Transcript Surgical proceduresx

SURGICAL PROCEDURES
By: Brian Glover and Jayme Annotti
WAYS TO USE FLUOROSCOPY IN SURGERY
• LIVE FLUORO: real-time images in motion
• SPOT: single image taken
• CINE: same as live fluoro EXCEPT it records it as a video and will replay over
and over
• Often times used when contrast is being injected
• Video can be paused and any single frame within it can be saved as an image
• SUBTRACTION
SUBTRACTION
• Procedure done to examine blood vessel
disease under fluoroscopy
• Often used in interventional radiology
• After correct position is found, the screen will
only show anything NEW that is introduced
into the field of view
• Contrast media is injected into the blood
vessel through a small catheter
• Called subtraction because it literally
subtracts the “pre-contrast image” leaving
only what is seen after the contrast is injected
SUBTRACTION
WHY IS IT DONE?
• Used to diagnose:
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Atherosclerosis (hardening of the arteries)
Heart disease
Occlusions of blood vessels
Aneurysms
Problems with retina of the eye
Abnormal tangles of arteries and veins
• Evaluate kidney function
• Gives an accurate “map” of the heart or brain prior to surgery
SUBTRACTION
OUR JOB IN SURGERY/TIPS
• Correctly set C-Arm up for subtraction
• Find position doctor would like
• Put brakes on
• Do not move C-Arm at all
• Use Cine to record
CENTRAL VENOUS LINE PLACEMENT
WHAT IS IT/WHY IS IT DONE?
• Many different types of CVADS (central venous access devices): port-acaths, PICCS (Hickman, Groshong, etc.)
• Used for the delivery of medication (often times chemotherapy) and blood
draws
• Drugs for chemotherapy are toxic and can damage skin, muscle tissue, and
sometimes veins
• Drugs often need to be delivered into a large central vein where they’ll be
immediately diluted by the bloodstream & delivered efficiently
• Cancer patients require frequent blood tests; this can be helpful for patients
with difficult veins
PORT-A-CATH
 Implanted beneath the skin
 Consists of 3 parts: portal,
catheter, and catheter
connector
 Can be placed in the chest or
arm (more commonly in the
chest)
 Septum (part that needle
punctures) made of a special
self-sealing silicone rubber; can
be punctured up to 1,000 times
 Done in the OR
PICC (GROSHONG, HICKMAN)
 Central venous
access devices
 May enter a large
vein in the neck
(internal jugular
vein) or into
superior vena cava
 Often inserted using ultrasound
to help guide the catheter
 Inserted into the upper arm
 Can be done in the patient’s
room- not done in OR
CENTRAL VENOUS LINE PLACEMENT
• For port-a-cath
placement we will
go in and take a
few (or even just
one) image(s) over
the catheter to
make sure it is
entering the correct
spot
• Often times you will
have to go in at an
angle and rotate
the image
PICC LINE
PORT-A-CATH
PACEMAKER
WHAT IS IT?/WHY IS IT DONE?
• Small device that helps control abnormal heart rhythms (arrhythmias)
• 3 leads: right atrium, right ventricle, and left ventricle
• Arrhythmias can be any abnormal heart rhythm (too slow, too fast, irregular)
• Uses electrical pulses to prompt the heart to beat at a normal rate
• HEART’S ELECTRICAL SYSTEM: Each time the heart beats, an electrical signal is
sent from the top of the heart to the bottom, causing it to contract and
pump blood. Any issue in this electrical signal can cause an arrhythmia;
pacemakers use low-energy electrical impulses to correct the problem.
• Can be placed in the chest or abdomen (more commonly seen in the
chest)
• Can be placed temporarily (short-term heart problems due to a heart
attack, heart surgery, overdose of medication) or permanently
PACEMAKER
OUR JOB IN SURGERY/TIPS
• Similar to port-a-cath placement for us
• May take a few images or fluoro over
the pacemaker and leads to ensure
correct placement
ERCP
WHAT IS IT?
• Endoscopic retrograde Cholangiopancreatography
• Non-sterile procedure
• Endoscope is fed down the patient’s esophagus to the duodenum
• Air is pumped in to help visualization of anatomy
• Catheter is fed into the duodenal papilla and dye is injected
• Visualized both on camera and on fluoroscopy with the C-arm
• Utilizes fluoro to show the injection of dye demonstrating any blockages or
narrowing of the ducts
• Blockages are opened, stones are removed, stents may be placed
ERCP
WHY IS IT DONE?
