surgical technology for the surgical technologist

1. Chapter 11 11-1 Laparoscopic Nissen Fundoplication . . . . . . . . . . .316 11-2 Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319 11-3 Total Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . .322 11-4 Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .327 11-5 Hemorrhoidectomy . . . . . . . . . . . . . . . . . . . . . . . .334 11-6 Repair of Liver Laceration . . . . . . . . . . . . . . . . . . .337 11-7 Liver Resection . . . . . . . . . . . . . . . . . . . . . . . . . . .339 11-8 Common Bile Duct Exploration . . . . . . . . . . . . . .342 11-9 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . .344 11-10 Pancreatectomy . . . . . . . . . . . . . . . . . . . . . . . . . .351 11-11 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354 11-12 Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .360 11-13 Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .363 11-14 Tracheotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .367 Chapter 12 12-1 Vaginal Delivery . . . . . . . . . . . . . . . . . . . . . . . . . .392 12-2 Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . .395 12-3 Tuboplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402 12-4 Laparoscopic Resection of Unruptured Tubal Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .404 12-5 Basic Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . .411 12-6 Basic Colposcopy . . . . . . . . . . . . . . . . . . . . . . . . .415 12-7 Hysteroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .416 12-8 Marsupialization of Bartholins Gland Cyst . . . . . .418 12-9 Simple Vulvectomy . . . . . . . . . . . . . . . . . . . . . . . .420 12-10 Anterior and Posterior Repair . . . . . . . . . . . . . . . .423 12-11 Dilation and Curettage . . . . . . . . . . . . . . . . . . . . .431 12-12 Myomectomy (Abdominal Approach) . . . . . . . . . .434 12-13 TAH-BSO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437 Chapter 13 13-1 Strabismus CorrectionRecession . . . . . . . . . . . .455 13-2 Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . .459 13-3 Keratoplasty (Corneal Transplant) . . . . . . . . . . . . .464 13-4 Cataract Extraction: Extracapsular Method . . . . . . .468 13-5 Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .471 Chapter 14 14-1 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .482 14-2 Myringoplasty/Tympanoplasty . . . . . . . . . . . . . . .484 14-3 SMR/Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . . .496 14-4 Caldwell-Luc . . . . . . . . . . . . . . . . . . . . . . . . . . . .501 14-5 Rigid Sinus Endoscopy . . . . . . . . . . . . . . . . . . . . .503 14-6 Tonsillectomy and Adenoidectomy . . . . . . . . . . . .515 14-7 Uvulopalatopharyngoplasty . . . . . . . . . . . . . . . . .518 14-8 Rigid Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . .520 14-9 Radical Neck Dissection with Mandibulectomy . . .522 Chapter 15 15-1 Tooth Extraction . . . . . . . . . . . . . . . . . . . . . . . . . .538 15-2 Application of Arch Bars . . . . . . . . . . . . . . . . . . . .543 15-3 Plate and Screw Fixation of Mandibular Fracture . .546 15-4 Orbital Floor Fracture Repair . . . . . . . . . . . . . . . .551 15-5 Le Fort I Fracture Repair . . . . . . . . . . . . . . . . . . . .554 15-6 Anterior Cranial Expansion . . . . . . . . . . . . . . . . . .557 15-7 Temporomandibular Joint Arthroscopy . . . . . . . . .561 Chapter 16 16-1 Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .584 16-2 Full-Thickness Skin Graft . . . . . . . . . . . . . . . . . . .590 16-3 Excision of Ganglionic Cyst . . . . . . . . . . . . . . . . .595 16-4 Reduction Mammoplasty . . . . . . . . . . . . . . . . . . . .603 Chapter 17 17-1 Simple Nephrectomy . . . . . . . . . . . . . . . . . . . . . .638 17-2 Radical Cystectomy with Ileal Conduit Male Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . .645 17-3 Marshall-Marchetti-Krantz Procedure . . . . . . . . . . .651 17-4 Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . .656 17-5 Orchiopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .659 17-6 Suprapubic Prostatectomy . . . . . . . . . . . . . . . . . .664 Chapter 18 18-1 Bone Graft Procedure, Donor Site . . . . . . . . . . . . .699 18-2 Knee Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . .701 18-3 Arthroscopic Repair of a Torn Meniscus . . . . . . . .704 18-4 Endoscopic Carpal Tunnel Release . . . . . . . . . . . .707 18-5 External Fixation of a Colles Fracture . . . . . . . . . .710 18-6 Internal K-wire Fixation of a Colles Fracture . . . . .712 18-7 ORIF of the Humerus . . . . . . . . . . . . . . . . . . . . . .713 18-8 Repair of Rotator Cuff . . . . . . . . . . . . . . . . . . . . . .717 18-9 Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . .722 Chapter 19 19-1 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .756 19-2 Thoracotomy for Upper Lobectomy . . . . . . . . . . .759 19-3 Coronary Artery Bypass Grafting . . . . . . . . . . . . . .769 19-4 Aortic Valve Replacement . . . . . . . . . . . . . . . . . . .775 Chapter 20 20-1 Aortofemoral Bypass . . . . . . . . . . . . . . . . . . . . . .803 20-2 Abdominal Aortic Aneurysmectomy . . . . . . . . . . .807 20-3 Femoropopliteal Bypass (Unilateral) . . . . . . . . . . .810 20-4 Femorofemoral Bypass . . . . . . . . . . . . . . . . . . . . .813 20-5 Axillofemoral Bypass . . . . . . . . . . . . . . . . . . . . . .816 20-6 Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . .819 Chapter 21 21-1 Craniotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .850 21-2 Craniotomy for Aneurysm Repair . . . . . . . . . . . . .856 21-3 Craniectomy or Craniotomy for Removal of Acoustic Neuroma . . . . . . . . . . . . . . . . . . . . . . . .860 21-4 Ventriculoperitoneal and Ventriculoatrial Shunt . . .863 21-5 Transphenoidal Hypophysectomy . . . . . . . . . . . . .866 21-6 Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .870 21-7 Anterior Cervical Discectomy (Cloward Technique) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .874 21-8 Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . .877 LIST OF PROCEDURES

2. Surgical Technology for the Surgical Technologist: A Positive Care Approach Association of Surgical Technologists, Inc. Executive Editors Bob L. Caruthers, CST, PhD Deputy Director, Association of Surgical Technologists Paul Price, CST/CFA, MBA Education Director, Association of Surgical Technologists Executive Director, Accreditation Review Committee on Education in Surgical Technology Editors Teri L. Junge, CST/CFA Education Coordinator, Association of Surgical Technologists Ben D. Price, CST Education Coordinator, Association of Surgical Technologists Government and Public Affairs Coordinator, Association of Surgical Technologists A u s t r a l i a C a n a d a M e x i c o S i n g a p o r e S p a i n U n i t e d K i n g d o m U n i t e d S t a t e s

3. Delmar Staff: Business Unit Director: William Brottmiller Acquisitions Editor: Maureen Muncaster Developmental Editor: Deb Flis Editorial Assistant: Maria Perretta Executive Marketing Manager: Dawn F. Gerrain Channel Manager: Tara Carter Executive Production Manager: Karen Leet Project Editor: Elizabeth B. Keller, Mary Ellen Cox Production Coordinator: Barbara A. Bullock Production Editor: Rich Killar Cover Design: Charles Cummings Advertising/Art Inc. Text Design: Charles Cummings Advertising/Art Inc. All rights reserved Thomson Learning 2001. The text of this publication, or any part thereof, may not be reproduced or transmitted in any form or by any means, electronics or mechanical, including photocopying, recording, storage in an information retrieval system, or otherwise, without prior permission of the publisher. You can request permission to use material from this text through the following phone and fax numbers. Phone: 1-800-730-2214; Fax 1-800-730-2215; or visit our Web site at http://www.thomsonrights.com Library of Congress Cataloging-in-Publication Data Surgical technology for the surgical technologist : a positive care approach / Association of Surgical Technologists, Inc. ; executive editors, Bob L. Caruthers, Paul Price; editors, Teri Junge, Ben D. Price. p. ; cm. Includes bibliographical references and index. ISBN 0-7668-0662-6 1. Surgical technology. 2. Operating room technicians. I. Caruthers, Bob. II. Association of Surgical Technologists. [DNLM: 1. Surgical Procedures, Operative. 2. Operating Room Technicians. WO 500 S96187 2000] RD32.3 .S866 2000 617.917dc21 00-020107 NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. The Publisher makes no representation or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers use of, or reliance upon, this material. COPYRIGHT 2001 Delmar is a division of Thomson Learning. The Thomson Learning logo is a registered trademark used herein under li- cense. Printed in the United States of America 1 2 3 4 5 6 7 8 9 10 XXX 05 04 03 02 01 00 For more information, contact Delmar, 3 Columbia Circle, PO Box 15015, Albany, NY 12212-0515; or find us on the World Wide Web at http://www.delmar.com

4. Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . .xix How To Use This Book . . . . . . . . . . . . . . . . . . . . . . .xx SECTION 1 Introduction to Surgical Technology CHAPTER 1 Orientation to Surgical Technology 3 History of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Surgery Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Surgical Specialties . . . . . . . . . . . . . . . . . . . . . . . . . .4 History of Surgical Technology . . . . . . . . . . . . . . . . . .6 Surgical Technology and Surgical Technologists . . . . . .6 Field of Surgical Technology . . . . . . . . . . . . . . . . . . .6 Surgical Technology Education and Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Surgical TechnologistRole(s) and Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Daily Roles in the Operating Room . . . . . . . . . . . . . .8 Job Descriptions for the Surgical Technologist . . . . .14 Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . .14 Hospital Organization . . . . . . . . . . . . . . . . . . . . . .15 Financial Considerations and Reimbursement . . .17 Organizations Related to Hospitals, Health Care, and Surgical Services . . . . . . . . . . . . . . . . . . . . .18 Hospital Departments and Interdepartmental Communication . . . . . . . . . . . . . . . . . . . . . . . . .18 Personal and Professional Relations . . . . . . . . . . . . . .20 Surgical Technologists Lifestyle . . . . . . . . . . . . . . . .21 Surgical Technologist as a Professional . . . . . . . . .21 CHAPTER 2 The Surgical Patient 24 The STSR and the Surgical Patient . . . . . . . . . . . . . . .25 Physical, Psychological, Social, and Spiritual Needs of the Surgical Patient . . . . . . . . . . . . . . . . . . . . . .25 Understanding the Surgical Patient . . . . . . . . . . . .26 Causes of Surgical Intervention . . . . . . . . . . . . . . .26 The Surgical Patient, a Human Being . . . . . . . . . .26 Prioritizing NeedsMaslows Hierarchy . . . . . . . .27 Select Basic Concepts in Developmental and Social Psychology . . . . . . . . . . . . . . . . . . . . . . . .27 Cultural and Religious Influences . . . . . . . . . . . . . .32 Patient Bill of Rights: A Formal View of the Patient as Human . . . . . . . . . . . . . . . . . . . . . . . . .41 Consent for Surgery: A Basic Right . . . . . . . . . . . . .43 Principles of Documentation . . . . . . . . . . . . . . . . . .45 Legal and Ethical Considerations . . . . . . . . . . . . . . . .46 AST Code of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . .48 Specific Legal Considerations . . . . . . . . . . . . . . . . .48 Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . .51 Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . .51 Geriatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . .51 Other Special Populations: Trauma, HIV Positive, and Organ Donor/Recipient . . . . . . . . . . . . . . . .53 Surgical Patient Care: Putting It All Together . . . . . . .54 Using the CARE Approach . . . . . . . . . . . . . . . . . . . .54 CHAPTER 3 Physical Environment and Safety Standards 57 Physical Design of the Surgery Department . . . . . . . .58 Areas of the OR . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Physical Components of the Operative Suite . . . . . .59 Substerile Area . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 Direct Support Services . . . . . . . . . . . . . . . . . . . . . .64 Hazards and Regulatory Agencies . . . . . . . . . . . . . . .66 Safety Considerations . . . . . . . . . . . . . . . . . . . . . . . . .67 Air-Handling System . . . . . . . . . . . . . . . . . . . . . . . .67 Surgical Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Noise in the Operating Room . . . . . . . . . . . . . . . . . .67 Ergonomics and Safety Considerations . . . . . . . . . .67 Fire Hazards and Safety . . . . . . . . . . . . . . . . . . . . .68 Table of Contents iii

5. Electrical Hazards . . . . . . . . . . . . . . . . . . . . . . . . . .69 Ionizing Radiation . . . . . . . . . . . . . . . . . . . . . . . . .70 Biologic Hazards and Safety Considerations . . . . . . . .71 Universal Precautions . . . . . . . . . . . . . . . . . . . . . . .71 Standard Precautions . . . . . . . . . . . . . . . . . . . . . . .71 Laser and Electrosurgical Plume . . . . . . . . . . . . . . .74 Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 Chemical Hazards and Safety Considerations . . . . . . .75 Waste Anesthetic Gases . . . . . . . . . . . . . . . . . . . . . .75 Methyl Methacrylate . . . . . . . . . . . . . . . . . . . . . . . .75 Formalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Ethylene Oxide . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Glutaraldehyde . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 SECTION 2 Principles and Practice of Surgical Technology CHAPTER 4 Asepsis 80 History of Sterilization . . . . . . . . . . . . . . . . . . . . . . . .81 Basic Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Pathogens and Infection . . . . . . . . . . . . . . . . . . . . . .82 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Pathogens Associated with Surgical Site Infection . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Methods of Transmission . . . . . . . . . . . . . . . . . . . . .85 Principles of Asepsis and Sterile Techniques . . . . . . .88 Principle 1: Sterile Field . . . . . . . . . . . . . . . . . . . . . .88 Principle 2: Sterile Team Member Attire . . . . . . . . .89 Principle 3: Movement in and Around Sterile Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Surgical Conscience . . . . . . . . . . . . . . . . . . . . . . . . . .91 Cleaning, Disinfection, and Sterilization . . . . . . . . . . .91 Cleaning and Disinfection . . . . . . . . . . . . . . . . . . .92 Disinfectant and Disinfectant/Sterilant Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Instrument Preparation and Wrapping for Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Specific Procedural Trays . . . . . . . . . . . . . . . . . . .100 Instrument Sets . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Packaging for Sterilization and Storage . . . . . . . . . . .101 Performance Standards of Packaging Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Performance Characteristics . . . . . . . . . . . . . . . . .101 Types of Packaging Materials . . . . . . . . . . . . . . . .102 General Principles of Packaging . . . . . . . . . . . . . .104 Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 Requirements and Essential Factors . . . . . . . . . . .107 Basic Components of a Steam Sterilizer . . . . . . . .108 Gas Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 Ethylene Oxide . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Alternative Gas Sterilization Methods . . . . . . . . . .111 Liquid Chemical Sterilization Processes . . . . . . . . . .112 Ionizing Radiation . . . . . . . . . . . . . . . . . . . . . . . . . .112 Methods of Monitoring the Sterilization Process . . . .113 Mechanical Methods of Monitoring the Sterilization Process . . . . . . . . . . . . . . . . . . . . .113 Chemical Methods of Monitoring the Sterilization Process . . . . . . . . . . . . . . . . . . . . .113 Biological Methods of Monitoring the Sterilization Process . . . . . . . . . . . . . . . . . . . . .113 Bowie-Dick Test . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Event-Related Sterility . . . . . . . . . . . . . . . . . . . . . . .114 Environmental Decontamination . . . . . . . . . . . . .115 Environmental Services . . . . . . . . . . . . . . . . . . . . .115 Case by Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 Daily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 CHAPTER 5 General Patient Care and Safety 118 Preoperative Patient Routines . . . . . . . . . . . . . . . . . .119 Surgical Consent . . . . . . . . . . . . . . . . . . . . . . . . . .119 Preoperative Education . . . . . . . . . . . . . . . . . . . . .120 Patient Possessions . . . . . . . . . . . . . . . . . . . . . . . .120 Evening/Morning Before Surgery . . . . . . . . . . . . .121 Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122 Makeup and Dress . . . . . . . . . . . . . . . . . . . . . . . . .122 Call to Operating Room . . . . . . . . . . . . . . . . . . . . .122 Family Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122 Patient Identification . . . . . . . . . . . . . . . . . . . . . .123 Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . .123 Transfer and Positioning . . . . . . . . . . . . . . . . . . . . .123 Basic Positioning for Surgery . . . . . . . . . . . . . . . . . .124 Supine Position . . . . . . . . . . . . . . . . . . . . . . . . . . .125 Trendelenburg Position . . . . . . . . . . . . . . . . . . . . .125 Reverse Trendelenburg Position . . . . . . . . . . . . . .125 Fowlers Position and Sitting Position . . . . . . . . . .125 Lithotomy Position . . . . . . . . . . . . . . . . . . . . . . . . .126 Prone Position . . . . . . . . . . . . . . . . . . . . . . . . . . . .126 Kraske (Jackknife) Position . . . . . . . . . . . . . . . . . .127 Lateral Position . . . . . . . . . . . . . . . . . . . . . . . . . . .127 Lateral Kidney Position . . . . . . . . . . . . . . . . . . . . .128 Thermoregulatory Devices . . . . . . . . . . . . . . . . . . . .128 Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 iv TABLE of CONTENTS

6. Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 Pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Urinary Catheterization . . . . . . . . . . . . . . . . . . . . . .133 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133 Skin Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . .134 Clean Areas and Contaminated Areas . . . . . . . . .136 Skin Preparation Setup . . . . . . . . . . . . . . . . . . . . .136 Perineal and Vaginal Preparations . . . . . . . . . . .138 Skin Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 Hemostasis and Blood Replacement . . . . . . . . . . . . .139 Factors Affecting Hemostasis . . . . . . . . . . . . . . . . .139 Control of Bleeding During Surgery . . . . . . . . . . .139 Mechanical Methods . . . . . . . . . . . . . . . . . . . . . . .140 Thermal Hemostasis . . . . . . . . . . . . . . . . . . . . . . .141 Pharmacological Agents . . . . . . . . . . . . . . . . . . . .142 Blood Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Blood Replacement . . . . . . . . . . . . . . . . . . . . . . . .143 Cardiopulmonary Resuscitation . . . . . . . . . . . . . . . .144 Cardiac Arrest in the Surgical Setting . . . . . . . . . .144 Malignant Hyperthermia . . . . . . . . . . . . . . . . . . . . .145 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Emergency Medical Services . . . . . . . . . . . . . . . . . .146 Indications of Emergency Situations . . . . . . . . . . . . .146 Objectives and Priorities in Emergency Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147 Convulsions/Seizures . . . . . . . . . . . . . . . . . . . . . . .147 Management of Seizure . . . . . . . . . . . . . . . . . . . .147 Anaphylactic Reactions . . . . . . . . . . . . . . . . . . . . .147 Clinical Manifestation of Impending Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Hemolytic Transfusion Reactions . . . . . . . . . . . . .148 CHAPTER 6 Surgical Pharmacology and Anesthesia 150 Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 Drug Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 Drug Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 Drug Nomenclature . . . . . . . . . . . . . . . . . . . . . . . .152 Route of Administration . . . . . . . . . . . . . . . . . . . .152 Drug Classifications . . . . . . . . . . . . . . . . . . . . . . .152 Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . .153 Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . .154 Drug-Handling Techniques . . . . . . . . . . . . . . . . . . .154 Medication Identification . . . . . . . . . . . . . . . . . . .155 Supplies for Medication Handling . . . . . . . . . . . . .156 Transfer of a Medication to the Sterile Field . . . . .156 Medications Commonly Used in the Operating Room . . . . . . . . . . . . . . . . . . . . . . . .157 History of Modern Anesthesia . . . . . . . . . . . . . . . . .160 Methods and Techniques of Anesthetic Administration . . . . . . . . . . . . . . . . . . . . . . . . . . .161 General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . .162 Depth of General Anesthesia . . . . . . . . . . . . . . . . .162 Phases of General Anesthesia . . . . . . . . . . . . . . . .162 Advantages of General Anesthesia . . . . . . . . . . . .163 Risks and Complications Associated with General Anesthesia . . . . . . . . . . . . . . . . . . . . . .163 Anesthetic Agents . . . . . . . . . . . . . . . . . . . . . . . . .165 Adjuncts to General Anesthesia . . . . . . . . . . . . . . .170 Anesthesia Equipment . . . . . . . . . . . . . . . . . . . . . .171 Nerve Conduction Blockade . . . . . . . . . . . . . . . . . .174 Nerve Conduction Blocking Agents . . . . . . . . . . . .174 Topical Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . .175 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . .176 Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . .176 Epidural Anesthesia . . . . . . . . . . . . . . . . . . . . . . .178 Nontraditional Anesthesia Options . . . . . . . . . . . . . .179 Team Member Roles during Anesthesia Administration . . . . . . . . . . . . . . . . . . . . . . . . . . .179 Preoperative Visits . . . . . . . . . . . . . . . . . . . . . . . . .180 Preoperative RoutineAll Types of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Postanesthesia Care . . . . . . . . . . . . . . . . . . . . . . .184 CHAPTER 7 Instrumentation, Equipment, and Supplies 187 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Classifications . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Care and Handling . . . . . . . . . . . . . . . . . . . . . . . .193 Types of Instrument Sets . . . . . . . . . . . . . . . . . . . .193 Specialty Equipment . . . . . . . . . . . . . . . . . . . . . . . .196 Endoscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196 Power Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 Microscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 Video Monitors, Recorders, and Cameras . . . . . . .200 Fiberoptic Headlights and Light Sources . . . . . . . .201 Irrigation/Aspiration (IA) Units . . . . . . . . . . . . . . .201 Cryotherapy Units . . . . . . . . . . . . . . . . . . . . . . . . .201 Insufflators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201 Nerve Stimulators . . . . . . . . . . . . . . . . . . . . . . . . .201 Accessory Equipment . . . . . . . . . . . . . . . . . . . . . . . .202 Suction Systems . . . . . . . . . . . . . . . . . . . . . . . . . . .202 Electrosurgical Unit . . . . . . . . . . . . . . . . . . . . . . . .202 Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 Pneumatic Tourniquets . . . . . . . . . . . . . . . . . . . .205 Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206 Drapes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206 Sterile Packs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207 Sponges and Dressings . . . . . . . . . . . . . . . . . . . . .207 Catheters, Tubes, and Drains . . . . . . . . . . . . . . . .209 TABLE of CONTENTS v

7. Nonsuture Needles . . . . . . . . . . . . . . . . . . . . . . . . .211 Irrigators and Syringes . . . . . . . . . . . . . . . . . . . . .212 CHAPTER 8 Wound Healing, Sutures, Needles, and Stapling Devices 214 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Types of Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Surgical Wound . . . . . . . . . . . . . . . . . . . . . . . . . .215 Traumatic Wound . . . . . . . . . . . . . . . . . . . . . . . . .215 Chronic Wound . . . . . . . . . . . . . . . . . . . . . . . . . . .216 Inflammatory Process . . . . . . . . . . . . . . . . . . . . . . . .216 Types of Wound Healing . . . . . . . . . . . . . . . . . . . . .216 First Intention (Primary Union) . . . . . . . . . . . . . .216 Phases of Wound Healing by First Intention . . . . .216 Second Intention (Granulation) . . . . . . . . . . . . . .217 Third Intention (Delayed Primary Closure) . . . . .217 Factors Influencing Wound Healing . . . . . . . . . . . . .218 Complications of the Healing Wound . . . . . . . . . . . .218 Intraoperative Wound Care . . . . . . . . . . . . . . . . . .219 Postoperative Wound Care . . . . . . . . . . . . . . . . . .220 Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221 Types of Suture Material . . . . . . . . . . . . . . . . . . . .222 Suture Sizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222 General Factors Affecting Choice of Suture . . . . . .222 Characteristics of Common Sutures . . . . . . . . . . .223 Packaging of Suture . . . . . . . . . . . . . . . . . . . . . . .225 Ligatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226 Ligating Methods . . . . . . . . . . . . . . . . . . . . . . . . . .226 Suture for the Procedure . . . . . . . . . . . . . . . . . . . .227 Layer Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . .228 Endoscopic Suture . . . . . . . . . . . . . . . . . . . . . . . . .229 Suturing Techniques . . . . . . . . . . . . . . . . . . . . . . .229 Accessory Devices . . . . . . . . . . . . . . . . . . . . . . . . .231 Stapling Devices . . . . . . . . . . . . . . . . . . . . . . . . . . .232 Types of Staplers . . . . . . . . . . . . . . . . . . . . . . . . . . .233 Meshes or Fabrics . . . . . . . . . . . . . . . . . . . . . . . . .234 Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234 Needle Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235 Needle Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235 Needle Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236 CHAPTER 9 The Surgical Technologist in the Scrub Role (Case Management) 238 Operating Room Attire . . . . . . . . . . . . . . . . . . . . . . .239 Clothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239 Head Coverings . . . . . . . . . . . . . . . . . . . . . . . . . . .240 Masks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240 Shoe Covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240 Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 Surgical Gown . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 Protective Eyewear . . . . . . . . . . . . . . . . . . . . . . . . .242 Other Protective Attire . . . . . . . . . . . . . . . . . . . . . .242 Daily Routines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242 Furniture Setup . . . . . . . . . . . . . . . . . . . . . . . . . . .242 Establishing the Sterile Field . . . . . . . . . . . . . . . . . . .243 Opening Sterile Supplies . . . . . . . . . . . . . . . . . . . .243 The Surgical Scrub . . . . . . . . . . . . . . . . . . . . . . . .246 Hand Drying and Donning the Surgical Gown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 Closed Gloving Technique for Gowning and Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . .251 Open Glove Technique When Not Gowned . . . . . .251 Gowning and Gloving Another Team Member . . .254 Turning Gown . . . . . . . . . . . . . . . . . . . . . . . . . . .254 Gown Removal . . . . . . . . . . . . . . . . . . . . . . . . . . .255 Glove Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . .255 Back Table Setup . . . . . . . . . . . . . . . . . . . . . . . . . . .255 Some Basic Principles of Back Table Setup . . . . . .256 The Mayo Stand . . . . . . . . . . . . . . . . . . . . . . . . . . .258 Draping the Surgical Patient . . . . . . . . . . . . . . . . . . .260 General Principles of Draping . . . . . . . . . . . . . . . .260 Intraoperative Activities of the STSR . . . . . . . . . . . . .265 Using the APOS Approach During the Intraoperative Phase . . . . . . . . . . . . . . . . . . . . .265 Case Management: Principles, Techniques, Considerations . . . . . . . . . . . . . . . . . . . . . . . . .267 Principles of Practice . . . . . . . . . . . . . . . . . . . . . . .267 Techniques of Practice: Passing Instruments . . . .268 Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Medications and Solutions in the Sterile Field . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Dressing Application . . . . . . . . . . . . . . . . . . . . . . .271 Communication . . . . . . . . . . . . . . . . . . . . . . . . . .271 Postoperative Routines . . . . . . . . . . . . . . . . . . . . . .272 SECTION 3 Surgical Procedures CHAPTER 10 Diagnostic Procedures 277 Sources of Patient Data . . . . . . . . . . . . . . . . . . . . . .278 History and Physical Examination . . . . . . . . . . . .278 Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . .278 Laboratory Reports . . . . . . . . . . . . . . . . . . . . . . . .285 Electrodiagnostic Studies . . . . . . . . . . . . . . . . . . . .288 Pulmonary Diagnosis . . . . . . . . . . . . . . . . . . . . . .289 Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 vi TABLE of CONTENTS

