Assisting

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Assisting in Minor Surgery Notes By Dr. Jay
Shahed
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Surgical supplies
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TYPES OF STERILE DRAPES

• Fenestrated ( With a hole )
• A drape used to cover the area around the wound
  leaving the wound exposed during surgery.
• Non-fenestrated ( Without a hole )
• A drape used to cover the wound during surgery.

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NEEDLES

• Shape
• Straight
• For superficial and continuous suturing.
• Curved
• For deep and disrupted sutures.
• Atraumatic
• Eyeless (most common).
• Traumatic
• With eye

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• Size
• Ranges between
• (3/8 inch- 5/8 inch)

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SUTURES

• Stitch
• Is a suture when sutured with a needle
• Ligature
• Is a tied suture
• Size
• 4-0thinner than 3-0 than 0-0 than 1,2,3,4, etc.
• length
• 17-60 inches

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Types of Sutures

• Absorbable
• Plain cat gut
• Surgical cat gut
• Chromic cat gut
• Non-absorbable
• Silk
• Polyester
• Nylon
• Cotton
• Steel

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Plain cat gut

• Used in areas that is most vascular and heals
  rapidly
• e.g. lips and tongue

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Surgical Cat Gut

• Used in areas that is partially vascular and
  heals moderately
• e.g. vagina

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Chromic cat gut

• Used in areas that is least vascular, heals
  slowly and has slow absorption.
• Holds tissue longer
• e.g. muscles

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Non-absorbable

• Used externally
• Removed manually after healing

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Silk

• Most expensive
• Most dependable
• Widely used
• Easy to tie
• All purpose suturing

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Polyester

• Strongest of all except for steel
• Used in
• Facial
• Ophthalmic
• Cardiovascular

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Nylon

• Elastic strong
• Used for joints
• Skin closure
• Not a very stable knot

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Cotton

• Not strong
• Not widely used

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Steel

• Staples
• -Widely used for major surgeries
• -Strongest of all

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• Wounds

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Types of wounds

• Intentional
• Accidental

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Intentional

• Open
• Surgical Incision
• neat clean cut with scalpel.
• -Hypodermic
• needle puncture (injection).
• -Laceration
• jagged, irregular cut.
• -Puncture
• pointed edge (nail)

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Accidental

• Open
• Incision -
• Non surgical cut (knife)
• Abrasion -
• Superficial scrapping.
• Avulsion -
• Imputed piece of tissue
• Closed
• Contusion -
• (hematoma or bruise)Broken vessel

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Wound Healing

• Types
• First intention
• Clean cut wound
• No scar or fine scar formation
• Second Intention
• Deep and irregular cut
• Granulation tissue formation
• Thick scar formation

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Wound Healing

• Phase One (lag phase)
• 1-4 days
• Blood vessels construct
• Platelets aggregate
• WBC migrate toward wound
• Fibrin net is formed

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• Phase Two (Proliferation Phase)
• 5-20 days
• Healing stage with new growth
• Tissue repair itself
• New cell forms
• Tissue continue to contract
• No permanent fibrous tissue formed yet

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• Phase Three (Remodeling)
• 21 days and up
• New cells bridge with collagen (connective
  tissue)
• Forming of scar tissue
• It is not true skin
• Very strong
• Lack of elasticity, nerve, or blood supply

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Healing Process Tips

• Young heals faster than old
• Adequate nutrition is needed
• Protection and rest is required
• Open wound are susceptible to infection
• Dry wound heals faster than moist
• Must debride wound from necrotic tissue pus, and
  contamination

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Surgical Dressing Bandages
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• Surgical Dressing

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Dressing

• Functions
• Project the wound
• Maintain a constant pressure
• Hold the wound edges together
• Controls bleeding
• Absorbs drainage and secretions
• Hides temporary disfigurements
• Try to obscure wound from patient when hanging
• If there is an infection tell physician

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Types of Dressing

• Non Adhesive pads
• Steri Strips
• Bandages
• Tape

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Non Adhesive

• Lubricated pads with antibiotics
• Used directly on to wound after suturing
• Example TELFA

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Steri - Strips

• Replace sutures
• Used for a clean laceration
• Used in areas protected from movements
• Used on fine structures
• Example (face)

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• Bandages

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• Types
• Plain Gauze
• Plain Elastic (ACE)
• Adhesive
• Seamless Tubular Gauze
• Placed over dressing for further help of pressure
  support
• Distal to proximal
• Smaller to larger circumference
• Roller facing up (always)
• Consistent in space to ensure even pressure

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Plain Gauze

• Wrinkled crepe
• Types
• Kling
• Has holes to adhere to the skin and itself
• Size 4x4, 2x2 rollers

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Plain Elastic

• Types (ACE)
• Reasonable
• Strong
• Used for stabilization

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Adhesive

• Types
• Band-Aids
• Rectangular
• Spots

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Seamless Tubular Gauze

• Types
• Surgi-tube
• Covering round surfaces
• e.g.-(extremities)
• Should not be sued under casts

