| Cataract Extraction Posted: 26 Sep 2010 05:13 PM PDT 
 Cataract Extraction Definition - The removal of an opaque ocular lens.
Discussion - A cataract may be a congenital defect or may be caused by trauma or certain medications. At an appropriate time in the maturation of the cataract, and with sufficient loss of vision, surgical intervention becomes necessary.
- A cataract is one of the most common causes of gradual, painless loss of vision.
- Types of Cataract Extraction Procedure:
- Intracapsular – removal of the opaque lens within its capsule.
- Extracapsular – removal of the opaque lens by irrigation and expression, leaving the posterior capsule in situ.
- Phacoemulsification – a variation of the irrigation/ aspiration technique. The contents of the lens capsule are fragmented with ultrasonic energy as the lens material is simultaneously irrigated and aspirated.
- The procedure may be followed by the implantation of an intraocular lens (L.O.L). The lens prosthesis is selected by the surgeon prior to the surgery, and may either be purchased by "consignment" with a company, or kept in stock in the operating suite.
Position Instrumentation - Basic eye procedure tray
- Cataract extraction tray
- Phacoemulsification tray
- Intraocular lens implant
Supplies/ Equipment - Basin set
- Balanced saline solution
- Irrigation/ aspiration pack
- Ophthalmic sponges
- Ophthalmic cautery
- Microscope drape
- Headrest
- Sitting stool with backrest
- Cryoextractor
- Phacoemulsifier
- Honan intraocular pressure reducer cuff
- Beaver blade
- Super blade
- Multipore filter
- Medications
- Sutures
Procedure Intracapsular - A lid speculum is placed and traction sutures are placed in the sclera.
- The conjunctiva is reflected from the superior cornea.
- Bleeders are cauterized.
- The anterior chamber is entered; an iridotomy is performed as the cornea is retracted by suture traction.
- An enzymatic solutioin is instilled into the anterior chamber to dissolve the zonule fibers suspending the lens.
- A cryoextractor is applied to the lens, which adheres to it, and the lens is withdrawn from the eye.
- The corneal incision is closed; traction sutures are removed, and the conjunctival flap is approximated.
- If an intraocular lens implant is used, it will be implanted following the extraction of the lens.
- The prosthesis is either sutured to the iris or simply held in place by the iris, depending on the type of prosthesis.
- Ophthalmic ointment may be instilled, and an eye dressing and patch is applied.
Extracapsular - This procedure is similar to the intracapsular procedure, except that the lens capsule is incised, and the lens is exposed or irrigated out leaving the posterior capsule, which remains as a barrier to the vitreous humor.
- When phacoemulsification is used, the anterior lens capsule is excised.
- The lens nucleus is prolapsed into the anterior chamber, and the ultrasonic probe is inserted into the capsule.
- The probe is set to irrigate/ aspirate and then fragment the remaining lens substance.
- After the "phaco" procedure, the wound is closed.
Perioperative Nursing Considerations - If a floor model microscope is used, it should be draped and brought in over the field on the opposite side of the affected eye.
- Thorough familiarity with all equipment used its mandatory for a smooth surgical procedure
- Check all the equipment before use.
- The circulator will usually be responsible for changing the settings on the phacoemulsifier unit.
image from aucklandeye.co.nz Related posts: - Cataract
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| Appendectomy Posted: 26 Sep 2010 05:06 PM PDT 
 Appendectomy - The excision of the appendix usually performed to remove an acutely inflamed organ.
- Many surgeons perform an appendectomy as a prophylactic procedure when operating in the abdomen for other reasons. This procedure is then referred to as an incidental appendectomy.
Position - Supine, with arms extended on armboards
Incision Site - McBurney (muscle splitting) incision.
Packs/ Drapes - Laparotomy pack
- Four folded towels
Instrumentation - Major Lap tray or minor tray
- Internal stapling device
Supplies/ Equipment - Basin set
- Blades
- Needle counter
- Penrose drain
- Culture tubes
- Solutions
- Sutures
- Internal stapling instruments
- Medication
Procedure - An incision is made in the right lower abdomen, either transversely oblique (McBurney) or vertically (for a primary appendectomy).
- The surgeon's assistant retracts the wound edges with a Richardson or similar retractor.
- The appendix is identifies and its vascular supply ligated.
- The surgeon grasps the appendix with a Babcock clamp, and delivers it into the wound site.
- The tip of the appendix may then be grasped with a Kelly clamp to hold it up, and a moist Lap sponge is placed around the base of the appendix (stump) to prevent contamination of bowel contents, in case any spill out occurs during the procedure.
