Solutions Manual For Surgical Technology for the Surgical Technologist 6th Edition by Association of by ACADEMIAMILL

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A patient has been scheduled for a diagnostic laparoscopy to confirm the pathology that may be causing chronic pelvic pain. While in the preoperative holding area, a registered nurse (RN) performs the nursing evaluation, including checking the patient’s documentation, confirming allergies and special needs, and providing emotional support. The anesthesia care provider reviews the preanesthesia assessment and starts an intravenous (IV) line. The RN and patient care technician transport the patient into the operating room (OR). The patient notices a person in the OR wearing a surgical gown, mask, gloves, hair cover, and protective eyewear. This person sets up surgical instruments, equipment, and supplies on a large table draped in blue material. The person steps back from the table, turns to the patient, and says, “Good morning, my name is Emma. I’m a Certified Surgical Technologist(CST), and I’ll be assisting Dr. 1. In what nursing role is the RN functioning? ANS: The nurse is functioning in the role of circulator. The circulating role is a licensed professional whose scope of practice is inclusive of patient care, patient identification, patient documentation, and patient advocacy. As part of the surgical team, the circulator will remain as the nonsterile professional capable of providing the sterile surgical team with needed supplies during a surgical procedure. 2. In what surgical technologist role is Emma functioning? ANS: Emma is the surgical technologist in the first scrub role. Within their scope of practice, the responsibility of a surgical technologist is to provide optimal patient care, advocate for the patient, demonstrate therapeutic support, and assist the surgical team by helping the patient return to their best possible state of wellbeing. 3. What organization is responsible for accrediting the program Emma attended?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: CAAHEP establishes standards for education of surgical technology program and grants accreditation to surgical technology programs. This will only take place upon the recommendation of ARCSTSA, which verifies and clarifies that programs are adhering to AST Core Curriculum developed by AST. 4. What is the preferred educational background for Emma, as established by the organization that accredits programs? ANS: Since Emma introduced herself as a CST, she had to have attended an accredited program. There are two recognized accreditation organizations, ARCSTSA and ABHES, which, under the umbrella of CAAHEP, are responsible for ensuring that education background is adhered to. 5. What organization offers the Certified Surgical Technologist (CST) examination that Emma successfully passed? ANS: The NBSTSA offers the Certified Surgical Technologist (CST) exam. Graduates of programs that have been granted accreditation status qualify to take the NBSTSA exam, which awards and owns the trademark of the CST and CFA credentials.

CLOSING CASE STUDY Ian is a CST with several years of experience working at a large urban hospital. They have just finished assisting the circulating RN and anesthesia care provider in positioning the patient and have been asked if they will perform the skin prep on the patient. 1. What role is Ian performing? ANS: Ian is performing the role of STCR (surgical technologist in the circulating role) since they are assisting the circulating registered nurse. The training provided by an accredited surgical technologist program incorporates performing some of the functions of circulator in an operating room. 2. Is the role a nonsterile or sterile role? ANS: The team member is functioning in the role of a circulator, which is a nonsterile role. Perioperative case management consists of the preoperative, intraoperative, and postoperative phases. During each of these phases, there are team members who perform tasks which require them to be sterile, and others may complete tasks which are nonsterile. When prepping the patient, the prepping solution and/or prep stick come in a sterile package, and the appropriate process is to don sterile gloves using open-glove technique. 3. What are the roles of the other OR team members?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Non-Sterile team members: Anesthesia care provider: responsible for monitoring patients’ vital signs Anesthesiology resident or a CRNA (certified registered nurse anesthetist): assists the anesthesia care provider Operating Room Attendants (patient care techs, transporters): assist with moving the patient from one place to another Nursing students Sterile team members: CST (certified surgical technologists): assists team with the procedure CFA (certified first assist): assists the surgeon with performing the procedure Surgical Residents: there to learn from the surgeons how to accomplish the procedure Medical Students (typically fourth-year students): students getting ready to select their specialization in medicine Surgical Technology students Surgeon

QUESTIONS FOR FURTHER STUDY 1. What is the difference between a job description and a role description? ANS: Role descriptions, by their very nature, are broad in scope, describing a typical or common set of activities and responsibilities. Job descriptions, however, are produced and approved by the institution for which one works. Depending on the type of job, they may be written fairly broadly, but they are usually quite specific regarding the surgical technologist’s responsibilities. Because (as of this writing) surgical technologists are subject to licensure in certain states, there may not be a directly related statute that applies to the surgical technologist’s job description for your state. (Examples of states requiring licensure or registration include: Colorado, Washington, District of Columbia, Texas, etc.) The job description is typically the work and property of the given institution in which the surgical technologist works. The surgical technologist should be familiar with the job description in the institution of employment in order to define his or her scope of practice for the institution. Job descriptions provide a job title and definition, specific requirements for the job, duties and tasks to be performed, and designation of one’s immediate supervisor to whom one is accountable. Job descriptions are placed within the context of an institution’s mission and a department’s role in accomplishing that mission. Surgical technologists have traditionally been assigned to the nursing department when employed by a facility such as a hospital or ambulatory surgical center. With the increased use of private surgical technologists and the “traveling” surgical technologist, the employer may be a physician, a physicians’ group, or an agency. In some locales, a surgical technologist who is employed outside the institution but will be assisting in the facility is required to seek permission to function through the medical credentials committee at the hospital. No matter the employment situation, the surgical technologist must be aware of the conditions of employment, the nature of the

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

job, required tasks, and specified limitations. The job description may establish the criteria by which the surgical technologist will be judged in a case concerning alleged negligence or malpractice. 2. How does health care financing affect the services that healthcare professionals provide? ANS: Health care financing may affect the type of surgeries performed, the schedule, and personnel ratios; the salary that the health care professional receives; the amount, type, and quality of equipment, supplies, and additional resources that are available for patient care; and many other variables. These variables, when combined, create the overall environment in which health care professionals work. 3. List several reasons why a surgical technologist might need to communicate with the diagnostic imaging department, medical laboratory department, or a medical-surgical floor nurse. ANS: The surgical technologist may be responsible for arranging patient transportation, obtaining patient records, or coordinating preoperative, intraoperative, and postoperative events. Communication between departments and specific individuals responsible for patient care is imperative. Minimally invasive procedures have also increased the amount of cooperation between departments. 4. Describe the “typical” workday for the surgical technologist. ANS: The surgical technologist functions in a sterile capacity during surgical procedures, but also performs many nonsterile duties throughout the course of the workday. Other roles include assistant circulator, second scrub, second assistant (providing exposure as a camera driver or handheld held retraction), or other duties as assigned. Some of the scrub role duties of the surgical technologist in each phase of surgical case management include: Preoperative Case Management • Donning OR attire and personal protective equipment • Surgical site verification • Preparing the OR • Gathering necessary equipment and supplies • Creating and maintaining the sterile field • Scrubbing and donning sterile gown and gloves • Organizing the sterile field for use • Counting necessary items • Assisting team members during entry of the sterile field • Placing sterile drapes to expose the operative site • Correct patient verification, e.g., “time out” Intraoperative Case Management • Maintaining the sterile field, including establishing neutral zone • Passing instrumentation, equipment, and sup• plies to the surgeon and surgical assistant as needed • Assessing and predicting (anticipating) the

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

• • • • • • •

needs of the patient and surgeon and providing the necessary items in order of need Preparing irrigation fluids Preparing and handling medications Counting necessary items Caring for the specimen Clearing residual blood and skin prep solutions from patient’s skin Preparing and applying the dressing

Postoperative Case Management • Maintaining the sterile field until the patient is transported from the OR • Disassembling the sterile field • Removing used instruments, equipment, and supplies from the OR • Caring for and maintaining instruments, equipment, and supplies following use • Preparing the OR for the next patient 5. Define the term competency as it relates to the role of the surgical technologist. ANS: The term competency means that one is well qualified and has the knowledge and/or skills to perform in a particular area. For the surgical technologist, skill assessments and the certification exam are often used to determine competency. 6. In addition to the traditional role of the surgical technologist in the surgical setting, list at least two other related employment options. ANS: Most surgical technologists are employed in hospital surgery departments, obstetric departments, and ambulatory care centers. However, because of the broad educational background combined with a specialized focus, the following options are also available to the surgical technologist: • Specialization in an area of interest such as cardiac, orthopedic, or pediatric surgery • Employment as a traveling Certified Surgical Technologist • Advancement to the role of surgical assistant • Employment by a veterinary surgeon or animal care facility • Employment by a medical corporation to represent its products • Research and product development • Employment in the material management or central supply areas • Assumption of supervisory responsibilities • Surgical technology educator • Military service • Volunteer opportunities (such as the Peace Corps) • Technical writing, illustration, and photography • Employment as a consultant Note: Some of these positions require experience and further education.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 2: Legal Concepts, Risk Management, and Ethical Issues

OPENING CASE STUDY Bret is a CST working with Dr. Jones on an open cholecystectomy procedure. Dr. Jones has both hands engaged and asks Bret to inject a contrast medium into the cystic duct under their direct supervision. 1. Is this act different from injecting medication into an IV line, and if so, how? ANS: As a Certified Surgical Technologist (CST) it is outside of the accepted scope of practice, whether under the supervision of a licensed professional or not, to administer any type of pharmaceutical substance to a patient. A CST is nationally certified but not a licensed healthcare provider. 2. What do you think that Bret should do in this situation? ANS: Having been trained as a CST and having graduated from an accredited program, Bret knows that he should remind the surgeon that he is not permitted to administer any medication to any patient at any time. If Bret were to follow the surgeon’s direction, and the patient subsequently sustained injury, Bret would be liable, as would the surgeon, for going outside his scope of practice. 3. How can Bret know what the best course of action would be in this situation? ANS: Since the scenario states that both of the surgeon’s hands are occupied, Bret could always inform the surgeon that he would gladly retract and/or suction for them, so the surgeon could then administer the contrast media. This solution would prevent a potential negligent act to take place which could easily lead to a civil malpractice lawsuit.

CLOSING CASE STUDY A nineteen-year-old female patient is scheduled to have an elective abortion in the OR. It is legal in your state for this procedure to be performed on this patient. © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

1. How does AST’s motto of Aeger Primo apply in this case? ANS: Aeger Primo is Latin for “patient first.” As healthcare professionals, a Certified Surgical Technologist has the ethical obligation to provide optimal patient care to all patients who arrive in an operating room. This mindset should include no judgment based on gender, culture, or religious beliefs. It is imperative that a CST remember their obligation is to the patient, who in this case, is the nineteenyear-old female. </question type="essay"> 2. How does AST’s Code of Ethics for Surgical Technologists apply to this case? ANS: There are ten statements in the AST Code of Ethics that a CST abides by, and in this case, the CST must maintain the highest standards of professional conduct and patient care. They are to respect the patient’s beliefs, protect their moral rights, and always adhere to the Code of Ethics. 3. What are the differences between morals and ethics? ANS: Ethics define what is good for individuals and society. It is a system of moral principles and rules that become standard for professional conduct. Morals are guides for ethical decisions, such as when we teach our children to trust, to be honest, and to care. Moral principles may be thought of as personal ethics; therefore, they may differ among varied cultures and religions. Morals incorporate an acknowledgement and respect for an individual human being’s autonomy. 4. Would you treat this patient any differently than you treat other patients? ANS: A CST has an obligation, responsibility, and expectation to provide the same level of care to all patients having surgery. The CST’s Scope of Practice clearly defines CSTs as health care providers who provide services for which they are accountable and responsible based on their education, experience, and national credentialing. The CST agrees to an unspoken oath to adhere to the principles of asepsis in each patient they encounter

QUESTIONS FOR FURTHER STUDY 1. Discuss how the two concepts of intraoperative counts and res ipsa loquitur intersect. ANS: Res ipsa loquitur – “The thing speaks for itself; harm obviously came from a given act or thing of which the defendant had sole control. Foreign bodies left in patients secondary to incorrect sponge, sharps, and instrument counts – the circulator and certified surgical technologist must count all items specified by hospital policy for counting before the procedure begins, at the time that wound closure begins and again during skin closure. If an item is left within the patient an x-ray or surgical removal of the item is proof that the item was left during surgery.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. Explain the fundamental change the Patient Care Partnership introduced as related to the patient. ANS: American Hospital Association’s (AHA) Patient Care Partnership reflect values that the patient is an autonomous individual who is in need of a serves that he or she cannot provide. Patient Care Partnership informs the patient about what he or she should expect and that the patient must be involved in his or her health care and ask questions. There are six expectations, including high-quality clean and safe environment, involvement in own care, help when leaving the hospital, and help with bill and insurance claims. The patient has the right to make decisions about and be involved in his or her care. 3. Discuss the differences between morals and ethics. Give as many examples of each as you can think of. ANS: Ethics is the system of moral principles and rules that become standards for professional conduct and should not be confused with morals. Morals dictate codes of conduct, which are put forward by a society and used as a guide to behavior by the members of that society. Moral principles are guides for ethical decisions making include the principles of benevolence, trustworthiness, honest, basic justice prevention of harm and the refusal to take unfair advantage, Ethics includes rules of conduct and standards of behavior principles such as impartiality, objectivity, duty of care, confidentiality, and full disclosure. Ethical principles include being trustworthy and honest. In simplest terms, it has been identified as the moral obligations that one person owes another TJC defines ethics as “the branch of philosophy that deals with systematic approaches to moral issues, such as the distinction between right and wrong and the moral consequences of human actions. Ethics involves a system of behaviors, expectations and morals composing of standards of conduct for the profession. 4. In a conversation with a CST fellow-worker, he relates a story about a recent case. You soon realize that the patient in question was one of your close family members. What do you do? ANS: The fellow-worker has committed an invasion of privacy. The Health Insurance Portability and Accountability Act (HIPAA) has been violated. Consumers may file a formal complaint regarding the privacy practices of a covered health plan or provider. You can also discuss the importance of this act with your fellow workers. This is an ethical plight, do you report them, do you discuss it with your fellow coworker or do you do nothing. HIPAA laws are to protect the privacy of the individual. Our ultimate responsibility is to the patient.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 3: The Surgical Patient

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A twenty-eight-year-old patient, who has never had surgery before and has Type I diabetes, is scheduled for a procedure that will require an overnight stay at the hospital. The patient is noticeably nervous as they enter the hospital and check into the preoperative area. The preop nurse takes vital signs and starts the IV with pre-warmed saline solution. After completing the final consent and verification with the surgeon and anesthesiologist, the patient is transported down the hall and into the operating room (OR). The room is cold and unfamiliar to the patient, who takes notice of the strange equipment and instrumentation on the tables near the far wall. The patient is asked to move from the stretcher to the OR bed, and they feel awkward with everyone watching and the IV pulling on their arm. Even though the anesthesiologist is calmly explaining what can be expected before the general anesthesia is administered, the patient begins to shake. 1. What is the patient’s concern when entering the preoperative area? The operating room? ANS: The case study does not reflect the HCP (healthcare provider) explaining to the patient what they will be doing (vital signs, IV etc.); if a patient is noticeably nervous, one of the HCP should explain what will be taking place to provide psychological reassurance that they are being well taken care of and are in the hands of competent professionals. This patient has an illness which can spiral out of control, and they are nervous, which may cause a rise in blood pressure. The added hustle and bustle taking place prior to being transported to the operating room will exacerbate the situation. 2. What level(s) would the patient be considered in Maslow’s hierarchy of needs? ANS: Safety needs, which are placed directly above physiological needs, are being compromised. Being transported and asked to move onto the OR bed from the stretcher, with the IV getting caught up by the movement, increased the patient’s safety concerns. Once physiological needs are met, it is imperative for the surgical team to assess their patient in accordance to Maslow’s hierarchy of needs and treat the patient accordingly. 3. What can the CST do to address these needs in the OR?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: CSTs are trained to react and assist with patients who are insecure and concerned about their safety. Although a CST should never make promises, they are capable to effectively provide therapeutic care by simply placing a hand on the patient’s shoulder or making eye contact and providing them with the assurance that they are all going to work together as a team. This reassurance will help put the patient at ease, as well as improve the outcome of the procedure. 4. What can healthcare providers do to continue meeting the patient’s needs throughout the stay in the hospital? ANS: Only by understanding and being familiar with all the components defined within Maslow’s hierarchy can the HCP meet patient needs. • Physiological: most basic needs all living beings require to live (food, oxygen, water) • Safety: directly relates to the perception of the patient’s view of the situation • Love and belonging: the social needs concerning caring about one another • Esteem: many patients may not have a very positive outlook about themselves and will seek to receive a level of respect from strangers • Self-actualization: Reflecting on one self’s purpose and accomplishments

CLOSING CASE STUDY A twenty-nine-year-old patient who is eight months pregnant is having an emergency appendectomy. They will have to receive general anesthesia for the procedure. 1. Is this procedure considered elective or nonelective? Why? ANS: This procedure would be considered nonelective. The ideal timeframe when performing an elective appendectomy would be during the patient’s second trimester. The use of the word emergency indicates it must happen now, categorizing the case as urgent and nonelective. An elective procedure would permit the patient to decide to have the procedure scheduled at a later date and time. 2. What special considerations should be made when positioning the pregnant patient? ANS: Due to the anatomical changes when a patient is pregnant, contents of the abdominal organs are easily displaced. For example, the appendix, the ureters, and the sigmoid colon are no longer where they typically would have been because there is an enlarged uterus with a fetus present. The surgical team must ensure that no organs or structures are compressed or compromised during the surgical intervention. Special precaution is taken to place a roll underneath the right side of the patient to prevent compression of the vena cava and aorta. 3. With what additional emergency procedure should the CST be prepared to quickly set up and assist the surgeon?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The CST should be prepared to quickly set up and assist in a cesarean section. There is a high probability the procedure could precipitate the need to perform a cesarean section due to fetal distress due to the administration of general anesthesia. 4. What postoperative symptoms should be closely monitored that might indicate preterm labor? ANS: Assuming the procedure is successfully completed, it will be imperative for the postanesthesia care unit to monitor the patient for any unusual vaginal bleeding, a spike in blood pressure, uterine contractions, or rupture of the amniotic sac. All these postoperative symptoms will lead to a cesarean section.

QUESTIONS FOR FURTHER STUDY 1. Find out which major world religions are practiced in your area. How do these different faiths view the topic of organ donation? ANS: Responses will vary. 2. As the patient becomes ill, requires a surgical procedure, and recovers, he or she changes levels within Maslow’s hierarchy. Discuss these changes. ANS: Responses will vary. 3. What device is frequently used during a surgical procedure and postoperatively to prevent thrombophlebitis in the diabetic patient? ANS: Sequential (or venous) compression device. 4. How might the healthcare provider best manage the potential removal of an Article of Faith from a Sikh patient prior to surgery? ANS: Ask permission before removing. Once removed, carefully place in a clean bag and place with patient’s belongings.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 4: Physical Environment and Safety Standards

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A CST is finishing a case in which a known IV drug user suffered a gunshot wound to the abdomen, and they are counting the instruments that are on the back table with the circulator. While completing the count, the surgeon placed a loaded needle holder onto the Mayo stand without informing the CST. As the CST reached to take the straight Mayo scissors from the Mayo stand to pass to the surgeon, the bloody needle penetrated the single glove and punctured the skin. The CST immediately reported the needle-stick injury to the circulator, who removed the glove, helped assess the wound, and paged for a replacement CST. After being relieved from the sterile field, the CST washed the wound with soap and water. Because occupational health was closed at this hour, the CST reported to the emergency department for treatment and then filed all appropriate reports. 1. What should the CST have done with the needle and needle holder after they became contaminated with blood? ANS: The needle holder and needle should immediately be passed off to the circulator, as both are now considered to be contaminated. Although this is a contaminated case, the Mayo stand, the back table, and all the instruments and supplies which are on the sterile field are still considered to be sterile items. 2. Did the CST handle this incident correctly? ANS: The CST adhered to some of the stipulated guidelines but failed to meet all. Depicted below are the protocols that healthcare professionals must follow in response to exposure incidents. If a sharps injury occurs: • Fellow team members must be immediately alerted and the contaminated sharp item must be handed off from the sterile field to the circulator. • Gloves must be removed to assess the injury and the exposure site should be treated immediately. • The circulator may assist with removing the gloves. • If the skin is broken, the wound must be washed with soap and water or a suitable scrub solution such as betadine. • After the wound is treated, the exposure must be reported and an assessment of the risk of infection should be made by the appropriate clinical personnel. 3. What should the CST have done to prevent the injury from occurring?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Most injuries in the HCF occur in the OR, and most of these are from scalpel and suture needles. Sharps injuries can occur during suturing, tissue retraction, passing a needle, and more. Following standard precautions guidelines, including the use of personal protective equipment, will minimize the risk of sharps injuries. It is the responsibility of the OR personnel to follow facility policies and use the PPE. Some of these guidelines include: • Practice double gloving. • Position sharps disposal containers at point of use. • Use sharps safety devices. • Never recap hypodermic needles. • ACS recommends the use of blunt-tip suture needles to reduce needle stick injuries. • Sharps should consistently be kept in a central location on the Mayo stand and back table. • Load needle holders with needle and suture as close to the time of use as possible. • Surgical blades should not be loaded or unloaded using hands.

