Pocket guide to the operating room

1. Pocket Guide to the Operating Room 00Goldman(F)-FM 10/19/07 9:25 PM Page i

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3. Pocket Guide to the Operating Room T H I R D E D I T I O N Maxine A. Goldman, BS, RN Clinical Nurse IV Formerly, Operating Room Clinical Education Instructor Medical Center of Tarzana Tarzana, California 00Goldman(F)-FM 10/19/07 9:25 PM Page iii

4. F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright 2008 by F.A. Davis Company Copyright 2008 by F.A. Davis Company.All rights reserved.This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor:Christa Fratantoro Developmental Editor:Marla Sussman Manager of Content Development:DeborahThorp Art and Design Manager:Carolyn OBrien As new scientic information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes.The author and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication.The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book.Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Goldman, Maxine A., 1947- Pocket guide to the operating room / Maxine A. Goldman. 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1226-6 ISBN-10: 0-8036-1226-5 1. Surgery, OperativeHandbooks, manuals, etc. 2. Surgical instruments and apparatusHandbooks, manuals, etc. 3. Operating roomsEquipment and suppliesHandbooks, manuals, etc. I. Title. [DNLM: 1. Surgical Procedures, OperativemethodsHandbooks. 2. Operating RoomsHandbooks. 3. Surgical EquipmentHandbooks. WO 39 G6193p 2008] RD32.3.G65 2008 617.91dc22 2007036130 Authorization to photocopy items for internal or personal use, or the internal or personal use of specic clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC)Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1829/08 $.10. 00Goldman(F)-FM 10/19/07 9:25 PM Page iv

5. I dedicate this work to those special registered nurses and surgical technologists who are entrusted daily with the responsibility of the care and safety of patients in the perioperative environment. M.A.G. 00Goldman(F)-FM 10/19/07 9:25 PM Page v

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7. Preface Although the format appears the same as in previous editions, this third edition of Pocket Guide to the Operating Room reects completely revised and thoroughly researched state of the art material that will enable the practitioner to elevate his/her level of perioperative patient care to new standards of excellence. The reader will nd approxi- mately 100 new procedures or their modications in this third edition; previously included procedures have been updated to reect current knowledge of evolving technology and perioperative patient care measures. Chapters containing the latest information on advanced surgical modalities employing lasers, endoscopy, robotics, microsurgical techniques and instrumentation, the Harmonic and Plasma scalpels, theArgon beam coagulator , and radiofrequency ablation are included and cited throughout the work. New chapters on various dental and orthognathic procedures and intraoperative radiotherapy are presented. New surgical entries and/or approaches to previously described surgeries include total joint replacement surgeries; microneuroendoscopy; prosthetic disc replacement; micro, percutaneous, and endoscopic discectomy; percutaneous vertebrpoplasty and kyphoplasty; and multiple approaches to correct scoliosis.The chapter on pediatric surgery provides comprehensive measures with explana- tions particularly designed for the care of the child in surgery. My intent is to continue to limit the texts physical size for convenience while maintaining the concise format of previous editions and describ- ing perioperative care with an emphasis on the intraoperative phase. The most recent principles, standards, recommendations, and/or mandates set forth by the Association of periOperative Registered Nurses (AORN), the Joint Commission (JC) [formerly the Joint Com- mission on Accreditation of Healthcare Organizations (JCAHO)], the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), and the North American Nursing Diagnoses Association (NANDA) International have been incorporated into the text. Measures for providing psychological support and physical safety of the patient in the perioperative environment are emphasized in this edition, particularly in the expanded Special Notes section at the end of each surgical entry.The Special Notes also serve to alert the circulator and the scrub person to important information that may not nec- 00Goldman(F)-FM 10/19/07 9:25 PM Page vii

8. essarily be found elsewhere. This information assists the practitioner with anticipating and predicting the perioperative needs of the patient and the surgical team members.The reader is encouraged in Chapter 1, and throughout conduction of the surgical procedures in Part 4, to assess individual needs unique to the surgical patient by developing a plan of care and by implementing that plan of care according to cur- rently established safe standards. Perioperative practitioners are also encouraged to evaluate the effectiveness of implemented care by examining patient outcomes to maintain a level of excellence.The discussion section for each surgery includes information on the application of state of the art technologic modalities and updated surgical techniques. More than 500 surgical procedures are presented in a preestablished, standardized format. Each includes a denition, a discussion, and a description of each procedure, as well as notes on preparation of the patient and safe positioning practices, skin preparation, draping techniques, equipment, instrumentation, supplies, and Special Notes pertinent to patient care for each procedure. In the Special Notes section, the perioperative practitioner is alerted to care measures of particular importance that are preceded by the notation N.B. The conduction of a surgical procedure may appear to differ from institution to institution, between different sections of the country, and according to the preferences of individual surgeons, but the com- mon goal regarding the best outcome for the patient remains the same. As noted in the previous editions, the particular equipment, instruments, and supplies suggested for use are not to be regarded as exclu- sive. Rather, the suggested surgical items represent those that are basic and commonly used; items can be added or deleted according to pref- erence. Draping techniques, instrument nomenclature, equipment, supplies, etc. will also vary accordingly. Precise details regarding certain items such as suture material have been omitted due to the ever- increasing availability of products and brands. In this edition, the bibliography lists references that include pertinent Internet sites.As in previous editions, the text is reective of the most current drug information with reference to safety precautions and includes anesthetic agents and their administration in their respective chapters. An encyclopedic reference to every surgical procedure has not been attempted. Infrequently performed procedures or those procedures performed only at select surgical facilities, such as organ transplantation surgery, complex cardiac procedures, etc. have been omitted. Incumbent upon the perioperative practitioner is the need to ever expand knowledge on a daily basis, to provide a continuum of safe viii Preface 00Goldman(F)-FM 10/19/07 9:25 PM Page viii

