Minor OR/Surgery

I. DEFINITION OF MINOR SURGERY

Minor surgery is defines as a set of procedures in which short surgical techniques are applied on
superficial tissues. Local anesthesia is often required for these procedures and their complication
rate as well as the risk involved is low. Lesions and problems requiring these procedures for
diagnostic or therapeutical reasons are frequently seen by general practitioners both in the
outpatient setting (excision of skin lesions, for instance) as well as in the emergency care setting
(wound suturing, for example).

A. KEY MEMBERS OF THE SURGICAL TEAM

a. Primary Surgeon and Assistants

 Is responsible for determining the preoperative diagnosis, identifying and performing the
appropriate surgical procedure to the patient, obtaining informed patient consent for surgical
procedure, identifying and making the surgical site, and managing postoperative care.
 Surgeon’s assistant is responsible for exposing the surgical site, providing hemostasis to
prevent blood from obstructing the anatomy, and assisting with suturing throughout the
operative procedure.

b. Anesthesiologist/Anesthetist

i. Anesthesiologist - is a physician who is trained in the administration of

anesthetics.
ii. Anesthetist – is a registered professional nurse who is trained to administer
anesthetics.

 Responsibilities:
o Anesthetizing the patient
o Providing appropriate level of pain relief for the patient
o Monitoring the patient’s physiologic status
o Providing the best operative conditions to the surgeon

c. Scrub Nurse
 Prepares the setup and assists the surgeon by passing instruments, sutures, etc.

 Responsibilities:
o Preparation of supplies and equipment on the sterile field
o Maintenance of patient safety and integrity of the sterile field
o Observation of the scrubbed team members for breaks in sterile technique
o Provision of appropriate sterile instrumentation, sutures, and supplies to the
operating surgeon
o Adherence to established policies and procedures for sponge, instrument, and sharp
counts

d. Circulating Nurse
 Is an RN whose responsibility is to serve as the patient advocate while coordinating events
before, during, and after surgical procedure.
  Responsibilities:
o Creating safe environment for the patient, managing the activities outside
the sterile field, and providing nursing to the patient.
o Enforcing the principle of aseptic technique.
o Recognizing and implementing actions to resolve possible environmental
hazards that involve the patient or surgical team members.
o Ensuring the sponge, instrument, and sharp counts are completed and
appropriately documented.
o Communicating relevant information to individuals outside of the OR,
such as family members and other health care members.

e. Other Personnel
 A number of allied personnel that contribute to meeting the needs of the patient
 Pathologist, radiologist, radiology technicians, perfusionist, environmental services personnel
and clerical staff.

B. TWO CATEGORIES OF THE OR TEAM BASED ON ITS MEMBER’S RESPONSIBILITIES

 Scrubbed sterile team:

 Scrub their hands and arms
 Don sterile gowns and gloves
 Maintain sterility
 Work in the sterile field

 Members of this team consist of:

o Surgeon
o Assistant surgeon
o Scrub nurse

 Non-scrubbed sterile team:

 Non-sterile surgical team function outside the sterile field
 Responsible for ensuring patient safety
 Positioning the patient
 Monitoring the patient
 Maintaining sterile technique
 Handling non-sterile supplies and equipment
 Providing items for the sterile team

 Members of the non-sterile team include:

o Circulating nurse
o Anesthesiologist/anesthetist
o Other allied personnel

C. THE MINOR SURGERY ROOM

 Minor surgical procedures do not involve very sophisticated devices. However, some basic
requirements in terms of infrastructure and equipment must be met. Although some minor
surgical procedures could be performed in a consulting room or office in the primary care
setting, it is recommended that each facility have a specific room for these procedures. The room
must include:
  Surgical room
o A well-ventilated, square or rectangular, 15-20 square-meter room is necessary,
with a suitable temperature and a good source of artificial light. It is imperative
that it is clean, but it does not require sterile isolation.

 Operating table
o It should be located in the center of the room to allow easy access from both
sides.
o Height-adjustable, articulated tables are preferred.
o It should be of washable material.

 Doctor’s stool
o Long procedures are best performed in a sitting position. A height-adjustable
stool on wheels is, therefore, necessary.