8. Plethysmography and Phleborheography . . . . . . .289 Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . .289 CHAPTER 11 General Surgery 291 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .292 Abdominal Cavity: General Dimensions . . . . . . . .292 Surface Features . . . . . . . . . . . . . . . . . . . . . . . . . .293 Abdominal Musculature . . . . . . . . . . . . . . . . . . . .293 Peritoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293 Retroperitoneum . . . . . . . . . . . . . . . . . . . . . . . . . .293 Alimentary Canal . . . . . . . . . . . . . . . . . . . . . . . . .293 Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293 Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .294 Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . .295 Mesentery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .296 Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .297 Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Anus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Omenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .300 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301 Biliary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301 General Surgery Instrumentation . . . . . . . . . . . . . . .303 General Surgery: Minor Set . . . . . . . . . . . . . . . . . .303 Local Excision Instruments . . . . . . . . . . . . . . . . . .303 Biliary Instruments . . . . . . . . . . . . . . . . . . . . . . . .303 Intestinal Instruments . . . . . . . . . . . . . . . . . . . . . .303 Other General Instruments . . . . . . . . . . . . . . . . . .303 Room Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307 Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307 Draping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307 Incisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307 Surgery of the Abdominal Wall: Hernias . . . . . . . . . .310 Specific Anatomic Features of the Groin Area . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . .312 Surgery of the Alimentary Canal . . . . . . . . . . . . . . . .313 Surgery of the Esophagus . . . . . . . . . . . . . . . . . . .313 Gastric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . .318 Pathological Conditions of the Stomach . . . . . . . .318 Procedures Related to Gastric Secretion, Ulcers, and Neoplasm . . . . . . . . . . . . . . . . . . . . . . . . . .320 Procedures for Morbid Obesity . . . . . . . . . . . . . . .321 Surgery of the Small Bowel . . . . . . . . . . . . . . . . . .321 Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .325 Colon Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .326 Stomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330 Anorectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . .330 Hemorrhoid Ligation and Excision . . . . . . . . . . . .333 Surgery of the Liver and Biliary Tract . . . . . . . . .333 Common Bile Duct Exploration . . . . . . . . . . . . . .342 Surgery of the Pancreas and Spleen . . . . . . . . . . . . .349 Select Pathology of the Pancreas . . . . . . . . . . . . . .349 Draining Pancreatic Cysts . . . . . . . . . . . . . . . . . .349 Whipple Pancreaticoduodenectomy . . . . . . . . . . .350 Surgery of the Spleen . . . . . . . . . . . . . . . . . . . . . . .353 Vascular and Other Procedures . . . . . . . . . . . . . . . .356 Treating Varicose Veins . . . . . . . . . . . . . . . . . . . . .356 Vascular Access Procedures . . . . . . . . . . . . . . . . .356 Muscle and Nerve Biopsies . . . . . . . . . . . . . . . . . .357 Incision and Drainage . . . . . . . . . . . . . . . . . . . . .357 Excision of Lesion . . . . . . . . . . . . . . . . . . . . . . . . .358 Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .358 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .358 Breast Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . .358 Breast and Axilla: Pathology and Diagnosis . . . .358 Breast Surgery (Noncosmetic) . . . . . . . . . . . . . . . .359 Surgery of the Thyroid and Parathyroid . . . . . . . . . .361 Anatomy of the Thyroid and Parathyroid . . . . . . .362 Pathologic Conditions of the Thyroid and Parathyroid Glands . . . . . . . . . . . . . . . . . . . . .363 Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 Tracheotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 Indications for Tracheotomy . . . . . . . . . . . . . . . . .366 Illustrative Procedure: Tracheotomy . . . . . . . . . . .367 CHAPTER 12 Obstetric and Gynecologic Surgery 375 Introduction to Obstetric and Gynecologic Surgery .376 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376 The Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376 External Genitalia . . . . . . . . . . . . . . . . . . . . . . . . .377 Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377 Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379 Fallopian Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . .380 Ovaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .380 PregnancyA Special Condition . . . . . . . . . . . . . . .381 Select Key Terms in Labor and Delivery . . . . . . . .381 Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .381 Special Instrumentation, Supplies, Drugs, and Equipment in Obstetric and Gynecologic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . .383 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .384 Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .390 Room Setup and Basic Patient Positioning and Draping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .390 Surgical Procedures: Obstetrics and Fertility Related . . . . . . . . . . . . . . . . . . . . . . . . . .391 Pathology and Surgical Conditions: Obstetrics and Fertility Related . . . . . . . . . . . . . . . . . . . . .391 Vaginal Delivery . . . . . . . . . . . . . . . . . . . . . . . . . .392 Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . .394 Sterilization Procedures . . . . . . . . . . . . . . . . . . . .399 Tuboplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .400 TABLE of CONTENTS vii

