess) and vascular malformations (arteriovenous malformations) can be successfully treated using stereotactic techniques. Biopsy of intracranial tumors for treatment planning has been the primary focus of this technique, but stereotactic techniques are currently being utilized for the surgical treatment of movement disorders such as Parkinson's disease. Skull clamp is placed and an image-guided navigation arm is attached to the skull clamp. Procedural Consideration: This provides a fixed reference point. The arm should be out of the way for the surgical team to ensure it will not be bumped from its fixed point, disrupting the navigation system. 2. The location of the fiducials is registered onto the computer, allowing the computer to align the preoperative images. The monitor shows the location of the navigation probe. 3. After the registration process is complete, the fiducials are removed and the area is prepped and draped for surgery. 4. An incision is made in the scalp with a #15 blade down to the skull The scalp is retracted with a small, self-retaining retractor or scalp clips (Figure 24-26B). 6. The periosteum is retracted with a periosteal elevator. 7. A drill is used to create a burr hole. 8. The burr hole is enlarged with a Kerrison rongeur (Figure 24-26C). 9. The dura is elevated with dural hook and incised with a #11 blade (Figures 24-26D and 24-27). Hollow cannulas, coagulating electrodes, cryosurgical probes, wire loops, and other biopsy instruments may be introduced to repair or excise a pathological condition. 11. Wound is closed in layers. Procedural Consideration: The bone is not replaced after a craniectomy.

Cranioplasty Procedure

Cranioplasty is performed to repair defects in the skull, resulting from a previous cranial procedure, trauma, or congenital anomaly. Cranioplasty is also performed to relieve headache, prevent secondary injury to the brain, and for cosmetic effect. If cerebral edema or infection is a concern after craniotomy, the bone flap may not be replaced in the cranium immediately. Also, a flap can be removed to relieve intracranial pressure. The flap can be sterilized and stored in a bone bank within the facility or stored under the subcutaneous layer in the patient's abdomen for future placement. Refer to the craniotomy section for the procedure to reattach the bone flap using microplates and screws. Titanium mesh and/or methyl methacrylate are the most common materials used for cranioplasty. The scalp flap is incised over the defect as for a craniotomy. 2. If additional bone fragments exist due to injury, they are removed with a rongeur. Procedural Consideration: The surgical technologist should have a laparotomy sponge ready to clean the rougeur. Bone fragments should be kept for specimen. 3. The edges of the defect are trimmed to form a saucer-like ledge using rongeurs. Procedural Consideration: See Step 2. 4. Wound is irrigated with warm saline solution. Procedural Consideration: The surgeon may also use antibiotic irrigation. 5. The methyl methacrylate is prepared and dropped into a sterile bag. The wet cement is molded over the cranial defect. 6. The cement is removed from the defect to allow for it to harden. Procedural Consideration: Cool saline should be used on the plate while exothermic reaction takes place. 7. Once cool, excess material is trimmed away from the plate with bone rongeurs or cut with a saw. 8. A craniotome is used to smooth the edges and allow the plate to blend gradually with the skull. 9. Holes are drilled in the plate and periphery of the skull defect. Sutures or small stainless steel wires are used to secure the plate. 10. The wound is irrigated and closed in routine fashion.

Craniosynostosis Repair Procedure

Craniosynostosis is a premature closure of the cranial sutures of an infant. These sutures should remain open up to the age of 2 to allow for brain expansion. If the sutures fuse too early, the brain may be damaged because of insufficient space for growth. The sagittal suture is the most commonly affected suture, creating a long and narrow skull. Bilateral coronal suture craniosynostosis creates a short, high head. Unilateral coronal suture involvement flattens the frontal bone and orbit. Surgical intervention involves a linear strip craniectomy. An incision is made midway between the anterior and posterior fontanelles from ear to ear posterior to the pinna. 2. The scalp is elevated off the skull with the periosteal elevator. Procedural Consideration: Care is used to leave the pericranium attached to the skull to minimize bleeding. 3. A burr hole is made using the Midas Rex. Procedural Consideration: The surgical technologist should irrigate the drill during use. 4. A craniotome is used to cut anteriorly to the anterior fontanelle on each side of the sagittal suture. 5. A Leksell rongeur is used to cut across the sagittal suture and connect the burr holes. Procedural Consideration: A sponge should be available to collect bone fragments from rongeur. 6. A Cobb periosteal elevator is used to dissect the sagittal suture off the underlying dura. 7. A burr hole is placed at the asterion on each side. The craniotome is used to make a cut just posterior to the coronal suture. 8. The parietal bone is fractured, leaving the periosteum intact. 9. The skin is closed with 3-0 and 4-0 absorbable sutures.

Intra-aortic Balloon Pump (IABP) Procedure

For patients who need cardiac support because they are waiting for cardiac transplantation or cannot be weaned from CPB, mechanical devices designed to assist in circulatory functions may be utilized. The mechanical device designed for circulatory support after cardiac procedures is called an IABP. Insertion of the balloon pump may increase cardiac output to a level that would permit separation from the pump oxygenator and allow time for the heart to recover. To be completely effective, the IABP must lower left ventricular pressure during systole (when the balloon is deflated) and increase coronary artery circulation during diastole (when the balloon is inflated). After percutaneous needle/cannula assembly placement into the femoral artery, a guidewire is threaded through the arterial cannula and the cannula is removed (Figure 22-26A). The artery is dilated to a 12 Fr diameter with plastic, graduated dilators threaded over the guidewire (Figure 22-26B). 3. A balloon sheath/dilator assembly is inserted over the guidewire, and the dilator is removed (Figure 22-26C). 4. The IABP catheter with a large balloon wound tightly around the distal end is inserted through the sheath and advanced slowly to a position just distal to the left subclavian artery (Figure 22-26D). 5. The balloon is unwound and the catheter is attached to the pump. The pump is then activated (Figure 22-27).

Decortication of the Lung Procedure

If blood or pus from a chest injury is not properly drained from the pleural cavity, it coagulates and forms a fibrin layer over the visceral and parietal pleura that interferes with the proper expansion of the lung. The condition is called empyema. The main goal of decortication is to restore the normal lung function. Two other goals include controlling infection, such as in the case of empyema, and prevention of deformity. If not treated, deformity can occur in the chest and spine of adolescents. A posterolateral incision is made in the fifth or sixth intercostal space. The incision is carried through the subcutaneous and muscle layers using the #15 knife blade and ESU. The fifth or sixth rib may or may not be stripped and removed, depending on the extent of the disease process. The rib retractor is placed and opened. The lung is inflated to visualize the extent of the entrapment. Using the #15 knife blade, the fibrin layer is incised. The dissection is performed with long Metzenbaum scissors and vascular forceps, blunt dissection with the finger, and Kitner sponge. The dissection is completed in the following manner: superior to inferior; medially to the superior vena cava, esophagus, and aorta; inferiorly and medially to the diaphragm and phrenic nerve. *During the dissection, extra care is taken to avoid injuring the subclavian vessels and phrenic nerve. It is important that the diaphragm be included in the dissection; if it is not included, it defeats the purpose of the decortication procedure in allowing the lung to fully expand. Additionally, injury to the phrenic nerve is avoided in order to prevent the paralysis of the diaphragm. The dissection can be a tedious process, and the surgical technologist must remain alert and vigilant throughout the procedure.* Upon completion of the dissection, the anesthesia provider will inflate the lung again in order for the surgeon to check for air leaks and hemorrhage from the lung. The rib retractor is removed, two chest tubes are placed, and the posterolateral incision is closed in layers.

Scleral Buckle Procedure

Medial to the central fovea is the optic nerve. This area of the nerve contains no rods or cones; therefore, vision is absent, and it is referred to as the blind spot: Retinal detachment occurs when the liquid in the vitreous cavity passes through a retinal tear, separating the retina from the choroid. Vision is lost wherever the retina becomes detached. Eventually, the entire retina will detach and all useful vision in the eye will be lost. Eye speculum is inserted and conjunctiva is incised with Westcotts around the limbus.* Be sure to intermittently irrigate the cornea with BSS.* Blunt-ended scissors such as small tenotomies are used to separate the conjunctiva from the sclera. An ophthalmic swab is used to clear any adherent tissue. Rectus muscles are tagged using 2-0 or 4-0 silk sutures (or surgeon's preference suture) and sutures are secured by using a mosquito hemostat (Figure 16-17). All four recti are tagged to allow the globe to be rotated in any direction during the surgical procedure.* The surgical technologist will be required to steady the globe in the required position by using the tag sutures.* The handheld lenses and headlight will be used to visualize the interior of the eye and check for holes or tears in the retina. The cryoprobe is used to seal any tears. Diathermy may also be used for the same purpose, but cryotherapy has become the preferred method The explant usually consists of a silicone or Silastic band, with or without a silicone sponge. The chosen explants are soaked in an antibiotic/saline solution. A mattress suture of 4-0 or 5-0 nylon is placed in each quadrant to hold the band in place. the patient may receive an injection of intraocular gas to create pressure on the retina while subretinal fluid is reabsorbed and scars form. Gases that may be used include C3F8 and SF6. Posterior cavity using a 27-gauge needle, or may be delivered by the vitreoretinal system via an infusion canula. An injection of antibiotic (such as vancomycin) and/or corticosteroids may be administered subconjunctivally.

Mediastinoscopy Procedure

Mediastinoscopy is performed for the evaluation of nodal involvement or mediastinal masses in patients with lung carcinoma. Typical of the lesions found within the mediastinum are thymomas, lymphomas, and germ cell tumors. Mass lesions tend to be enterogenous cysts, lymphomas, neurogenic tumors, and pleuropericardial cysts. The most common tumors found within the mediastinum of children are neurogenic tumors; in adults, thymomas and lymphomas appear most frequently. Complaints typically include cough, dyspnea, and chest pain. Symptomatic lesions are malignant in 60 percent of all patients. Using a #15 knife blade, the surgeon makes a 1- to 2-cm transverse incision just above the suprasternal notch and carried down to the platysma muscle. Dissection is continued through the pretracheal fascia until the trachea is exposed. Using blunt dissection, the surgeon creates a tunnel along the trachea into the mediastinal space. The mediastinoscope is inserted and advanced through the tunnel into the space. The surgeon visualizes the lymph nodes, tracheal bifurcation, and bronchi Using the tissue biopsy forcep, the surgeon excises lymph node tissue specimens. The mediastinoscope is removed. The platysma muscle is closed with interrupted absorbable sutures. The skin is closed with interrupted nonabsorbable sutures or skin staples. A small dressing is applied.

Nipple Reconstruction Procedure

Nipple reconstruction may be performed at the time of breast reconstruction. However, some surgeons prefer to wait until the breast tissue from the reconstruction procedure has healed, swelling has disappeared, and reconstructed breasts are in normal anatomical position. The procedure is usually performed 8 to 10 weeks post-reconstruction. The surgical technologist should confirm the graft site with the surgeon. An FTSG will be taken. Surgeon outlines the incision with the marking pen. The nipple design is composed of two wing flaps and a central flap. Procedural Consideration: The width of the two wing flaps determines the length of projection of the new nipple and the diameter of the central flap determines the diameter and top of the new nipple. The wing flap design permits primary closure and the central flap for forming the tip of the nipple, as well as providing a circular site for wrapping the wing flaps into place. The base of the central flap must not be divided, since the blood supply to this flap is from the underlying subcutaneous tissue. Using the #15 knife blade, the wing flaps are elevated from the subcutaneous tissue (Figure 19-34A). *Some fatty tissue is left on the underside of the wing flaps.* The donor sites are closed, leaving the wing and central flaps on the outside. The wing flaps are wrapped around the central flap, creating the nipple (Figure 19-34B, C). A paper template of the nonoperative breast's areola circumference is prepared. The template is centered on the new nipple and the circumference is marked (Figure 19-34D). The inner portion of what will be the new areola is deepithelialized from the areolar border to the center toward the new nipple using the #15 knife blade. Using the dermatome knife, an FTSG is taken from the upper inner thigh or labial fold. The graft is cut to size and secured using interrupted sutures The surgeon mixes the tattoo ink to achieve the desired color and, using the tattoo equipment, creates the areolar tattoo. The graft is held in place with a nonadherent dressing.

Ventriculoscopy Procedure

Patients considered for ventriculoscopy have enlarged lateral and third ventricles and normal-sized fourth ventricle. Contraindications for the procedure include age (younger than 6 months; however, studies are being conducted on the effectiveness of ventriculoscopy on infants younger than 6 months). Cause of hydrocephalus Previous shunt placement, which can cause small ventricles Meningitis The scalp incision is made and a 6-10-mm burr hole is created. 2. The dura mater is opened. 3. A #14 French peel-away catheter is used to cannulate the lateral ventricle. The stylet is removed, and the two peel-away tabs of the catheter are peeled downward and secured to the drapes, usually with staples to stabilize the catheter and prevent it from penetrating deeper into the ventricle. Another alternative is the use of an endosopic sheath with trocar. After insertion, the sheath is held in place with two Leyla retractor arms. 4. The endoscope is passed through the sheath into the lateral ventricle. 5. The scope is maneuvered into the third ventricle and the basilar artery is identified. 6. At this point, the surgeon may perform a ventriculostomy to reestablish the free flow of cerebral spinal fluid between the ventricles and subarachnoid space. 7. A wire is inserted through the 2-mm working channel of the scope and used to create the initial opening in the floor of the third ventricle. 8. The wire is removed and the #3 Fogarty balloon catheter is inserted through the opening in the floor. The balloon is slightly inflated to widen the opening/stoma to approximately 5 mm. 9. The endoscope and sheath are removed. 10. Gelfoam is packed into the burr hole and the scalp is sutured.

