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5 categories of surgical procedures
- diagnosis
- reconstruction
- repair
- removal
- replacement or implantation
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what do the results of a diagnostic procedure provide?
information about the nature of a medical problem and the options available for treatment
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what is done in reconstructive surgery?
tissue is remodeled or replaced for functional or aesthetic reasons
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what is the goal of repair?
to restore function to a structure, organ, or system
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what does tissue replacement involve?
implantation of an organ or other anatomical structure that has lost function through disease or trauma
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implant derived from the patient or from another person or animal, or biosynthetic material
graft
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lists cases and assigned personnel
assignment board
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most commonly used method of gathering supplies
case cart method
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who prepares wrapped sterile supplies and places on stainless steel case cart for transport to OR room?
central supply
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what is surg tech responsible for after case cart is brought to OR room?
completing it by using surgeon's preference card
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information listed on surgeon's preference card
- instrument sets and special instruments required for case
- special equipment
- suture preferences
- glove and gown size
- skin prep and draping routine
- intraoperative drugs, dosages and strength
- surgeon's individual techniques
- dressings
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preparing the OR room
- arrange head of OR table in appropriate position and directly under lights
- arrange room so contamination and clutter is prevented
- furniture no closer than 18 inches from nonsterile surface
- clean linen on OR table
- connect suction tubing
- gather diagnostic studies
- assemble monitoring equipment
- test power equipment
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recommendations for sterile setup
- increase size of sterile working area
- avoid shifting items from one place to another - try to handle sterile items only once
- prepare items needed at beginning of the procedure first
- avoid doing several things at once
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procedure setup sequence
- towels distributed to team members, gowned and gloved
- patient prepped
- patient draped
- suction tubing and electrosurgical pencil set up
- sterile light handles are attached
- two sponges placed on field
- incision made
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items retrieval sequence
- towels, gowns, gloves, drapes
- light handles, suction tubing and electrosurgical pencil and holder
- knife and basic instruments
- sponges and sutures
- "priority equipment"
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suture sequence
- suture ties may be needed shortly after surgery begins
- suture reels can remain on mayo stand
- swaged (atraumatic) needles can be placed in small basin on the back table until needed
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sequence of instrument trays if they need to be stacked
heavier trays on the bottom
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what is the mayo stand used for?
- instruments and supplies frequently needed during surgery
- supplies are exchanged from back table to mayo stand as case progresses
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when are irrigation and soaking solutions distributed?
after the case is underway or just before case begins
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where are irrigation and soaking solutions distributed?
into basins in a ring stand, solution warmer or slush basin
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what is the purpose of the count?
to prevent items from being retained in the patient
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active responsibility of ensuring that no items are left within the patient lies with whom?
scrub and circulating nurse
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when is count performed?
- before surgery begins to establish a baseline count
- before closure of hollow organ
- before closure of body cavity
- before skin closure
- whenever suspicion of retained item arises
- whenever permanent change in personnel occurs
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count is performed by how many people?
2
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specific order in which items are counted
- items on the sterile field
- items on the mayo stand
- items on the instrument table
- items discarded from the field
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how is lost item reported?
as a sentinel event
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when does anesthesia begin?
only after surgeon has arrived and is ready to scrub
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mandatory steps for timeout procedure
- verification that the correct patient is present
- verification of correct side and site
- agreement on the procedure to be done
- verification of correct patient position
- verification of availability of correct implants and any special equipment or requirements
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how are instruments handled as they are being passed back from the field?
- they should be wiped clean to prevent blood and body fluids from drying on the surface
- suction tips are cleared by running small amounts of water through them
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small, round or oval sponge covered with gauze
sponge dissector (peanut, pusher, etc.)