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• Electro Surgery (Cauterization)

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Usage of electrical current

• Incises/ Excises or Destroys tissues
• Used instead of scalpel or curettes
• Control the shape and size of a surgical site
• Area is automatically sterilized (burned)

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Advantages

• Controls bleeding
• Aseptic technique

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Components

• Power unit
• Cable with a grounding pad
• Electrosurgical wire that connects to
• Blade
• Needle
• Disc
• Loops

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Types of Current

• Damped
• Used for coagulation
• Undamped
• Used for cutting

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Procedure

• Before Procedure
• Remove all metals
• Apply freezing for anesthesia
• Site should be dry (moist could heat tissues)
• After Procedure
• No dressing needed
• Dont sterilize wires tip
• The heat burns sterilizes it.

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Types of Procedure

• Electrocoagulation
• Electrofulguration
• Electrodesiccation
• Electrosection

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Electrocoagulation

• Needle or disc touches the tissue directly
• Burn tissue (grayish discharge)
• Tissues are pushed out after 5-15 days
• Give antibiotics
• Usage
• Bleeding coagulation

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Electrofulguration

• Lighting or spark
• Needle does not touch tissue directly had to be
  1-2 mm away
• Usage
• Excise polyps or cancer cells

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Electrodesiccation

• Needle is inserted into tissues
• Usage
• Used to destroy warts, polyps

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Electrosection

• Knife, blade, electrode
• Usage
• Excise incise

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Laser

• Description
• Emission of radiation by light amplification
  through a tube at a microscopic level
• Usage
• Coagulation and vaporization (carbon steam)
• Delicate and fine tissues
• Example Eyes (retina detachment repair), brain,
  spinal cord, GI
• Must wear safety goggles
• Suction of steam ( Co2 ).

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Aseptic Technique and Sterile Field
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Facts

• Either it is sterile or non sterile and no in
  between.
• No motion in a sterile field
• Air carry bacteria so Sterile team faces each
  other
• Never turn your back to sterile field
• The back is non sterile
• 1 inch around and below the sides of a sterile
  field is considered non sterile
• Moisture contaminates the sterile field

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Types of Surgical Assistants

• Scrubbed
• Scrub surgically and does not leave the sterile
  field
• Circulating
• Assistant handling both sterile and non sterile
  steps or procedure
• Scrub or un-scrub according to the situation.

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Steps in Preparing a Patient for Surgical
Procedure (Circulating Assistant).

• Non Sterile Steps
• Wash hands (medical aseptic)
• Lay patient in needed position
• Drape the non sterile parts of patient if does
  not have a gown
• Assemble all instruments needed for procedure
  without contaminating the sterile field

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• Sterile Steps
• Scrub, glove and gown
• Approach the sterile field and prepare the
  patients skin surgical site ( Open wound or
  closed wound).
• Cover site with fenestrated and non fenestrated
  drapes.
• Line all sterile instruments in the correct order
  per needed procedure.

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• Back to Non Sterile Steps
• Unglove from the previous sterile procedure.
• Assemble all missing sterile instruments
• Call physician
• Assist in scrubbing and gloving gowning the
  physician.
• Assist in handing the physician all side counter
  instruments and materials
• Ask Physician if he or she needs you to scrub.

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• Procedures
• And
• Surgical Trays

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Preparing Patient (Intact Skin)

• Procedures tray setup
• Sterile field
• Sterile drapes
• Gauze(4x4)
• Stainless steel bowl
• Betadine swaps
• Forester Forceps
• Side counter ( Non sterile )
• Contamination waste bag.

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Preparing Patient (Intact Skin)

• Procedure ( Sterile )
• Used in any procedure with intact skin before
  surgical procedure
• Apply betadiene using the swap in a circular
  motion.
• Dry with sterile gauze using the Foresters
  forceps in an in-out motion
• Repeat procedure three times

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Preparing Patient skin Open Wound

• Procedures tray setup
• Sterile field
• Same as for the Intact skin procedure.
• Side counter ( Non sterile )
• Same as for the Intact skin procedure

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Preparing Patient skin Open Wound

• Procedure ( Sterile )
• Apply Betadine in an (in-out) motion from inside
  wound out to periphery.
• Dry with sterile gauze in (in - out) motion the
  intact skin.

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Laceration Repair

• Procedures tray setup
• Sterile field
• Drape( fenestrated non-fenestrated
• Sterile syringe
• Scissors ( Mayo, OS S/S, S/B
• Scalpel/Blade
• Forceps( Plain thumb, Forester,
  Kelly,Halsted,Needle holder).
• Gauze ( 4x4 )
• Sutures
• Cauterizer or Coagulant gel.

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Laceration Repair ( continue )

• Procedures setup ( continue )
• Side counter( Non sterile )
• Local Anesthesia ( Lidocaine or Xylocaine)
• (Use a bottle of sterile water)
• Hydrogen Peroxide
• Dressing material
• Neosporin ointment
• Non adhesive pads ( Telfa )
• Gauze ( 4x4 )
• Elastic tape
• Roller gauze bandage.