Microdecompression Endoscopic Spinal Discectomy Procedure

Performed for the same reason as an open lumbar laminectomy: decompression of an injured spinal disc. With the help of standard X-rays, fluoroscopy, and endoscopic instruments, the disc is removed and/or shrunk with the use of a laser. The procedure can also be performed for the removal of bony spurs. Advantages of the procedure include: Small incision No traumatic muscle dissection No bone removal No bone fusion No manipulation of the nerves in the area Minimal X-ray exposure No hospitalization required No postoperative scarring in or around the nerves Patient can begin exercise program on the day of the procedure. Cost of procedure is approximately 40 percent less than an open lumbar laminectomy. High success rate; approximately 90 percent of patients experience permanent pain relief. Local anesthetic is injected. 2. Skin incision is created with #15 blade. 3. Using X-rays, fluoroscopy, and endoscopic imaging for guidance, a small-diameter tube is inserted through the skin incision. 4. A variety of surgical instruments can be inserted through the tube, including the endoscope, micro-forceps, curettes, and discotome. 5. Using the discotome, the surgeon removes disc material to decompress and relieve the pressure on the nerve root. 6. The laser probe is used to shrink, tighten, and burn away other portions of the disc. 7. A probe is used to suction out small pieces of disc material. 8. The hollow tube is removed and a small bandage is applied over the incision.

Centralization of Radial Dysplasia Procedure

Radial dysplasia or hypoplasia is a congenital defect commonly referred to as "club hand" and is often seen in conjunction with deformities of the thumb ranging from hypoplasia to complete absence of the radius. Due to the failure of the radius and adjacent soft tissues to fully develop, the hand is medially deranged. The degree of derangement is determined by the size or absence of the radius. There are four classifications, based on the degree of deformity Type I: Elbow and proximal radius are normal; distal radius physis is deficient and radius is abnormally short; soft tissue contractions limit motion; thumb may show varying degrees of hypoplasia. Type II: Hypoplastic radius; unstable wrist and radially deviated Type III: Partial absence of radius Type IV: Most common type; complete absence of the radius, often accompanied by absence of the radial carpi and first and second metacarpals. Elbow might be stiff. There might be severe soft tissue contractures on the radial and volar side of the wrist and, if not treated, the contractures worsen with age and growth. Repair of radial dysplasia is a complicated procedure and, depending on the extent of the deformity, may require an orthopedic and plastic surgeon to perform the procedure. Five types of surgical procedures have been developed to correct radial dysplasia: soft tissue release; centralization (procedure performed most often and described here); replacement of the deficient radius; tendon transfer; arthrodesis. Using the #15 knife blade, the surgeon makes a radial Z-plasty incision along the fold between the hand and forearm.* The incision allows for Z-plasty closure of the skin.* The median nerve is identified and preserved at the skin fold at the wrist. Using the #15 knife blade and/or tenotomy scissors, the contracted fibrous bands are released to allow passive correction of the carpus that are centered over the ulna. A second incision is made beginning dorsally at the midline of the wrist and continues ulnarly in a transverse direction to the volar midline.*This incision exposes the carpus and allows the surgeon to excise the redundant ulnar tissue.* The flexor carpi ulnaris muscle and ulnar nerves are identified in order to avoid injury to the structures. The carpus is exposed by a transverse arthrotomy with the #15 knife blade and extra fibrous tissue is excised from the ulnocarpal joint. The distal ulna is squared off using the #15 knife blade and rasp, and inserted into a rectangular notch that has been created on the radial side of the carpus for centralization.*If the centralization cannot be achieved, the surgeon will examine the surgical site for additional contracted radial tissue to be excised. In severe cases of deformity, to affect centralization the surgeon may need to perform carpectomy and shave some bone off the distal ulna epiphysis but avoid damage to the growth plate.* Soft tissue stabilization is performed by distal advancement of the extensor carpi ulnaris insertion and transfer of the flexor carpi ulnaris to the dorsum. A Kirschner wire (K-wire) is inserted through the carpus and third metacarpal into the ulnar shaft to reduce the wrist and hold it in position (Figure 19-25B).* If the ulnar bowing is more than , a diaphyseal osteotomy is performed at the top of the deformity and the position of the osteotomy is maintained by the same K-wire used to maintain the centralization. The surgeon may need to use additional K-wires to aid in stability.* The surgical wound is thoroughly irrigated and the skin closed with interrupted sutures. The patient is placed in a restrictive dressing that may include a splint or cast.

Positioning Oral and Maxillofacial Surgery (6 total)

Supine= Plate and Screw Fixation of Mandibular Fracture, Orbital Floor Fracture Repair, Le Fort I Fracture Repair, and Le Fort II and III Fracture Repair Patient is supine, with head tilted back to provide exposure; a roll towel may be placed to aid in slightly extending the neck; A donut or foam headrest may be used for stabilization; Tuck arms at patient's sides; protect ulnar nerves; Patient prep may not be required for oral procedures. Facial procedures may require prep with mild antiseptic; the eyes and ears should be protected from contact with the prep solution=Tooth Extraction/Odontectomy Patient is supine, with head positioned to provide maximum exposure. A donut or foam headrest may be used for stabilization. Tuck arms at patient's sides; protect ulnar nerves. The controls on the power equipment must be in the "safe" position when preparing the tool for use or when it is not in operation; The surgeon will typically stand at the head of the OR bed; The OR bed should be reversed to create knee room if the surgery is performed in a sitting position, and the bed should be turned to allow free movement around the head close enough to accommodate the anesthesia provider= Application of Arch Bars

Keratoplasty (Corneal Transplant) Procedure

Replacing cloudy or damaged corneal tissue with healthy donor tissue through a corneal transplant will correct the vision. There are many causes of clouding of the cornea, including ____ Eye injuries that leave a dense white scar on the cornea. These injuries may be due to penetrating wounds or burns from fire or chemicals. Severe bacterial, viral, or fungal corneal infection that leads to corneal scarring (various herpes viruses are known to cause such scarring). Corneal dystrophies Inherited diseases of the cornea Cataract or other eye surgery The medium is poured into a sterile medicine glass and the donor tissue is placed on a punching block with a concavity that conforms to the anterior corneal curvature. Calipers are used to verify the correct size of the donor cornea. The endothelial surface is placed facing upward. The donor cornea is punched using a Cottingham punch to the correct size for placement. A punch of slightly greater diameter than the punch used for the patient's host eye is used for the donor cornea. The eyelids are retracted and 4-0 silk traction sutures are placed at the insertions of the superior and inferior rectus muscles and clamped to the surgical drape using a mosquito. *These sutures are used to fix and steady the eye while the graft bed is prepared. If a cataract is present, the surgeon can remove it in addition to the corneal transplant operation. If an artificial lens is already in place and it is believed to be responsible for the clouding of the cornea, the artificial lens can be replaced with a type of lens less likely to irritate the donor cornea tissue.* A Fleringa ring is sutured on the patient's eye with a 5-0 or 6-0 nylon to stabilize the eye. The surgeon may choose to use a radial marker to create spoke-like guidelines on the eye. A trephine is placed on the cornea and is used to make the corneal cut around the cornea and into the anterior chamber. *If the trephine cut is complete, the cornea is removed; if incomplete, corneal scissors or a diamond knife will be used to finish the cut.* If necessary, the anterior chamber may be irrigated with the irrigation/aspiration handpiece and Phaco machine. The edge of the donor corneal disc is slid from its silicone base, laid in the trephine opening, and placed in position. The transplant is gently held in place while 10-0 nylon sutures are used to suture the graft in place. After the graft is sutured in place, BSS or acetylcholine solution is injected into the anterior chamber through a fine cannula (30 gauge) at the graft margin. Antibiotic drops are instilled and the traction sutures removed. The eye is covered with antibiotic-impregnated gauze, an eye pad, and a shield.

Rhizotomy Procedure

Rhizotomy is a surgical procedure to sever nerve roots in the spinal cord. The procedure effectively relieves chronic back pain. For spinal joint pain, a facet rhizotomy may provide lasting low back pain relief by disabling the sensory nerve at the facet joint. Rhizotomy is also performed on patients with spasticity that is insufficiently responsive to oral medications or injectable therapies. It is commonly performed on patients with lower extremity spasticity that interferes with walking and on children with cerebral palsy. A 1- to 2-in. incision is made over L1. 2. A laminectomy is performed to gain access to the spinal cord and spinal nerve. 3. Ultrasound and X-ray technology is used to locate the tip of the spinal cord to find the natural separation of the sensory and motor nerves. 4. A special rubber pad is then placed to provide a division between these two nerve sets. The sensory nerve roots are tested and selectively eliminated; they are placed on top of the pad while the motor nerves will remain beneath the pad for their protection. 5. Once the sensory nerves have been exposed they are divided into three to five rootlets. These rootlets are then tested with electromyography recording the electrical patterns in the muscles. The severity of the damage is rated from 1 to 4, with the later being the most severe. Rootlets that are severely abnormal are severed, and the procedure is repeated between spinal nerves L2 and S2. 6. When testing and severing of the damaged nerves is complete, the dura mater is closed. A direct application of fentanyl is administered. 7. The wound is closed in layers.

Fixation plates/devices; sizes

Rigid fixation by plates and screws, or screws alone, is the most common repair technique for craniofacial fractures. Bone plates are available in L, Y, H, and T shapes and range in thickness from 0.5 to 3.00 mm. The screws come in diameters of 1.0 to 4.0 mm. The smaller screws are designed for the delicate facial bones; the larger-diameter screws are for placement in the mandible. Implant materials can be absorbable or nonabsorbable. Absorbable implants are of great value in pediatric cases, but other applications are limited. Nonabsorbable implants are most commonly used for facial fractures in adults. Titanium is a strong, lightweight, noncorrosive metal that is used most often in craniofacial procedures. Most fractures require a combination of plates and screws for proper fixation. For example, a four-hole 2.0-mm miniplate and four-hole 2.4-mm direct compression plates can be used together to fixate a symphyseal fracture. Two 2.4-mm lag screws, without a plate, can also be used to fixate the same fracture. The fracture and surgeon's discretion dictate how each one should be fixated.

Suture needles (12 total)

Round bodied, Available with plain collagen and polyglactin, Conjunctival closure Round bodied with cutting tip (taper cut), Initially cuts like cutting needle, minimal trauma, Lacrimal sac and nasal mucosa Reverse cutting (micropoint), Triangular needle with third cutting edge on the outside of curvature, Eliminates possibility of outward tearing while suturing Spatula micropoint, Fine needles with thin flat profile, Corneal and corneoscleral suturing Spatulated, Similar to spatula, Scleral passage in strabismus correction, retinal detachment repair Nonabsorbable suture Monofilament nylon, Strong monofilament; does not support bacterial growth, Corneal incision closure Monofilament polypropylene, Supple nonabsorbable; ties well, Intraocular lens fixation Multifilament polyester-polybutilate coated, Multifilament braided coated with polybutilate for lubrication and smooth passage, Scleral tissue, retinal surgery Braided silk, Tensile strength is high; tissue reaction is less than chromic gut, but more than synthetic sutures, Various Absorbable sutures Plain and chromic gut, Plain maintains tensile strength for 7-10 days; complete absorption is within 70 days. Chromic maintains tensile strength for 10-14 days, with some strength remaining up to 21 days; complete absorption is by 90 days, Various Extruded collagen, Bovine tendon; consistent in strength; absorbs at about the same rate as plain gut, Various Polyglactin (Vicryl), Braided synthetic suture, less irritating than gut, absorbable coating; absorbs in 60-90 days, but retains strength for 30 days, Various

Release of Syndactyly Procedure

Syndactyly, or webbed digits, occurs when the digits of the hands or feet fail to separate. Any combination of two or more digits may be partially or completely connected by a web of skin. It most often occurs in the hand and often bilaterally. The middle and ring finger are the most frequently affected digits of the hand. It may be a simple connection to the skin, or it may be more complex, involving conjoined bone and fingernails (Figure 19-26). But each finger contains its own blood vessels, tendons, bones, and nerves. The surgeon marks the Z-plasty incisions with the marking pen on the volar and dorsal side of the hand. Using a #15 knife blade, the surgeon makes a Z-plasty incision in the interdigital space on the volar and dorsal side of the hand. *The Z-plasty incision allows for maximizing the size of the skin flaps for full coverage of the separated digits in order to reduce the future risk of developing contractures.* The neurovascular bundles are identified and prevented from injury. Using the Metzenbaum or tenotomy scissors, the interdigital fibrous band of tissue is cut and excised, fully separating the digits (Figure 19-27C). *Hemostasis is achieved with the use of the ESU pencil with needle tip.* The full-thickness tissue flaps are slightly undermined with the tenotomy scissors to free up and form large enough flaps to fully cover the digits creating a new interdigital space. The flaps are sutured into place using interrupted sutures (Figure 19-27D). If the flaps do not fully cover the digits, an FTSG will be taken and sutured into place. *The surgeon will use the sterile unexposed X-ray film as a template to place on the exposed area of the digit(s) and draw an outline. The outline is used to cut the FTSG into the shape needed to cover the defect. The fat must be trimmed from the FTSG prior to being sutured into place.* Stent dressings are placed over the FTSGs. A bulky dressing and splint are applied to the arm or a long arm cast.