9. Laparoscopic Resection of Unruptured Tubal Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .403 Surgical Procedures: Gynecologic Procedures . . . . .406 Gynecologic Pathology . . . . . . . . . . . . . . . . . . . . .406 Surgical Intervention: Overview . . . . . . . . . . . . . . . .406 Abdominal Incisions for Gynecologic Surgery . . .406 Surgical Intervention: Laparoscopy . . . . . . . . . . . .411 Basic Colposcopy . . . . . . . . . . . . . . . . . . . . . . . . . .414 Hysteroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .416 Marsupialization of Bartholins Gland Cyst . . . . .417 Simple Vulvectomy . . . . . . . . . . . . . . . . . . . . . . . . .419 Anterior and Posterior Repair (Colporrhaphy) . . .423 Cervical Biopsy, Cryotherapy, Laser Treatment, LEEP, and Conization . . . . . . . . . . . . . . . . . . . .429 Dilation and Curettage . . . . . . . . . . . . . . . . . . . . .431 Myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434 Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy (TAH-BSO) . . . . . . . . .436 Vaginal and Laparoscopically Assisted Vaginal Hysterectomy (LAVH) . . . . . . . . . . . . . . . . . . . .441 Radical Cancer Surgery: Total Pelvic Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . .442 CHAPTER 13 Ophthalmic Surgery 447 Anatomy of the Eye . . . . . . . . . . . . . . . . . . . . . . . . .448 Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448 Extrinsic Muscles . . . . . . . . . . . . . . . . . . . . . . . . . .448 Lacrimal System . . . . . . . . . . . . . . . . . . . . . . . . . . .449 Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .449 Ophthalmic Surgical Pathology . . . . . . . . . . . . . . . .451 Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .451 Small Retinal Detachment . . . . . . . . . . . . . . . . . . .451 Large Retinal Detachment . . . . . . . . . . . . . . . . . . .452 Vitreous Hemorrhage . . . . . . . . . . . . . . . . . . . . . .452 Proliferative Vitreoretinopathy (PVR) . . . . . . . . . .452 Traction Retinal Detachment . . . . . . . . . . . . . . . .452 Epiretinal Membrane . . . . . . . . . . . . . . . . . . . . . .452 Corneal Pathology . . . . . . . . . . . . . . . . . . . . . . . . .452 Chalazion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .452 Dacryocystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . .452 Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .452 Special Considerations in Ophthalmic Surgery . . . . .453 Special Equipment . . . . . . . . . . . . . . . . . . . . . . . . .453 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .453 Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . .454 Strabismus Correction: Recession/Resection . . . . .454 Adjustable Suture Surgery . . . . . . . . . . . . . . . . . . .457 Scleral Buckle . . . . . . . . . . . . . . . . . . . . . . . . . . . .458 Enucleation and Evisceration of the Eye (Traditional Approach) . . . . . . . . . . . . . . . . . .462 Keratoplasty (Corneal Transplant) . . . . . . . . . . . .464 Cataract Extraction . . . . . . . . . . . . . . . . . . . . . . . .468 Phacoemulsification . . . . . . . . . . . . . . . . . . . . . . .470 Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .470 CHAPTER 14 Otorhinolaryngologic Surgery 475 Anatomy of the Ear . . . . . . . . . . . . . . . . . . . . . . . . .476 Outer Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .476 Middle Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .476 Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .476 Pathology of the Ear . . . . . . . . . . . . . . . . . . . . . . . .477 Pathology Affecting the Outer Ear . . . . . . . . . . . . .477 Pathology Affecting the Middle Ear . . . . . . . . . . . .478 Pathology Affecting the Inner Ear . . . . . . . . . . . . .479 Diagnostic Procedures/Tests for the Ear . . . . . . . .479 Special Preoperative Considerations . . . . . . . . . . . . .479 Special Instruments, Supplies, Drugs . . . . . . . . . . . .480 Intraoperative Preparation . . . . . . . . . . . . . . . . . . . .480 Ear Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .480 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .480 Myringoplasty/Tympanoplasty . . . . . . . . . . . . . . . .484 Mastoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .487 Stapedectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .487 Stapedotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .488 Cochlear Implants . . . . . . . . . . . . . . . . . . . . . . . . .488 Anatomy of the Nose and Sinuses . . . . . . . . . . . . . .488 External Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . .488 Internal Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . .488 Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . .489 Blood Supply to the Nose . . . . . . . . . . . . . . . . . . . .490 Olfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .490 Pathology of the Nose and Paranasal Sinuses . . . . . .490 Rhinitis/Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . .490 Nasal Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491 Hypertrophied Turbinates . . . . . . . . . . . . . . . . . . .491 Deviated Nasal Septum . . . . . . . . . . . . . . . . . . . . .491 Septal Perforation . . . . . . . . . . . . . . . . . . . . . . . . .491 Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .492 Diagnostic Procedures/Tests . . . . . . . . . . . . . . . . . .492 Direct Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . .492 Mirror Examination . . . . . . . . . . . . . . . . . . . . . . .492 Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . .492 Special Preoperative Considerations . . . . . . . . . . . . .492 Special Instruments, Supplies, and Drugs . . . . . . . . .493 Intraoperative Preparation . . . . . . . . . . . . . . . . . . . .496 Nasal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . .496 Submucous Resection (SMR) . . . . . . . . . . . . . . . . .496 Polypectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499 Intranasal Antrostomy . . . . . . . . . . . . . . . . . . . . .499 Removal of Foreign Body . . . . . . . . . . . . . . . . . . . .499 Internal Maxillary Artery Ligation . . . . . . . . . . . .500 Sinus Procedures . . . . . . . . . . . . . . . . . . . . . . . . . .500 Caldwell-Luc . . . . . . . . . . . . . . . . . . . . . . . . . . . . .500 Ethmoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .502 Sphenoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . .502 Drainage of the Frontal Sinus . . . . . . . . . . . . . . . .503 Sinus Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . .503 viii 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10. Anatomy of the Upper Aerodigestive Tract . . . . . . .505 Pharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505 Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506 Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .507 Bronchi and Lungs . . . . . . . . . . . . . . . . . . . . . . . .507 Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .507 Pathology Affecting the Upper Aerodigestive Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .508 Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .508 Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .508 Tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .508 Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .509 Laryngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .509 Polypoid Corditis or Vocal Cord Polyps . . . . . . . . .510 Vocal Cord Nodules . . . . . . . . . . . . . . . . . . . . . . . .510 Vocal Cord Granulomas . . . . . . . . . . . . . . . . . . . .510 Laryngeal Neoplasms . . . . . . . . . . . . . . . . . . . . . . .510 Tracheitis and Bronchitis . . . . . . . . . . . . . . . . . . .510 Laryngotracheobronchitis (Croup) . . . . . . . . . . . .510 Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . .511 Pathology Affecting the Esophagus . . . . . . . . . . . . .511 Esophagitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .511 Ulceration of the Esophagus . . . . . . . . . . . . . . . . .511 Neoplasms Affecting the Esophagus . . . . . . . . . . . .511 Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . .511 Zenkers Diverticulum . . . . . . . . . . . . . . . . . . . . . .511 Diagnostic Procedures/Tests . . . . . . . . . . . . . . . . . .511 Direct Visualization . . . . . . . . . . . . . . . . . . . . . . .511 Indirect Visualization . . . . . . . . . . . . . . . . . . . . . .512 Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . .512 Radiologic Examinations . . . . . . . . . . . . . . . . . . .512 Videostroboscopy . . . . . . . . . . . . . . . . . . . . . . . . . .512 Polysomnography . . . . . . . . . . . . . . . . . . . . . . . . .512 Multiple Sleep Latency Test (MSLT) . . . . . . . . . . . .512 Special Preoperative Considerations . . . . . . . . . . . . .512 Special Instruments, Supplies, Drugs . . . . . . . . . . . .513 Intraoperative Preparation . . . . . . . . . . . . . . . . . . . .514 Aerodigestive Tract Procedures . . . . . . . . . . . . . . . .514 Adenoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .514 Tonsillectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .514 Incision and Drainage of a Peritonsillar Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .517 Uvulopalatopharyngoplasty . . . . . . . . . . . . . . . . . .517 Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .519 Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .521 Esophagoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .522 Panendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .522 Radical Neck Dissection with Mandibulectomy . .522 CHAPTER 15 Oral and Maxillofacial Surgery 529 Anatomy of the Oral Cavity . . . . . . . . . . . . . . . . . . .530 Lips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530 Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530 Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530 Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530 Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .530 Anatomy of the Face and Cranium . . . . . . . . . . . . . .531 Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .532 Facial Muscles and Innervation . . . . . . . . . . . . . .532 Embryologic Development of the Face . . . . . . . . . . .533 Pathology of the Oral Cavity . . . . . . . . . . . . . . . . . .533 Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533 Jaw Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534 Mandibular Fractures . . . . . . . . . . . . . . . . . . . . . .534 Frontal Fractures . . . . . . . . . . . . . . . . . . . . . . . . .535 Orbital Fractures . . . . . . . . . . . . . . . . . . . . . . . . . .535 Zygomatic Fractures . . . . . . . . . . . . . . . . . . . . . . .535 Midfacial Fractures . . . . . . . . . . . . . . . . . . . . . . . .536 Craniofacial Deformities . . . . . . . . . . . . . . . . . . . .536 Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .536 Oral Procedures: General Considerations . . . . . . . . .537 Tooth Extraction . . . . . . . . . . . . . . . . . . . . . . . . . .538 Tooth Restoration . . . . . . . . . . . . . . . . . . . . . . . . .541 Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541 Maxillofacial Procedures: General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . .541 Graft Materials . . . . . . . . . . . . . . . . . . . . . . . . . . .542 Repair of Mandibular/Maxillary Fractures . . . . . .543 Application of Arch Bars . . . . . . . . . . . . . . . . . . .543 Wire Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . .546 Plate and Screw Fixation of Mandibular Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546 Frontal Fracture Repair . . . . . . . . . . . . . . . . . . . . .549 Orbital Floor Fracture Repair . . . . . . . . . . . . . . . .550 Reduction of Zygomatic Fractures . . . . . . . . . . . .553 Le Fort I Fracture Repair . . . . . . . . . . . . . . . . . . .554 Le Fort II and III Fracture Repair . . . . . . . . . . . . .557 Craniofacial Reconstruction . . . . . . . . . . . . . . . .557 Correction of Retrognathism or Prognathism . . . . . . . . . . . . . . . . . . . . . . . . . . .560 Temporomandibular Joint Procedures . . . . . . . . .561 CHAPTER 16 Plastic and Reconstructive Surgery 566 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .567 Skin and Underlying Structures . . . . . . . . . . . . . .567 Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .568 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .570 Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .570 Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575 Surgical Pathology . . . . . . . . . . . . . . . . . . . . . . . . . .575 Pathology Affecting the Skin . . . . . . . . . . . . . . . . .575 Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . .577 Pathology Affecting the Hand . . . . . . . . . . . . . . . .578 Pathology Affecting the Breast . . . . . . . . . . . . . . . .581 Diagnostic Procedures and Tests . . . . . . . . . . . . . . .582 TABLE of 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11. Special Instrumentation, Supplies, Drugs, and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .582 Nasal Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .582 Dermatome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .583 Mesh Graft Device . . . . . . . . . . . . . . . . . . . . . . . . .584 Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . .584 Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .584 Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .586 Suction Lipectomy . . . . . . . . . . . . . . . . . . . . . . . . .587 Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .588 Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .589 Cheiloplasty and Palatoplasty . . . . . . . . . . . . . . . .592 Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .593 Hand Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .595 Mammoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .602 CHAPTER 17 Genitourinary Surgery 610 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611 Suprarenal (Adrenal) Glands . . . . . . . . . . . . . . . .611 Kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611 Ureters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .614 Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . .614 Male Reproductive System . . . . . . . . . . . . . . . . . . .615 Pathology Affecting the Adrenal Glands . . . . . . . . . .617 Cushings Syndrome . . . . . . . . . . . . . . . . . . . . . . .617 Adrenal Insufficiency (Addisons Disease) . . . . . .617 Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . .618 Pathology Affecting the Urinary System . . . . . . . . . .618 Bladder Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . .618 Urinary Calculi . . . . . . . . . . . . . . . . . . . . . . . . . . .618 Kidney Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .619 Pathology Affecting the Male Reproductive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .621 Phimosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .621 Hypospadias/Epispadias . . . . . . . . . . . . . . . . . . . .621 Benign Prostatic Hyperplasia . . . . . . . . . . . . . . . .622 Cancer of the Prostate . . . . . . . . . . . . . . . . . . . . . .622 Cryptorchidism . . . . . . . . . . . . . . . . . . . . . . . . . . .622 Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . .622 Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . .622 Trauma to the Genitourinary System . . . . . . . . . .623 Diagnostic Procedures/Tests . . . . . . . . . . . . . . . . . .623 History and Physical . . . . . . . . . . . . . . . . . . . . . . .623 Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . .623 Radiologic Findings . . . . . . . . . . . . . . . . . . . . . . . .629 Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630 Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630 Special Equipment, Instruments, Supplies, Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630 Preoperative and Intraoperative Preparation . . . . . . .632 Incisional Options . . . . . . . . . . . . . . . . . . . . . . . . .633 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . .635 Adrenalectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .636 Nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .637 Renal Transplant . . . . . . . . . . . . . . . . . . . . . . . . . .641 Stone Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . .642 Cystostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .643 Cystectomy/Ileal Conduit . . . . . . . . . . . . . . . . . . . .645 Procedures for Stress Incontinence Affecting Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .650 Transurethral Endoscopy of the Genitourinary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .653 Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . .655 Orchiectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .657 Orchiopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .657 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .660 Vasovasostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .660 Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .660 CHAPTER 18 Orthopedic Surgery 668 Bone and Bone Tissue . . . . . . . . . . . . . . . . . . . . . . .669 Bone Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .670 Types of Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . .671 Types of Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . .672 Bone Growth and Bone Cells . . . . . . . . . . . . . . . .673 Intramembranous Bones . . . . . . . . . . . . . . . . . . .674 Endochondral Bone . . . . . . . . . . . . . . . . . . . . . . .674 Mineral Storage . . . . . . . . . . . . . . . . . . . . . . . . . .674 Factors That Affect Bone Growth . . . . . . . . . . . . .675 Clinical and Bone Landmark Terms . . . . . . . . . . .675 Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .676 Types of Fractures . . . . . . . . . . . . . . . . . . . . . . . . .676 Normal Bone Healing . . . . . . . . . . . . . . . . . . . . . .676 Pathologic Bone Healing . . . . . . . . . . . . . . . . . . . .682 Diagnostic Terms and Procedures . . . . . . . . . . . .684 The Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . .685 The Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .685 Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . .688 Bones of the Thoracic Region . . . . . . . . . . . . . . . .689 Clavicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .689 Scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .689 Pectoral Girdle . . . . . . . . . . . . . . . . . . . . . . . . . . .689 Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690 Radius and Ulna . . . . . . . . . . . . . . . . . . . . . . . . . .690 Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . .690 Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .691 Hip and Femur . . . . . . . . . . . . . . . . . . . . . . . . . . .692 Tibia and Fibula . . . . . . . . . . . . . . . . . . . . . . . . . .692 Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . .694 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .695 Positioning Devices . . . . . . . . . . . . . . . . . . . . . . . .695 Pneumatic Tourniquets . . . . . . . . . . . . . . . . . . . . .696 Traction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Air Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Continuous Passive RangeofMotion Machines (CPM) . . . . . . . . . . . . . . . . . . . . . . . .696 x TABLE of CONTENTS

