Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 06: Sutures, Needles, and Instruments
- The primary use for suture is essentially to:
|a.||strengthen, re-form, and close tissue.|
|b.||ligate, suture, and close tissue.|
|c.||ligate, strengthen, and stop bleeding.|
|d.||clamp, divide, and attach tissue.|
Suture is a generic term for all materials used to sew severed body tissues together and to hold these tissues in their normal position until healing takes place; to suture is to stitch together cut or torn edges of tissue. A ligature is a strand of suture material used to tie off (seal) blood vessels for the prevention of minor bleeding, or to isolate a mass of tissue for excision (cut out). A variety of suture materials are available for ligating, suturing, and closing the wound.
REF: Page 174
- The ideal suture material is one that has handling characteristics such as:
|c.||ease of tying.|
Key features used to evaluate the general properties of suture material are (1) physical characteristics, (2) handling characteristics, and (3) tissue reaction characteristics. Handling characteristics of suture material are related to pliability (how easily the material bends) and the coefficient of friction (how easily the suture slips through tissue and can be tied).
REF: Page 174
- Tissue reaction characteristics are important in a suture material because:
|a.||the suture should absorb and nourish the healing tissue.|
|b.||the suture should not cause tissue inflammation or an allergic response.|
|c.||the suture should not support infection.|
|d.||the suture should not cause tissue inflammation or an allergic response and the suture should not support infection|
The ideal suture material is one that causes minimal inflammation and tissue reaction while providing maximal strength during the lag phase of wound healing. Tissue reaction characteristics include inflammatory and fibrous cell reaction, absorption, potentiation of infection, and allergic reaction.
REF: Pages 174-176
- The surgeon needs a suture material that will not degrade over time, but becomes encapsulated and supports a tissue structure that will continue to be exposed to pressure and stretching forces throughout the patient’s life. These physical properties are best described by a suture that:
|a.||is nonabsorbable, has good tensile and knot strength, and is the appropriate diameter for the tissue.|
|b.||has a large diameter, is nonabsorbable, is highly reactive, and is a monofilament.|
|c.||is a monofilament, is synthetically manufactured, is absorbable, and has a large diameter.|
|d.||has good tensile strength, memory, and ease of tying and is absorbable.|
Physical characteristics of sutures can be measured or visually determined and include the following properties: Diameter (size) is measured in millimeters, and expressed in USP sizes with zeroes. The finer diameter (smaller size) provides better handling qualities and small knots. Improved suturing techniques are possible with sutures of finer diameter. Tensile strength is defined as the amount of weight (breaking load) necessary to break a suture (breaking strength); it varies according to the type of suture material. Knot strength is the force necessary to cause a given type of knot to slip, either partially or completely. The most common nonabsorbable suture materials are silk, nylon, polyester fiber, polypropylene, and stainless-steel wire.
REF: Pages 176-179
- Dr. Garrison was teaching the new residents as he closed the muscle and fascia layer following an open cholecystectomy. He stated that he liked the tensile strength of this monofilamented synthetic suture and also liked the pretty blue color, but it was hard to manage with its memory and slipperiness and normally needed six surgeon’s knots to hold. He was using:
Prolene (polypropylene) is a clear or pigmented polymer. This monofilament suture material (Prolene, Surgilene, Surgipro, Dermalene) is used for cardiovascular, general, and plastic surgery. Because polypropylene is a monofilament and is extremely inert in tissue, it may be used in the presence of infection. It has high tensile strength and causes minimal tissue reaction. Sizes range from 10-0 to #2.