9. patient care in the perioperative environment, and to adapt the latest surgical modalities to established basic concepts. I hope the information presented herein will serve as a generally applicable foundation upon which to build. M.A.G. Preface ix 00Goldman(F)-FM 10/19/07 9:25 PM Page ix

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11. Acknowledgments In writing this third edition, I am indeed indebted to many surgeons, anesthesia providers, perioperative nurses, and surgical technologists for sharing their knowledge with me.They offered highly informative insights gained through years of diligent observation and active partic- ipation in the conduction of their respective specialties. I wish to thank the many providers of surgical instruments, equipment, prostheses, and pharmaceuticals who have generously supplied detailed product information and resources. I wish to acknowledge and thank my long-term friend and col- league, Patricia Gautreau, RN, BSN, CNOR, director of perioperative services at West Hills Hospital and Medical Center,West Hills, Cali- fornia, who suggested that I write the rst edition of this text over twenty years ago. She continues to be a great source of professional encouragement, support, and enlightenment, unsparing in her assis- tance in obtaining technical information. I also wish to thank Chris Keegan, CST, MS, FAST Professor/Chair SurgicalTechnology and Surgical Assisting,Vicennces University, Evansville, Indiana, who advised me on the role of the surgical technologist. She initially reviewed and proposed a number of suggestions regarding surgical entries for the text and lent her expert- ise to the writing of the chapter on dental surgery. I appreciate the considered critique of the 2nd edition of this Pocket Guide by the following Reviewers: Janet Cadorette, Instructor, Surgical Technology, Tennessee Technical Center at Knoxville, Knoxville,TN Tracy L. Ray, RNFA, CNOR, ST, Coordinator and Instructor, Surgical Technology, Ozarks Technical Community College, Springeld, MO Jane Roman, RN, MEd, Chair, SurgicalTechnology, Bunker Hill Community College, Chelsea, MA, and Elizabeth Slagle, MS, RN, CST, Director andAssociate Professor, Surgical Technology, University of Saint Francis, FortWayne, IN. These highly qualied professionals provided encouragement and certain insights to write a future 3rd edition. I very much appreciate the patience and understanding of my editor, Christa Fratantoro, regarding the nature of delays inherent in com- piling the text and the support and encouragement I received from her 00Goldman(F)-FM 10/19/07 9:25 PM Page xi

12. and the staff at F.A. Davis Company, especially Elizabeth Zygarewicz, Editorial Assistant. I also thank Robert H. Craven, Jr., President, who encouraged me to proceed with the writing of the third edition of this text. I again thank Francine Kubrin, former medical librarian, Valley Presbyterian Hospital,Van Nuys, California, for obtaining many valu- able references. I thank ColleenWard, Marla Sussman, and Linda Kern and her staff at Progressive Publishing Alternatives for their efforts in preparing the manuscript for production. I am also pleased to acknowledge the love, kind encouragement, and unwavering support of my adult children Laurie, Emily, Judith, and David, and that of my dear friends during the preparation of this work. And nally, as always, I wish to thank my husband Harris, my partner in all endeavors, whose knowledge and love sustained me through the completion of this work. xii Acknowledgments 00Goldman(F)-FM 10/19/07 9:25 PM Page xii

13. Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii PART 1: Perioperative Considerations: Preoperative, Intraoperative, and Postoperative Care Including Psychological Support of the Surgical Patient . . . . . . . . . . . . . .1 CHAPTER 1 Perioperative Care of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Psychological Support of the Patient in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Surgical Assessment and Preoperative Checklist Chart . . . . . . . . . . . . . . . . . . . . . .3 Authorization for and Consent to Surgery Document . . . . . . . . . . . . . . . . . . . . . . . .6 Authorization for and Consent to Surgical Sterilization Procedure Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Preoperative Care Plan Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Perioperative Record Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 CHAPTER 2 Protection of the Patient in Surgery/ Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Admission Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Procedure for SafelyTransferring the Patient to the OperatingTable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Positioning/Surgical Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Surgical Positions Drawings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Medication Practices and Guidelines to Avoid Medication Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Environmental Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Electrosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Counting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Sterilization Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Emergency and Disaster Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Legal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Legal Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Death in the OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 CHAPTER 3 Safety Measures for Operating Room Personnel. . . . . . . . . .50 Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Surgery Department In-Service Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 00Goldman(F)-FM 10/19/07 9:25 PM Page xiii

14. Body Mechanics/Ergonomic Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Fatigue Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Radiation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Infection Control and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Latex Allergy Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 ChemicalWaste Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Noxious Smoke Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Fire Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 PART 2: Anesthesia General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 CHAPTER 4 Anesthesia Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 General Anesthesia, Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Conduction Anesthesia, Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Conscious Sedation and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 PostoperativeTransfer of the Patient to the PACU . . . . . . . . . . . . . . . . . . . . . . . . . .75 CHAPTER 5 General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Perioperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 CHAPTER 6 Conduction Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Central Nerve Blocks: Spinal, Epidural, and Caudal. . . . . . . . . . . . . . . . . . . . . . . . .84 Regional, Local,Topical Anesthesia Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 PART 3: Technical Adjuncts to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 CHAPTER 7 LaserTechnology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Types of Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 CHAPTER 8 Endoscopy: A Minimal Access Approach . . . . . . . . . . . . . . . . . . . .99 CHAPTER 9 Robotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 CHAPTER 10 Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 CHAPTER 11 Harmonic Scalpel and Plasma Scalpel. . . . . . . . . . . . . . . . . . . .109 Harmonic Scalpel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 Plasma Scalpel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 CHAPTER 12 Argon Beam Coagulator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 CHAPTER 13 Radiofrequency Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 PART 4: Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 CHAPTER 14 Integumentary and Minimally Invasive Surgery. . . . . . .113 Excision (or Destruction) of Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Muscle Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Excision of Subcutaneous Lipoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Incision and Drainage of an Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 Percutaneous Insertion of Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 xiv Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xiv