12. Transcutaneous Electric Nerve Stimulation (TENS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Electrical Stimulation of Bone . . . . . . . . . . . . . . . .697 Saws, Drills, and Reamers . . . . . . . . . . . . . . . . . . .697 Arthroscopic Equipment . . . . . . . . . . . . . . . . . . . .697 Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .697 Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .697 Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .698 Polymethyl Methacrylate (PMMA) . . . . . . . . . . . . .698 Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . .698 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .699 Bone Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . .699 Knee Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . .700 Arthroscopic Repair of Meniscal Tear . . . . . . . . . .703 Endoscopic Carpal Tunnel Release . . . . . . . . . . . .706 Colles Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . .709 Open ReductionInternal Fixation (ORIF) of the Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . .713 Repair of Rotator Cuff . . . . . . . . . . . . . . . . . . . . . .716 Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . .720 CHAPTER 19 Cardiothoracic Surgery 728 Anatomy of the Chest . . . . . . . . . . . . . . . . . . . . . . .729 The Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .729 The Trachea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .730 The Bronchial Tree . . . . . . . . . . . . . . . . . . . . . . . .730 The Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .731 Anatomy and Physiology of the Heart . . . . . . . . . . .732 Location of the Heart . . . . . . . . . . . . . . . . . . . . . . .733 Coverings of the Heart . . . . . . . . . . . . . . . . . . . . . .733 The Heart Wall . . . . . . . . . . . . . . . . . . . . . . . . . . .733 The Heart Chambers . . . . . . . . . . . . . . . . . . . . . .733 The Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . .733 Blood Flow Through the Heart . . . . . . . . . . . . . . .735 Blood Supply for the Heart . . . . . . . . . . . . . . . . . .735 The Cardiac Cycle . . . . . . . . . . . . . . . . . . . . . . . .735 Cardiac Output . . . . . . . . . . . . . . . . . . . . . . . . . . .736 Cardiac Conduction . . . . . . . . . . . . . . . . . . . . . . .736 Anatomical Development of the Heart . . . . . . . . .736 Operative Pathology . . . . . . . . . . . . . . . . . . . . . . . .738 The Chest Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . .738 The Mediastinum . . . . . . . . . . . . . . . . . . . . . . . . . .739 The Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .739 Thoracic Trauma . . . . . . . . . . . . . . . . . . . . . . . . .739 Thoracic Outlet Syndrome . . . . . . . . . . . . . . . . . . .741 Thoracic Aortic Aneurysm . . . . . . . . . . . . . . . . . .741 Coronary Artery Disease . . . . . . . . . . . . . . . . . . . .742 Valvular Disease . . . . . . . . . . . . . . . . . . . . . . . . . .745 Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . .746 Cardiac Dysrhythmias . . . . . . . . . . . . . . . . . . . . .746 Congenital Heart Defects . . . . . . . . . . . . . . . . . . . .748 Diagnostic Procedures: Thorax . . . . . . . . . . . . . . . . .750 Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .750 Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . .751 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .751 Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .751 Diagnostic Procedures: Cardiac . . . . . . . . . . . . . . . .751 Radiologic Studies . . . . . . . . . . . . . . . . . . . . . . . . .753 Surgical Intervention: Thoracic . . . . . . . . . . . . . . . . .753 Special Preoperative Considerations . . . . . . . . . . .753 Special Instrumentation, Supplies, Drugs, and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .753 Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . .754 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .755 Scalene/Supraclavicular Node Biopsy . . . . . . . . . .758 Thoracotomy for Upper Lobectomy . . . . . . . . . . . .758 Thoracotomy for Right Pneumonectomy . . . . . . . .762 Thoracotomy for Wedge Resection or Segmentectomy . . . . . . . . . . . . . . . . . . . . . . . . .762 Decortication of Lung . . . . . . . . . . . . . . . . . . . . . .762 Surgical Intervention: Cardiac (Adult) . . . . . . . . . . . .763 Preoperative Considerations . . . . . . . . . . . . . . . . .763 Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . .764 Techniques of Cardiopulmonary Bypass (CPB) . .765 Mechanical Circulatory Assistance . . . . . . . . . . . .767 Coronary Artery Bypass Grafting (CABG) . . . . . . .769 Aortic Valve Replacement . . . . . . . . . . . . . . . . . . .774 Mitral Valve Replacement . . . . . . . . . . . . . . . . . . .778 Thoracic Aortic Aneurysmectomy (TAA) . . . . . . . .779 Pericardictomy/Pericardial Window . . . . . . . . . .781 Heart Transplantation . . . . . . . . . . . . . . . . . . . . .781 Permanent Pacemaker Insertion . . . . . . . . . . . . . .782 Percutaneous Transluminal Coronary Angioplasty (PTCA) . . . . . . . . . . . . . . . . . . . . . .783 Surgical Intervention: Cardiac (Pediatric) . . . . . . . . .784 Special Preoperative Preparation . . . . . . . . . . . . .784 Atrial Septal Defect . . . . . . . . . . . . . . . . . . . . . . . .784 Ventricular Septal Defect . . . . . . . . . . . . . . . . . . .785 Patent Ductus Arteriosus . . . . . . . . . . . . . . . . . . . .785 Correction of Aortic Coarctation . . . . . . . . . . . . . .785 Procedure for Correction of Tetralogy of Fallot . . .787 Procedure for Correction of Transposition of the Great Arteries . . . . . . . . . . . . . . . . . . . . . .787 CHAPTER 20 Peripheral Vascular Surgery 789 Peripheral Vascular Surgery . . . . . . . . . . . . . . . . . . .790 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . .790 Blood Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . .790 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . .791 The Arterial System . . . . . . . . . . . . . . . . . . . . . . . .793 The Venous System . . . . . . . . . . . . . . . . . . . . . . . .795 Operative Pathology and Diagnosis . . . . . . . . . . . . .796 Arterial Embolism . . . . . . . . . . . . . . . . . . . . . . . . .796 Arteriosclerosis Obliterans . . . . . . . . . . . . . . . . . . .797 Aneurysms of the Abdominal Aorta . . . . . . . . . . .797 Surgical Interventions . . . . . . . . . . . . . . . . . . . . . . .799 Peripheral Vessel Angioplasty . . . . . . . . . . . . . . . .799 Bypass Grafting and Endarterectomy . . . . . . . . . .800 TABLE of CONTENTS xi