CLOSING CASE STUDY The CST scheduled to be the first scrub on a procedure in which a laser will be used to ablate abnormal laryngeal tissue is preparing the OR. 1. What specific safety issues should the CST consider in preparing for this case? ANS: Laser safety precautions must be in place: • All OR members must wear laser eyewear to protect the retina from the beam. • All window shades must be drawn. • All glass and reflective surfaces should be covered. • Moist sponges should be used during laser use. • Use non-reflective Laser ET tube. • Fire extinguisher (halon) should be readily available. • Fire retardant drapes are needed. • High filtration laser mask must be worn. • Laser Use Warning placard must be placed on all doors. • Preliminary test of the equipment must be performed. • Smoke evacuator must be used to remove plume. • Sterile water and extra towels must be provided for use during the case. 2. What policies and procedures should be in place to ensure the patient’s safety? ANS: As a component of the preoperative preparation, the patient would have been instructed not to use any hair spray, body lotions, or any other substances that could cause a spark and conduct a fire. When draping the patient, care is taken to ensure no substances are left underneath the drapes (betadine prepping solution) that could cause a surgical fire.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Around the mouth and anus, towels should be saturated with sterile water, and the same should be readily available intraoperatively. Corneal protectors placed on the patient’s eyes for protection, as well as laser eyewear. All instrumentation used during the case should be ebonized to prevent reflection. 3. What are the possible concerns regarding the anesthetic used in this case? ANS: Special anesthesia equipment and supplies may be needed to prevent fires. A fire resistant endotracheal tube is used. The anesthesiologist will use nonexplosive anesthetic gases, and care is taken with the nitrous oxide and oxygen to prevent buildup. As a surgical technologist, one should have a syringe filled with at least 60 mL of saline or water to be used immediately in the event of a fire.

QUESTIONS FOR FURTHER STUDY 1. Name four ancillary departments in the hospital that directly support the OR. ANS: Most hospital departments could be considered ancillary to the OR, including environmental services, material management, central sterile supply and processing department (CSPD), radiology department, laboratory department, pathology, department and pharmacy. 2. At what temperature and humidity levels should the OR be maintained? ANS: Humidity levels should be maintained no higher than 20%–60%. These levels provide for infection control and patient/staff comfort. Care is taken to prevent patient hypothermia. 3. What agency is dedicated to protecting the health and safety of the workers in the OR? ANS: The Occupational Safety and Health Administration (OSHA) is the federal organization that is dedicated to protecting the health of workers by establishing standards that address issues related to safety in the workplace. The standards are legally enforceable in order to protect workers, and many of the standards are based on the findings of other agencies, such as National Fire Protection Agency (NFPA), American National Standards Institute (ANSI), and National Institute for Occupational Safety and Health (NIOSH). Other organizations include AAMI (Association for the Advancement of Medical Instrumentation) and ASTM (American Society for Testing and Materials).

4. Should a latex-sensitive patient be scheduled in the OR as the first patient or the last patient of the day? ANS: A latex-sensitive patient should be scheduled as the first patient of the day. This allows latex particles that may be in the environment from the previous day’s surgeries to settle or be removed during terminal cleaning.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

5. What are the three important safety factors for surgical technologists to consider when exposed to ionizing radiation? ANS: The three most important safety factors to be considered during exposure to ionizing radiation are time (length of exposure), shielding, and distance from the radiation source.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 5: Technological Science Concepts

OPENING CASE STUDY A thirty-year-old patient with a history of ureterolithiasis had a double-J catheter inserted a few months ago and was later scheduled to have it removed endoscopically. Anesthesia was induced, and the patient was placed in the lithotomy position and draped. However, because of the long-term catheterization, removal wasn’t possible, creating the need for an abdominal approach through a suprapubic incision. The patient was repositioned on the OR table in the supine position. A disposable dispersive pad was placed on their back, and the patient was re-draped to isolate the surgical site. The operation continued to proceed uneventfully. While transferring the patient to the stretcher, the CST noticed that the linens of the OR bed were damp. In the PACU, the patient complained of mild pain on one side of their back, which was not investigated. Upon discharge, there were no complaints reported in the hospital records. One month later, the patient followed up with a urologist and reported the occurrence of two burn wounds located on their left flank. After analyzing the injury, it was found that the shape of the burns was consistent with the metal frame of the operating table. The patient was referred to the plastic surgery department for clinical management of the wounds. 1. Explain the principles behind what could be the primary cause of these burns. ANS: One of the dangers of electrosurgery is electrical burn. During surgical procedures performed endoscopically, patients may be at risk for unintended and potentially unrecognized burns due to instrument insulation failure or direct coupling. Some patient burns have a delayed appearance and may

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

not be noticed until several hours after the procedures. The pad should be placed on a large fleshy area, preferably over a muscle mass that is clean and dry. Areas that may get wet or are wet during the procedure can cause the pad to slip and cause a burn. 2. What specific factors in this situation contributed to what occurred? ANS: General safety and patient considerations were not followed. Safety factors include: • Dispersive pads can be cold, so apply after the patient is asleep or inform them they will feel something cold. • Apply pad after positioning the patient. • Apply pad to a large fleshy area. • Avoid placing pad over a bony area. • If the patient is supine, avoid placing pad on buttocks. • Do not apply pad over a metal prosthesis. • Handle pad as little as possible. • Confirm that the entire pad is making full contact with the skin. • Check for an expiration date or if the gel is dry. • Place the dispersive pad as close to the operative site as possible. • If pad is placed, but the placement is not satisfactory, remove and reapply with a new pad. • Do not let skin prep solution pool around or under pad. • Flammable anesthetics should not be used during electrosurgery. • ECG electrodes have metal tips that can serve as an alternative pathway for the current, thus burning the patient. • A pacemaker or internal defibrillator can malfunction during electrosurgery. • Jewelry or other metallic objects belonging to the patient should be removed prior to surgery. 3. What complications might result from the burn injury? ANS: Since the patient has sustained significant burns, they need to meet with a plastic surgeon to assess, plan, and schedule required procedures for treatment. Burns may be consistent with second- to third-degree burns, requiring multiple debridement procedures for the elimination of any devitalized tissue, followed by autologous grafting, wound care, and extensive healing time. 4. What could the CST and other surgical team members do to help prevent this type of injury? ANS: The surgical team should have followed safety precautions. This includes being conscientious when placing the patient in the lithotomy position and when draping them. The sheets on the OR table should have been checked for moisture, and caution should have been used when moving the buttocks and legs. When repositioning the patient onto the OR table, the OR bed sheets should have been checked for any moisture or strike through. Placement of the dispersive pad was not applied where recommended. Additionally, the patient had verbally complained about pain on one side of their back, and no one in the OR or PACU documented this.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

CLOSING CASE STUDY Your facility has recently been featured in the news for breaching patient confidentiality after a famous sports figure was admitted into the surgical unit. One of the unassigned surgical staff members made a social media post with the hospital logo in the background after viewing the patient’s information at the OR front desk. 1. In what way was the employee violating policy by looking at the patient information? ANS: The Health Insurance Portability and Accountability Act (HIPAA) ensures that this information remains private and secure. Healthcare professionals (HCP) should know that publicizing a patient’s health history information without prior consent is a breach. The individual posting on social media is in violation of HIPAA. 2. What type of damages can the hospital and employee incur when protected health information is shared publicly? ANS: The patient can file a lawsuit, and the hospital and employee will be held accountable and responsible for this breach. Privacy regulations ensure a national level of protection for patients by limiting how health plans and healthcare facilities can use patients’ personal medical information. The regulations protect medical records and individually identifiable health information, whether on paper, in computers, or communicated orally. 3. What type of physical, administrative, and technical safeguards could have been put in place to prevent such an occurrence? ANS: Safeguards and provisions are in place, and the facility has an obligation to ensure all their employees will adhere to the following provisions and standards, including: • Who has access to medical records • Notice of privacy practices • Limits on the use of personal medical information • Ban on marketing • Confidential communications HIPAA aims to provide improved patient service, protect patients’ privacy, and reduce fraud and abuse.

QUESTIONS FOR FURTHER STUDY 1. What are the applications for and advantages of electronic devices in the perioperative departments? ANS:

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Most hospital systems in the USA currently have one of the myriad of medical records systems implemented at their facility. Having patient’s medical records accessible provides ease of transfer of information, ease of use, and ease of input and sharing. These records may contain preoperative documentation such as a copy of the informed consent, intraoperative records such as frozen specimen results, or post-operative information such as routine vital signs maintained after a procedure. One other system that has been introduced in hospitals is the tracking of soft goods used during a procedure. This electronic process of tracking would provide a much easier way of knowing when and how an item was lost or misplaced. 2. How does the electrical current pathway differ between monopolar and bipolar electrosurgery? ANS: The monopolar cautery cuts and coagulates, or does a blend of both. It consists of a generator, active electrode (the hand control), and patient return electrode (grounding pad). The electrocautery hand control is activated by the surgeon, allowing for the electrical current to travel through the patient’s body and divert to the grounding pad, preventing the patient from sustaining any internal burns. The bipolar cautery only coagulates. There is no need for a grounding pad. The hand control looks like a forceps, and the two tips enable the active and return electrodes to transmit current flow. The current never travels through the patient’s body. 3. Why might a patient’s jewelry be hazardous in the OR? ANS: Jewelry worn by a patient in the OR may conduct electrical current, resulting in a burn to the patient. Jewelry may also be constrictive and cause a neurovascular injury. It may also become entangled, causing injury to the patient. 4. What are the safety precautions to be considered with the placement of the patient return electrode? ANS: Apply a pad to a large fleshy intact area (muscle mass), being sure to avoid bony areas, prominences, and implants, and ensure it is in full contact. No prep solution, lotions or ointments should be on the skin. The pad should be approximately sized for the patient and never cut to resize. Check the pad expiration date and ensure there is no folding of pad/wrinkles and no pooling of fluids near or on the pad. 5. What are the three properties of laser light that are different than normal light? ANS: Laser light is monochromatic (same color/wavelength), collimated (runs parallel to each other), and coherent (lines up with each other running in same direction). 6. Why is a laser safety checklist important? Provide an example of what items may be included in this checklist. ANS:

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

A laser safety checklist is important because significant risk factors exist when using lasers for surgical procedures. The most significant risks include fires, eye damage, and biological hazards due to the surgical plume. Some items which may be included in a laser safety checklist include: • That all personnel in the OR must wear appropriate eye protection to safeguard against retinal damage from the beam. • That a danger sign must be posted at all entrances to the OR to limit traffic into the OR. • That non-reflective laser instruments be used. • That glass windows have shades. • That eye pads are placed on patients’ eyes. • That flammable solutions are not on the sterile field. • To avoid using cloth, paper drapes, and foam.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 6: Principles of Microbiology

OPENING CASE STUDY A CST is participating in an appendectomy procedure. As the surgeon opens the peritoneum, the CST observes that the peritoneal fluid appears thick, yellow, and has a foul odor. While the surgeon extends the peritoneal incision, the CST requests that the circulator provide the aerobic and anaerobic culture tubes that were set aside for possible use. 1. What is the rationale for obtaining the culture tubes? ANS: A culture and sensitivity test is performed in the laboratory and requires two steps. During the first step, a sample is collected, usually with the use of a culture tube that may be designed to preserve the sample in an aerobic or anaerobic environment until it can be transported to the lab.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. What is the basis for collection of both aerobic and anaerobic specimens? ANS: When the sample is cultured, it means it is allowed to grow under controlled circumstances, usually in a petri dish containing a specific culture medium and at a controlled temperature (incubated). The goal of the culture is to allow the microorganism to colonize, so a pure sample of the organism can be obtained and identified using one of the staining methods. An anerobic culture media consists of an anerobic blood agar that is enriched with other substances. Aerobic specimens require oxygen to colonize, and anaerobic specimens do not require oxygen to colonize. 3. What should be done with the culture specimens following collection? ANS: The culture tubes should immediately be labeled and sent to pathology to undergo the two-step process. Transport culture media is used to preserve the viability of the specimen from the time of collection to the time of processing without allowing the growth of the organism. Transport culture media is often a buffered solution that contains peptones and carbohydrates but no growth factors.

4. What additional actions might you anticipate later in the procedure based on the presence of infection? ANS: Intraoperatively, the CST would anticipate the use of copious amounts of irrigation, perhaps mixed with a broad-spectrum antibiotic, the use of monofilament suture for tissue approximation, and a surgical drain or wound-vac. Once the organism has been identified, it may be necessary to preserve a pure form of the organism for an extended time. If the organism is sensitive to an antibiotic, it is susceptible to treatment with that antibiotic, confirming that the patient will thereafter be prescribed the correct antibiotic.

CLOSING CASE STUDY During the morning report prior to procedures beginning, the surgery team that is assigned to the OR where a cataract procedure will be performed are told to use as much disposable equipment, surgical instruments, and supplies as much as possible, and at the end of the procedure place the indisposable surgical instruments into a biohazard bag to be properly disposed. 1. What type of microbe might the patient be infected with, causing the indisposable instruments to be thrown away as biohazardous material? ANS: This would be a prion (proteinaceous infectious particle). Prions are different from other infectious agents in that they are nonliving protein strands and do not contain DNA or RNA. For example, Creutzfeldt-Jakob disease (CJD) is a rapidly progressive fatal central nervous disease characterized by dementia and myoclonus. Exact mode of transmission is unknown but is thought to be by percutaneous

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

inoculation with brain tissue or cerebral spinal fluid from infected persons; transmission has been associated with use of contaminated instruments. 2. What tissue is typically targeted by the microbe? ANS: The tissues that have been identified as high risks for transmission include eye tissue, dura mater, brain tissue, and spinal cord tissue. Recommendations and guidelines concerning the postoperative decontamination and sterilization of surgical instruments and equipment used on suspected CJD patients are not well established or universal. 3. What is the reason for not steam or gas sterilizing the surgical instruments? ANS: Prions are very resistant to chemical and physical sterilization methods such as steam under pressure, ethylene oxide, and dry heat. The World Health Organization’s Infection Control Guidelines for Transmissible Spongiform Encephalopathies recommend single use disposable instruments and the destruction of all reusable instruments.

4. Is there an incubation time for the disease caused by the microbe? ANS: CJD develops very slowly, with an incubation time of up to twenty years. Symptoms early in the course of the disease mimic those of Alzheimer’s disease and include depression and poor memory. Later stages are characterized by dementia and progressive loss of physical functions. A diagnosis of CJD is obtained by observing changes in EEG results and MRI changes. Definitive diagnosis is through microscopic histologic examination of affected brain and lymphoid tissue.

QUESTIONS FOR FURTHER STUDY 1. What precautions should be followed to prevent cross-contamination of patients when a disease process has been diagnosed in a healthcare provider? ANS: If an infected patient requires surgical care, the surgical team members must practice meticulous techniques in the care of the patient to prevent cross-contamination, or the infection of the team members, other patients, and the environment. Healthcare facility policies and procedures pertaining to providing care for these types of patients must be followed, and the surgical team should implement the required precautionary safety measures. Protective measures include respiratory confinement techniques or the use of the sterile field’s neutral zone for passing sharp items, such as scalpels, during a surgical procedure. 2. What is the type of immunity that occurs when a person becomes ill and recovers from the disease? ANS: Natural active immunity occurs when an individual is exposed to a pathogen, becomes ill, and recovers from the disease. The body produces antigens that protect the individual from contracting the

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

same disease again. The length of natural active immunity varies from a few months to a lifetime, depending on the type of pathogen. 3. What are the two primary sources of SSI risk to the patient? Describe the two sources. ANS: The two primary sources of SSI risk to the patient are the endogenous microflora encountered in contaminated procedures and the indigenous microflora of the skin. This is certainly true for procedures where the gastrointestinal tract is opened and the surrounding tissues of the surgical wound are exposed to the contamination. Patients who are carriers of S. aureus are at particular risk for SI, even in clean procedures. Carriers have colonies of these bacteria living in the nares or the deeper layers of the skin, making preoperative skin preparations less effective. As time passes following preop skin prep, rebound growth of indigenous bacteria reach the surface, where they may be shed and contaminate the open surgical incision. 4. Describe types of fomites and why are they a source of microbial transmission. ANS: Fomites are inanimate objects, such as walls, floors, cabinets, furniture, and equipment, that may contain infectious microorganisms. A safe, clean, and spacious OR helps to provide a lower level of microbes in the environment. For example, ORs designed with a clean zone, filtered and controlled air systems, and the use of soil-resistant building materials have become routine. A great example of a fomite would be water from a park fountain from which many people drink. Infectious agents deposited by one person can potentially be transmitted to a subsequent drinker. A cell phone is another example of an inanimate object that could easily transmit bacteria to another user.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 7: Surgical Asepsis and Sterility: Best Practices and Techniques

TABLE OF CONTENTS Opening Case Study.................................................................................................................................. 23 Case Study Part II..................................................................................................................................... 24 Case Study Part III ................................................................................................................................... 25 Case Study Part IV ................................................................................................................................... 25 Closing Case Study ................................................................................................................................... 26 Questions For Further Study ................................................................................................................... 27

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A CST is breaking down the field following a lumbar laminectomy and fusion. The OR supervisor enters the OR and asks the CST if the chemical indicators (Cis) from the trays had turned because the biological indicator (BI) vial used to test the steam sterilizer turned yellow for the load in which the surgical instruments were processed. 1. What does the yellow color of the BI indicate to the CST? ANS: A biological indicator is a device which contains a specific type of microorganism that is killed when exposed to sterilizing conditions. The microbe is in the spore stage, and therefore is difficult to kill. The BI is the only test that guarantees that items are sterile and that the conditions necessary for sterilization have been met. The BI vial is crushed and the broth within is red in color. If the liquid remains red after incubation, then the results are considered negative, meaning the spores have been killed. If the broth turns yellow, then the results are positive, meaning the conditions for sterilization were not met, the spores were not killed, and the items in the load must be considered nonsterile. 2. What color would the CIs be for the steam sterilized trays? ANS: Chemical indicators consist of paper impregnated with a dye that changes color in the presence of temperature and sterilant. The most popular type of external CI is autoclave tape. This tape starts out cream-colored with light white candy cane stripes which, following exposure to the process, change to black. 3. What other process monitors are used to assess proper functioning of the steam sterilizer? ANS: Readout challenge packs for gravity displacement sterilizer cycles provide reliable incubated BI results in three hours. A super rapid readout challenge test is also available for dynamic air removal and gravity displacement steam sterilization cycles that meet ISO and FDA requirements, providing BI results in twenty to twenty-four minutes. Most CSPDs routinely perform the standard twenty-four-hour BI incubation in addition to any rapid or super rapid readout results and maintain both records in case an SSI is investigated. 4. How will the CSPD personnel track the other instrument trays from that same sterilizer load? ANS: A tracking management system with lot numbers and bar codes allows CSPD personnel to quickly recall any nonsterile tray that may have been released to storage or the OR. Quality assurance is an essential component of any type of sterilization process. Methods must be used to confirm the sterility of items and proper operation of the sterilizers. Besides the mechanical, chemical, and biological means of assurance, it is imperative for CSPD personnel to maintain appropriate documentation.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

CASE STUDY PART II A CST is preparing for a total hip arthroplasty. The CST had opened both wrapped trays and rigid instrument containers brought in by the orthopedic vendor before scrubbing in and is now ready to begin setting up for the procedure. The CST asks the RN circulator to check the tray wrappers and containers after lifting the baskets up, but before putting them on the back table. 1. What should the CST have checked for inside the instrument basket before picking it up? ANS: The CST should have checked the chemical indicator inside to be certain it changed to black, which would then indicate the tray has successfully gone through the process of sterilization. 2. What is the CST asking the circulating nurse to check for with the wrappers? ANS: The CST is asking the circulating nurse to be sure there is no moisture or strike-through on all sides of the wrapper, including front and back, and to check that there are no holes in the wrapper. Strikethrough or moisture would be an indication that the process of sterilization was not successful. 3. What would the circulating nurse look for inside the rigid instrument container? ANS: The circulating nurse would be checking the inside cover lid filters for moisture and strike-through, as they would do for the outer wrapper, as well as checking that there are no cracks in the rubber/silicone gasket. 4. What types of information and process monitors were included on the outside of the container? ANS: Since this was a rigid container, on the outside handles of the container there would have been tags with dots that must turn black to indicate that the items went through the process of sterilization, along with the tray name/contents, the date of sterilization, the lot number, and perhaps a barcode for instrument tray tracking. 5. How should the CST manage the used instruments intraoperatively and at completion of the procedure to minimize potential for biofilm formation and facilitate the decontamination process prior to transfer to the decontamination room? ANS: Intraoperatively, it is the responsibility of the CST to always use sterile water to wipe off any gross debris or bioburden from instrument tips, box locks, jaws, and all instrumentation which possesses a lumen. Postoperative management of instruments would include opening all instruments, placing them back into their correct trays, and spraying them with an enzymatic foam or gel which prevents drying of bioburden. As a first line of defense in the process of decontamination, this helps the CSPD staff to properly continue the required process of instrumentation care and processing.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

CASE STUDY PART III The CST setting up for a total hip arthroplasty had a surgical technology student in the OR and took the opportunity to quiz the student regarding the topic of sterilization using this procedure’s setup because of the variety of instrument trays supplied by the vendor. 1. Which sterilization method or methods would most likely have been used for the orthopedic instrumentation? ANS: These are critical items that will be used for invasive procedures. They would have gone through the process of steam sterilization, which is the destruction of all microorganisms on or about an object with steam under pressure, chemical agents, and high velocity electron bombardment. 2. What study was performed in CSPD prior to releasing the load of implantable items and instrument trays brought in by the vendor? ANS: The CSPD staff is required to adhere to the general principles of rigid container sterilization recommendations. This includes making sure the rigid containers can be safely sterilized in the same load with other supplies. Containers should be placed on shelves beneath absorbent items to prevent the condensation from the containers from dripping onto the absorbent items. The drying phase should be increased to allow revaporization. Prevacuum sterilization should be used instead of gravity displacement. Gaskets should be inspected and replaced if torn. Disposable filters should be replaced after each use. 3. What is the generally accepted weight limit for instrument trays? ANS: ANSI/AAMI 2017 guidelines recommend instrument sets should not exceed twenty-five pounds. 4. Why would tray weight and number of instruments inside be a consideration? ANS: This is a generally accepted limit not only for sterilization but also for protecting personnel from the undue physical strain of frequently lifting heavy trays during their routine duties.

