1. The Care and Handling of Intraoperative Surgical Specimens
Please begin by displaying overhead #1
Give the following information to the learner(s)
1. Introduce yourself (instructor).
2. Pass out the packet that contain the handouts.
3. Introduce the learner(s) to the Operating Room Policy and Procedure manual.
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2. OBJECTIVES
1. Identify the proper handling of intraoperative surgical specimens.
2. Discuss the labeling, preserving, storing, and maintaining of intraoperative surgical specimens.
3. Discuss the intra-operative documentation of surgical specimens on the surgical record.
4. Describe the legal implications related to the handling of intra-operative surgical specimens.
We do not want an incorrect diagnosis!
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3. Surgical Specimens: Handling of, AS 201170-300.61
The Four Rights
Right patient
Right medical record number
Right procedure
Right surgeon
The Four RIGHTs
Just as the nurse checks a patient for the “Four RIGHTs” before giving a medication, the circulating nurse checks the patient before he/she enters the operating room. Confirming the spelling of the patient’s name and identification number with the patient and against the chart will insure that the specimens removed during surgery will be properly identified in the laboratory. This allows the laboratory and pathology reports to be put on the proper chart with follow-up to the surgeon.
STOP and discuss the four RIGHTs
1. Discuss the Four RIGHTs. It is important that the patient is identified before entering the operating room.
2. Has the learner(s) had any experiences with patients with similar names or hospital numbers? What was the outcome of this experience?
3. Ask the learner(s) for examples of incorrect surgical consents and the effect on the patient.
4. Ask for questions.
Surgical Specimens: Handling of, AS
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4. Pathology Studies Gross analysis Frozen section Permanent section
Biopsy
Culture and sensitivity
Slides
Cytology
Pathology Studies
There are many specimens that may be obtained during an intraoperative surgical procedure which will help the surgeon confirm a diagnosis and determine follow-up therapy. The storing, preserving, and method of maintaining a specimen or culture is stated in a policy and procedure. Always follow your facility’s specific policy and procedure manual. The pathology report or laboratory results become part of the patient’s chart and is legal documentation of the tissue removed or the test performed which may lead to a diagnosis and/or therapy. Clinical pathology is the use of laboratory methods to establish a clinical diagnosis. Surgical pathology is the study of alterations in body tissue removed by surgical intervention. Both are used to establish or confirm a diagnosis. Many times a surgical procedure will be based on the pathology report. The methods used to obtain the tissue or fluid are always invasive. Intraoperative surgical specimens can be categorized into the following groups. Surgical Specimens: These specimens are removed intraoperatively and sent to the Pathology department for routine pathological examination and verification of a diagnosis. The specimen may be sent to the Pathology department for a “gross” identification such as pacemakers, prosthetic devices, amputated limbs, stones or calculus, bullets and foreign bodies. The pathology report will become part of the chart and there is a legal record of the tissue or device removed. Frozen Section: Tissue is removed, frozen and immediately examined by the pathologist to determine a diagnosis, usually to rule out a malignancy or define margins. The specimen is then sent to be processed in the Pathology department for a permanent stain. A verbal or written report is given by the pathologist to the surgeon and the surgeon may or may not proceed with the planned surgery. Permanent Section: Once the specimen is removed, the Pathologist can process the tissue for a diagnosis by dehydration, staining, slicing, or making permanent slides which can take 48 hours to process. This allows the Pathologist to be able to study the tissue under a microscope for an accurate identification of the cells. Biopsy: Tissue is surgically removed for diagnostic purposes. The pathologist will study the cells possibly performing a histologic and/or cytologic analysis. The type of tissue to be examined will determine how it is to be handled and transported. Cultures: Cultures may be taken from tissue, drainage or body fluid and are aerobic and anaerobic. Cultures enable the surgeon to identify an organism or bacteria and determine the appropriate therapy. Slides: Slides may be taken from tissue or body fluid. An example of this is the PAP (Papanicolaou's) smear. Many times slides are taken from cultures. Cytology: This is the study of cell biology. Tissue and body fluid may be obtained during a surgical procedure and sent to the laboratory for cytology for the identification of the function and origin of cells in that fluid or tissue. This is done when a malignancy is suspected. Forensic Specimens: This refers to physical evidence from a person involved as a victim or suspected perpetrator in a crime. Any patient’s belongings, body tissue, fluids, or foreign bodies removed from the patient must be handled as potential evidence. They are submitted to the Pathology department labeled as “forensic specimen” or released to the law enforcement officials, according to the facility’s policy and procedure. This type of specimen will be used as evidence in a court of law to help reconstruct events of an accident, civil or criminal complaint, or crime.
