One of the roles of the personnel working in a clinic or hospital that frequently goes unsupported by veterinary technicians is in the surgical suite – not an anesthetist or a circulating nurse, but rather a surgical assistant for the surgeon. Surgeons working without a surgical assistant are at the mercy of fate when it comes to speed and timely completion. Surgeons who work with a qualified and efficient assistant can attest to the benefit of the extra knowledgeable body. Working as a team, with the patient’s best possible outcome as their goal, the surgeon and the assistant will set the tone and pace for the procedure. A surgeon with a well-qualified proficient assistant can reduce the surgical procedure time significantly. Technicians that perform as assistants must be familiar with all instrumentation to be used and the process with which the surgeon will advance through the procedure. Assistants must master the skill of anticipation and ensure that the instrument/equipment is in the hand of the surgeon even before he/she even knows it is needed. Sometimes the surgeons’ needs are made known nicely… and other times, not so nicely (Beale, B.S. 2010). Regardless of how the need is made known, it is the technician’s job to make available at the right time what the surgeon is requesting. Even before the patient is anesthetized, the surgical assistant is involved with the case. Making sure that the appropriate equipment and instrumentation is available is the most critical factor. Nothing can impede the progress of a surgery more than having to wait for equipment or instruments to be sterilized, or worse yet, not having the necessary item available at all. The assistant needs to be sure that the required instrument is functioning and ready for use. In addition to the assistant, the circulating technician in the operation room can greatly influence the flow of the case. A circulating technician who knows what the surgeon needs, can find and open the item quickly and correctly, is a wonderful resource to have. Circulating technicians also grow to the point of being able to offer suggestions to the surgeon about equipment that may be useful to them. Sometimes when procedures do not go as planned, someone outside of the sterile field will have a different perspective of the situation, which allows them the ability to offer a suggestion that may not have otherwise been thought of. Once the patient is moved into the operating room, it is the responsibility of the surgical assistant to appropriately position the patient for the procedure to be done. Proper positioning of the patient is a critical step in the patient preparation process. Surgeons require the patient be positioned in a straight and anatomically correct fashion (Figure 4.1). One must consider first of all, the procedure being performed and the surgeons positioning preference. For example, for stifle surgery, sometimes the patient is positioned in dorsal recumbency with the instrument table over the chest of the patient (Figure 4.2). This positioning of the instrument table allows the surgeon to stand at the end of the surgery table and not have a non-sterile back of a gown facing the sterile instrument table. Although controversial in its safety, the author suggests that placement of the table be done judiciously. Other procedures where the patient is in dorsal recumbency, the instrument table will be placed behind the surgeon, exposing the instruments to the non-sterile back of the gown. Conversely, for forelimb surgery and most thoracic or abdominal procedures, the instrument table is placed over the caudal end of the patient. If it is a procedure to remove a mass from an unusual location, the technician must be certain that the positioning of the patient does not impede the surgeon’s ability to perform the procedure. It is advised to have the surgeon verify the positioning of the patient on the surgery table before they scrub and before the final patient prep is performed. Patients in dorsal recumbency that are leaning to one side or another risk receiving an incision through the muscle layers of the abdominal wall instead of through the linea alba. Once a patient has been positioned to the surgeon’s liking, the patient must not shift or move from that position until the end of the case. Figure 4.1 Positioning the patient on the surgery table. Figure 4.2 The instrument table over the chest of a patient having stifle surgery. The use of positioning aids will greatly assist in maintaining the animal in the desired position. Some surgery tables have a split top that allows either one or both sides of the table top to be adjusted (Figure 4.3). With this type of table, patients can be positioned in any manner from flat on the table to any degree of “V”. For patients that need to be in dorsal recumbency, the