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GU Procedures Operative Sequence

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  1. GU ProceduresOperative Sequence

  2. 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.

  3. Circumcision • Define the procedure: • Circumcision is the removal of some or all of the foreskin (Prepuce) from the penis

  4. Circumcision • Wound Classification: 1

  5. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

  6. 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.

  7. Circumcisioncont. Operative Sequence • Dissection and Exposure: • Clamps are placed on the edge of the prepuce.

  8. Circumcisioncont. Operative Sequence • Hemostasis: Handheld Bovie, hemostats, and free ties are utilized.

  9. CircumcisionBegin your Operative Sequence • Incision: 15 kb on #3 handle or Iris scissors for incision.

  10. Circumcisioncont. Operative Sequence • Exploration and Isolation: Any?

  11. 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.

  12. Circumcisioncont. Operative Sequence • Hemostasis and Irrigation: • All bleeding is controlled with cautery. • Use of warm Saline to irrigate.

  13. Circumcisioncont. Operative Sequence • Closure: • Wound edges are brought together with small absorbable suture. • Incision is dressed with wet gauze, petroleum impregnated gauze.

  14. 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.

  15. 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.

  16. GU ProceduresOperative Sequence Orchidopexy (aka – Orchiopexy)

  17. 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.

  18. Orchidopexy • Wound Classification: 1

  19. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

  20. 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.

  21. 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?

  22. Orchidopexycont. Operative Sequence • Hemostasis: Handheld Bovie and hemostats are utilized.

  23. Orchidopexycont. Operative Sequence • Dissection and Exposure: • Metz for dissection. • Blunt dissection also used to ID Spermatic cord.

  24. 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.

  25. 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.

  26. 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.

  27. Orchidopexycont. Operative Sequence • Hemostasis and Irrigation: • Controlled with ESU. • Warm Saline • Closure: • Surgeon choice – Chromic with Bacitracin oint.

  28. Orchidopexy • Major Arteries: • external and internal pudendal arteries • Major Veins: • The scrotal veins accompany the arteries and join the external pudendal veins.

  29. GU ProceduresOperative Sequence Simple Nephrectomy

  30. 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.

  31. Simple vs. Partial vs. Radical • The three basic groups of nephrectomies are simple, partial, and radical. • Simple nephrectomy removes the kidney along with a small section of the tube that connects the kidney to the bladder (ureter). • Partial nephrectomy, only that portion of the kidney that is diseased is removed. • Radical nephrectomy removes the kidney, surrounding fat, fascia, lymph nodes, and two-thirds of the ureter.

  32. 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

  33. 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.

  34. Simple Nephrectomy • Define the procedure: • A simple nephrectomy is removal of an entire kidney. • Wound Classification: 1 WHY IS IT A CLASS 1?

  35. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

  36. 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.

  37. 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.

  38. 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.

  39. Simple Nephrectomycont. Operative Sequence • Hemostasis: Handheld Bovie, hemostats, Hemoclips, and free ties are utilized.

  40. Simple Nephrectomycont. Operative Sequence • Dissection and Exposure: • Self retaining retractor is placed in wound. • Some surgeons use two Balfours.

  41. 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.

  42. 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.

  43. 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.

  44. Simple Nephrectomycont. Operative Sequence • Hemostasis and Irrigation: • Controlled with ESU and chemical hemostasis. • Warm Saline • Closure: • Surgeon choice • Are we putting the rib back?

  45. Simple Nephrectomy • Major Arteries: • Renal Arteries

  46. Simple Nephrectomy • Major Veins: • The renal veins drain into the IVC. • Major Nerves: • renal plexus

  47. Lap Hand Assisted Nephrectomy • Watch this video! • This is how most nephrectomies are completed today. • Hand Assisted

  48. GU ProceduresOperative Sequence Cysto and TURP SuprapubicProstatectomy

  49. 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

  50. Cysto