 Side table
o It is used to place the surgical instruments and material used during the surgery.
o It must have wheels and be height-adjustable, and it should not be placed near
the surgical field, facilitating the procedure

 Lamp
o It must provide adequate lighting with at least 45,000 lux of illuminance.
o May be fixed to the wall or ceiling of the room, but portable lamps with wheels
are acceptable.
o It is advisable to have another auxiliary lamp with a magnifying glass, which will
be useful for removing foreign bodies or working under magnification.

 Showcase and containers

o Some space should also be left for storing consumables and surgical instruments.
o There should also be properly marked containers for bio-contaminated material,
and a disposal system in accordance with current health legislation.

 Resuscitation equipment
o Including material for vascular access, airway intubation, saline, drugs for
resuscitation (e.g. epinephrine, atropine, bicarbonate) and a defibrillator.

 Sterilization system
o Any medical facility performing surgical procedures must have an autoclave to
sterilize surgical equipment or set up an external circuit to sterilize the material.

D. SURGICAL INSTRUMENTS FOR MINOR SURGERY

 Scalpel
o It allows the surgeon to cut with precision through the skin and other tissues and is also
used fto non-blunt dissection.

 Scissors
o They are used both for cutting or sectioning tissues and different materials such as
sutures, drains, and bandages, and dissecting through different tissues.
 Example: Mayo scissors (cutting scissors), Metzanbaum scissors (dissecting
 scissors)

 Needle-holder
o Are meant to hold curved needles while stitching. Their jaws are especially designed to
hold needles safely atraumatically.

 Dissecting forceps
o Use of a 12-cm long Adson forceps with teeth to handle the skin, plus a toothless Adson
forceps for suture removal is recommended.

 Hemostats
o Are used to pull tissue, for homeostasis, and, in some cases, for blunt dissection in
absence of small scissors.

 Surgical retractors
o These instruments are used to expose the surgical field through separation or retraction of
the edges of the wound.
o In minor surgery, it is advisable to have a Senn-Mueller retractor (which is also called a
double-end retractor due to its having a wide plate on one side and three sharp hooks on
the other).

 Biopsy punch
o It is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for
obtaining tissue biopsies.
o They are usually disposable and are manufactured in different diameters (2-8 mm).

 Curette
o It is an instrument consisting of a handle and a spoon-shaped or cutting ring end that
allows scraping of lesions on the skin surface.

 Cryosurgical equipment
o These are devices that spray a cryogen, which is usually liquid nitrogen that uses
extremely cold temperatures to treat benign and malignant skin lesions.

 Electrocautery
o It applies an electric current with ability to coagulate and cut through different tissues.
There are different terminals depending on the type of procedure that is to be performed.

E. SUTURES
 They are classified according to their origin (natural, such as silk or synthetic polymers that
produce less tissue reaction), their configuration (monofilament or multifilament), their size (the
thickness of the suture is measured using a zero-scale <USP system> with ore zeros meaning
finer sutures). The most commonly used in minor surgery range from 2 / 0 to 4 / 0 or 5 / 0, the
finest sutures are usually attached to smaller needles and require the use of more precise needle
holders.

i. Features of main sutures

 a. Nonabsorbable Sutures
 They are not degraded by the body.
 They are used for skin wounds in which stitches that are to be removed or
for internal structures that must maintain a constant tension (like tendons
and ligaments).

1. Silk – suitable for skin suture and for removable sutures in general,
although it may cause significant tissue reaction.
2. Nylon – indicated for precise skin sutures and internal structures
that must maintain constant tension (e.g. tendons).
3. Polypropylene – indicated in continuous intradermal skin closure.
It is a very soft suture with high package memory and, therefore, it
requires more knots for secure tying.

b. Absorbable Sutures
 A suture is considered absorbable if, when placed under the skin surface, it
loses most of its tensile strength in 6 0 days.

1. Polyglactin 910 – indicated in dermal suturing, subcutaneous

tissue, deep suturing and ligatures of small vessels.
2. Polyglycolic acid – its indications are similar to the previous

II. LOCAL ANESTHESIA IN MINOR SURGERY

Local anesthetics are drugs that block the transmission of nerve impulses causing, at least, the
absence of pain sensation in the area of injection.
According to a small chemical difference, local anesthetics can be classified into two groups:

1. Esters (procaine, tetracaine, chloroprocaine, benzoine which is obsolete due to its high
incidence of sensitization), and
2. Amides (lidocaine, mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For
their remarkable safety and efficacy, on use amides, namely lidocaine and mepivacaine.

