Surgical Instrumentation for Gynecological Procedures
Transcription
Surgical Instrumentation for Gynecological Procedures
Sponsored by: Surgical Instrumentation for Gynecological Procedures LEARNING OBJECTIVES: 1. Discuss common gynecological surgical procedures. 2. List five instruments unique to gynecology instrument sets. 3. Name three anatomic structures potentially damaged by faulty instrumentation. CIS Self-Study Lesson Plans (Instrument Continuing Education-ICE) 4. Review instrument set audit procedure for quality improvement. Surgical instrumentation designed for gynecological procedures cover a wide range of specialties, including laparoscopic, robotic, and microscopic. This lesson will focus on basic instruments utilized in open gynecology procedures. Unique attributes of female anatomy has given life to Plato’s expression, “Necessity is the mother of invention.” (circa 375 B.C.) Instrument designers, frequently the surgeons themselves, have worked to meet the need with an eye toward safety. Certified Instrument Specialists (CIS) continue the tradition by maintaining and processing gynecologic instrumentation to the highest standard. Objective 1. Discuss common gynecological surgical procedures. Carla McDermott, RN, CRCST, ACE Education Specialist, Morton Plant Mease Healthcare Dunedin, FL [email protected] Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation. You can use these lessons as an in-service with your staff, or visit www.iahcsmm.org for online grading at a nominal fee: $5 per lesson, or bundled packages of 6 lessons for $25 (save $5) or 2 lessons for $50 (save $10). Each lesson plan graded online with a passing score of 70% or higher is worth one point (contact hour). You can use these points toward either your recertification of CRCST (12 points) or CIS (6 points). Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the ICE Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions). The CIS will utilize their knowledge of medical terminology and anatomy to assure the proper instruments are prepared for specific surgical procedures. For instance, if the surgery schedule lists the procedure as “Bilateral Tubal Ligation”, a phone call will be placed for additional information. To appropriately prepare the instrument set and/or case cart for the procedure, the CIS needs to know if the procedure is being performed in the ‘post partum’, ‘interim’ or laparoscopic mode. If the patient has very recently delivered a baby, the procedure is ‘post partum’ and only short instruments are required since the uterus and fallopian tubes are still very high in the abdomen. An ‘interim’ tubal ligation is performed six weeks or longer past the previous pregnancy so longer Babcocks and Kellys are required in the instrument set. The fallopian tubes are very deep in the pelvic area and not accessible with shorter instruments. The laparoscopic procedure is only done in the ‘interim’ and requires a GYN laparoscopic instrument set. Preparing instrumentation for a hysterectomy also requires the CIS to exercise their knowledge. Information must be included in the scheduling function that identifies the specific approach, abdominal versus vaginal, and open versus laparoscopic. Likewise, if the patient is scheduled for an endometrial ablation, the CIS must verify the specific surgical approach and whether a laser will be utilized. By following through to obtain adequate information, the CIS helps assure a more positive experience for the patient, surgeon and surgical team. Preparation allows smooth delivery of care for the patient and decreases frustration for the team by eliminating delays. Objective 2. List five instruments unique to gynecology instrument sets. Instruments specific to gynecology include retractors, vessel clamps, scissors and needle holders. Retractors unique to gynecology include the O’Connor – O’Sullivan self-retaining ring retractor, Balfour retractor with bladder blade IAHCSMM CIS Self-Study Lesson Plans and Heaney hand-held retractor. A crucial consideration in processing these retractors is assuring the edges are smooth. A burr on the blades can cause tissue and nerve damage. The self-retaining retractors have multiple moving parts that must be thoroughly inspected for cleanliness, burrs and all removable parts. Blades, wing-nuts or set screws assure proper function in use. Any missing or broken part delays the procedure and causes undue stress. Should missing or broken pieces go undetected until the conclusion of the procedure, valuable time is wasted searching for an item that was not present as expected. Clamps designed to grasp and occlude large blood vessels and ligaments supporting the uterus in the pelvis include the Heaney, Ballantine and Rodgers. These large sturdy clamps can be straight or curved jaws with serrations running horizontally or longitudinally. The strength and size is critical in controlling blood loss. The CIS’s inspection of this clamp must include the ratchet strength to assure secure closing and prevent inadvertent opening of the clamp in use, cleanliness and smooth operation of the jaws. A set usually includes three of each kind in exactly matching size and shape. This helps optimize available space for the surgeon’s hand and required clamps in the surgical field. Clamps of unequal length increase the risk of bleeding. Scissors must be of appropriate length. Routine sizes are needed for opening and closing the incision and length of 8 to 9 inches are needed to reach structures deep in the pelvis. The Jorgensen scissor is a curved right angle scissor used to seperate the cervix from the vaginal mucosa. The prudent CIS will test the cutting edge of this scissor with each use because of the dense, fibrous nature