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GU Procedures Operative Sequence. Circumcision. Overall Purpose of Procedure : Performed to prevent infection and inflammation of the glans. a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases.

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circumcision
Circumcision
  • Overall Purpose of Procedure:
    • Performed to prevent infection and inflammation of the glans.
    • a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases.
    • Circumcision may also be used to treat Phimosis: a constriction of the opening of the foreskin so that it cannot be drawn back over the tip of the penis.
circumcision1
Circumcision
  • Define the procedure:
    • Circumcision is the removal of some or all of the foreskin (Prepuce) from the penis
circumcision2
Circumcision
  • Wound Classification: 1
operative sequence
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
circumcision3
Circumcision
  • Instrumentation: Minor Instrument Tray/ Ped Tray (age specific).
  • What basic instruments will you expect to see in this tray?
  • Positioning: The patient is in supine position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient.
  • Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Prep groin area and far lateral on both sides.
  • Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.
    • Age specific – if ped- MD might want ped drape.
circumcision cont operative sequence
Circumcisioncont. Operative Sequence
  • Dissection and Exposure:
    • Clamps are placed on the edge of the prepuce.
circumcision cont operative sequence1
Circumcisioncont. Operative Sequence
  • Hemostasis: Handheld Bovie, hemostats, and free ties are utilized.
circumcision begin your operative sequence
CircumcisionBegin your Operative Sequence
  • Incision: 15 kb on #3 handle or Iris scissors for incision.
circumcision cont operative sequence2
Circumcisioncont. Operative Sequence
  • Exploration and Isolation: Any?
circumcision cont operative sequence3
Circumcisioncont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • Iris, Tenotomy or Metz.
    • Long Incision on the dorsal side of the foreskin.
    • Incision is continued round the foreskin, circumferentially.
circumcision cont operative sequence4
Circumcisioncont. Operative Sequence
  • Hemostasis and Irrigation:
    • All bleeding is controlled with cautery.
    • Use of warm Saline to irrigate.
circumcision cont operative sequence5
Circumcisioncont. Operative Sequence
  • Closure:
    • Wound edges are brought together with small absorbable suture.
    • Incision is dressed with wet gauze, petroleum impregnated gauze.
circumcision4
Circumcision
  • Major Arteries:
    • The dorsal arteries, which run in the interval between the corpora cavernosa on each side of the deep dorsal vein.
    • The dorsal and deep arteries are branches of the internal pudendal arteries.
    • The deep arteries are the principal vessels that supply the cavernous spaces (erectile tissue) in the three corpora.
circumcision5
Circumcision
  • Major Veins:
    • Blood from the cavernous spaces is drained by a venous plexus that joins the deep dorsal vein located in the deep fascia.
  • Major Nerves:
    • pudendal nerve.
orchidopexy aka orchiopexy

GU ProceduresOperative Sequence

Orchidopexy

(aka – Orchiopexy)

