Expertise in the Operating Room: Logistics, Fundamentals and Nuances

Preface
Acknowledgments
Contents
List of Videos
Contributors
Part I: Preparation Before the Operating Room
	Chapter 1: The Surgeon’s Preparation Before the Operating Room
		Appendix 1: Patient Preoperative Timeline
			Today
			Two Weeks Before Surgery
			Two Days Before Surgery
			Day Before Surgery
			Day of Surgery
		Appendix 2: Aspirin and Aspirin-Like Drugs to Avoid Before Surgery
		Reference
	Chapter 2: The Anesthesiologist’s and Nursing Team’s Preparation Before the Operating Room
		2.1 The Anesthesiologist
			2.1.1 Patient History, Physical Exam, and Laboratory Assessment
				2.1.1.1 Anesthesia-Specific History Form
				2.1.1.2 Patient Physical Examination
				2.1.1.3 Cardiac Risk Assessment
					2.1.1.3.1 METs and Perioperative Risk
					2.1.1.3.2 Examples of Activities Greater Than 4 METs
					2.1.1.3.3 Examples of Activities Less Than 4 METs
			2.1.2 Surgical and Cardiac Risk Assessment
				2.1.2.1 Airway Assessment
		2.2 Appropriate Anesthetic Materials
			2.2.1 Standard Preparation
			2.2.2 Emergency Equipment/Planning for Crisis/Contingency
			2.2.3 Appropriate Medications
				2.2.3.1 Routine
				2.2.3.2 Emergency
		2.3 Possible Need for Transfusion
		2.4 Perioperative/Circulator Nurse
		2.5 Scrub Nurse/Scrub Technologist
		References
Part II: Preparation in the Operating Room-Before Anesthesia
	Chapter 3: Universal Protocol
		3.1 Universal Protocol
			3.1.1 Conduct a Preprocedure Verification Process
			3.1.2 Mark the Procedure Site
			3.1.3 Perform a Time-Out
		Appendix
			Speak Up™
				The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
					Guidance for Healthcare Professionals
						Conduct a Preprocedure Verification Process
						Mark the Procedure Site
						Perform a Time-Out
		Reference
	Chapter 4: Sterility
		4.1 The Operating Staff
			4.1.1 Attire: Clothing, Headwear, Jewelry, and Footwear
			4.1.2 Hand Preparation: “Scrubbing”
			4.1.3 Avoiding Hand Contamination: “Scrubbed” Hand Position
			4.1.4 Hand Drying
			4.1.5 OR Environment
			4.1.6 Instruments
		4.2 Patient
			4.2.1 Preoperative Preparation
			4.2.2 Intraoperative Optimization
			4.2.3 Prophylactic Antibiotics
		References
Part III: Preparation in the Operating Room-After Anesthesia
	Chapter 5: Patient Preparation
		5.1 The Airway
		5.2 Tracheal Tube Security and Access
			5.2.1 Endotracheal Tube Security
			5.2.2 Nasotracheal Tube Security
			5.2.3 Tracheal Tube Access and Visualization
		5.3 Eye Protection
		5.4 Ear Canal
		5.5 Patient Positioning
		5.6 Skin Preparation
			5.6.1 Debridement
			5.6.2 Solutions
		5.7 Draping
			5.7.1 Drapes
		5.8 Tubes and Cords
		5.9 Monopolar Electrocautery: The Bovie and the Grounding Pad
		5.10 Intermittent Pneumatic Compression (IPC) Devices (Venodyne Boots) (Fig. 5.7)
		References
Part IV: Surgery
	Chapter 6: Logistics and Ergonomics
		6.1 Equipment
			6.1.1 Operating Table
			6.1.2 Lighting
			6.1.3 Team Positioning
			6.1.4 Operative Assistance
			6.1.5 Retraction
		6.2 Instrument Selection and Passing
		6.3 Hemostasis (Suctioning)