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5. Frozen Section
Tissue is frozen and sliced to view under microscope for diagnosis
If know malignancy exists, surgeon may send additional frozens to verify margins are clear of tumor
Now we will take a closer look at the different types of pathology procedures.
Frozen Section
A frozen section is usually completed when an immediate diagnosis or confirmation of a diagnosis is needed. The surgery to be performed depends on the diagnosis such as a lumpectomy or mastectomy after a breast biopsy and frozen section. All tissue for a frozen section is sent “dry” so that it can be frozen and thinly sliced into sections to be examined under a microscope by the pathologist. Depending on the facility, the pathologist may come to the operating room and pick-up the specimen, or it can be transported to the Pathology department. Very small specimens, such as “True-Cut” needle biopsies or tissue from cup biopsy forceps can be placed on a section of dampened Telfa before it is put in a sterile container and passed off the field. The specimen should be verified by the surgeon. All containers are labeled with the identification of the source of the specimen, patient’s name and identification number, surgeon’s name, date, the operating room suite number and the test(s) requested. A pathology requisition must accompany the specimen(s).
Lymph nodes sent for frozen section are important for diagnosis. Follow your facility’s policy and procedure for the handling and preserving of lymph nodes, especially for off-shift cases when there is less staff in the Pathology department. A staging laparotomy for Hodgkin’s disease or an oophorectomy for ovarian cancer are examples of when lymph nodes are used for diagnostic purposes. Always follow the facility’s specific policy and procedure for frozen sections.
STOP and discuss Frozen Sections
1. Ask the learner(s) for examples of frozen section specimens such as:
A. Breast mass. B. Lung tissue biopsy. C. Ovarian tumor.
2. Ask the learner(s) why margins are important.
3. If possible demonstrate a “Tru-Cut” needle Ask for questions.
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6. Biopsy Types “Tru-cut” needle biopsy Nerve biopsy Muscle biopsy
Bone marrow biopsy
Biopsy
A biopsy is the removal and examination, usually microscopic, of tissue for diagnostic purposes. Examples are a biopsy of the breast, liver, colon, or lung. A biopsy can be incisional, where a portion of the tumor is removed, or excisional, where the whole tumor is removed. A “True-Cut” needle biopsy removes a core of tissue for diagnosis. A frozen section is usually performed on the tissue with a permanent stain to follow. The resulting surgery will depend on the pathology findings and diagnosis, as well as other therapy, such as chemotherapy or radiation therapy.
Nerve, muscle, testicular, and bone marrow biopsies once removed from the body, must be prepared and processed by specialized methods to preserve the cells. Bone marrow biopsy requires specialized needles which can puncture directly, or with a twisting motion, penetrate the bone. A muscle biopsy requires specialized forceps which are applied to the muscle before it is removed and keeps the muscle stretched during processing. Always follow your facility’s policy and procedure for the scheduling, processing, and requisitioning of these specialized biopsies
STOP and discuss Biopsy
1. Ask the learner(s) for examples of surgical procedures that would involve a biopsy.
Examples:
A. Breast biopsy. B. Axillary node biopsy. C. Ovarian cystectomy. D. Colon resection.
2. Ask for questions.
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7. Handling Specimens on the Field
Edges and margins may be tagged with “short short “and “long suture”
Use glove wrapper if surgeon wants to draw a picture for pathologist
Never hand specimen off on a surgical sponge; use telfa
Keep moist with saline
Verify specimen with surgeon
9. Edges and margins of the specimen may be tagged for orientation such as anterior, posterior, right or left.
10. Use a glove wrapper for right and left orientation of the specimen and to hand the specimens off the surgical field.
11. Keep specimen moist with saline.
12. Place the specimen in a basin until it can be passed off the field.
13. Ask surgeon to verify specimen.
14. Never hand specimen off on a surgical sponge.
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8. Guidelines for Circulators
Always wear gloves when handling specimens
Only one specimen per container
Complete label
Complete requisition
Save all specimens
Scrub may use a needle for small biopsy tissue to remove from jaws of biopsy forceps
STOP and discuss each guideline as they appear on the slide/overhead.
State the guidelines practiced at your facility. Use your facility’s policy and procedure as a reference for questions.