III. BASIC TECHNIQUES OF LOCAL ANESTHESIA

A. TOPICAL ANESTHESIA
 Have been developed as an alternative to infiltration both for intact skin and for lacerations and
mucosa, especially in children.
 Are used in minor surgical procedures.

B. INFILTRATION ANESTHESIA

1. Angular infiltration: From the point of entry, the anesthetic is infiltrated in three or more
different directions, like a fan.
 2. Perilesional infiltration: Starting from each point of entry the anesthetic is infiltrated in a single
direction, so that after several injections, the lesion will have been surrounded by anesthetic, and
the different points of entry will be forming a polyhedral figure.

3. Linear infiltration: If the lesion to be operated on is a skin laceration

IV. PREPARING ROOM FOR MINOR SURGERY

A. PURPOSES:
1. To make sure that all necessary instruments and supplies are complete.
2. To maintain sterility of the surgical instruments.
3. To prevent accidents in the surgical field
4. To facilitate the performance of the surgical procedure.

B. ASSESSMENT:
1. Check the operation schedule since there might be changes.
2. Check what type of operation will be done.
3. Identify the patient who will undergo the surgical operation.

C. PLANNING:
1. Determine the surgical operation that will be done.
2. Determine the instruments, equipment and supplies that will be used during the
operation.

D. POSSIBLE NURSING DIAGNOSES:

1. Risk for infection
2. Risk for unnecessary injury

E. OUTCOME IDENTIFICATION:
1. Complete instruments and supplies prepared.
2. Sterility of the instrument is maintained.
3. No accidents occur during the course of operation.
4. Smooth and fast surgical operation.

F. EQUIPMENT:
 Surgical cap
 Surgical mask
 Wipe cloth
 Disinfectant solution
 Lap or drape pack
 Gown pack
 Betadine solution
 Blade (2)
 Sterile water
  Mayo tray
 Sterile basin set
 Prep set
 Instrument set
 Picking forceps
 Sterile gloves
 Sterile gauze
 Suture
 Cotton applicator

G. IMPLEMENTATION

Circulating Nurse:
1. In operating room attire, with surgical cap and mask
2. Wash hands
3. Turn on air conditioner
4. Dump dust to the operating room
5. Set up equipment and check for proper functioning:
a. Switch on the overhead lights
b. Check operating room table
c. Check suction machine
d. Line kick buckets with plastic bag

6. Wash hands
7. Gather needed packs and put them on their respective tables or stands:
a. Gown pack on glove table
b. Lap or drape pack on the large instrument table
c. Mayo tray on Mayo stand
d. Sterile basin on the ring or basin stand
e. Prep set on prep table
f. Instrument set on ring stand or table

8. Check the integrity of the packs:

a. Tears
b. Punctures
c. Water marks
d. Expiration date
e. Sterilization indicator

9. Untie and open the outer covering of all packs with bare hands.

Note: Use two sterile picking forceps from this point

10. Open inner covering of the gown pack:

a. Position packages to that flap is on top
 b. Lift the distal flap up and away from the package
c. Open the left flap
d. Open the right flap
e. Open the near flap

11. Put the necessary number of gloves with the correct sizes.
12. Move one of the nurse’s gowns with hand towel over the scrub nurse’s gown with
hand towel over scrub nurse’s gloves at the right side of the table.
13. Cover gown and glove table with the inner pack’s distal flap (keep it in line with the
table with a flap)
14. Open inner covering of the flap pack

a. Position packages so that flap is on top

b. Lift the distal flap up and away from the package
c. Open the left flap
d. Open the right flap
e. Open the near flap

15. Add the following to the lap pack:

 Blade
 Sutures
 Gauze
 Suction tubing, etc.
16. Open inner covering of basin set:
a. Position packages so that flaps is on top
b. Lift the distal flap up and away from the package
c. Open the left flap
d. Open the right flap
e. Open the near flap