CASE STUDY PART IV After performing the scrub and donning the sterile gown and gloves, a CST begins to set up and prepare the back table and Mayo stand for a breast biopsy procedure. The CST adjusts the sterile back table cover by repositioning and centering it because one end hung much farther down than the other side. The CST then moves the back table away from the wall by grasping the table edge with fingers curled under the lip of the table edge. The circulating RN asks the CST if they are ready to have the local anesthetic poured into a specimen cup. Turning around with their back turned towards the back table, the CST holds the cup as the circulator pours the bupivacaine. While organizing the back table, the CST

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

lifts the suction tubing that had fallen a few inches below table level and places it on top of the prepared draping materials. Hearing that the case is delayed, the CST finishes setting up and then carefully rolls a stool next to the back table and sits down to wait. To keep their hands from resting in the lap, the CST crosses the arms and puts gloved hands in the axillae. The patient is brought into the OR and positioned, and the surgeon is gowned and gloved. The CST stands across from the surgeon on the opposite side of the prepped patient, handing the woven towels across the OR table for the surgeon to square off the incision. Working together, the surgeon and CST place the sterile fenestrated drape over the patient. The armboard cover dropped below the table level, failing to cover the patient’s arm, so the CST picks up the edge of the drape to fully cover the armboard. The CST brings the suction tubing and Bovie (cautery) with cord up onto the sterile field and attaches them to the paper drape using a perforating towel clip. The surgeon asks the CST to move the cords in relation to where the surgeon is standing, so the CST removes the towel clip and repositions the cords, reattaching them with the same perforating towel clip. ANS: Sterile back table cover is adjusted; front edge of the table is grabbed to move the table forward; back is turned to the sterile table while loading the medicine cups; portion of the suction tube hangs below the table edge. CST sits down on a stool; CST folds arms with hands in axillary region; CST fully picks up the edge of the drape to cover the armboard; perforating towel clip is used to anchor the suction tubing and Bovie; and the perforating towel clip is then repositioned.

CLOSING CASE STUDY A CST is setting up the back table and Mayo stand for a laparoscopic tubal ligation. One of the trays was steam sterilized in a rigid container and the wrapped laparoscopy tray was sterilized by vaporized hydrogen peroxide (VHP). While organizing the back table for the instruments, the CST asked the circulator to check the tray wrapper for holes after the CST picked the tray up. No holes were noted, and the CST placed the tray on the back table, along with the laparotomy tray from the container. As the circulator was putting the tray wrapper in the trash hamper, there was an audible gasp followed by an alarmed, “Stop! The tray isn’t sterile. Look, the indicator tape didn’t turn black like the other tray did!” 1. What are the colors of chemical indicators for VHP and steam before and after being processed in their respective sterilizers? ANS: Chemical indicators are assigned a class designation based on the specific information indicated by the device. External indicators provide a visual indication of exposure of the package to the sterilizing agent. These chemical indicators consist of paper that has been impregnated with a dye that changes color based on temperature and level of sterility. The most popular external chemical indicator is autoclave tape. Prior to exposure to steam, the tape is cream-colored with light diagonal lines of ink; following sterilization, the ink lines change to a uniform black color. Internal steam chemical indicators are placed inside packages, peel packs, and trays. These internal indicators will change to black. Some chemical locking devices have a dot which changes to black during sterilization.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. Why would the circulator have thought the tray was unsterile? ANS: The circulator noticed the tape had not turned black. Chemical indicators are used externally and internally to verify that items have been exposed to sterilizing conditions. It must be emphasized that chemical indicators only validate that the contents of the package were exposed to a specific temperature, humidity, and sterility. They do not verify the sterility of the item. Chemical indicators aid in detecting potential sterilization failure. 3. Was either tray actually unsterile or were they both processed accordingly? ANS: As soon as the CST placed the tray on the back table with the laparotomy tray from the container, both items became a component of that sterile field. As soon as the circulator said, “Stop,” all items on that sterile field are now considered to be contaminated. 4. What corrective action would need to be taken if one tray actually was found to be nonsterile? ANS: The CST came in touch with the potentially contaminated tray; therefore, not only are all the items on the field considered to be contaminated, but the CST’s gloves and gown need to be changed, and the table would need to be redraped. There is an expression which should be remembered in a sterile environment: “If in doubt throw it out.” In other words, if we think something has been contaminated, then it should be considered contaminated. 5. How could this type of situation be prevented in the future? ANS: It is the responsibility of the CST and the circulator to always verify that the outer indicator strip and the inner indicator strip has turned color, therefore assuring the item has gone through the process of sterilization. Absolute sterility cannot be assured; however, checking all these components by both team members would have prevented all the other items on the sterile field from becoming contaminated.

QUESTIONS FOR FURTHER STUDY 1. How does understanding the sterilization processes and activities performed by sterile processing personnel affect the CST’s overall job performance and the quality of patient care? ANS: Practices involved in preventing disease transmission in the surgical environment consist of disinfection of areas within the operating room; decontamination of surgical instrumentation and their preparation and packaging for sterilization; exploration of various methods used for instrument sterilization, sterile storage, and surgical distribution systems; and delineating specific guidelines for best practices, principles of asepsis, and sterile techniques for CSTs.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Because the primary method by which microbes are kept to an irreducible minimum in the OR is through the creation of a sterile field for each procedure, two departments could not be more dependent on each other than the sterile processing and operating room department’s team members. They each need to have a clear understanding of the other department’s responsibilities to achieve and master the overall job performance of quality patient care. 2. What are ways to enhance the balance of the supply of reprocessed sterile instrument trays with the demands of a busy surgery schedule and the increasingly complex procedures requiring specialized instrumentation? ANS: The cost of running an operating room is significant, as is the cost of waste disposal. Among many HCS operating room departments, any type of cost savings would have a broad financial impact. For years, professionals and practitioners have conducted studies to determine the best way to deal with the issue of managing surgical supplies and instruments (which are directly related to the surgeons’ preferences and specialties). Today, research has demonstrated that the field of inventory management of surgical supplies and instruments, inclusive of reprocessing, can enhance a facility’s ability to perform diverse procedures if they maintain an overstock of supplies and instruments to satisfy demand. Recent trends have developed that are aimed at improving supply ordering processes by incorporating electronic data and internet connections. For example, one method of tracking reprocessed surgical instrument sets is automated bar code labeling. This bar code scan creates a tracking mechanism to locate instrument trays and their availability for use, as well as the date of sterilization and all other relevant sterilization process monitoring information in case of the need to recall any trays. 3. What steps are required to verify both contact with the sterilant and sterilization of an instrument set so that compliance with all process monitoring is demonstrated to inspectors from the Joint Commission? ANS: Organic debris should be removed by wiping instrument tips clean with sterile gauze and processing the tips of the instruments in a glass bead sterilizer for twenty to thirty seconds. All items must be open or disassembled to allow penetration of the sterilant to all surfaces. Placement of the packages in the sterilizer must allow contact with the sterilant. Contact is presumed once all other conditions of sterilization have been met. The only way to verify sterilization is with a biological indicator, and that only verifies sterilization at that specific location. In accordance with the Joint Commission, facilities must use evidence-based guidelines and standards when developing infection prevention and control. They are expected to articulate their infection control practices based on the AAMI’s guidelines for reprocessing of sterile instruments and endoscopes. Quality control would be inclusive of time, temperature, pressure, biological and chemical indicators, and documentation. 4. What are prions, and why do they create concern in both the OR and CSPD following surgical procedures on patients suspected to have CJD?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: A prion is an infectious agent that is smaller than a virus and has severe consequences. Prions are difficult to destroy using conventional methods of sterilization. The World Health Organization (WHO) recommends the use of single-use disposable instruments and the destruction of reusable instruments found to have been contaminated by a prion. When a known case of CJD is present in a surgical unit, terminal cleaning of that operating room is conducted, along with the protocols stated above. 5. What would the impact be on the surgical outcomes for patients and the HCF if one or more CSTs were not aware of or were not dedicated to strict adherence to the principles of asepsis and demonstrated improper sterile technique? ANS: The impact would be surgical site infection, delayed wound healing, additional medication, possible repeat surgical procedures, and possible complications that may lead to poor outcome or patient death. AST has established guidelines for best practices related to principles of asepsis and sterile technique. They are as follows: • Monitor sterility. • Ensure humidity in the OR is established in compliance with federal regulations. • Establish a sterile field. • Don appropriate surgical attire, perform surgical scrub, hand hygiene, and hand washing. • Don gown and gloves using sterile technique. • Follow surgeon’s preoperative orders inclusive of the skin prep. • Utilize best practices in urinary catheterization. • Placement of sterile drapes should not compromise the integrity of the sterile field. • Do not break down the sterile field until the patient has been transported outside of the room.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 8: Emergency Situations and All-Hazards Preparation

OPENING CASE STUDY An 82-year-old patient arrives in the emergency department after falling and hitting their head. They have a history of rheumatoid arthritis. The patient is alert on arrival but quickly loses consciousness. An

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

EKG is taken and suggests that they are having a left ventricular myocardial infarction. They are taken to the OR and prepped for coronary artery bypass surgery. 1. While typing and cross-matching the patient’s blood, it is determined that the patient is a universal recipient. What is the blood type? ANS: There are four main types of blood, A, B, O, and AB, based on the presence or absence of A and B red cell antigens. In addition, the blood contains agglutinins, which are antibodies that work against the A and B antigens. Individuals with type A blood naturally produce anti-B, and individuals with type B blood naturally produce anti-A agglutinins. An individual with type O blood, however, naturally produces both A and B agglutinins, making the O individual a universal donor. Type AB individuals produce neither antibody, and therefore they may receive any type and are called universal recipients. 2. Because the patient’s blood cannot be used for transfusion during the procedure, what blood product will be used? ANS: The most common type of homologous blood replacement therapy used in the OR is the administration of packed red blood cells (PRBCs). 3. What other blood factor must be identified when typing and cross-matching is completed? ANS: Another consideration in blood matching is the Rh (Rhesus factor), which is an antigenic substance found in the erythrocytes in most people. Individuals with the factor are termed Rh positive, whereas individuals lacking the factor are termed Rh negative. If blood given to a Rh-negative individual is Rh positive, hemolysis occurs, leading to anemia. Due to these factors, blood is carefully typed and crossmatched prior to being administered.

CLOSING CASE STUDY A 45-year-old patient is undergoing a breast biopsy. The surgeon has just injected the incision site with 1 percent xylocaine. After a few minutes, the patient reports feeling an overall itching sensation, and the anesthesia provider notes that the patient has broken out into hives. Seconds later, they are having trouble breathing and have become slightly hypotensive and tachycardic. 1. Based on these signs and symptoms, what is the patient experiencing? ANS: This forty-five-year-old female is experiencing an anaphylactic reaction, which is an exaggerated allergic reaction to a substance or protein. A patient suffering an anaphylactic attack generally first shows only mild inflammatory symptoms. As the reaction progresses, the patient experiences difficulty breathing because of bronchospasm and laryngeal edema. At the same time these respiratory symptoms are occurring, another chain of events is taking place which causes vascular collapse because of shifts in body fluid.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. What is the surgical team’s first priority? ANS: During an anaphylactic reaction, the surgical team must maintain the airway and provide supplemental oxygen, or the patient may die of respiratory failure. The symptoms of vascular collapse and shock must also be treated to prevent death from cardiovascular failure. 3. What medication will be given first, and what are the actions of that medication? ANS: Epinephrine is the first line drug in the treatment of a severe anaphylactic reaction. The administration of Epinephrine will cause bronchodilation, reduce laryngeal spasm, and raise blood pressure. 4. What medication is given to slow the chain of events that caused the reaction to occur? ANS: Steroids are administered to stabilize mast cells and slow or stop the chain of events that caused the reaction. Intravenous fluids and plasma may also be utilized to restore fluid volume, and vasopressor agents, such as Levophed, are given to increase blood pressure.

QUESTIONS FOR FURTHER STUDY 1. What are three signs of malignant hyperthermia? ANS: Increase in end-tidal CO2, muscle rigidity such as masseter jaw rigidity, and the late sign of a rapid increase in body temperature. 2. When a patient experiencing a sudden cardiac arrest has an advanced airway in place, how many breaths should be provided to the patient? ANS: 8–10 breaths per minute or one breath every 6–8 seconds. 3. What solution is used to decontaminate the skin and superficial wounds of patients who have been exposed to chemical agents? ANS: 0.5% sodium hypochlorite (household bleach mixed with water) followed by irrigation with normal saline.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 9: Surgical Pharmacology and Anesthesia

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A 45-year-old patient with breast cancer is scheduled to have a venous access device implanted that will allow chemotherapy drugs to be administered without continual venipuncture. The procedure will be performed under local anesthesia with monitored anesthesia care. These are the medications listed on the surgeon’s preference card. a. Xylocaine 1 percent plain in a 10-cc vial b. Normal saline for irrigation—500 mL c. Heparin sodium 5000 units per milliliter—3 mL d. Heparin sodium 5000 units in 500 mL normal saline for injection 1. Which medication is used to prevent the patient from feeling pain during the procedure? ANS: Xylocaine, lidocaine HCI, is the used to prevent the patient from feeling pain during the procedure. Drugs in the amino amide group are metabolized in the liver and excreted by the kidneys. Lidocaine HCl is a widely used local anesthetic agent with a rapid onset of action with moderate duration. Lidocaine can be administered topically for application on mucous membranes, injected locally for peripheral nerve block, or injected into the tissues surrounding a major nerve root to provide regional blockage. Please know that this medication is also used to treat heart arrhythmias. 2. What three items from the medication label must be verified when accepting medications onto the sterile field? ANS: The generic and trade name of the medication, the concentration of the medication, and the expiration date are the three items which must be verified when accepting medications on the sterile field. 3. Which medication is considered the “dilute” heparin solution? What is the concentration of that solution in units per mL? ANS: Heparinized saline solution for intravascular irrigation is commonly used during cardiac and peripheral vascular procedures. Dilute and concentrated heparin solutions may be required for use during the same procedures, and the CST should clearly label and separate these solutions to prevent medication

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

errors. Heparin sodium 5,000 units in 500 mL normal saline is the dilute heparin solution. The concentration of this solution is 10 units per milliliter (5,000 units divided by 500 mL equals 10 units per mL). Often heparin comes in premixed IV bags containing heparin in normal saline or heparin in D5W. 4. Which medication is the “final flush” to assure that the device and its catheter are not occluded by a blood clot between uses? What is the total amount of heparin in units of that solution? ANS: Heparin sodium 5,000 units per mL would be used as the final flush, as heparin sodium is an anticoagulant that prevents thrombus formation in a concentrated dose to fill the lunen of the reservoir and tubing with heparin solution. At 5,000 units per mL in a 3 mL syringe, it would be 15,000 units. 5. What medication is used to counteract the effects of heparin sodium if too much is administered, or the effects of heparin are no longer desired? ANS: Protamine is a medication used to reverse and neutralize the effects of heparin. It is an antagonist medication and specifically neutralizes heparin-induced anticoagulation.

CLOSING CASE STUDY A 55-year-old patient who is positive for MRSA is having a laparoscopic cholecystectomy. During the procedure, the surgeon encounters unexpected heavy bleeding from the liver bed and decides to convert to an open cholecystectomy. 1. What medication category will be used during the “intraoperative cholangiography” part of the procedure? Name three medications from this category. ANS: Drugs are classified according to their principal action, for example, barbiturate, and by the organ or body system affected. This medication is a contrast media. This classification of medication is a radiopaque contrast to outline hollow structures for radiologic imaging. Three examples would be Cystografin, Hypaque, and Angio-Conray. 2. The surgeon requests half-strength diatrizoate sodium solution; you have 30 mL of diatrizoate sodium and a 50-cc syringe on the field. How much of the medication and how much normal saline will you add to the syringe? ANS: The 30 mL of diatrizoate needs to be diluted so that its concentration is half-strength. With a 50-cc syringe, you would have 25 mL of the medication and add 25 mL of the solute (normal saline), making the 50-cc half-strength. 3. The surgeon requests an antibiotic irrigation for closure. Considering the patient’s medical history, what antibiotic will be requested? What information should be included on the label for the basin containing the requested irrigation? What will be used to deliver the irrigation to the wound?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Vancomycin added to a basin of saline as an irrigation solution would be ideal. The basin and bulb syringe should all be labeled with the name, strength of the medication, solute and expiration date. 4. What three medications might be used to control the bleeding on the liver bed intraoperatively? ANS: Oxidized Cellulose is an absorbable product that is plant based and available in the form of high density pads. Blood clots rapidly form in the presence of oxidized cellulose, and these products form a gel which aids in hemostasis as it becomes soaked with blood. Microfibrillar collagen (Avitene) is derived from purified bovine (beef) collage shredded into fibrils (powered) and available in preloaded applicators, powered dispensers, or compacted nonwoven sheets. The collagen is soluble, and is absorbed as hemostasis occurs. Absorbable gelatin sponge is composed of collagen, a structural protein found in connective tissues. Gelfoam is derived from purified porcine (pork) gelatin which is whipped to a foamy consistency, then dried and sterilized. The sponge may be applied dry, soaked in saline to increase its pliability, soaked in thrombin (Thrombinar) to enhance clot formation, or soaked in epinephrine to enhance vasoconstriction. 5. The surgeon is concerned that the patient might have some postoperative liver inflammation leading to nausea and vomiting. What single medication would the surgeon ask the anesthesia care provider to give intraoperatively to treat this possibility? ANS: Antiemetic agents are used to prevent post-operative vomiting and nausea (POVN). Droperidol (Inapsine), metoclopramide (Reglan), ondansetron HCl (Zofran), granisetron HCl (Kytril), and dolasetron mesylate (Anzemet) have antiemetic properties and are usually given by IV injection.

