Surgical Skills Lecture - Exam 3

Responsibilities of Surgery Tech

• Examination of patient

• diagnostic workup

• anesthesia induction/maintenance

• setting up/breaking down OR

• Preparations OR for specific sx

• maintenance/sterilization of instruments

• prep of surgical patient

Responsibilities of Scrub Nurse

• retraction of tissue

• bone reduction

• wound sponging

• suction

• hemostasis

• monitoring of anesthetized patient

Intraoperative Responsibilities

• assist in sterille draping

• maintain and orderly surgical field

• organization of instrument table and instruments

• count sponges and instruments

• properly pass instruments

• tissue handling, retraction, bone reduction, hemostasis, suture cutting, wound sponging

• specimen collection

• collecting all sharps

Postoperative Responsibilities

• monitor patient recovery

• care/treatment of patient

• cleaning/maintenance of OR

• cleaning/maintenance/sterilization of instruments

Responsibilities for Ovariohysterectomy (OHE) (spay)

• examine patient

• bloodwork performed for patient

• induction/monitoring of patient

• properly clipping patients hair - xiphoid process to pubis

• patient position - dorsal recumbency

• draping of patient - 4 quadrant

• running/organizing the table

• maintaining asepsis

• passing instruments

• tissue handling (retraction, flashing or elevating pedicle)

• hemostasis

• appropriate size of suture material (surgeon’s preference)

What are the indications for an OHE?

• neoplasia of reproductive tract - early spay

• treatment of neoplasia elsewhere influenced by repro hormones (mammary tumors)

• injury to repro tract

• dystocia

• uterine torsion

• abolition of heat cycle

• congenital abnormalities

• stabilization of other systemic diseases

  • diabetes melitus

What are the indications to perform a cesarean section?

Dystocia

• maldeveloped fetuses

• oversized fetuses

• malpositioned fetuses

• small pelvic canal size of dam

• previous pelvic trauma

• insufficient dilation

• uterine inertia

What breeds are associated with dystocia?

• boxers

• bulldogs

• pekingese

• pugs

• animals with a history of dystocia

Stage 1 of Labor:

• nesting stage

• last several hours

• ends with dilation of the cervix

Stage 2 of Labor:

• dilation of cervix

• fetus enters birth canal

• rupture of fetal membranes

• abdominal contractions

• normal up to 4 hours for first fetus

• up to 2 hours between each fetus

Stage 3 of Labor:

* passage of placenta

What are the 3 types of c-section procedures?

Procedure 1:

• En bloc resection

Procedure 2:

• Standard C-section without OHE

Procedure 3:

• Standard C-section with OHE

Supplies needed for C-section (pup removal):

• hemostats

• warm towels

• drugs to administer (naloxone, doxapram, epinephrine)

• suture

• incubator

• oxygen

• lots of people on hand to stimulate pups

Duties of Neonatal Team during a C-section:

• obtain fetus aseptically

• stimulate neonate

• suction nares/mouth

• warm neonate

• suture umbilicus

• perform PE - cleft palate, umbilical hernia

• organize team not scrubbed in

What is an Exploratory Laparotomy?

abdominal exploratory surgery

What are the indications for an exploratory laparotomy?

• surgical biopsies

• removal of abdominal masses

• gastrointestinal obstruction

• traumatic injury

  • ruptured bladder

  • biliary tract rupture

  • gunshot/puncture

  • diaphragmatic hernia

  • pneumoperitoneum

  • acute abdomen (etc)

Items that may be needed in an exploratory laparotomy:

• balfour retractors - all abdominal surgeries

• radiopaque gauze and lap sponges

• specialized instruments

• lavage

• retractors

• clean sterile instruments

• stapling devices

• red rubber catheters

What is a gastrotomy?

incision into the stomach

What are the indications for a gastrotomy?

• foreign body removal

• biopsy of mass (neoplasia/fungal)

• mass removal

• pyloric outflow obstruction

Items needed for gastrotomy:

• balfour retractors - all abdominal surgeries

• radiopaque gauze and lap sponges

• lavage

What is an enterotomy?

incisions into the small intestine

What are the indications for an enterotomy?

• foreign body removal

• biopsy of small bowel

Items needed for an enterotomy:

• balfour retractors - all abdominal surgeries

• radiopaque gauze and lap sponges

• lavage

• doyen clamps

What is an intestinal resection and anastomosis?

excision of a segment of bowel followed by reestablishment of the two remaining segments

What are the indications of an intestinal resection and anastomosis?