		6.4 The Operation’s End
			6.4.1 The Patient
			6.4.2 The Instruments
		References
	Chapter 7: Fire
		7.1 The “Fire Triad”
			7.1.1 Oxidizer
			7.1.2 Heat or Ignition Source
			7.1.3 Fuel
		7.2 Fire Prevention
			7.2.1 Oxidizer
			7.2.2 Heat or Ignition Source
			7.2.3 Fuel
		7.3 Specific Guidelines for Using a LASER [4]
		7.4 Responding to an OR Fire
			7.4.1 OR Fire Resources
		References
Part V: The Surgeon’s Tools
	Chapter 8: Surgeon’s Instruments
		8.1 Cutting and Dissecting
		8.2 Scalpel: Surgical Blades and Handles
			8.2.1 Surgical Blades
				8.2.1.1 Standard Blades
			8.2.2 Knife Handles
		8.3 Scissors
			8.3.1 Mayo Scissors
			8.3.2 Metzenbaum (“Metz”) Scissors
			8.3.3 Small, Delicate Scissors
				8.3.3.1 Iris Scissors
				8.3.3.2 Tenotomy Scissors
		8.4 Forceps
			8.4.1 Toothed vs. Smooth
				8.4.1.1 Toothed Forceps
					8.4.1.1.1 Adson
					8.4.1.1.2 Adson-Brown
					8.4.1.1.3 Bishop-Harmon (“Iris”)
					8.4.1.1.4 Bonney
					8.4.1.1.5 Rat Tooth
				8.4.1.2 Smooth Forceps
					8.4.1.2.1 DeBakey
					8.4.1.2.2 Nonvascular
		8.5 Clamps (Locking Forceps)
			8.5.1 Clamps That Secure Tissue
				8.5.1.1 Allis
				8.5.1.2 Babcock
			8.5.2 Clamps That Crush Tissue
				8.5.2.1 Jacobson (“Mosquito”)
				8.5.2.2 Crile (“Snap”)
				8.5.2.3 Kelly
				8.5.2.4 Kocher
				8.5.2.5 Mixter (“Right Angle”)
				8.5.2.6 Tonsil “Schnidt”
		8.6 Exposing and Retracting
			8.6.1 Simple Retractors
			8.6.2 Handheld Retractors
				8.6.2.1 Army-Navy
				8.6.2.2 Senn-Miller (“Senn”)
				8.6.2.3 Hooks
				8.6.2.4 Richardson (“Abdominal Wall”) Retractor
				8.6.2.5 Deaver
			8.6.3 Self-Retaining Retractors
				8.6.3.1 Weitlaner
				8.6.3.2 Gelpi
				8.6.3.3 Bookwalter and Lonestar
		8.7 Suctioning
			8.7.1 Yankauer
			8.7.2 Pediatric (“Tonsil”)
			8.7.3 Frazier
		8.8 Needle Holders
		Reference
	Chapter 9: Sutures and Needles
		9.1 Sutures
		9.2 Suture Diameter
		9.3 Biomechanical Properties
			9.3.1 Tensile Strength
			9.3.2 Memory
			9.3.3 Elasticity
			9.3.4 Coefficient of Friction
			9.3.5 Knot Security
			9.3.6 Tissue Reactivity
		9.4 Mono- and Multifilament Sutures
			9.4.1 Monofilament
			9.4.2 Multifilament
		9.5 Suture Degradation
			9.5.1 Absorbable
			9.5.2 Nonabsorbable
			9.5.3 Materials
				9.5.3.1 Absorbable Suture Materials
					9.5.3.1.1 Plain Gut
					9.5.3.1.2 Chromic Gut
					9.5.3.1.3 Vicryl (Polyglactin 910)
					9.5.3.1.4 Monocryl (Poliglecaprone 25)
					9.5.3.1.5 PDS (Polydioxanone)
				9.5.3.2 Nonabsorbable Suture Materials
					9.5.3.2.1 Silk
					9.5.3.2.2 Nylon
					9.5.3.2.3 Prolene (Polypropylene)
					9.5.3.2.4 Polyester
		9.6 Barbed Sutures
		9.7 Topical Skin Adhesives
		9.8 Needles
			9.8.1 Suture Attachment: Needle Eye/Swage
			9.8.2 Body
				9.8.2.1 Needle Body Curvature (Fig. 9.2)
					9.8.2.1.1 Typical Uses of Needle Body Curvatures (Adapted from Byrne and Ally)
			9.8.3 Needle Point
				9.8.3.1 Cutting Needles
				9.8.3.2 Taper
				9.8.3.3 Blunt Point Needles
			9.8.4 Securing the Needle
Part VI: Surgical Devices
	Chapter 10: Local Anesthetics
		10.1 Local Anesthetics
			10.1.1 Mechanism of Action