15. CHAPTER 15 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 CHAPTER 16 Abdominal Extraintestinal Surgery . . . . . . . . . . . . . . . . . . . . . . .132 Abdominal Laparotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 Abdominal Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Abdominal Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Laparoscopic Groin Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 Drainage of Pancreatic Cyst (Pseudocyst) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 Pancreaticoduodenectomy (Whipple Procedure) . . . . . . . . . . . . . . . . . . . . . . . . .159 Pancreatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 Drainage of Abscess(es) in the Region of the Liver . . . . . . . . . . . . . . . . . . . . . . .163 Hepatic Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174 CHAPTER 17 Gastrointestinal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 Esophagoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 Gastroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 Sigmoidoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 Laparoscopic Esosphagomyotomy for Achalasia (Heller Procedure) . . . . .191 Esophagectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Esophageal Hiatel Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199 Laparoscopic Fundoplication (Nissen Procedure) . . . . . . . . . . . . . . . . . . . . . . . . .202 Vagotomy and Pyloroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 LaparoscopicVagotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207 Closure of a Perforated Peptic Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210 Laparoscopic Closure of a Perforated Ulcer (WithVagotomy) . . . . . . . . . . . .211 Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212 Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218 Laparoscopic Adjustable Gastric Banding and Proximal Gastric Bypass .219 Jejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226 Small-Bowel Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230 Cutaneous Ileostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232 Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234 Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236 Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238 Contents xv 00Goldman(F)-FM 10/19/07 9:25 PM Page xv

16. Closure of Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242 Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244 Transverse Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246 Anterior Resection of the Sigmoid Colon and Rectum . . . . . . . . . . . . . . . . . . . .248 Abdominoperineal Resection of the Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250 Laparoscopic-Assisted Colon Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254 Proctocolectomy with Ileal Pouch Anal Anastomosis . . . . . . . . . . . . . . . . . . . . .259 Transanal Endoscopic Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262 Hemorrhoidectomy, Anal Fissurectomy, Anal Fistulotomy . . . . . . . . . . . . . . .265 Anal Sphincteroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268 Thiersch Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269 Ripstein Procedure (Presacral Rectopexy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .271 Perineal Resection of the Rectum for Complete Rectal Prolapse (Procidentia). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .272 Pilonidal Cystectomy and Sinusectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273 CHAPTER 18 Gynecologic and Obstetric Surgery . . . . . . . . . . . . . . . . . . . . . . .277 Dilation of the Cervix and Curettage of the Uterus (D&C) . . . . . . . . . . . . . . . .277 Conization of the Uterine Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281 Therapeutic Abortion by Suction Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285 Marsupialization of Bartholins Gland Duct Cyst . . . . . . . . . . . . . . . . . . . . . . . . . .287 Culdoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 Vaginal Hysterectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 Anterior and/or Posterior Colporrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293 Gynecologic Laparoscopy/Pelviscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295 Uterine Myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Total Abdominal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306 Salpingo-Oophorectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Tubal Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .312 Laparoscopic Hysterectomy and Laparoscopic-AssistedVaginal Hysterectomy With Or Without Salpingo-Oophorectomy . . . . . . . . . . .317 Hysteroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .322 Surgery for Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326 Tuboplasty of the FallopianTubes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332 Cytoreductive Surgery for Ovarian Cancer (Debulking Procedure) . . . . .335 Pelvic Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .339 RadicalVulvectomy With Regional Lymphadenectomy . . . . . . . . . . . . . . . . . .343 Cerclage Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .346 Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .348 CHAPTER 19 Genitourinary Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353 Hypospadias Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353 xvi Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xvi

17. Epispadias Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .358 Urethroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .359 Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 Penile Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365 Marshall-Marchetti-Krantz Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .368 Burch Procedure (Retropubic Colposuspension) . . . . . . . . . . . . . . . . . . . . . . . . . .371 Tension-FreeVaginalTape (TVT) Procedure for Bladder Suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376 Varicoelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379 Hydrocelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .385 Vasovasostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .387 CutaneousVasostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .388 Spermatocelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Orchiectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Cystoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391 Cystostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .397 Cystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .399 Transurethral Resection of the Prostate (TURP) and/or Lesions of the Bladder or Bladder Neck (TURB) . . . . . . . . . . . . . . . . . . . . . .402 Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .406 Nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412 UpperTract Urolithotomy (Ureterolithotomy, Pyelolithotomy, Nephrolithotomy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .416 Percutaneous Nephrostomy and Nephrolithotomy . . . . . . . . . . . . . . . . . . . . . . .420 Cutaneous Ureterostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .423 Ileal Conduit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425 Adrenalectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .427 Extracorporal Shockwave Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .430 Ultrasonic Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434 Electrohydraulic Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437 Implantation of an Articial Urinary Sphincter . . . . . . . . . . . . . . . . . . . . . . . . . . .440 CHAPTER 20 Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445 Bronchoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445 Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .451 Segmental Resection of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455 Wedge Resection of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .459 Pulmonary Lobectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .460 Pneumonectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461 Decortication of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .462 Contents xvii 00Goldman(F)-FM 10/19/07 9:25 PM Page xvii