• removal of section of dead tissue or diseased bowel

  • foreign body

  • neoplasia

  • intussusception

  • necrosis

• Neoplasms of GI tract

  • leiomyoma

  • lymphosarcoma

  • adenocarcinoma

  • fibrosarcoma

Post-op Consideration for Intestinal Sx:

• IV nutrition may be needed

• IV fluids and antibiotics

• may be warranted

• clinical signs monitored for peritonitis

  • depression

  • vomiting

  • fever

  • abdominal pain

  • discharge from incision

What is Gastric Dilation Volvulus (GDV)?

• Dilation - organ stretched beyond its normal dimension

• Volvulus - rotation of organ on its axis

• Gastric Dilation Volvulus - distended stomach that has rotated on its own axis

• Surgical Emergency!!

Breeds predisposed to GDV?

* Deep-chested, large breed dogs
* rarely seen in cats

Clinical signs of GDV?

• distended abdomen

• retching without production

• shocky

• abdominal pain

• hyper salivation

• restlessness

1st step in treating GDV:

* IV catheters
* stabilize
* reverse shock

2nd step in treating GDV:

* Decompress stomach
* nasogastric tube
* trochar
* temporary gastrotomy

3rd step in treating GDV:

* Correct GDV surgically (once stable)

What is a gastropexy?

permanent fixation of stomach to body wall

Items needed for gastropexy:

• balfour retractors - all abdominal surgeries

• radiopaque gauze and lap sponges

• lavage

• stapling equipment - partial gastrectomy or splenectomy

Postoperative monitoring of GDV/Gastropexy:

• correct fluid/electrolyte abnormalities

• monitor for cardiac arrhythmias

• monitor for peritonitis/sepsis

What is a cystotomy?

surgical incision into bladder

What are the indications for a cystotomy?

• cystic calculi

• biopsy

• correct congenital abnormalities

Items needed for a cystotomy:

• balfour retractors - may or may not need

• radiopaque gauze and lap sponges

• lavage

• bladder spoon

• red rubber catheters

• specimen collection

• culture/sensitivity of bladder wall

Postoperative considerations for a cystotomy:

* IV fluids and antibiotics may be warranted

Clinical signs monitored for peritonitis:

• depression

• vomiting

• fever

• abdominal pain

• discharge from incision

What are the most common presentations for orthopedic procedures?

• Cranial Cruciate Ligament (crCL rupture repairs

• Fracture Repairs

• Medial Patella Luxation (MPL) repairs

• Hip Dysplasia surgeries

• Arthroscopic surgery of joints

• Other ligament/joint surgeries

  • dislocated joints

Non-surgical management of injuries:

• Arthritis

• Sprains

• Muscle injuries

What is the most common surgery seen/done in orthopedic procedures?

Cranial Cruciate Ligament Rupture Repairs

What is the most common orthopedic disease seen?

Arthritis

What is the most common presentation for orthopedic procedures?

Lameness

• most patients will need help getting up and walking

• many need support due to their injury

Do fractures need to be stabilized?

Yes

Are orthopedic/fracture patients painful?

YES

What are considered “elective orthopedic” patients?

CrCL tears, MPL’s, arthritis

Do “elective orthopedic” patient’s still need help moving?

yes

What are good questions to ask for the history of an orthopedic patient?

• How did the patient get injured?

• When did the patient get injured?

• How stable is the patient?

• Can they walk and get up on their own?

• Are the bleeding from anywhere?

• Are the breathing okay?

• Can they urinate on their own?

• Are they on any medications?

  • If so, how did they respond?

• Are they on any herbals or supplements?

  • Over the counter meds?

• Other medical issues?

  • Endocrine (diabetes, cushings)

  • Neurological (seizures)

Triage of orthopedic patients:

• Is the patient stable?

• Is the patient bleeding?

  • many fractures are due to severe trauma

• Can the patient walk unassisted?

  • do they need a stretcher?

  • Sling?

  • Help ‘em up harness?

• What level of pain is the patient in?

50% of dogs that tear one CCL will rupture the other CCL within 1 year. T/F?

