| Nephrectomy Posted: 29 Sep 2010 10:46 PM PDT 
 Definition
The surgical removal of a kidney (partial or total). Discussion - A nephrectomy may be performed for many reasons, including hydronephrosis, pyelonephritis, renal atrophy, renal artery stenosis, trauma, and tumors of the kidney and uterus.
- If a major portion of the ureter is also excised, the procedure is termed a Nephroureterectomy.
Positioning - Lateral lumbar frank or transthoracic with affected side up.
Incision Site - Flank (posterior axillary line, beneath the twelfth rib to suprapubic area).
Packs/ Drapes - Laparotomy pack with transverse Lap sheet
- Extra drape sheets
- Towels
Instrumentation - Major procedure tray
- Kidney tray
- Thoracotomy tray with vascular clamps
- Hemoclips
- Internal stapling instruments
Supplies/ Equipment - Positioning aids
- Basin set
- Blades
- Suction
- Needle counter
- Asepto syringe
- Hemoclips
- Dissector sponges
- Penrose drains
- Closed-wound drainage
- Chest tube and drainage unit
- Suprapubic catheter
- Solutions
- Medications
- Sutures
Procedure Overview - A curved incision is made across the flank, and the fascia and muscle tissues are divided with a dissecting scissors or cautery.
- Occasionally a rib must be sacrificed to gain access to the retroperitoneal space.
- If a rib is to be taken, periosteal elevators and rib shears should be available.
- The kidney and ureters are mobilized. The ureter is divided and the distal end ligated.
- For malignant disease, a radical nephrectomy is performed. On the right side, the duodenum is protected with moist Lap sponges.
- The vascular pedicle is transected and lymph node-bearing tissue is excised.
- Gerota's fascia is dissected from surrounding tissue; the ureter is divided and the kidney and surrounding fat, adrenal gland, and fascia are removed en bloc.
- If a flank incision is being used, a second lower flank or inguinal incision is used to expose the distal ureter extraperitoneally.
- The distal ureter is dissected free of surrounding tissues and a small cuff or bladder is excised with the intramural portion of the ureter.
- The bladder incision is repaired; a suprapubic cystostomy catheter may be placed, and the distal ureter and bladder cuff are delivered into the flank wound and removed with the kidney.
- The flank incision may be closed with or without drainage, in separate layers.
- For trauma and some presentations of calculus disease involving only a portion of the kidney, a partial nephrectomy may be performed.
Perioperative Nursing Considerations - The surgeon or anesthesiologist may request hypothermia measured during the procedure.
- Have all X-rays in the room.
- Verify with the blood bank the number of available units.
- Chest tube and drainage unit will be needed for a transthoracic approach.
- A suprapubic catheter and drainage unit may be used if nephroureterectomy is performed.
- When two incisions are used, the patient is repositioned. Additional instrument tray is necessary.
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| Abdominal Hysterectomy Posted: 29 Sep 2010 10:41 PM PDT 
 Definition
Surgical removal of the entire uterus through an abdominal incision. Discussion - A hysterectomy is indicated for a variety of conditions, including endometriosis, adnexal disease, postmenopausal bleeding, dysfunctional uterine bleeding, and benign fibromas or malignant tumors.
- For women in their childbearing years, this surgery, as with a vaginal hysterectomy, can be a devastating blow psychologically, since they may feel they have lost their primary sexual characteristic and therefore can no longer function as women.
Positioning - Supine, with arms extended on armboards.
Incision Sites - Lower transverse (Pfannenstiel), vertical, midline, or paramedian.
Packs/ Drapes - Laparatomy pack and/ or transverse Lap sheet.
- Four folded towels
Instrumentation - Major Laparotomy tray or abdominal hysterectomy tray
- Self-retraining retractor
- Internal stapling instruments
Supplies/ Equipment - Basin set
- Blades
- Needle counter
- Suction
- Foley catheter with drainage bag
- Solutions
- Suture
- Internal stapling
Procedure Overview - After incising the skin, the incision is deepened through the subcutaneous tissue with the deep knife or cautery pencil.
- The fascia is nicked with the deep knife and incised using a curved Mayo dissecting scissors.
- Grasping one edge of the fascial margin with two or more Kocher clamps, blunt dissection separates the fascia from the underlying muscle.
- The muscle is divided manually. The peritoneum is then knicked with the deep knife, and the incision is lengthened with Metzenbaum scissors.