QUESTIONS FOR FURTHER STUDY 1. What is Sellick’s maneuver, when is it used, and how is it performed? ANS: Sellick’s maneuver is the application of cricoid pressure and is performed to reduce the risk of aspiration of stomach contents causing aspirational pneumonia. Cricoid pressure is employed in the operating room (OR) in situations in which the patient requires emergency surgery shortly after eating, the NPO status of the patient cannot be verified, or the patient is experiencing gastrointestinal (GI) bleeding. Cricoid pressure may also be applied as needed during basic life support or cardiopulmonary resuscitation (CPR) settings. External pressure is applied to the cricoid cartilage, causing occlusion of the esophagus between the cricoid ring and the body of the sixth cervical vertebrae. This maneuver is designed to prevent the stomach contents from ejection during vomiting, thereby reducing the risk of aspiration into the respiratory tract. 2. Why might bupivacaine HCl be a better choice of local anesthesia during an inguinal herniorrhaphy than lidocaine HCl?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Bupivacaine is a longer-acting local anesthetic than lidocaine and may provide extended postoperative pain relief for the patient without any cardiac effects. 3. Describe Korotkoff’s sounds and their implication in measuring blood pressure. How many sounds are commonly heard, and which are of significance? ANS: When blood pressure is assessed manually using a cuff with a manual inflation device, a sphygmomanometer, and a stethoscope, Korotkoff’s sounds are heard as a tapping sound that gradually increases in intensity as the cuff is deflated. These sounds take place in five distinct phases, which must be recognized for proper blood pressure measurement. The two initial tapping sounds are Phase I and are recorded as the systolic blood pressure. Phase V is when all tapping sounds disappear and is recorded as the diastolic blood pressure, such as 120/60. If you hear tapping sounds all the way to zero/complete deflation, Phase IV (the point at which they become muffled) becomes the recorded middle number, 120/90/0. 4. What is the primary difference between spinal and epidural anesthesia? Ans: The primary difference between spinal and epidural anesthesia is the site of administration of the anesthetic agent. The position of the patient and the skin injection site are similar. With spinal anesthesia, the medication is injected directly into the cerebrospinal fluid (CSF) in the subarachnoid space between the meningeal layers of the spinal cord. With epidural anesthesia, the medication is injected into the tissues directly above the dura mater, where the agent is then absorbed into the CSF. 5. Is the placental barrier effective in protecting the fetal environment from the effects of general anesthetics? Why or why not? ANS: No, the placental barrier is not effective against most medications used in general anesthesia. It is preferred that the pregnant patient receive a local or regional anesthetic such as an epidural or spinal anesthetic. If a general anesthetic is used during a C-section, the patient is completely draped with a Time out completed and is ready to make the incision prior to the general anesthetic being administered. The surgeon and assistant work to remove the infant as quickly as possible to limit the depression effects on the infant, particularly his or her respirations. The placental barrier protects the fetal environment from most toxicants in the maternal circulation. The barrier is comprised of several cell layers between the fetal and maternal circulatory vessels in the placenta. Lipids in the cell membranes limit passage of water-soluble toxicants; however, nutrients, gases, and wastes of the developing fetus can pass through the placental barrier. The placental barrier is not totally impenetrable, but it effectively slows the diffusion of most toxicants from the mother into the fetus. The effectiveness of the placental barrier has been determined for some types of medications and is still under investigation for others. The package insert or the PDR will provide all related information and list necessary precautions during pregnancy.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 10: Instrumentation, Equipment, and Supplies

OPENING CASE STUDY A surgical technology student is completing a rotation at the clinical site’s central sterile processing department. The preceptor notifies the student that a patient has just arrived in the emergency department with a gunshot wound to the chest, and the student needs to assemble a case cart containing everything that will, or might, be needed for the case. The patient will be in the OR in ten minutes, so the student must work quickly. 1. What instrument trays should be gathered for this case? ANS: Due to the pathway of a bullet (bullets are capable of ricocheting in the body), and the fact that the gunshot is to the chest, we will require a thoracic instrument and retractor tray. Placing a major abdominal instrument and retractor tray would be good practice. In addition to the instrumentation, it will be important to include numerous drapes, soft goods, sutures, and closed seal drainage systems. A bullet entering the chest cavity can easily lead to a collapsed lung, which would then require a very specific drainage system. 2. What equipment must be in the OR for this case? ANS: The equipment the surgical team should gather would include all that is referenced in question one as well as: Power sources for all power instrumentation such as a sternal saw Cell saver Defibrillator ESU machine Fiberoptic headlamps and light source Hypothermia/hyperthermia unit Multiple suction systems

3. What supplies must be available for this case?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: There are many supplies that will be necessary to have available for this case. It would be a good idea for the team to seek out the thoracic trauma surgeon’s preference card information and choose supplies that are appropriate to the case. This will avoid taking time during the case to go and retrieve the items. Here are examples of some (not all) that will be gathered: Basin set Bulb syringes Chest tube Dressings ESU pencil and grounding pad Gloves Gowns Knife blades Laparotomy pack Laparotomy sheet Laparotomy sponges Numerous suction tubing Peanut dissectors Plastic adherent drape Raytecs Stapling devices Sutures Ties Towels Vessel loops 4. Considering the extremely limited amount of time available, what should be opened first, and what can be opened as the case progresses? ANS: In an emergency situation, such as this case, it is imperative that the surgical team immediately open all the items that will be required upon the patient’s arrival to the operating room. The patient will need to be quickly prepped, the surgical team will need to be gowned and gloved, the patient will need to be draped, and then they will need to immediately open the chest to control any hemorrhage that could become life threatening. The surgical technologist should be sure to have sponges, blades, clamps, graspers, retractors, and irrigation on the Mayo stand.

CLOSING CASE STUDY A surgical technology student is completing rotation in the central sterile processing department. The student has been asked to assemble a dilatation and curettage (D&C) tray from the racks of sterilized instruments. 1. How will the student know what instruments this facility routinely puts in the D&C instrument tray?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: In the central sterile processing departments of all healthcare facilities, the staff has access to instrument set cards or instrument set lists, as well as computerized lists. These lists are comprised of the names of the types of instrumentation and how many of each should be included in all surgical specialty trays. The student will have the ability to seek out the list for the Gynecologic Surgeries and D&C and will then know what needs to be placed in that tray. 2. Think about the different categories of instruments. Which categories would you put in this tray? ANS: The gynecologic instrument categories that will be placed in the D&C set include retracting/viewing instruments such as an Auvard vaginal speculum and a Graves retractor; cutting/dissecting instruments such as Metzenbaum scissors, Mayo scissors, and curettes; grasping forceps such as tenaculum and pickups; and accessory instrumentation such as knife handles, a probe, dilators, a uterine sound, and clamps. 3. What specific instruments would you put in this tray? ANS: Sims Sound, Auvard Speculum, Graves Speculum, Hanks Cervical Dilators or Hegar Cervical Dilators, Thomas dull Curettes, Sims sharp Curettes, Heaney serrated uterine curette, Kevorkian cervical curette, Forrester Sponge Stick, Polyp Forceps (straight and curved), Braun or Schroeder Tenaculum, Gaylor cervical biopsy forceps, Jacobs tenaculum, Bozeman forceps, Eastman or Sims retractor, long dressing forceps and tissue forceps. In addition, scalpel handles, hemostats, needle holders, and towel clamps should be included as needed.

QUESTIONS FOR FURTHER STUDY 1. What are the strengths and weaknesses of each type of material used for drapes? ANS: The advantages and disadvantages of nonwoven and woven drape materials are compared in the following table. The two primary types of materials for surgical drapes are compared in the box below. Type of Fabric Advantages Disadvantages Nonwoven textile fabrics Disposable (do not need to be washed, More expensive folded, repaired, or sterilized, so exposure to contaminants is decreased

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Woven textile fabrics

Light, yet strong Relatively impermeable to liquids Less expensive than disposable Relatively impermeable to liquids

Must be laundered, folded, inspected for wear, and sterilized after every use Must be repaired Small defects may be missed, compromising the integrity of the barrier Staff exposure to contaminants is increased due to handling

2. Why are specific instrument finishes used? ANS: Dull or black finishes (ebonized instruments) prevent glare from surgical light sources (overhead or microscope) from reflecting off the instruments’ finish into the surgical team’s eyes. Ebonized instruments are also necessary for some laser procedures to prevent injury (to patient or staff) from reflection of the laser beam. 3. In what situation(s) is a water-seal drainage system used? ANS: A water-seal drainage system is used in conjunction with a chest tube to maintain negative pressure within the pleural space, allowing adequate expansion of the lung(s). 4. What is the purpose of a Tenckhoff catheter? ANS: A Tenckhoff catheter is placed into the peritoneal cavity through an opening in the abdominal wall for the purpose of dialysis. 5. Explain the difference between a scalpel and a knife. List one or more examples of each. ANS: Technically, a knife refers to a nondisposable handle and blade as a single unit (e.g., amputation knife, cataract knife) and a scalpel typically has a detachable disposable blade and a nondisposable handle (e.g., a #10 blade on a #3 handle). How- ever, the terms knife and scalpel are often used interchangeably in the surgical environment

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 11: Hemostasis, Wound Healing, and Wound Closure

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Questions For Further Study ................................................................................................................... 38

OPENING CASE STUDY A sixty-three-year-old diabetic patient with a high body mass index (BMI) is complaining of diffuse upper right quadrant pain that becomes more intense after eating. Sonography indicates many stones in the gallbladder. The surgeon has scheduled the patient for an open cholecystectomy with common bile duct exploration. 1. What surgical wound classification would be expected in this case? ANS: Wounds are classified as follows: Class I is clean. Class II is clean contaminated. Class III is contaminated. Class IV is dirty/infected. The patient’s incision will start out as a Class I. Since it is attached to the GI tract, once the biliary tract is entered, the classification is changed to a Class II. Depending on what sequences of events take place next, the same wound may be subsequently increased to a Class III or a Class IV. Those conditions are inclusive of a possible break in aseptic technique, entry into the aerodigestive tract of spillage, or acute inflammation. A presence of infection would make the classification a Class IV. 2. How must the patient’s comorbidities be considered during closure? ANS: Because the patient is diabetic and obese, the natural wound healing process is much more complex. The patient’s vascular system has been compromised; therefore, the surgeon may consider changing the sutures to include heavier or nonabsorbable material to assist with the wound healing process. The closure must be able to withstand the stress of increased intraabdominal pressure during coughing and vomiting. Retention sutures may be incorporated to support the primary closure. 3. How is the wound expected to heal? ANS: Wound healing may be categorized in three different ways:  First intention wound healing is by primary closure and no infection present.  Second intention wound healing is healing from the inside out, beginning with granulation.  Third intention wound healing is when the wound is left open and dressed for a short period of time, and then the patient is returned to have the wound closed. It is as if it begins to heal by second intention and then first intention. The initial phase designated to this patient would be first intention wound healing.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

CLOSING CASE STUDY A CST is assisting a surgeon on a deep abdominal case. The surgeon unexpectedly asks the CST for a stick tie. 1. Describe what the CST should pass to the surgeon, particularly in terms of instrument length, suture length, needle type, suture type, and gauge. ANS: The surgical technologist should have already gathered some basic information from the surgeon’s preference card, including the expected type of suture, size, and needle. The surgical technologists will choose a needle holder that will reach the structure that is bleeding. The length of the needle holder will depend on the depth of the bleeder. The suture already should be loaded on the needle holder in anticipation of its possible use. In this situation, a 3-0 silk on a small round SH needle on at least a 10inch needle holder would likely be appropriate. 2. What should the CST do if the required items are not at hand? ANS: At this point, as the surgical technologist is in the scrub role monitoring and managing their sterile field, the surgical technologist will ask the circulator (or someone not sterile) to open the item(s) needed if not already opened. In the event that a specific item is not available, the surgical technologist should offer the surgical team an item to replace the one needed until that specific item may be obtained. 3. What might the CST ask the surgeon after the case to ensure that the correct items were available the next time they perform this type of procedure? ANS: At the conclusion of the case, it is the responsibility of the surgical team to review with the surgeon any changes that they wish to provide to their preference card on file. This way, in the future, the appropriate items will be readily available in advance of the case. Preference card information is stored in an easily accessed computerized system, with access to any corrections needed.

QUESTIONS FOR FURTHER STUDY 1. During what situations would a controlled-release needle be used? ANS: Controlled-release needles are used in situations in which rapid, efficient placement of interrupted sutures is desired. Examples include dural closure, hysterectomy, and bowel anastomosis. 2. What type and gauge of suture would be used to anastomose a synthetic aortic graft onto an aorta during an abdominal aortic aneurysmectomy? ANS: Double-armed Prolene suture is often the suture of choice for a vascular anastomosis. Suture sizes 4-0 and 5-0 on a taper needle are typically used for aortic anastomoses.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

3. Under what conditions are retention sutures used? ANS: Retention sutures are used as a secondary suture line to reinforce the primary suture line by taking some of the tension off the primary suture line. Retention sutures are placed lateral to the primary suture line and are employed when the surgeon suspects that the wound will not heal properly or will heal slowly due to immunosuppression, obesity, diabetes, or other compromising factors. Retention sutures can also prevent wound disruption that may result from sudden increases in intra-abdominal pressure created by postoperative edema, vomiting, or coughing. 4. What are the classic signs of systemic inflammation? ANS: The classic signs of systemic inflammation response syndrome (SIRS) include fever and an elevated white blood cell count. Noninfectious causes of SIRS include trauma, burns, pancreatitis, ischemia, hemorrhage, and complications of surgery. Systemic inflammation occurs when chronic inflammation moves beyond local tissues and into the lining of blood vessels and organs. Rampant systemic inflammation has been shown to lead to autoimmune diseases, food intolerances, and even obesity. 5. How does phagocytosis contribute to wound healing? ANS: Phagocytosis contributes to wound healing by engulfing and removing foreign particles such as microbes, devitalized tissue, and broken-down suture remnants.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 12: Preoperative Surgical Case Management

OPENING CASE STUDY After applying a skin prep solution to a patient’s chest, the CST notices a reddish discoloration of the patient’s skin where the solution has been applied. 1. What is potentially happening in this scenario? ANS: This patient is exhibiting signs and symptoms of an allergic reaction which could precipitate an anaphylactic shock reaction. Several products are available for use in skin preparation, including scrub © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

soaps, scrub solutions, and single use prep applicators. The agent should be a broad-spectrum antimicrobial that provides residual protection. The choice of agent should be based on the patient’s skin sensitivity, surgical site, and surgeon’s preference. The patient’s allergy status should be considered prior to applying any chemical. An alternate antiseptic may be needed, particularly if the patient is allergic to iodine. 2. How should the CST respond? ANS: The surgical technologist should immediately inform the anesthesiologist, as well as the individual applying the prep solution. Thereafter, they should cease application and cleanse the area already prepped in the hopes to minimize further complications. The anesthesiologist will then assess the patient’s vital signs to ensure they are once again stable enough to undergo surgery. Prior to prepping the patient, confirmation of potential allergies should be verified, and a different prep solution would need to be used.

CLOSING CASE STUDY During preoperative preparation, the patient is told that hair will not be shaved at the operative site, and they must remove makeup, nail polish, and their dentures. 1. Discuss the reasons for why each of the actions required of the patient must be performed. ANS: Certain preoperative preparation procedures will be scheduled the evening or morning before surgery. If the patient is being admitted on a same-day basis, some of these procedures will be explained in the office to the patient, and the patient will be expected to complete these procedures at home, such as preoperative bathing, bowel prep, or specific hair removal guidelines. Hair removal may need to be performed prior to surgery. Patients may be provided with specific hair removal guidelines to follow at home prior to the operation. On occasion, patient hair removal is performed in the OR, although objections have been raised to this on the grounds that the operation is delayed and loose hair is released in the operative environment, where it may find its way onto the sterile field. Recent studies have shown the preoperative use of clippers is the best method for hair removal if hair is to be removed at all. CDC recommends not removing hair preoperatively unless it interferes with the operation, as microbial counts have been shown to increase in pre-shaved areas of the skin. The patient is also instructed not to wear any makeup to the OR. While the danger of makeup shedding and entering the operative site is minimal, it does exist, and the use of makeup may prevent the anesthesia provider from monitoring skin tone and color properly. The patient is generally required to remove all personal clothing and wear a clean gown and hair and feet coverings. Prior to surgery, nail polish should be removed. The pulse oximeter, a device used intraoperatively to measure blood oxygen saturation, cannot function properly with nail polish present, as it relies on a light beam focused through the skin and nail of the finger. Colored nail polish also prevents the nail bed color from being properly assessed for capillary blanching and refill. Dentures, prostheses, and removable implants must be removed prior to surgery, labeled, and placed in safekeeping with the rest of the patient’s possessions. Dentures must be removed because of

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

the danger that they will fall into the pharynx and cause respiratory obstruction when the jaw relaxes under anesthesia. Some anesthesia providers prefer that the patient leave the dentures in until the moment of intubation, as the shape of the dentures provides a better fit for the face mask.

QUESTIONS FOR FURTHER STUDY 1. What factors must be considered before selecting a skin prep agent? ANS: Several products are available for use in skin preparation, including scrub soaps, scrub solutions, and single-use prep applicators. The agent should be a broad-spectrum antimicrobial that provides residual protection. The choice of agent should be based on the patient’s skin sensitivity, surgical site, and surgeon’s preference. The patient’s allergy status should be considered prior to applying any chemical. 2. Discuss the process for transferring a sedated patient from the stretcher to the OR table. How would this process change with a patient with obesity? ANS: The patient is normally transported into the OR from the preoperative area by the anesthesia provider and the circulating nurse on a stretcher and transferred to the operating table. Patients who are not too heavily sedated and are ambulatory may move by their own effort onto the operating table. Patients who are too heavily sedated or unable to move will need to be transferred onto the operating table by an appropriate number of personnel. At least four individuals are required for this process. If too few individuals attempt to move a patient, injuries may occur to the surgery team or patient. With the bariatric patient, there may be a need for a transfer roller or board and additional staff to assist, remembering always that the anesthesia provider supports the head, neck, and shoulders, one person lifts the feet and legs, and one person stands on either side to lift and stabilize the patient’s trunk. With the bariatric patient, where there is one person, two may be needed. 3. Why is it important that all patient jewelry be removed prior to surgery? ANS: Because during surgery we use electrosurgical units to cut and coagulate, jewelry allows for a potential risk of the patient sustaining a burn. The patient should be instructed to leave valuables at home. Prior to surgery, any remaining valuables and possessions should be collected and either given to a family member or significant other or placed in a patient locker for security if they include jewelry. Generally, all jewelry should be removed prior to surgery. 4. Why must the CST have extensive knowledge of anatomy and physiology before participating in patient positioning? ANS: Positioning for surgery usually takes place after the administration of anesthesia. The goal of positioning is to provide the best possible access and visualization of the surgical site, while causing the least possible compromise in physiological function and stress to the joints, skin, and other body parts,

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

and preserving patient safety. The surgical technologist has a responsibility of understanding the anatomy and physiology of the human body to position and provide safety to the patient. 5. Describe the most common methods of thermoregulation for surgical patients. ANS: Controlling the patient’s body temperature is important in the OR environment, and several devices are available to assist with providing hypothermia, normothermia, or hyperthermia intraoperatively. During operative procedures, the body core temperature tends to drop because of heat loss in the cool, dry climate of the OR, the length of the operation, and the use of cold or room temperature irrigation fluids. Intraoperative heat loss occurs through the following processes: radiation, convection, conduction, and evaporation. Radiation and convection are the major modes of patient heat loss. The safest noninvasive methods of maintenance of body temperature are keeping the OR at a warmer temperature until the skin is prepped and the patient is draped with blankets placed on the extremities. Invasive means are the use of warmed gastric lavage; peritoneal irrigation; and fluid warmers for blood, blood products, and IV fluids.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 13: Intraoperative and Postoperative Surgical Case Management

OPENING CASE STUDY A CST is assisting a surgeon on a lumbar discectomy procedure. The CST removes tissue from the jaws of the pituitary rongeur that the surgeon is using to remove the disc material. The CST looks at the specimen and says to the physician, “I think you should stop and look at this—it doesn’t look like disc material to me.” The surgeon asks, “How so?” and the CST responds, “It has a lumen.” The surgeon examines the tissue, has the circulator page a genitourinary specialist, completes the discectomy, and assists on the repair of the ureter. 1. What did the CST have to know to make this critical observation? ANS: Wiping a rongeur that the surgeon uses during the removal of disk material is common practice and one of the many responsibilities of surgical technologists when assisting with a lumbar discectomy. The surgical technologist had to be familiar with how disk material normally appears, the possible © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

structures that are at risk during the procedure, and the importance of observing this kind of specimen upon removal. 2. Discuss the relationship between knowledge of anatomy and physiology and its practical application in the OR setting. ANS: As a surgical technologist, one of the primary responsibilities is to be an advocate for the patient. They need to anticipate the next steps of a procedure, the next items needed, and the potential for an emergent situation to arise in a quick and efficient manner. Anatomy, physiology, and pathophysiology are fundamental areas a surgical technologist must understand. Anatomy defines organs, cavities, and structures; physiology defines functions of the same; and pathophysiology describes what can happen to those organs and/or structures. When working in the field, this knowledge will be an asset in recognizing where the surgeon is, what the procedure will entail, what will be needed “in case of”, and how, working together, the patient will successfully leave the operating room and be on the road to recovery. 3. Did the CST handle this situation properly? What would you have done differently? ANS: Yes, the CST handled this situation properly. The surgical technologist relied on their knowledge and experience to provide the surgeon with a potential problem. The surgical technologist’s intuition prevented the surgeon from accidentally removing tissues that would cause complications.