• To unblock bile or pancreatic
ducts blocked by:
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ERCP
Tumors
Gallstones
Illness such as pancreatitis
Scar tissue
Pseudocysts
Trauma
Faulty valves in the ducts
http://upload.wikimedia.org/wikipedia/commons/5/5d/ERCP_Roentgen.jpg
ERCP
OUR JOB IN SURGERY/TIPS
• Usually* a very straightforward exam
• Move into place and locate the end of the endoscope making sure it is at
the bottom/center of the field of view
• Physician will repeatedly ask for fluoro on/fluoro off
• When ready to inject you will most likely use cine to catch a run of the
contrast filling the ducts
• Once the surgeon is done removing stones or placing stents move out.
• Usually done in a small room where space is extremely limited
• Often have to come in at an awkward angle and rotate the image to the
surgeons liking.
LAP CHOLE
WHAT IS IT?
• Laparoscopic cholecystectomy
• Sterile procedure
• Incisions are made in the abdomen and tools are inserted through
these
• The abdomen is distended with air to aid visualization of the
anatomy
• Contrast is injected to visualize the bile duct before any cuts are
made and to verify any blockages or strictures
• Gallbladder is removed through one of the small incisions
LAP CHOLE
WHY IS IT DONE?
Lap Chole
• Acute cholecystitis
• Performed laparoscopically
to reduce invasiveness and
hospital stay
• Risk factors for cancer
• Gallstones
• Prevents future pancreatitis
http://www.hopkinsmedicine.org/healthlibrary/GetImage.aspx?ImageId=126078
LAP CHOLE
OUR JOB IN SURGERY/TIPS
• Usually* a very straightforward exam
• Almost like a sterile ERCP radiographically speaking
• Move into place and locate the end of the laparoscope
making sure it is at the bottom/center of the field of view
• When ready to inject you will most likely use cine to catch a run
of the contrast filling the ducts
• Usually done in a small room where space is extremely limited
• Often have to come in at an awkward angle and rotate the
image to the surgeons liking.
• Usually leave before the cholecystectomy is performed
RETROGRADES
WHAT IS IT?
• Retrograde Pyelogram
• Dye is injected to show the lining of the kidney and drainage down the
ureter on X-ray
• Scope and guide wire are inserted through the urethra to the bladder and
then into the ureters
• Contrast is injected from the bottom of the ureter and followed to the kidney
• Retrograde refers to the direction of the flow of contrast
• Stents may be placed to ensure ureter patency
• Can be performed singularly or bilaterally
• Does not always require a sterile drape on the C-arm
RETROGRADES
Retrograde Pyelogram
WHY IS IT DONE?
• Blockages in the ureters
• Kidney stones
• Tumors
• Strictures
• Place stents
• Evaluate trauma
http://www.nature.com/ki/journal/v76/n1/images/ki200964f2.jpg
RETROGRADES
OUR JOB IN SURGERY/TIPS
• Often the Urologist will control the fluoro with the foot pedal
• C-arm is moved in, often over the bladder initially
• Fluoro is used to help guide the guidewire into the ureter
• Surgeon will instruct when he is ready to inject the contrast into the ureter
• C-arm is moved from the bladder superiorly and laterally to follow the flow of
contrast to the kidney
• May require more than one run from bladder to kidney
• May be repeated on the opposite side if ordered bilaterally
• May take repetitive spot films if stents are being placed
ORIF
WHAT IS IT?
• Open Reduction/Internal Fixation
• Incision is made… Open Bones are manipulated into correct
alignment…Reduction and then plated and/or screwed to hold
everything together…Internal fixation
• Hardware is internal as opposed to external fixation methods
• Commonly done on extremities but also ribs, clavicles, pelvis, and patella
etc.
• Surgical approach is surgeon determined
• Size and shape of hardware is patient and injury specific
ORIF
WHY IS IT DONE?