Strabismus Correction: Recession/Resection Procedure

The ____ ____ of the eye originate from the bones of the orbit and are attached by tendons to the sclera. Various forms of ____ include esotropia, where the affected eye turns medially ("crossed eyes"), exotropia, where the affected eye turns laterally ("wall eyes"), and hypertrophia, where the affected eye turns upward. Recession or resection of the muscles of the eye may be used to correct strabismus. Recession is generally more effective when performed on the vertically acting muscles, and resection has a greater effect on the lateral rectus. A lid speculum is placed for lid retraction. *Intermittently moisten the cornea with drops of BSS.* A radial incision is made from the limbus, level with the upper border of the affected muscle. *Incision is made using a Westcott scissors or disposable eye knife of the surgeon's choice.* Westcott scissors are inserted through this incision to dissect free the conjunctiva from the limbus. A second radial incision is made toward the lower border of the muscle. *This second radial incision forms a flap of conjunctiva-Tenon's capsule that will be dissected further to expose the upper and lower borders of the muscle.* A strabismus hook is introduced beneath the muscle insertion, and is swept backward, freeing the muscle from the sclera, and then forward. Sutures are passed through the muscle for traction using 4-0 or 6-0 Vicryl or silk sutures. Disposable cautery will be needed to control bleeding at this point. After this "flap" of muscle is further developed, the muscle is measured and marked at the points of recession.* A caliper may be used to measure the distance from the original point of insertion to the new one. The sterile marking pen may be used to mark the points of recession.* Two absorbable sutures (6-0 polyglactin) are placed at this point in the end of the muscles. These should be left untied with the needles attached. The tendinous insertion is divided with scissors.* Westcott scissors are used to divide tendinous insertion. A straight mosquito hemostat may be used to compress small blood vessels in the muscle between the suture and the insertion.* The conjunctiva is closed using 6-0 absorbable or 7-0 chromic gut. Antibiotic drops are instilled into the eye, and usually no dressing is required.

Femoropopliteal Bypass Procedure

The femoral artery continues down the medial and posterior side of the thigh at the back of the knee joint, where it becomes the popliteal artery. The popliteal artery supplies a few small branches to the knee joint, then divides into two branches. The first branch, the anterior tibial artery, serves the anterior aspect of the leg and, at the ankle, becomes the dorsalis pedis artery, which serves the ankle and dorsum of the foot. The second branch, the posterior tibial artery, continues down the posterior side of the leg between the knee and the ankle. The posterior tibial artery sends off a large branch called the peroneal artery, which supplies the peroneal leg muscles. At the ankle, it bifurcates into the lateral and medial plantar arteries, which supply the bottom of the foot. Although obstruction in the distal portion of the femoral artery can be adequately bypassed with synthetic graft material, the material of choice remains the autogenous saphenous vein, particularly for more distal obstructions. Veins are composed of the same three layers as arteries, but there are differences in their relative thicknesses. The middle layer of the venous wall is poorly developed, with far less smooth muscle tissue. The tunica adventitia is the thickest layer of the vein, consisting of collagen and elastic fibers, while the tunica intima is much thinner than that of an artery. The lumen of a vein, however, is larger than that of an artery (Figure 23-6). Veins are also equipped with flap-like valves made of thin layers of tunica intima that close if blood begins to back up in a vein. For in situ bypass, the valves of the vein must be stripped for unimpeded flow of arterial blood. The first incision is made over the distal portion of the popliteal artery, extending from the posterior border of the medial femoral condyle to just below the tibial tuberosity. Procedural Consideration: The surgical technologist should keep contact with the exposed leg to a minimum. Weitlaner retractor will likely be used. 2. The saphenous vein is identified and inspected for size and quality and is dissected free with its branches ligated and divided with 4-0 or 5-0 silk ties. Procedural Consideration: The surgical technologist should have synthetic graft material available in case the saphenous vein is inadequate for grafting. 3. The distal popliteal artery is exposed by retracting the tendons of sartorius, gracilis, and semitendinosus superiorly. The gastrocnemius is retracted posteriorly. Procedural Consideration: Retractors for this phase may be U.S. Army, Richardson (small double-ended), Cushing, or vein. 4. The dissection continues distally and the anterior tibial vein is identified, ligated, and divided. Procedural Consideration: The anterior tibial vein is ligated with 4-0 silk ties, 18 in. in length, and/or small or medium-sized hemoclips. 5. A longitudinal incision is made into the groin over the saphenofemoral junction and the proximal portion of the saphenous vein is located, inspected, and dissected free. Procedural Consideration: Dissection is made with Metzenbaum scissors and DeBakey forceps. Handheld and/or Weitlaner self-retaining retractors will be necessary. 6. The tributaries of the saphenous vein are ligated with 4-0 or 5-0 silk ties and small clips. Procedural Consideration: Small, short hemoclip applicators are used with clips from the small (blue) carrier. Handheld and/or Weitlaner self-retaining retractors will be necessary. 7. The common femoral vein is cleared in the area of its junction with the saphenous vein, and a small Satinsky partial-occlusion clamp is applied. Procedural Consideration: The partial-occlusion clamp allows blood flow to continue through the vessel because the clamp is applied to only the top portion of the vessel. 8. The saphenous vein and a small cuff of the common femoral vein are cut free from the saphenofemoral junction. The junction is closed with 6-0 Prolene suture. Procedural Consideration: The 6-0 Prolene is frequently loaded onto a Castroviejo needle holder. 9. The patient is administered systemic heparin. The common femoral artery is exposed and clamped with a DeBakey angled vascular clamp. Procedural Consideration: The femoral artery will be isolated with vessel loops placed proximally and distally. 10. An arteriotomy is performed on the anterolateral portion of the common femoral artery, and the saphenous vein is anastomosed in an end-to-side fashion with a continuous 6-0 Prolene suture. If the valvulotome is used, the vein is reversed prior to anastomosis. Procedural Consideration: Arteriotomy is performed with #11 blade on #7 knife handle and Potts-Smith scissors. 11. The clamp is removed, and blood is allowed to flow up to the first valve. Procedural Consideration: Clamp will be replaced several times as procedure progresses. 12. The distal end of the saphenous vein is transected at the anastomosis site, and a Cartier valvulotome is introduced and passed through the full length of the vein. Procedural Consideration: The valvulotome will remove any valves that may prevent the flow of arterial blood to target tissues. 13. The arterialized saphenous vein is ligated at its distal end, and its medial side is marked to prevent torsion. Procedural Consideration: Marking of the vein is done with a purple marking pen so that the vein is anastomosed without a twist. 14. The knee is flexed and the popliteal artery is occluded with small vascular clamps. Procedural Consideration: Popliteal artery occlusion is usually accomplished with small bulldog vascular clamps or vessel loops tightened around the artery. 15. An incision is made into the popliteal artery and the spatulated saphenous vein is anastomosed with a continuous 6-0 or 7-0 Prolene suture. Before completion of the suture line, clamps are released to flush and the lumen is irrigated with heparinized saline. Procedural Consideration: Rubber shods (Prolene clamps) should be available for all vascular anastomoses. Heparin solution is prepared in advance. 16. The suture ends are tied, and the anastomosis is completed. The wounds are closed in layers. Procedural Consideration: Have the Doppler probe and unit available for post-anastomosis vessel evaluation.

Cleft Palate Repair: V-Y Palatoplasty Technique Procedure

The function of the palate is to separate the nose from the mouth, which is important in swallowing and speech. The anterior portion of the palate is the hard palate that consists of the palatine processes of each maxilla and the palatine bones. It is covered with mucous membrane. The posterior portion is the soft palate and is composed of muscle, fat, and mucous membrane. It terminates with the uvula at the fauces. To understand the pathology, fetal development of the nose and mouth must be understood. The fetal development occurs during the first trimester of intrauterine life. The grooved middle portion from below the nose to the upper lip called the philtrum and the middle curve called Cupid's bow are formed by the joining of the frontal nasal prominence. Bilaterally the lips are formed by the maxillary prominences. The palate is formed from the joining of the central nasal prominence to the right and left maxillary prominences A cleft is a split or a gap between two structures that are normally joined. Cheiloschisis (cleft or hare lip) and palatoschisis (cleft palate) are two congenital deformities that can occur individually or are often seen in conjunction with one another The cleft can be unilateral or bilateral. When a disruption in normal fetal development causes the three prominences that should fuse to form the midface remain separated, a "cleft" occurs. The cleft may affect just the upper lip, just the palate, or a combination of both structures, depending on which stage of fetal development was affected. There are four categories of cleft lip: Unilateral incomplete cleft and nasal deformity Unilateral complete cleft and nasal deformity Bilateral incomplete cleft Bilateral complete cleft on one side and incomplete on the other side The infant with these deformities may suffer from difficulty sucking, swallowing, and eventually forming proper sounds. After the patient is positioned the surgeon inserts the Dingman mouth gag and attaches the other end to the Mayo stand. A throat pack consisting of sponges may be inserted to absorb blood and prevent it from draining into the throat. *The surgical technologist should assist the surgeon with irrigation and suctioning of the operative site throughout the procedure.* The palatal flaps are outlined and the local anesthetic with epinephrine is injected Using a #15 blade, the surgeon makes a V-shaped incision along the mucosal borders. The incision is extended with the #15 blade and palate blade through the oral mucosa, muscle, and nasal mucosa. On both sides of the cleft, the surgeon uses Freer and Cottle elevators to dissect the nasal mucosa from the muscle (Figure 19-15B). Next, using the same elevators, the oral mucosa is dissected from the muscle, thus creating the three layers to be closed. During the tissue dissection, the surgeon identifies the greater palatine vessels in order to prevent them from being injured. 9. Holes may be drilled in the hard palate to facilitate suture placement. *The surgical technologist should be prepared to set up the drill with the drill bit to facilitate placement of the sutures.* A Y-shaped closure in three layers is achieved that closes the cleft and lengthens the palate (Figure 19-15C). The closure is as follows: Nasal mucosa are closed first with 4-0 or 5-0 absorbable suture. Muscle is closed second with the same type of suture. Palatal mucosa is closed last over the other layers, using the same type of suture. Area is irrigated and checked for bleeding, throat pack is removed, mouth gag is removed, and patient is extubated and transported to the PACU. The anesthesia provider must be very careful during extubation to avoid injuring the repaired palate. The surgical team should be prepared to treat the patient for airway obstruction.*As mentioned earlier, the surgical technologist should be ready to assist the team in treating a patient who experiences airway obstruction upon extubation. The surgical technologist should not break down the back table and Mayo stand until the patient has left the OR.*

Cheiloplasty or Cleft Lip Repair Procedure

The function of the palate is to separate the nose from the mouth, which is important in swallowing and speech. The anterior portion of the palate is the hard palate that consists of the palatine processes of each maxilla and the palatine bones. It is covered with mucous membrane. The posterior portion is the soft palate and is composed of muscle, fat, and mucous membrane. It terminates with the uvula at the fauces. To understand the pathology, fetal development of the nose and mouth must be understood. The fetal development occurs during the first trimester of intrauterine life. The grooved middle portion from below the nose to the upper lip called the philtrum and the middle curve called Cupid's bow are formed by the joining of the frontal nasal prominence. Bilaterally the lips are formed by the maxillary prominences. The palate is formed from the joining of the central nasal prominence to the right and left maxillary prominences A cleft is a split or a gap between two structures that are normally joined. Cheiloschisis (cleft or hare lip) and palatoschisis (cleft palate) are two congenital deformities that can occur individually or are often seen in conjunction with one another The cleft can be unilateral or bilateral. When a disruption in normal fetal development causes the three prominences that should fuse to form the midface remain separated, a "cleft" occurs. The cleft may affect just the upper lip, just the palate, or a combination of both structures, depending on which stage of fetal development was affected. There are four categories of cleft lip: Unilateral incomplete cleft and nasal deformity Unilateral complete cleft and nasal deformity Bilateral incomplete cleft Bilateral complete cleft on one side and incomplete on the other side The infant with these deformities may suffer from difficulty sucking, swallowing, and eventually forming proper sounds. Using either a #11 or #15 blade, the first incision is made along the superior vermilion border, extending to the midline of the cleft into the nose. Skin hooks are used for retraction; the surgeon uses curved tenotomy scissors to dissect the mucosa off the orbicularis oris muscle.*The main role of the surgical technologist will be retraction.* A second incision is made extending from the cleft to the midline to dissect the medial lip free from the maxilla. Using either a #11 or #15 blade, a Z-plasty incision is made to create three flaps; however, they are not necessarily rotated in order. First flap: Rotation incision made in such a manner that the flap is rotated down to form Cupid's bow and philtrum groove (Figure 19-13A). Third flap: Rotated into columella and forms lower portion of nostril (Figure 19-13B). Second flap: Advanced into the gap left by the rotations and skin used to form Cupid's bow Closure is as follows: Mucous membrane of the upper lip is closed first with interrupted absorbable sutures. Next, the orbicularis oris muscle is closed with absorbable sutures. Skin is closed last, with every attempt made to create Cupid's bow; absorbable suture is used *Due to the small size of the needles and suture, the surgical technologist will need to carefully keep track of the suture.* Dressing is a small mustache type with a small 2 × 2 sponge and tape. *Do not break down the back table and/or Mayo stand until the patient has left the room for transport to the PACU.*