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Laceration Repair

• Procedure ( Sterile )
• Prepare the patient open wound/ Assemble
  instruments
• Physician will
• Apply anesthesia.
• Remove any contamination be either irrigating the
  wound with Normal Saline solution or by Hydrogen
  Peroxide.
• Stops bleeding using gauze, hemostats or a
  Cauterizer.
• Dry wound with gauze.
• Debride necrotic tissues with a Mayo Scissors.

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Suture Removal tray

• Procedures tray setup
• Sterile field
• Scissors ( Littauer)
• Forceps ( plain thumb )
• Gauze ( 4x4 )
• Side counter( Non sterile )
• Dressing material

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Suture Removal tray

• Procedure (Non-sterile)
• MA is capable of removing sutures.
• Using a Littauer Scissors and a Plain Thumb
  Forceps cut the opposite side of the knot then
  pull the side of the knot out.
• Keep removed sutures on a gauze for physician to
  confirm that the same number removed as the
  number sutured..

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Needle Biopsy Procedure

• Procedures tray setup
• Sterile field
• Sterile syringe
• Biopsy needle( Silverman )
• Gauze ( 4x4 )
• Side counter( Non sterile )
• Local Anesthesia
• Band-aid
• Specimen bottle
• (Use a urine cup)

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Needle Biopsy Procedure

• Procedure (Sterile)
• M.A will
• Prep. Patient intact skin
• Physician will
• Numb site
• Insert Silverman biopsy needle into biopsy site
• Place sample tissue into Formalin container.
• Place a bandage on site to stop possible bleeding.

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Cyst Removal Procedure

• Procedures tray setup
• Sterile field
• Same supplies as for the Laceration repair tray.
• Drape( fenestrated non-fenestrated
• Sterile syringe
• Scissors ( Mayo, OS S/S, S/B
• Scalpel/Blade
• Forceps( Plain thumb, Forester,
  Kelly,Halsted,Needle holder)
• Gauze ( 4x4 )
• Sutures
• Cauterizer or Coagulant gel

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Cyst Removal Procedure (continue)

• Procedures setup ( continue )
• Side counter( Non sterile )
• Local Anesthesia ( Lidocaine or Xylocaine)
• (Use a bottle of sterile water)
• Hydrogen Peroxide
• Specimen bottle (Formalin)
• Use a urine cup
• Dressing material
• Neosporin ointment
• Non adhesive pads ( Telfa )
• Gauze ( 4x4 )
• Elastic tape
• Roller gauze bandage.

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Cyst Removal Procedure

• Procedure (Sterile)
• M.A will
• prep. Patient intact skin
• Physician will
• Numb patient
• Incise around cyst using a Scalpel
• Remove cyst and place in Formalin
• Stop bleeding
• Close wound

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Incision Drainage Procedure ( I D )

• Procedures tray setup
• Sterile field
• Drape( fenestrated non-fenestrated
• Sterile syringe
• Scissors ( Mayo, OS S/S, S/B
• Scalpel/Blade
• Gauze ( 4x4 )
• Forceps( Plain thumb, Forester, Kelly,Halsted)
• Packing material ( Iodine ).
• Probe
• Oschsner.
• Side counter( Non sterile )
• Waste bag.

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Incision Drainage Procedure ( I D )

• Procedure ( Sterile )
• M.A will
• Prep. Patient open wound
• Physician will
• Numb Patient
• Incise the absence site to make it larger
• Drain manually or using the Oschsner
• Stop bleeding
• Irrigate the wound
• Pack wound with packing material
• Leave wound open

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Pap Smear

• Procedures tray setup
• Sterile field
• Vaginal speculum( Graves)
• Side counter( Non sterile )
• Drape
• Light source
• Pap Kit( Scraper,cotton applicators
• Slides
• Fixative solution.

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Pap Smear

• Procedure (Non-Sterile)
• M.A will
• Patient in the lithotomy position
• Physician will
• Scrap sample form cervix using the spatula or
  scraper smear on slide-A
• Swap another sample and smear on slide-B
• Fix the smear
• Label card

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Cervical Biopsy

• Procedures tray setup
• Sterile field
• Vaginal speculum ( Graves)
• Forceps ( Bozeman, Schroder Tenaculum)
• Gauze ( 4x4)
• Cutaneous punch
• Coagulant gel ( Mustard )
• Side counter( Non sterile )
• Drapes
• Lubricant
• Skin antiseptic
• Specimen bottle ( Formalin )
• Tampon.

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Cervical Biopsy

• Procedure ( Sterile)
• M.A willPatient in the Lithotomy position
• Physician will
• Apply antiseptic to cervix
• No anesthesia is needed-cervix has very small
  amount of nerve ending
• Using a cutanous punch, incise a piece of tissue
• Preserve in Formalin
• Stop bleeding using coagulation gel (mustard)
• Use a tampon for security