REF: Page 180
- Dr. Schumann, an older surgeon who was educated in Germany, explains his justification for his suture choice to the new perioperative nurse in the scrub role. He prefers to suture his intestinal anastomosis with a suture that has multiple filaments braided together because it ties well and holds the knot, which tightens when the thread absorbs the tissue fluids. He also needs a strand that is easy to see and only needs to retain its tensile strength for about 1 year, at which time the intestinal junction will be healed, even though this suture is considered nonabsorbable. He will ask the nurse for a 24-inch 4-0:
Silk (Sofsilk) is prepared from thread spun by the silkworm larva while making its cocoon. Top-grade raw silk is (1) processed to remove natural waxes and gum, (2) manufactured into threads, and (3) colored with a vegetable dye. The strands of silk are twisted or braided to form the suture, which gives it high tensile strength and better handling qualities. Silk handles well, is soft, and forms secure knots. Because of the capillarity of untreated silk, body fluid may transmit infection along the length of the suture strand. Silk is not a true nonabsorbable material. When buried in tissue, it loses its tensile strength after about 1 year and may disappear after several years.
REF: Page 179
- Dan Clements had a vasectomy in his urologist’s office. The small incision was closed with sutures that are synthetic and will “dissolve and fall out” after 2 to 3 weeks. As the procedure ended, he heard the doctor ask the nurse for 5-0:
To produce synthetic absorbable sutures, specific polymers are extruded into suture strands. The base material for synthetic absorbable sutures is a combination of lactic acid and glycolic acid polymers (Vicryl, Dexon, and Polysorb). The molecular structure of these products has a tensile strength sufficient for approximation of tissues for 2 to 3 weeks, followed by rapid absorption, which combine the desirable qualities of extended wound support and eventual absorbability.
REF: Page 178
- Linda, a veteran perioperative nurse, remembers a time when all suture needles had eyes and she even had her own needle rack. She hand-threaded all sutures according to the surgeon’s preference. The newer sutures were originally called “atraumatic” sutures because they did not double back through a needle eye and cause tissue trauma during pulling or suturing through the tissue. Today, we call this manufacturing process of connecting the suture thread to the needle:
The swaged needle is the most universally used needle type, eliminating threading eyed needles before and during surgery. A single strand of suture material is drawn through the tissue, and tissue damage is minimized (atraumatic). The swaged needle may need to be cut off with suture scissors or swaged for controlled release of the suture (semi-swaged).
REF: Page 181
- When creating a vascular or intestinal anastomosis (connecting two tubular structures together) the surgeon will typically suture one half of the anastomosis with one half of the suture and the other half of the anastomosis with the other half of the suture. This technique minimizes the drag and wear on the suture material and needle. The correct name for this type of suture and needle is:
A double-armed suture is a strand of suture material with a needle on each end. These are typically used in vascular surgery for anastomoses. During initial count, the scrub person counts the needles depicted on the outside of the package and recounts with the circulating nurse when the package is opened.
REF: Page 188
- This hemostatic device offers a rapid and secure method of clamping arteries, veins, nerves, and other small structures. They will remain in the patient, are not counted, and are made of a metal that is compatible with MRI. Select the correct hemostatic device that fits this description.
Ligating clips are available in several sizes. These clips are available in individual sizes that must be loaded by the scrub person or as preloaded, disposable, prepackaged units. There are multiple sizes and lengths of clips that can be used in both open and endoscopic procedures. Ligating clips afford a rapid and secure method of achieving hemostasis when arteries, veins, nerves, and other small structures are ligated. Since the introduction of minimally invasive endoscopic surgery, the need for ligating clips that can be applied through a trocar has emerged.
REF: Page 187
- These hemostatic devices date back to a period in time when they consisted of a product that was harvested from the ocean. They continue to be used today in every surgical procedure where a considerable amount of bleeding may be encountered and are still made of a natural product, but not from the ocean. Select the appropriate hemostatic device that fits this description.
|d.||All of the options are correct.|
Surgical sponges are used to affect hemostasis via direct pressure, absorb intraoperative blood loss and drainage, act as aids to blunt dissection, pack the viscera from the field, and keep areas of the wound moist. Laparotomy sponges (also referred to as “laps,” “lap pads,” or “tapes”) are either square or oblong and have a loop of colored twill tape with a radiopaque marker sewn to one corner. Used for major surgical procedures with large incisions, laparotomy sponges are presented to the surgeon either moist or dry.
