1. Surgeon Name: HYPOSPADIAS OR Protocols Template for: HYPOSPADIAS There are explanations of each template - how it will look when finished and how to correctly complete each template. Please fill each section out and return to max.maizels@gmail.com 1.OR Checklists 2.Procedure Sequence Guide 3. Room Arrangement 4. Instrument Labels Margarett Shnorhavorian, MD, MPH

2. Surgeon Name: Glove Size: OR Protocols - General Checklist Please use the line shape below to cross out items on the example checklist that you do not wish to have included on your personal checklist. If you wish to add additional items not listed here, please use the following slides to add them to the appropriate section. Copy, paste and move this line as many times as required. Margarett Shnorhavorian, MD, MPH 6 Sensicare

3. DoneN/A 1. Pre-Flight (Preparations) Checklist Please add any items you wish to include on your list. General: For All Cases Anesthetic plan established, type of regional block Preoperative antibiotics established Fellow or resident participating in case established Pagers removed from self and placed on counter Site marked Time out performed Dressing: Dermabond Sutures selected

4. DoneN/A Please add any items you wish to include on your list. 2. In-Flight (Procedure) Checklist General: For All Cases

5. DoneN/A Please add any items you wish to include on your list. DoneN/A DoneN/A NEXT Case Preparations: THIS Case Preparations: 3. Landing (Post-Procedure) Checklist General: For All Cases Determine location of next patient Need for H/P or consent of next patient Safety sign out performed Parents notified PACU orders written Postoperative antibiotics and pain medication plan established Postoperative orders written Disposition established Equipment issues Improvements

6. Surgeon Name: Procedure: Glove Size: OR Protocols – Procedure Checklist Please use the line shape below to cross out items on the example checklist that you do not wish to have included on your personal checklist. If you wish to add additional items not listed here, please use the following slides to add them to the appropriate section. Copy, paste and move this line as many times as required. Hypospadias Margarett Shnorhavorian, MD 6 Sensicare

7. DoneN/A 1. Pre-Flight (Preparations) Checklist Please add any items you wish to include on your list. Hypospadias-Specific If over age 2: Sutures: 3-0 PDS on RB1, 5-0 monocryl on P3 Needle tip on bovie electrocautery If under age 2: Sutures: 4-0 PDS on RB1, 6-0 monocryl on P3

8. DoneN/A Please add any items you wish to include on your list. 2. In-Flight (Procedure) Checklist Hypospadias-Specific

9. DoneN/A Please add any items you wish to include on your list. DoneN/A DoneN/A NEXT Case Preparations: THIS Case Preparations: 3. Landing (Post-Procedure) Checklist Hypospadias-Specific

10. OR Protocols – Procedure Sequence Guide Here is an example of the procedure sequence guide. It contains components and steps for each part of the surgery. The 3 rd column lets the nurse or scrub tech know what instrument to have ready. Please use the following slides to create your procedure sequence guide with the specifics of how you perform the surgery.

11. Components StepsInstruments / Scrub Tech Surgical Procedure: HYPOSPADIAS Mark Incision 1.Mark 2 cm incision along Langerhans lines 1/3 of the distance between ASIS and pubic tubercle 1.Marking pen 2.Raytec Incision and Dissection 1.Make incision at skin 2.Incise dermis with electrocautery 3.Use Metzenbaum scissors to dissect through Scarpa’s fascia 4.Divide Scarpa’s and develop plane to external oblique fascia 5.Define shelving edge and superficial inguinal ring 1.15 blade scalpel 2.Adson x 2 3.Metzenbaum 4.Electrocautery with needle tip 5.S retractors x 2 Open Fascia and Expose Cord 1.Incise fascia with blade 2.Open fascia by spreading scissors 3.Sweep cremasterics and nerve off posterior side of fascia 4.Separate cremasteric fibers 1.15 blade 2.Metzenbaum scissors 3.Debakey forceps x 2 Dissect out hernia sac and ligate 1.Identify and lift up hernia sac 2.Deliver entire sac with cord out of incision 3.Identify testicular vessels and vas deferens 4.Dissect hernia sac off cord proximally 5.Divide sac and twist proximal end 6.Suture ligate hernia sac and place second tie proximal to suture 7.Open distal sac and express fluid 1.Debakey forceps x 2 2.Raytec 3.Straight snap 4.Metzenbaum scissors 5.4-0 PDS (if over age 2, use 3-0 pds) Close Fascia and skin 1.Close external oblique fascia 2.Close Scarpa’s fascia 3.Deep dermal approximating stitch 4.Close skin 5.Pull on testicle 6.Dermabond skin 1.4-0 PDS (if over age 2, use 3-0 pds) 2.Debakey forceps 3.6-0 monocryl (if over age 2, 5-0 monocryl) 4.Adson forceps x 2 5.Dermabond

12. Components StepsInstruments / Scrub Tech

13. Components StepsInstruments / Scrub Tech

14. OR Protocols – Room Arrangement This section shows how the room should be arranged for each procedure and where each staff member generally stands. On the following slide, move the objects around to position them correctly for your hypospadias procedure. If you need more objects, simply copy and paste one, then double click the text to change the name of the item. IV Pole Foot Pedal

15. Room Arrangement: Hypospadias Please use the shapes below as shortcuts for any new items. OR Table Surgeon Assistant Scrub Video Bovie Back table IV Pole Anesth Door to OR Circulator’s Computer Mayo Circulator Foot Pedal Patient’s head Text Extra Text

16. OR Protocols – Instrument Labels This section shows how to correctly set up the mayo stand or back table. It also shows the names of each instrument so that mistakes are avoided. On the following slide, please insert your own photo of your mayo stand or back table. Then use the blank labels to type in the correct names and position the labels appropriately.

17. Mayo Stand | Hypospadias Copy/Paste to re-use. The shape will change to fit the amount of text. Text Label Mosquito (2) Straight Snap (2) S Retractor (2) Light Handles (3) Metzenbaum Adson (2) Debakey (4) Marking Pen Raytec Electrocautery with Needle Tip