Laparoscopic chole procedure STUDY!!

OPENING

  • Around the world

  • Check for integrity

  • Open back table (basic pack)

  • Open basin-kick back next to back table

  • When opening lap tray check for indicators and locks intact. Step back when you open and flip lid check filters→pass lid to nurse

  • “Checking indicator tapes” looks good→Open camera tray since it’s a sterile tray open like a towel and step away DO NOT TOUCH YOU ARE NOT STERILE YET!

  • Open gown and gloves on mayo stand

  • “SCRUB”

  • glove and have nurse tie you while gloving, gown→DANCE!

  • Go to your back table and DOUBLE GLOVE!

  • When circulator is opening your towels have them check holes on EVERY SINGLE drape

  • Drape mayo stand tuck in right side first (that will be the side near you and the patient) then the left (put all towels on mayo stand) because you need to reinforce back table

  • REINFORCE YOUR TABLE WITH DRAPE!!!

  • Grab instruments out of tray, be mindful of your sleeves can’t touch side of tray (check bottom of the tray and have your nurse swipe check for any debris, condensation, dust, hair,blood and check filters)

  • Place both trays on your back table

  • Once they are confirmed sterile place on back table (lap instruments on right side, instruments in the back

  • Before opening camera tray look for indicator, lift the lid and ask circulator to check wrap for holes if it’s good place on table in front of your instruments

  • Grab your basin and empty it out on table and place everything as normal on left side of back table

  • When taking your trocars from nurse put them on mayo

  • Ask nurse for 5mm clip (this is the one you will need first)

  • 0 vycril ur6 for fascia and 4-0 monocryl PS-2 for skin

BASIN SET UP

  • Suction irrigator (bottom)→nurse will open for you grab sterilely

  • Insufflation tubing (grey chord")→nurse will open

  • Camera cords/light cord

  • Light handles (sides)

  • Bovie (sticking up for count)

  • Light cord (green one)

  • Abdominal drape

  • 4 towels to drape pt→Surgeon gown (KIM IS XL)→gloves→towel

  • ONCE YOUR DONE PUTTING STUFF IN IT PUT IT BACK TO SIDE OF THE TABLE SO YOU DON’T TOUCH IT ACCIDENTALLY W/ YOUR BACK

BACKTABLE SETUP

  • Ask circulator for 5mm endo clip and endo catch (endo catch infront of table, endoclip, right angle, 5mm scope

  • 2 rochester peans

  • raytecs

  • Small needle holder with suture needle ready, Large needle holder with suture needle ready

  • Above needle holders red box open with syringe and hypo on magnet side

  • Above red box basin, measuring cup inside ask your circulator for saline to fill measuring cup

  • Saline=NaCl: CHECK NAME, WARMER DATE, AMOUNT, AND EXPIRATION DATE→have circulator fill→LABEL WITH BLACK INK NaCl/SALINE→ASK IF PATIENT HAS ANY ALLERGIES!!!!

  • Place measuring cup with saline in basin and fill the asepto

  • Next to basin, kidney basin

MAYO SET UP

  • ALL the trocars (right side) set these up first (OPEN AND CLOSE THEM, ONLY LEAVE HASSON OPEN OTHERS ARE CLOSED SO THE GAS WONT COME OUT) Make sure to put the pointy sides towards the door blunt towards pt so it’s easy to pass to surgeon

  • Put trocars together (Hassan 3 piece, Exel, Veress step, Balloon trocar

  • Empty syringe 5cc of air for balloon trocar

  • FRED (3 piece count)

  • Local (medication) YOU ASK YOUR SURGEON WHAT MEDICATION THEY WOULD LIKE TO USE WHEN YOU’RE GLOVING THEM (YOU WILL PUT THE LOCAL ON MAYO AFTER SURGEON TELLS YOU MED INFO→ASK YOUR NURSE FOR IT SOMETIME DURING PATIENT SET UP)

  • Loaded #11 blade (top left, blade facing towards the door)

  • Str Mayo scissors (top right)

  • Metz scissors (top right)

  • 2 criles to clamp (top right)

  • 2 raytecs on top

  • 2 kockers

  • Rat tooth/bonnie (WHEN NURSE GIVES YOU THIS FORCEP, TELL THEM TO ADD TO COUNT BOARD)

  • “S” retractors (2) (middle)

  • Right angle

  • Suction tip

  • 10'“ scope (bigger)

  • 2 alligators

  • Maryland

READY TO COUNT!

  1. Raytecs 10

  2. Sutures 2

  3. Blade 1

  4. Hypo 1

  5. Bovie w/ tip 1

  6. Asepto 1

  7. Fred 3

  8. Bonnie 1

Stringer

  1. Nonporforating towel clamp-2

  2. Perforating towel clamp-4

  3. Mosquitos-4

  4. Criles-4

  5. Peans-2

  6. Allis-2

  7. Oschner Kocker-2

  8. Needle holders-2

  9. Scissors-3

  10. Randall Stone-1

  11. S-retractor

  12. Knife handle-1

  13. Forceps-3

AFTER COUNTING

  • Take instruments off stringer and place in tray

  • Edna towel clamp on bovie

  • Assistans gown, gloves and towel angled on scope tray

READY FOR THE DOCTOR!

  • Introduce yourself and put the towel on surgeons hand (right hand to right hand)

  • Put on gown and ask “What kind of local would you like to use today?”

  • Put on gloves (thumb facing the doctor!)

  • DANCE!!!!

GO TO PATIENT

  • Bring basin (DON’T GET IT CLOSE TO THE BED!)

  • 4 towels (3 to surgeon folded towards the you, 1 towel folded towards surgeon (because it goes on your side)

  • Abdominal drape (little man head towards pt head untape, drop by end of bed)

  • Unfold w/ surgeon carefully, when pulling drape down and up cover your hand with the drape over, CRNA will clip above pt head.