General Guidelines
Surgical specimens are cared for according to the specific guidelines set-up by your facility’s policies and procedures. Remember that a mislabeled or error in identification of a specimen can be disastrous to the patient. Generally, when handling surgical specimens, follow these basic guidelines.
1. Only one specimen per container
2. Completed patient label placed on the outside of specimen container with:
Patient’s name, · Patient’s hospital identification number,
Identification of specimen, · Surgeon,
Date, · Operating Room Number, and
Initials or name of nurse collecting specimen.
3. Completed laboratory or pathology requisition.
4. Documentation on the surgical record.
5. Save all specimens according to facility’s policy and procedure.
6. Save all tissue removed from the patient even if it appears to be of no value.
7. Do not use large crushing instruments on specimens.
8. Use a needle to remove very small specimens from instrumentation.
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9. How to verify a label
Both the label and pathology sheets must contain matching first and last names and medical record number of the patient, and must be verified by another staff member (circulator, scrub, anesthesia provider). The staff member verifying information will then place his/her initials on the specimen label.

10. Documentation in Nursing Record
When was the specimen sent to pathology (the sooner the better to ensure specimen freshness)
The person who sent the specimen.
Write the initials of the person who you verified the specimen label information with. This person can be a RN, LPN, ST, MD, CRNA.

11. Circulator Guidelines
Verify if permanent or frozen section
No abbreviations
All specimens are biohazardous
Fluid covers the specimen or dry –per specimen type
Avoid contaminating the outside of the specimen container
Legal responsibility
If you throw a specimen away
Call Surgeon
Possible loss of diagnosis
Complete Veritas report
15. Verify with the surgeon if the specimen is to be placed in formalin (formaldehyde) for a permanent section or dry for frozen section.
16. Abbreviations should not be used to identify specimens.
17. All specimens are biohazardous.
18. The fluid (saline or formalin) should cover the specimen in the container.
19. Avoid contaminating the outside of the specimen container with blood and body fluids. If contamination occurs, disinfect exterior surface of container with a tuberculocidal hospital grade disinfectant or a 1:10 dilution of household bleach before removal from the operating room. If tubes or containers cannot be disinfected, place them in an impervious clear bag for transportation to the laboratory or Pathology department.
20. The circulating and scrub nurse are responsible for the proper identification, preservation, handling, and transportation of that specimen to the Pathology department or laboratory.
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12. Labeling and Packaging
Place the label on the side of the container for easy identification.
Place the container inside a plastic bag to prevent risk of spillage during transport.

13. Specimen to Lab Unit Specific Pick up area & Log book
Take directly to pathology and Log it in.
Frozens may be picked up in OR if surgeon wants to speak to pathologist
Cultures are tubed to lab or if large amount of fluid, a courier takes them to the lab.
Routine Handling
Each facility has policies and procedures that guide the staff on how to gather, preserve and transport the specimen. The following are general guidelines. Routine specimens that do not require immediate attention by the pathologist can be collected, placed in a container with preserving fluid (formalin) and taken to a holding area, such as a refrigerator or a storage container in the decontamination room. The specimens will be transported to the Pathology department at a later time. A pathology logbook is kept in this area. The patient’s name, identification number, identification of the specimen(s) and nurse’s initial are logged into this book. When the specimen is transported to the Pathology department, the person transporting the specimen initials the logbook.
Formalin (formaldehyde)is the main chemical used by most facilities for preserving surgical specimens. This chemical is very toxic if inhaled or splashed on mucus membrane of the eyes or skin of the hands. If exposed to formalin, rinse the effected area with copious amounts of water or saline. Material Safety Data Sheets (MSDS) should be readily available for information on the first aid and handling of environmental spills.
Cultures from body fluid or tissue should be sent to the Laboratory department immediately as the air and warmth of the operating room can affect the bacteria and cell count. In the laboratory, cultures can be placed onto a media plate and stored (refrigerated). A smear on a glass slide can be made from tissue or body fluids. This smear is then sprayed with a fixant and should be labeled, handled, and documented in the same way as cultures.
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14. All Specimens to Pathology
Record of the Specimen
Tissue
Body fluids
Cultures
Cytology
Prosthetics
Fixation appliances
Verification of the surgical procedure
Confirm diagnosis
May determine treatment and/or therapy
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15. Lab Specimens Pathology Specimens
Let us review and discuss the handout “Pathology Specimens” (Appendix A). This reference is from the 1996 book, Berry & Kohn’s Operating Room Technique (8th edition) by Atkinson and Fortunato (page 563). The table will be presented over the next five slides/overheads.