True

Physical Exam Findings of Cranial Cruciate Ligament Ruptures:

• partial or non-weight bearing lameness

• Cranial tibial thrust

• Cranial drawer

• Pain on extension

• joint effusion

• muscle atrophy

• medial meniscal click

Surgical Options for Cranial Cruciate Ligament Tears:

TPLO surgery

• Tibial Plateau Leveling Osteotomy

TTA surgery

• Tibial Tuberosity Advancement

Extra-capsular repair

CBLO surgery

• Cora-based leveling osteotomy

Tightrope surgery

Others

(close to 30 options to repair)

Pre-anesthetic diagnostics for CrCL, MPL surgeries:

• Blood work

  • CBC

  • Serum Biochemistry

• Urinalysis

• ECG

• High Quality Radiographs

• Perioperative antibiotics

• Anesthesia protocol

• Pain management!!

Patient Positioning for CrCL, MPL surgeries:

• dorsal or lateral recumbency

• hanging leg technique

  • clipped from hip to tarsus

  • cover foot

  • rough prep

  • move into OR

  • aseptic prep

Draping

• surgeon will hold leg

• foot covered in sterile manner

• quarter drapes

• final drape

Surgical Assisting

• instrument table set-up

• anticipate surgeon’s needs

• maintain an aseptic environment

• maintain surgery table until post-op radiographs

• anesthesia recovery

• pain management!!`

Post-op considerations and instructions for CrCL, MPL surgeries:

• soft bandage

• sling

• e-collar

10-14 day recheck

• sutures/incision

EXERCISE RESTRICTION!!

• gradual return to normal function

• repair failure

Pain management

• perioperative

  • local anesthetic into joints

• post-op

  • injectable opioids and NSAIDs

  • discharge meds

PT/Rehab

Recheck appointment

Post-op Rehab/PT of CrCL, MPL surgeries:

Rehab

• promote wound healing

• decreases muscle spasms, adhesions formation, and edema

• increase muscle strengths and ROM

• low impact exercises

• PROM

• Heat/Ice

• hydrotherapy

• other modalities

Fractures

Usually associated with high trauma

• hit by cars frequently

• may be a low-impact injury

Limb needs to be stabilized

• most of the pain come from the bones moving

Assess for other injuries

• thorax, abdomen, open wounds

• neurologic

These patients are very painful

Fracture Pre-op Considerations:

History

• age

  • young

    • decreases healing time

    • angular limb deformities

    • more active

  • older

    • increases healing time

    • complications

    • more sedentary

• other injuries present

• size and weight of patient

• overall health

  • anesthesia risk

  • other metabolic diseases

• temperament

  • aggressive?

  • difficult to handle?

  • difficult to treat?

• owner issues

  • financial considerations

  • compliance

Fracture Assessment:

Which bone(s)?

Open or closed fracture

Cn it be splintered initially?

Type of Fracture

• simple vs. comminuted

Radiographs

• sedation

• joint above and below

• articular fractures centered on film

• 2 views

• post-op

• radiograph measuring marker!

Open Fractures

Cultured

Open…NOT compound

Classified

Classifications fro open fractures:

Grade 1

• small puncture

• no longer visible

• minimal soft tissue damage

Grade 2

• larger puncture/tear

• more soft tissue damage

Grade 3

• large tears

• +/- loss of skin

• extensive soft tissue damage

• shearing injuries (part of the bone may be sheared or missing)

• bone exposed

Complications of open fractures:

• skin necrosis/vascular compromise and infection leading to bone death

• bleeding

• soft tissue damage

• swelling

• contaminations

• vascular compromise

Closed Fractures:

• no skin puncture/tear

• soft tissue damage may be mild to severe

Complications of Closed Fractures:

• bleeding

• soft tissue damage

• swelling

Salter-Harris fractures

• young growing animals

• angular limb deformities may result

S: Type 1

__S__traight across

A: Type 2

__A__bove

L: Type 3

__L__ower or be__L__ow

T: Type 4

__T__wo or __T__hrough

ER: Type 5

__ER__asure of growth plate or c__R__ush

Articular Fractures will likely develop _____________ at the joint later.

arthritis

Goals of fracture repair:

Realign fracture ends

Stabilize

• internal fixation

  • on bone surface or in medullary cavity

• external fixation

  • exterior to interior

Protect repair until healed

Re-assess healing

Internal Fixation:

Bone plates and screws

• titanium or stainless-steel implants

• soft-tissue and muscle dissection

  • open or closed techniques

• exposure fracture

• plate pacement

• screw placement

Internal Fixation Post-op Care:

Strict confinement for 6-8 weeks

• e-collar

• sling support

• suture removal

• follow-up rads

  • 4 & 8 weeks post-op

  • young animals

    • faster healing in general

• implants usually not removed

• pain management!