REF: Page 187
- The instrument devices depicted below are designed to ligate, divide, resect suture, and anastomose tissue. They are commonly called:
|d.||stapling instruments and surgical staplers.|
Various instruments to suture tissue mechanically are used for ligation and division, resection, anastomoses, and skin and fascia closure. Employed in many surgical specialties, the mechanical application of these instruments reduces tissue manipulation and handling.
REF: Pages 198-199
- Surgical instruments that do not fall under the category of clamps, retractors, or cutting instruments, but are used in most procedures, are typically included within the category of:
|d.||accessory and ancillary instruments.|
Accessory and ancillary instruments are designed to enhance the use of basic instrumentation or to facilitate the procedure. These include suction tips and tubing; irrigators-aspirators; electrosurgical devices; and special-use devices, such as probes, dilators, mallets, and screwdrivers.
REF: Page 198
- Dr. Schuman decided to convert to an open instead of the laparoscopic approach for the colectomy because the patient was morbidly obese and he needed a larger incision. He asked the circulating nurse to bring the largest self-retaining retractor in the sterile storage room. Select the appropriate retractor.
|a.||Large wide Deavers|
Retractors are used to hold back the wound edges, structures, or tissues to provide exposure of the operative site. A surgeon needs the best exposure possible that inflicts a minimal degree of trauma to the surrounding tissue. Retractors are self-retaining or manually held in place by a member of the surgical team. The two types of self-retaining retractors are: (1) retractors with frames to which various blades may be attached, and (2) retractors with two blades held apart with a ratchet. An example of the latter is a Weitlaner retractor. Other very large self-retaining retractors, such as the Omni or Bookwalter, are equipped with multiple blades and attachments of varying lengths and sizes.
REF: Pages 196-197
- During the draping procedure, Dr. Martin Newhouse (the anesthesia provider) asked the scrub person for two towel clamps to secure the top of the drape to the IV poles. The scrub person had two penetrating and two nonpenetrating clamps on her back table. She knew she would need to secure the suction and electrosurgical pencil to the sterile field as soon as draping was finished. How should the scrub person respond to Dr. Newhouse’s request for towel clips?
|a.||Refuse to give him any towel clamps because they are counted.|
|b.||Give him two Allis clamps instead.|
|c.||Give him the penetrating towel clamps.|
|d.||Give him the nonpenetrating towel clamps.|
Towel clamps also are considered holding instruments. Of the two basic types, one is a nonpenetrating towel clamp used for holding draping materials in place. The other has sharp tips used to penetrate drapes and tissues, and it is damaging to both. The use of sharp towel clamps to secure drapes is highly discouraged because they penetrate the sterile field.
REF: Page 196
- The circulating nurse received the trauma call from the emergency department and called sterile supply to assemble the instruments for an abdominal trauma case with possible aortic rupture. When the cart arrived, she saw the vascular set; however, the most important instrument set was missing. What important instrument set was needed for this procedure besides the vascular set?
|a.||Sternal saw and blades|
|b.||Basic laparotomy set|
|c.||Basic laparoscopy set|
Designated OR or central supply personnel arrange the various instruments into trays or sets. The trays are named according to their functions. Tray/set names and instrument composition will vary by institution, but three basic OR instrument sets are the minor/plastic, the basic laparotomy, and the dilation and curettage (D&C). A minor (or plastic surgery) set includes instruments needed for simple superficial incision, excision, and suturing. A basic laparotomy set includes instruments to open and close the abdominal cavity and repair any gross defects in the major body musculature.