Mentoplasty Procedure

The mandibular symphysis, better known as the chin, is the region inferior to the labiomental fold, the groove that separates the lower lip from the chin. Several muscles cover the chin, including the mentalis, orbicularis oris, quadratus labii inferioris, triangularis, and small superior portion of the platysma. The anterior middle portion of the digastric muscle and the genioglossus and geniohyoid muscles attach along the posterior and inferior surface of the chin. The mental nerves are situated on either side of the chin. Mentoplasty is performed for purely cosmetic reasons, correcting micrognathia, a condition characterized by the underdevelopment of the jaw, in particular the mandible, or restoring post-traumatic facial disfigurement. The chin-to-nose relationship is an important consideration when evaluating the patient and discussing options. A small chin has the effect of making the nose look larger. Additionally, chin implantation will have an effect on the jaw line and contour. Using a #15 knife blade, the surgeon makes a short submental transverse incision in the middle of the chin. The incision is carried down to the periosteum; the periosteum is incised along the inferior mandibular surface on both sides of the midline. The periosteum is elevated off the bone using a small periosteal elevator such as a Key elevator. *The mental nerves must be identified and kept from injury.* The periosteum is gently retracted with Senn retractors, creating a subperiosteal pocket. *The pocket is slightly larger than the implant to facilitate insertion. The surgeon may place an implant sizer over the chin and outline it on the skin as an aid in creating a pocket that is not excessively large.* Implant sizers are used to determine the correct size of permanent implant. The permanent implant is placed in the subperiosteal pocket. The implant must be placed inferior to the mental nerves. The surgeon moves the implant into the correct position according to the previously marked anatomical landmarks and visualization of the patient's face. *The surgical technologist should confirm the size of implant with the surgeon and communicate the information to the circulator who will open the sterile implant to facilitate transfer to the sterile field.* To prevent slippage of the implant, the surgeon fixes it in place with an absorbable mattress suture to the periosteum or soft tissue at the lower border of the mandible in two places. The wound is thoroughly irrigated with antibiotic solution. The periosteum is closed with 3-0 or 4-0 absorbable suture and the skin closed with 5-0 or 6-0 nonabsorbable suture. Then 4 × 4s are placed for dressing.

Application of Arch Bars Procedure

The maxillary bones meet inferior to the nasal septum to form the upper jaw; the point of connection is called the intermaxillary suture. The maxillary bones articulate with the following facial bones: inferior turbinate; lacrimal; nasal; palatine; vomer; zygomatic. The maxilla does not articulate with the mandible. The frontal and ethmoid bones articulate with the maxillary bones. Each maxillary bone contains a maxillary sinus, which is a cavity within the bone that is lined with mucous membrane and opens into the nasal cavity. The upper teeth are located in the maxillae; the alveolar portions of the teeth are located in the alveolar process in the maxilla. The hard palate, or roof of the mouth, is the palatine process of the maxilla. The infraorbital foramen, found below the eye, contains the infraorbital nerve and artery. The largest and strongest facial bone is the mandible. It articulates with the glenoid fossa of each temporal bone to form the synovial joint called the temporomandibular joint (TMJ). The mandible consists of three portions, the first being the body, which lies horizontally and contains the alveolar process for the lower teeth. The mental foramen is located on the body and below the first molar tooth (Figure 18-5). The mental protuberance is the chin. The second portion is the ramus. The rami project upward at an angle from the posterior part of each mandibular body. The condylar process is the posterior projection of the ramus. The TMJ contains the condylar process, portions of the temporal bone, mandibular fossa, and articular tubercle. The coronoid process is the anterior projection of the ramus. The temporalis muscle attaches here (Figure 18-6). The depression between these two processes is the mandibular notch. Located on the medial surface of the rami, the manidbular foramen contains the inferior alveolar nerve along with its vessels. The mental foramen, like the mandibular foramen, is used by dentists for the injection of anesthetics. Condyle fractures occur within the capsular head of the mandible, and subcondylar fractures are below the capsule. Both can be approached through submandibular and preauricular incisions, or combination of both. The last area of the mandible is its angle. The angle connects each ramus to the body. Mandibular fractures can occur anywhere along the mandible (Figure 18-7). There are four categories of fractures: Symphysis and parasymphyseal fractures occur along the mandible between the bicuspid teeth. Most of these fractures do not dislocate. Hematomas can form sublingually due to damage along the floor of the mouth. They are repaired intraorally by making an incision into the anterior gingivobuccal area for reduction and placement of rigid fixation implants. Horizontal ramus fractures occur along the lateral portion of the mandible between the bicuspid teeth and molars. The degree of fracture dictates the type of incision, which may be intraorally or transbuccal. Mandibular angle fractures occur from the second molar to the ascending ramus. A submandibular or preauricular incision is used. When using the submandibular incision, the mandibular branch of the facial nerve must be preserved. Preauricular incision requires the preservation of the frontal branch of the facial nerve. Insert mouth prop and plastic cheek retractor. Insert throat pack. The arch bars are measured, shaped, and cut to size. *Have two (one for the mandible and one for the maxilla) appropriate-sized arch bars ready, along with the wire cutter.* The arch bar is attached to the maxilla with prestretched wires to the individual viable teeth. *Prepare wire as previously instructed. Place one end of wire in jaws of wire twister and secure. Pass wire with caution—the exposed ends can easily puncture.* Place 10-cm segments of wire around the neck of each tooth, securing the bar to the tooth. * As soon as wire is passed, hand the wire twister and the V-shaped probe to position the wire during tightening.* A probe facilitates placement of the wires. The wire twisters are used to tighten the wires using a clockwise motion.* Wire cutter will be needed next. Provide suction and retraction as needed.* Another arch bar is secured to the mandible with wire. *The wire, probe, cutter sequence will be repeated until the arch bars are secured to each tooth in the mandible and maxilla.* If a throat pack was used, it must be removed prior to fixation of the mandible and maxilla to one another. *Provide bayonet to remove throat pack. Count. Anticipate use of irrigation and suction.* The upper and lower jaws are then stabilized to each other.* Additional wire or elastic bands may be used. Loops of precut, prestretched, preshaped wire may be fashioned beforehand to facilitate this step of the procedure.* Wire or elastic loops can now be placed over the hooks of the arch bars and tightened to immobilize the jaw. *Variations of mandibulomaxillary fixation are used according to the surgeon's preference and the patient's need.* A final rinse of the oral cavity is performed, and all fluid and debris are removed.* Provide irrigation fluid and Yankauer suction tip.* Retractors are removed

Le Fort I Fracture Repair Procedure

The pair of nasal bones come together to form what is known as the "bridge" of the nose. Each nasal bone articulates with the frontal, ethmoid, maxillary, and the opposite nasal bone. In the anterior view, the nasal bones are bordered laterally by the maxilla and superiorly by the frontal bone. Cartilage attaches to the anterior portion of the small nasal bones to form the tip of the nose. The zygomatic bones (malar bones) form the prominences of the cheeks and a portion of the inferior and lateral wall of the orbit. Le Fort II fractures, also called pyramidal maxillary fractures, may be triangular or pyramidal in shape. The vertical fracture line extends upward to the nasal and ethmoid bones. Le Fort II fractures can be unilateral or bilateral in nature. The bones do not articulate with one another, but they do join with the frontal, sphenoid, temporal, and maxillary bones. Each zygomatic bone has a zygomatic arch, which is a temporal process that is located posteriorly to join the zygomatic process of the temporal bone. The L-shaped palatine bones articulate with each other, sphenoid, ethomoid, maxillary, inferior turbinate, and vomer. The horizontal plates of the bones form the anterior (hard) palate. The palate separates the nasal and oral cavities, thus forming the floor and lateral wall of the nasal cavity. Le Fort III fractures, also called craniofacial disjunction fractures, are located high in the midface. The fracture line extends transversely from the zygomatic arches, through the orbits, and to the base of the nose. These fractures can exist unilaterally, bilaterally, alone, or in conjunction with other facial fractures. The vomer contributes to the posterior and inferior portion of the nasal septum. It is surrounded by the sphenoid, ethmoid, both maxillary, and palatine bones. It is singular and triangular. A Le Fort I fracture, also called transverse maxillary, is the most common type of mid-facial fracture. The alveolar process of the maxilla is horizontally separated from the base of the skull. The upper jaw can be floating free in the oral cavity A gingivobuccal sulcus incision provides adequate exposure of the maxilla; actual prosthesis placement will depend on the fracture site. The gingiva may be injected with local anesthetic with epinephrine prior to incising with a #15 blade. Hemostasis is achieved. * Anticipate retractor use for exposure of incision site. Medications are obtained in advance and prepared for use. Notify anesthesia provider of epinephrine use. Pass a #15 blade on a #7 knife handle. Anticipate the use of the electrosurgical pencil and suction with appropriate tip.* Exposure of the operative site is attained. *Retractors may be replaced or repositioned.* The fracture line is exposed by dissecting the gingiva from the alveolar process with a small periosteal elevator. *A Freer or slightly larger elevator will be used to expose the fracture site.* The fracture is reduced, using caution not to disrupt the breathing tube.*Reduction of the fracture may be achieved with the use of an elevator or manually.* If wire fixation is anticipated, sites for the drill holes are identified.* Drill with appropriate-size bit is preassembled and connected to the power source.* A drill hole is made on each side of the fracture line.* Suction and irrigation fluid will be necessary to cool the drill site.* A single wire is passed through each hole and pulled taut, reducing the fracture. *Precut, prestretched lengths of wire of appropriate size are loaded onto the wire twister and passed to the surgeon.* The wire is twisted clockwise, cut, and the ends of the wire imbedded in the drill hole. The wire technique can also be used to apply traction by simply placing the wires through the holes and pulling the impacted maxilla up and forward. * Anticipate the use of the wire cutter. The fracture may require placement of more than one wire for stabilization.* Plate and screws can also be employed to fixate the maxilla. The plate is placed over the fracture line and secured to the bone by the compressive force of the screw. Both the wiring and plating techniques can be utilized several times throughout the procedure, often in conjunction with one another. * Be prepared for a combination procedure that employs wire, screw, or plate and screw fixation. Refer to Procedure 18-3 for related technical considerations.* Fracture reduction and stabilization may be verified with the use of intraoperative X-rays (Figure 18-12).* Prepare to accept X-ray cassette into sterile field if requested. Anticipate closure as next step. Prepare irrigation fluid and suture.* The wound is irrigated and closed.* Count.* Retractor is removed.*Dressing is not needed with intraoral approach.*

Le Fort II and III Fracture Repair Procedure

The pair of nasal bones come together to form what is known as the "bridge" of the nose. Each nasal bone articulates with the frontal, ethmoid, maxillary, and the opposite nasal bone. In the anterior view, the nasal bones are bordered laterally by the maxilla and superiorly by the frontal bone. Cartilage attaches to the anterior portion of the small nasal bones to form the tip of the nose. The zygomatic bones (malar bones) form the prominences of the cheeks and a portion of the inferior and lateral wall of the orbit. Le Fort II fractures, also called pyramidal maxillary fractures, may be triangular or pyramidal in shape. The vertical fracture line extends upward to the nasal and ethmoid bones. Le Fort II fractures can be unilateral or bilateral in nature. The bones do not articulate with one another, but they do join with the frontal, sphenoid, temporal, and maxillary bones. Each zygomatic bone has a zygomatic arch, which is a temporal process that is located posteriorly to join the zygomatic process of the temporal bone. The L-shaped palatine bones articulate with each other, sphenoid, ethomoid, maxillary, inferior turbinate, and vomer. The horizontal plates of the bones form the anterior (hard) palate. The palate separates the nasal and oral cavities, thus forming the floor and lateral wall of the nasal cavity. Le Fort III fractures, also called craniofacial disjunction fractures, are located high in the midface. The fracture line extends transversely from the zygomatic arches, through the orbits, and to the base of the nose. These fractures can exist unilaterally, bilaterally, alone, or in conjunction with other facial fractures. The vomer contributes to the posterior and inferior portion of the nasal septum. It is surrounded by the sphenoid, ethmoid, both maxillary, and palatine bones. It is singular and triangular. A Le Fort I fracture, also called transverse maxillary, is the most common type of mid-facial fracture. The alveolar process of the maxilla is horizontally separated from the base of the skull. The upper jaw can be floating free in the oral cavity The bilateral eyebrow incisions are made to expose the edges of the infraorbital area and zygomatic frontal suture lines. Hemostasis is achieved. The Rowe forceps are situated intranasally and intraorally to reduce the maxilla. Holes are drilled into the bone on each side of the fracture along the infraorbital rim; for Le Fort III fractures holes are also drilled in the zygomatic frontal areas after the zygomatic fracture is reduced. Stainless steel wires are passed through the drill holes and using the wire twister, twisted downward in clockwise fashion to keep the reduction in place. The suspension wires are passed through the eyebrow incisions, behind the zygomatic arches and into the oral cavity using the Brown needle. A pullout stainless steel wire is looped through the suspension wire at the eyebrow incision, pulled through the skin at the hairline, and tied down over a sterile polyethylene button and foam padding. Depending on surgeon's preference, mini-compression plates, screws, and bone grafts may be used. Incisions are closed and the nasal fracture is reduced.