use of the surgery table “V” may be all that is needed. For deep-chested dogs, long sandbags, as opposed to square sandbags, will be an effective method for supplementing the table top to maintain the patient in the proper position. Foam wedges may also be used but may slip and if contaminated by blood or other fluids, may be difficult to clean and disinfect. Additional positioning aids include Plexiglass/plastic positioners, vacuum bean bags, or similar devices and leg ties. All can be easily disinfected between patients by laundering or wiping down with a disinfecting solution. Vacuum positioning aids are extremely helpful in maintaining patients in unusual positions. These devices are especially helpful for ophthalmic procedures or thoracic cases that necessitate the patient be positioned in an oblique state, rather than a level lateral position. Because they can be conformed around the patient in any fashion, and then have the air vacuumed out to maintain the position, these devices are very unique. Leg ties are extremely common and in most cases, are the only positioning assistance that is needed. Soft ropes or commercially available leg ties are recommended. Roll gauze, IV tubing, or elastic bands are not recommended as they may apply too much pressure to the soft tissue and impede distal limb circulation. An adjustable loop on the leg tie should be placed just proximal to the carpus/tarsus; then a half hitch is placed just distal to those joints (Figure 4.4). Double placement, as described, aids in the better distribution of pressure to reduce circulation issues. Most surgery tables have either brackets or side bar rollers on the side table rails, which are used to secure the leg ties. Brackets require a figure 4.8 method of securing the leg tie with a half hitch on the last loop to secure placement (Figure 4.5). Rollers are easier to use and simply require the leg tie be passed between the two rubber rollers to securely hold the rope Figure 4.3 A surgery table with the split top in a “V”. Figure 4.4 Leg with a half hitch. Figure 4.5 Leg tie in a figure 4.8 on a surgery table bracket. (Figure 4.6). Care should be taken to avoid excessively extending the limbs to prevent unnecessary strain on joints or muscles. Limbs should be maintained in as normal a position as possible, depending on the position the patient is in. Some surgery-specific positioning aids are available such as an arthroscopy brace. It is used to position the limb of dogs having a stifle arthroscopy performed. The brace holds the limb in a flexed position to assist the surgeon. The brace must be covered by a sterile drape before the limb can be placed on it. Figure 4.6 Leg tie through a roller style bracket on a surgery table. The use of sand bags and/or vacuum aids is required in order to achieve and maintain proper positioning of the patient when a dorsal or ventral approach for a spinal surgery is indicated. Patients in this position must be monitored for adequate respiratory capability due to the potential respiratory complications from the compression on the chest wall required to keep the spine straight. The vacuum-positioning aids are quite stiff and hard following the evacuation of the air and are therefore not very forgiving at allowing the expansion of the chest wall if conformed too tightly to the patient. It is important to remember that whichever positioning aid is employed, it should not be wrapped around or laid over the chest of the patient, but rather gathered or formed along the sides of the chest. It is impossible to describe all the potential positions for surgical patients as it is dependent on the surgeon’s preference. It is even difficult to make the statement that all patients for a certain procedure (i.e., stifle surgery) are always placed in the same position (i.e., dorsal recumbency). Factors such as procedure being done, size of the patient, and surgeon’s familiarity all determine the positioning of the patient on a case–by-case basis. The most important thing to remember is that excellent communication must exist between the technician doing the positioning and the surgeon performing the procedure in order to avoid unnecessary delays. Following positioning of the patient, the sterile prep may begin. It is highly recommended that the patient has the clipping and initial skin prep (scrub) performed in an area outside of the surgery room. Once completed, the patient is moved to the surgical suite, positioned and a final sterile prep is done. A sterile surgical patient prep is done in a very similar fashion as the initial prep with the major difference being the use of sterile products. Prep sets can be made a couple of ways, depending on clinic choice. A small instrument pan (3″ × 8″) or a kidney (emesis) basin can be used as the pan. Two stacks of 10 4 × 4 gauze