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Intraoperative Case
Management
Reading Assignment
• You are responsible for the reading material
• The operative sequence will be more thoroughly
explained next class, but is the largest part of the
intraoperative case management
Critical Thinking
• Involves organizing your thoughts and
actions which allows you to make case
management decisions
• Identify goal or issue
• Gather info and evaluate it
• Generate responses to issue or goal and
consider implications for each (usually a
series of actions)
• Implement, act on, or produce best
response
• Assess results of your actions and make
adjustments if needed
Anticipation
• This is the ability to implement your critical
thinking skills
• You are able to predict or anticipate the
needs of the patient, surgeon, and other
surgical team members
• The surgical technologist must be
observant, organized, efficient, and able to
think clearly
• The success of the operation depends
largely on the STSR and his or her ability to
anticipate the needs as they present
themselves
Anticipating the Sequence of
Events in Surgery
Example: An incision requires a knife blade (#3
handle with #10 blade), patient will bleed,
surgeon needs a raytex or lap and cautery to
cauterize bleeders. All of this is anticipated and
the surgeon does not need to ask you for them
because you know or can anticipate the needs
as the situation presents. If you have passed a
tie, you anticipate the surgeon will need another
tie, then metz to cut the structure ligated, then
straight mayos or suture scissors to cut the
ligatures. None of this should have to be
requested of you. Most of you actions will
directly follow the operative sequence which you
will learn backwards and forwards.
Operative Sequence
• Pgs. 372-373 St for the ST book
• By the Book
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Incision
Hemostasis
Dissection
Exposure
Procedure
Hemostasis
Irrigation of wound
Closure
Dressing application
Communication
• Do not engage in idle chit chat
• Do not participate in inappropriate conversation or
commentary
• If you don’t have anything nice to say, keep your mouth shut
• Speak when spoken to
• Respond when surgeon speaks to you
– If he or she asks you for something and you don’t have it, let
them know you’re getting it (ask circulator)
• DO NOT get defensive or argumentative EVER!
• You are a surgical team member and will act professionally at
all times
• Be advised surgeons yell and cuss when they get frustrated
sometimes. Remember, 99.9% of the time they ARE NOT
yelling at you but at the situation. DO NOT take it personally.
• This is NOT about you, this is about the patient!
Communication
• The Intraoperative phase is when most verbal
communication occurs (and sometimes least!)
• Provide what the surgeon asks for quickly and
efficiently
• If you anticipate the surgeon will need something
you do not have, ask for it from your circulator or
make sure they have it available in the room
Conflict Management
• If you have an issue with a circulator or other team
member
– Ask that person if you guys can talk after the case
– Choose a quiet, private area
– NEVER deal with issues in an OR room in front of others
especially the patient!
– Approach the person by stating that you felt they were
upset with you during the case. Do they have suggestions
for ways you might improve? Yes, take the responsibility
for the situation even if you didn’t create it. Often times,
folks just get frustrated and take things out on whoever is
available. They may apologize and say you haven’t done
anything. They may give you feedback on ways to
improve. Either way it’s a win-win situation for you. None
of us are perfect and we can always improve!
Safety
• Use bovie holster even if the surgeon
doesn’t. Keep it in front of yourself and
reholster when not needed. If you see
minor bleeding, anticipate the surgeon
needs the bovie and have it ready to pass to
him or her.
• Safe transfer techniques
• Cautious/proper handling of sharps
• Double glove
• Protect self and patient from radiation (lead
aprons) and laser (appropriate goggles for
type of laser being used)
Passing Instruments
• Know how to pass instruments correctly
Order and Neatness
• Keep your mayo and back table orderly and
neat at all times
• Put things back in their original place after they
are used
• This will help you find them next time you need
it
• Nothing is worse than an unorganized STSR
• Surgeons do not enjoy working with these folks
as they impede the progress of the procedure
• Keep instruments clean after used
• Do not give surgeons bloody instrumentation to
work with (keep a lap handy to wipe prn
Counts
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Initial
First count (closing 1)
Second count (closing 2)
Final count
Anytime there is a change in scrub or
circulator personnel (lunch relief or end
of shift relief)
• TOTAL NUMBER OF COUNTS – 4 (ON
STANDARD BELLY CASE)
• How many on a C-Section?
