THE PHASES OF SURGERY INCLUDING THE OPERATIVE SEQUENCE

“Be curious always! For knowledge will not acquire you; you must acquire it...” Sudie Black

The Art of Intelligent Assistance... Requires a working knowledge of the

sequential steps for a specific surgical procedure based upon four concepts:

Approach Procedure Possible Complications Closure

Approach Determined by Physician Approved by Anesthesia Based upon positioning of patient Offers the best exposure Has the lowest amount of tissue trauma Subject to change given the situation

Procedure Determined by the Physician Agreed to by the patient Specific principles of surgery Basic principles applied from similar

surgeries Services related to surgical intervention

Possible Complications Known and unknown factors Short term and long term Direct and indirect Towards the patient Towards the Surgical team Towards the environment

Closure Determined by Physician Many different methods May not be able to close operative site Marks the beginning of recovery

Five Phases of Surgery Preparation Preincision Operative Sequence Closing Post operative

Preparation… Phase 1 Selection of room and supplies Preincision count

Preincision…Phase 2 Transfer and positioning of Patient Induction Prep and drape Suction and electrosurgical equipment

OPERATIVE SEQUENCE…PHASE 3

IncisionSequence 1 The skin and subcutaneous tissue are

divided with a skin knife Knife is placed on backtable

HemostasisSequence 2 Bleeders are dealt with by electrical or

mechanical hemostatic means according to surgeon’s preference

A raytex sponge or laparotomy sponge (lap) is used to aid in further visualization for sources of bleeding

Dissection and ExposureSequence 3 A clean knife, Metz scissors, or cautery are

used to incise deep fascia and peritoneum Various instrumentation is used to elevate

tissue and expose tissue that is to have surgery performed on it

For example a hemostat may be used to elevate the peritoneum to avoid damage to underlying contents as it is penetrated and cut with a cautery

Toothed forceps are use on fascia

Exploration and IsolationSequence 4 Operative area is explored and pathology

is isolated At times the operative site is obscured by

surrounding tissue Bone will be scraped to expose a fracture

for plating and screw application Sponges, retractors, tissue extraction, and

manual manipulation of tissue may be used to maximize exposure

Surgical RepairSequence 5 Excision or revision Depends upon purpose and local

anatomy May require a certain amount of

dissection Instrument length increases with depth

of incision Needed instruments and supplies given

to surgeon as needed

Surgical Repair continued... Operation focuses on removal,

resection, reconstruction, or all to correct abnormality

May require specialized instruments

Hemostasis and IrrigationSequence 6 Prep for closing Control bleeding Irrigate wound with saline with or

without antibiotics Insert drain if needed

SpecimenSequence 7 Gather specimen Identify specimen verbally to surgeon

then to circulator prior to passing off Pass off field to circulator (ask surgeon’s

permission) Be sure to ask how specimen is to be

preserved (permanent or frozen/fresh)

Closing…Phase 4 The first count takes place before the

any cavity is closed. This means everything!

The second count is done after the cavity and fascia are closed serially, again everything!

If a cavity has not been entered all sponges and miscellaneous items must be counted and verified prior to wound closure

Anesthesia reversal and stabilization Application of dressing and tape

Postoperative…Phase 5 Maintain sterile field until patient stability has ensured by

the anesthesia provider Get their permission to break down Some cases require preservation of the sterile field until the

patient has left the room: any case where airway compromise is a potential complication (Thyroidectomy/parathyroidectomy/facial or throat surgery) and any case that has potential hemorrhage as a complication (Carotid artery endarterectomy/Abdominal aortic aneurysmectomy /trauma)

Prepare to transfer Transfer to PACU Post-procedural routine

In conclusion... Discussed the four concepts of surgery Named five phases of surgery and

discussed them Discussed preparation, preincision

operative, closing, postoperative phases.

Discussed in depth the seven steps in the operative sequence