Transsphenoidal Hypophysectomy Procedure

The pituitary gland is about the size of a grape and is located at the base of the brain within the sella turcica, a small bony depression in the sphenoid bone. The pituitary gland is connected to the hypothalamus by a stalk called the infundibulum. The hypothalamus releases neurosecretory substances that stimulate the anterior pituitary gland to release hormones. The pituitary gland is considered the master gland. Tumors of the pituitary gland are usually benign, and are often responsible for the overproduction of specific pituitary hormones. There are two basic approaches in the surgical treatment of pituitary tumors. Craniotomy is indicated if the tumor is large and pressing against the optic nerves and is similar to the technique previously described. Transsphenoidal resection is indicated for smaller tumors (Figure 24-30). The sella turcica is easily approached through the sphenoid sinus, and complete tumor removal is possible for most tumors. The transsphenoidal approach to pituitary tumor removal offers several advantages. The cranium is not opened, so recovery time is much shorter. Pain may be considerably less for the patient, as well. Complications associated with manipulating the brain and vital structures are avoided. The nasal mucosa is typically injected with lidocaine with epinephrine for hemostasis. Cocaine may be applied to the nasal mucosa. An image intensifier that has been covered with a sterile drape is positioned in the lateral tilt with the beam aimed directly into the sella turcica. An ENT surgeon and neurosurgeon may both be working on this case. Be prepared to work with ENT and neuro instruments. The surgeon injects the nasal mucosa and gingiva with lidocaine and epinephrine for hemostasis. 2. The surgeon may approach the sella turcica with an incision in the upper gum margin just under the upper lip, or through the nasal cavity. Procedural Consideration: The surgical technologist should know which approach the surgeon will take in order to have the proper instrumentation available. 3. An assistant may take the fascial graft from the thigh while the pituitary is being exposed. Procedural Consideration: The graft should be kept on the back table in saline to prevent it from drying out. 4. After elevation of soft tissues by the periosteal elevator, the nasal septum is exposed and the mucosa is separated from septal cartilage. Procedural Consideration: The C-arm and microscope should be properly draped for visualization of the sella turcica. 5. A special bivalved speculum designed for this procedure is inserted. After cartilage is resected and the floor of the sphenoid sinus is removed, the floor of the sella turcica is viewed Procedural Consideration: All nasal instruments are considered contaminated and are kept isolated on a separate Mayo stand. 6. The microscope is brought in, and the sella turcica is punched with the Kerrison rongeur and osteotome (Figure 24-31B). Procedural Consideration: The surgical technologist may be asked to gently tap on a small osteotome at the base of the sella turcica. 7. The dura is incised and the tumor is removed with pituitary curette, dissector, enucleator, and suction.

Posterior Cervical Decompression Procedure

The posterior cervical approach is used for laminectomy for decompression, intradural tumor removal, cordotomy, discectomy, and fusion A midline incision is made over the cervical spinous process. 2. Soft tissue dissection is completed. 3. Correct level placement is verified with X-ray. 4. A laminectomy is performed using a drill, Leksell rongeurs, curettes, and Kerrison rongeurs. 5. Disc is removed with pituitary rongeurs and curettes. 6. If fusion is required, follow steps above. 7. The wound is irrigated and closed in layers. 8. Dressings same as for Procedure 24-11, Cloward Technique

Carotid Endarterectomy Procedure

The primary indication is carotid stenosis that may cause transient cerebral ischemia. Small pieces of plaque break away from the common carotid or internal carotid artery and are flushed upstream to lodge in small cerebral vessels, temporarily blocking blood flow to that particular area of the brain. The warning sign of a stroke is referred to as transient ischemic attacks (TIAs). Patients suffering from TIAs often demonstrate a weakness on the opposite side of the body (plaque is located on right side of body, patient experiences the weakness on the left side of the body) that worsens over a series of TIAs. The patient may exhibit confusion and/or slurred speech that resolves within 1 to 2 days after a TIA. A cervical incision is made parallel and anterior to the sternocleidomastoid and centered over the carotid bifurcation. This incision can be extended proximally to the sternal notch for more proximal lesions of the common carotid artery (CCA) and distally to the mastoid process for higher exposure. The incision is carried down through the platysma, and the sternocleidomastoid is retracted laterally with self-retaining retractors. Procedural Consideration: Incision is made with a #10 blade on a #3 knife handle. Two folded sponges should be placed on opposite sides of the operative site. A magnetic mat placed over the chest is useful for procedures of the neck. 2. The internal jugular vein is visualized, and the carotid sheath is opened along the anterior border of the vein. The internal jugular vein is retracted laterally, and the common facial vein is ligated with a combination of silk ties and/or clips. Sharp dissection is continued anterior to the CCA to keep from injuring the vagus nerve. The vagus nerve usually lies in a posterior lateral position within the carotid sheath but occasionally may spiral anteriorly, particularly in the lower end of the incision. The CCA, external and internal carotid arteries, and superior thyroid artery are dissected and isolated with vessel loops in a Potts tie fashion (double looped). Procedural Consideration: Dissection is accomplished with small or medium Metzenbaum scissors and small or medium DeBakey forceps. Care must be taken not to retract or injure the hypoglossal nerve that typically runs horizontally across the field 1-2 cm cephalad to the bifurcation. Injury to the nerve can result in tongue deviation and dysphagia. 3. The carotid body may be injected with 1% plain lidocaine to decrease the incidence of bradycardia and hypotension with manipulation. 4. Heparin is administered systemically, and clamps are applied first to the internal carotid, then to the CCA and finally to the ECA. Procedural Consideration: Angled vascular and bulldog vascular clamps are used for occlusion. The internal and external carotid arteries may be occluded with vessel loops. The anesthesia provider and circulator will record the time heparin was administered and the clamps placed on the carotid arteries. If cerebral oxygen monitoring is used, any significant decrease in the amount of perfusion should be monitored. A significant decrease may indicate the need for the placement of a shunt. 5. An arteriotomy is made along the lateral portion of the distal common carotid artery and, with the use of Potts-Smith scissors, is extended into the internal carotid artery to a point where the artery is relatively clear of atherosclerotic material. Procedural Consideration: Arteriotomy is begun with a #11 or #12 knife blade on a #7 knife handle. Surgeon's preference determines the choice of knife blade. 6. A Sundt, Javid, or Argyle shunt is placed into the CCA and ICA. The Sundt or Javid shunt is held in place with Javid shunt clamps. The Argyle shunt is held in place with clamped vessel loops or tapes. Procedural Consideration: If the surgeon prefers to proceed without shunting, the surgical technologist should be prepared for a faster-paced procedure. The surgeon will not delay with blood flow shutoff to one side of the brain. 7. The atheromatous core is carefully lifted from the arterial wall with a blunt dissector, beginning in the distal common carotid artery and moving into the external and internal carotid arteries. The clamp or loop used to occlude the external carotid artery may be loosened and a mosquito clamp is used to perform an eversion endarterectomy. Procedural Consideration: The plaque is elevated with a Freer elevator or Penfield #4 dissector. Remaining pieces are removed with DeBakey forceps and mosquito clamp. Tenotomy scissors may also be used to divide the plaque. 8. An end point is established for the plaque in the distal internal carotid artery, and the arteries are irrigated with heparinized saline to wash away any stray media or fibrin strands. Procedural Consideration: If a heparin needle is not available, the plastic cannula of an Angiocath needle works nicely. 9. The arteriotomy is closed directly with double-armed 6-0 and 7-0 polypropylene sutures in a running fashion. Prepare to irrigate the surgeon's hands with heparinized saline solution when the suture is tied to facilitate the sliding of the knot and decrease the chance of the suture breaking due to friction. If a patch angioplasty is performed, have several polypropylene sutures available. Procedural Consideration: Note time blood flow is restored. Vein patch may be procured at this time, but it is likely that it has been secured prior to neck incision if its use is anticipated. 10. Final irrigation of the carotid artery is performed prior to reestablishment of blood flow. The vascular clamps are removed from the external, common, and internal carotid arteries (in that order). Non-pulsatile leaking from the suture line may be controlled with Gelfoam® or other hemostatic agent. If needed, a drain is placed and secured, and the wound is closed in layers. Procedural Consideration: The surgical technologist should have additional polypropylene sutures available in the event bleeding at the suture line is not controlled by topical methods. An intraoperative ultrasound or Doppler may also be utilized to assess blood flow of the carotid artery. The surgical technologist should also keep the back table and Mayo stand sterile until the patient leaves the operating room in the event the neck needs to be reentered.

Dacryocystorhinostomy (DCR) Procedure

The procedure is performed when the nasolacrimal duct is obstructed by fibrous tissue or bone and has become impermeable, to establish a new communication pathway between the lacrimal sac and the nose. The lacrimal sac is the dilated segment of the nasal duct. It is positioned in a groove formed by the lacrimal bone and nasal process of the superior maxillary bone. The superior portion of the sac is oval shaped, which narrows inferiorly at its connection with the nasolacrimal duct. After general anesthesia is induced, local anesthetic (tetracaine 1% with epinephrine 1:5000 two drops) is instilled into the conjunctival sac. Lidocaine 2% with epinephrine is injected at the beginning of the lacrimal crest, and lidocaine is sprayed into the anterior third of the nasal meatus. Lidocaine is injected into the mucoperiosteum after the insertion of a nasal speculum. A curved incision is made using a #15 blade, conforming to the anterior lacrimal crest and deepened through the orbicularis muscle to expose the entire lacrimal crest.* Bleeding is controlled with bipolar coagulation.* Retractors are inserted on each side of this incision. *Rake retractors are commonly used; some surgeons may place 4-0 traction sutures in the skin.* Using blunt dissection, the anterior lacrimal crest is exposed and the periosteum elevated. The lacrimal sac is separated from the lacrimal fossa and retracted. *A Freer elevator may be used for the dissection.* A small burr is used to create an ostium in the lacrimal bone. The ostium may be enlarged with a Kerrison rongeur or sphenoid punch.* When a burr is used, the eyelids are protected with sterile gauze. Irrigation is used to keep the field clear of debris and provide cooling of the tissues.* A vertical cut is made in the anterior wall of the lacrimal sac, and a probe is passed into the lumen to verify the patency of the sac. The wall of the sac is slit horizontally, and the nasal mucosa is incised horizontally The flaps of the nasal mucosa and lacrimal sac are then joined. Flaps are joined using 6-0 polyglactin or 6-0 chromic gut sutures. This is done under the microscope. The muscle layer is closed using 5-0 absorbable sutures. The skin is closed using 6-0 nylon.

Endoscopic Brow Lift Procedure

The procerus is a small pyramid-shaped muscle located between the two eyebrows extending slightly downward on the superior portion of the nose covering the nasal cartilage. It is inserted into the skin over the lower part of the forehead between the two eyebrows on either side of the midline and merges with the frontalis muscle. It is responsible for pulling the skin between the eyebrows downward, causing horizontal wrinkles. The corrugator muscle is situated superior to the orbit. It arises medially from the frontal bone and inserts on the skin of the medial half of the eyebrow. It is the muscle that pushes the skin between the eyebrows into vertical folds and draws the brow medially and inferiorly. Brow lift is performed to reduce or eliminate the permanent horizontal and vertical wrinkles that occur on the forehead primarily due to aging. Surgeon injects tumescent solution beneath the periosteum with the 60-mL syringe and 18-gauge needle. Small transverse incision is made in the forehead and the endoscope is inserted Three to five small radial or transverse incisions are made behind the hairline.* Radial incisions in the anterior scalp tend to avoid transsection of the branches of the supraorbital nerve. Incisions in the temporal region may be either radial or vertical. In patients who are balding or have a high hairline, transverse incisions are made on the forehead.* The forehead is dissected free from the skull at the periosteal level. The periosteum is separated to completely free the brow and allow access to the corrugator and procerus muscles. Supraorbital nerve and multiple small veins are located just lateral to the middle of the orbit; the nerve must be identified and preserved. The corrugator muscle is either separated, avulsed, or resected according to surgeon's preference. *The surgical technologist should know the surgeon's preference in order to have the proper instrumentation and equipment available for use. Blunt avulsion of the muscle is rarely performed because of uneven effectiveness in decreasing the corrugator function. Resection of the muscle is more effective, but overresection can cause surface indentations in the skin. The best method is ablation of the muscles with the use of the carbon dioxide laser.* The surgeon performs either temporary or permanent fixation. Temporary: Titanium screws are placed posterior to the hairline. See Chapter 21 for the screw placement procedure. Staples or sutures are placed around them to anchor the elevated brow in place for 10 to 14 days. Permanent: Permanent fixation is achieved with use of Mitek anchors and suture or short permanent titanium screws. See Chapter 21 for placement of Mitek anchors. The small incisions are closed with nonabsorbable suture, interrupted technique. 4 × 4s are placed for dressing and kept in place for 1 to 2 days.