sponges are placed in the pan. An indicator strip should be placed in the middle of the sponges. A right hand glove (usually size 7 or 7 ½) can then be laid on top of the sponges (Figure 4.7). Some clinics prefer not to include the glove, which is an acceptable modification because it permits the flexibility of allowing any qualified person to perform the sterile prep, regardless of their glove size. The pan is double wrapped using the envelope style of wrapping and is sterilized in the autoclave. Figure 4.7 Sterile prep set with squeeze bottles of solutions. In addition to the sterile prep set, squeeze bottles of the prep solutions also need to be available. The solutions and prep set should be set up in the surgery room when the rest of the packs and equipment are placed in the room. Once the patient is positioned, the prep set can be opened. Both wraps are aseptically opened to reveal the sterile contents. Before proceeding, the caps of the solution bottles should be opened. If a glove was not included in the sterile prep set, a pack of appropriate-sized gloves should now be aseptically opened and using the open gloving technique, a sterile glove is placed on the dominant hand. If a glove was included, it is now aseptically put on the dominant hand. Having one sterile hand and one non-sterile hand allows the technician the independence to perform the sterile prep without assistance. The non-sterile hand is also available to stabilize the suspended limb during the prep for orthopedic cases. With the sterile, gloved hand, 1–2 sponges are picked up. The non-sterile hand picks up the surgical scrub bottle and aseptically applies some scrub solution to the sterile sponges. Care must be taken to ensure that the cap of the bottle does not touch the sponges. The prep now continues using the same pattern that the initial scrub used (Figure 4.8). New prep sponges should be retrieved as needed. The rinsing agent is aseptically applied to the sponges in the same manner as the scrub product. Be sure to save a few dry sponges to be used for the application of the final paint solution. Figure 4.8 Sterile prep being performed. Once the final paint is applied, the draping may begin. Every effort should be made to allow the final solution to dry prior to draping the patient to encourage optimal efficacy of the product. Once the patient has received the second, “sterile” prep, draping can begin. Assistants must be thoroughly knowledgeable about the procedure and the approach the surgeon will use in order to effectively drape the patient. Depending on the procedure to be done, draping may need to include extra wide margins away from the incision. For example, draping to allow access to the exit of a chest tube for a thoracic procedure or allowing access to a bone graft site for harvesting a graft for a fracture repair. Especially during the draping sequence, but throughout the entire procedure, both the surgical assistant and the circulating technician must be acutely aware of strict asepsis in the surgical suite and sterile field. According to Dr. Brian Beale, “the surgical assistant should be cognizant of the need for strict asepsis and act as the asepsis police in the operating room” (Beale, B.S., 2010). Any question as to a break in aseptic technique must be treated as a valid break and corrective measures must be taken. Whether that means changing a pair of gloves, a gown, or an entire pack of instruments, it must be done. Although often times not very well liked by all members of the surgical team, the veterinary technician is acting as the patient’s advocate and looking out for their well being. Breaks in asepsis are not to be argued or debated, but accepted and corrected. Draping for non-orthopedic procedures is a fairly simple process. After the sterile drape pack has been opened aseptically by the circulating technician, and is available to the sterile team members, draping may begin using the four corner draping method. Usually ground/field drapes (also known as quarter drapes or huck towels) are placed first. It is important that before draping, all skin prep solutions (alcohol, paint solutions) have adequate time to dry/evaporate. Not only is this important for optimal efficacy of the prep products, it also decreases the complications from the use of electrocautery and/or lasers. Presuming the ground drapes are folded as described earlier, find the short side of the drape that has the open folds (Figure 4.9). Place the index finger of each hand in the outermost opening and the thumb in the innermost opening (Figure 4.10). Using the thumb and middle finger of each hand, hold the drape and lift it up (Figure 4.11). Figure 4.9 Short side, open folds of ground drape towels. Figure 4.10 Fingers in the appropriate folds of the towel. Figure 4.11 Picking up the towel. The long