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commonly used in neurosurgical procedures, especially around brain and spinal cord tissue and manufactured to resist shredding
surgical cotton ball
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how are all instruments passed?
in closed/locked position unless surgeon requests otherwise
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any item or instrument that can potentially puncture or cut through tissue
sharps
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designated area established on the field near the surgical wound used specifically for passing sharps/instruments, avoiding passing from hand to hand
neutral zone technique
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process the entire surgical team uses to care for tissues during surgery
wound management
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what can rough handling of tissues cause?
extensive bruising, tissue swelling and ischemia
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peristalsis ceases, possibly leading to intestinal obstruction
paralytic ileus
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when does surg tech offer irrigation fluids?
when surgeon asks for it and whenever tissues appear dehydrated
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signs of dehydration in internal tissues
- dullness
- loss of surface elasticity
- tissue fraying
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what type of fluid is used for irrigation?
warm normal saline
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what are retractors used for?
to expose underlying tissue
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Balfour retractor
large self-retaining retractor used for abdominal surgery
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Finochietto retractor
large self-retaining retractor used for thoracic surgery
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Weitlaner retractor
small self-retaining retractor for groin
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what can excess pressure of retractor or inattention to the retractor blade or tip result in?
nerve damage resulting in loss of mobility and sensation for the patient
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who is directly responsible for receiving and handling specimens?
scrub
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when submitting a specimen for analysis, are you supposed to remove suture material?
negative batman
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when submitting a specimen for analysis, how are multiple specimens handled?
- each specimen should be identified separately
- "write down, read back"
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can you remove a specimen from the sterile field without the surgeon's specific permission to do so?
nope
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what should you wrap a specimen with?
- moist teflon pad to protect a bone or tissue specimen
- place specimen in a conspicuous, protected area until it can be passed to circulator
- do not use sponges
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should you discard any tissue?
negatory
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why should you not use bone clamps, hemostats or other crushing instruments on specimens?
they can destroy cells
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how does the circulator receive the specimen?
in a designated container
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how must each specimen be identified?
- identification of the patient with 2 identifiers
- type of tissue
- origin of specimen
- clinical diagnosis and other information
- any special markings and their significance
- other registration information, date and time of removal, surgeon's name
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removal of tissue or cells for analysis by pathologist
biopsy
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types of tissue biopsies
- excisional biopsy - used when large, deep section of tissue required for analysis
- fine-needle aspiration - long, fine needle to aspirate small pieces of tissue from a tumor
- needle biopsy - large-bore, hollow trocar or needle used to collect tissue
- brush biopsy - performed during flexible endoscopic procedures - fine brush used to collect cells on surface of mucous membrane tissue
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in what setting are body fluids obtained?
- outpatient setting
- occasionally during surgery
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from where are stones removed?
urinary tract, salivary ducts and gallbladder
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where are removed stones submitted?
in a dry container
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nontissue item obtained from the patient's body
foreign body
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how are all foreign bodies submitted?
dry unless surgeon requests another method
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principles of successful wound management
- handle tissues gently
- control bleeding as efficiently as possible
- use correct instruments and sutures
- careful but efficient use of time to minimize tissue exposure
- meticulous aseptic technique to prevent infection
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controlling bleeding with sutures, surgical instruments, thermal energy and drugs
hemostasis
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why is bleeding controlled in the surgical wound?
to control infection and promote healing
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how can blood be a barrier to healing?
blood forms a physical barrier between tissue edges
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uncontrolled oozing or insecure hemostasis can lead to what?
hematoma
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collection of blood that may become a source of infection
hematoma
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coagulation process
- blood vessel is injured
- vasospasm occurs - vessel retracts and constricts, reducing blood flow
- platelet plug forms - initiates release of coagulation factors
- coagulation begins - meshwork of fibrin strands forms around blood cells, creating clot
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coagulation is activated by 2 pathways:
intrinsic and extrinsic
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intrinsic pathway is activated by?
factors present in the blood
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extrinsic pathway occurs where?
in the tissues
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factor III
thromboplastin, thrombokinase
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factor V
proaccelerin, labile factor
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factor VII
serum prothrombin conversion accelerator (SPCA)
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factor VIII
antihemophilic globulin (AGH)
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factor IX
plasma thromboplastin component
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factor X
Christmas factor
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factor XII
Hageman factor
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factor XIII
fibrin-stabilizing factor
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when applied to oozing tissue, what does topical thrombin do?
it combines with fibrinogen to promote coagulation
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what is absorbable gelatin used for?