REF: Page 199
- The scrub person, Toby, was precepting a surgical technology student, Mandy, on her first orthopedic case, a tibial IM rodding. Toby explained the importance of keeping the instruments free of blood and bioburden during the procedure and demonstrated the best practice and how to:
|a.||dip and agitate the instruments in saline after the surgeon returns them.|
|b.||wipe the instruments with a sponge moistened with sterile water after each use.|
|c.||rinse or soak the instruments in sterile water and dry them before placing on the back table.|
|d.||wipe the instruments with a sponge moistened with sterile water after each use and rinse or soak the instruments in sterile water and dry them before placing on the back table|
Instruments must be handled gently. Bouncing, dropping, and setting heavy equipment on top of them must be avoided. During the procedure, the scrub person should wipe the used instruments with a damp sponge or place them in a basin of sterile distilled water to prevent blood from drying on the surfaces and in the box locks. Saline solution should never be used on instruments because the salt content is corrosive and accelerates rusting or deterioration of the metal. As time allows during the procedure, the scrub person should rinse and dry the used instruments and replace them on the back table to facilitate wound closure closing counts.
REF: Page 200
- The safest practice for passing sharps and instruments is to:
|a.||use a “no-touch” technique by passing all instruments and sharps with a sponge forceps.|
|b.||establish a neutral zone on the closest corner of the Mayo stand.|
|c.||employ a robotic arm designed to deliver sharps and instruments to the surgeon.|
|d.||None of the options are best practices.|
Use a neutral zone or hands-free method for passing sharps. Establish the neutral zone before the initial surgical incision (a magnetic pad or basin may be used to create the neutral zone; if a basin is used, it should be placed on the sterile field). Dedicate the neutral zone for sharps only and only one sharp at a time should be in the neutral zone. Avoid handling suture needles manually whenever possible, using a needle holder, forceps, or suturing assist device. Announce the transfer of a sharp before placing it in the neutral zone. The scrub person and surgeon or assistants should communicate about the best placement of sharps in the neutral zone.
REF: Page 192
- The perioperative nurse and the surgical technologist have a responsibility to maintain a safe environment of care for the surgical patient. A surgical complication concerning surgical counts that poses serious harm for the patient and potential consequences for the involved staff is called:
|a.||a malpractice suit.|
|b.||a retained foreign object.|
|c.||“res ipsa loquitur.”|
In 2002 the AORN initiated its Patient Safety First Program and has continued to assist perioperative nurses in maintaining a safe environment for surgical patients. Retained foreign objects after surgery are a complication with serious potential consequences for the people involved.
REF: Page 202
- Careful counting (according to established policy), situational awareness, and conscientious and meticulous attention to the field are believed to prevent miscounts and lost items. A recent patient safety statement about preventing retained foreign objects recommends which of these practices?
|a.||Consistent practice according to a routine|
|b.||Good communication among the team|
|c.||Wound exploration by the surgeon before closure|
|d.||All of the options are best practices.|
In 2005 the American College of Surgeons issued a patient safety statement regarding the prevention of retained foreign objects after surgery. Paramount to preventing retained foreign bodies are good communication, consistent practices, and wound exploration before closure of the surgical site (ACS, 2005).
REF: Page 202
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 07: Surgical Modalities
- An endoscope is a diagnostic or therapeutic instrument that enters the body through a:
|b.||small incision into a body compartment.|
|c.||externalized sinus tract.|
|d.||All of the options are correct.|
An endoscope is a tube inserted into a natural body orifice or through a small incision to access internal organs or structures. Endoscopes are flexible, rigid, or semirigid. Flexible endoscopes include angioscopes, bronchoscopes, choledochoscopes, colonoscopes, cystonephroscopes, hysteroscopes, mediastinoscopes, ureteroscopes, and ureteropyeloscopes. Rigid endoscopes include cystoscopes, laparoscopes, sinuscopes, arthroscopes, bronchoscopes, laryngoscopes, and hysteroscopes.
REF: Page 204
- The light transmission through an endoscope is achieved by way of:
|a.||a charge-coupled device chip in the tip of the scope.|
|b.||a chain of small connected micro light bulbs.|
|c.||bundles of fiberoptic glass rods.|
|d.||electrified silicon cables.|
Endoscopic light is often referred to as cold light, meaning that the heat from the light source is not transmitted through the length of the scope. Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers. In 1966 the rod-lens system designed by the British optical physicist Hopkins improved brightness and clarity.