Counting
• Initial counts are done prior to the procedure when all items
are on the back table
• Count instruments, sponges, laps, kittners/peanuts,
miscellaneous
• Items close together to prevent items being overlooked
• Be organized when counting, do not jump around
• Additional items are counted as added to the field with the
circulator
• Items and instruments must be visible to both parties involved
in the count
• Count members must include an STSR and an RN circulator
• Any time a cavity is entered instruments must be counted
in the initial and first count!
Counting
• First count (closing 1)
 Instruments
 Begin at the field, move to mayo stand, to back table, then to
off table (in kick bucket or other-case cart if an instrument
dropped - is where it is usually placed)
 Sponges, laps, kittners/peanuts
 Miscellaneous (blades, suture, bovie tip, etc,)
• Performed prior to or as the cavity that is being
worked inside of is closed or being closed
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Abdominal cavity
Pelvic cavity
Chest (thoracic) cavity
Cranial cavity (facility dependent)
Any time a cavity is entered instruments must be
counted in the initial and first count!
Counting
• Second (closing 2)
 Begin at the field, move to mayo stand, to back table,
then to off table (in kick bucket or other-case cart if
an instrument dropped - is where it is usually placed)
 Sponges, laps, kittners/peanuts
 Miscellaneous (blades, suture, bovie tip, etc,)
• Performed after a cavity has been closed as
fascia or subcutaneous layer is being closed
Counting
• Final count
• As skin closure initiated
• Begin at the field, move to mayo stand, to back
table, then to off table (in kick bucket or othercase cart if an instrument dropped - is where it is
usually placed)
 Sponges, laps, kittners/peanuts
 Miscellaneous (blades, suture, bovie tip, etc,)
Counting
• If something is missing: It is your
responsibility to let the surgeon know
immediately
• Do not reach in front of a surgeon
• Do not grab items form a surgeon
• Point to items counted that may be in their
hand, by saying “forceps, one up (point to
his or her hand)….
• Let surgeon know immediately when item is
located that may have been missing
• Patient cannot leave room until all items
accounted for
Incorrect Counts
• Radiology technicians come to take x-rays for incorrect counts
• Sterility must be maintained of yourself, your tables, and your
field
• You may need to cover the patient with a separate sterile
drape to protect the filed should the x-ray be positive for a
missing item and you need to retrieve it prior to transport of
the patient
• Occasionally a patient is too unstable to stay in the OR for this
• Surgeons may request the patient be moved to ICU in these
situations
• Reports are delivered by phone or hard copy x-rays may be
returned to room for surgeon inspection
Specimen Care
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You may pass off specimens ONLY IF the surgeon says you may do
so
You must identify the specimen as the surgeon presents it to you
and again prior to passing it off to the circulator so that he or she
may record it correctly on the laboratory paperwork
You must verify with the surgeon and circulator how the specimen is
to be sent to the lab
1. Permanent (In formalin)
2. Fresh/Frozen
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With or without margins
With margins determines if all of a tumor has been cut out (clear margins
indicate all of it is excised)
Unclear margins indicate further excision is required
DO NOT break down set ups when awaiting frozen results with margins!
3. Culture
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Specific microbiology tests to be run: Acid Fast Bacillus (AFB), fungal,
aerobic, anaerobic, etc.
Medication Handling
• Ask circulator patient allergies if they do not tell you
what they are
• PCN allergies: typically will not used cephalosporins
such as Kefzol or Cefazolin
• Ask surgeon prior to putting it in your irrigant!
• Six med rights
• Verify medication with circulator before allowing it
onto your field
– Identify medication
– Identify expiration date
• Keep up with amounts used of all medications that
are solutions including irrigants
Dressing Application
• Do not receive dressings until FINAL count
is complete (4x4s can be confused with
raytex)
• Ensure that dressing is protected from
becoming wet during drape removal
• Place a dry towel over the dressing that you
apply, hold in place with one hand and
remove drape with other hand
• Remove outer gloves and assist circulator
prn with taping or securing dressing
• Continue/move on to post-operative case
management