LABORATORY GENERAL PROTOCOL
Rules 1. Appropriate surgical protocol will be observed and enforced at all times in the laboratory while any surgery is in progress. Surgical attire is required. Each student must be in his or her full scrub suit, for ALL laboratory sessions (including cadaver and model laboratories). Do not wear sleeved shirts underneath your scrub suits if they hang below the scrub sleeves - if you are cold (and remember for the most part you will be gowned) wear a sleeveless shirt underneath the scrub suit. Scrub tops must be tucked in. No open shoes are allowed. Students should have their full names affixed (tape, print, etc.) to the front of the surgical cap. NO ONE SHOULD WALK INTO THE LABORATORY IN HIS OR HER STREET CLOTHES. Wear scrubs covered by a laboratory coat.
2. Caps, masks and gloves (and booties) will be provided. Use only one item of each per lab (that is all you have paid for).
3. Books, notebooks, bags, food, and drink are prohibited in the laboratory. If desired, the laboratory protocol, drawings, notes, etc. can be taped to the walls but they should be removed at the end of surgery.
4. One group each week will be assigned to CLEAN THE LABORATORY as a whole and any other clean-up tasks assigned by Sam.
Equipment 1. Suture materials for the laboratories have been purchased by the bookstore and will be distributed by Sam Frazier at the beginning of the laboratory.
Other stuff 1. Once you have prepared for a laboratory, it helps to visualize yourself doing the procedure (the night before laboratory is best). This helps to solidify your knowledge, and may help you identify questions you need to answer or materials (suture, special equipment, etc.) which you will need. It helps the procedure go more smoothly if you've had a "dry run".
2. If you need help or have questions during laboratory, do not hesitate to ask any of the laboratory mentors. (Please note: there are many "right" ways to do some surgical procedures so you may get different suggestions from different mentors. If you become confused about a procedure or technique consult the primary mentor for that laboratory.)
3. If you have any questions or problems before, during, or after a laboratory, please contact Dr. Hosgood or one of the laboratory mentors.
LAB 1. SURGEON PREPARATION, GOWNING AND GLOVING, DRAPING. Laboratory organization Jan 11 Thursday Group A will come to lab from 1:OO-3:OOpm. Group B will come to lab from 3:OO-5:OOpm. Jan 18 Thursday Group C will come to lab from l:00-3:OOpm. Group D will come to lab from 3:OO-5:OOpm.
You will work in pairs for the lab. Objectives This laboratory is designed to give the student the opportunity to review and practice the principles of aseptic technique. After preparing for the laboratory the student should know: 1. Why fingernails must be short and 'natural' (no polish or artificial nails)? 2. What constitutes appropriate surgical attire? 3. Why scrubs should not be worn on the way to work/school and why they must be covered when outside the surgical suite. 4. How a surgeon performs a surgical scrub. 5. How to gown and perform closed gloving. 6. Once gowned, what portions of the gown are considered to be sterile? 7. How to aseptically drape a patient for abdominal surgery. 8. The names and uses of the instruments in a basic surgical pack. Required Reading 1. Fossum TW. Preparation of the operative site. In: Fossurn TW, Hedlund CS, Hulse DA, et al. Small Animal Surgery. St. Louis, Mosby-Year Book, Inc. 2. Fossum TW. Preparation of the surgical team. In: Fossum TW, Hedlund CS, Hulse DA, et al. Small Animal Surgery. St. Louis, Mosby-Year Book, Inc. Laboratory procedure Preliminary Arrive to lab wearing scrubs, shirt tucked in and covered by a laboratory coat. Fingernails should be trimmed short and nail polish removed prior to lab. Surgical scrub Scrub after removing all jewelry from arms and hands. Lather the hands and arms for about one minute without a brush. You may also wish to clean under the fingernails with a pick at this point. Rinse both hands, keeping the elbows lowered so the water runs off of them. Then use a sterile brush and scrub the hands. Start at the fingers (scrubbing all four sides of each finger), then scrub all four sides of the hands, and finally scrub all four sides of the arms down to the elbow. Rinse both hands and arms and start all over again. You should scrub for about 10 minutes. Always keep your hands above your elbows! Pick up the sterile towel with one hand. Dry the fingers, hand, and arm (in that order!) using the top half of the towel. Hands should stay on opposite sides of the towel. Use the other end of the towel to dry the other hand and arm. Be sure the towel doesn't touch anything else.