MID-CABG Procedure

The surgeon makes a 10-cm posterolateral incision. The incision is carried through the subcutaneous layer down to the pectoralis muscle, which is divided with the ESU. Procedural Consideration: The coronary artery to be bypassed must lie directly beneath the incision due to the small size of the incision. 2. A small section of the rib is stripped and removed. The minimally invasive chest retractor of the surgeon's preference is placed and the IMA is harvested. 3. The frame for the MID-CAB stabilizer system is fitted into the incision and the rigid arm with stabilizer foot is positioned. Three other items positioned are the site blower, site light for illumination, and a site manipulator to move the heart. 4. The surgeon continues in much the same fashion as when performing a conventional CABG. An incision is made in the pericardium to expose the LAD. Procedural Consideration: The surgical team must be prepared to quickly switch to a conventional CABG and place the patient on the CPB due to complications such as bleeding. 5. One end of the IMA is sutured to the LAD above the blockage and the other end is sutured below the blockage. 6. The site is checked for control of hemorrhage, the MID-CAB instrumentation is removed, and the layers are closed in routine fashion

OPCAB Procedure

The surgeon makes a median sternotomy that will vary in length, depending on the physiology of the patient. However, the incision is usually smaller than that made for a conventional CABG. The self-retaining sternal retractor is placed. Procedural Consideration: While the surgeon is opening the chest, the saphenous vein or IMA is harvested. Once the surgeon has entered the chest and the retractor is placed, either adenosine or esmolol is used to slow the heart rate. 2. To permit access to the entire heart muscle, cardiac displacement must be accomplished. Special instruments are placed that move the heart into position to allow the surgeon access to blocked arteries. 3. The pericardium is incised. Sponges are used to soak up blood; they also serve to aid in further displacing. Procedural Consideration: Displacement of the heart is important because it is a challenge for the surgeon to perform a bypass on the lateral and posterior of a beating heart. 4. The Octopus® stabilizer with suction cups is positioned. 5. The surgeon may prepare the heart and vessels for attachment of the CPB in case it becomes necessary; not all surgeons will do so. 6. The rest of the procedure is performed similar to a CABG, including closure, with the exception that a stent is used because the heart is still beating. After the arteriotomy is made in the artery that is blocked, the stent is placed to allow blood to flow through while the bypass is performed. The ends of the graft are placed above and below the blockage.

Lumbar Laminectomy for Discectomy with Spinal Fixation Procedure

The vertebral column of a normal adult is comprised of 33 vertebrae and is part of the axial skeleton. These 33 individual bones are separated into five regions. They are, from superior to inferior, cervical, thoracic, lumbar, sacral, and coccygeal There are seven bones in the cervical region. The uppermost, or first, cervical vertebra (C1) is the atlas, which supports the skull. The second cervical vertebra (C2) is the axis, which is fused with the body of the atlas; it is responsible for allowing rotation, flexion, and extension of the head. The remaining five vertebrae (C3-C7), which are similar to each other in their structure, function in a supportive role of the skeleton. There are 12 bones in the thoracic region (T1-T12). They are larger and stronger than the cervical vertebrae and are the main support for the thorax, as each of the 12 ribs forming the thoracic cage articulates with each of the thoracic vertebrae. There are five lumbar vertebrae (L1-L5). The lumbar vertebrae have two main responsibilities. They provide support for a major portion of the weight of the body and allow for much of the flexibility of the trunk. Thus, the lumbar vertebrae are very large and have heavy bodies. The sacrum is formed by five individual bones that fuse to form one bone in adulthood. The sacrum is considered part of the pelvic girdle. The coccyx consists of four fused vertebrae. The coccyx serves as an important attachment for several hip and pelvic muscles Each vertebra has a body or centrum anteriorly. Posteriorly, a neural arch encircles the opening for the spinal cord called the vertebral foramen. As the neural arch extends from the body on each side of the vertebra, it is referred to as the pedicle. The lateral extensions of the pedicles are called the transverse processes, which support the facets. The facets provide the articulating surfaces between the vertebrae. The bony surface extending posteriorly from the facet is the lamina. Laminae that extend from each side of the vertebra connect to form the spinous process of each vertebra. The spinal nerves pass through openings between adjacent vertebrae. These openings are referred to as the intervertebral foramina. Intervertebral discs are located between the vertebrae. The disc itself comprises fibrous connective tissue. Its tough outer layer is termed the annulus fibrosis, and the soft core is called the nucleus pulposus. The intervertebral discs bear most of the stress, in the form of pressure from gravity (body weight and lifting objects), that is transmitted to the vertebral column When disc material extrudes through the annulus due to degeneration or trauma in the lumbar region, nerve roots may be compressed (Plate 24-1A, B). This compression can, in severe cases, result in paraplegia or quadriplegia. In less severe cases, it may cause sensory loss in the upper extremities. n some cases, the disc does not extrude, but simply degenerates. This causes narrowing of the joint space, causing the cartilage at the end plates of the adjacent vertebrae to wear more quickly. Sometimes an osteophyte, or bony spur, may develop due to this increased mobility. When osteophytes form within the spinal canal, the cord may be compressed by the bony structure. This formation of osteophytes is called spondylosis. A great majority of the problems in this region occur in the L4-L5 and L5-S1 intervertebral spaces. Problems associated with lumbar disc disease include: Lumbar spondylosis: advanced lumbar disc disease Lumbar stenosis: advanced constriction of the spinal canal caused by spondylosis Lumbar spondylolisthesis: forward displacement of the upper vertebral body on the lower vertebral body For lumbar as well as thoracic and cervical disc degeneration, surgical treatment involves removal of the degenerated disc and fusion of the joint when necessary. This is usually achieved with a posterior approach and laminectomy. Laminectomy for discectomy is a common surgical procedure for the decompression of a nerve root that has been impinged by an extruded fragment of disc material in the cervical, thoracic, or lumbar region of the spine. Due to its weight-bearing configuration, the lower lumbar region is affected the most often. Surgical treatment is often necessary to remove the extruded fragment and decompress the nerve root. Laminectomy or hemilaminotomy is also the surgical approach for spinal cord tumor and to provide exposure for insertion of pain control infusion pumps, cordotomy, and rhizotomy. The interspace of the affected levels of the spine is approached posteriorly via a midline or paramedian incision with a #10 blade on a #3 knife handle The paraspinous muscles are separated from the spinous processes and laminae in the area with a periosteal elevator or osteotome. As the muscles are separated, sponges (Ray-Tec opened and folded lengthwise) are packed around the margins to assist with hemostasis and to aid in blunt dissection After the muscles have been reflected, a retractor is placed to provide exposure. Procedural Consideration: Martin-Meyerding, Taylor, Adson-Beckman, or angled Gelpi are examples of retractors used for exposure The spinous process is removed and rongeurs are used to remove the margin of the lamina above the interspace, the ligamentum flavum, and the medial margin of the adjacent facet. Care is taken not to damage the epidural veins when incising the ligamentum flavum After the necessary amount of the lamina has been removed with a Kerrison rongeur, the dura and nerve root are carefully retracted medially with a nerve root retractor. Procedural Consideration: The surgical technologist should remove bone fragments from the rongeur with a sponge. The bone fragments can be saved to use to promote osteogenesis in fusion Pituitary rongeurs are then used to remove extruded fragments of disc material. If removing a spinal tumor, blunt and sharp dissection with scissors and a periosteal elevator will be performed Procedural Consideration: The surgical technologist will need to remove disc fragments from the rongeur with a sponge and place into sterile specimen container. The disc material may be sent to the pathologist. 7. Once the extruded disc material has been removed, the inner portion of the disc may be removed using rongeurs. Curettes are used in the intervertebral disc space to remove all remaining fragments of disc material. Care must be taken not to injure the aorta or vena cava that lie anterior to the vertebral column If the spine has been destabilized following laminectomy, fusion of the vertebrae may be performed. Fusion is achieved by placing struts of bone in and along the intervertebral spaces after curettage Curettage of the vertebral bodies assists in the formation of bony material after bone graft material is placed into the vertebral interspace. This bone is either taken from the iliac crest of the patient or homogenous banked bone is used. Procedural Consideration: For certain pathological conditions or fractures, stability may not be achieved by simple bone grafting. In these cases, stability is achieved by using any of several implanted device systems. These involve rods, cages, and plates and screws attached to nondamaged vertebra above and below Prior to wound closure, the wound is irrigated free of debris. All cottonoids and sponges are removed. Hemovac drains are typically placed in the wound before closure 11. The paraspinous muscles are approximated with heavy-gauge polyglactin suture. The wound is closed in layers, and the skin is closed with monofilament nylon or stainless steel staples

Cataract Extraction Procedure

The word cataract is used to describe a lens that has become opaque. Cataracts are a condition affecting the eye, not a disease. As the lens gradually clouds, less light is able to pass through, blurring and distorting images received by the retina. Vision is gradually impaired; if untreated, a cataract can cause needless blindness. Cataracts are usually white but may take on a yellow or brown color. Cataracts may form in the nucleus of the lens, the outer cortical portion, or involve the entire lens. The development of cataracts is usually due to the normal part of the aging process, but they can develop due to other reasons, including traumatic cataracts resulting from an injury or blow to the eye, use of certain drugs, exposure to harmful chemicals, exposure to excessive sunlight, and congenital disease. Intracapsular cataract extraction involves a large incision and the entire capsule is removed; suturing is required for closing the incision. Extracapsular cataract extraction is performed through a small incision and only the lens is removed; incision is self-sealing with no sutures required Phacoemulsification is a variation of the irrigation/aspiration technique. The tip of the phaco handpiece is inserted through the small incision and ultrasonic energy fragments the lens while simultaneously irrigating and aspirating the fragments. After the nucleus of the lens is removed, the irrigating/aspirating unit is used to remove the remaining pieces of cortex. IOLs are small prescription lenses placed inside the eye for clear lens replacement surgery. IOLs may be foldable or hard. Foldable lenses are made of silicone or acrylic and can be rolled up and placed inside a tube that is inserted through the small incision, or folded by locking forceps, and once inside the eye the IOL unfolds. Hard plastic lenses are rarely used and must be inserted through a larger incision. The lid is retracted *A superior rectus bridle suture may be used, but its use is rare* An incision is made, either corneoscleral or corneal, with the Supersharp. Lidocaine is injected into the anterior chamber *A corneal incision is self-sealing.* A second incision is made in the limbus with the keratome. Viscoelastic material is injected into the anterior chamber to inflate the chamber and protect the back of the cornea. The anterior capsule is incised and capsulorrhexis performed with Uttrata forceps. BSS or lidocaine is used for hydrodissection, loosening the lens inside the capsule, and freeing the nucleus from the cortex. *the capsulorrhexis is a very delicate procedure* The Phacoemulsification handpiece is inserted through the larger incision and used to fragment the nuclear portion of the lens. After the nucleus is removed, the Phaco handpiece is switched out for an irrigation/aspiration handpiece, and the cortex is removed. *microhook such as a Clayman or Nagahara to manipulate portions of the nucleus.* Viscoelastic is injected to reinflate the capsule. The intraocular lens is inserted into the capsule, and an Ogawa or other microhook used to gently direct the IOL into its final position The I/A is used to remove remaining viscoelastic. The incisions are sealed using BSS, injected with a 30-gauge cannula. The surgeon will test the seal and proper inflation of the anterior chamber with Weck-Cel sponges. * If the incisions fail to self-seal, the surgeon will use 10-0 or 11-0 nylon suture to close the incision.* Antibiotic drops are instilled.

Repair of Traumatic Eyelid Laceration Procedure

Traumatic laceration of the eyelid can be due to blunt and penetrating trauma, including dog bites, penetration by a small tree limb, hit by human fist, and cut by glass such as during a vehicle accident. Canaliculus not involved ____ Lateral canthotomy is performed in order to prevent traction and tension on the wound closure. Sutures are placed through the lid margins restore stability. The tarsal plate is approximated with absorbable sutures. Skin and canthus are approximated with nonabsorbable sutures. Canaliculus involved ____ Veirs rod is placed through the laceration and the canaliculus is approximated with nonabsorbable suture around the rod. The rod is removed. The subcutaneous layer and skin are closed with nonabsorbable suture.