to promote coagulation in bleeding capillaries
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what happens when absorbable gelatin is applied to tissue?
it absorbs blood quickly and forms an artificial clot
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examples of absorbable gelatin
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how is oxidized cellulose applied?
always applied dry
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what happens when oxidized cellulose becomes in contact with blood?
it rapidly forms a gelatin clot, which is absorbed by the body during the healing process
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manufactured name for oxidized cellulose
Surgicel
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collagen absorbable hemostat that is approved for use in all surgeries
Avitene
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how is hemostasis in bone achieved?
by occlusion using a waxy substance called bone wax
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how must all bone hemostasis materials be prepared before use?
must be warmed slightly before use by kneading them between the gloved fingers
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salvaging blood at the operative site and reinfusion into the patient
autotransfusion
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how is autotransfusion achieved?
- Cell Saver device
- blood is collected through a suction tip and routed through tubing in device, rinsed, anticoagulated, and blood cells separated from unwanted components
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how is coagulation surgically performed?
- ESU
- laser
- high-frequency electricity
- ultrasound
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what is a pneumatic tourniquet used for?
used in limb surgery to create a bloodless surgical site
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how is pneumatic tourniquet used?
- bandaging material Webril is wrapped around the limb
- tourniquet is placed around Webril
- Esmarch bandage wrapped from distal to proximal end of limb, pushing the blood proximally away from surgical site
- tourniquet is inflated, preventing blood from flowing back into vessels
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period from pneumatic tourniquet cuff inflation to deflation
tourniquet time
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how long can the pneumatic tourniquet remain inflated?
- up to 1 hour on upper extremity
- up to 1-1/2 to 2 hours on lower extremity
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who can apply pneumatic tourniquet?
surgeon or RN circulator
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pneumatic tourniquet pressure
- adult upper extremity - must not exceed 50-75 mmHg above systolic BP
- adult lower extremity - must not exceed 100-150 mmHg above systolic BP
- pediatric - upper limit is 100 mmHg above systolic BP
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how is pneumatic tourniquet used if surgery continues beyond recommended inflation time?
- tourniquet is deflated for 10 minutes and then reinflated
- hemostasis must be maintained while it is deflated
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what is done with the Esmarch bandage once removed?
surg tech should always roll it because it may be needed again during the procedure
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hold tissue together by suture
approximate
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2 main structural categories of sutures
- monofilament suture - single continuous fiber
- multifilament suture - many filaments combined to form one strand
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multifilament subcategories
- twisted - multiple fibers twisted in same direction
- braided - mulitple fibers intertwined
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what do multifilament sutures do?
absorb moisture and hold body fluids (wicking/capillary action)
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why is some multifilament suture coated?
to reduce tissue drag and wicking
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suture sizes
range from 12-0 (thinnest) to 5 (thickest)
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Brown & Sharp sizing system
from size 38/40 gauge (thinnest) up to 18 gauge (thickest)
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the amount of force needed to break the suture
tensile strength
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tensile strength is influenced by these factors:
- type of knot - 10-40% weaker when knotted
- biological environment of the suture - vary in strength when exposed to body fluids
- uniformity - must be uniform in diameter to maintain tensile strength
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suture's tendency to retain its shape or configuration after it is removed from the package
memory
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high-memory suture
springy and tends to tangle during preparation and use
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flexibility of a suture material
pliability
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material's ability to stretch and then return to its former configuration
elasticity
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ideal suture
one that retains its strength throughout the healing period and then dissolves when healing is complete
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how do absorbable protein-based sutures dissolve?
it is attacked by enzyme-releasing lysosomes that digest the suture
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how do absorbable synthetic sutures dissolve?
they are degraded by hydrolysis
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body's response to suture
bioactivity
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natural absorbable suture used on tissues that heal rapidly
surgical gut (catgut)
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what is plain surgical gut suture used for?
primarily in mucous membrane or in tissue where stones can form (biliary or urinary systems)
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sutures treated with chromic salt to resist digestion and absorption
chromic gut
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chromic gut absorption
usually absorbed in 7 to 21 days
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plain surgical gut absorption
retains tensile strength for 7 to 10 days
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synthetic absorbable polymers
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synthetic sutures tensile strength
provide wound support for 3 weeks to 6 months, depending on material
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the use of very fine silk sutures placed in close approximation was developed by?