13. Features of Peripheral Vascular Procedures . . . . .802 Aortofemoral Bypass . . . . . . . . . . . . . . . . . . . . . . .803 Abdominal Aortic Aneurysmectomy . . . . . . . . . . .806 Femoropopliteal Bypass . . . . . . . . . . . . . . . . . . . . .810 Femorofemoral Bypass . . . . . . . . . . . . . . . . . . . . .813 Axillofemoral Bypass . . . . . . . . . . . . . . . . . . . . . . .815 Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . .818 CHAPTER 21 Neurosurgery 824 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . .825 Divisions of the Nervous System . . . . . . . . . . . . . . .825 Cranium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .825 Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . .831 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . .833 Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . .833 Spinal Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . .833 Neurosurgical Pathology . . . . . . . . . . . . . . . . . . . . .834 Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . .835 Thoracic Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . .836 Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . .836 Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .837 Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .838 Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . .840 Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . .840 Congenital Abnormalities . . . . . . . . . . . . . . . . . . .841 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .842 Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .842 Spinal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . .843 Peripheral Nerve Disorders . . . . . . . . . . . . . . . . . .843 Neurosurgical Procedures . . . . . . . . . . . . . . . . . . . .844 Special Instrumentation, Supplies, Drugs, and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . .844 Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . .848 Craniotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .849 Craniectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .858 Ventriculoperitoneal and Ventriculoatrial Shunt .862 Transphenoidal Hypophysectomy . . . . . . . . . . . . .865 Stereotactic Procedures . . . . . . . . . . . . . . . . . . . . .868 Cranioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . .869 Spinal Procedures . . . . . . . . . . . . . . . . . . . . . . . . .869 Peripheral Nerve Procedures . . . . . . . . . . . . . . . . .876 Appendix A Common Prefixes and Suffixes . . . . . . .881 Appendix B Measurements . . . . . . . . . . . . . . . . . . .884 xii TABLE of CONTENTS

14. Bob L. Caruthers, CST, PhD Association of Surgical Technologists Englewood, CO Chapter 1: Orientation to Surgical Technology Chapter 2: The Surgical Patient Chapter 9: The Surgical Technologist in the Scrub Role (Case Management) Chapter 11: General Surgery Chapter 12: Obstetric and Gynecologic Surgery Paul Price, CST/CFA, MBA Association of Surgical Technologists Englewood, CO Chapter 7: Instrumentation, Equipment, and Supplies Chapter 8: Wound Healing, Sutures, Needles, and Stapling Devices Chapter 10: Diagnostic Procedures Chapter 19: Cardiothoracic Surgery Chapter 20: Peripheral Vascular Surgery Chapter 21: Neurosurgery Ben D. Price, CST Association of Surgical Technologists Englewood, CO Chapter 3: Physical Environment and Safety Standards Chapter 4: Asepsis Chapter 5: General Patient Care and Safety Chapter 9: The Surgical Technologist in the Scrub Role (Case Management) Chapter 13: Ophthalmic Surgery Chapter 21: Neurosurgery Teri Junge CST/CFA Association of Surgical Technologists Englewood, CO Chapter 6: Surgical Pharmacology and Anesthesia Chapter 14: Otorhinolaryngologic Surgery Chapter 16: Plastic and Reconstructive Surgery Chapter 17: Genitourinary Surgery Kevin Frey, CST, MA Pueblo Community College Pueblo, CO Chapter 3: Physical Environment and Safety Standards Chapter 4: Asepsis Chapter 18: Orthopedic Surgery Gary Allen, CST Ludlow, MA Chapter 11: General Surgery Chapter 12: Obstetric and Gynecologic Surgery Amy Croft, CST, BS South Plains Community College Lubbock, TX Chapter 15: Oral and Maxillofacial Surgery Ann Marie McGuiness, CST, RN, CNOR Charles H. McCann Technical School Adams, MA Chapter 6: Surgical Pharmacology and Anesthesia Jim Swalley, CST Redmond, WA Chapter 13: Ophthalmic Surgery xiii CONTRIBUTORS

15. Betty F. Arnett, RMA, CST Director/Instructor, Surgical Technology Program Orlando Technical Educational Centers Orlando, Florida Dorothy Donesky, RN, MPH, CNOR Assistant Professor of Surgical Technology Program Coordinator and Clinical Director Cardiopulmonary Sciences Loma Linda University Loma Linda, California Shelly Hayden, CST, CFA Surgical Technology Instructor Northwest Technical Institute Springdale, Arkansas Linda W. Higgins, RN, BSN, MPA, CNOR Commander (Ret.), U.S. Navy Nurse Corps Adjunct Faculty Instructor Coastal Carolina Community College Jacksonville, North Carolina Jeannie Hurd, RN, BS, CNOR Program Director, Surgical Technology Spokane Community College Spokane, Washington Marie Jacobs, CST Program Head, Surgical Technology Larry G. Selland College of Applied Technology Boise State University Boise, Idaho Ruth Jones, RN, BSN, MSC Divisional Chair, Surgical Technology Northwest Technical Institute Springdale, Arkansas Dean A. Kendall, CST Lander Valley Medical Center Surgical Technology Instructor Central Wyoming College Lander, Wyoming Arthur A. Makin, CST, BS Instructor, Surgical Technology Guilford Technical Community College Jamestown, North Carolina Vicky D. Tesar, CST Surgical Technology Instructor Northwest Technical Institute Springdale, Arkansas Kimberly A. Whitson, RN Surgical Technology Instructor Moore Norman Technology Center Norman, Oklahoma Katherine J. Wolfer, RN, BSN, CNOR Instructor, Surgical Technology Cincinnati State Technical and Community College Cincinnati, Ohio xiv REVIEWERS

16. Surgical Technology for the Surgical Technologist: A Positive Care Approach represents a significant change in the field of surgical technology. Surgical technology faculty and students have long de- pended upon textbooks prepared by and for the nursing student or nursing graduate to serve as the foundation text for surgical technology education. These textbooks, while excellent for their primary audience, contained a significant amount of information not related to the role of the surgical technologist. More significantly, these texts lacked the subtle observations and nuances that come from years of experience in the role of surgical technologist. This book approaches the surgical technology student and instructor in a fresh and innovative manner. Primarily, this textbook is focused on the knowledge and cognitive skills required of the surgical technologist. Many specific practices and techniques are described, but all are placed in the context of the A Positive Care Approach. It is a systematic approach to surgical problem solving focused on the ability of the surgical technologist to predict the patients and surgeons needs. Preface xv