17. Transfer two bowls, kidney basin, two sponges’ basins, and prep cup to the lap pack.
18. Pour sterile water into one of the bowls and into the sponge basins and also the wash
bin.
19. Cover the Washington with the inner pack’s distal flap.
20. Pour betadine antiseptic solution to prep cup
21. Cover lap pack with the inner pack’s distal flap (keep it in line with the table with
flap)
22. Open inner covering of prep set:
a. Position packages so that flaps is on top
b. Lift the distal flap up and away from the package
c. Open the left flap
d. Open the right flap
e. Open the near flap

23. Add the following to the prep set:

 a. One pair of glove
b. 4x4 sponges
c. Cotton applicator
d. One sterile bowl

24. Pour betadine cleanser to the bowl

25. Cover prep set with the inner pack’s distal flap (keep it in line with the table with a
flap)

Scrub Nurse
26. In operating room attire with surgical cap and mask.
27. Does surgical hand scrub.
28. Don on sterile gown and gloves (open handed or close handed glove technique)
29. Prepare the prep set:
a. Check the sterilization indicator inside the inner covering of the prep set
b. Arrange the prep table:
 Sponges
 Sponges bowl
 Sponge forceps
 Prep cup
c. Put prep gloves on prep table with hand towel resting on them
d. Moisten a sponge and wipe the powder from glove
30. Prepare basin set:
a. Check the sterilization indicator inside the inner covering of the basin set
b. Put basin on basin stand

31. Prepare lap pack:

a. Check for sterilization indicator inside the inner covering of the basin set.
b. Separate the Mayo stand covering from drapes and sheets.
c. Arrange the drapes (2) and Sheet (fenestrated sheets) according to use
d. Separate the hard towels (4)

32. Drape the mayo stand.

a. Insert both hands, right over left, into the folds of the mayo stand cover.
b. Pull side of the mayo cover over forearms. Carry with technique near mayo
stand.
c. Keep folded part of cover over forearms. Carry with technique near mayo
stand.
d. Put foot on base of mayo stand to stabilize it.
e. Fit drape into mayo tray (circulating nurse may help)
f. Take a hand towel from lap pack, open it then fold it in half and drape it over
the tray
g. Take another hand towel from the lap pack and tool it, then place it on the
mayo tray.
 33. Preparing instrument set:
a. Check the sterilization indicator inside the inner covering of the instrument
set.
b. Put instrument on the mayo tray

34. Arrange instruments at the lap table:

a. Put the ringed instrument on the rolled towel (allis, Kelly’s, etc.)
b. The retractors (Richardson retractor, army-navy retractor, etc.) are placed at
the rear center of the table.
c. Place the sponges at the front center.
d. Emesis basin is placed at the rear of the table.
e. Needle rack is placed on a folded towel in front of the basin.

35. Arrange instruments in the mayo table: knives scissors, tissue forceps, hemostatic
forceps, clamps, retractors, needle holders, sponges, etc.
36. Prepare 2 wet strips and place on top of the instruments.
37. Cover instruments table
38. Assist surgeon in gowning and gloving
39. Check sheet depending on patient’s anatomical position.
40. Drape the pint sheet:
a. Take the paint sheet and check direction indicated for the foot or the head of
the table
b. Protect your gloved hand by cuffing the sheet over them
c. Drop the folds over the sides of the table, then open downward towards the
feet and upward over the anesthetic screen by enclosing your gloved hand
with the turned back cuff of the drape

41. Give supplies and prep cup to surgeon.

42. Hand four lap towels to surround operative area.
43. Drape the laparotomy sheet.
a. Hold rolled side of the sheet and place its opening directly over the site of
incision
b. Keep the gloved hand protected by the folds, open the sheet over the feet area.
Anchor the sheet with opposite hand to prevent dragging it from position.
44. Take your place to assist in the surgical surgery.
45. Circulating nurse moves the mayo table; lap table and sponge table near the operative
field.

H. EVALUATION
 The expected outcome is met when all instruments, supplies and materials used in the
operation are complete before and at the end of the operation, no unnecessary injury
happened, operation was fast and smooth, and all instruments, materials and supplies used
where sterile.