Assisting at Surgical Operations : A Practical Guide

There are many superb books on how to do operations but there are few or none on how to assist at them, and none written either by or for medical students or doctors. Therefore, the skills that make an expert surgical assistant are difficult to acquire. Normally, they can only be learnt in a haphazard way, by spending years in the operating theatre. This book describes those skills in a concise and systematic way, in surgery in general, and in ten different speciality areas. Although intended mainly for clinical-level medical students and junior doctors, other people who assist at surgical operations, including general practitioners, nurse assistants and surgical technologists, will also find it useful. Whether planning a career in surgery, or simply aiming for high marks in a surgical rotation, there are few better ways to impress a surgeon than by skilfully assisting at surgical operations. Half-title 3 Title 5 Copyright 6 Contents 7 Contributors 9 Foreword 11 Preface 13 Part 1 Introduction to the perating theatre 15 A note on terminology 15 1 General conduct in the operating theatre 17 Relationship with theatre staff 17 Medio tutissimus ibis. [The middle course is safest and best.] 19 Activity versus passivity 19 Stress 19 Talking in the operating theatre 20 Pagers and mobile (cell) phones 21 Food and drink 21 If you feel faint 22 Know dimensions 22 2 Universal Precautions 23 Transmissible disease in the operating theatre 23 If you suffer a needle-stick injury 23 If you suffer an eye splash 24 3 Clothing in the operating theatre 25 Scrubs 25 Other operating theatre clothing 26 Hat 26 Face mask 27 Eye protection 27 Footwear 28 Jewellery 28 Re-entering the operating suite 29 4 Personnel: who’s who in the operating theatre 30 Doctors 30 Nurses 30 Instrument nurses or ‘scrub nurses’ 30 Scout nurses (known as ‘runners’ in the United Kingdom) 31 Anaesthetic nurses 31 Other personnel 31 Theatre orderlies 31 Radiographers 31 Part 2 The operation itself 33 5 Preparing for the operation 35 6 General intra-operative principles 38 Concentrate on your task 38 Anticipation 39 Sharps 41 Adjusting the light source 41 Steady hands 42 Improving the surgeon’s view 43 7 General stages common to operations 44 Preparation by the anaesthetist 44 Setting up (positioning the patient and equipment) 44 Patient positioning 44 Applying anti-thromboembolic devices 45 Shaving 46 Skin preparation 46 Draping 46 Marking the incision with a surgical skin-marking pen 46 Entry 46 Mobilisation 46 The key therapeutic objective 47 Reconstruction 47 Haemostasis (‘stopping the bleeding’) 47 Washing out (also known as irrigation or lavage) 47 Drain insertion 47 Closure of the wound 48 Local anaesthetic instillation 48 Dressings 48 Other: key points 48 8 Sterility and the ‘sterile zone’ 49 Waterproof gowns 50 Scrubbing 50 Scrub taps 50 When to scrub 51 Scrub technique 51 Drying the hands 52 Gowning 52 Gloving 53 Glove size 53 Glove type 53 Donning gloves 54 Donning gloves: assisted method 56 Donning gloves: unassisted method (see Figure 8.1) 54 Where to put your hands (see Figure 8.3) 56 Shaving, antiseptic painting and draping 59 Shaving 59 Antiseptic painting 59 Sterility Draping 61 Clipping the drapes 61 Setting up instruments 63 Incise drapes 63 9 Tissue planes: traction and counter-traction 65 10 Surgical instruments: their names and how to use them 68 Introduction 68 Types of surgical instruments 69 Basic instruments 69 Cutting instruments 69 Gripping instruments 77 Diathermy 90 Types of diathermy (see Figure 10.19) 90 ‘Touching’ with the diathermy (see Figure 10.20) 92 Haemostatic techniques 93 Overview 93 Assisting with the different haemostatic techniques 94 Simply ignore it 94 Diathermy (see also ‘Touching with the diathermy’) 95 Clip and tie 96 Clip and double-tie 101 Suture 101 Transfixion-ligation 101 