Insertion of Long-Term Indwelling Central Venous Catheter Procedure

Venous catheters are a type of central indwelling catheter that is placed to facilitate the long-term intravenous administration of chemotherapy, antibiotic therapy, intravenous (IV) fluids, and pain medications. The catheter allows for the patient to infuse IV fluids and pain medications at home. Under fluoroscopy, the surgeon selects the insertion site 1-2 cm lateral to the insertion of the clavicle and first rib. Procedural Consideration: The right subclavian vein is used unless it has been affected by infection or thrombosis due to a previously placed catheter. In that instance, the left subclavian vein will be used. Fluoroscopy will be used throughout the procedure. 2. Using the micropuncture device, a 21-gauge introducer needle is inserted at the site into the subclavian vein. Contrast dye is injected through the needle to confirm correct insertion. Modified Seldinger technique is a technique to obtain safe access to blood vessels using a needle, guidewire, dilator, and sheath. Procedural Consideration: A micropuncture device allows for the placement of a 0.035-in.-diameter guidewire into a vessel later in the procedure. It also allows the use of the 21-gauge introducer needle for the initial venous puncture instead of the larger 18-gauge needle that is provided in the catheter kit. The use of the 21-gauge needle decreases the risk for pneumothorax and bleeding from an accidental puncture of the subclavian vein. 3. A 0.018-in. guidewire is inserted through the needle and advanced into the superior vena cava. Procedural Consideration: A challenge with inserting the guidewire is to prevent it from traveling cephalad into the jugular vein. If this occurs, the guidewire will curve upward, looking like a "J," meaning it has entered the jugular vein. The surgeon will carefully withdraw the guidewire from the jugular vein and reposition into the superior vena cava. 4. The micropuncture device is used to change from the 0.018-in. guidewire to the larger-diameter 0.035-in. guidewire. The guidewire is advanced into the inferior vena cava. Procedural Consideration: The surgeon avoids placing the guidewire into the right ventricle to avoid causing dysrhythmias. 5. The dilator and peel-away sheath is inserted over the guidewire into the subclavian vein. 6. The catheter is advanced through the sheath, over the guidewire to the junction of the superior vena cava and right atrium. The position is confirmed with the injection of 1 mL of contrast solution and a permanent image recorded. Procedural Consideration: Hand the catheter to the surgeon coiled and tip first. The surgeon may need the assistance of the surgical technologist in controlling the catheter until a good length of it has been inserted. 7. The small Dacron cuff that is attached around the catheter is subcutaneously tunneled along with the catheter end and tubing. The cuff is left in the subcutaneous layer at the exit site and the rest of the tubing exteriorized. Procedural Consideration: The cuff helps to prevent the catheter from migrating inward or being pulled out. 8. The catheter is secured to the skin with 3-0 or 4-0 silk suture for approximately 2 weeks to allow the cuff to become imbedded in the subcutaneous tissue layer. 9. A standard chest X-ray may be taken in the OR to exclude a pneumothorax.

Ventriculoperitoneal Shunt Placement Procedure

Within the brain are a series of interconnected canals and cavities called ventricles. The first two ventricles are referred to as the lateral ventricles (right and left). The two large ventricles that are located in each cerebral hemisphere connect to the smaller third ventricles, by way of the interventricular foramen (foramen of Monro). The third ventricle connects to the even smaller fourth ventricle, located in the brain stem anterior to the cerebellum, by way of the cerebral aqueduct (aqueduct of Sylvius). The fourth ventricle is continuous with the central canal of the spinal cord he ventricles are filled with a clear, colorless fluid containing small amounts of protein, glucose, lactic acid, urea, and potassium, as well as a relatively large amount of sodium chloride. The fluid, known as cerebral spinal fluid (CSF), helps to support and cushion the brain and spinal cord and stabilizes the ionic concentration of the central nervous system. It also acts to filter the waste products of metabolism and other substances that diffuse into the brain from blood. CSF is produced by specialized capillaries called choroid plexuses. The choroid plexuses are located in the lateral ventricles and the third and fourth ventricles. However, the choroid plexuses located in the lateral ventricles produce the largest amount of CSF. CSF flows through the interventricular canal into the third ventricle. From the third ventricle, CSF flows through the aqueduct of Sylvius into the fourth ventricle, where a small portion enters the subarachnoid space through the fourth ventricular wall. CSF flows from the fourth ventricle into the central canal of the spinal cord and around the cord's surface, eventually surrounding the brain and spinal cord. The CSF is reabsorbed by fingerlike projections of the arachnoid that project into the dural sinuses called arachnoid villi. This reabsorption occurs at approximately the same rate that CSF is formed, allowing for a constant CSF pressure. The obstruction of the flow of CSF through the ventricular system and into the subarachnoid space (noncommunicating hydrocephalus), an increase in the amount of CSF normally produced (communicating hydrocephalus), or the improper absorption of CSF by the arachnoid villi causes CSF pressure to rise within the cranial cavity. Obstructive hydrocephalus in the infant may result from a congenital tumor or hemorrhage at the foramen of Monro, aqueduct of Sylvius, or the canal of exit from the fourth ventricle. Childhood hydrocephalus may be a result of meningitis, tumors, hemorrhage, or aqueductal stenosis. Hydrocephalus in adults may be caused by obstructive tumors, meningitis, or hemorrhage. Infants with hydrocephalus have an enlarged head circumference and present with enlarged and distended scalp veins. Increased intracranial pressure may cause optic atrophy. A small linear incision is made, and a burr hole is drilled in the occipital or parietal bone with Hudson brace and D'Errico bit, cranial perforator, or Midas Rex or Anspach burr. Procedural Consideration: Shunt may be soaked in a saline and antibiotic mixture before use. 2. The dura is nicked and coagulated, and a ventricular catheter with stylet is placed into the posterior lateral ventricle. The stylet is removed, and a small bit of CSF is taken as specimen. Procedural Consideration: The surgical technologist should be loading the stylet into the catheter as the dura is nicked. A rubber shod may be necessary to clamp the end of the catheter closed after it is placed to prevent CSF loss. Intracranial pressure may be monitored with manometer. 3. The proximal portion of the ventricular catheter is connected to the reservoir. A tunneling device is used to make a tunnel from the burr hole to the abdomen, and the distal end of the shunt system is threaded under the skin and soft tissues to an incision in the abdomen. Procedural Consideration: Tunneling devices may be hollow CV tunnelers, Sarot clamps, or uterine dressing forceps. Long, heavy silk sutures will be used to draw the shunt system under the skin to the abdomen. For ventriculoatrial shunts, an incision is made in the neck and the internal or external jugular vein is exposed. A tunnel is made from the burr hole to the neck incision and the distal end of the shunt is threaded through the tunnel into the opened jugular vein and into the right atrium The peritoneum is exposed and opened, and the abdominal catheter is placed into the peritoneal cavity and secured with a purse-string suture. The wounds are irrigated with antibiotic solution and closed after patency of the system is verified. 5. The wounds are irrigated and the incisions are closed.

Abscess Acute Cerebellum Cerebrum Circle of Willis CNS Craniosynostosis Decompress Epidural hematoma Extruded Glioma Intracranial pressure Meninges Osteophyte PNS Transsphenoidal

____ Area of broken-down tissue containing pus and liquefied tissue ____ Severe but of short duration ____ The portion of the brain located in the posterior cranial fossa posterior to the brainstem; consists of two lobes; functions include coordinating voluntary muscular activity ____ The largest section of the brain, divided by a fissure into the right and left cerebral hemispheres; at the bottom of the fissure the hemispheres are connected by the corpus callosum, and the surface of the hemispheres is convoluted and lobed; functions include motor functions, sensory functions, and functions associated with the many mental activities of the individual ____ A complex vascular network located at the base of the brain and formed by the following interconnected arteries: internal carotid, anterior cerebral, posterior cerebral, basilar, anterior communicating, and posterior communicating ____ The system, composed of the brain and spinal cord, responsible for processing information to and from the peripheral nervous system. It is the main component that coordinates and controls the body's activities ____ Premature closure of the cranial sutures of an infant ____ To remove pressure ____ Accumulation of blood between the skull and dura mater that is usually caused by trauma _____ Forced out of position ____ Group of malignant tumors composed of glial cells ____ Pressure produced within the cranium; when elevated, represents a space-occupying lesion or brain edema _____ Three tissue membranes (called dura mater, arachnoid, pia mater) that enclose the brain and spinal cord ____ An abnormal bony growth ____ A division of the autonomic nervous system that slows the heart rate, relaxes sphincters of the body, and increases peristalsis in the GI tract ____ Across or through the sphenoid bone

Surgical Repair of Chalazion Procedure

____ is a small lump on the inner or outer surface of the eyelid (A red, swollen area of the eyelid) It is caused by an inflammatory reaction to material trapped inside a meibomian gland. Incisional approach depends on the location transcutaneous (outside of the eyelid) or transconjunctival (through the inside of the eyelid). The affected eyelid is everted with a chalazion clamp m,for exposure. (#11 or #15 blade) The orbicularis muscle is incised to expose the meibomian gland. The gland is incised and the lesion is curetted. Bleeding is controlled by cautery. (Procedural Consideration: Irrigating the surgical site with drops of ____ shows the surgeon points of bleeding).

Enucleation Procedure

____ is excision of an eye due to malignant neoplasm, penetrating wounds, or when the eye has been so extensively damaged that no vision can be regained. Evisceration allows the retention of the sclera and extrinsic muscles of the eye. It eliminates corneal sensitivity and allows the patient to wear a prosthetic eye that will have mobility and a better cosmetic result A lid speculum is placed. The conjunctiva is divided around the cornea with Westcott scissors. Tenotomy scissors or small Metzembaums are used to free the conjunctiva and Tenon's capsule from the globe. The rectus and oblique muscles are isolated and secured with 5-0 polyglactin sutures. The rectus muscles are divided, leaving a stump of medial rectus muscle. *If an hydroxyapatite implant with donor sclera will be used, the four rectus muscles and two oblique muscles are identified and secured with 6-0 nonabsorbable suture to be used to reattach muscles to cut-out areas in donor sclera before muscles are divided.* The globe is separated from the Tenon capsule with blunt-pointed curved scissors, retractors, hemostats, and forceps. The eye is rotated laterally by grasping the stump of the medial rectus muscle. The optic nerve is identified and a large, curved hemostat is passed behind the globe, and the optic nerve is clamped for 60 seconds. The hemostat is removed, the enucleation scissors are passed posteriorly, and the optic nerve is transected. The oblique muscles are severed as the eye is delivered by the stump of the medial rectus muscle. . The muscle cone is packed with saline-soaked sponges to obtain hemostasis. Bipolar forceps are used on any bleeders remaining after the sponges are removed. Sizers are used to determine the size of the ocular implant. The muscle cone is filled with a prosthetic sphere implant and the Tenon capsule and conjunctiva are carefully closed with a 5-0 absorbale suture. Hydroxyapatite spheres, with donor sclera to reattach the muscles, are frequently placed for later use, which will allow synchronous movement. A socket conformer is placed into the cul-de-sac.

Abbreviated Burn Severity Index (ABSI) Aesthetic Arthrodesis Augmentation Cheilo Cleft Dermatome Diarthroses Dorsal carpal ligament Elliptical Eschars Integumentary MPJ Poly Radial hypoplasia Replantation Rhinoplasty Schisis Sebum STSG Syndactyly Synthesis Xenograft

_____ A scale used to assess the severity of a burned patient's condition based on the patient's age and gender, presence of inhalation injury, depth of burn according to degree, and the percentage of the total body surface that has been burned ____ Visually pleasing _____ Surgical fixation of a joint to relieve pain and provide support ____ Process of increasing; refers to size, quantity, degree, or severity ____ Combining form that means lip ____ Cleave, crack, or fissure ____ Powered or manually operated surgical instrument used to cut thin slices of skin for grafting purposes ____ Freely movable joint ____ There are two ligaments: dorsal intercarpal and dorsal radiocarpal. The dorsal intercarpal extends transversely across the dorsal surfaces of the carpal bones, and the dorsal radiocarpal is attached to the lower end of the radius and proximally attached to the scaphoid, lunate and triquetral carpal bones _____ Curved or crescent shaped ____ Charred and pearly white skin that results from third-degree burns ____ Pertaining to or composed of skin ____ A synovial hinge-type joint consisting of a metacarpal that articulates with a phalange; commonly referred to as a knuckle ____ Prefix meaning many or much ____ A congenital condition caused by the failure of the radius and adjacent soft tissue to develop, causing the hand to be medially deranged; typically associated with deformities of the thumb; also referred to as radial dysplasia ____ The replacement of an organ or other structure to the site from which it was previously lost or removed; also known as reimplantation ____ Surgical reshaping of the nose ____ Combining form pertaining to split or cleft ____ Oily substance produced by the sebaceous glands that reaches the skin through ducts that enter the hair follicle; aids with fluid regulation and acts to keep the skin and hair soft and pliable ____ A graft that involves the epidermis and approximately half the dermis; used when a large surface area needs to be covered ____ Webbed digits; congenital abnormality that occurs when the digits of the hands or feet fail to separate _____ The formation of a new entity out of previously existing ones _____ Graft obtained from a dissimilar species

Adventitia Bifurcation Capillaries Claudication Contralateral Embolus Fogarty embolectomy catheter In situ Intima Morbidity Mortality Occlusion Patency Pledget Plethysmography Thrombus Valve