• Commonly done as emergency surgery
as a result of trauma
• To repair displaced fractures that
cannot be aligned using closed
reduction methods such as casts and
splints
• To strengthen site of repeat break
Tib/Fib Fixation Hardware
ORIF
OUR JOB IN SURGERY/TIPS
• Each surgery is different as far as
approach
• Distal extremities are usually easier to
maneuver the c-arm
• Series of AP and Lateral images to check
screw placement and depth
• Can be either a short exam or a very
long exam depending on the number of
screws placed
• Usually attendance is required the entire
time from reduction through hardware
placement
• Surgeon may manipulate the limb to
obtain the view needed as opposed to
manipulating the c-arm
WHAT IS IT?
I&D AND
ARTHROSCOPY
• Irrigation and Debridement
• Arthroscopy
• Open wounds and infected
bone are irrigated usually
using saline
• Very small incisions are made
and then tools and scope are
inserted into the joint
• Dead or infected bone
material is scraped and
removed with more irrigation
to follow
• Minimally invasive and
generally a much quicker
recovery
• Often followed by joint
replacement
I & D AND
ARTHROSCOPY
WHY IS IT DONE?
I & D with anti-biotic beads
• I &D most often is performed to remove
infection such as osteomyelitis
• Commonly performed on open fractures
• May also include the introduction of antibiotics to combat return of infection
• Arthroscopy is perfomed to clean, repair, or
remove tears, osseus malformations , and
foreign bodies
• Often indicated by chronic progressive
joint pain
• Performed commonly on knees, hips and
shoulders but may include any joint
http://3.bp.blogspot.com/-EgSE_UwaoKo/TbCHDwujxJI/AAAAAAAAAB4/bwcwEDqiDXQ/s1600/image-9.jpg
I & D AND
ARTHROSCOPY
OUR JOB IN SURGERY/TIPS
• May approach the patient from any angle or direction
• Commonly only one view (AP) but may also include laterals
• Common to only be present for the osseus involved parts of the
exam, such as screw placement, as soft tissue, like menisci, are not
visible with the C-arm
• May be asked to manipulate traction, for example during an
arthroscopic hip surgery
• Many I & D and arthroscopic procedures are performed without
the use of our services
http://upload.wikimedia.org/wikipedia/commons/thumb/b/bc/Figure_9._Intraoperative_fluoroscopy_image_during_arthroscopic_resection_of_a_cam_lesion_of
_the_femur._The_upper_instrument_is_the_arthroscope_%28viewing_device%29%2
C_and_the_lower_the_highspeed_burr_%28for_reshaping_the_bone%29..png/230px-thumbnail.png
WHAT IS IT?
TOTAL JOINT
REPLACEMENT
• Removal and Replacement of the entire joint
• Performed on ball and socket joints like hip and shoulders
• Performed on hinge joints like knees and ankles
• Worn surfaces of the bones are removed or prepared
• Implant is placed onto the prepared surface or anchored into the shaft
• May use cement, with or without antibiotics
• New research being done with bone stem cells to encourage bone
regrowth around the hardware
TOTAL JOINT
REPLACEMENT
WHY IS IT DONE?
Total Hip Replacement
• Arthritis
• Trauma to the joint that is otherwise
non-repairable
• Bone tumors
• Other pathological destruction
• Done after other methods of treatment
such as physical therapy or arthroscopy
have failed
http://sussexphysio.co.uk/wp-content/uploads/2008/09/total-hip-joint-replacement.jpg
TOTAL JOINT
REPLACEMENT
OUR JOB IN SURGERY/TIPS
• Requires special PPE
• Approach varies but most often is made from the opposite side as the surgeon
• Usually stay in the room from the time of entry to just before closing of the incision
• May be as short as an AP and Lateral of the new joint to verify hardware placement
• May be complicated as in a hip replacement where a series of AP and Laterals are
repeated, verifying placement as well as alignment of both hips to ensure proper
leg length
• The same procedure is common for shoulders but uses an AP and a Grashey view
with the C-Arm
KYPHOPLASTY
WHAT IS IT?
• Minimally invasive procedure in which a cement-like material is placed into a
vertebral body
• A needle is placed through the skin and into the vertebral bone; a balloon is
then placed through the needle, into the bone, and inflated to the height
that the vertebral body should be at
• The balloon is removed and cement is injected into the space
• Often times this is performed by an interventional radiologist or
neuroradiologist, but occasionally performed in the operating room
KYPHOPLASTY
WHY IS IT DONE?