CLOSING CASE STUDY A CST is assisting the surgeon on the midline closure of an episiotomy. The surgeon says, “Something’s wrong, but I can’t identify it.” The CST replies, “I’m worried also. Do you think they might have DIC (disseminated intravascular coagulopathy)?” The surgeon responds, “Why do you think that?” and the CST says, “I’ve seen this before, and the blood doesn’t look right. I placed some of the patient’s blood in a plain test tube seven minutes ago, and no clot has formed.” The surgeon has the circulator page the attending obstetrician to the room and alerts the anesthesia provider. The patient became slightly hypotensive, but the quick response of the OR team avoided any serious complications. The patient was discharged several days later without further complications. 1. What observation did the CST make that helped the patient in this case? ANS: The surgical technologist noticed that the patient’s blood did not appear to be clotting normally. 2. Discuss whether the CST’s response was appropriate in this situation. ANS: The surgical technologist response was appropriate. Having collected some blood from the operative field on a sponge is not an action that would have been considered to be invasive. The surgical technologist did not try to diagnose but instead waited until the concern was obvious. The surgical technologist added information to the physician’s observation, and in the process, may have sped up treatment by several minutes.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

QUESTIONS FOR FURTHER STUDY 1. Why is it important to anticipate the needs of the patient and surgical team members? ANS: Learning to anticipate the needs of the patient and the surgical team members is a valuable tool. The surgical technologist who is able to anticipate will be able to have the necessary items available prior to the items being needed. This will allow the surgical procedure to progress in an orderly fashion, saving valuable time. 2. What are the procedures for correct counting of instruments and sponges? ANS: Instruments are counted in the sterile processing room, and the initial instrument count sheet is signed by the person preparing the instrument set. The count sheet is removed from the instrument set by the surgical technologist and handed to the circulator during the setup phase. The proper time to complete the initial count is when all items are on the back table but before the preparation of the Mayo stand has begun (refer to Table 9–2 in textbook). Although it is not always possible to meet the recommended practice, it should serve as the expected norm. Counting requires both the surgical technologist and circulator to see each individual item. Items should be counted as they are listed on the count sheet. Any disagreement with the count from sterile processing should result in a recount. If the count remains at variance, the actual number should be written and initialed. If the hospital has a policy and procedure for reporting this type of error, the procedure should be initiated. Extra instruments should be listed and counted. When both the surgical technologist and circulator agree on the instrument count, they proceed to sponges, sharps, and miscellaneous items. 3. What steps must be taken if any part of the count is incorrect? ANS: Any variance in the count should initially result in a recount. • If the initial instrument count does not agree with the items listed on the count sheet, the items should be recounted and the correct number written on the count sheet and initialed. • If the initial sponge count does not agree with the number of items expected within the package, the items are recounted. If a discrepancy remains, the items are removed from the OR and replaced with a complete set. • If one of the closing counts is incorrect, the items should be recounted. If the misplaced item is not found on the recount, steps must be taken (e.g., notify the surgeon, expand the search area, request an X-ray) to ensure that the missing item is not retained within the patient. If the item is not accounted for, an incident (variance) report must be completed. 4. Describe the OR cycle and explain how the CST participates in the OR cycle. ANS: The OR cycle correlates with the three phases of surgical case management. The three phases of the OR cycle and the related duties of the surgical technologist (and other team members) are outlined below. Preoperative Phase: • Preparation of the OR for a specific surgical procedure © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

• Prior to the first case of the day, all surfaces are cleaned with a damp cloth and disinfectant solution. (This step is eliminated for subsequent cases.) • Necessary furniture and equipment are brought into the OR and any extraneous items are removed, according to the type of procedure planned and the surgeon’s preference. • Function of all equipment is verified. • The case cart is brought into the OR and the items to be opened are positioned for use. (The remaining items are kept available for possible later use; they are placed in a location that will be convenient for the circulator to retrieve and open during the procedure, if needed.) • The sterile field is established and prepared for the intraoperative phase of the OR cycle. • The patient and all surgical team members (nonsterile and sterile) are present in the OR. • The patient is anesthetized, positioned, prepped, and draped. • Accessory items (e.g., light handles or covers, electrosurgical pencil, and suction apparatus) are placed, connected, and activated. • The sterile furniture is moved into position. • Time out is performed. Intraoperative Phase • Use of the OR during the surgical procedure • The doors to the OR are kept closed. • Traffic into and out of the OR is restricted. • Opening sequence is completed: incision, hemostasis, dissection, and exposure. • The surgical procedure is performed. • Closing sequence is completed: usually begins with irrigation and inspection of the surgical site, placement of drains, wound closure by layer, and counts performed. Some hospitals consider the dressing application part of the procedure; others stop time at the point at which the incision is closed. Postoperative Phase • The sterile field is preserved until the patient is transported to the post anesthesia care unit (PACU). • Immediate postoperative patient care is provided, which includes patient clean-up; then the patient is transferred to the gurney and transported to the PACU. • The setup is broken down and reusable items are placed in/on the case cart and taken to the decontamination area. • Sharps are placed in a puncture-proof biohazardous waste container. • All unused supplies are returned to their storage locations. • Anesthesia equipment is cared for and any disposable items are discarded. • The specimen is taken to the collection area where it will be picked up and transported to the laboratory for later examination by the pathologist. • Suction canisters and tubing are discarded according to facility policy. • Any remaining linen and waste is placed in the appropriate receptacles. (Biohazardous materials are kept separate.) • Bags are removed from the receptacles, sealed, and processed according to facility policy. • The OR is decontaminated according to facility policy. • The OR is set up for reuse.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

5. What corrective options are available to the surgical team members when a breach in sterile technique occurs? ANS: Three options are available to the surgical team members when a breach in sterile technique occurs. Disregard the contamination. This is a real option, but only when the patient’s life is immediately at risk. Once the patient is stabilized, the contamination must be reported and appropriate corrective measures must be taken (e.g., the surgeon may want to place the patient on prophylactic antibiotics). Remove the contaminated item from the sterile field. This is the most common action chosen and is appropriate in most situations. The contaminated item is removed from the sterile field and replaced with a sterile one. Any items subsequently contaminated must also be removed (e.g., gloves) or covered. Typically, the circulator will assist with removal of the contaminated item(s) from the sterile field. Cover the contaminated item or area. Some contaminated items cannot be removed from the sterile field due to the timing or other circumstances of the contamination. An impervious drape may be placed over the contaminated area, thereby reestablishing the sterile field. Note: Certain types of contamination may require a decontamination step after the discarding process. For example, if the drape is placed incorrectly, you would discard the drape and may need to reprep prior to replacing the drape correctly.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 14: Diagnostic Procedures

OPENING CASE STUDY An eight-year-old patient arrives in the emergency department with their parents. They complain of generalized periumbilical pain that has now shifted to the right-lower quadrant and intensified. They have begun to experience nausea and vomiting and are febrile. 1. What structures in the right-lower quadrant might play a role in the patient’s symptoms? ANS: The structures that would potentially become involved differ in males and females. In both males and females, the radiating pain could indicate the possibility of appendicitis or an occlusion (a calculi) in © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

the patient’s right ureter. In a female, this pain could also indicate the possibility of appendicitis, as well as adnexal structures (female reproductive organs). 2. Which of the details given represent objective signs and which are subjective symptoms? ANS: The patient’s complaint of generalized periumbilical pain and its intensification and nausea are what the patient is feeling and describing. The vomiting and the fever are actual signs of a present infection. 3. Discuss the diagnostic studies that might be performed. ANS: The parents of the eight-year-old will be required to provide the healthcare professional with a detailed patient and family history. They will need to share a timeline of when the discomfort began, and what, if anything, precipitated this malaise. The healthcare professional will then perform a physical exam to the four quadrants of the abdominal cavity to assess where there may be rebound tenderness. Prior to any diagnostic imaging, there would be a lab workup inclusive of blood and urine. The results will provide the healthcare professional with key information to assist in making a diagnosis. 4. Which diagnostic study will indicate the presence of an infection? ANS: One of the key components of blood consist of leukocytes (white blood cells); they are the cells responsible to fight infection. If the blood work returns with an elevated white blood cell count, then further testing will be performed to better assess the condition. 5. What surgical procedure might be performed to treat the patient’s condition? ANS: With these signs and symptoms, there is a high likelihood that the appendix is inflamed. Because the appendix is attached at the cecum (containing fecal matter), the doctors will want to perform an appendectomy as soon as possible to prevent the appendix from rupturing, which would then cause spillage in the peritoneal cavity that could lead to sepsis.

CLOSING CASE STUDY A thirty-four-year-old patient has been diagnosed with a possible ruptured ectopic pregnancy. The patient is scheduled for a diagnostic laparoscopy, possible laparotomy. While the patient is in the preoperative care unit (PCU or holding), the CST assembles supplies and gets the OR ready for the case. </question type=”narrative”> 1. What laboratory studies would the surgeon most likely have ordered when making the diagnosis for this patient?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: A complete blood count would be done to check for anemia or other signs of blood loss. The doctor may also have ordered tests to check for the patient’s blood type in case they need a transfusion. They may have tested the blood to see how much of the HCG they have in their body, as the body only makes HCG during pregnancy. A low amount may indicate an ectopic pregnancy because HCG levels increase when a fertilized egg implants in the uterus. 2. What diagnostic imaging studies might have been performed as part of the patient’s preoperative workup? ANS: A pelvic exam can help the doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. However, this alone cannot diagnose an ectopic pregnancy. They would need to do an ultrasound. Ultrasonography is the best initial investigation in problematic early pregnancies. 3. What diagnostic studies might be performed as part of this surgical procedure, and how should the CST prepare for them? ANS: Culdocentesis is a procedure used to diagnose the presence of a ruptured ectopic pregnancy by evaluating for hemoperitoneum by inserting a needle and drawing back fluid from the pouch of Douglas. In some patients, a transvaginal scan is also performed, which has been successful in confirming ectopic pregnancies in up to one-third of patients. </question type="essay"> 4. What type of specimen would the CST expect to receive and pass off to the circulator? ANS: Depending on the extent of the ectopic pregnancy and the fact that in this case it has ruptured, there could be a lot of bleeding, so they will likely remove the fallopian tube that is involved. A ruptured tube may not be salvaged. 5. What kinds of studies might be ordered for pathology to perform on the specimen? ANS: An ectopic pregnancy’s gross pathology will consist of a distended fallopian tube. The histopathological findings are paraovarian cyst(s) (POC) within the fallopian tube.

QUESTIONS FOR FURTHER STUDY 1. Would a CT scan or an X-ray be the best diagnostic method to demonstrate a soft tissue tumor? Why? ANS: The CT scan is more valuable in diagnosing a soft tissue tumor because cross-sections of tissue are identified and contrast media may be used to enhance the view. A plain X-ray is best used on bone. 2. What is a frozen section and why is it performed?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Frozen sections are performed to provide an immediate diagnosis (1) to determine if it is necessary to excise more tissue or (2) to initiate postoperative therapy as soon as possible. The tissue is kept dry and sent immediately to pathology with no tissue preservative added. 3. What is an intraoperative cholangiogram (IOC) and in which surgical procedure would it be performed? ANS: An IOC is a radiographic study of the bile ducts. A cholecystectomy or common bile duct exploration is done to determine if or where a stone may be present and to ensure the bile duct is patent. 4. What are the differences between contrast media and radiotracers used to enhance diagnostic imaging studies? ANS: Contrast media is a radiopaque solution that is injected into an artery, vein, or duct during a radiographic exam to differentiate various structures. An isotope is a radioactive solution that is injected intravenously prior to a nuclear medicine study. The isotope is taken up metabolically by specific types of tissue, and a collection of the isotope may indicate a pathologic condition. 5. What are the steps of the Seldinger technique and for which studies would it be used? ANS: With the Seldinger technique, the skin and subcutaneous tissues in the femoral region are injected with Xylocaine 1%, and a small incision is made with a #11 knife blade. The subcutaneous tissues are spread with a hemostat for free passage of the catheter and guidewire. The access needle/cannula is then inserted into the femoral artery at an angle of 45–60 degrees, and the stylet is gently and slowly withdrawn until blood spurts forcefully from the lumen of the proximal end of the cannula. The guidewire is then inserted into the cannula of the needle which proceeds into the artery. The needle cannula is removed by sliding off the guidewire, and while digital pressure is applied to the puncture site to reduce blood loss, the distal tip of the catheter is threaded over the guidewire and into the artery. The guidewire provides a pathway and mild rigidity to the tip of the catheter. Once positioned at the proper level under fluoroscopy, the guidewire is removed from the catheter. The catheter is then flushed with heparinized saline to prevent clot formation. Contrast is injected and fluoroscopic images or X-rays are taken. 6. What type of imaging study is a C-arm unit used? ANS: Fluoroscopy including angiography, cholangiography, retrograde urography, and therapeutic imaging such as bone realignment and catheter placement. 7. What would the CST need to wear in addition to the usual PPE and sterile attire when the C-arm is to be used intraoperatively? Ans: A fluoroscope uses ionizing radiation to project images on body structures onto a monitor in real time. The portable image intensifier is referred to as the C-arm because of its configuration; it is

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

designed so that the image intensifiers and tube are always in direct opposition. The C-arm is frequently used in conjunction with a special radiographic table or OR table that allows X-rays to pass through the tabletop, which is referred to as being radiolucent. The three most important factors that the surgical technologists should remember concerning ionizing radiation are time, shielding, and distance. The shielding refers to the fact that all sterile surgical team members should wear lead aprons and a thyroid shield. 8. What is the difference between signs and symptoms? ANS: Signs are objective and measurable indicators of health or illness; symptoms are those reported by the patient as complaints which are subjective to interpretation by the patient. 9. Which types of microorganisms would demonstrate a Gram-negative result and why is that important for the physician to know? ANS: Gram stain remains a valuable tool in identifying bacteria by exposure to stains of crystal violet and iodine, rising with alcohol, and stained again. Bacteria that fade to pink are called Gram-negative, demonstrating the type of cell membrane of the microorganisms. This quick method of identification helps the physician determine a preliminary course of treatment for seriously ill patients. When the culture and sensitivity results are available, treatment may then be revised. </question type="essay"> 10. Which type of intraoperative study is performed to assess potential nerve compression and paralysis? ANS: Neuromonitoring provides immediate electrical nerve velocity feedback. 11. How are gallstones or kidney stones prepared for transfer to the pathology department? ANS: Calculi (gallstones and kidney stones) must be sent to pathology dry. If a preservative is added, it will dissolve the stones or permanently alter them. This type of specimen is referred to as a frozen specimen.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 15: Minimally Invasive Applications

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A surgical technology student is helping set up for a laparoscopic cholecystectomy. The surgeon’s preference card states that the open laparoscopy method for abdominal entry will be used. 1. What equipment will the OR team need to gather for the case? ANS: For the open component, the surgical team will need to open a laparotomy instrument set, long and deep instruments, gallbladder instrument set that includes CBD exploration and stone extraction instruments, large self-retaining retractor set, and hemoclip appliers with ligating clips. For the laparoscopic component they will require a 30-degree laparoscope, two 5-mm trocars, two 10- or 11mm trocars, endoscopic instrumentation, and laparoscopic equipment tower with insufflator. </question type="essay"> 2. What instruments should be placed on the Mayo stand for abdominal entry? ANS: Since a right subcostal Kocher incision is made, the Mayo stand should have two #10 knife blades, long, curved Metzenbaum scissors, tissue forceps such as a DeBakey, and right-angle clamps to be used for dissection. Some peanut sponges loaded on a Pean clamp may be used for blunt dissection. 3. Why would a surgeon choose the open laparoscopy method? ANS: There are a multitude of scenarios: the gallbladder may have ruptured, and therefore there is bile spillage and possible stones involving the peritoneal cavity; the surgeon, based on the diagnostic testing, is concerned that the gallbladder may rupture; the patient has had numerous surgical procedures prior to this one and has developed many adhesions.

CLOSING CASE STUDY A healthcare facility has just purchased a surgical robotic system, and the OR staff is being trained in its use for gynecological and urological procedures. 1. How will working with the robot affect your role as a CST? ANS: The CST who is involved with robotic surgery must have an understanding of the robotic system. Responsibilities include preoperatively draping the nonsterile robotic manipulators, positioning the patient and OR table according to the surgeon’s preference and procedure; positioning the patient cart over the patient, docking the camera arm; docking the instrument arms; connecting the additional suction, power, or energy cords and equipment as well as checking the system setup and testing. Additional responsibilities include intraoperatively anticipating the surgeon’s needs; switching out and loading the surgical instruments; troubleshooting the robotic system; and postoperatively, have a clear

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

understanding of the methods of cleaning and sterilizing the instruments, endoscope, cameras, and light cords that are later attached to the robot’s manipulators. 2. What will be the variations in surgical instrumentation between gynecological and urological procedures? ANS: The instrumentation required for each individual specialty, including open or laparoscopic procedures, are specified to those organs and body structures encountered. The tips of the instruments would differ depending on what organ or structure they are dissecting and/or ligating. 3. What gynecological and urological procedures can be performed using a surgical robotic system? ANS: Gynecologic procedures would include hysterectomies, endometriosis resections, and pelvic organ prolapse repairs, while urology cases would include radical prostatectomies, cystectomies, and nephrectomies.