  • Now your basin can touch the draped bed (blue to blue)

  • Place light handles and bovie on top of pt

  • Black camera cord, camera on right hand small end to the left give to nurse

  • White cord (red tapeo side goes to nurse)

  • insufflation this is the C (goes to the umbilicus, you took this one in

  • Green cord on top of pt

  • thicker cord with your right hand tuck in the small part on your side and goes on velcro strap (big part you fish down)

  • Green cord also tuck in on your side and strap with velcro

  • Fix your bovie and clip on drape

  • Make sure you seal all your cords with the velcro

READY TO BRING YOUR BACK TABLE & MAYO

  • Mayo goes over patients feet, basin at end of bed

  • Back table right next to mayo

  • Load your asepto with saline

  • Why do we put asepto upside down? because you just grab it and throw it right to surgeons hand

  • Connect 10MM scope to light cord (white and camera cord)

  • Ask nurse to turn on light source

  • Get your lap and do white balance (hit W till it says ok)

  • FRED green sponge and stick on top of drape and squirt a little on it

  • Suction tip goes on thick cord

  • green cable goes on right angle

  • ASK YOUR NURSE FOR THE LOCAL SURGEON ASKED FOR!!!!!!! AND CHECK IT!→EXPIRATION DATE, PERCENTAGE, NAME, CHECK FOR RED (EPI), STRENGTH, AMOUNT (ALWAYS PUT A 0 AT THE FRONT EX. 0.25% MARCAINE W/ EPI)

  • LABEL MEDICATION!

TIMEOUT!!

What is a lap chole? Removing the gallbladder laparoscopically

What 5 things do we need in case we have to convert to an open procedure?

  1. #10 balde

  2. laps

  3. yankour suction tubing

  4. Bovie

  5. Suction Tubing

Possible IOC? Intraoperative Cholangiogram→procedure that may be done during lap chole to see if there are gallstones in the common bile duct (CBD), CONTRAST IS USED.

What equipment to we need? C arm, contrast, lead gown and thyroid shield

START

  • Local→MAKE SURE YOU SAY NAME OF MED WHEN YOU HAND TO SURGEON

  • DISSECT→Metz scissors

  • Fat in the way-S retractors

  • Facia-what kind of clamp? kockerx2

  • If any bleeding→bovie (coagulation)

  • Why is she holding it up? to not penetrate the bowel, aumentum anything below surface because of suture (0 vicryl ur6 FOR THE FASCIA) →pass that suture on the needle holder

  • Bonnie/rat tooth and kockers to grab fascia

  • TAG SUTURE (CRILE) FIRST ABOVE SURGEON HAND

  • CUT (STRAIGHT MAYO SCISSORS) UNDER HER FINGER

  • PASS ANOTHER SUTURE 3 O’CLOCK

  • CRILE SHOULD BE IN HAND AFTER THAT

  • hasson→attach insufflation→Carbon dioxide to fill the abdominal cavity, creates better visualization

  • LOCAL (If you just said it 5 min ago you don’t have to say it again till the next time)

  • XL trocar

TRANSITIONAL MAYO

  • Straight mayo scissor

  • Peans x2

  • Endoclip

  • Endoshear

  • Endocatch

  • 5mm scope

  • Empty 5cc syringe

  • Obturator (Hasson)

  • Raytec

NEXT..

  • Cauterize the gallbladder (grab bovie w/green cord on your side)

What are we looking for? The cystic artery, cystic duct and avoiding the common bile duct (CBD)

  • LOCKING ALLIGATOR GOES INTO XL TROCAR

  • Use hypo to fill your syringe with more medicine

  • CLIP, CLIP, CLIP (WHITE)

  • CUT, CUT CUT (BLACK)

  • 4-0 monocryl PS-2 (FOR SKIN) on a webster needle holder (small NH) to suture the skin

  • XL trocar→locking alligator

  • LOCAL (CALL IT OUT SAY THE NAME)

  • cut give knife

  • Balloon trocar

  • Inject 5cc of air

  • LOCAL

  • Another incision is made (make sure you’re putting your blade down on your mayo safely and correctly)

  • Trocar step-up alligator→maryland

  • Endocatch

  • Need to stretch the incision→Pean

  • Gallbladder is pulled out have specimen cup ready

  • Hand pean

CLOSING MAYO

  • 1 wet raytec

  • 1 dry raytec

  • Adson forcep (to hold the skin) make sure you place it on patients side ready to pass kind of off the mayo sort of

  • Straight mayo scissor

  • 4-0 monocryl PS-2 on a webster needle holder

  • Crile

  • Local

  • Medicine cup with local

CLOSING

  • 0 Vicryl-UR 6 to close fascia w/ MAYO NEEDLE HOLDER

COUNT!-NOW THAT FASCIA IS CLOSING

  • Soft count (your instruments only need to be counted if the procedure is converted to open)

LOCAL

  • Suture skin w/ 4-0 monocryl PS-2 on a webster needle holder

  • Adson forcep

  • Mayo scissor to cut suture

FINAL CLOSING COUNT!

  • Raytecs

  • sutures

  • hypos

  • blade

  • bovie w/tip

  • fred

  • asepto

Use wet and dry raytec

  • Ask for the dermabond this is opened after final count

CASE IS DONE!!

  • What do we take care of first? The patient

  • Have to wait 3 minutes is dermabond is not sterile

  • Remove all the cords

  • Push back table to wall

  • Ask CRNA for the drape→protect the incisions roll it down carefully to the patients feet

  • Cover up patient

What do we get rid of first? SHARPS

Throw away sutures and blades

Hypo stays in redbook'

Tell nurse how much medication was used