- The surgeon isolates the appendix from its attachments to the bowel (mesoappendix) using a Metzenbaum scissors.
- Taking small bits of tissue along the appendix, the mesoappendix is double-clamped, and ligated with free ties.
- The base of the appendix is grasped with a straight Kelly clamp, and the appendix is removed.
- The stump may be inverted into the cecum, using a purse-string suture on a fine needle, cauterize with chemicals, or simply left alone after ligation.
- Another technique is to devascularize the appendix and invert the entire appendix into the cecum.
- The appendix, knife, needle holder, and any clamps or scissors that have come in contact with the appendix are delivered in a basin in the circulating nurse.
- The wound is irrigated with warm saline, and is closed in layers, except when an abscess has occurred, as with acute appendicitis.
- A drain may be placed into the abscess cavity, exiting through the incision or a stab wound.
- An alternative technique may be use the internal stapling device, by placing the stapling instrument around the tissue at the appendiocecum junction.
- By using the technique, the possibility of contamination from spillage is greatly reduced.
Perioperative Nursing Consideration - Instruments used for amputation of the appendix are to be isolated in a basin.
- If ruptured, the case must be considered contaminated, and the surgeon may elect to use antibiotic irrigation prior to closure of the abdomen with an insertion of a drain.
- There may be no skin closure of the wound if the appendix has rupture.
image from www.health.stateuniversity.com Related posts: - Open Prostatectomy
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| Open Prostatectomy Posted: 26 Sep 2010 04:58 PM PDT 
 Open Prostatectomy Definition - Excision and removal of the prostate gland via a surgical incision.
Discussion - Although 90 percent of prostectomies are performed via the transurethral approach, there are occasions when a surgical incision and removal is required.
- Four approaches can be used to excise the prostate gland:
- Transurethral prostectomy – removal of the prostatic tissue and/ or lesions transcystoscopically.
- Suprapubic prostectomy – performed after incising the bladder, which permits correction of associated conditions, such as calculi or diverticula.
- Retropubic prostectomy – avoids entry into the bladder and allows for good visualization of the field. Limited malignancies may be treated by this approach.
- Perineal prostectomy – affords excellent visualization and access to the prostate and seminal vesicle.
- A bilateral vasectomy may be performed in conjunction with a prostectomy to avoid retrograde infections.
Positioning - Suprapubic and retropubic: Supine with slight trendelenberg
- Perineal: Exaggerated lithotomy with slight trendelenberg.
Packs/ Drapes - Suprapubic: Laparotomy pack, extra drape sheets, transverse lap sheet.
- Retropubic: Laparotomy pack, impervious sheet, folded towel over scrotum and penis.
- Perineal: Cysto pack, towels around the perineal area, fenestrated sheet.
Instrumentation - Majoy tray
- Long instruments
- Heaney needle holder
- Lahey clamps
- Prostatic urethral sounds
- Hemoclips
Supplies/ Equipment - Basin set
- Blades
- Needle counter
- Dissector sponges
- Irrigation syringe
- Suction
- Solutions
- Lubricants
- Sutures
- Suprapubic catheter
- Drain
- Foley catheter
Procedure - The surgeon makes the appropriate incision, and after access is gained into the space of Retzius, a self- retraining retractor is placed into the wound.
- Before the bladder is opened, the surgeon places two traction sutures on either side of the incision.
- The bladder may be grasped with a Allis clamp and pulled upward.
- A short incision is made into the bladder, and suction is applied to drain its contents.
- After draining the bladder, the surgeon places a bladder retractor in the bladder wound.
- The surgeon incises the prostatic mucosa by either knife or cautery, and the bladder retractors are removed.
- Using finger dissection, the surgeon enucleates the diseased prostate from its fossa, and the specimen is delivered and passed off to the scrub person.
- The cavity is inspected for bleeders. Many surgeons prefer to pack the cavity with a sponge for a few minutes to maintain hemostasis.
- Large bleeding vessels are ligated with suture or ligiclips.
- Oozing surfaces may be covered with a hemostatic agent.
- A foley catheter is placed into the bladder neck. Some surgeons prefer to drain the bladder through a suprapubic catheter, which is placed in the wound at this time through a small incision near the suprapubic incision.
- The bladder is then closed with two layers of 0 or 2-0 chromic interrupted sutures.
- A large penrose drain is placed into the space of Retzius; and the wound is closed in a routine manner.
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