18. Insertion of ImplantableTransvenous Endocardial Pacemaker . . . . . . . . . .463 Insertion of Implantable Cardioverter Debrillator (ICD) . . . . . . . . . . . . . . . . .467 Correction of Pectus Excavatum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .467 Thymectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .472 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .474 Video-AssistedThoracoscopic (VATS)Wedge Resection of the Lung. . . . .479 Video-AssistedThoracoscopic (VATS) Pneumonectomy . . . . . . . . . . . . . . . . . .480 Video-AssistedThoracoscopic (VATS) Esophagogastromyotomy . . . . . . . . .481 CHAPTER 21 Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483 Cartoid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483 Abdominal Aortic Procedures (Abdominal Aortic Aneurysmectomy, Abdominal Aortic Endarterectomy) with Aortoiliac Graft . . . . . . . . . . .490 Femoropopliteal Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .496 Femoral ArterialThromboembolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .500 Greater SaphenousVein Ligation and Stripping . . . . . . . . . . . . . . . . . . . . . . . . . .503 Portosystemic Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506 Arteriovenous Shunt or Arterioveneous (Bridge) Fistula . . . . . . . . . . . . . . . . .509 CHAPTER 22 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512 Cardiac Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512 Cardiopulmonary Bypass (CPB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .514 Intra-Aortic Balloon Catherization (IABC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .516 AorticValve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .518 MitralValve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .519 Coronary Artery Bypass Graft (CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .521 Pulmonary Embolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .523 MAZE Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .524 Transmyocardial Laser Revascularization Procedure (TMLR) . . . . . . . . . . . . .525 CHAPTER 23 Orthopedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535 Open Reduction and Internal Fixation of a Carpal Bone Fracture . . . . . . . .535 Excision of Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .540 CarpalTunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541 Endoscopic CarpalTunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542 Arthroscopy of theWrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .544 Arthroplasty of theWrist with Prosthetic Replacement of the Carpal Bones. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .548 Open Reduction and Internal Fixation of the Radius and/or Ulna Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549 Open Reduction and Internal Fixation of an Olecranon Process Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552 Transposition of the Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .555 xviii Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xviii

19. Arthroscopy of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .556 Open Reduction and Internal Fixation of Fractures of the Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .559 Arthroscopy of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .563 Repair of Recurrent Anterior Dislocation of the Shoulder . . . . . . . . . . . . . . . .567 Open Reduction and Internal Fixation of Fracture(s) of the Humeral Head (Including Humeral Head Replacement by Prosthesis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .570 Arthroplasty of the Shouder with Hemi (Partial) or Total Prosthetic Replacement of the Shoulder Joint . . . . . . . . . . . . . . . . .574 Open Reduction and Internal Fixation of Fractures of the Hip . . . . . . . . . . .581 Prosthetic Replacement of the Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . .586 Total Hip Arthroplasty with Prosthetic Replacement of the Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .589 Open Reduction and Internal Fixation of Fractures of the Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .595 Arthrotomy of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .598 Arthroscopy of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602 Excision of Popliteal (Bakers) Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .606 Arthroplasty of the Knee Joint with Unicompartmental or Total Knee Prosthetic Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .608 Open Reduction and Internal Fixation of Fractures of theTibial Shaft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .613 Open Reduction and Internal Fixation of Fractures of the Ankle. . . . . . . . .615 Arthroscopy of the Ankle and Foot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617 Triple Arthrodesis of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619 Total Ankle Arthroplasty with Prosthetic Joint Replacement . . . . . . . . . . . .620 Repair ofTendo Calcaneus (AchillesTendon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622 Bunionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624 Correction of HammerToe Deformity with Interphalangeal Fusion . . . . .626 Metatarsal Head Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .627 Procedure for Correction of Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628 Amputation of Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .636 CHAPTER 24 Neurologic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640 Craniotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640 Cranioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .660 Transsphenoidal Hypophysectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .662 Ventricular Shunts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .666 Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .670 PercutaneousVertebroplasty and Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .679 Contents xix 00Goldman(F)-FM 10/19/07 9:25 PM Page xix

20. Excision of Cervical Intervertebral Disc with Fusion, Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .681 Cordotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .686 Rhizotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .688 CHAPTER 25 Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690 Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690 Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .692 Cleft Lip Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Cleft Palate Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .701 Reduction of a Nasal Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .704 Reduction of a Mandibular Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .708 Reduction of a Zygomatic Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .713 Open Reduction of Orbital Floor Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .717 Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .720 Mentoplasty (Genioplasty) Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .723 Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .727 Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .729 Dermabrasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .732 Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .735 Repair of Syndactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .740 Digital FlexorTendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .743 Peripheral Nerve Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745 MicrosurgicalVascular Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .748 Palmar Fasciectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .751 Reduction Mammoplasty/Mammaplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .752 Augmentation Mammoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .757 Abdominoplasty/Abdominal Lipectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .762 Liposuction andTumescent Liposuction/Suction-Assisted Lipectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .765 CHAPTER 26 Neck Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .771 Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .771 Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .776 Thyroglossal Duct Cystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .779 Excision of Pharyngoesophageal (Zenkers) Diverticulum . . . . . . . . . . . . . . . .782 CHAPTER 27 Otorhinolaryngological (ENT) Surgery . . . . . . . . . . . . . . . . . . .785 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .785 Tympanoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .789 Stapedectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .796 Mastoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801 Cochlear Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .808 xx Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xx

21. Submucous Resection (SMR) of the Nasal Septum . . . . . . . . . . . . . . . . . . . . . . .811 Functional Endoscopic Sinus Surgery (FESS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .814 Intranasal Antrostomy/Intranasal Fenestration of the NasoantralWall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .822 Caldwell-Luc Procedure (Radical Drainage of the Maxillary Sinuses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .824 Nasal Polypectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .825 Drainage of the Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .827 Tonsillectomy and Adenoidectomy (T & A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .831 Uvulopalatopharyngoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .837 Laryngoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .840 Tracheostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .843 Excision of Submandibular (Submaxillary) Gland . . . . . . . . . . . . . . . . . . . . . . . .846 Parotidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .850 Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .853 Radical Neck Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .857 Excision of Lesions of the Oral Cavity (Partial Glossectomy with Marginal Resection of the Mandible) . . . . . . . . . . . . . . . . . . . . . . . . . . .863 CHAPTER 28 Ophthalmic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .868 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .868 Excision of Chalazion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .875 Canthotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .877 Tarsorrhaphy/Canthorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .877 Ectropion Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .878 Entropion Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .880 Blepharoptosis Repair/Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .881 Excision of Eyelid Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .883 Eyelid Laceration Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .884 Lacrimal Duct Probing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .886 Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .888 Correction of Strabismus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .894 Evisceration of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .896 Enucleation of the Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .899 Orbital Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .900 CornealTransplant/Keratoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .902 Cataract Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .907 Secondary Lens Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .913 Extraction of an Intraocular Foreign Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .915 Trabeculectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .918 Excision of Pterygium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .922 Contents xxi 00Goldman(F)-FM 10/19/07 9:25 PM Page xxi