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16. Pathology Specimens gallbladder
Continue the discussion with the next slide/overhead of the table Pathology Specimens.
1. Discuss the table “Pathology Specimens” as it relates to the test required, preparation of the specimen and examples given.
A. Handout: “Pathology Specimens” (Appendix A)
2. Examples on the table are for Tissue.
3. Ask for questions.
Basal cell carcinoma will be sent for frozen section
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Breast tissue for biopsy

17. Special Consideration Pathology Specimens
Tissue
Method to send
Calculi
Dry in container
Muscle
Muscle biopsy clamp

18. Other items to Pathology
Continue the discussion with the next slide/overhead of the table Pathology Specimens.
1. Discuss the table “Pathology Specimens” as it relates to the test required, preparation of the specimen and examples given.
A. Handout: “Pathology Specimens” (Appendix A)
2. Examples on the table are for Nonbiological Specimens.
3. Ask for questions.
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19. Explant Examples Identify on pathology requisition
Serial numbers ( if available)
Manufacture’s codes (if available)
Document on surgical record
Explants
Many times surgery is performed to remove an implant such as orthopedic plates, screws or total hip components or a pacemaker generator and leads. The removed implant is called an “explant”. Depending on your facility’s specific policy and procedure, explants are usually sent to the Pathology department for gross analysis. This will also document the removal of the implant.
Further documentation on the surgical record includes any serial numbers or manufacture codes that are on the explant. The same information should be on the pathology requisition. If the patient wants the explant it can be noted on the pathology requisition. Record the explant and place the patient’s identification label in the “Explant Logbook”
STOP and discuss Explants
1. Give examples of explants such as:
A. Pacemaker generators and lead wires. B. Orthopedic plates and screws
2. If possible have these explants available for the learner(s) to examine
3. Have an “Explant Logbook” available to show to the learner(s).
4. Have the learner(s) document an explant on the surgical record.
5. Ask for questions.
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20. Surgical Tissue Banking
Retrieval
Processing
Preserving
Storing
Surgical Tissue Banking, AS
Surgical Tissue Banking
Tissue may be removed from a patient and preserved for later transplant into that patient or another patient. The storing of tissue is called Surgical Tissue Banking. AORN has a Recommended Practice for Surgical Tissue Banking. As stated in the 1998 Standards and Recommended Practices, surgical tissue banking encompasses the retrieval, processing, preserving, and storing of selected human tissue. Human tissue includes, but is not limited to, bone, cartilage ossicles, corneas, heart valves, and skin. It is beyond the scope of these recommended practices to address all areas of tissue banking. Rather, these recommended practices provide guidance for developing institutional procedures that are specific and compatible with patient’s needs, the practice setting’s facility, and personnel capabilities and expertise.
STOP and discuss Surgical Tissue Banking
1. Discuss the AORN guidelines and the five Recommended Practices. This is one of the required readings.
A. Handout: “AORN Recommended Practices for Surgical Tissue Banking, 1998” (Appendix B).
2. Have examples available to show the learner(s) tissue for surgical banking such as:
A. Frozen cadaver bone B. Heart valves C. Corneas
2. Have the Surgical Tissue log book available.
3. Ask for questions.
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21. Organ Procurement
Specialized scheduling, handling, and preserving of the tissue
Organ and Tissue Donation after Death, OP
Organ Donation After Cardiac Death OP
Organ Procurement
Another significant surgery is organ procurement. In death there is a gift of life. The procurement of kidneys, heart, liver, pancrease, lung, skin, eyes, and bone is specialized. Always follow the policy and procedure of your facility and the procurement agency. There are resource books available within the department on the scheduling, handling, and preserving of this cadaver tissue and organs.
STOP and discuss Organ Procurement
1. Discuss the learner’s(s’) knowledge and experiences with the organ procurement agency “Gift of Life”.
2. Discuss if your facility has a policy and procedure for organ procurement.
3. Ask for questions.
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22. Summary
The following objectives were identified, defined, and discussed:
1. Identify the proper handling of intraoperative surgical specimens.
2. Discuss the labeling, preserving, storing, and maintaining of intraoperative surgical specimens.
3. Discuss the intraoperative documentation of surgical specimens on the surgical record.
4. Describe the legal implications related to the handling of intraoperative surgical specimens.
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