REF: Pages 204-205
- Endoscopic instruments are designed to perform the intervention at the target tissue site through the tubular endoscope. The endoscopic instrument is considered:
|a.||an instrument on a stick.|
|b.||an extension of the surgeon’s hand.|
|c.||a means to perform hands-free surgery.|
|d.||surgery without tactile sensation.|
Endoscopic minimally invasive surgery (MIS) instrumentation has been designed to correspond with the surgical site and the technique used while functioning as an extension of the surgeon’s hand. The length and working end of the instrument must be adequate to perform surgery at the target site.
REF: Page 206
- Flexible fiberscopes and flexible videoscopes share many of the same components; however, in a video gastroscope, the eyepiece and lens of the fiberscope are replaced by a:
|a.||CCD image intensifier.|
There are two types of flexible endoscopes: fiberoptic endoscopes and videoscopes.
Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers. Videoscopes have, at their distal end, a video chip that provides an image that is directly viewed on a monitor; a videoscope does not have an eyepiece for direct viewing; the eyepiece is replaced with an endoscopic video camera.
REF: Page 204
- The design of laparoscopic instruments aims to provide a clamping, cutting, dissecting, electrocoagulating, suturing, or stapling instrument on the tip of a shaft that is long or short enough to reach the target tissue. The hand control on the surgeon’s end of the instrument is engineered to provide:
|a.||ergonomic comfort and control.|
|b.||smooth operation of the lubricated instrument tips to prevent tissue adherence or entrapment.|
|c.||a perception of haptic and tactile sense to prevent crushing or losing tissue.|
|d.||adaptors for monopolar electrosurgery connection and laser fibers.|
The length and working end of the instrument must be adequate to perform surgery at the target site. The hand control is ergonomically designed for the operator’s maximum comfort and reduced fatigue. Graspers and other instrumentation used by the assistant in surgery often are built for a shorter hand span because many women function in this role.
REF: Page 206
- The instrument tips in laparoscopic instruments are designed to produce the same tissue effects as a traditional instrument used for open surgery. Because of the process challenges of the laparoscopic approach, it is time-consuming to insert and withdraw instruments repeatedly during the procedure. Instrument manufacturers have attempted to make their products efficient by combining functions. An appropriate combined function for a laparoscopic instrument would be:
|a.||ultrasound capability in a suturing forceps.|
|b.||electrosurgery conduction through the tips of a Babcock grasper.|
|c.||blunt dissection with the smooth, rounded edge of the closed endoscopic scissors.|
|d.||suction and irrigation combined with an argon beam coagulation handpiece.|
Dissecting instruments are used to cut, divide, or separate tissue. Scissors and dissectors that are similar to their open-procedure counterparts have been designed for use in MIS procedures. Scissors are available for blunt or sharp dissection. They can be straight or curved (including hook scissors), depending on the location of the target tissue and technique used. Scissors usually have a rounded tip when closed so that they also can be used to manipulate tissue without trauma. When open, both jaws of the scissors should be visualized to prevent inadvertent injury. Some scissors are designed to be connected to an electrosurgical energy source so that coagulation can be provided during cutting. Dissectors are used to separate or divide tissue. Many different tip shapes are available to dissect, spread, divide, grasp, retract, and coagulate structures.
REF: Page 206
- The challenge of suturing intra-abdominally is not as great as the process needed to tie and tighten the surgical knot. The knot-tying process can be achieved within or outside of the abdominal compartment. One technique uses laparoscopic grasping forceps and a laparoscopic needle holder only, and another uses the same instruments plus two obturator sleeves to push, slide, and tighten the knot into place. When sutures are tied and knotted during an open procedure, the surgeon may tie the knot with gloved fingers, called a one- or two-handed tie, or wrap the suture around the tip of a needle holder and grasp the other end of the suture to pull it through the wrapped coils; this is called an instrument tie. The intracorporeal suture technique uses the suture-tying process analogous to the:
|d.||All of these techniques could be accomplished through the intracorporeal approach.|