			10.1.2 Structure
				10.1.2.1 Onset of Action
			10.1.3 Potency
			10.1.4 Types of Local Anesthetics
			10.1.5 Duration of Action (DOA)
			10.1.6 Types of Nerve Fibers and Their Sequence of Blockade
		10.2 Local Anesthesia and Hemostasis
			10.2.1 Vasoconstrictors and Hemostasis
			10.2.2 Dosing
		10.3 Safety and Toxicity
			10.3.1 Maximum Dosing
			10.3.2 Toxicity
				10.3.2.1 Central Nervous System (CNS) Toxicity
				10.3.2.2 Cardiovascular Toxicity
				10.3.2.3 Methemoglobinemia
				10.3.2.4 Digital Ischemia
				10.3.2.5 Allergic Reactions
		10.4 Management of Suspected Toxicity
		References
	Chapter 11: Electrocautery
		11.1 Electrosurgical Unit (ESU)
		11.2 Monopolar Electrocautery (The Bovie)
			11.2.1 Modes of Operation
				11.2.1.1 Pure Cut Function
				11.2.1.2 Coagulation Function
				11.2.1.3 Blend-Cut Function
			11.2.2 Monopolar Safety
				11.2.2.1 Fire
				11.2.2.2 Burns
				11.2.2.3 Jewelry
				11.2.2.4 Pacemaker and Internal Cardiac Defibrillator (ICD) Interference
		11.3 Bipolar Electrosurgery
		References
	Chapter 12: Surgical Tourniquets
		12.1 Use of Tourniquets
		12.2 Tourniquet Application (See Video 12.1)
		12.3 Tourniquet Placement
		12.4 Tourniquet Guidelines
		12.5 Tourniquet Effects and Complications
		References
Part VII: Wound Closure
	Chapter 13: Drains
		13.1 Active (Suction) Drains
			13.1.1 Indications
			13.1.2 Function
			13.1.3 Design
			13.1.4 Skin Exit and Stabilization
			13.1.5 Drain Removal
			13.1.6 Antibiotics
		13.2 Passive Drains
			13.2.1 Indications
			13.2.2 Design
			13.2.3 Positioning
			13.2.4 Drain Removal
			13.2.5 Skin Immobilization
		13.3 Summary
		References
	Chapter 14: Suture Closure
		14.1 Surgical Knots
		14.2 Knot Construction
			14.2.1 Slip Knots and Square Knots
				14.2.1.1 The Square Knot
		14.3 Knot Failure
		14.4 Hand Tying
			14.4.1 Two-Hand Tying
			14.4.2 Instrument Tying
		14.5 Technical Considerations for Primary Wound Closure
			14.5.1 General
				14.5.1.1 Skin Markings and Temporary Closure
				14.5.1.2 Suturing Techniques for Primary Closure
					14.5.1.2.1 Interrupted Buried Deep Dermal Closure
					14.5.1.2.2 Running Subcuticular (Intradermal) Closure
					14.5.1.2.3 Continuous Percutaneous Closure
					14.5.1.2.4 Simple Interrupted Closure
		14.6 Skin Adhesives
		References
	Chapter 15: Surgical Dressings
		15.1 Passive Dressings
			15.1.1 Primary Dressings
			15.1.2 Secondary Dressings
			15.1.3 Tertiary Dressings
		15.2 Interactive Dressings
			15.2.1 Wet-to-Dry Dressings
		15.3 Negative Pressure Wound Therapy (NPWT)
			15.3.1 Basic Components
			15.3.2 Mechanism of Actions of NPWT
				15.3.2.1 Macrostrain
				15.3.2.2 Microstrain
			15.3.3 Fluid Removal from the Wound
			15.3.4 Indications for NPWT
			15.3.5 Contraindications to NPWT
			15.3.6 NPWT Application (Fig. 15.6)
				15.3.6.1 NPWT Pressure Setting
				15.3.6.2 NPWT Removal
			15.3.7 Potential Complications
			15.3.8 Troubleshooting
			15.3.9 Difficult Scenarios
				15.3.9.1 Y Technique
				15.3.9.2 Bridging Technique
				15.3.9.3 Fecal Incontinence
				15.3.9.4 Tunneling
		References
Index