Preventing suture material from tangling 102 ‘Following’ a suture line (see also p. 61 and p.178) 102 Placing packs to protect suture material 103 Drains 103 Prosthetic materials 104 Part 3 Assisting at special types of surgery 107 11 Cardiothoracic surgery 109 Introduction 109 Assisting at cardiac surgery 109 The median sternotomy 109 Harvesting the internal mammary artery 110 Cannulation of the heart for cardiopulmonary bypass 111 Harvesting of the long saphenous vein and radial artery for grafting 111 Coronary bypass grafting 111 Coming off cardiopulmonary bypass 112 Insertion of drains after a median sternotomy 113 Closure of the sternotomy 113 Assisting in aortic valve, mitral valve or tricuspid valve surgery 113 Assisting at thoracic surgery 114 Introduction 114 Video-assisted thoracoscopic procedures 114 Open thoracic surgery 115 Specific situations in thoracic surgery 115 12 Laparoscopic surgery 117 Introduction 117 Setting up for laparoscopic operations 117 General layout of instruments 117 Camera and associated instruments 118 The light cord 119 The laparoscope (see Figure12.1) 120 Gas 120 White balance 120 Ports 121 Instruments 122 Quiver instruments 122 Sucker-irrigator 122 Diathermy 122 Instruments on the scrub nurse’s trolley 123 Driving the camera 123 Use the correct grip (see Figure12.2) 123 Watch the screen continuously 124 Frame the picture (see Figure 12.3) 124 Avoid unnecessary movement 127 ‘Zoom in’ or ‘Zoom out’ when it is helpful 127 Use both hands 128 Keep yourself oriented 128 Keep the picture in focus (see Figure12.2) 129 Some common errors in driving the laparoscopic camera 129 ‘Batman view’ 129 ‘Doris Day view’ 130 13 Neurosurgery 132 Introduction 132 Equipment 132 Surgical access 133 Use of suckers 134 Retraction 134 Assisting using the microscope (see also p. 126 and 154) 135 Shunt surgery (see also ‘prosthetic materials’, p. 90) 135 SUGGESTED FURTHER READING 135 14 Obstetric and gynaecological surgery 136 Obstetric operations 136 SUGGESTED FURTHER READING 137 Gynaecological operations 138 SUGGESTED FURTHER READING 138 15 Ophthalmic surgery 139 Pre-operative preparation 139 16 Orthopaedic surgery 143 Introduction 143 General factors related to orthopaedic surgery 143 Clothing in the operating theatre (see also Chapter 3, p. 11) 143 Marking the operation site (see also p. 21) 143 Anatomical knowledge 144 Elective orthopaedic surgery: arthroscopic surgery 144 General tips 144 Setting up 144 Fluid irrigation 145 Handling of instruments 146 Holding the scope 146 Arthroscopy of larger joints 147 Shoulder arthroscopy 147 Knee arthroscopy 147 Arthroscopy of smaller joints 147 Ankle arthroscopy 148 Elbow arthroscopy 148 Wrist arthroscopy 148 Elective orthopaedic surgery: major joint replacement 148 General principles 148 Preparation 148 Draping 149 Setting up 149 Intra-operatively 149 Tips for assisting at specific operations 150 Total hip replacement 150 Total knee replacement 150 Post-operatively 151 Emergency orthopaedic surgery 151 Positioning the patient 151 Preparation 152 Intra-operatively 152 Post-operatively 153 Tips for assisting at specific common operations 153 Fractured neck of femur 153 Distal radial fracture (Colles’ fracture) 153 17 Otorhinolaryngology-head and neck surgery 154 Introduction 154 Preparation of the patient 154 Ear surgery 155 Nasal surgery 156 Head and neck surgery 156 Conclusions 157 FURTHER READING 158 18 Paediatric surgery 159 Keep infants warm 159 Positioning child, airway and lines 160 Skin preparation 160 Local anaesthetic considerations 160 Retraction 161 Specific regions 161 Thoracotomy 161 Laparotomy 162 The groin 162 Indwelling catheters 162 SUGGESTED FURTHER READING 162 19 Plastic surgery and microsurgery 163 Introduction 163 Plastic surgical terms 163 Graft 163 Flap 163 Instruments in plastic surgery 164 Cutting sutures (see also p. 57) 164 Assisting at skin