orchidopexy
Orchidopexy
  • Define the procedure:
    • to move an undescended testicle into the scrotum
  • Overall Purpose of Procedure:
    • Relieve Cryptorchidism - a medical term referring to absence from the scrotum of one or both testes. This usually represents failure of the testis to move, or "descend," during fetal development.Can lead to sterility due to heat in the abdomen.
    • Orchiopexy can also be performed to resolve a testicular torsion. If caught early enough and the blood supply can be restored to the testicle, this operation can be performed to prevent further occurrence of torsion.
orchidopexy1
Orchidopexy
  • Wound Classification: 1
operative sequence1
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
orchidopexy2
Orchidopexy
  • Instrumentation: Minor Tray
  • Positioning: The patient is in supine position arms on arm boards.
  • Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Prep from pubic line to iliac crest to groin and far lateral on both sides.
  • Draping: 4 towels and a lap drape. Ask about towel clips.
orchidopexy begin your operative sequence
OrchidopexyBegin your Operative Sequence
  • Incision: 15 kb on #3 handle for incision.
  • Incision over the external ring, extended into the deep inguinal ring.
  • Anything wrong with this picture?
orchidopexy cont operative sequence
Orchidopexycont. Operative Sequence
  • Hemostasis: Handheld Bovie and hemostats are utilized.
orchidopexy cont operative sequence1
Orchidopexycont. Operative Sequence
  • Dissection and Exposure:
    • Metz for dissection.
    • Blunt dissection also used to ID Spermatic cord.
orchidopexy cont operative sequence2
Orchidopexycont. Operative Sequence
  • Exploration and Isolation:
    • The spermatic cord is freed high into the inguinal ring to provide enough slackness for the testicle to fall into the scrotum.
orchidopexy cont operative sequence3
Orchidopexycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • A tunnel must be created thru the external oblique fascia for the testicle to follow into the scrotum.
    • This tunnel can be created with blunt dissection or a kelly clamp.
orchidopexy cont operative sequence4
Orchidopexycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • A small incision is made into the scrotum to expose the scrotal septum.
    • The testicle is moved thru the tunnel into the scrotum.
    • Sutures (Chromic) are placed into the testicle and scrotal septum to hold testicle into place.
orchidopexy cont operative sequence5
Orchidopexycont. Operative Sequence
  • Hemostasis and Irrigation:
    • Controlled with ESU.
    • Warm Saline
  • Closure:
    • Surgeon choice – Chromic with Bacitracin oint.
orchidopexy3
Orchidopexy
  • Major Arteries:
    • external and internal pudendal arteries
  • Major Veins:
    • The scrotal veins accompany the arteries and join the external pudendal veins.
simple open nephrectomy
Simple (Open) Nephrectomy
  • Overall Purpose of Procedure:
    • The reasons for performing a simple nephrectomy include:
    • Cancer in the kidney.
    • Large stones in the kidney.
    • The kidney may be damaged and very small, causing high blood pressure.
    • The kidney may have an infection that antibiotic treatment cannot cure.
simple vs radical
Simple vs Radical
  • A simple nephrectomy is indicated in patients with irreversible kidney damage due to symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury.
  • Simple nephrectomy is also indicated to treat renovascular hypertension due to noncorrectable renal artery disease or severe unilateral parenchymal damage caused by nephrosclerosis, pyelonephritis, reflux dysplasia, or congenital dysplasia of the kidney.
  • Sometimes, just a part of the kidney may be removed
simple vs radical1
Simple vs Radical
  • Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). In certain circumstances, radical nephrectomy is also indicated to treat locally advanced RCC and metastatic RCC.
  • Radical nephrectomy remains the procedure of choice for surgically resectable lesions.
  • Your surgeon will also take out the adrenal gland and some lymph nodes.
simple nephrectomy1
Simple Nephrectomy
  • Define the procedure:
    • A simple nephrectomy is removal of an entire kidney.
  • Wound Classification: 1 WHY IS IT A CLASS 1?
operative sequence2
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
simple nephrectomy2
Simple Nephrectomy
  • Instrumentation: Major Tray, Long Abdominal Tray, Self Retaining Ret x2, Chest/Rib Tray (if you facility has one) Have Vascular tray in room -hold
    • What basic instruments will you expect to see in the Chest/Rib tray?
  • Positioning: The patient is in lateral kidney position, lower arm tucked at the side or on an arm board, upper arm on arm board/ airplaned. 2 Surgeons for this procedure. One in front of and one in back of patient.
  • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from nipple line to iliac crest and far lateral on both sides.
  • Draping: 4 towels and a lap drape. Ask about towel clips.
simple nephrectomy begin your operative sequence
Simple NephrectomyBegin your Operative Sequence
  • Incision: 10 kb on #3 handle for incision.
  • Flank incision
  • Incision over or between the 11th or 12th rib.
  • Another approach – less used- incision under the rib cage.
simple nephrectomy begin your operative sequence1
Simple NephrectomyBegin your Operative Sequence
  • Incision:
    • If the surgeon(s) wants to remove the rib, instead of going between the ribs:
      • Need Doyen rib rasp to remove the periosteum from the bone.
      • Have rib shear ready to remove bone.
      • Usually not sent as a specimen.
      • Do not take home with you for rib roast.
simple nephrectomy cont operative sequence
Simple Nephrectomycont. Operative Sequence
  • Hemostasis: Handheld Bovie, hemostats, Hemoclips, and free ties are utilized.
simple nephrectomy cont operative sequence1
Simple Nephrectomycont. Operative Sequence
  • Dissection and Exposure:
    • Self retaining retractor is placed in wound.
    • Some surgeons use two Balfours.
simple nephrectomy cont operative sequence2
Simple Nephrectomycont. Operative Sequence
  • Exploration and Isolation:
    • Incision is made thru the subcutaneous and oblique muscles.
    • Gerota\'s Capsule is ID’d
      • A fibrous envelope of tissue that surrounds the kidney. Also called renal fascia and Gerota\'s fascia.
simple nephrectomy cont operative sequence3
Simple Nephrectomycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • The ureter is identified, clamped and ligated.
    • The kidney pedicle and renal Artery and Renal Vein are clamped and ligated.
    • Renal Vessels are usually triple clamped/tied for safety.
simple nephrectomy cont operative sequence4
Simple Nephrectomycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • Care is taken to not damage the ureter.
    • The kidney is then mobilized with blunt dissection.
    • The kidney is then removed from the wound.
    • Check the pedicle vessels for bleeding.
simple nephrectomy cont operative sequence5
Simple Nephrectomycont. Operative Sequence
  • Hemostasis and Irrigation:
    • Controlled with ESU and chemical hemostasis.
    • Warm Saline
  • Closure:
    • Surgeon choice
    • Are we putting the rib back?
simple nephrectomy3
Simple Nephrectomy
  • Major Arteries:
    • Renal Arteries
simple nephrectomy4
Simple Nephrectomy
  • Major Veins:
    • The renal veins drain into the IVC.
  • Major Nerves:
    • renal plexus
lap hand assisted nephrectomy
Lap Hand Assisted Nephrectomy
  • Watch this video!
  • This is how most nephrectomies are completed today.
  • Hand Assisted
cysto and turp suprapubic prostatectomy