QUESTIONS FOR FURTHER STUDY 1. How is distention achieved in minimally invasive procedures? Why is it necessary? Ans: A small diameter, cannulated needle called a Veress needle is used to establish abdominal distention by a method called insufflation that utilizes CO2 gas as a distention medium. This provides a visual safety measure for determining the appropriate placement of the trocars, which is accomplished by using a #11 blade and making a small stab incision in the supra or infra umbilical area. 2. What types of trocars are used for a laparoscopy? Ans: Numerous trocar designs are available for laparoscopic procedures. They may be sharp, blunt, dilating, single site multiport, straight or pistol shaped, disposable plastic or reusable metal, standard or long, and have cannula diameters from 2 mm to 15 mm. 3. What are some of the patient risks when performing an interventional radiology procedure in the hybrid OR? What can the CST do to minimize or prevent these risks? Ans: The risks associated with a complication during an interventional radiology procedure can be magnified if OR personnel are not adequately trained to manage them. Potentially preventable adverse events include the following: wrong site, wrong side, wrong medication, improperly secured device, exposure to a known allergen, use of malfunctioning equipment, catheter-related infections (sepsis), and incorrect placement of the catheter — for example, venous catheter into arterial. When complications occur and are unexpected, they can result in considerable morbidity. The possibility of converting to an open case should always be considered and prepared for. The CST should be ready to quickly convert with a scalpel, lap sponges, suction, self-retaining retractors, and clamps as the priority, and having suture material loaded onto needle holders as a second priority.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

4. What is the role of computer-aided planning when using navigational guidance technology? Ans: Surgical navigation uses computer-assisted technology to allow surgeons to plan, guide, and optimally perform surgical tasks and has become a reliable way of transforming surgical interventions into less invasive and safer procedures. Intraoperatively, navigation helps project instrumentation, devices, or anatomical landmarks into imaging data, like how GPS tracking works to provide a precise location on a map when driving a vehicle. Over the years, navigation systems have evolved from bulky systems to a streamlined network of capabilities and pocket-sized devices. 5. What are the reasons for creating hybrid rooms within the OR suite? Ans: Many health care facilities have begun building new facilities within the OR suite that integrate the latest endoscopic and MIS video equipment and radiologic delivery systems such as fluoroscopy, angiography MRI, and CT scanning. This merging of advanced technology allows specialists from a variety of specialties such as cardiac surgery, thoracic surgery, vascular neurosurgery, interventional cardiology and radiology, and anesthesia services to work in concert for enhanced diagnostic and surgical treatment of their patients.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 16: General Surgery

OPENING CASE STUDY A forty-five-year-old patient with an unhealthy body mass index is seen by the primary care physician. The patient complains of severe pain in the right upper quadrant about two hours after meals but is otherwise healthy. After a history and physical, the physician diagnoses the patient with cholelithiasis. 1. Describe the condition and causes of cholelithiasis. ANS: The definition of cholelithiasis is the presence or formation of stones (gallstones) in the gall bladder or bile ducts. Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Additionally, if the gallbladder does not empty completely on a recurrent basis, there is a high risk of developing stones. © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. What are three possible treatments for this condition? ANS: Since surgery is invasive to the body, although open, laparoscopic and/or robotic surgery is an option, it would not be the first option. Typically, a physician will prescribe medication and instruct the patient to adjust their diet in the hopes that it will dissipate the stones. When medication is not effective, extracorporeal shock-wave lithotripsy can be done. Lithotripsy is a non-invasive procedure that attempts to destroy the stones without the need to remove the gall bladder. If neither of these are effective, we would surgically remove the gall bladder by one of the three surgical approaches. 3. How would a patient’s diet affect this condition? ANS: Bile is the greenish-yellow fluid that is secreted by the liver, and excess bile is stored in the gallbladder. Its job is to carry away waste and break down fats during digestion. If the patient continues to consume fatty foods and does not monitor their cholesterol, this can lead to stones and obstruction, resulting in a cholecystectomy having to be performed.

CLOSING CASE STUDY A surgical technology student is being supervised by the CST preceptor during a Whipple procedure. The CST comments that the student will have learned several procedures by the time they are done with this case. </question type=”narrative”> <question type="essay"> 1. What does the CST mean by this statement? ANS: The Whipple is a pancreatoduodenectomy where there is a combination of both resection and reconstruction. Some of the other procedures the CST will learn are:          

Exploratory laparotomy Cholecystectomy Partial gastrectomy Vagotomy Division of the pancreas Dissection of the retropancreatic vessel Division of the jejunum Pancreatojejunostomy Hepaticojejunostomy End to side gatrojejunostomy

2. What are the different procedures that constitute a Whipple procedure?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Roux-en-Y: This allows for a variety of application in gastric, intestinal, biliary, and pancreatic surgery. Using the small bowel as an example, the proximal end of the divided intestine is anastomosed end-to-side to the distal loop and a section of the distal loop is anastomosed to another organ of the digestive system such as the stomach, which forms the shape of the letter Y. End-to-side: This procedure attaches the end of one section of bowel into the side of another section (Tshaped right-angle configuration), best accomplished by a two-layer closure technique. This procedure uses continuous 3-0 absorbable for mucosa-to-mucosa anastomosis and 3-0 silk interrupted sutures for seromuscular closure. The staple line from transection is excised electrosurgical on the end section prior to anastomosis. Open ends of bowel may be suctioned to remove any residual fecal material prior to anastomosis. Side-to-side: This procedure is a creation of parallel openings in two sections of the bowel with anastomosis. This is an especially good technique between lumens of unequal dimension and is best accomplished with staplers. The technique requires opening the bowel minimally to allow passage of the halves of the linear cutter into each lumen, followed by activation of the device to divide the bowel, thereby creating a terminal tube pouch twice the diameter of the bowl. The end of the tube is closed with a linear stapler. 3. Discuss the different instrument trays that will be used for this case. ANS: Depending on whether the procedure is open, laparoscopic, or robotic, the following instruments will be needed:            

Knife blades (several) Suction tubing Laparotomy instrument set Peripheral vascular instrument set Gallbladder instruments Long and deep instruments GI resection instruments Deep retractors GI linear stapling devises Yankauer and Poole suction tips Hemoclip appliers and ligating clips Self-retaining abdominal retractors (Bookwalter, Balfour)

QUESTIONS FOR FURTHER STUDY 1. Why should the surgical team be concerned about a patient’s voice following a thyroidectomy? ANS: Complications of a thyroidectomy include damage to the larynx or nerves that serve the upper aerodigestive tract (specifically, the laryngeal and recurrent laryngeal nerves). One must be acutely

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

aware of the bilateral existence of a recurrent laryngeal nerve during dissection. Damage to the nerve may result in hoarseness, temporary or permanent, following surgery. 2. Name and describe the variations for large bowel anastomosis ANS: End-to-end—Two ends of approximately the same size structures are attached. End-to-side—The end of one section of bowel is attached to the side of another section (sometimes referred to as a “T” anastomosis). Side-to-side—Creation of parallel openings in two sections (sides) of bowel with anastomosis. Roux-en-Y—Specific technique of anastomosis that allows a variety of applications in gastric, intestinal, biliary, and pancreatic surgery. 3. Imagine that a gunshot wound entered a patient’s left chest and exited above the right iliac crest. How many structures can you name that the bullet could have passed through? ANS: Answers will vary, but a typical list should include skin, subcutaneous tissue, intercostal muscles, lung, diaphragm, peritoneum, spleen, tail of pancreas, fundus of the stomach, transverse colon, duodenum, jejunum, and lower ascending colon or cecum. Almost every structure (organ, blood vessel, or nerve) in the thorax, mediastinum, and abdomen (including the retroperitoneal space) could potentially be damaged by the bullet. 4. Describe the patient position that is necessary when a thoracoabdominal approach is planned. ANS: The patient who will receive a thoracoabdominal incision is placed in a lateral or supine position. This sometimes presents difficulty in positioning the patient. (Note: Patient may be positioned with a large wedge behind the torso to maintain a semi-lateral or semi-supine position.)

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 17: Obstetric and Gynecologic Surgery

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A twenty-four-year-old patient is nearing delivery of her first child. The patient is healthy, and the pregnancy has progressed normally. During labor, the patient’s cervix has dilated to 4 cm and no further. The contractions have continued for twelve hours, and the patient is tired and frustrated. Although the fetus is not in distress, the patient is being prepped for a cesarean section. 1. Which term describes what is occurring in the labor process? ANS: One of the most common reasons for a C-section is termed “failure to progress.” The uterus is contracting and the patient is in active labor, but the cervix is not fully dilating. 2. Under what conditions would this become an emergency cesarean section? ANS: Because the contractions have been intense over a long period of time, and the cervix is not dilating or effacing (thinning), it becomes an emergency cesarean section to prevent the possibility of distress to the unborn child and the patient giving birth. 3. Why should the CSTs in a HCF use the same, standardized setup for this procedure? ANS: Ideally all surgical cases should be set up in a standardized manner. The reason for this is it would increase efficiency, decrease changes of missing something during a count, and the CST may easily be relieved and may also assist during any emergency that may arise. 4. Describe the rationale for modification of the environmental conditions (i.e., temperature, ambient sound, equipment, and personnel movement) while the procedure is in progress. ANS: The most important component to remember when a C-section is taking place is there are two patients on that OR table, the patient giving birth and the unborn baby. Measures to reduce stress can help create an environment that can permit the procedure to progress successfully. Temperature should be in a comfortable range from 68 degrees to 75 degrees, sound should be quiet with music preferred by the patient, personnel should provide care as appropriate, and the CST should remain focused on assisting the surgical team with the procedure.

CLOSING CASE STUDY A thirty-two-year-old patient complains of vague abdominal discomfort and a feeling of heaviness in the groin region. The patient has never been pregnant and is healthy but has a family history of uterine cancer. The gynecologist’s examination reveals that several irregularly shaped nodules that are firm and immobile are located within the uterus. Laboratory tests are normal, but ultrasonography shows the presence of tumors. After a period of unsuccessful drug therapy, the patient is scheduled for surgery. 1. Describe the decision-making path that the gynecologist took to reach a final diagnosis.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The diagnosis is obtained by history and physical as well as direct examination, ultrasound, and lab results. The patient has a family history of uterine cancer, and the gynecologist can palpate some irregularly shaped nodules that do not move. Although the lab results are normal, the ultrasound diagnostic demonstrates visible tumors (abnormal growths). Since the patient has undergone treatment unsuccessfully, the decision to perform surgery is warranted. 2. What is the probable diagnosis in the patient’s case? ANS: The uterus may have developed fibroids or myomas. Fibroids are tumors which grow from the fibrous lining of the uterus, and myomas grow from the myometrium (muscular layer) of the uterus. Neither are cancerous; however, if not treated and not responding to treatment, they could become cancerous. This patient has been diagnosed with myomas. 3. If the patient wants to have children in the future, what procedure would be performed? ANS: Since the patient wants to have children in the future, the surgeon will perform a myomectomy, which removes all existing myomas and leaves the uterus intact so that if they wish to, they may carry a child. It is important to remember that since the myomas will be excised from the uterus, if this patient were to become pregnant, it would be best to deliver that child via C-section because the part of the uterus which was incised and could potentially not be viable enough to withstand a contracting uterus during the normal progression of labor. 4. What are the common complications of the procedure? ANS: Approximately twenty to twenty-five patients who undergo a myomectomy will require additional pelvic surgery. Complications include bowel obstruction or damage, bladder injury, fallopian tube or ureter compromise, infertility secondary to the procedure, and hemorrhage.

QUESTIONS FOR FURTHER STUDY 1. List five reasons for performing a cesarean section and state the most frequent reason for this procedure. ANS: The following outlines several conditions that are indications for performing a cesarean section. Failure to progress is the most common diagnosis associated with cesarean section. Maternal Diseases Eclampsia or severe preeclampsia Cardiac disease Diabetes mellitus Cervical cancer Herpes

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Prior surgery of the uterus Cesarean section (especially classical type) Previous rupture of the uterus Full-thickness myomectomy Obstruction to birth canal Fibroids Ovarian tumors Other Uterine rupture Failure to progress (cause unknown) Maternal demise Fetal Fetal distress (sustained low heart rate) Prolapse of the umbilical cord Malpresentation Breech Transverse Brow Multiples (depends on number and presentation) Fetal demise Maternal/Fetal Dystocia Cephalopelvic disproportion Failed induction Abnormal uterine action Sexually transmitted disease Placental Placenta previa Placental abruption 2. What steps performed in a traditional vaginal hysterectomy may be performed laparoscopically? What is the advantage of the laparoscopic approach? ANS: The laparoscopic procedural steps that are performed during a laparoscopic assisted vaginal hysterectomy (LAVH) include: • Incision of round ligaments • Incision of broad ligaments • Incision of cardinal ligaments • Dissection of bladder from uterus • The advantages of the LAVH procedure are as follows: • Allows more potential abdominal hysterectomies to be converted to vaginal approaches • Provides visualization advantages of the abdominal procedure • Shortens facility stay considerably

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

3. Define and list the basic steps in a Pfannenstiel abdominal incision. ANS: The following outlines the basic steps when performing a Pfannenstiel incision: • Gently curved transverse incision, 10–15 cm long, at any level between the umbilicus and symphysis pubis • Skin and subcutaneous fat are incised to the level of the anterior rectus sheath • Fascia is incised transversely on either side of the linea alba • Linea alba is then divided joining the two incisions • Rectus sheath is separated from the underlying rectus muscle by blunt dissection • Rectus muscles are separated in the midline • Peritoneum is opened vertically 4. List the structures that will be removed during a total pelvic exenteration. ANS: Total pelvic exenteration involves removal of the vagina, uterus, cervix, fallopian tubes, ovaries, bladder, and rectum. 5. Name at least two medications that may be used to treat uterine hemorrhage following childbirth. ANS: Oxytocin (Pitocin, Syntocinon), carboprost (Hemabate), and ergonovine/methylergonovine (Ergotrate, Methergine) may be used to treat uterine hemorrhage following childbirth. 6. Briefly describe how the sequence of events for an emergency cesarean section (e.g., prolapsed umbilical cord, placenta abruption) may differ from a planned cesarean section. ANS: When preparing for an emergency cesarean section, speed is of the essence. Some of the differences that may occur when preparing for the emergency cesarean section rather than a planned procedure include: • General anesthesia may be used—it will likely be a rapid-sequence induction and the use of cricoid pressure is anticipated. • The patient may be prepped and draped prior to induction of general anesthesia. • No initial counts • The incision may be classic rather than Pfannenstiel. • Incisional bleeding may not be controlled until delivery of the neonate has occurred. • Family members may not be allowed in the operating room.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 18: Ophthalmic Surgery

TABLE OF CONTENTS Opening Case Study.................................................................................................................................. 64

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Closing Case Study ................................................................................................................................... 65 Questions For Further Study ................................................................................................................... 66

OPENING CASE STUDY A thirty-five-year-old patient is complaining of pain, redness, and inflammation in the left eye, including the area between the eye and nose. The area is sensitive to touch, and there has been a discharge from the medial corner of the eye for a few days. After several weeks of conservative therapy, the patient is referred to an ophthalmic surgeon for treatment. 1. What is the likely diagnosis? ANS: Most likely the patient is suffering from dacryocystitis, which is caused by an obstruction of the nasolacrimal duct. The lacrimal system consists of the lacrimal gland that secretes the tears and keeps the conjunctiva moist. The fluid is carried away by the lacrimal canals into the lacrimal sac and along the nasolacrimal duct into the nasal cavity. This condition is indicated when there is an inflammation of the lacrimal system causing severe obstruction and discomfort. 2. What surgical procedure will likely be performed? ANS: Dacryocystorhinostomy (DCR). This procedure is performed to establish a new communication pathway between the lacrimal sac and the nose when the nasolacrimal duct is obstructed by fibrous tissue and bone. 3. Describe the steps of the procedure, including the medications that are specific to the procedure. ANS: After general anesthesia induction, local anesthetic, two drops of tetracaine 1% with epinephrine 1:5,000 are instilled into the conjunctival sac. Lidocaine 2% with epinephrine is injected at the beginning of the lacrimal crest, and lidocaine is sprayed into the anterior third of the nasal meatus. Lidocaine is injected into the mucuperiosteum after the insertion of a nasal speculum. The local anesthetics are vasoconstrictors that help control bleeding intraoperatively and provide some pain relief in the immediate postoperative phase. 1. A curved incision is made while controlling bleeding with bipolar coagulation. 2. Retractors are inserted on each side of the incision, commonly rakes or 4-0 sutures as traction in the skin. 3. A freer elevator may be used for blunt dissection, the anterior lacrimal crest is exposed, and the periosteum is elevated. 4. A small bur is used to create an ostium in the lacrimal bone while being sure to protect the eyelids with sterile gauze, and irrigation is used to keep the field clear of debris and cool the drill bit and tissue. 5. A vertical incision is made in the anterior wall of the lacrimal sac, and a probe is passed into the lumen, being sure the probe is free of lint.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

6. A horizontal slit is made in the wall of the sac and the nasal mucosa is also incised horizontally. 7. The flaps of the nasal mucosa and lacrimal sac are then joined. Flaps are approximated using a 6-0 polyglactin or chromic gut suture. The surgeon may wish to place silicone tubes in the canaliculi to the nasal cavity to ensure patency during healing. 8. The muscle layer is closed using 5-0 absorbable sutures and the skin is closed using 6-0 nylon. Bleeding will be controlled using absorbable gelatin sponges soaked in topical thrombin.

CLOSING CASE STUDY A seventy-three-year-old patient complains of progressive dimming and clouding across the entire left eye’s field of vision. The patient reports no pain or trauma, and the progression has taken place very gradually. The surgeon establishes the diagnosis as a cataract in the left eye. 1. What type of surgical procedure will likely be performed in this case? ANS: Extracapsular and intracapsular cataract extraction methods are performed to remove the opaque lens. With either method, an artificial intraocular lens (IOL) is inserted to replace the defective lens. Extracapsular cataract excision using laser guidance can include treatment of astigmatism at the same time. Intracapsular cataract extraction involves a larger incision to allow removal of a dense lens for which phacoemulsification would be insufficient, and the entire capsule is removed. Extracapsular cataract extraction is performed through a small, self-sealing incision, and only the lens is removed with no sutures required. New minimally invasive laser cataract approaches are available for precision in creation of the corneal incision, capsulotomy, opening of the thin, clear covering of the lens, and fragmentation of the cataract without need for phacoemulsification. 2. Describe the equipment and supplies used for the surgical procedure. ANS: A disposable cystotome, headrest, ophthalmic microscope, phacoemulsification unit, disposable attachments, and headpiece, irrigator/aspirator unit, cataract extraction tray, IOL implant, Keratome, antibiotic ophthalmic ointment, local anesthesia with sedation, and retro bulbar or peribulbar block may be used. 3. What anatomical structures are involved? ANS: The lens is a transparent, biconvex structure that is situated behind the pupil and anterior to the vitreous body. It is encircled by the ciliary processes and encapsulated in a transparent, elastic delicate membrane. Anteriorly, the lens contacts the border of the iris, forming the posterior chamber — the back portion of the anterior cavity. It is held in position by the suspensory ligaments. The central points of its surfaces are known as its anterior and posterior poles. 4. What is the relevance of the patient’s age to this patient’s diagnosis and pathological condition? ANS: Cataracts usually appear white but may take on a yellow or brown color. The development of cataracts is usually a normal part of the aging process, but they can also develop because of trauma,

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

such as an injury or blow to the eye, the use of certain drugs, exposure to harmful chemicals, diabetes, genetic predisposition, and exposure to excessive sunlight. Untreated cataracts can cause preventable blindness. 5. What is the likely postoperative treatment plan and outcome for the patient? ANS: Immediately postop, after balanced salt solution irrigation, an antibiotic eye drop is instilled, usually without a dressing. Some surgeons may prefer a rigid eye shield which may be worn at night for two or three days. Dark glasses should be worn the first day. There must be no straining postop, and the patient may return to normal activities in one to three days. Sight will be significantly improved.

QUESTIONS FOR FURTHER STUDY 1. What type of energy is used during phacoemulsification? ANS: Phacoemulsification is accomplished using ultrasonic energy to break up the lens. The fragments are subsequently aspirated while the IOP is maintained with BSS irrigation. 2. List two minimally invasive procedures to correct myopia, hyperopia, or astigmatism. ANS: Astigmatism (uneven curvature of the eye’s surface layer), myopia (short-sightedness) and hyperopia (long sightedness) are all improved or corrected with eyeglasses, contact lenses, or laser corrective surgery. PRK (photorefractive keratectomy) has been performed since the 1990s for correction of these three conditions. It involves removal of the corneal surface layer and laser ablation using an excimer laser. The laser is used to reshape the surface of the eye. 3. What is meant by the term retrobulbar block and how is it performed? ANS: Retrobulbar block is the injection of local anesthetic behind the globe at the origins of the extrinsic muscles to paralyze them and anesthetize the eyeball. Retrobulbar block is often accompanied by local infiltration of the facial (seventh cranial) nerve to anesthetize the lids and tissue surrounding the eyes.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 19: Otorhinolaryngologic Surgery

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A sixteen-month-old patient is seen by an ENT specialist. The father reports that the patient has a cold and runny nose. The nasal discharge is yellow and purulent. Although the patient was uncooperative during the exam, the physician was able to see a foreign object wedged between the superior and middle turbinates in the left nostril. The physician calls a surgery center to schedule removal of the object that afternoon. 1. Why is the case considered urgent and not emergent? ANS: This case is considered urgent because it is not life threatening. An emergent case is a medical condition that requires immediate surgical intervention, such as craniotomy for a subdural hematoma or ruptured abdominal aortic aneurysm. It is a life or death condition. An urgent case is a medical condition that requires surgical intervention within a short period of time, such as an unruptured ectopic pregnancy with stable vital signs. When vital signs are stable, the team has an opportunity to do diagnostic testing, lab work, and such prior to going into the OR. 2. Why can’t the object be removed in the doctor’s office? ANS: Due to the patient’s age and inability to cooperate, they will most likely need a general anesthetic for removal of the foreign object. The object may have penetrated the wall of the nasal cavity. Additionally, their condition is serious due to the infection, which could cause sinusitis and possible meningitis, but not serious enough to risk anesthesia complications because they have not been NPO. There is a small risk that the patient will aspirate the object, but it has been lodged there for quite a while. The bigger danger is that the object will erode the nasal mucosa and the infection will extend. 3. What special equipment and supplies will be required for this procedure? ANS: Very few instruments will be needed for the procedure. Minimally, a nasal speculum, bayonet forceps, and suction with a Frazier tip will be used. Nasal packing and an ESU should be available. 4. Will the CST have to use sterile technique in this case? ANS: Nasal surgery is not considered sterile, and it is unlikely that a prep will be performed. The surgical technologist is expected to use the best technique possible to maintain microbes at their minimum level during the procedure.

