Class Notes

–Bovie 35/35, Ligasure available

–Position: supine. Prep: shave (PRN), Foley (ask), ChloraPrep

–Local: 0.5% Marcaine with epinephrine (HOLD)

–Dressing: Telfa, 4×4s, soft tape

–Likes peanuts, Ligasure, and Glassman bowel clamps open on the field

–SCDs on ALL of his patients

A laparotomy is open surgery of the abdominal cavity, for access to the abdominal organs.

We do an ex lap to examine the abdominal cavity when less invasive measures fail to confirm a diagnosis.

This checkoff: a general ex lap, a bowel obstruction is found, then taken care of (resection and anastomosis).

1.Skin

2.Adipose (fat)

3.Fascia

4.Muscle (rectus abdominis), linea alba

5.Peritoneum

6.Greater omentum: extension of the serous membrane covering the stomach, duodenum and part of the colon

7.Mesentery: extension of the peritoneum that attaches to the posterior abdominal wall and fans out to cover the small intestine

1.Serosa

2.Muscularis

3.Submucosa

4.Mucosa

–Cecum → ascending colon → hepatic flexure → transverse colon → splenic flexure → descending colon → sigmoid → rectum

–Put on non-sterile gloves

–2 towels on both sides of the patient, to prevent pooling

–Put on sterile gloves

–Begin at the umbilicus with a cotton-tipped applicator and prep solution (ChloraPrep 26 mL)

–Start at the incision site and move to the periphery

–Nipple line to mid thigh, both sides of the body to the OR table

–Perform a hand wash, wipe down the OR, arrange the OR furniture

–Check the preference card (she will ask questions on the card), gather all supplies and equipment

–Open the back table, supplies and instruments properly and sterile:

–Perform Avagard ("15 minutes starts now")

–Gown and glove

–Drape the Mayo stand

–Put 2 towels on the Mayo stand

–Grab your towel, put your silk in the towel, fold it back up and put it in the corner of the Mayo stand

–Light handles · suction tip · 5-pack laps · skin marker · Bovie with the normal tip

–Suction tubing · long Bovie tip · Ligasure

–Tonsil, clamped to one piece of silk

–2 curved Kelly

–1 6" DeBakey · 1 8" DeBakey

–2 Pean, each with a peanut

–1 Metzenbaum scissors · 1 straight Mayo scissors

–2 Army-Navy retractors · 1 Richardson-Eastman retractor

–5 towels · Glassman bowel clamps · reloads · GIA stapler

–Forester sponge stick · 3–4 Allis clamps · needle driver

–8" DeBakey · curved Mayo · some lap pads

–New gloves (mine) · surgeon's new gloves · gowns

–New suction · new Bovie · towels · Poole suction tip

–Square off the abdomen with 4 towels (3 toward you, 1 away from you)

–Hand the drape to the surgeon: they place it, hand off to the feet, hold placement on the abdomen, then hand off to the head

–Bring over the Mayo, back table and double ring stand

–Hand light handles to the surgeon. Throw off the Bovie, suction, +2 laparotomy sponges on the field, and the Ligasure

–Skin marking

–Skin incision with the 10 blade; laps can be used to pull for tension

–Sub Q: Bovie and DeBakey to EXTEND the incision and cauterize

–Sub Q: dissection with Metz, Bovie, peanuts on a Pean, 10 blade on a 7 handle

–Fascia: dissection with the 10 blade, curved Mayo, Bovie

–Muscle: blunt dissection of the linea alba and muscle, with fingers or lap sponges

–Exposure with the Richardson

–Kocher forceps to lift up the muscle tissue; incise the peritoneum with the 10 blade on a 7 handle, or Bovie, curved Mayo

–Through the peritoneum: explore the abdominal cavity

–Give the surgeon 2 moistened laps to cover the tissue, THEN hand the Balfour retractor for deeper exposure

–The omentum is lifted back with the Ligasure and 8" DeBakey

–Mobilization of the bowel with the Ligasure and 8" DeBakey, to find the obstruction

–Switch to the extended Bovie tip

–Square off the abdomen with 4 NEW towels, passed to the surgeon

–You CANNOT touch anything on your Mayo or back table

–Put down a towel on the field for your "new" Mayo setup

–Pull up everything you need for the resection: 4 towels, Glassman bowel clamp, small bowl, needle driver, 8" DeBakey, curved Mayo (to cut sutures if needed), 5 laps, Forester sponge stick, 3–4 Allis, GIA stapler, 4 reloads

–Specimen: ask how they want it sent, what it is called, and whether it is okay to pass off. Put it in the basin

–Bowel: slanted cut with Metz; Bovie with the long tip, with the 8" DeBakey

–Anastomosis (side to side) with the GIA

–Pass up the Forester sponge stick to check both lumens

–Close up the bowel: 3–4 Allis clamps hold up the bowel, and the surgeon seals the bowel with the GIA stapler

–Check: there can possibly be a tear

–Roll up the dirty towels with the Bovie, suction and Ligasure, and toss them off the bed. All used instruments go in the basin; the circulator takes them away

–Roll toward the feet

–Change gloves (say it out loud)

–Throw off a new suction, Bovie, lap sponges

–When all the clean things are back on the field:

–Load the suture (Vicryl) and organize your things while they examine the bowel

–REMOVE the Balfour

–Pass up the Ferris Smith with the suture for fascia closure; straight Mayo in the ST's hand

–Start with the fascia, follow with closure, THEN start the CLOSING count halfway

–When the count is done, pass up the skin stapler to the surgeon; the ST holds 2 Adson

–FINAL COUNT after skin closure (sponges and sharps)

–Wet and dry laps

–Dressings: Telfa, 4×4, soft tape