GU ProceduresOperative Sequence

Cysto and TURP

SuprapubicProstatectomy

cystoscopy
Cystoscopy
  • Cystoscopy is a procedure that allows the doctor to look at the inside of the bladder and the urethra using a thin, lighted instrument called a cystoscope
cysto2
Cysto
  • Cystoscopy may be done to:
  • Find the cause of symptoms such as blood in the urine (hematuria), painful urination (dysuria), urinary incontinence, urinary frequency or hesitancy, an inability to pass urine (retention), or a sudden and overwhelming need to urinate (urgency).
cysto3
Cysto
  • Find the cause of problems of the urinary tract, such as frequent, repeated urinary tract infections or urinary tract infections that do not respond to treatment.
  • Look for problems in the urinary tract, such as blockage in the urethra caused by an enlarged prostate, kidney stones, or tumors
  • Evaluate problems that cannot be seen on X-ray or to further investigate problems detected by ultrasound or during intravenous pyelography (IVP), such as kidney stones or tumors.
cysto4
Cysto
  • Remove tissue samples for biopsy.
  • Remove foreign objects.
  • Place ureteral catheters (stents) to help urine flow from the kidneys to the bladder.
  • Treat urinary tract problems. For example, cystoscopy can be done to remove urinary tract stones or growths, treat bleeding in the bladder, relieve blockages in the urethra, or treat or remove tumors.
  • Place a catheter in the ureter for an X-ray test called retrograde pyelography. A dye that shows up on an X-ray picture is injected through the catheter to fill and outline the ureter and the inside of the kidney.
slide54
TURP
  • (TRANSURETHRAL RESECTION OF PROSTATE).
  • During transurethral resection of the prostate (TURP), an instrument is inserted up the urethra to remove the section of the prostate that is blocking urine flow.
slide55
TURP
  • TURP is now the most common surgery used to remove part of an enlarged prostate. Open prostatectomies (in which an incision is made into the abdomen) generally are needed only when the prostate is very large.
fluids
Fluids
  • Old School: Glycine is fluid of choice
  • New School: NACL!!! Usually the team will not use NACL due to the fact that they can’t use the electrode needed for a TURP with NACL present. However, too much NACL will throw the fluid balance of your patient off. Your pt can end up with fluid toxicity!
  • New systems are bipolar instead of monopolar.
suprapubic prostatectomy2
Suprapubic Prostatectomy
  • Overall Purpose of Procedure:
    • Performed to treat BPH (benign prostatic hypertrophy) and for cancer of the prostate.
    • Inguinal nodes may be removed for diagnosis of metastasis.
suprapubic prostatectomy3
Suprapubic Prostatectomy
  • Define the procedure:
    • The prostate gland is removed via a suprapubic (above the pubic bone) incision.
    • Three primary approaches are commonly employed:
      • Suprapubic - removal through an incision above the pubis and through the urinary bladder;
      • Retropubic – same incision as for suprapubic but without entering the urinary bladder
      • Transurethral (TRANSURETHRAL RESECTION OF PROSTATE).
radical vs simple
Radical vs Simple
  • Radical vs Simple Prostatectomy
    • Radical – nerve sparing
    • Simple – not so much! Simple coring of the prostate. No nerves spared.
suprapubic prostatectomy4
Suprapubic Prostatectomy
  • The major advantage of the suprapubic approach over the retropubic approach is that it permits better visualization of the bladder neck and ureteral orifices and, therefore, is better suited for patients with the following conditions:
    • Enlarged, protuberant, median prostatic lobe
    • Bladder diverticulum
    • Large bladder calculi
    • Obesity (to a degree that makes access to the retropubic space more difficult)
suprapubic prostatectomy5
Suprapubic Prostatectomy
  • Wound Classification: 2
operative sequence3
Operative Sequence
  • 1- Incision
  • 2- Hemostasis
  • 3- Dissection
  • 4- Exposure
  • 5- Procedure (Specimen Collection possible)
  • 6- Hemostasis
  • 7- Irrigation
  • 8- Closure
  • 9- Dressing Application
suprapubic prostatectomy6
Suprapubic Prostatectomy
  • Instrumentation: Major Tray, Long Abdominal Tray, Self Retaining Ret, Prostate Tray (if you facility has one) Have Vascular tray in room -hold
    • What basic instruments will you expect to see in the Prostate tray? McDougal?
  • Positioning: The patient is in supine position (possible low Lithotomy), arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient. Slight Trendelenburg possible, might need shoulder boards.
  • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep mid-chest to groin area and far lateral on both sides. Watch for pooling of prep around groin. Catheter?
  • Draping: 4 towels ( Top, side, side, under scrotum) and a lap drape. Ask about towel clips.
suprapubic prostatectomy begin your operative sequence
Suprapubic ProstatectomyBegin your Operative Sequence
  • Incision: 10 kb on #3 handle for incision.
  • Made into the space of Retzius(named after a Swedish professor of anatomy, Anders Retzius.)
  • The separation of transversalis fascia and peritoneum contains loose fatty tissue allowing for the filling of the bladder. This space is called the retropubic space of Retzius.
