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The Phases of Surgery including the Operative Sequence. “Be curious always! For knowledge will not acquire you; you must acquire it...” Sudie Black. The Art of Intelligent Assistance.

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“Be curious always! For knowledge will not acquire you; you must acquire it...” Sudie Black

the art of intelligent assistance
The Art of Intelligent Assistance...
  • Requires a working knowledge of the sequential steps for a specific surgical procedure based upon four concepts:
  • Approach
  • Procedure
  • Possible Complications
  • Closure
approach
Approach
  • Determined by Physician
  • Approved by Anesthesia
  • Based upon positioning of patient
  • Offers the best exposure
  • Has the lowest amount of tissue trauma
  • Subject to change given the situation
procedure
Procedure
  • Determined by the Physician
  • Agreed to by the patient
  • Specific principles of surgery
  • Basic principles applied from similar surgeries
  • Services related to surgical intervention
possible complications
Possible Complications
  • Known and unknown factors
  • Short term and long term
  • Direct and indirect
  • Towards the patient
  • Towards the Surgical team
  • Towards the environment
closure
Closure
  • Determined by Physician
  • Many different methods
  • May not be able to close operative site
  • Marks the beginning of recovery
five phases of surgery
Five Phases of Surgery
  • Preparation
  • Preincision
  • Operative Sequence
  • Closing
  • Post operative
preparation phase 1
Preparation… Phase 1
  • Selection of room and supplies
  • Preincision count
preincision phase 2
Preincision…Phase 2
  • Transfer and positioning of Patient
  • Induction
  • Prep and drape
  • Suction and electrosurgical equipment
incision sequence 1
IncisionSequence 1
  • The skin and subcutaneous tissue are divided with a skin knife
  • Knife is placed on backtable
hemostasis sequence 2
HemostasisSequence 2
  • Bleeders are dealt with by electrical or mechanical hemostatic means according to surgeon’s preference
  • A raytex sponge or laparotomy sponge (lap) is used to aid in further visualization for sources of bleeding
dissection and exposure sequence 3
Dissection and ExposureSequence 3
  • A clean knife, Metz scissors, or cautery are used to incise deep fascia and peritoneum
  • Various instrumentation is used to elevate tissue and expose tissue that is to have surgery performed on it
  • For example a hemostat may be used to elevate the peritoneum to avoid damage to underlying contents as it is penetrated and cut with a cautery
  • Toothed forceps are use on fascia
exploration and isolation sequence 4
Exploration and IsolationSequence 4
  • Operative area is explored and pathology is isolated
  • At times the operative site is obscured by surrounding tissue
  • Bone will be scraped to expose a fracture for plating and screw application
  • Sponges, retractors, tissue extraction, and manual manipulation of tissue may be used to maximize exposure
surgical repair sequence 5
Surgical RepairSequence 5
  • Excision or revision
  • Depends upon purpose and local anatomy
  • May require a certain amount of dissection
  • Instrument length increases with depth of incision
  • Needed instruments and supplies given to surgeon as needed
surgical repair continued
Surgical Repair continued...
  • Operation focuses on removal, resection, reconstruction, or all to correct abnormality
  • May require specialized instruments
hemostasis and irrigation sequence 6
Hemostasis and IrrigationSequence 6
  • Prep for closing
  • Control bleeding
  • Irrigate wound with saline with or without antibiotics
  • Insert drain if needed
specimen sequence 7
SpecimenSequence 7
  • Gather specimen
  • Identify specimen verbally to surgeon then to circulator prior to passing off
  • Pass off field to circulator (ask surgeon’s permission)
  • Be sure to ask how specimen is to be preserved (permanent or frozen/fresh)
closing phase 4
Closing…Phase 4
  • The first count takes place before the any cavity is closed. This means everything!
  • The second count is done after the cavity and fascia are closed serially, again everything!
  • If a cavity has not been entered all sponges and miscellaneous items must be counted and verified prior to wound closure
  • Anesthesia reversal and stabilization
  • Application of dressing and tape
postoperative phase 5
Postoperative…Phase 5
  • Maintain sterile field until patient stability has ensured by the anesthesia provider
  • Get their permission to break down
  • Some cases require preservation of the sterile field until the patient has left the room: any case where airway compromise is a potential complication (Thyroidectomy/parathyroidectomy/facial or throat surgery) and any case that has potential hemorrhage as a complication (Carotid artery endarterectomy/Abdominal aortic aneurysmectomy /trauma)
  • Prepare to transfer
  • Transfer to PACU
  • Post-procedural routine
in conclusion
In conclusion...
  • Discussed the four concepts of surgery
  • Named five phases of surgery and discussed them
  • Discussed preparation, preincision operative, closing, postoperative phases.
  • Discussed in depth the seven steps in the operative sequence