side of the drape with the folds should be facing the ceiling. Holding the drape in front, move the hands away from each other to open the drape (Figure 4.12). Lift the thumb of each hand to allow the drape to unfold (Figure 4.13). Drapes should never be flipped, shaken, or fanned as that action may release dust and/or lint into the air and potentially onto the sterile field. Holding the towel with the index finger and the thumb of each hand, rotate the hands so all the fingers and palms are facing the operator (Figure 4.14). Rotate the hands again so the palms are down and the edges of the drape cover the gloved hands (Figure 4.15). This action protects the sterile hands from becoming contaminated as the drape is laid on the patient. This method of unfolding results in a crisp fold being closest to the incision, which helps the drape to lay as flat as possible. Communication with the surgeon prior to draping is strongly recommended in the event special draping requests may be made. Once a drape is placed on the patient, it cannot be moved or adjusted; therefore, proper initial placement is imperative. The side of the patient closest to the person draping should be draped first. As the drape is being placed, it is critical that no part of the sterile gown or sterile hands come in contact with a non-sterile surface. The folded edge of the drape should be placed 1/2″–1″ laterally to the proposed incision site. The second drape is placed opposite from the first. The person draping must never reach over the non-sterile area to place a drape. Walking around the table to place the drape is the only acceptable practice. The second drape should be placed at the same distance from the proposed incision site as the first drape. The third drape is placed on the cranial aspect of the proposed incision. As before, a 1/2″–1″ margin from the incision’s cranial end should be followed. When placing the third drape, care must be taken to keep the front of the gown facing the surgery table. The person draping should turn just the arms and shoulders to place the drape. Especially with long haired patients, arms may need to be elevated to avoid sleeve contamination from the fur. After the third drape is placed, penetrating towel clamps should be placed at the intersecting corners of the towels to secure them to the patient. Penetrating towel clamps are used to pierce the skin and securely hold the drapes in place. Depending on the area of the body being draped, caution must be taken to avoid penetrating an important structure with the towel clamp (i.e., jugular vein, nerve, etc.).The caudal drape is the last to be placed using the same physical stance as with the cranial drape. The person draping the patient is not allowed to stand at the end of the surgery table to place the drape. In most cases, this would require reaching over the non-sterile table and that is a break in aseptic technique. Penetrating towel clamps can now be placed in the two remaining intersecting corners of the drapes. After all four ground drapes are placed and secured; the same draping process is repeated with larger drapes. The top drapes need to be large enough to completely cover the patient and table top to reduce the risk of contamination. Some surgeons will choose to use a large fenestrated drape instead of the four top drapes. Either option is acceptable. However, four corner draping (sometimes referred to as four quadrant draping) allows more flexibility, whereas the fenestrated drape is one fixed size and cannot be changed no matter the size of the patient. Fenestrations that are too large, risk over exposure of the patient’s skin, thereby increasing infection risk. Fenestrations too small may hinder the surgeon’s ability to visualize as needed due to a smaller incision. Top drapes can be secured with either penetrating or nonpenetrating towel clamps. Figure 4.12 Opening the towel. Figure 4.13 Lift each thumb and allow towel to open. Figure 4.14 Rotate each hand so palms are facing the operator. Figure 4.15 Pronate the hands so the fingers are protected by the towel. When patients are having an orthopedic procedure and the limb has been suspended for the prep, the draping procedure is quite involved. After the drape pack has been aseptically opened for the sterile team, the first ground drape can be placed. In order to keep the limb freely moveable for the surgeon the ground drapes are placed approximately 1″ from the clipped margins at the proximal end of the limb. Ground drapes should be placed in the order which will allow the last drape placed to be the one by the IV pole that is suspending the limb (Figure 4.16). The risk of contamination is higher when placing that drape, and so it should be done last. After all ground drapes are placed and secured, the suspended limb will need to be cut down. To