suprapubic prostatectomy cont operative sequence
Suprapubic Prostatectomycont. Operative Sequence
  • Hemostasis: Handheld Bovie, hemostats, Hemoclips, and free ties are utilized.
suprapubic prostatectomy cont operative sequence1
Suprapubic Prostatectomycont. Operative Sequence
  • Dissection and Exposure:
    • Self retaining retractor is placed in wound.
    • Have MANY sutures available.
    • Chromic, Vicryl, Monocryl etc.
suprapubic prostatectomy cont operative sequence2
Suprapubic Prostatectomycont. Operative Sequence
  • Exploration and Isolation:
    • 2 traction sutures or Allis Clamps are placed in the bladder wall and an incision is made between them (cystotomy).
    • The bladder wall edges are them lifted up and away, providing visualization of the bladder neck, ureters and prostate.
suprapubic prostatectomy cont operative sequence3
Suprapubic Prostatectomycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • Prostate mucosa is incised with the ESU.
    • Bladder neck is incised with the ESU.
    • Urethra is transected.
    • Enucleation = in this case it means to remove the prostate en bloc without trauma to the bed of the tissue.
      • (Enucleation usually refers to the removal of the eye, leaving the eye muscles and remaining orbital contents intact)
suprapubic prostatectomy cont operative sequence4
Suprapubic Prostatectomycont. Operative Sequence
  • Surgical Repair/Removal/Specimen Collection:
    • This is where the book goes into closure.
    • What step have we not covered?
suprapubic prostatectomy cont operative sequence5
Suprapubic Prostatectomycont. Operative Sequence
  • Surgical Repair:
    • We must reattach the urethra!
      • Using 2-0 Vicral sutures on 5-8 circle tapered needles, full thickness sutures are placed at 12, 3, 6, and 9 o\'clock positions through the urethral mucosa, smooth muscle, striated urethral sphincter, and fascia. At the 6 o\'clock position the suture is placed with care to avoid injuring the neurovascular bundles, which are located posterior to the striated sphincter. At the 12 o\'clock position the suture incorporates the anterior dorsal vein/striated urethra sphincter hood.
suprapubic prostatectomy cont operative sequence6
Suprapubic Prostatectomycont. Operative Sequence
  • Hemostasis and Irrigation:
    • Many, many, many chromic and Vicryl sutures and hemoclips and ESU
    • Warm Saline
  • Closure:
    • Surgeon choice
suprapubic prostatectomy7
Suprapubic Prostatectomy
  • Major Arteries:
    • the inferior vesical and middle rectal arteries which are branches of the internal iliac artery.
suprapubic prostatectomy8
Suprapubic Prostatectomy
  • Major Veins:
    • prostatic venous plexus around the sides and base of the prostate which drains into the internal iliac veins.
  • Major Nerves:
    • Parasympathetic fibers arise from the pelvic splanchnic nerves (S2, S3, and S4).
    • The sympathetic fibers are from the inferior hypogastric plexuses.
slide79
Vids
  • Robotic: Weill Cornell Robotic Prostatectomy
  • Actual View: Nerve Sparing Prostate Cancer
implants
Implants
  • Penile implants are artificial devices implanted inside the penis that allow men with erectile dysfunction (ED) to achieve an erection. They\'re also sometimes used to treat Peyronie\'s disease, a disorder that causes bent or painful erections.
  • There are two basic designs of implants:
  • Inflatable. Also called hydraulic, inflatable implants can be pumped up to create an erection and then deflated.
  • Semirigid. These implants are always somewhat firm.
history
History
  • First introduced in the 1970s, penile implants were the most reliable treatment for erectile dysfunction until the 1980s when medications injected into the penis became available. In the 1990s, oral agents such as sildenafil (Viagra) were introduced.
there are two basic types of penile implants
There are two basic types of penile implants
  • 1) Semirigid rods.
  • This type of implant is always firm. The penis may be bent away from the body to have sex and toward the body to conceal the device.
old school
Old School
  • Old School manual implant.
2 inflatable implants
2) Inflatable implants
  • Three-piece implants use a fluid-filled reservoir implanted under the abdominal wall, a pump-and-release valve placed inside the scrotum, and two inflatable cylinders inside the penis. Before sex, the patient pumps the fluid from the reservoir into the cylinders to cause an erection. After sex, the pt release the valve inside the scrotum to drain the fluid back into the reservoir.
  • The two-piece model currently available in the United States works in a similar way to a three-piece design, but the fluid reservoir is part of the pump mechanism implanted in the scrotum.
new school1
New School
  • Pumps in abdomen, thigh or scrotum.
slide91

In the United States, inflatable devices are the most common type of penile implant.

Three-piece inflatable devices are used in about 70 percent of penile implants.

Two-piece inflatable devices are used about 20 percent of the time.

Semirigid devices are the least used, accounting for about 10 percent of implants.

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