- A self-retraining retractor is placed in the wound, with moist lap sponges to protect the wound edges; the surgeon will "pack the bowel" away from the uterus with additional moist warm Lap sponges, and the operating table is placed in slight Trendelenberg position.
- The uterus is isolated by severing it from the uterine ligaments ans adnexa.
- The round ligaments of the uterus are ligated, divided, sutured, and tagged with a hemostat.
- To divide the ligaments, a curved Mayo scissors or scalpel is used. An internal stapling device can be used to free the uterus from the adnexa.
- The surgeon mobilizes the uterus to the level of the bladder.
- Using a Metzenbaum scissors and long tissue forceps, the surgeon separates the two structures by dissecting the peritoneal covering away from the bladder. This is called the bladder flap, and will be reattached (reperitonealized) later.
- Once the bladder has been separated from the uterus, mobilization is continued.
- At the level of the cervix, long Allis or Kocher clamps are placed around the edge of the cervix, and it is divided from the vagina using a long scissors or a long knife.
- If the ovaries are to be preserved, the ovarian ligaments is ligated and divided adjacent to the uterus.
- The uterosacral ligaments are ligated and divided, along with the cardinal ligaments.
- To close the wound, the surgeon begins by suturing the vaginal vault using an absorbable suture.
- The wound is irrigated with warm saline, and hemostasis is achieved.
- To close the peritoneum, the surgeon grasps the edges with several Kelly hemostats and the peritoneum is closed with a running suture.
Perioperative Nursing Considerations - Foley catheterization is usually performed after the internal vaginal prep is completed but before the abdominal prep is begun.
- A sterilization permit may be required in addition to the operative permit.
- Instruments that have come in contact with the cervix and or vagina must be treated as contaminated and discarded into a basin that can be passed off the yield.
- Once the abdomen is opened, 4 x 4 Raytec sponges should be replaced by Lap sponges.
- If a free sponge has been placed in the vagina prior to closing, it is included in the sponge count and must be removed from the vagina before the count is correct and the patient leaves the room.
- Internal staples are usually contraindicated in severe cases of pelvic inflammatory disease or endometriosis.
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| Tonsillectomy and Adenoidectomy Posted: 29 Sep 2010 10:32 PM PDT 
 Definition
The excision of the palantine tonsils, and if applicable, the removal of the nasopharyngeal tonsils (adenoids). Description - Chronic tonsillitis associated with otitis media and nasal obstruction due to enlarged adenoid glands are indications for a tonsillectomy and adenoidectomy procedure.
- The adenoids are usually absent in patients over 15 years of age.
- In children, the procedure is relatively simple. The older patient, the more fibrosis there is and the more difficult the procedure, with a greater incidence of postoperative complications.
Positioning - Supine, arms may be extended on armboards or tucked at the patient's side and restrained.
- The table is placed in slight Trendelenberg position. A rolled towel is placed under the shoulder to hyperextend the neck.
Packs/ Drapes - Head or neck or basic pack with split sheet.
Instrumentation - Tonsillectomy and adenoidectomy tray
- Suction/ cautery with cord
- Bayonet coagulating forceps with cord.
Supplies/ Equipment - Basin set
- Suction
- Blade
- Tonsil sponges
- Medications
- Sutures
- Solutions
Procedure Overview - The surgeon will usually sit during the procedure.
- The mouth is retracted open with a self-retraining mouth gag, or a Davis model, which attaches to Mayo stand.
- The adenoids are removed first with an adenotome and/ or curette.
- A tonsil is grasped with a small tenaculum or tonsil-grasping forceps, and the mucosa is dissected free, preserving the posterior tonsil pillar.
- The capsule of the tonsil is separated from its bed.
- Suction should be immediately available.
- A tonsil snare is then looped over the tonsil and snapped over the pillar thus releasing the tonsil.
- The fossa may be packed with a tonsil sponge to aid in hemostasis.
- One or two plain catgut sutures may be placed over the tonsillar fossa.
- The procedure is repeated on the opposite side.
- An alternative method of hemostasis may be use of a combined suction-cautery unit.
- It is important to remember that the snare wire can only be used once, and is replaced for the removal of the other tonsil.
- The specimen should be separated, and one of the tonsils is tagged with a suture for identification.
Perioperative Nursing Considerations for Tonsillectomy and Adenoidectomy - The suction tip and tubing are never dismantled until the patient is completely out of the room.
- The patient is placed on his or her side before being transported to the postanesthesia care unit.
- Have ties mounted on a tonsil clamp ready in advance.
- Sponges and needles are counted at routine intervals.
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