grafting procedures 165 Split thickness grafts 165 Full thickness grafts 166 Assisting at flap procedures 166 Pedicled flaps 166 Free flaps 167 Microsurgery 167 Equipment 168 Microscope 168 Sutures 168 Commonly used microvascular instruments 168 How to hold microsurgery instruments (Figures 19.5 and 19.6) 168 Quiet during microsurgery (see also, ‘talking in the operating theatre’, p. 6) 171 Handling tissues 171 Assisting when the microscope has no assistant’s eyepiece 172 Dressings 172 Conclusion 172 20 Surgery in difficult circumstances: (1) Rural hospitals 173 Tips for the GP 173 Tips for the medical student 174 21 Surgery in difficult circumstances: (2) Developing countries 175 General considerations 175 Standards 175 Cultural matters 176 Language 176 Work productivity 177 The surgical team 178 Personal safety 179 Trauma 179 Infectious diseases 179 Fatigue 179 Hydration 180 Specific considerations for surgical assisting 180 Operating theatre conditions 180 Specific operating theatre safety 180 Instruments 181 Instrument, swab and pack counts 183 The patient 183 The operation 183 The local surgical staff 184 Recommendations before a visit to the developing world 185 Summary 185 22 Vascular surgery: (1) Open surgery 186 General principles 186 Open operations 186 Control of vessels 187 Temporary occlusion of vessels 188 The ‘therapeutic’ part of the operation 189 Specific situations in vascular surgery 193 Carotid surgery 193 Aortic surgery 193 23 Vascular surgery: (2) Endovascular surgery 194 Introduction 194 Medical preparation of the patient 195 Endovascular access 195 Endovascular procedures 195 Handling catheters and wires 196 Preparing equipment 197 Specialised equipment: balloons, stents, etc. 197 Endovascular repair of abdominal aneurysms 198 Embolisation 198 Part 4 Immediately after the operation 201 24 Immediately after the operation 203 Glossary 206 Abdominal aortic aneurysm (AAA) 206 Adhesions 206 Anastomosis 206 Anterior superior iliac spine (ASIS) 206 Appose (verb) 206 Balanced salt solution (BSS) 206 Barium enema 206 Betadine 207 Chlorhexidine 207 Cholecystectomy 207 Colonoscopy 207 Consultant 207 Continuous suture (cf. interrupted suture, below) 207 CT scan 207 Depth of field 207 Distal (cf. proximal, below) 207 Drain (noun) 208 Drain (verb) 208 DVT/PE 208 Enoxeparin (trade name ‘Clexane’) 208 Eponymous 208 Extra Capsular Cataract Extraction (ECCE) 208 Gauge (in reference to suture material) 208 Heparin 209 Histology 209 Inferior (cf. superior, below) 209 Intern (United States and Australia) 209 Interrupted suture (cf. continuous suture, above) 209 Intraocular lens (IOL) 209 Irrigation and aspiration (I/A) 209 Ischaemia (noun)/ischaemic (adjective) 209 JHO (United Kingdom) 210 Laparoscopy/laparoscopic surgery 210 Laparotomy 210 Lateral (cf. medial, below) 210 Ligate/ligature 210 Medial (cf. lateral, above) 210 Mesentery 210 Mobilise 210 Necrose (verb) 210 Open procedure/open operation 211 Pathologist 211 Peribulbar anaesthesia 211 Peritoneum/peritoneal cavity 211 Phacoemulsification (‘phaco’) 211 Prophylactic 211 Proximal (cf. distal, above) 212 Ratchet 212 Registrar (United Kingdom and Australia) 212 Resident 212 RMO 212 Scrubbed 212 Scrubs 212 SHO 212 Sigmoidoscopy 212 Superior (cf. inferior, above) 213 Suture/stitch 213 Torticollis 213 Trabeculectomy 213 Trochar 213 Viscoelastic or ophthalmic viscoelastic device 213 Warfarin 214 Suggested further reading 215 General principles of surgery 215 Anatomy 215 Textbooks of operative surgery 215 Miscellaneous 215 References 217 Index 219 This book is a practical manual for assisting at surgical operations. Simple language and diagrams describe both the basic principles of surgical assisting, and advanced techniques needed in the surgical subspecialities. It will help medical students, junior doctors and surgical technologists excel at assisting at any surgical operation