CLOSING CASE STUDY A twenty-six-year-old patient was involved in an automobile accident and the air bag deployed, fracturing the nasal septum. The patient feels fortunate to have escaped serious injury but is concerned when informed that only local anesthetic will be used during the procedure. In preoperative holding, the patient reports their fears of feeling pain to the anesthesia provider.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

1. What surgical procedure will be performed to repair the patient’s fractured septum? ANS: The nasal cavity is divided into two chambers by the nasal septum. A septoplasty is most often performed to straighten a deviated nasal septum and also used to repair a perforated septum damaged by trauma. The cartilaginous portion of the septum will be removed, and readjusted or reinserted. Care is taken not to perforate or cause a weakness on the remaining septum which could lead to future deformity. 2. What steps will be taken to ensure that the surgical site is anesthetized? ANS: The patient will likely be provided with a sedative of some type. Additionally, the nasal mucosa will be topically anesthetized with topical cocaine and/or injected with a local anesthetic with epinephrine. 3. What medications and supplies will the CST expect the surgeon to use to administer anesthesia? ANS: The surgical technologist should anticipate that the surgeon will use a separate field to provide the patient’s local anesthesia. The area should include the pharmaceuticals of surgeon preference, medicine cups, syringes, needles, gauze, packing material, nasal speculum, and bayonet forceps. 4. What reassurances can the OR team give the patient to alleviate their fears? ANS: The patient should be aware that they will feel pressure and hear noises related to the surgery. They should be reassured that the surgical team members will respond to their needs during the procedure. The patient needs to be advised to remain still and to anticipate vibrations caused by bone remodeling; for example, the use of a mallet and osteotome.

QUESTIONS FOR FURTHER STUDY 1. What special preparations should be made in advance of the pediatric patient’s arrival into the OR? ANS: The room may be warmed, specialized anesthesia equipment assembled, and the instruments made ready. The patient may be brought into the room straight from outpatient rather than preop holding to limit the amount of time the pediatric patient is separated from his or her caretaker. 2. What type of anesthesia will the pediatric patient undergoing foreign body removal from the nose most likely receive? Will an IV line be necessary? ANS: The patient will likely receive an inhalation general anesthetic. The anesthetist may or may not require an IV line. The procedure is expected to take less than a minute unless there are extenuating circumstances. 3. Outline the draping sequence for exposure of the face.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The draping sequence for the face is as follows: • The operative area may be outlined with towels; the towels may be secured with towel clips, skin staples, or sutures. • A turban-style head wrap may be used. • Remove protective paper from disposable drapes with adhesive edges. • Place bar drape across patient’s forehead, allowing remainder of drape to cover head of operating table. • Situate the U-drape under the patient’s chin. Bring the edges of the “U” lateral toward the head. • Extend the remainder of the drape to cover the patient’s body. 4. What position will the patient be placed in for an adenoidectomy? ANS: The patient will be placed in the supine position for an adenoidectomy. A rolled towel may be placed under the shoulders to extend the neck. The arms are usually tucked at the patient’s sides. 5. What bone houses the tympanic cavity? ANS: The tympanic cavity (middle ear) is housed within the temporal bone. 6. What is the function of the turbinates? ANS: The turbinates, also called the conchae, function to increase the surface area of the mucous membranes to filter, warm, and humidify the air inhaled through the nose.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 20: Oral and Maxillofacial Surgery

OPENING CASE STUDY A twenty-three-year-old patient is admitted to the emergency department after a motorcycle accident. The patient was not wearing a helmet but is alert and awake. The patient reports having double vision and trouble breathing to the ER physician.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

1. Why might the patient have dyspnea, and what can be done to protect the airway? ANS: It is imperative to always secure a patient’s airway before addressing the injuries sustained. The Le Fort I fracture is the most common type of mid-facial fracture. The alveolar process of the maxilla is horizontally separated from the base of the skull. The upper jaw can be floating free in the oral cavity, causing difficulty breathing. However, in this case, the patient is also suffering from double vision, which could indicate an extension of the fracture upward to the nasal and ethmoid bones, involving the orbits. 2. What diagnostic tests should be ordered to determine the cause of the symptoms? ANS: Diagnosis of midfacial fractures is made through the examination of X-rays, CT scans, and the physical examination of the patient. Pretrauma photographs and dental records can aid the surgeon in determining proper placement of the fractured facial bones. 3. What surgical procedure might be performed, and is this an emergent case? ANS: As defined, an emergent case is deemed to be “life or death.” This case is urgent, and an airway must be established. There is a small window of time (now) to take an X-ray, CT scan, and whatever other tests that will prove to be useful for the procedure. This would most likely be a Le Fort II fracture repair.

CLOSING CASE STUDY An emergency department physician calls the OR desk concerning a patient. The physician tells the charge nurse, “We have a twenty-three-year-old patient status post MVA, no air bag deploy, moderate facial injuries, bruising and swelling about the left eye, diplopia, and enophthalmos. CT confirms left orbital floor fracture. The patient will be up in preoperative holding in ten minutes.” 1. What does MVA stand for? ANS: MVA stands for motor vehicle accident. It is imperative to remember that when a car accident occurs at any rate of speed, while upon impact the vehicle stops, the individuals and any items within the vehicle are still moving at the speed the vehicle was going, and the body behaves as a projectile. When the vehicle struck, the patient’s body hit forward and bounced back because the air bag did not deploy. MVA are responsible for a magnitude of facial fractures in patients involved. 2. Define diplopia and enophthalmos. ANS: Diplopia is a condition commonly referred to as double vision, or when one is looking at a single object but sees two. There are some serious health conditions which could cause this to occur, but it is often only temporary due to a traumatic injury. Enophthalmos is the term used to describe when the posterior (back) portion of the globe (eyeball) is displaced into a separate plane within the orbit, indicative of a possible orbital floor fracture.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

3. What implant material must the CST confirm is sterile and available to repair the fracture? ANS: Depending on the surgeon’s preference, an internal fixation system would be required, as well as orbital retractors, a corneal shield, and implant material such as Teflon or Silastic sheeting that has been washed and sterilized according to the manufacturer’s instructions. 4. What instrument is often used to free up the periorbital fat that is entrapped in the fracture line? ANS: A freer elevator or scissors and tissue forceps may be repeatedly needed to release and retract the periorbital fat and muscle entrapped in the fracture line. 5. If the fracture is not stable after being reduced, what instrument tray should the CST have available? ANS: Loose bone fragments can be repositioned; however, if the reduction is not stable, a rigid fixation device may be implanted, followed by inserting the Silastic sheeting. It is imperative to communicate additional instrument set and supply needs to the circulator.

QUESTIONS FOR FURTHER STUDY 1. Does the surgeon always stand while performing oral and maxillofacial procedures? If not, how does the choice to sit or stand affect patient positioning? ANS: The surgeon may stand or sit to accomplish cranial, maxillofacial, or oral procedures. If the surgeon plans to be seated during the procedure, the operating table should be assembled in a fashion that allows chair access under the head of the table. The table should be placed where operating room lights illuminate the field properly. Fluoroscopy and X-ray machines should be able to enter the area without disturbing the sterile field. The table may be angled to allow access. 2. What is the danger created by operating in the area of the endotracheal tube? How is it minimized? ANS: Two dangerous situations are created by operating in the area of the endotracheal tube. First, the tube may become kinked or dislocated. This risk can be minimized by using an armored endotracheal tube and securing it in position. The second danger is the fact that oxygen is administered through the endotracheal tube, creating an oxygen-enriched environment that can present a fire hazard. Caution must be exercised when using electrosurgery or laser in the area. 3. What graft materials can be used in maxillofacial surgery? ANS: Graft material can be autogenous (autograft from patient’s own body), allogous (allograft from same species), xenograft (from different species), or synthetic.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

4. What intraoperative measure may be taken to prevent drying and cracking of the patient’s lips? ANS Cream or ointment may be applied to the patient’s lips intraoperatively to prevent drying and cracking. 5. Why are rubber bands applied to arch bars? ANS: Rubber bands are applied to the arch bars to stabilize the upper and lower jaws to each other.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 21: Plastic and Reconstructive Surgery

OPENING CASE STUDY An infant has just been born. Prenatal sonograms show the existence of cheiloschisis. 1. What is cheiloschisis? ANS: Cheiloschisis (cleft lip) is a congenital deformity. The function of the palate is to separate the nose from the mouth, which is important in swallowing and speech. The anterior portion of the palate is the hard palate, and the posterior portion is the soft palate. Fetal development of the nose and mouth occurs in the first trimester of intrauterine life. The grooved middle portion from below the nose to the upper lip is referred to as Cupid’s bow. This is typically formed by the joining of the frontal nasal prominence. Bilaterally, the lips are formed by the maxillary prominences. The palate is formed from the joining of the central nasal prominence to the right and left. A cleft is a split or a gap between two structures that are joined normally. Cheiloschisis (cleft lip) and palatoschisis (cleft palate) are two congenital deformities that can occur individually or in conjunction with one another. 2. What supportive assistance can be provided to the parents?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The infant with these deformities may suffer from difficulty sucking, swallowing, and eventually in forming proper sounds. There are many organizations in the world that provide supportive family care after their infant has a procedure done to correct this deformity. This aftercare is inclusive of orthodontic therapy, speech therapy, the use of different nipples on their bottles when feeding, and much more. 3. Will a surgical procedure be immediately performed on the infant? ANS: The infant will undergo a Cheiloplasty (cleft lip repair). This procedure is usually performed between three and eighteen months of age and is often performed in combination with the palatoplasty. Often the lip and anterior palate defects are corrected at the same time with the posterior palate repair done later. The commonly used technique is called rotation advancement. The less common procedure is the triangular flap. The more common technique imitates the Z-plasty used in other types of plastic surgery. It will provide additional height and length of the lip if there is minimum tissue available. 4. What is the long-term expected outcome of the surgical procedure for the infant? ANS: There should be no complications. The patient is expected to have good aesthetic and functional results from the cheiloplasty and palatoplasty, but this is by no means the end of the treatment. As stated previously, speech therapy, orthodontia, and nasal reconstruction are all options to be considered for the future. Both types of repairs leave a permanent exterior scar that will partially fade over time. If there are to be complications, those would include postoperative SSI, hemorrhage, scarring, and edema. This must be monitored because severe edema may obstruct the airway.

CLOSING CASE STUDY A fifty-two-year-old patient had a modified radical mastectomy a year ago after being diagnosed with breast cancer. The patient completed additional treatments such as chemotherapy, and the wound has healed. Now the patient is discussing breast reconstruction with a plastic surgeon. 1. Discuss the different reconstructive options that the surgeon might perform and whether each uses an implant or muscle. ANS: There are two main options for breast reconstruction. The first option would be accomplished with implants. The approach of this procedure would depend on the viability of the tissue. At times, if this is the option selected, the surgeon may need to insert tissue expanders so that tissue may be stretched to be capable of comfortably accommodating an implant. The other means of reconstruction would incorporate the use of a flap. There are two different types of flap reconstructions; one is a free flap, and the other is a pedicle flap. These flap reconstructions would most likely take place with a patient who has undergone a radical mastectomy in which there is no muscle left and there is need of a flap. Since this patient had a modified radical mastectomy and the muscle was preserved and the wound is

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

healed, implants would be ideal. Additionally, if the nipple and areola need reconstruction as well, there are various means of accomplishing this. 2. For each option, list the differences in surgical instruments that the surgeon will require. ANS: For the implant reconstruction, the instruments would include a plastic instrument set, basic back table pack, tunneling devices, temporary implant sizers, permanent implants, and any endoscopic equipment the surgeon would prefer. The implants can be saline or silicone gel. For a flap reconstruction, the procedure is much more extensive and is regarded as an abdominoplasty. This procedure would include ESU unit with two bovie tips, a doppler with a sterile probe, a basic laparotomy set, basic plastic instrument set, skin graft instrumentation, synthetic mesh, many #10 and #15 blades, and specific surgeon preference with sutures, drains, and dressings.

QUESTIONS FOR FURTHER STUDY 1. What are the steps in a facelift procedure? ANS: “Facelift” is the common term for rhytidectomy. The procedural steps are as follows: (1) Incision is initiated within the hairline in the temporal region of the scalp, approximately 5 cm above the ear. The incision is continued to just below the earlobe and then back up and around the ear. The subcutaneous tissue in the preauricular areas is undermined. (4) Moving inferiorly to the jaw line and superiorly to the lateral aspect of the nose, the subcutaneous tissue is separated (dissected) from the platysma below. (5) Wound edges of the developed flap are pulled taut to determine the amount of redundant skin to be excised. The opposite side of the face will be compared during this stage to maintain symmetry and create a natural appearance. (6) Redundant tissue is excised. (7) The wound is closed, using suture of the surgeon’s choice, and a Jackson-Pratt drain may be placed to help eliminate dead space and reduce the risk of hematoma. (8) This process is duplicated contralaterally. 2. Why is the term plastic used to define this field of surgery? ANS: The word plastic has its origins in the Greek word “plastikos,” meaning to “mold or shape with one’s hands.” Plastic, or cosmetic, and reconstructive surgery refers to those procedures that have as a primary goal the restoration of appearance or function to a particular body structure. 3. What types of suture are typically used to close incisions or wounds on the face? ANS: Small-gauge monofilament nonabsorbable suture attached to an eyeless needle is recommended for closure of facial wounds. Colored suture is often used if the suture line is near the hair or eyelashes to differentiate it from the hair and facilitate removal. 4. What are the reasons for the use of sterile mineral oil when preparing to take a splitthickness skin graft?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The mineral oil serves to reduce friction between the skin and dermatome, and provides for a smooth surface so an even layer of skin graft is obtained. 5. Describe the most commonly used technique for performing a cheiloplasty referred to as the “rotation advancement.” ANS: Initial incision is made along the superior vermilion border to extend from the lip into the nostril. Then incisions are made from the cleft to dissect the medial lip free from the maxilla. Next, a Z-plasty incision is made to create three flaps. Tissue from the cheek is rotated to eliminate the defect. (Note: The first flap rotates down to form the cupid’s bow and philtrum groove, the third flap is rotated into columella and forms the lower part of the nostril, the second flap is advanced into the gap left to form the cupid’s bow.) Suture repair occurs in the following order: mucous membrane layer of upper lip is closed; orbicularis oris muscle layer is sutured together; skin is sutured last. 6. What are the purposes of using cocaine when a rhinoplasty is performed? ANS: Liquid or crystalized cocaine is placed on a sponge, which is then packed into the nose, left in place for several minutes, and removed. Cocaine is a local anesthetic that numbs the tissues of the nose and shrinks the mucous membranes to aid in controlling bleeding and in visualization of the operative site.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 22: Genitourinary Surgery

OPENING CASE STUDY A sixty-eight-year-old male patient is scheduled to have a TURP performed. 1. What does the acronym TURP mean? ANS: The TURP acronym means transurethral resection of the prostate. This approach can be accomplished because of a determination by the patient’s pathological condition. Removal of a cancerous prostate usually requires an open procedure, whereas the patient suffering from benign prostatic hypertrophy (BPH) is treated transurethrally. © 2024 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. What is the most likely cause of the patient’s condition? ANS: Benign prostatic hypertrophy is a normal part of aging, affecting most males over the age of fifty. As a man matures, the prostate gland increases in size. This is thought to be due to hormonal changes that occur throughout the life span. Eventually, the capsule surrounding the prostate prevents it from expanding and it begins to exert pressure on the urethra that it encircles. As the urethra narrows, urination becomes more difficult, leading to urinary urgency, frequency, and retention. Retained urine can lead to chronic UTIs. 3. Would the surgeon perform this procedure if the tumor was malignant? ANS: If the diagnosis is cancerous, this procedure would not be done, and the patient would undergo either a retropubic prostatectomy, suprapublic prostatectomy, or (uncommon) perineal prostatectomy. When there is indication of a malignancy, the procedure must be performed open to assure that seeding of the cancer cells does not spread to other surrounding areas. The three approaches described above are all determined based on the location of the malignancy within the prostate gland. 4. Can the patient expect that their sexual function will be normal after the procedure? ANS: Without complications, the patient remains hospitalized for several days until the urine draining from the catheter is clear, the catheter can be removed, and the patient is able to void on their own satisfactorily. Normal activity, including sexual activity, can be resumed in four to six weeks. With complications, there can be postoperative SSIs, hemorrhage; urethral stricture; injury to the urethra; or TURP syndrome.

CLOSING CASE STUDY A sixteen-year-old male patient arrives in the emergency department after a soccer injury, in which a soccer ball hit in the right groin at a high speed. Later that afternoon, the patient noticed that the right side of the scrotum was swollen and painful. The patient is otherwise healthy. The physician notes that the right testicle is still palpable and seems to be surrounded by a clear fluid. 1. What condition does the patient have? ANS: Fluid has apparently built up in the scrotal sac. This is referred to as a hydrocele which is defined as an abnormal accumulation of serous fluid around the testis contained within the tunica vaginalis. The fluid buildup is often the result of trauma or infection. 2. What is the clear fluid, and what is its source?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: The fluid is serous fluid. Within the tunica vaginalis is an invaginated serous sac that covers most of the testis, epididymis, and lower end of the spermatic cord. It does not cover the posterior portion of the testis, and it is here that the blood vessels and nerves of the testis enter. 3. Describe the surgical procedure that will be performed to correct the pathology. ANS: A hydrocelectomy would need to be performed, which would require the surgeon to expose the tunica vaginalis and dissect free the hydrocele. The contents of the sac (herniation) would be aspirated, followed by the surgeon averting the edges of the sac and creating a pouch between the tunica vaginalis and the internal spermatic fascia. This newly created pouch will be used to hold the testis in place. 4. Will the patient experience any long-term effects of the injury? ANS: When there are no complications, the patient is expected to have a full recovery and return to normal activities within seven to ten days. Possible complications would include postoperative SSIs or scrotal edema (swelling).

QUESTIONS FOR FURTHER STUDY 1. What is end-stage renal disease? Is it serious? ANS: End- stage renal disease (ESRD), or kidney failure, is a term that refers to the final stages of many types of kidney diseases, such as polycystic kidney disease or diabetic nephropathy, that occur when filtration by the kidney is no longer effective. A person is considered to be in ESRD when the kidneys are functioning at less than 10% of their normal capacity. Almost half of the population suffering from ESRD is diabetic. The main symptom of ESRD is severely decreased or no urine output. This will probably be accompanied by malaise, fatigue, headache, hypertension, and decreased mental alertness. Lab findings will include increased creatinine and blood urea nitrogen (BUN) levels. The patient should already be aware of the underlying condition leading to ESRD and be prepared for the eventual outcome. Death will occur from the accumulation of waste products and fluids if treatment is not started immediately. The only two treatments for ESRD are dialysis and kidney transplant. 2. Which kidney is preferred for live donor transplantation, and why? ANS: The left kidney is the preferred kidney for donation from a living donor because the renal vein is longer on the left side

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

3. What types of incisions are most common to GU surgery in the male? ANS: The male genitourinary tract is often accessed through the same approach that is used for the female reproductive system. The Pfannenstiel incision is a transverse lower abdominal incision that provides excellent access to the bladder and prostate. For both male and female urinary tract procedures, the incision will be determined by several factors, including the type and location of the lesion. 4. When a simple nephrectomy is being performed, which is clamped first, the renal artery or vein, and why? ANS: The renal artery is clamped first to prevent the blood from further perfusing the kidney and to allow the vein to drain additional blood from the kidney before the vein is clamped. 5. What other purpose does the indwelling Foley catheter with balloon serve besides urinary drainage when a patient has undergone a TURP? ANS: The balloon puts pressure on the tissue; this aids in controlling hemorrhage. In addition, the irrigation often allows the dilution of hematuria and prevents the formation of clots that could occlude urinary drainage, causing urinary retention.