22. Repair of Retinal Detachment/Scleral Buckling . . . . . . . . . . . . . . . . . . . . . . . . . . .925 Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .930 Refractive Keratoplasty Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .933 CHAPTER 29 Dental Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .936 Dental Extraction/Odontectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .936 Dental Restoration with Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .941 Arch Bar Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .948 TotalTemporomandibular Joint (TMJ) Replacement Surgery . . . . . . . . . . . .952 Orthognathic/Maxillofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .957 CHAPTER 30 RadiationTherapy/Radiotherapy Procedures . . . . . . . . . . .963 Introduction to RadiationTherapy Procedures in Surgery . . . . . . . . . . . . . . . .963 RadiationTherapy for Head and NeckTumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . .966 RadiationTherapy forTumors of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .969 RadiationTherapy for GynecologicTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .971 RadiationTherapy for Carcinoma of the Prostate . . . . . . . . . . . . . . . . . . . . . . . . .974 RadiationTherapy for RectalTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .976 CHAPTER 31 Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .978 Pediatric General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .978 PediatricTracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .989 Branchial Cleft Sinusectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .993 Correction of Congenital Dislocation of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . .996 Repair of Congenital Diaphragmatic Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1002 Omphalocele Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1006 Repair of Exstrophy of the Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1009 Pediatric Umbilical Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1013 Pediatric Inguinal Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1015 Repair of Congenital Atresia of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . .1017 Insertion of a Pediatric CentralVenous Catheter . . . . . . . . . . . . . . . . . . . . . . . .1022 Pediatric Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1025 Pyloromyotomy for Congenital Hypertrophic Pyloric Stenosis . . . . . . . . .1031 Pediatric Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1035 Pediatric Hepatic Portoenterostomy/Kasai Procedure. . . . . . . . . . . . . . . . . . .1041 Relief of (Pediatric) Intestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1045 Reduction of Pediatric Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1048 Pediatric Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1051 Pediatric Colorectal Resection for Aganglionic Megacolon (Hirschsprungs Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1054 Repair of Imperforate Anus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1061 Pediatric Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1067 xxii Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xxii

23. Pediatric Laparoscopic Fundoplication/Nissen Procedure . . . . . . . . . . . . . . .1070 Excision ofWilmsTumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1074 Excision of SacrococcygealTeratoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1078 PediatricThoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1081 Pediatric Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1087 PART 5: Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1091 CHAPTER 32 General Surgery InstrumentTrays . . . . . . . . . . . . . . . . . . . . . . .1093 Major ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1093 Basic/Minor ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1094 Limited ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1095 ThyroidTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1096 Long InstrumentsTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1097 BiliaryTract ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1098 CholedochoscopyTray (OpenProcedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1099 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1099 Laparoscopic Choledochoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1100 Basic Rigid SigmoidoscopyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1100 Gastrointestinal ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1101 Ano-Rectal ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1101 CHAPTER 33 Gynecologic and ObstetricTrays . . . . . . . . . . . . . . . . . . . . . . . . . .1103 Dilation and Curettage (D&C)Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1103 Cervical ConizationTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1104 HysteroscopyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1104 Pelvic LaparoscopyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1105 Vaginal HysterectomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1106 Abdominal HysterectomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1107 Laparoscopic Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1108 LaparoscopicTubal Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1109 Cesarean SectionTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1110 CHAPTER 34 GenitourinaryTrays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 HypospadiasTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 VasectomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 VasovasostomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1112 CystoscopyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1112 Prostatectomy InstrumentTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1114 Kidney, Ureter, BladderTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1117 CHAPTER 35 Thoracic InstrumentTrays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1118 Bronchoscopy InstrumentTrays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1118 Contents xxiii 00Goldman(F)-FM 10/19/07 9:25 PM Page xxiii

24. MediastinoscopyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1119 Thoracoscopy orVideo-AssistedThoracic SurgeryTray . . . . . . . . . . . . . . . . . .1120 ThoracotomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1121 PacemakerTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1122 CHAPTER 36 Cardiovascular Procedures InstrumentTrays . . . . . . . . . .1124 Abdominal andThoracicVascular ProceduresTray . . . . . . . . . . . . . . . . . . . . . .1124 Arteriovenous (A-V) and Carotid Artery (C-A) Shunt InstrumentTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1125 PeripheralVascular ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1127 Cardiac Procedures InstrumentTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128 Open Heart Basic InstrumentTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128 CHAPTER 37 Orthopedic InstrumentsTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . .1132 Minor Orthopedic ProceduresTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1132 Basic Orthopedic ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1133 Bone-Holding InstrumentsTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1134 Knee ArthrotomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1135 Hip InstrumentsTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1135 Total Hip Systems InstrumentTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1137 CHAPTER 38 Neurosurgical Procedures InstrumentTrays . . . . . . . . . . .1139 CraniotomyTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1139 Kerrison Rongeurs and Pituitary ForcepsTray . . . . . . . . . . . . . . . . . . . . . . . . . . .1143 LaminectomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1143 CHAPTER 39 Plastic Surgery InstrumentTrays . . . . . . . . . . . . . . . . . . . . . . . . .1147 Basic Plastic ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1147 CHAPTER 40 Otorhinolaryngologic (ENT) InstrumentTrays . . . . . . . .1153 Ear Procedures InstrumentTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1153 Myringotomy InstrumentsTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1155 Nasal Procedures InstrumentTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1156 Tonsillectomy and Adenoidectomy InstrumentsTray . . . . . . . . . . . . . . . . . . .1158 Tracheostomy InstrumentsTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1159 CHAPTER 41 Ophthalmic ProceduresTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1162 Basic Eye ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1162 Basic Eye Procedures MicroscopeTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1163 Basic Eye Muscle ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1164 Eyelid and Conjunctival ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1165 DacryocystorhinostomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1166 Globe and Orbit ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1167 Corneal ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1168 Cataract Extraction and Lens ProcedureTray . . . . . . . . . . . . . . . . . . . . . . . . . . . .1170 Glaucoma ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1171 xxiv Contents 00Goldman(F)-FM 10/19/07 9:25 PM Page xxiv