Gowning Pick up a sterile gown and move away from the table. Hold the gown by the inside shoulder seams and let it unfold. Locate the sleeve openings and slide your arms in, allowing a nonsterile assistant to secure the gown. Do not let your fingers come out of the sleeves because you need to perform a closed gloving technique. Gloving If you are right handed, it is easiest to put the left glove on first. Lay the left glove on the cuff of the left sleeve with the fingers of the glove pointing toward the left elbow and the thumb of the glove against the thumb of your left hand. With your left hand, grasp the free edge of the glove cuff through the gown sleeve. Now use your right hand (within the gown sleeve) to grasp the free edge of the glove cuff and flip it over your left hand. Slide your left hand into the glove, pulling on the glove andlor the gown sleeve. Glove the right hand in the same manner. Then adjust the cuffs for comfort and be sure the glove completely covers the cuff of the gown sleeve.
If you need to change a glove during surgery have a nonsterile assistant pull your glove off by grasping the glove and gown cuff beneath it simultaneously. Once the sleeve is pulled over your fingers the glove is removed and thrown away. You can reglove using the same closed gloving technique described above. You should review open gloving technique, but this is primarily used when gloving with no gown (e.g. putting gloves on to perform sterile scrub, CSF tap, etc.).
Draping Note: You will be using pillows for patients in this lab. However, the draping is described as if you were draping a dog for an abdominal surgical procedure.
Open the surgical pack on the Mayo stand. a. 'Quarter drape' the surgical site using sterile towels. The long edge of the towel should be folded under by 113. Grasp the ends of the towel between the first two fingers of each hand (palms facing you) and roll your hands in so the towel wraps around them and protects them fiom being contaminated. Place the first towel 1 cm from midline, on the side nearest you, (to help prevent you from contaminating yourself on the dog or the table as you place the other 3 towels). Once a towel or drape touches the patient's skin, it should not be moved. This means you need to plan ahead to accurately place the towel or drape exactly where you want it. Place a second towel 1 cm cranial to the xyphoid. Place a third towel 1 cm caudal to the pubis. Place a fourth towel 1 cm from midline on the opposite side. Now there should be a 2 cm strip of skin exposed on midline from xiphoid to pubis. b. Place a towel clamp at each of the 4 comers, including the edge of both towels and some skin in each clamp. The towel clamps should be very near the folded edge of the towel to prevent the towel edge from everting. Do NOT tuck the rings of the towel clamps under the drapes. Place additional towel clamps on the lateral towels to prevent gaping between the towel and the skin. Once a towel clamp has clamped the skin it is considered contaminated and should not be reused or put back on the Mayo stand.
c. Both surgeons are needed to unfold the large, fenestrated drape above the dog. The fenestration (hole) in the middle of the drape is positioned over the incision site and the drape is laid on the patient. If you do not have a fenestrated drape, it's even easier. Just place the drape and you will cut a hole in the correct location by palpating the underlying towel clamps. The drape should extend onto the Mayo stand so there is no break in the sterile field between the incision and the instruments. The instrument tray is lifted so the drape can be pinned underneath it. The drape can be secured by placing towel clamps through it to the underlying towel clamps.
Instrumentation & Packing Review the instruments in your pack. You should be able to name every instrument and know its function. Review what you can before lab, but make sure you get through them during lab - Ms Sam Frazier will be happy to help you with this. Ms Sam Frazier will demonstrate how to fold and pack your gowns, and how to pack the instrument trays.