maintain the asepsis of the limb, the circulating tech should hold the foot of the suspended limb with one hand and use a scissors to cut the tape hanging the limb. The tape should be cut close to the foot to avoid any risk of a piece of tape from touching the prepped leg. The circulating technician can then move the IV pole away from the surgery table so the sterile team member can place the first large drape. This is done so a sterile area is provided on which to lay the limb, once the limb is ready to be laid down. The sterile team member can now take a sterile hand towel and take the foot from the circulating technician. It is imperative that the circulating tech not let go of the foot until it is known that the sterile member has control of the foot. Lack of observation of this detail can result in the limb being dropped, the sterile drapes, and potentially the sterile team members being contaminated and re-draping and re-gowning/gloving of the sterile team members will need to occur. The towel is wrapped around the foot of the patient to cover all the non-sterile tape and then secured with a towel clamp. Another option is to grab the foot with sterile Vetwrap® and cover all the tape (Figure 4.17). The limb can now be laid down on the sterile field. If a stockinette is used, it is now placed on the limb and unrolled proximally to cover all of the limb. As the stockinette reaches the proximal end of the limb, an operating scissors can be used to cut the remaining rolled portion of the stockinette so it can be completely unrolled. At this point, the remaining drapes can be placed in the following order: opposite the drape that is already on the table, cranial then caudal. It is important to remember that if the patient is in dorsal recumbency and the instrument table is over the chest of the animal, that table needs to be in place prior to beginning draping. In addition, if the table is over the patient, the caudal drape should be placed before the cranial drape. Some surgeons choose to use the povidone-iodine impregnated sticky drape for orthopedic cases. In most situations, the sticky drape is applied after all the drapes are in place. Making sure the limb is completely dry before application of the sticky drape will provide the greatest opportunity for good adhesion of the drape. Figure 4.16 Securing ground drapes for an orthopedic case. Figure 4.17 Surgeon grabbing the foot with sterile Vetwrap® while the circulating nurse cuts down the suspended limb. Other responsibilities of the surgical assistant include setting up the “back” or instrument table, passing surgical instruments, lavaging the tissue to insure tissue viability; providing hemostasis with either manual pressure with a gauze sponge or use of electrocautery; providing tissue retraction or limb manipulation as needed, and alerting the surgeon to any problem that may not have been noticed by the surgeon. The surgical assistant is in charge of the “back” table or instrument table. The instruments should be laid out so the assistant can easily see the tips to quickly identify the instrument requested. For some surgical cases, the assistant will be standing opposite the surgeon on the other side of the surgery table. For other cases, they may be standing behind the instrument table at the caudal end of the surgery table. Some technicians like to assemble the instruments on the table so the “sharp” instruments (scalpel blades, scissors) are on one side and then progress across the table top to the “dull” instruments (hemostats). This order is logical and helps other sterile members find an instrument if need be. Correctly and firmly passing an instrument to the surgeon or other sterile member is a critical skill. Communication or lack thereof, between the assistant and the surgeon can either enhance or negatively affect the flow of the case. Instruments handed with less than a firm “slap”, may result in the instrument being dropped. Handing a scalpel handle loaded with a scalpel blade must be done safely because the risk of injury to the surgeon is great. Using an overhand grip the assistant should hold the handle with the blade facing them. The noncutting edge of the blade should be facing the palm. The handle and blade should be firmly placed in the waiting hand of the surgeon – noncutting edge first (Figure 4.18) (Tear, M. 2012). Figure 4.18 Proper method of passing a loaded scalpel blade and handle. Ring-handled instruments should be held at the box lock or screw hinge in a vertical position, tips to the ceiling and ring handles to the floor (Figure 4.19). The instruments should be locked to the first ratchet or closed if no ratchet is present; so it is easier for the surgeon to grasp the ring handles. The instrument should be placed firmly in the palm of the waiting hand with the ring handles