William Halsted in the late 1800s
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sutures that are soft and pliable, and have excellent tensile strength
silk sutures
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are cotton sutures still available in the US?
nope
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first synthetic suture material available
nylon
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nylon sutures
- Dermalon
- Ethilon
- Monosof
- Nurolon
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when are nylon sutures used?
- when long-term strength is not required
- passes very easily through delicate tissues of the eye or blood vessels
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sutures used in cardiovascular surgery, especially when grafts are used, because of its strength-to-size ratio
polyester sutures
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sutures popular for plastic, ophthalmic, and vascular surgery, and for retention sutures in abdominal wall surgeries
polypropylene
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strongest of all suture materials
stainless steel
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when are stainless steel sutures used?
in the approximation of bone and other connective tissue
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what are surgical needles made of?
high quality steel alloy
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3 types of needle eyes
- closed eye
- French eye
- atraumatic (swaged)
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what does closed eye needle look like?
- resembles sewing needle
- eye hole is round, rectangular or square
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what do French eye needles look like?
have 2 eyes that are connected by a slit from the top through the eyes with ridges that hold the sutures in place
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what do swaged sutures look like?
- suture is inserted into the eye end and the area is crimped and sealed
- suture comes preattached
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swaged suture that can be detached from the needle by pulling it straight back from the swage
Control-release (De-tach)
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swaged suture with a needle swaged to each end
double-armed suture
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what is a double-armed suture used for?
- circular tissue such as ophthalmic surgery
- hollow structures such as blood vessels or intestine
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what is blunt needle used for?
does not puncture tissue, but slides between tissue fibers
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what is tapered needle used for?
punctures tissue, making an opening for body of the needle to follow
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what is cutting needle used for?
fibrous connective tissue such as skin, joint capsule, tendon
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dispensing methods of sutures
- suture-needle combination - one combination per pack
- multiple suture strands
- suture reel - spool of suture material
- multiple suture-needle combinations
- double-armed suture - one suture strand/needle per pack
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each loop of a suture knot
throw
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2 types of suturing techniques
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single long suture length that is anchored at one end of the tissues
continuous suture (running suture)
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continuous suture technique
needle is alternated from one side of the tissue edge to the other
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pros/cons of continuous suture technique
rapid and uses relatively little suture material, but does not allow surgeon to make adjustments in aligning wound edges
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suture used for cosmetic closure and in pediatric patients
subcuticular or buried suture
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subcuticular technique
- needle is placed within the dermis from side to side
- brings the skin edges together in close approximation
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continuous suture for closing the end of a tubular structure
purse-string suture
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purse-string technique
one end of suture is anchored and stitches are placed around the periphery of the open "tube"
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locking suture technique
as needle is passed through each side of wound edges, it is passed underneath one loop
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sutures that are individually placed, knotted and cut
interrupted sutures
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interrupted suture technique
tension of the wound edges is distributed over many anchor points
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sutures that provide additional support to wound edges in abdominal surgery
retention sutures
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retention suture technique
heavy sutures are placed through all tissue layers of the body wall several centimeters from the primary suture line, perpendicular to the incision line
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what prevents retention sutures from cutting into the patient's skin?
plastic or rubber bolsters are threaded through the suture
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used to ligate a large bleeding vessel
suture ligature (stick tie)
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what are the most delicate needle holders used for?
microsurgery and ear and ophthalmic surgery
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what are smooth forceps used for?
mucous membrane organ tissue and any tissue that bleeds easily
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what are toothed forceps used for?
connective tissue including the skin
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vascular forceps
specially designed with a scored insert at the working tip, preventing puncturing of the blood vessel but provides sufficient friction to hold
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before passing suture to the surgeon, how far from the end of the swaged section should the needle be mounted?
about 0.5 mm
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left-handed surgeon sutures in what direction?
counterclockwise
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right-handed surgeon drives needle in which direction?