25. Basic Eye Procedures MicroscopeTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1173 Retinal ProceduresTray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1174 CHAPTER 42 Dental InstrumentTrays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1176 Dental Instruments for ExtractionsTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1176 Dental Restoration with ImplantTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1178 Temporomandibular Joint (TMJ) Procedures InstrumentTray . . . . . . . . . .1178 Orthognathic/Maxillofacial Procedures InstrumentTray . . . . . . . . . . . . . . . .1179 CHAPTER 43 Pediatric InstrumentTrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1180 Pediatric Major ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1180 Pediatric Minor ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1181 Pediatric Gastrointestinal ProceduresTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1182 PediatricThoracotomyTray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1182 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1184 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1217 Contents xxv 00Goldman(F)-FM 10/19/07 9:25 PM Page xxv

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27. PART 1 PERIOPERATIVE CONSIDERATIONS: Preoperative, Intraoperative, and Postoperative Care Including Psychological Support of the Surgical Patient CHAPTER 1 Perioperative Care of the Patient Psychological Support of the Patientin Surgery When surgery is recommended to an individual, the proposed opera- tion, regardless of its extent, is perceived by the patient to be a major procedure.The patients emotional support begins with the referring physician who recommends a surgeon qualied to perform the surgery. The surgeon explains the indications for surgery, the course of events prior to and following the surgical procedure, and the medical terminology used. During the discussion, the surgeon, in a supportive manner, will outline a favorable course of events, but will not make any guarantees regarding the outcome of the surgical procedure. In addition, the surgeon must inform the patient of the possibility of poor results and the potential complications or injuries related to the procedure or the anesthetic, including death, even though the likelihood may be remote.The surgeon then claries any information pertaining to the surgery until the patient (or legal representative) indicates that he/she understands and is satised with the explanation. If there are alternative treatments or therapies, these must be disclosed prior to asking the patient to sign the informed consent. The surgeon may comfort the patient by stating that the chosen hospital or surgicenter is an accredited facility that has a capable and dedicated staff and that every measure will be taken to assure a successful outcome. In some facilities, when time permits, a perioperative nurse tele- phones the patient prior to the day of surgery to verify the patients name, date of birth, height and weight, and other personal data, as necessary. He/she answers the patients questions and tries to help the patient feel more comfortable about the impending surgical procedure. This initial patient contact optimally is made prior to the date of surgery, but may not take place until immediately before the surgical procedure. The patient usually arrives at the hospital or surgicenter the day before or the day of the scheduled surgery, according to the surgeons orders.Following admission to a unit,as time permits,the patient may be offered a perioperative teaching session and/or a teaching video.When- 01Goldman(F)-01 11/7/07 12:18 PM Page 1

28. ever possible, the patient is afforded an opportunity to express anxieties and/or ask questions.The nurse preparing the patient for surgery com- pletes the SurgicalAssessment and Preoperative Checklist (Form 1-1). Prior to transporting the patient to the surgical suite, operating room personnel must use at least two sources of identication to verify the identity of the patient.This may include any two of the following methods: 1. ask the patient to state his/her name 2. compare the name on the chart to the patients stated name 3. compare the name on the patients armband to the name on the chart 4. compare the name on the addressograph plate to the name on the chart. In addition, as a safety measure, personnel should check the front of the chart to obtain a list of the patients allergies and current medications. Once the patient arrives in the surgical holding area preopera- tively, the circulator, a perioperative practitioner, will implement the Joint Commission (JC) (formerly the Joint Commission on Accredita- tion of Healthcare Organizations) 2004 Universal Protocol to identify the patient by asking the patient to state his/her name and by using another identier from the list above. (Note that by asking for the patients name, rather than by asking directly, Are you Mary Jones, one minimizes the possibility of misidentication.)The patients name, date of birth, the name of the admitting doctor or surgeon, and other identiers on the patients hospital armband must match those identiers on the chart.The patient is asked to state the proposed procedure; the perioperative practitioner records the patients response in the patients own words on the record. Obtaining and conrming important information from the patient and the patients chart helps to ensure the patients safety in the operating room. For patients who are unable to communicate effectively (e.g., a young or shy child, a patient with a language barrier, or a patient who is physically or emotionally impaired or otherwise unable to speak coherently or obtunded), the above information is veried with the patients legal representative. In the surgical suite, the circulator again asks the patient to state his/ her name.(Note that the patients name and identiers are veried a number of times by different personnel.)The circulator compares the patients name and identication number with the armband, chart, and addressograph plate.The procedure to be performed, the appropriately marked site/side (or laterality) of the body as applicable, and the name of the surgeon are reconrmed with the patient or the patients representative. 2 Chapter 1 Perioperative Care of the Patient 01Goldman(F)-01 11/7/07 12:18 PM Page 2

