Genitourinary Surgery Chapter 25 Genitourinary Surgery

Genitourinary Surgery Review terms and definitions listed at beginning of chapter Use your medical dictionary if necessary Familiarize yourself with the chapter terminology. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Surgical areas Female Urethra Bladder Ureters Kidney Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Surgical areas Male Urethra Bladder Ureters Kidney Prostate Testicles Penis Accessory structures What organs make up the genitourinary system? What structures are part of the external male genitalia? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Common surgical approaches Transurethral Cystoscopy Ureteroscopy Open surgery Minimally invasive Urinary procedures are classified as open or closed. Open procedures require an incision to be made. Closed procedures are performed through cystoscopy. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Kidney Each kidney weighs about 150 g and is about 11 cm long. Describe the layers of renal tissue. Anatomy of the kidney. (From Brundage DJ: Renal disorders, St Louis, 1992, Mosby) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Kidney Nephron Functional filtering unit of the kidney Kidney stones Precipitation of specific salts from the filtrate and the urine Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Urinary bladder. How many tissue layers make up the bladder? Which nervous system controls the emptying of the bladder? (From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St Louis, 2007, Mosby Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Urethra Female Originating at the trigone Ending at the meatus Male Prostatic urethra Membranous urethra Cavernous urethra Why is the male urethra longer than the female urethra? Name the three distinct parts that make up the male urethra. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Male reproductive organs. Reference Figure 25-6, A, male reproductive organs, in the textbook. What organs make up the male external genitalia? (From Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Scrotum Lies at base of penis Protects the testicles What purpose does the scrotum serve? How does the scrotum help in regulating temperature for maximum sperm protection? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Testicles Epididymis Vas deferens Seminal vesicles Prostate gland Bulbourethral glands What does the epididymis secrete? What is testosterone, and why is it important? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Penis Male copulatory organ Highly vascular Flaccid except during sexual stimulation The penis is composed of how many tissue columns? The foreskin, or prepuce, is removed during a circumcision. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Vas deferens Forms a portion of the path that the seminal fluid travels Continues across bladder and ureter Meets opening of seminal vesicle and forms ejaculatory duct The vas deferens may become trapped in an inguinal hernia. The ejaculatory duct is formed by the joining of the vas deferens and the seminal vesicle’s duct. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Kidney dialysis Removal of waste products from the blood of the patient with chronic kidney disease or end-stage renal disease Hemodialysis Peritoneal Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Diagnostic tests Urinalysis Blood test Glomerular filtration rate Blood urea nitrogen (BUN) Tissue biopsy Imaging studies Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Positioning Lithotomy Cystoscopy Supine Bladder, prostate Lateral Kidney and ureters Prone Nephroscopy Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Open Instruments Open GU instruments. Left to right. A, Fine hemostatic forceps. Satinsky clamp. Herrick kidney clamp. Satinsky vascular clamp. Right-angle clamp. Mayo kidney clamp. (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) B, Nephrectomy and ureteroplasty. Left to right. Metzenbaum scissors. Potts scissors, probe and grooved director. Two nerve hooks. Two love nerve retractors, straight and right angle. Two little retractors. Four vein retractors. What instruments are common to both a major tray and the tray used for an open genitourinary (GU) procedure? What instruments are specific to GU procedures? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Endoscopic Instruments A,Cystourethroscope. B, Cystoscope and light guide. (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery The rigid cystourethroscope Fiberoptic light cable and source Light cable connects cystoscope to fiberoptic light source. Light sources used are same as those in other endoscopic procedures and include xenon and halide Cables are fiberoptic or liquid light As with all endoscopic equipment, light cords and camera cords should be handled carefully Why is tungsten not used as a light source for cystoscopy? Do not coil the light cable tightly, because the fiberoptic cables can break. