3.  Requires a working knowledge of the sequential steps for a specific surgical procedure based upon four concepts:  Approach  Procedure  Possible Complications  Closure

4.  Determined by Physician  Approved by Anesthesia  Based upon positioning of patient  Offers the best exposure  Has the lowest amount of tissue trauma  Subject to change given the situation

5.  Determined by the Physician  Agreed to by the patient  Specific principles of surgery  Basic principles applied from similar surgeries  Services related to surgical intervention

6.  Known and unknown factors  Short term and long term  Direct and indirect  Towards the patient  Towards the Surgical team  Towards the environment

7.  Determined by Physician  Many different methods  May not be able to close operative site  Marks the beginning of recovery

8.  Preparation  Preincision  Operative Sequence  Closing  Post operative

9.  Selection of room and supplies  Preincision count

10.  Transfer and positioning of Patient  Induction  Prep and drape  Suction and electrosurgical equipment

12.  The skin and subcutaneous tissue are divided with a skin knife  Knife is placed on backtable

13.  Bleeders are dealt with by electrical or mechanical hemostatic means according to surgeon’s preference  A raytex sponge or laparotomy sponge (lap) is used to aid in further visualization for sources of bleeding

14.  A clean knife, Metz scissors, or cautery are used to incise deep fascia and peritoneum  Various instrumentation is used to elevate tissue and expose tissue that is to have surgery performed on it  For example a hemostat may be used to elevate the peritoneum to avoid damage to underlying contents as it is penetrated and cut with a cautery  Toothed forceps are use on fascia

15.  Operative area is explored and pathology is isolated  At times the operative site is obscured by surrounding tissue  Bone will be scraped to expose a fracture for plating and screw application  Sponges, retractors, tissue extraction, and manual manipulation of tissue may be used to maximize exposure

16.  Excision or revision  Depends upon purpose and local anatomy  May require a certain amount of dissection  Instrument length increases with depth of incision  Needed instruments and supplies given to surgeon as needed

17.  Operation focuses on removal, resection, reconstruction, or all to correct abnormality  May require specialized instruments

18.  Prep for closing  Control bleeding  Irrigate wound with saline with or without antibiotics  Insert drain if needed

19.  Gather specimen  Identify specimen verbally to surgeon then to circulator prior to passing off  Pass off field to circulator (ask surgeon’s permission)  Be sure to ask how specimen is to be preserved (permanent or frozen/fresh)

20.  The first count takes place before the any cavity is closed. This means everything!  The second count is done after the cavity and fascia are closed serially, again everything!  If a cavity has not been entered all sponges and miscellaneous items must be counted and verified prior to wound closure  Anesthesia reversal and stabilization  Application of dressing and tape

21.  Maintain sterile field until patient stability has ensured by the anesthesia provider  Get their permission to break down  Some cases require preservation of the sterile field until the patient has left the room: any case where airway compromise is a potential complication (Thyroidectomy/parathyroidectomy/facial or throat surgery) and any case that has potential hemorrhage as a complication (Carotid artery endarterectomy/Abdominal aortic aneurysmectomy /trauma)  Prepare to transfer  Transfer to PACU  Post-procedural routine

22.  Discussed the four concepts of surgery  Named five phases of surgery and discussed them  Discussed preparation, preincision operative, closing, postoperative phases.  Discussed in depth the seven steps in the operative sequence