29. 3 Use at least two identifiers Ask the patient to state his/her name Compare stated name to the name on chart Compare the name on chart to the name on armband. Compare armband information to addressograph plate Name of anticipated surgical procedure (write in patients own words) Surgical procedure Consent signed yes no Comment Special consent signed yes no N/A Comment Prep by Skin condition before prep after prep History and physical examination charted yes no Comment Medications on front of chart (include OTC, herbal products) yes no Comment Sensitivities on front of chart yes no Comment ALLERGIES on front of chart yes no Comment Blood or blood products ordered yes no Time available Initials Preoperative instructions given by Skin preparation by Site Solution Skin condition before prep After prep NPO since (time) Height B/P Weight TPR Old charts in OR yes no Comment Patient Identification Verification for Patient Safety refuses transfusions FORM 1-1 Surgical Assessment and Preoperative Checklist continued on following page 01Goldman(F)-01 11/7/07 12:18 PM Page 3

30. 4 Chapter 1 Perioperative Care of the Patient Drains type site N/A Comment Catheter(s) type (1) site (2) site Comment Intravenous line started: solution type by Comment Prostheses: Dental (dentures, bridges, retainers) disposition Limb type/location Implanted Electronic Devices (IED): Hearing devices: implantable hearing aids, cochlear implant bone conduction aids type signature Cardiac: defibrillator, pacemaker, or ventricular assist devices (VAD) type signature Bone growth stimulator type signature Medication infusion pump type signature Neurologic devices: ventricular shunts, nerve stimulators, brain stimulators type signature VALUABLES: Eyeglasses removed/disposition by Contact lenses R L removed/disposition by Hearing aids R L retained/removed/disposition by Jewelry type retained/removed/disposition by Shaver/radio type removed/disposition by Wallet/money removed/disposition by Eye: R L removed retained by by by disposition removed retained by by by disposition removed retained by by by FORM 1-1 Surgical Assessment and Preoperative Checklist (continued). 01Goldman(F)-01 11/7/07 12:18 PM Page 4

31. Entries on the Surgical Assessment and Preoperative Checklist (pp. 34) are begun on the nursing unit as the information is reviewed with the patient.The circulator is also required to verify the information with the patient and initial each item on the checklist. (Note that every facility has its own policy and procedure.) The patients fasting status, prosthetic devices, special physical needs, and drug and substance intol- erances,including sensitivities andALLERGIES,are reviewed by the circulator with the patient or his/her representative and noted in the chart.The patients allergies and current medications should be listed on the front of the chart, although this requirement is not mandated in every health-care institution.Documentation of this information is valu- able for preventing errors in patient care; it provides an extra measure of patient safety. Laboratory data are reviewed; a current record of the patients history and physical examination (dated according to institution policy) are conrmed.Any deviations from the norm,omissions,or discrepancies are to be reported immediately to the anesthesia provider and surgeon. Any valuables or personal property items not previously collected are secured, and their destination is noted on the chart. When the patient enters the operating room, the circulator may offer a warm blanket and/or touch the patients hand or shoulder to indicate concern for the individual.When the circulator answers the patients questions or directs the questions to the surgeon as appropriate, the patient may feel more secure.Adding to that security, the circulator should inform the patient that he/she acts as the patients advocate during surgery, particularly when the patient is anesthetized or otherwise unable to respond. A simple explanation of patients advocate may contribute signicantly to the patients condence in the course of events to follow. Incidentally, operating room personnel must know and implement patient care safety measures when inter- acting with patients (e.g., protecting the patients ngers from injury when the foot of the table is dropped and later raised). The chart is checked once again by the circulator with respect to the Authorization for and Consent to Surgery (Form 1-2), p. 6.This document may include authorization for the administration of blood, blood products, and/or blood transfusions.Additional special consents may be required, i.e.,Authorization for and Special Consent to Surgi- cal Sterilization Procedure (Form 1-3), p. 7.This document indicates that the patient will become sterile. The circulator must verify and document in the Perioperative Record that the surgeon has informed the patient and the patient has stated that he/she understands that he/she will no longer be able to procreate. Once the patient data requirements are veried by the circulator, everyone on the surgical team must agree that the patient on the operating table is the correctly named patient,of the named surgeon present, Chapter 1 Perioperative Care of the Patient 5 01Goldman(F)-01 11/7/07 12:18 PM Page 5

32. 6 Chapter 1 Perioperative Care of the Patient I, , do hereby authorize Dr. and his/her assistant (certified to assist in surgery) to perform the following procedure(s) at this hospital (name) on (date) . Patient (or legal representative) Signature date Relationship to patient, if patient is a minor or if patient requires a legal representative Signature date Signature of witness date I have been informed of the risks, benefits, and alternative treatments to this surgery. I do/do not authorize permission for a blood or blood products transfusion, if necessary, as deemed advisable by my surgeon and/or anesthesia provider. (If consent is withheld, as for religious reasons, document refusal in (Form 1-1) Surgical Assessment and Perioperative Checklist.) I have been informed and understand the purpose of the procedure and the possible complications. I have received no guarantee regarding the consequences or outcome of the aforementioned procedure, including risk of death. I agree to photography (in which I cannot be identified). The photographer and others may be in the operating room for educational purposes. I leave to the discretion of the pathologist the disposition of any specimen(s). I understand that I am responsible for the fees for any specialized services I receive while in surgery, independent from hospital fees. I acknowledge that I read this document, that I fully understand it, and that I am not under the influence of any preoperative or other sedating medication. FORM 1-2 Authorization for and Consent to Surgery 01Goldman(F)-01 11/7/07 12:18 PM Page 6