LAB 2. MODEL SUTURING Laboratory organization Jan 25 Thursday Groups A&B will come to lab from l:00-5:OOpm. Feb 1 Thursday Groups C&D will come to lab from l:00-5:OOpm.
Objectives At the completion of the lab, the student should be able to demonstrate the following; 1. Given a needle holder and needle, be able to hold the instrument and place the needle in the instrument correctly 2. Complete a square knot and a surgeon's knot using needle holder 3. Given a needle holder, needle and incision model, be able to perform all the suture patterns and techniques outlined 4. Have knowledge of the function of each suture pattern 5. Be able to recognize several different sutures and recognize the characteristics of the suture i.e. memory, handling, drag Outline Review the appropriate pages in your notes and any surgery text (Fossum, Auer, Slatter) you may want to bring your lecture notes or other notes you have made on suture pattern construction.
Suture model will be provided - 1 per student. Suture material, needle holders and thumb forceps will be provided. Surgical scrubs are required and should be worn to lab - with your lab coat over the top.
Preliminary Arrive to lab wearing scrubs, shirt tucked in and covered by a laboratory coat. Fingernails should be trimmed short and nail polish removed prior to lab. Laboratory procedure The following procedures and suture patterns should be performed in the laboratory. You may be asked to satisfactorily perform any or all the procedures by the laboratory mentors. Have a mentor check your progress as proceed through the laboratory. Do not leave the laboratory until a mentor has viewed your final closure.
1. Correct technique for holding the needle holder with correct placement of the needle 2. Correct technique for holding thumb forceps 3. Square knot using the needle holder 4. Surgeon's knot using the needle holder 5. Simple interrupted suture 6. Simple continuous suture 7. Horizontal mattress suture
8. Vertical mattress suture 9. Cruciate suture 10. Ford interlocking suture 11. ConnellICushing suture 12. Lembert suture
Tape the suture model to the table by placing a strip of white tape across each end. Work 3 people to a table - one at each end and one in the middle. Draw some incision lines along the model. Place the surgery tray along one side of the table so all surgeons have access. Make an incision along the lines (the lines will help visualize the incision). Use a fingertip grip with the #10 scalpel and use the non dominant hand to tense the skin edges and separate the cut edges. Close the incision. Start with the simple interrupted and work then through the other techniques. Remember if right-handed - wrok R to L; if left handed work L to R. if you made you incision vertically - work top to bottom. Perform the inverting closures (cushing, connel, lembert) on the cloth provided. Time permitting -- Practice burying knots in the depths of the incision. You may be able to also practice a subcutaneous closure. Have someone check your closures. Familiarize yourself with the different suture materials and needles.
LAB 3. SURGEON PREPARATION, GOWNING, GLOVING, SURGICAL PREPARATION, DRAPING AND SUTURING - CADAVER
Laboratory organization Groups A&B will come to lab from l:00-5:OOpm. Feb 8 Thursday Feb 15 Thursday Groups C&D will come to lab from l:00-5:OOpm.
You will work in pairs for the lab. Objectives The objective of this laboratory is to combine the procedures of the previous two labs and extend the situation to the animal. The laboratory will require all students to assist in aseptic preparation of the surgical site, surgical scrub, gowning, gloving, draping of the surgical site, and skin incision and suturing.
All objectives of the previous laboratories apply. In addition, the student should know 1. How to clip and prepare the skin for aseptic surgery 2. How to aseptically perform a surgical scrub of the skin of the patient The student should be able to apply the basic suturing skills gained from the second laboratory to tissue from euthanized animals and after preparing for the laboratory the student should also know 1. How to appose the skin edges of an incision. 2. How to bury a knot at the beginning or end of an incision.