clockwise
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with a back-handed suture, left-handed surgeon drives needle in which direction?
clockwise
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with a back-handed suture, right-handed surgeon drives needle in which direction?
counterclockwise
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suture strand lengths
precut or full-length strands ranging from 12-60 inches
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what are continuous reels or rolls of sutures used for?
repeated blood vessel ligation
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when suture reels are used, how much of the reel is passed?
entire reel
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what clamps are commonly used to pass a tie?
right-angle or long, curved clamp
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what types of sutures are used on circular or tubular suture lines?
double-armed sutures
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what works best for pulling out an old suture embedded in scar tissue?
straight, fine-tipped hemostat
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clamps the tissue against the staple cartridge
anvil
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places a single line of staples across the incision border and is used for closing a skin incision
skin stapler
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places a double row containing two staples in each row and severs the tissue between rows when fired
ligation-dividing stapler
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used for end-to-end intestinal resection (cutting and rejoining) - joins two arms of intestine with double row of staples
circular or end-to-end stapler
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right-angle firing section that fits around deep structures for resection and anastomosis - commonly used in lung or abdominal surgery
thoracoabdominal stapler
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performs same function as purse-string suture and places circumferential nylon sutures and staples
purse-string stapler
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small, V-shaped staples that close down and occlude vessel or duct
hemostatic or vessel clips
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used to join wound edges without using sutures
synthetic tissue adhesive
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examples of tissue adhesives
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where are tissue grafts usually obtained?
from registered tissue bank or from the patient's body
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tissue graft derived from human tissue
allograft
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obtained from the patien'ts body and implanted in another site
autologous autograft
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tissue graft of beef origin
bovine graft
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migration of epithelial cells into the wound during healing
epithelialization
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any type of tissue replacement or device placed in the body
implant
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graft taken from pig tissue
porcine graft
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tissue used to cover large defects in skin
wound cover
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graft taken from a different species than that of the donor
xenograft
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what is porcine graft used for?
full thickness injury
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what is an amniotic membrane graft used for?
to cover spina bifida defects and in corneal surgery
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biosynthetic dressing made of silicone film in which nylon fabric is partially embedded
Biobrane
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skin substitute derived from human fibroblasts
TransCyte
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semipermeable silicone layer that acts like epidermis
Integra Bilayer Matrix Wound Dressing
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only approved skin substitute that regenerates dermis
Integra Dermal Regeneration Template
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epidermal replacement generated from biopsy of skin taken from the patient
Epicel
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how often are keratinocytes duplicated
2-3 weeks
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has 2 layers, human-derived epidermis and bovine collagen dermis
Apligraf
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used for structural support and to stimulate new bone growth in defect caused by trauma or congenital anomaly
bone grafts
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2 types of bone used for grafting
cancellous and cortical bone
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bone that is porous in which tissue fluid can reach, allowing most of the bone cells to live
cancellous bone
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bone that is very rigid and strong
cortical bone
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grafts made from nonliving cadaver bone
allogenic grafts
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grafts made of a combination of cadaver bone, morcelized allograft bone and marrow
composite grafts
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processed material made from collagen, protein, and growth factors
demineralized bone matrix
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what is used in vascular surgery to replace an artery when saphenous autografting is not feasible?
human umbilical cord
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types of synthetic implants
- metal
- methylethacrylate
- resorbable implants
- polyethylene
- silicone
- woven synthetics
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what type of implant is used for orthopedics?
metal
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what type of implant is used to secure prosthetic implants into bone and for remodeling during cranioplasty?
methylethacrylate
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what type of implant is used for orthopedic and maxillofacial surgery?
resorbable implants
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what types of implants are used in facial reconstruction?
polyethylene
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what type of implant should not be handled with bare hands?
silicone
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what type of implants are used for vascular grafts?
woven synthetics
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when are drains placed in the wound?
before complete closure
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drain that creates a passage from the tissue inside the wound to the outside of the body
passive drain
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simple tubular length of nonlatex material similar to surgical glove material
Penrose drain
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drain that is used in wounds or hollow structures that produce significant amounts of fluid but do not require suction for removal
gravity drain
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examples of gravity drainage
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