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery The rigid cystourethroscope (cont.) Obturator Metal rod with blunt, rounded tip Prevents end of sheath from abrading mucosal lining of urethra as it is inserted May be either straight or deflecting Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Resectoscope Transurethral instrument used to remove small fragments of tissue Endoscope Sheath Obturator Electrical loop Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Electrosurgical Unit (ESU) Left to right, enlarged tips: - Cutting electrode with round wire - Cutting electrode with pointed end - Coagulating electrode with ball end Nonelectrolytic solution must be used to irrigate the bladder when an ESU is used. The patient must be grounded before the ESU is activated. (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Catheters Urinary Catheters A, Conical-tip urethral catheters. B, Robinson urethral catheter. C, Whistle-tip urethral catheter. D, Coudé hollow olive-tip catheter. E, Malecot self-retaining, four-wing urethral catheter. F. Malecot self-retaining, two-wing catheter. G, Pezzer self-retaining drain, open-end head, used for cystotomy drainage. H, Foley-type balloon catheter. I, Foley-type, three-way balloon catheter. Why would your surgeon want the surgical patient to have a urinary catheter? Catheters are measured in French (Fr). The larger the French, the larger the diameter of the catheter. (Modified from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Catheters (cont.) In-dwelling urinary catheters Most hospitals use prepackaged one-time-use catheters Catheter is hollow tube of flexible synthetic material Variety may be used during genitourinary (GU) procedures Ureteral catheters have graduated markings so the surgeon can see how deeply the catheter has been inserted. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Catheters (cont.) Ureteral Catheters Round-tip Olive-tip Spiral-tip Conical- or "bulb-tip" What are the various types of ureteral stents? When is the Braasch bulb catheter used? (B from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Catheters (cont.) Ureteral catheters Ureteral stent with tether. (A from Nagle GM: Genitourinary surgery: Perioperative nursing series, St Louis, 1997, Mosby.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Equipment Electrosurgical unit Microscope Laser Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Transurethral surgery Cystoscopy Use of a rigid or flexible cystoscope Ureteroscopy Use of a rigid or flexible ureteroscope Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Diagnostic cystoscopy Goal of cystourethroscopy (cystoscopy) – to examine inside of urinary bladder and urethra for evidence of disease Cystoscopy is considered diagnostic. Why would a male patient need to have a cystoscopy? A female patient? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral dilation and urethrotomy Urethra is dilated to relieve a stricture Phillips filiforms and followers Graduated sounds Balloon dilators Urethrotomy—Small incision made in internal urethra to release scar tissue What causes a urethral stricture? What is the difference between filiforms and van Buren sounds? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Management of bladder calculi using the Cystourethroscope Bladder calculi or stones are removed because of pain or urinary blockage Lithotrite Specialized instrument that grasps and crushes the stone Extracorporeal shockwave lithotripsy (ESWL) uses ultrasonic waves to pulverize the calculi. What causes bladder calculi? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Management of Bladder Calculi Top, left Mayo dissecting scissors, curved. Bottom, left to right Crile hemostatic forceps, straight. Crile hemostatic forceps, curved. Five Van Buren urethral sounds, male, sizes 8 to 16. Right, top to bottom Two nonperforating towel forceps. Ellik evacuator. All of the instruments needed to perform a cystourethroscope should be laid out neatly on the back table for easy accessibility. An Ellik evacuator is used to flush the crushed stone from the bladder. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Transurethral Resection of the Prostate (TURP) What effect does an enlarged prostate have on the male urinary system? The TURP and the transurethral resection of a bladder tumor (TURBT) can be performed using either a resectoscope, laser, or ESU. The choice is based on surgeon preference and the tissue involved. (From Rothrock JC: Alexander’s care of the patient in surgery, ed 17, St. Louis, 2007, Mosby.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Transurethral Resection of the Prostate (TURP) (cont.) Left to right, enlarged tips: Cutting electrode with round wire. Cutting electrode with pointed end. Coagulating electrode with ball end. The surgeon may use one of three electrode shaving tips to remove tissue. What are the three tips? The tissue excised will be collected in a specially designed trap on the patient’s drape. The trap is made of a gauge sponge type of material that is designed to collect and hold tissue shavings. The sponge is removed at the end of the case and placed in a specimen cup. (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Tissue biopsy Performed to determine if tissue specimen is benign or malignant Tissues biopsies are taken with what accessory instruments? Why is the cytology cell specimen placed in saline and not formalin? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Tumor removal Removal of neoplasm can be performed by fulguration or by using the holmium:YAG (yttrium aluminum garnet) laser. Laser precautions must be observed The holmium:YAG laser uses long, flexible laser fibers, which slide into the scope’s accessory channel to remove neoplasms. The surgical technologist must inspect the laser fiber for breakage before use. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Circumcision in the adult Removal of the prepuce (foreskin), which is done to improve and to abide by cultural and religious reasons. What causes phimosis to occur? The skin is not approximated in a young infant. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Chordee repair A congenital downward curvature of the penis cause by a band of connective tissue between the opening of the penis and the glans penis Release of the connective tissue allowing the penis to assume a normal position Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Hypospadias Repair What causes hypospadias? In mild cases of hypospadias, the meatus may be positioned anywhere along the shaft of the penis. In severe cases, the meatus may be located at the base of the scrotum. Repair may require many stages. Incisions are approximated, and the intervening strip of tunica albuginea and suture knots are buried. (From Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Insertion of Penile Implant What conditions typically cause a malfunction of the male erectile system? The inflatable reservoir type of implant must have its reservoir prefilled and checked for leaks before placement. A, Preparation of the reservoir. B, Placement of the reservoir and cuff in the perineal incision. Courtesy American Medical Systems, Minnetonka, Minn. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Insertion of Penile Implant (cont.) There are many types of penile implants available through various manufacturers. The surgical team should read the manufacturer’s guide before implanting the device. The implant must be documented in the patient’s chart. Documentation includes type, manufacturer, size, lot number, location, and implanting surgeon. The patient should receive the implant information as well. C. The reservoir and the pump are filled with Hypaque to the appropriate volume. D. The pump is tested. Courtesy American Medical Systems, Minnetonka, Minn. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Varicocelectomy High ligation of gonadal veins of testes To reduce venous backflow of blood into the venous plexus of the testes and to improve spermatogenesis Why do varicoceles occur most often on the patient’s left side? Varicocelectomies can now be performed laparoscopically, much like a laparoscopic hernia repair. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Hydrocelectomy. What causes a hydrocele to form? The scrub should have suction available to collect the cystic fluid when it is incised. The sac may be sent as a specimen. A small Penrose drain may be placed in the wound before closing. (Rothrock J: Alexander’s care of the patient in surgery, ed 17, St Louis 2007, Mosby) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Orchiectomy Surgical removal of one or both testicles An orchiectomy is commonly performed under local anesthesia. The patient must have his vital signs checked repeatedly throughout the procedure. It is not uncommon for the patient to develop vagal symptoms because of the tugging on the testicles. If a vagal response occurs, the patient should be placed in the Trendelenburg position until the symptoms pass. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Vasectomy. Many vasectomies are performed in outpatient settings under local anesthesia. (From Walsh PC, Retik AB, Vaughan ED et al: Campbell’s urology, ed 8, Philadelphia, 2002, WB Saunders). Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Vasovasostomy Reversal of the vasectomy by surgical anastomosis of the vas deferens to restore continuity of flow of sperm The vasovasostomy procedure requires the use of a microscope. The ends of the severed vas deferens will be reanastomosed using 10-0 nonabsorbable suture. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Implantation of testicular implants Following an orchiectomy, testicular implants are placed via a suprapubic approach Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Suprapubic cystostomy Insertion of a suprapubic catheter via a percutaneous or open approach into the bladder for drainage of urine Why is a suprapubic catheter more comfortable than a Foley catheter? A Cystocath kit, made by Dow Corning Wright, Arlington, TN, is a complete set used to insert a suprapubic Silastic catheter that is placed in the bladder through a skin stab incision. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Cystectomy Total or partial removal of the bladder. A cystectomy is performed for what diagnosis? If the patient is male, the surgical technologist should have prostatic instruments available. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ileal Conduit Procedure for urinary diversion where a functional bladder is constructed with a loop of bowel that is brought out of the abdominal wall An ileal conduit is performed most often after what surgical procedure? A functional bladder is made from what structure? (From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingstone Elsevier.) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Vesicourethral suspension of the bladder Performed to treat urinary stress incontinence in the female When caused by reduction in the angle at the urethrovesical junction What are the symptoms of urinary stress incontinence? What causes urinary stress incontinence? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Vesicourethral suspension (Marshall-Marchetti-Krantz) procedure. The surgical technologist must have vaginal instrumentation and abdominal instrumentation set up on separate tables. (From Walsh PC, Retik AB, Vaughan ED et al: Campbell’s urology, ed 8, Philadelphia, 2002, WB Saunders) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Pubovaginal sling Suspension of the bladder neck with a biosynthetic strip or fascia graft that is attached to the abdominal wall The suburethral sling uses a graft strip of fascia lata or synthetic material, placed between the urethra and anterior vaginal wall, to lift the bladder. A power drill is required to attach the graft to the pubic bone. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Types of prostatectomy Prostatectomy is performed to treat benign prostatic hypertrophy (BPH) and for cancer of the prostate Perineal prostatectomy Suprapubic prostatectomy Retropubic prostatectomy Laparoscopic or robot-assisted prostatectomy Transuretheral resection prostatectomy (TURP) What are the symptoms of BPH? What are the symptoms of prostate cancer? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Perineal Prostatectomy A, Incision through the perineum, B, Exposure of the central tendon. C, The preprostatic fascia (gray) has been incised to expose the prostatic capsule. D, Mobilization of the vascular pedicle. E, The vascular bundle is severed. F, Closure of the bladder neck. (Rothrock J: Alexander’s care of the patient in surgery, ed 17, St Louis 2007, Mosby) What is the goal of a perineal prostatectomy? What are the advantages of performing a perineal prostatectomy? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Suprapubic prostatectomy Removal of the prostate through a suprapubic incision Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Retropubic prostatectomy Patient is placed in supine position, prepped, and draped as for suprapubic prostatectomy In this approach, bladder is not entered for access to prostate For what indications is a retropubic prostatectomy performed? A Foley catheter with a 30-ml balloon is placed before closure. The surgical technologist must fully inflate the balloon to check for leaks. Lubricant must be applied to the Foley catheter before insertion. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion Pyeloplasty Strictures in ureter are relieved by fine electrosurgical or laser devices introduced through the endoscope Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion (cont.) Urethrotomy If urethrotomy (release of structure) is planned, optical urethrotome is inserted into stricture, and blade incises scar tissue Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion (cont.) Ureteroplasty Reconstruction of the ureter Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion (cont.) Ureterostomy Anastomosis of the ureter with another hollow structure to provide continuity Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion (cont.) Transureterureterostomy Crossing one ureter to another and creating an anastomosis between the two ureters May also be referred to as a ureterureterostomy Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Ureteral diversion (cont.) Vesicoureterostomy Reimplantation of the ureter into the bladder Helps prevent subsequent renal failure Causes of renal obstructions Congenital malformations Stasis Metabolic imbalances Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Percutaneous nephrolithotomy (PCNL) Insertion of a nephroscope via a small incision in the skin for the purpose of removal of stones from the kidney or the upper ureter Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Simple nephrectomy (flank approach) Removal of one kidney A nephrectomy is performed for what conditions? Getting access to the kidney may require resection of a rib. Which rib is typically resected? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Laparoscopic radical nephrectomy Removal of the kidney and lymph nodes via a laparoscopic approach Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Kidney transplant Removal of kidney from living donor or cadaver Implantation of kidney to surgical patient Performed for acute or chronic end-stage renal failure For what conditions is a kidney transplant performed? What screening is performed for a donor kidney? Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Kidney transplant (cont.) Ideal tissue donor Young Free of drugs and alcohol History is known Tissue and blood type match the recipient’s Describe the ideal organ donor. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary Surgery Adrenalectomy Adrenal diseases often life threatening Procedure has potential for many postoperative metabolic complications An adrenalectomy is performed for what reasons? The vena cava can be nicked accidentally during removal of the adrenal gland. The surgical technologist should have vascular suture loaded and ready in case this occurs. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.