33. Chapter 1 Perioperative Care of the Patient 7 I, , do hereby authorize Dr. and his/her assistant (certified to assist in surgery) to perform the following procedure(s) at this hospital (name) on (date) Signature date Witness date My physician has fully explained the hysterectomy/tubal ligation/vasectomy (or other) surgical procedure and appropriate alternatives to me. I was offered the opportunity to ask questions and to refuse to have the procedure. I understand that following the hysterectomy/tubal ligation/vasectomy I will be sterile, that is, not able to have children. I understand that the procedure is to be regarded as irreversible. If I change my mind after the sterilization procedure (e.g., tubal ligation or vasectomy) has been performed, a reversal procedure, if available, may not be successful in restoring my fertility. Following a hysterectomy procedure there is no possibility that I will be able to become pregnant. AFFIRMATION OF INFORMED CONSENT BY PHYSICIAN I, in agreement with the Health and Safety Code of the (state), have given the above named patient (or legal representative) information explaining the nature of the procedure: purpose, alternative methods, risks and potential complications, and limitations. After receiving the foregoing information, the patient consents to the treatment and/or procedure described. Signature date Witness date FORM 1-3 Authorization for and Consent to Surgical Sterilization Procedure 01Goldman(F)-01 11/7/07 12:18 PM Page 7

34. 8 Chapter 1 Perioperative Care of the Patient with the correct site and side marked for the particular surgery, and that the patients position on the table is correct for the procedure to be performed. Should any member of the team notice something amiss, it is his/her obligation to bring it to the attention of the team. Any special equipment, instrumentation, and/or implants must be available in the operating room, ready for use prior to starting the surgery. If blood or blood products have been ordered, their availability should be deter- mined prior to surgery by the circulator.The information above needs to be corroborated by all members of the surgical team during the obliga- torytime outmandated by the JC before the surgery may proceed.Any unresolved discrepancies must be reported to the surgeon, the anesthesia provider, and the surgery supervisor, documented in the Periopera- tive Record, and reported in an Incident Report.The surgery may not proceed until all discrepancies are resolved. All pertinent issues and events during the patients surgery must be documented on the Periop- erative Record, p. 12. Documentation on this record provides the legal accounting of the surgery in detail. Any incident that occurs while the patient is in the operating room that has not been documented cannot be considered fact in a court of law. Documentation of all that occurs intraoperatively during the patients perioperative experience is recorded for medicolegal purposes as well as to provide information. During the induction of anesthesia, the circulator may hold the patients hand and/or make eye contact with the patient until the patient is anesthetized; these measures may be continued intermit- tently throughout the surgical procedure when the patient experiences varying degrees of awareness (e.g., when sedation and analgesia/ conscious sedation are employed). Be aware that the patient may be able to perceive, in varying degrees, what is said during the induction of general anesthesia, and even subsequently, as hearing is the last sense to be lost. It is imperative that all who are in the operating room maintain silence during the induction of anesthesia to prevent distraction. Talking is best kept to a minimum throughout the surgical procedure. The number of people in the operating room should be kept to a minimum to avoid distractions and to avoid the possibility of inadvertent contamination of the sterile eld. Postoperatively, the anesthesia provider and the circulator safely transport the patient to the Post Anesthesia Care Unit (PACU), alert to any untoward events.The perioperative RN in the PACU is given orders from the anesthesia provider upon the patients arrival. Simi- larly, the circulator from the operating room gives report to the PACU RN regarding the patients condition, pertinent surgery details, and the patients immediate needs.The patients care is transferred at that time to the perioperative RN in the PACU, who now assumes the role of the patients advocate. 01Goldman(F)-01 11/7/07 12:18 PM Page 8

35. Chapter 1 Perioperative Care of the Patient 9 PREOPERATIVE CARE PLAN NURSING FOCUS I: PATIENT APPEARS ANXIOUS DUE TO ANTICIPATED SURGERY/PROCEDURE AND UNFAMILIAR ENVIRONMENT ASSESSMENT Cognitive Status Awake Alert Oriented Asleep Drowsy Responsive Obtunded Lethargic Disoriented/confused Unresponsive/comatose Comment PAIN 110 Other Factors: Alcohol abuse history Drug abuse history Language: Speaks English yes no Patient speaks another language Deficits: Hearing Sensory Mobility Visual Memory Discuss impairment(s): CARE PLAN DESIRED OUTCOME Patient is able to speak calmly, cooperate, and follow directions. Outcome met yes no Comment NURSING FOCUS II: PATIENT MAY PERCEIVE BODY IMAGE AS ALTERED/IMPAIRED SELF ESTEEM CARE PLAN DESIRED OUTCOME Patient refers to the surgery with positive attitude, acceptance, and understanding. Outcome met yes no Comment NURSING FOCUS III: PREVENT INJURY TO NERVES, JOINTS, AND SKIN INTEGRITY WHEN POSITIONING PATIENT CARE PLAN Patient position Positioning aids Padding used Type Site Grounding pad used yes no Type Control lot number # Location Skin condition before surgery After surgery DESIRED OUTCOME: Patient shows no signs or symptoms of injury to nerves, joints and skin integrity. Outcome met yes no Comment (NOTE: When patient arrives in PACU or on the floor unit, patient should be examined and asked about PAIN 110 or paresthesiae,and the ability to move, i.e., to rule out paralysis) Greet patient by name (with titles), as necessary Encourage patient to express concerns and questions; incorporate them into the care plan Respond to concerns or questions with calm reassurance and accurate facts; defer to surgeon/anesthesia provider when appropriate Orient patients to surroundings and advise them of events as they occur Consider using touch to enhance communication Consider special needs of pediatric and geriatric patients Consider developmental age of all patients, especially pediatric or geriatric patients Answer patients questions and explain procedures before doing them Avoid unnecessary exposure of patients body Adhere to policy regarding visitors and photography; keep number of people in the room to a minimum Smooth sheets under the patient, remove knots on gown ties to maintain smooth surfaces for skin integrity Consider pediatric patients size and adjust table, accessories, equipment, and instrumentation accordingly Pad all bony prominences, e.g., the sacrum, particularly in elderly patients with fragile skin; use adequate padding also on elbows and heels to prevent pressure sores; use positioning aides for support,

Health & Medicine

Pocket guide to the operating room