Preliminary Arrive to lab wearing scrubs, shirt tucked in and covered by a laboratory coat. Fingernails should be trimmed short and nail polish removed prior to lab. Laboratory overview You will work in pairs. All students will be responsible for clipping and preparing the surgical site. As the preparation is finishing, one student can open their gowns and gloves, and go and scrub. The remaining person can organize the cubicle and be available to open scalpels etc. Once the surgeon comes back and begins to gown, the other can go scrub. Laboratory procedure Patient preparation Position the cadaver in lateral recumbency such that the lateral abdomedthorax is exposed. This will be your surgical site. Liberally clip hair from the surgery site. Vacuum all lose hair. Scrubbing The surgical site is prepared for aseptic surgery by at least 3 scrubs and 3 alcohol rinses - scrub until you see no dirt on your sponges. Use of an alcohol scrub first helps to de-fat the skin and allow contact of the iodine.
Scrub, starting at the area of the incision and working outwards from that site, never to return to the incision site with that sponge again. A final spray of iodine can be applied and left to dry. Once the dog is prepared, the Mayo surgical stand should be positioned as close to the dog as possible to facilitate creation of a continuous sterile field with the drapes. The outer wrap of the surgical pack can be opened by the assistant surgeon before they leave the cubicle to scrub for surgery and the assistant surgeon should also open the gown packs and gloves (onto the opened gown pack). Once scrubbed, the surgeons can gown using the closed method. Draping The towels should be held so they prevent you from accidentally touching the skin with your gloved hand: hold the towel in front of you with one end in each hand; fold 113 of the towel over (away from you); grasp the towel ends between your first two fingers of each hand, palms facing you; roll your hands inward and the towel should now be wrapped around your hands to shield them and the short edge of the fold is toward the patient. One towel is placed longitudinally on the side closest to the person draping. It is easiest to work around in a square, placing the cranial or caudal towel next and securing with towel clamps as you go to prevent any towel from slipping. Do not walk around the table - you should be able to drape the entire incision from one position. Place the towels exactly where you want them initially because once they touch the skin they should not be moved around. A towel can be moved backwards slightly but not forward to the incision site. Remember also that once a towel clamp has been used is contaminated, so repeatedly securing the drape is not acceptable. The towel clamps must be placed near the edges of the folded towels to avoid eversion of the towel that has previously been touching the skin. DO NOT tuck these towel clamps under the towels. REMEMBER - this is a large area exposed so secure the drapes with additional towel clamps along the towels (not just comers) to prevent gaping. The fenestrated field drape is applied over the entire dog AND instrument table. It is best to hand part of the drape to the other surgeon so it can be opened and then accurately laid down with the fenestration (window) over the surgical field. Remember- you don't want to slide drapes around once they've been set down. Cut a hole in the filed drape over the area of your incision - since two of you are working at the same time - simple cut your own hole. If both are right handed (or both left handed)- work on opposite sides and ends of the dog. If one left handed and one right - work on the same side but opposite ends of the dog.
The fenestrated drape can be secured by clamping the larger towel clamps to the underlying small towel clamps. Don't save towel clamps for this - if you need the extras on the underlying towels - use them here - this is the most important barrier layer.
Skin incision and closure
Overview The entire side of the dog will be draped in to expose as much skin as possible. Each student will make an incision on the lateral thorax, abdomen, shoulder or thigh, in a dorsoventral direction (along the lines of skin tension). Make your incision far away from the others in your group to give yourself as much space as possible because you will all be working simultaneously. You will close the incision with a vertical subcutaneous suture pattern followed by skin sutures. If time permits, make a second incision and close it with a horizontal intradermal suture pattern. Procedures
A. Incision closure using vertical subcutaneous suture pattern and skin sutures. 1. Make a 10 cm incision through the skin and subcutaneous (SQ) tissue so the skin edges gape. Hold the scalpel with a fingertip grip and use the opposite thumb and forefinger to stabilize the skin and provide some tension. 2. Bury a knot at the beginning of the incision: Introduce the needle deep in the SQ tissue and exit in the SQ near the dermis (more superficially). Then pass across the incision and introduce the needle in the SQ tissue near the dermis (more superficially) and exit deeper in the SQ. Tie two square knots (four throws). You should now have an 'upside down' knot. 3. Pr...