• PT/rehab protocol

Fixation Complications

• non-union (bone does not heal)

• malunion (heals but heals crooked)

• delayed union (longer to heal than it should)

• aseptic loosening (implant loosens not due to infection)

• implant failure

• infection

Amputation Analgesia:

• local anesthetic injection into nerve

• local nerve blocks

• epidural

  • morphine

  • opioids and and local anesthetic

• Systemic opioids

• NSAIDs

• Fentanyl patches

Technician Responsibilities with Orthopedic Cases:

• initial triage

• stabilization

• radiographs

• lab work

• patient prep/anesthesia

• pain assessment and management

• external computation care

  • reduce further disruption or damage to fracture and soft tissue

  • monitor daily

• assist patient in walking and bathroom

  • PT/rehab

Surgical Oncology: Surgery in the Management of Cancer

• diagnosis

• cure

• palliation of clinical signs

• debulking prior to adjunctive therapy

• ancillary procedures

  • placement of a vascular access port

  • spay/neuter

Work-up and Diagnosis of Cancer

• history

• physical examination

• clinical pathology

• diagnostic imaging

• tissue sampling

• surgery

What does palliation mean?

removing the pain associated with cancer

Biopsy of Masses: Indications

• treatment will differ depending on tumor

  • tumor type

  • tumor behavior

    • benign, malignant, aggressive, non-aggressive

• planning for surgical resection

  • margins

  • prognosis

• diagnosis would change owner’s desire to treat

Biopsy of Masses

Tissue Sampling Techniques

• impression smears

• fine needle aspirate (FNA)

Minimally Invasive Biopsy Techniques

• needle core biopsy

  • Tru-Cut biopsy

  • bone biopsy

• punch biopsy

• image-guided biopsy

  • using ultrasound or CT

Surgical Biopsy Techniques

• incisional biopsy

• exceisionar biopsy

• biopsy via minimally invasive surgery techniques

  • laproscopic

  • thoracoscopic

  • arthroscopic

Impression Smear Procedure

• Press a glass slide against open lesion or cut edge of excised lesion

• Direct sampling of superficial ulcerated lesions or other exfoliated cells (e.g. TCC in urine)

Upsides of Impression Smears:

• cheap

• noninvasive

• no sedation needed

• immediate result

  • preliminary reading

send to pathologist

Impression Smear - Technique

• Blot surface with paper towel

• open lesion

  • press slide firmly against lesion

  • pull straight up when removing

• Excised lesion

  • gently touch surface to glass slide

  • make several smears on each slide

  • do not squash, twist, or rub tissues on slide

Fine Needle Aspirate (FNA)

• easy

• cheap

• minimally invasive

• no sedation needed

• low diagnostic yield

20-22 gauge needle

• too big = painful

• too small = no cells, or lyse cells

3-5 cc syringe

• too big = not enough suction

• too small = too much suction, gets blood contamination

Fine Needle Aspirate - Technique: Woodpecker

• Needle placed in mass

• quickly stab repeatedly

• move needle tip direction

• DO NOT remove needle from skin until finished

• remove syringe and pull plunger back

• reattach needle

• push plunger down rapidly to squirt cells onto a labeled slide

Fine Needle Aspirate - Technique: Suction

• needle placed in mass

• quickly pull plunger back 1-2 mls

• repeat in same spot 3-4 times

• if you get blood, STOP

• DO NOT remove needle from skin until finished

• remove syringe and pull plunger back

• reattach needle

• push plunger down rapidly to squirt cells onto labeled slide

Needle Core Biopsy

Indications

• no diagnosis with FNA or impression smear

• need more tissue for characterization

Uses

• palpable masses

  • skin

  • muscle

  • bone

• organs visible by ultrasound or CT

  • near body wall

  • liver or kidney

Needle Core Biopsy Instruments

Soft Tissue

• Tru-Cut Biopsy needle

  • manual

  • automatic

Bone

• Jamshidi Needle

• Michele Trephine

Tru-Cut Biopsy needle

Jamshidi Needle

Michele Trephine Needle

Does Needle Core Biopsy require surgical prep?

Yes; clip, scrub, sterile gloves

Locations for bone marrow biopsy technique:

• proximal humerus

• ilial wing

• proximal femur

• proximal tibia

  • young dogs only

Indications for a Punch Biopsy:

• cutaneous masses

• focal organ masses

  • liver, pancreas, spleen

• intestinal biopsies