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The Phases of Surgery including the Operative Sequence

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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The Phases of Surgery including the Operative Sequence

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  1. The Phases of Surgery including the Operative Sequence

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

  3. 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

  4. 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

  5. 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

  6. Possible Complications • Known and unknown factors • Short term and long term • Direct and indirect • Towards the patient • Towards the Surgical team • Towards the environment

  7. Closure • Determined by Physician • Many different methods • May not be able to close operative site • Marks the beginning of recovery

  8. Five Phases of Surgery • Preparation • Preincision • Operative Sequence • Closing • Post operative

  9. Preparation… Phase 1 • Selection of room and supplies • Preincision count

  10. Preincision…Phase 2 • Transfer and positioning of Patient • Induction • Prep and drape • Suction and electrosurgical equipment

  11. Operative Sequence…Phase 3

  12. IncisionSequence 1 • The skin and subcutaneous tissue are divided with a skin knife • Knife is placed on backtable

  13. 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

  14. 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

  15. 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

  16. 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

  17. Surgical Repair continued... • Operation focuses on removal, resection, reconstruction, or all to correct abnormality • May require specialized instruments

  18. Hemostasis and IrrigationSequence 6 • Prep for closing • Control bleeding • Irrigate wound with saline with or without antibiotics • Insert drain if needed

  19. 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)

  20. 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

  21. 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

  22. 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

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