6. When a TURP is being performed, why should the CST report a sudden jerking of the patient’s leg to the surgeon and anesthesia provider? ANS: This could indicate that electrical stimulation produced by the electrosurgical unit is near the obturator nerve and that perforation of the prostatic capsule could occur.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 23: Orthopedic Surgery

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A CST is working the night shift at a large urban trauma center and has just been advised by the charge nurse that a patient is inbound to the hospital with a possible Colles’ fracture. After X-rays have been taken, the patient will be transported from the Radiology Department to Preoperative Holding. 1. Describe a Colles’ fracture. ANS: A Colles’ fracture is a fracture of the distal radius that occurs at the epiphysis within 2.54 cm of the wrist joint, forcing the hand into a dorsal and lateral position. This is caused by a direct force, such as when falling and stretching out the hand to break a fall. 2. What are the surgical procedures that can be used to treat a Colles’ fracture? ANS: A Colles’ fracture may easily be treated through a closed reduction external fixation (CREF) and application of a cast. If the fracture is comminuted (segmental), meaning the fracture is with more than two pieces of bone fragments which may have caused a notable amount of associated soft tissue trauma, it would need to be repaired with an open reduction internal fixation (ORIF). This open procedure would include the use of K-wires. 3. What equipment and supplies will the CST need to make sure are available in the OR? ANS: Basic orthopedic instrument trays; ORIF hardware instrument trays (which may be provided by vendors); positioners, battery powered systems such as a drill, reamer, sagittal, and reciprocating saws with attachments of IM nailing or arthroplasty, as well as small battery powered systems when reaming is not needed. A fluoroscopy machine will be needed to ensure the K-wires are properly placed to promote bone healing without malalignment.

CLOSING CASE STUDY A twenty-two-year-old patient arrives in the emergency department after a skiing accident. The patient was going downhill quickly, twisted, fell, and reports hearing and feeling a “pop” in the right knee. The ED physician has diagnosed an ACL tear and refers the patient to the orthopedic surgeon for arthroscopic repair. 1. What equipment is required for all arthroscopic procedures? ANS: To perform arthroscopy, the surgeon requires well-functioning equipment that allows clear visualization of the interior of the joint. The required equipment includes: Camera system Fluid pump and tubing Light source Powered shaving system

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

Still photograph system Video monitor 2. What is the ACL, what purpose does it serve, and how is it positioned in relation to the other knee ligaments? ANS: The anterior cruciate ligament is attached to the posterior lateral condyle of the femur and to the notch in the midline of the tibia between the tibial condyles. The purpose is to prevent the femur from sliding posteriorly on the tibia to prevent hyperextension of the knee. It also limits the medial rotation of the femur when the leg is in a fixed position with the foot planted. 3. Can ligaments be repaired, and if so, how? ANS: Yes, ligaments and tendons can be repaired. They are made of tough collagen tissue and have a poor vascular supply; therefore, they heal more slowly than vascular tissues. Generally, nonabsorbable suture is used to suture ligaments, tendons, muscles, and bone. ACL graft selection is based on the surgeon’s preference, graft availability, and the patient’s choice. There are two types of grafts: autograft that is taken from the patient’s own tissue, and allograft that is tissue taken from another person (cadaver). At times, the surgeon may decide to use the patellar tendon, hamstring, quadriceps tendon, or allograft. 4. What is the long-term postoperative prognosis? How long until the patient can ski again? ANS: During the postoperative period up to the eighth week, the patient will use crutches or a cane for assisted ambulation in combination with rehabilitation that includes range of motion exercises, straight leg raises, toe raises, and mini-squats. By two weeks postoperative, the patient should be able to obtain zero degrees of extension and by four weeks, ninety degrees of flexion. Possible complications include SSIs, postoperative prolonged immobilization, or poor compliance with rehabilitation, which can lead to not achieving full range of motion. Anterior knee pain is the most common chronic complication. Surgical failure of the graft because of poor surgical technique or chronic effusion as well as graft rejection are other possible complications. With no complications, the patient should have ROM in three to four months.

QUESTIONS FOR FURTHER STUDY 1. What safety steps should be followed when using cement in orthopedic procedures? ANS: The surgical technologist is responsible for mixing the sterile powder and liquid to create the cement. Because the fumes from this process are irritating to the mucous membranes and possibly toxic to the liver, most ORs now use a closed mixing system that safely exhausts the fumes. 2. What is the difference between a Steinmann pin and a K-wire?

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

ANS: Steinmann pins have a wider diameter, are more substantial than K-wires, and are always smooth. K-wires are more delicate, were originally available in only three small diameters, and are available either smooth or threaded. Steinmann pins are used for heavy skeletal traction, such as for the femur and tibia. 3. What is the difference in structure between a cortical and cancellous screw? ANS: Answers may vary 4. What is the purpose of placing a cement restrictor within the femur during a total hip arthroplasty? ANS: The cement restrictor is placed within the femoral canal to prevent the liquid bone cement from migrating farther into the canal than desired. 5. Place the following in their order of use during a knee arthroscopy: blunt trocar, irrigation/inflow cannula, sharp trocar, #11 knife blade. ANS: #11 knife blade Irrigation/inflow cannula Sharp trocar Blunt trocar

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 24: Cardiothoracic Surgery

OPENING CASE STUDY A fifty-four-year-old patient arrives in the emergency department complaining of severe chest pain that radiates to the mid-back along with dyspnea. The patient has a high body mass index, has smoked two packs of cigarettes a day for the past twenty years, and has two immediate family members who have died of heart disease.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

1. What does the ED physician suspect is causing the patient’s symptoms? ANS: The emergency department physician suspects that this patient is having a myocardial infarction. This is a medical emergency in which the supply of oxygenated blood to the heart is suddenly and severely reduced or completely cut off, which in turn, causes the muscle to die from lack of oxygen. This can happen when there is a blockage that prevents the oxygen-rich blood from getting to the heart. Heart attacks are often treatable when diagnosed quickly. However, they can be fatal. 2. What tests should the ED physician order? ANS: To determine the patient’s diagnosis the following tests will be useful: Cardiac catheterization to locate specific occluded vessel and to check the function of the left ventricle Chest X-ray to assess condition of the lungs and the size of the heart and great vessels Complete blood count to rule out infection and establish hemoglobin and hematocrit baselines Coagulation studies to determine an abnormality ECG to identify infarcted sites and any possible conduction disease Full chemistry profile to rule out baseline electrolyte abnormalities and assess serum glucose, cholesterol, and triglyceride levels. 3. Will surgical intervention be necessary, and if so, what procedure will be used? ANS: Depending on the cause, whether a blockage and its location or a conduction problem, if the patient is not a good candidate for PTCA, then they would be scheduled for a CABG. 4. What invasive diagnostic procedure is typically performed before surgery? In what department is that procedure performed and by what type of physician specialist? ANS: The one test mentioned in a previous question refers to a cardiac catheterization. During this procedure, the cardiologist will assess the coronary vessels and make a decision about the best treatment for the patient. If the patient is a good candidate for the stenting to be done (PTCA), then it may be performed by the cardiologist in the catheterization lab.

CLOSING CASE STUDY A fifty-year-old patient arrives in the emergency department complaining of severe chest pain. The patient is taken to the cardiac catheter lab for a coronary angiogram and left ventriculogram. The cardiologist discovers a lesion in the left main coronary artery branch and orders an immediate CABG. 1. What does the acronym CABG stand for? ANS: The acronym stands for coronary artery bypass graft. This is a condition that arises for various reasons. CAD (coronary atherosclerotic disease) is the most common type and is the leading cause of

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

death in the industrialized Western world. Factors include age, gender, race, genetics, hypertension, cigarette smoking, diet, obesity, clotting factors, and psychosocial influences. 2. Why does the location of this lesion make it more dangerous than lesions in other locations? ANS: This lesion is the most dangerous of all coronary lesions because a blockage in the proximal segment of the left coronary system will shut off blood flow to the entire left side of the heart, including the left ventricle, resulting in a massive myocardial infarction. 3. Could the cardiologist perform an angioplasty to repair the lesion? ANS: Angioplasty would not be ideal in this region because the balloon inflation will shut off blood flow to all the distal branches of the left coronary system. Percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Cath Lab, and the OR’s cardiac team is asked to stand by in case the patient requires an emergency open heart procedure. Coronary angioplasty balloons can dissect a coronary artery during inflation, and this will require immediate surgical repair. 4. Assuming that the CABG is successful, what is the patient’s postoperative prognosis? ANS: Care must be taken when transferring the patient from the OR table to the CCU bed. The patient will have monitoring lines, an ET tube, and urinary and chest drainage tubes in place. The prognosis is no complications; recovery depends on the condition of the myocardium, especially the left ventricle, and the degree of atherosclerosis. Time spent on the CPB is a factor. The patient’s lifestyle will be altered to a certain degree. If the patient experiences no or minimal complications, they will be hospitalized for fifteen to twenty-one days. Recovery time is six to eight months.

QUESTIONS FOR FURTHER STUDY 1. What is the proximal saphenous vein sutured to during CABG? ANS: The proximal saphenous vein is sutured to the ascending aorta during the CABG surgery. 2. What is the purpose of the left ventricular vent? ANS: During cardiopulmonary bypass, blood has a tendency to collect in the left side of the heart, elevating left heart pressure. An elevated left heart pressure in a heart that is not beating could result in lung damage and distension of the left ventricle. Venting of the left ventricle prevents this elevation of left heart pressure and removes air from the heart. 3. What is the purpose of the IABP, and where is it positioned? ANS: For patients who cannot be weaned from cardiopulmonary bypass (CPB), the intra-aortic balloon pump (IABP) may increase the cardiac output index significantly enough to allow the patient to “come

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

off the pump.” The IABP is positioned in the descending aorta, with the balloon tip just below the left subclavian artery orifice. 4. During cannulation, where are the cannulas of the pump oxygenator machine placed for CPB surgery? ANS: Venous blood is removed by placing a cannula into the right atrium or venae cavae. The other cannula is placed in the ascending aorta to receive the returning arterial blood 5. Describe what occurs when a patient experiences a mediastinal shift. ANS: Patients can experience a mediastinal shift when sustaining a tension pneumothorax that causes a lung to collapse. Due to the collapse of the lung, the pressure within the thoracic cavity decreases, creating a space into which the other organs and vessels of the cavity may shift. A mediastinal shift is an emergency situation because it decreases venous return and arterial output; in addition, the organs and vessels can become damaged by the shift.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 25: Peripheral Vascular Surgery

OPENING CASE STUDY A sixty-seven-year-old patient arrives in the emergency department complaining of progressively worsening bouts of right leg weakness. Family members comment that the patient is confused and often has trouble forming words for periods that typically last about a day. The right leg weakness improves only slightly from instance to instance, leaving the patient weaker each time. Because the symptoms are transient, the patient has put off seeing a physician until now. The patient reports having smoked a pack of cigarettes each day for forty-five years. 1. What tests might the ED physician order to arrive at a diagnosis? ANS: An ultrasound study on the carotid vessels can help confirm the clinical diagnosis. A CAT scan should be performed to identify any cerebral infarction, and a selective carotid arteriogram should be performed to effectively diagnose the location and severity of the carotid stenosis.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

2. What are the possible diagnoses, and which is most likely? ANS: The patient’s attacks are transient in nature, but his weakness gets progressively worse with each attack. These symptoms are indicative of ischemic attacks. These types of attacks occur because small pieces of plaque break away from the common and internal carotid arteries and travel into the brain, temporarily blocking blood flow to specific portions of the cerebrum. TIAs usually involve discrete motor or sensory dysfunctions lasting less than twenty-four hours. A type of transient attack in which the patient experiences temporary monocular vision is called amaurosis fugax. Although the resulting ischemia of a TIA produces transient symptoms, it is indicative of an impending stroke that may result in permanent disability. 3. What surgical procedure will be scheduled? ANS: The primary indication for a carotid endarterectomy is carotid stenosis that may cause transient cerebral ischemia. Small pieces of plaque may break away from the common carotid or internal carotid artery and be flushed upstream to ledge in small cerebral vessels, temporarily blocking blood flow to that area of the brain.

CLOSING CASE STUDY A sixty-five-year-old patient is scheduled for a femoropopliteal bypass procedure. The patient is diabetic, and their overall health appears to be worsening. 1. What effect of diabetes might lead to the patient needing to have this procedure? ANS: A diabetic patient is far more likely to suffer atherosclerosis one who is non-diabetic. Studies have been conducted to demonstrate that risk factors such as high glucose, oxidative stress, and inflammation can induce endothelial dysfunction, inflammation, and platelet activation and aggregation by regulating inflammasome, thereby promoting atherosclerosis. 2. What are the possible postoperative prognoses for this patient? ANS: There are numerous lifestyle changes the patient will need to make to slow the progress of both conditions. The patient cannot be cured of either diabetes or atherosclerosis. The combined disease process will continue to cause additional severe problems. 3. What are the complications of this procedure, and for which of these is the patient at most risk? ANS: Due to their very poor circulatory system, diabetic patients are prone to infection and delayed healing. Postoperatively, the patient should be monitored closely for signs of infection, thromboembolism, and hemorrhage.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

QUESTIONS FOR FURTHER STUDY 1. What is meant by collateral flow? ANS: Collateral flow is the development of secondary, or accessory, branches of a blood vessel. 2. What is the difference between ischemia and infarction? ANS: Ischemia is a deficiency of blood flow to a particular area and may be evidenced by cyanosis or pain. Ischemia is often due to an obstruction or constriction of the vessel and may be reversible. Infarction is a localized area of necrosis that results from a prolonged episode of ischemia. Infarction is not reversible. 3. Why aren’t the neurological deficits associated with transient ischemia attacks permanent? ANS: The neurological deficits associated with TIAs are not permanent because the small pieces of plaque that break away from the common carotid or internal carotid artery and are flushed upstream only lodge temporarily in small cerebral vessels, blocking blood flow to that particular area of the brain for a short period before they again become dislodged or dissolve. 4. Describe the method for loading a pledget with a double-armed needle for use during an aortofemoral bypass. ANS: When loading a pledget for use during an aortofemoral bypass, the pledget is folded in half and one of the needles is placed through the upper portion of the fold. 5. Why is preclotting a PTFE or woven polyester graft not necessary? ANS: Preclotting a PTFE or woven polyester graft is not necessary because the graft material is microporous due to a lattice framework that promotes tissue in-growth and creates a thin layer for contact with the blood. 6. What two surgical instruments are used to create the arteriotomy in the common carotid artery during an endarterectomy? ANS: Typically, a #11 scalpel blade on a #7 scalpel handle is used to create the arteriotomy, and an angled Potts-Smith scissors is used to extend the incision to the desired length.

Solution and Answer Guide AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; CHAPTER 26: Neurosurgery

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

OPENING CASE STUDY A ten-year-old patient arrives in the emergency department after falling from a playground slide and injuring their head. The patient lost consciousness at the scene but is awake on arrival to the ED. The patient complains of nausea and left-sided headache but responds to verbal commands appropriately. The neurosurgeon is called in to examine the patient. During the examination the patient loses consciousness again, becomes hypertensive and bradycardic, and the left pupil is now fixed and dilated. The surgeon calls the OR to set up for an emergency procedure. 1. What is the suspected diagnosis? ANS: With hemiparesis (partial or complete paralysis) occurring within minutes of the injury, it appears there could be some type of left-sided intracranial hematoma or bleed that causes the stroke-like symptoms. As the intracranial pressure rises, other symptoms may result. 2. Why was an emergency procedure ordered? ANS: An emergency procedure was scheduled because the resulting clot was building rapidly and elevating the intracranial pressure to a dangerous level. Eventually, if not relieved, pressure against the brainstem will shut down respiratory and heart centers. 3. What is the procedure that will be performed? ANS: For the surgical team to be capable of removing the hematoma, they need to perform a craniotomy which involves incising the cranium to access the brain and relieve the pressure being caused by the hematoma. 4. What is the long-term prognosis for the patient? ANS: The long-term prognosis would depend on the pathological situation and the condition the patient was in preoperatively. There is always a potential for wound infection, meningitis, neurological deficits, intraoperative damage to vital structures, subdural or epidural hematomas or intracerebral hemorrhage. With proper observation and monitoring, the patient should fully recover.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

CLOSING CASE STUDY A thirty-three-year-old patient visits the primary care physician complaining of right buttock and right leg pain with no known injury. The patient is employed as a long-haul truck driver and is healthy. Upon examination by a neurosurgeon, the patient exhibits normal range of motion except that raising their right leg causes sharp pain. The surgeon orders an MRI that shows an L4-L5 herniated disc. The patient is scheduled for a lumbar discectomy. 1. Discuss the differences between a laminectomy and a discectomy. ANS: Discectomy is the removal of all or a portion of the nucleus pulposus that has herniated through the weakened or torn outer ring. A discectomy can be performed from an anterior or posterior approach. If an anterior approach is used, laminectomy is not necessary. Laminectomy is the surgical removal of the bony structure over the nerve root that is being compromised by the herniated nucleus pulposus or disc fragment. This bony structure is called the lamina. A laminectomy is necessary for the completion of a discectomy from a posterior approach. 2. What instruments and special equipment will be used during a discectomy? ANS: Instruments that will be needed for a discectomy include an #11 knife blade on a #7 knife handle, a nerve root retractor, a pituitary rongeour, bone curettes, nerve hooks, and Penfield dissectors. A microscope may be used for micro laminectomy during discectomy procedures. Recovery time for these procedures is shorter because a smaller incision is made and less lamina is removed. Smaller disc fragments can be visualized and removed with the aid of the microscope, resulting in less potential trauma to the nerve root. 3. What are the possible complications associated with surgery on the lumbar spine? ANS: If too much bone is removed during a laminectomy, the spine can become unstable and require fusion. The dura may be torn, resulting in a cerebral spinal fluid leak that will require suturing for repair. The nerve root can be damaged if mishandled, resulting in permanent nerve damage. The proximity of the aorta to the spine can result in a tearing of the vessel, requiring immediate repair. Poor hemostasis can result in blood clots that place pressure on the nerve root; these can cause nerve damage if not remedied in a timely fashion. The wound can become infected as well.

QUESTIONS FOR FURTHER STUDY 1. What is the difference between a subdural and an epidural hematoma? ANS: A subdural hematoma typically results from a tear in a vein on the surface of the cerebral cortex beneath the dura. Because the resulting clot builds slowly, intracranial pressure also builds slowly; this allows more time to perform craniotomy. Subdural hematomas may be chronic or acute.

AST, Surgical Technology for the Surgical Technologist, 6e, ISBN: 9780357625736; C HAPTER 1: Introduction to Surgical Technology

An epidural hematoma is typically the result of a tear in a branch of the middle meningeal artery, resulting in a clot that builds rapidly above the dura and requires immediate surgical intervention. 2. Which is the most dangerous type of intracranial hematoma, and why? ANS: The epidural is more dangerous than the subdural because the blood within an artery is under a great deal more pressure than in a vein. Blood escapes from the arterial tear swiftly, the epidural clot forms rapidly, and pressure on the brain builds to a dangerous level at a quicker pace than with a subdural clot. 3 What is the difference between a craniotomy and a craniectomy? ANS: A craniotomy involves the “turning of a bone flap” for eventual replacement later in the procedure; a craniectomy involves the removal of a portion of the cranium that will not be replaced immediately, if at all. (The resulting defect may be left as is, or may later be repaired with a bone graft or methyl methacrylate.) A craniotomy and a craniectomy require different instrumentation. A craniotomy is performed with a perforator and craniotome; to secure the bone flap at the end of the procedure, suture, a plate and screw system, or stainless steel wire will be needed. A craniectomy is performed with a perforator and rongeur (such as Adson, Raney, or Kerrison). 4. Which approach is used for exploration of the posterior fossa, and why? ANS: The approach used for posterior fossa exploration is the prone, sitting, lateral, or semi lateral position to enter the posterior or occipital area. 5. Why is a multilevel, bilateral laminectomy usually necessary for removal of an intradural spinal tumor? ANS: Intradural spinal tumors require the dura to be opened and retracted for proper exposure. The delicate dissection that is required for proper removal of this type of tumor requires space to employ the operating microscope. Additionally, the tumor frequently extends along many spinal levels.