• Performed to treat painful
compression fractures
• Compression fractures can be
caused by:
• Osteoporosis due to old age (most
common)
• Multiple myeloma
• Lymphoma
• Kidney disease
• Metastatic carcinoma
KYPHOPLASTY
OUR JOB IN SURGERY/TIPS
• If performed in the operating
room, surgeon would have
the C-Arm in a lateral
position
• Tech. would take an image
after needle insertion, and
use live fluoroscopy during
injection of the cement
BEFORE
DURING/AFTER
O-ARM
WHAT IS IT?
• Portable CT Scanner
• Used during surgery
• Produces 2-d and 3-d images
• Takes about 30 seconds to
produce the images
• High-definition takes about 750
images in 26 seconds
• Low-definition takes about 391
images in 13 seconds
O-ARM
WHY IS IT DONE?
• Deep brain stimulation:
• Used to treat movement disorders (Parkinson’s, tremors, OCD)
• Device similar to a pacemaker is implanted into the brain
• Electrodes connected from wires in the brain to an electrical generator in the
chest wall
• Electrical current blocks the signals that cause the disorders
• Spinal surgeries
• Produces coronal images of the spine
• Allows surgeon to perform major spine surgery through minimal incision
O-ARM
OUR JOB IN SURGERY/TIPS
• Be extremely careful driving O-Arm into operating rooms since it is so large
• O-Arm may be positioned around patient’s head, and many times there are
devices we need to be aware of
• While the O-Arm is actually taking the images, the doctor/nurses/scrub techs
may step outside
• Best place to stand to get the least amount of radiation is directly behind the
O-Arm controls (as if you were going to drive it)
• Know how to adjust the tilt of the O-Arm if needed (Deep brain stimulation)
SPINAL FUSION
WHAT IS IT?
• Can be done on cervical, thoracic, or lumbar spine
• Fusion of two or more vertebrae; the idea is to fuse together painful
vertebrae so that they heal into a single, solid bone
• Will take away a little flexibility but not much
• Surgeon may take an anterior, posterior, or lateral approach to reach the
spine
• A bone graft is used (often a piece of bone from the pelvis) and placed
between the vertebrae to initiate bone growth
• Plate and screws may be inserted to help stabilize the vertebrae
SPINAL FUSION
CERVICAL SPINAL FUSION
WHY IS IT DONE?
• To relieve back pain caused by
conditions such as scoliosis, fractures,
infections, tumors, etc.
SPINAL FUSION
OUR JOB IN SURGERY/TIPS
• Move C-Arm into a lateral position
• Surgeon will eventually have you take images of the plate and screws;
he/she may adjust the hardware and continue having you take images
• Surgery team may tell you that you can leave and they will call you back to
the room; they will almost always have you move the C-Arm “north” up
toward the patient’s head
• **When you move the C-Arm north, you need to move it up as far as you
can to allow as much room as possible to work
SPINAL LAMINECTOMY/DISKECTOMY
WHAT IS IT?
• LAMINECTOMY: Removal of the lamina
(posterior portion of the vertebrae)
DISKECTOMY: Removal of the damaged portion
of a herniated disk in the spine
• Surgeon cuts open the back, removes part of A herniated disk occurs when part of the softer
the spinous process, and then removes part of intervertebral disk pushes out through an opening
or the entire lamina
between vertebrae
• Bony growths that press against nerves are
also cleared away
SPINAL LAMINECTOMY/DISKECTOMY
WHY IS IT DONE?
• Both are typically done to treat spinal stenosis
• Spinal stenosis is narrowing of the open spaces within the space, putting
pressure on the spinal cord and nerves traveling through the spine
• Usually occurs in the neck and lower back
• RISK FACTORS include:
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Age: typically people over 50
Genetics
Spinal injury history
Obesity
SPINAL LAMINECTOMY/DISKECTOMY
OUR JOB IN SURGERY/TIPS
• Usually pretty quick for the radiologic technologist
• Surgeon will begin procedure and place a needle into the skin where he/she
believes is correct
• You will take an image for needle placement (often using the portable
machine and a cassette)
• If needle placement is correct, surgeon will have you come back shortly and
take another image with instruments in place
• **You aren’t centering at the needle- must have C1 down for cervical and
top of sacrum up for lumbar
• **Nurse may pull on patient’s legs for cervical images to help drop shoulders
RESOURCES
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//www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/kyphoplasty_135,36/>.
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