of the cervix. This scissor dulls quickly. Needle holders and forceps must be matching in length to enable the surgeon to repair the tissue severed in removal of the uterus. Heaney needle holders have curved jaws to increase visibility of needle placement. The jaws of the needle holders are critical in this function. The needles used to repair this tissue are round bodied. The jaws are flat surfaced. Undue wear of the serrated jaw surface will not hold the needle securely causing it to spin in the tissue. Bleeding results, and can be difficult to control. Inspection is key in providing quality instruments and a positive patient outcome. Objective 3. Name three anatomic structures potentially damaged by faulty instrumentation. Vital structures not directly involved in gynecological surgeries are at risk of damage from instrumentation. Abdominal wall tissues and nerves can be compressed by malfunctioning or poorly placed retractors, resulting in increased post-operative pain. A burr on the blade used to retract the bladder or bowel can tear the tissue requiring additional repair. Major blood vessels can be damaged by clamps that are sprung and do not hold properly. Damaged blood vessels means increased blood loss that may require blood transfusion for the patient, which significantly increases the risk of the procedure. Objective 4. Review instrument set audit procedure for quality improvement. Quality improvement is a vital function for the CIS. Along with the routine care and maintenance of surgical instruments, education is required to assure a strong knowledge base of the instrumentation. It is difficult to recognize when items are missing or damaged if there is no information describing complete and functional use of the instruments. Maintaining a record of preventative care provided by a reputable instrument service company helps determine budgeting for repair or replacement of instrumentation. Surgical teams appreciate knowing the instrument sets are properly cared for each time they are used. Processing and sterilization do take a toll on the instruments. Audits that reveal “use versus presence” of instruments in the set can guide set make-up. Removing instruments no longer used decreases wear and tear on the instrument and reduces unnecessary work load of inspection and handling. An added plus for the surgery team is they do not have to count instruments that will not be used. The audit can also point out instruments that need to be placed in the set. Are there instruments that are opened for a majority of cases? Placing them in the set reduces the time and expense of handling, packaging and sterilizing wrapped or peel pouched instruments. The surgery team saves time and effort in opening an additional item. Improving quality provides benefits for the patient, surgeon and the facility! Bibliography International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Sixth Edition. 2005. Scultz, R. Inspecting Surgical Instruments, An Illustrated Guide. 2006. International Association of Healthcare Central Service Materiel Management. Instrumentation Resource Course: Identification Handling and Processing of Surgical Instruments. 2006. Chen, NC; Towler, MA; Moody, FP; McGregor, W. Mechanical Performance of Surgical Needle Holders. Journal of Emergency Medicine. 1991; 9:477 CIS Self-Study Lesson Plan Quiz (Instrument Continuing Education-ICE) Surgical Instrumentation for Gynecological Procedures Questions (circle correct answer): 1. “Post partum” refers to the time period immediately after giving birth. 7. Burrs occur only on orthopedic instruments and not considered a problem for GYN instruments. True False True False 2. A laparoscopic tubal ligation can be scheduled when ever the patient chooses. 8. Wing nuts are completely interchangeable, therefore do not need to be counted. True False True False 3. Surgeons are often involved in designing instruments that meet specific needs. 9. Heaney clamps are always used in pairs. True False True False 4. Lasers are never used in gynecological surgery procedures. 10. Ballantine clamps are interchangeable with Rodgers clamps if you run short. True False True False 5. The CIS knows to provide longer Babcocks for a “post partum” tubal ligation. 11. Clamps of unequal length are preferred over equal length clamps. True False 6. Self-retaining instruments hold the incision open during the procedure. True False 13. Heaney needle holders must have smooth jaws and inserts. True False 14. Tissue damage to the bladder and bowel can occur from faulty instruments. True False 15. Quality improvement is a hallmark of the caring and competent CIS. True False Sponsored by: True False 12. Jorgensen scissors are designed to be slightly curved and cut only delicate tissues. True False REQUEST FOR PAPER/PENCIL SCORING (please print or type information below) REQUEST FOR ONLINE SCORING (payment and scoring made directly online at www.iahcsmm.org using either online check or credit card) q I have enclosed the scoring fee of $15. (Please make checks payable to Purdue University. We regret that no refunds can be given.) Name Mailing Address (Be sure to include apartment numbers or post office boxes) q Check here if you have a change of address q Check here if you wish to have your results emailed to you Detach quiz, fold, and return to: Purdue University PEC Business Office Stewart Center, Room 110 • 128 Memorial Mall West Lafayette, IN 47907-2034 (800) 830-0269 City ( State Zip code ) Daytime telephone IAHCSMM Membership Number Email Address If your name has changed in the last 12 months, please provide your former name Purdue University is an equal access/equal opportunity institution
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