_____ The outermost layer of an artery composed of elastic connective tissue _____ Division into two branches; "Y" shaped ____ The smallest blood vessels; composed of a single layer of endothelial cells where oxygen and carbon dioxide exchange occurs _____ Severe pains in the muscle of the lower leg caused by poor circulation of blood to the muscle; usually caused by atherosclerosis ____ The opposite side ____ A piece of tissue, thrombus, air, or gas that circulates in the circulatory system until it becomes lodged in a vessel ____ A type of catheter that is small in diameter and is balloon-tipped; used to facilitate the removal of an embolus _____ At the site of origin, or in its normal place _____ Inner layer of the arterial vessel wall _____ Pertaining to disease _____ Pertaining to death ____ An obstruction ____ The condition of being wide open ____ Small square of Teflon sutured over a hole in a vessel; it exerts external pressure over any small needle holes to prevent bleeding and to promote clotting; often used in peripheral vascular surgery ____ An instrument for measuring the amount of blood present in an extremity or passing through it; useful in patients with diffuse, small-vessel arterial disease ____ Stationary blood clot within a blood vessel ____ A membranous fold in a passage that prevents backflow of material passing through it

Iridectomy Procedure

_____ is removal of a section of iris tissue. A ____ ____ can be performed for treating angle closure glaucoma. The laser beam creates a small hole in the peripheral portion of the iris to connect the posterior and anterior chambers of the eye. This permits the iris to fall back away from the trabecular meshwork, opening the angle of the anterior chamber to allow the outflow of the aqueous fluid through the Schlemm canal. (Common side effects of laser iridectomy are increased intraocular pressure (IOP) and anterior uveitis.) Before the incision is made, the patient's IOP is measured with a tonometer; if too high, drugs are administered to reduce the IOP. A lid speculum is placed for lid retraction. *Remember to periodically irrigate the eye with BSS.* Next, a 6-0 Vicryl or silk suture may be placed at the limbus for traction. (suture is tagged with a mosquito clamp or a serrafine) The conjunctiva is incised using toothed colibri forceps and knife. Tenon's capsule is dissected free from the sclera with forceps and Westcott scissors toward the limbus to create a Tenon capsule-conjunctiva flap. Using the #57 beaver blade, the surgeon gently removes blood clots from the limbus. Using the disposable cautery, the surgeon marks the incision line on the sclera and, using the beaver blade, makes the incision in the sclera, creating a square or triangular scleral flap. The incision is begun at the apex of the sclera and continued upward toward the iris. * To decrease postoperative fibrosis, the surgeon may use a sponge soaked in the chemotherapeutic agent 5-FU and/or mitomycin. After the flap is made in the sclera, the small piece of 5-FU-saturated sponge is placed underneath the flap. Because 5-FU and mitomycin are antimetabolites, they must be disposed of as hazardous waste due to their toxicity.* The scleral flap is retracted and Vannas or iridectomy scissors are used to remove a segment of trabecular meshwork. At this point an _____ is performed. A small incision is made at the superior limbus or a perpendicular incision is made in the cornea. The iris is grasped with forceps, brought up through the incision, and, using a knife, scissors, or Kelly punch, is excised. The iris is placed back into position by carefully rubbing the cornea with a blunt muscle hook (Figure 16-11) or by gentle injection of BSS. Procedural Consideration: Provide the muscle hook of the surgeon's preference for repositioning the iris. The corneal incision is closed with 10-0 nylon The scleral flap is closed with interrupted 10-0 nylon. Continuous 8-0 polyglactin is used to close the Tenon capsule-conjunctival flap, and the same suture is used to close the conjunctiva. BSS is injected into the anterior chamber. Antibiotics and steroids are injected, and antibacterial ointment is placed into the eye. Eye pad and shield are positioned over the eye.

Alveolar process Calvarial Condyle Glenoid fossa Labia Malar bones Malocclusion Maxillofacial Mouth prop Orthognathic Pan Ramus Reduction Symphysis TMJ

_____The part of the mandible or maxilla that forms the dental arch, which contains the sockets for the teeth _____Pertaining to the superior portion of the cranium where the fontanels of the infant are situated ____ Rounded projection/process at the epiphysis of a bone that articulates with another bone; serves as the point of attachment for ligaments ____ The socket in which the head of the humerus articulates to form the shoulder joint; a ball-and-socket join. ____ Side of tooth that is closest to the lips _____ Cheek bone ____ Abnormal alignment of the teeth of the upper jaw with those of the lower jaw ____ Pertaining to the face and maxilla _____ A self-retaining retractor used to keep the mouth open during oral or dental procedures ____ Surgery to correct conditions of the jaw and face related to structure, growth, TMJ disorders, and malocclusion problems ____ Combining form meaning all _____ Smaller branch of a structure that extends from a larger branch that divides into two parts, such as the rami of the pubis ____ Correction or placement of a body structure back into normal anatomical position ____ A joint in which the two bony surfaces are joined by fibrocartilage (meniscus) ____ The joint formed by the mandible that articulates with the glenoid fossa in each temporal bone

Craniotomy Procedure

raniotomy involves incising the cranium for access to the brain. The cranium encloses and protects the brain and is covered with skin, subcutaneous tissue, galea aponeurotica, and periosteum. The cranium consists of eight bones: One frontal bone, forming the forehead, nasal cavity, and orbital roofs Two parietal bones on each side of the skull, just posterior to the frontal bone, forming a large portion of the sides and roof of the cranium One occipital bone, forming the back and a large portion of the floor of the cranium Two temporal bones, forming a small portion of the sides and floor of the cranium The sphenoid bone, forming portions of the base of the cranium, sides of the skull, and base and sides for the orbits One ethmoid bone that forms portions of the roof and walls of the nasal cavity, the floor of the cranium, and the walls of the orbits Three layers of protective tissue called the cranial meninges cover the brain and spinal cord. The outermost layer, referred to as dura mater, is composed of tough fibrous connective tissue. The middle layer is the arachnoid, which is a serous membrane. The layer closest to the brain is the pia mater; it contains blood vessels and nerves to provide nourishment to the neural tissue underneath. The space created between the arachnoid mater and the pia mater is referred to as the subarachnoid space, an area that contains cerebral spinal fluid The cerebrum represents the largest portion of the human brain. Its surface is covered with convolutions (gyri) that are separated by shallow depressions (sulci) and deep grooves (fissures) into specific lobes, each with complex functions and named for the cranial bone that covers it The cerebellum is the second largest structure of the brain and is located posterior to the medulla oblongata and inferior to the cerebrum's occipital lobe. The structure of the cerebellum is similar to that of the cerebrum. The brain stem connects the brain to the spinal cord and consists of the midbrain, pons, and medulla oblongata The cranial nerves are 12 pair of nerves that, with the exception of the first and second, originate in the brain stem (Figure 24-17). They are responsible for sensory and motor functions of the body Primary and secondary neoplasms can affect the nervous system. Primary neoplasms arise from neural tissues or the meninges. Secondary neoplasms are metastatic lesions from other parts of the body. Symptoms for patients with intracranial neoplasms include compression of cranial nerves, destruction of brain tissue, irritation of cerebral cortex resulting in seizures, and increased intracranial pressure. Benign tumors can usually be excised totally through craniotomy. These tumors include craniopharyngiomas, epidermoids, dermoids, hemangiomas, meningiomas, acoustic neuromas, and pituitary microadenomas. Malignant tumors, such as the astrocytomas or gliomas, usually cannot be totally excised, but as much tumor as possible is removed. Head injuries that require craniotomy include epidural hematoma, subdural hematoma, and brain injury, including hemorrhage. A brain abscess requires surgical drainage to relieve pressure if the abscess is not treated in its early stages. A brain abscess arises from any of several causative factors, among them secondary infection from a primary infection such as bacterial endocarditis, direct contamination of the brain from a penetrating wound, and bone fragments or debris from traumatic injury. An epidural hematoma may result from a fractured skull or blow to the head. The pressure of blood from this arterial bleeding strips the dura away from the skull, causing more bleeding as the tiny veins from the dura to the skull are torn. There may be a symptomless period as the hematoma enlarges to a size sufficient to compress the cerebrum, resulting in a gradual loss of consciousness that can progress to coma and death without surgical intervention. Craniotomy is performed to relieve the resultant pressure of the hematoma, as well as to debride the area and control bleeding. A subdural hematoma occurs in relation to severe head injuries (Figure 24-18). When veins bridging the cerebral cortex to the venous sinuses are torn or the cortex is lacerated, hemorrhage occurs. Arteriovenous malformations (AVMs) are congenital defects causing abnormal communication between arteries and veins that divert blood from surrounding brain tissue. The surgery involves microsurgical resection of the malformation. Many AVMs have associated aneurysms, increasing the danger of hemorrhage. High-resolution MRI confirms the existence of an AVM, but selective cerebral angiography is usually necessary to identify details of the lesion. Cerebral angiography is used to show the vascularity of tumors and aids in determining the type of tumor. It is also used for detection of AVMs. Digital pressure is applied to each side of the marked incision line for hemostasis, a U-shaped incision is performed, and Raney scalp clips are applied over the upper skin edges. Procedural Consideration: Quickly load Raney scalp clips as appliers are received from the surgeon. Bleeding from the scalp can be profuse. 2. Dandy hemostatic clamps may be placed onto the lower skin edges and secured with rubber bands around the handles. Procedural Consideration: Dandy clamps should be passed to surgeon with tips pointing downward. 3. The galea and periosteum are incised by electrosurgery, and the cranium is exposed. Procedural Consideration: Smoke should be evacuated with suction. 4. After hemostasis has been achieved, the scalp flap is dissected away from the cranium, folded backward over a laparotomy sponge, and secured to the drape for retraction. 5. Muscle and periosteum are stripped away from the cranium with a periosteal elevator and retracted. 6. Two or more burr holes are made into the cranium with an air-powered burr, such as the Midas Rex, or an electric-, battery-, or air-powered cranial perforator. Occasionally, burr holes are drilled manually with a Hudson brace and D'Errico bit Procedural Consideration: Irrigate drill bit while in motion with saline to counteract heat generated by friction and to remove bone dust. 7. After the holes are drilled, they may be enlarged with a double-action rongeur or Kerrison rongeur. Any bleeding from the edges of the burr holes is controlled by bone wax and neurosurgical sponge. Procedural Consideration: Bone wax balls may be pressed against the tip of a #4 Penfield dissector and passed to the surgeon. 8. A small, straight bone curette is used to carve away the inner table and expose the dura. 9. The dura around the burr hole is separated from the cranium by a #3 Penfield dissector to prevent tearing of the dura mater when the flap is turned The cranium between the burr holes is cut with an electric-, battery-, or air-powered craniotome saw with dural guard attachment. Occasionally, the cranium is manually cut with a Gigli saw. Procedural Consideration: Irrigate the craniotome with saline. 11. After each burr hole has been connected, the bone flap is carefully lifted away from the dura with a periosteal elevator 12. If muscle has been left attached, the bone flap is covered with a moistened laparotomy pad and retracted in a manner similar to the scalp flap; otherwise, it is removed. Procedural Consideration: Place bone flap in basin on back table to soak in betadine solution or normal saline and antibiotic. The container must be labeled with the name of the solution and antibiotic and bone flap. 13. Bleeding around the bone edges is controlled with bone wax; bleeding from the dura is controlled with the bipolar forceps and thrombin-soaked Gelfoam. 14. Holes may be drilled along the edges of the cranial defect with an air drill for epidural tacking to prevent postoperative epidural dead space. 15. Dural traction may be necessary to pull the dura away from the brain surface before incising. This is achieved with 4-0 braided nylon or dural hook. 16. A small incision is made into the dura with #11 or #15 blade and extended with Metzenbaum or dura scissors. 17. Cottonoid patties are placed under the dura with bayonet forceps as the dura is incised to protect the delicate brain tissue underneath, and 4-0 dural traction sutures are placed along the dural edges and tagged with mosquito hemostats for retraction. 18. Brain spoons/spatulas are placed and held manually or attached to the Leyla-Yasargil self-retaining retractor Procedural Consideration: Brain spoons should be moistened with saline before handing to the surgeon. 19. The pathological condition is treated, and hemostasis is achieved with warm saline irrigation, Surgicel, thrombin-impregnated Gelfoam, and bipolar cautery. Procedural Consideration: The microscope may be needed at this time. 20. The brain is irrigated with copious amounts of body-temperature saline and antibiotic, and the dura is closed in an airtight fashion with a running 4-0 braided nylon or silk suture. 21. The Midas Rex or small air drill is used to place holes at strategic locations along the edges of the cranial defect and the bone flap, and the flap is secured to the cranium with titanium plates and screws. Some surgeons may prefer to wire the bone flap to the cranium with stainless steel wire. Procedural Consideration: A stainless steel brain spoon or periosteal elevator placed between the cranium and the dura prevents the drill from penetrating brain tissue. 22. A Hemovac drain is placed in the epicranium and brought up through the scalp through a small stab wound and secured with a 0 or 2-0 silk suture on a cutting needle. The wound is closed in layers.