17. The A Positive Care Approach focuses on the cognitive process used by the surgical technologist who is serving in the traditional role called first scrub. The A Positive Care Approach for the surgical technologist finds its foundations in the following assumptions: The surgical technologist serves the patients interest primarily by providing assistance to the surgeon. The surgical technologists primary task during an operative procedure is to predict the intraoperative needs of the surgeon and surgical patient. In order to accomplish the primary task efficiently and effectively, the surgical technologist must learn to think like the surgeon intraoperatively. The surgical technologist must be well grounded in the basic sciences, especially anatomy, microbiology, and pathophysiology. The surgical technologist contributes to global patient care by serving as one of several team members who monitors the surgical environment. The intraoperative team commonly makes these same assumptions and uses them to judge the competency of the surgical technologist. Educators struggle to get students to predict the surgeons next move or the effects of a given surgical action. Surgical technology graduates suddenly feel at home in the operating room when they begin to plan many steps ahead during an operative procedure. More importantly, the surgical technologist can be observed repeatedly following a specific sequence of cognitive steps. The cognitive steps require an adequate preparatory education. The surgical technologist must be well grounded in anatomy and microbiology, as these studies are the foundation of all practices in the OR. Normal physiology and a basic understanding of pathology come next. All of this information is the springboard to the cognitive activity of the surgical technologist. The basic steps of the cognitive process are easy to define. The surgical technologist: has a mental image of normal anatomy. makes a mental comparison between the idealized anatomy and the actual anatomy of a specific patient. knows an idealized operative procedure used to cor- rect the pathological condition. makes a mental comparison between the idealized procedure with the actual procedure being performed. allows for a particular surgeons variations to the idealized procedure. allows for variances in anatomy, pathology, and surgeons responses to the variances. predicts and prepares to meet the needs of the surgical patient and the surgeon prior to the need being verbalized. The cognitive sequence described is a predictive model. Its basis is the scientific method, and it differs only in type and depth of information from other predictive models. The more information surgical technologists have, the better they will be able to predict needs in the surgical setting, and contribute to better patient care. Several presumptions were made in the writing of this book: Students will have had at least one basic anatomy and physiology course that focused on systemic anatomy. Surgical anatomy must be taught within the context of surgical procedures without regard to the number of systemic anatomy courses that have been taken. Due to the variance in surgical technology programs, some basic microbiology is included in the chapter on asepsis (the authors do not suggest that it is inclusive). Due to the variance in surgical technology programs, some basic pharmacology is included in the chapter on anesthesia and pharmacology (the authors do not suggest that it is inclusive). ORGANIZATION OF THE TEXT Surgical Technology for the Surgical Technologist: A Pos- itive Care Approach is divided into two major divisions. These divisions correspond to the A POSitive CARE Ap- proach. The first nine chapters are related to the CARE acronym. The CARE division itself is divided into two sections: Introduction to Surgical Technology, and Prin- ciples and Practice of Surgical Technology. The last twelve chapters relate to the A POSitive acronym. These chapters focus on operative procedures by surgical specialty. A brief introduction to diagnostics precedes the specialty sections. This is intended to provide a standard background for all specialties. The CARE division will establish a broad context in which the instructor will help the student place the more specific technical information that dominates surgical technology. Introductory and foundational information is taught using the CARE approach which is intended to serve as a reminder to the surgical technologist that all activities affect the care given to the patient. The reader should be aware that the highly variable topics of the first nine chapters do not allow for a simple one-to-one correlation of the CARE memory tool, but that it is a con- ceptual tool intended to help organize the information: Care (directed toward the patient and/or surgical team) Aseptic principles (and practice of sterile technique) Role of the surgical technologist Environmental Awareness (and concern) The A POSitive division relates directly to the final twelve chapters with the desire to CARE as the underly- xvi PREFACE C A R E

18. ing theme. The surgical procedures are presented by surgical specialty using the illustrative procedure format. The A POSitive approach does allow for the one-to-one correlation of the procedural chapter objectives, and should be used to reinforce every surgical procedure presented to the student: Anatomy Pathology Operative Procedure Specific Variations SPECIAL FEATURES OF THE TEXT Several features are incorporated into each chapter to help you master the content. Review the How to Use This Book section for a detailed description and benefit of each feature. Illustrative Procedures The illustrative procedure format is based on the con- cept that allows one procedure to highlight several important steps that are repeated in related procedures. Rather than presenting many procedures with brief out- lines of the steps, fewer procedures are presented in detail allowing the surgical technologist to predict the necessary preparation and action to be taken. Space constraints dictate certain questions, one being, how does one best present procedures to an entry-level student? Upon review of current textbooks and discus- sion with educators, two ideas seemed especially important: Current books did not provide adequate insight into the intraoperative thinking or tasks of the surgical technologist in the scrub role. Some procedures have more instructive value than others. In the first instance, listing procedural steps focuses on the tasks of the surgeon only. These are important to know, but the surgical technology student should be directed to a line of thinking and sequence of tasks that are related to each step of the procedure. In the second instance, a procedure such as a total abdominal hysterectomy with bilateral salpingo-oophorectomy requires the knowledge of skills used in many gynecologic procedures. A procedure such as a tubal ligation, on the other hand, may not require the same expanse of knowledge and skills. This book uses the illustrative procedure format. In each specialty section, a select number of procedures will be presented in detail in a specified format. This format will be used repeatedly to help the student habitu- ate a pattern for learning procedures. Illustrations Color inserts provide a general overview of select anatomic systems, and photographs are included to depict practical aspects of surgical technology. The students will most likely refer to each color insert several times throughout their educational experience and their career as a surgical technologist. Illustrations in the chapters related to CARE have been selected to help the student identify general equipment and supplies or demonstrate the steps necessary to perform a specific skill. Illustrations in each of the procedural chapters are designed to demonstrate instruments and supplies specific to the surgical specialty, and regional anatomy in context for the illustrative surgical procedure. These illustrations should help the student learn to predict the intraoperative needs of the patient and the surgeon. Pearl of Wisdom These tips, based on years of the authors experience, are intended to help the student keep a practical focus on the procedure. Case Studies The case studies are intended to stimulate critical thinking through application of the information presented in each chapter to a specific situation or patient variation presented in the case. Questions for Further Study These questions stimulate the student to seek and apply additional related information. PREFACE xvii A P O S

19. LEARNING SUPPLEMENT Study Guide The study guide is designed to enhance the material in the text. It includes various critical thinking exercises and case studies that correspond to each chapter in the text, as well as skill assessments and anatomical labeling exercises. ISBN 0-7668-0664-2 Text and Study Guide Value Package The study guide enhances material in the text through various critical thinking exercises, case studies, skill assessments, and art labeling exercises. ISBN 0-7668-7929-1 GUIDELINES FOR THE STUDENT: LEARNING SURGICAL PROCEDURES Surgical procedures are important to the surgical technologist for several reasons: Surgical procedures are the medical intervention taken to restore health to the surgical patient. Surgical procedures are the event around which most of the knowledge and skills of a surgical technologist are focused. Surgical procedures provide the best educational experience for learning to think like the surgeon. Learning to think like a surgeon is the best way to organize the knowledge and skills required. So how does one learn to think like the surgeon? The pattern of presentation is one that encapsulates a mind- set. The information included follows a rather pre- dictable pattern: Patient identification Preoperative diagnosis Surgical procedure performed Postoperative diagnosis Report of surgical procedure (step-by-step, including notations of anatomical conditions or variances) Report concerning drains, dressings, or other relevant information Initial status of patient following completion of the surgical procedure Surgical technologists should organize their mental approach following this pattern with variations that re- flect the needs of the first scrub role. The student in particular, should mimic this organizational style until it be- comes habitual. Keeping these basic assumptions and guidelines in mind, the surgical technology student should find this text easy to use. TO THE INSTRUCTOR Teaching Support Materials Resource materials are available to accompany this text. Instructors Manual The text was written to support the Core Curriculum for Surgical Technology as set forth in the Standards and Guidelines of the ARC-ST. A correlation chart is included in the Instructors Man- ual to indicate the location of the core components in the text. The manual is designed to enhance the instructors own teaching style by providing suggestions for exercises and activities beyond those offered in the study guide. Answers to text questions, study guide exercises, and competencies for all skill assessments found in the study guide are also included. ISBN 0-7668-0663-4 Electronic Testbank By offering 1,000 multiple choice questions organized by chapter, this CD-ROM testbank assists you in creating chapter, midterm, and final examinations. An interview mode or wizard guides you through the steps to create a test in less than five minutes. You also have the capability to edit questions or to add an unlim- ited number of your own questions. xviii PREFACE

20. The Association of Surgical Technologists would like to thank the staff at Evans U.S. Army Hospital, Fort Carson, Colorado for making their facility and personnel available for the photographs included in this text. The Association of Surgical Technologists would like to thank Joshua G. Weitzman-Merritt, LPN/BSW, for his contribution to Chapter 16Plastic and Reconstructive Surgery. Access was granted to the following historical doc- uments of the Association of Surgical Technologists, Englewood, CO: Minutes of the Board of Directors Minutes of the House of Delegates Policy and Procedures Manual The Surgical Technologist (every edition) AORT Newsletter (select editions) Recommended Standards of Practice Code of Ethics Surgical Technologist Performance Appraisal Pamphlets xix ACKNOWLEDGMENTS

21. The case studies are intended to stimulate critical thinking through application of the information presented in each chapter to a specific situation or patient variation presented in the case. The textbook employs a systematic approach to problem- solving using the CARE and A POSitive acronyms. The CARE division of the textbook deals with an introduction of surgical technology and its principles and practices. It is designed to remind you that the care of the patient in the operating room is the surgical technologists highest priority, and to establish a broad context for the place- ment of the specific technical information that dominates this field. CARE represents: Care (directed toward the patient and/or surgical team) Aseptic Principles (and practice of sterile technique) Role (of the surgical technologist) Environmental Awareness (and concern) A POSitive, which relates to the textbooks section on operative procedures by surgical specialty, represents: Anatomy Pathology Operative Procedure Specific Variations xx How to Use This Book 1 Case Study 2 Objectives 1111 CHAPTER O B J E C T I V E S Af

surgical technology for the surgical technologist

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