hitting the palm. Loading the needle holder with a suture needle should also be the assistant’s responsibility. The needle holder should be placed about 3/4 of the way on the needle curve, closer to the suture attachment. The needle holder should never be clamped on the needle at the needle/suture junction. The needle should have the curve up so the surgeon is ready to place the first stitch. Figure 4.19 Proper method of passing a ring-handled instrument. Thumb tissue forceps should also be held in a vertical fashion when being passed to the surgeon (Figure 4.20). The assistant should hold the thumb tissue forceps at the fused end with the tips facing the floor. Using this method will provide the surgeon with an instrument they can use right away instead of having to flip it around as well as keeping the assistant’s hand out of the way of the surgeon accepting the instrument. Figure 4.20 Proper method of passing a thumb tissue forceps. Maintaining the integrity of the tissue is a critical role of the surgical assistant. Sterile bowls should be filled, aseptically, with sterile saline and kept on the instrument table. The surgical assistant should hold the bowl off the sterile field to allow the circulating nurse to fill the bowl. The circulating nurse must be careful to not touch the bowl with the bottle of lavage fluid. Additionally, the bowl should not be overfilled, to avoid spillage once on the table (Figure 4.21). The bowl should be readily accessible, yet out of the way so as to avoid repeated bumping and spilling. Bulb syringes or gauze sponges are most commonly used to apply sterile fluid to the exposed tissues. Tissue must be kept moistened at all times. Exposure to room air and heat from the surgical lights can lead to rapid dehydration and decreased viability. Tissues that may be exposed for long periods of time (exteriorized intestine, urinary bladder, etc.) should be covered with a saline-soaked radiopaque sponge or lap pad for increased moisture retention (Figure 4.22). Rehydrating the sponge, without removing it, can be done with a bulb syringe saturating the sponge as necessary. Surgeries that require using large amounts of lavage fluid (i.e., abdominal exploratory) should have warmed lavage fluids used. It is the responsibility of the circulating technician to warm the fluids. Continuous storage of the fluids in a warmer is ideal, but warm water bath warming is also an option. Warming fluids in a microwave is discouraged as hot spots within the bottle could result in fluids that are too warm damaging the patient. Figure 4.21 Fluid bowl too full. Figure 4.22 Options for hemostasis: radiopaque gauze sponge, radiopaque laparotomy pad, surgical spear, cotton-tipped applicator. Electrosurgery, often called electrocautery, can be utilized by either touching the tissue/vessel directly with the electrocautery pencil, or by touching an instrument clamping a vessel or tissue (Figure 4.23). Technicians may be the one applying the electrosurgical pencil to the tissue or clamping the vessel with the hemostat. If electrosurgery is to be used, the cord from the hand piece must be secured on the sterile field to avoid having the hand piece slide off the field. Once the hand piece is on the sterile field, measure the cord to allow enough cord to reach all areas of the field. At the determined length, loop the cord in half and slip it through one ring handle of a towel clamp securing a drape. Then take the loop and place it around the other ring handle of the same instrument (Figure 4.24). This will secure the cord without inhibiting electric flow to the hand piece. Then the rest of the cord can be tossed off the sterile field so the circulating nurse can plug it in. Hemostasis can also be achieved by applying pressure with a gauze sponge. Small vessels or capillaries that are bleeding can often be controlled with pressure rather than using electrosurgery. A 16 ply 4″ × 4″ radiopaque sponge that is completely soaked will hold approximately 13 mls of blood. A 12″ × 12″ laparotomy sponge, soaking wet will hold ∼65 mls. Radiopaque should ALWAYS be used on surgical fields. The radiopaque thread or strip in the sponge will allow for easy identification on a radiograph should a sponge be unaccounted for at the end of the procedure. Figure 4.23 Assistant activating electrosurgery handpiece. Figure 4.24 Electrosurgery pencil and suction tubing set up on the sterile field.
Chapter 4
Surgical Assistant and Circulating Nurse
Patient positioning
Sterile patient prep
Patient draping
Non-orthopedic draping (soft tissue, neuro, etc.)
Orthopedic draping
Other responsibilities
Setting up the instrument table
Passing surgical instruments
Scalpel handle and blade
Ring handled instruments
Thumb tissue forceps
Lavaging
Hemostasis
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
