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Types of Anesthesia
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FUNDAMENTALS OF NURSING / NURSING
21 OCT, 2021
NEWS & BLOG / STUDENT'S REVIEWER
Anesthesia, or anaesthesia has traditionally
Physical Assessment The World
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allows patients to undergo surgery and other 4 MAY, 2020

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was coined by Oliver Wendell Holmes, Sr. in Covid 19
Pandemic
MATERNAL & CHILD HEALTH NURSING / 1846. Another definition is a “reversible lack
20 APR, 2020
MEDICAL SURGICAL NURSING / STUDENT'S of awareness”, whether this is a total lack of
REVIEWER
awareness (e.g. a general anaesthestic) or a Multiple
Metabolic Alkalosis in Pediatrics
lack of awareness of a part of a the body Sclerosis (MS)
Could be
such as a spinal anaesthetic or another nerve
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Lumbar Puncture A. General Anesthesia – is the loss of all

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sensation and consciousness. Protective 23 OCT, 2019
reflexes such as cough and gag reflexes are
Bronchiolitis
lost. A general anesthetic acts by blocking Signs,
awareness centers in the brain so that Symptoms and
Treatment
amnesia (loss of memory), analgesia
20 OCT, 2019
(insensibility to pain), hypnosis (artificial
sleep), and relaxation (rendering a part of the Inflammation:
body less tense) occur. General anesthetics Maybe the Main
Driver of Autism
are usually administered by intravenous
16 OCT, 2019
infusion or by inhalation of gases through a
mask or through an endotracheal tube Diabetics: Say
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inserted into the trachea.
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readily regulated.
2. The anesthesia can be adjusted to
the length of the operation and the
client’s age and physical status.
Disadvantage:
1. It depresses the respiratory and
circulatory systems.
2. Some clients become more anxious
about a general anesthetic that
about the surgery itself. Often this is
because they fear losing the capacity
to control their own bodies.
B. Regional Anesthesia – is the temporary
interruption of the transmission of nerve
impulses to and from a specific area or region
of the body. The client loss sensation in an
area of the body but remains conscious.
Several techniques are used:
Is applied directly to the skin and
mucous membranes, open skin
surfaces, wounds, and burns.
Topical (surface) The most common used topical
Anesthesia agents are lidocaine (Xylocaine)
and benzocaine. Topical
anesthetics are readily absorbed
and act rapidly.
(Infiltration)is injected into a
specific area and is used for
minor surgical procedures such
Local Anesthesia
as suturing a small wound or
performng a biopsy. Lidocaine or
 tetracaine 0.1% may be used.

Is a technique in which the

anesthetic agent is injected into

and around a nerve or small

nerve group that supplies

sensation to a small area of the

Nerve Block
body. Major blocks involve

multiple nerves or a plexus (e.g.

the brachial plexus anesthetizes

the arm); minor blocks involve a

single nerve (e.g. a facial nerve)

Is used most often for

procedures involving the arm,

wrist and hand. An occlusion

tourniquet is applied to the

Intravenous block
extremity to prevent infiltration
(Bier block)
and absorption of the injected

intravenous agent beyond the

involved extremity.

It requires a lumbar puncture

through one of the interspaces

between lumbar disc 2 (L2) and

the sacrum (S1). An anesthetic

agent is injected into the

subarachnoid space surrounding

the spinal cord. Categorized into

Low Spinals (saddle or caudal
Spinal anesthesia
blocks) are primarily used for
(Subarachnoid block)
surgeries involving the perineal

or rectal areas. Mild Spinals

(below the level of the umbilicus

– T10) can be used for hernia

repairs or appendectomies. High

Spinals (reaching the nipple line

– T4) can be used for surgeries

such as cesarean sections.

Is an injection of an anesthetic

agent into the epidural space,

the area inside the spinal column

but outside the dura mater.
Epidural (peridural)

anesthesia

Conscious Sedation may be used alone or in

conjuction with regional anesthesia for some
diagnostic tests and surgical procedures.
Conscious sedation refers to minimal
depression of the level of consciousness in
which the client retains the ability to
maintain a patent airway and respond
appropriately to commands.

Intravenous narcotics such as morphine or

fentanyl (Sublimaze) and antianxiety agents
such as diazepam (Valium) or midazolam
(Versed) are commonly used to induce and
maintain conscious sedation. Conscious
sedation increases the client’s pain threshold
and induces a degree of amnesia but allows
for prompt reversal of its effects and a rapid
return to normal activities of daily living.
Procedures such as endoscopies, incision and
drainage of abcesses, and even balloon
angioplasty may be performed under
conscious sedation.

Risk Factors for Complications During the

Procedure:

Current or past health problems

Taking medications, supplements, or
herbal remedies, blood thinners
Allergies (eg, food allergies, medication
allergies, latex allergies)
Smoking
Drinking alcohol
Taking recreational drugs
Personal or family history of adverse
reactions to anesthesia

Possible Complications:

Pain and tenderness around the injection

site
Bruising, infection, or bleeding of the
injection site
Hematoma (a mass of clotted blood that
forms in a tissue, organ, or body space as
 a result of a broken blood vessel)

Spinal headache (a severe headache that

may occur after spinal or epidural
anesthesia)
Decrease in blood pressure
Nerve damage
Medication mistakenly injected into a
vein; symptoms include dizziness, rapid
heartbeat, and funny taste or numbness
around the mouth
Horner’s syndrome (change of pupil size
on one side)
Ptosis (drooping of the eyelid)
Pneumothorax (air trapped between the
lung and rib cage)

Call Your Doctor If Any of the Following

Occurs:

Signs of infection, including fever and

chills
Redness, swelling, increasing pain, or
discharge from the injection site
Tingling, numbness, or trouble moving
around the affected area
Headache
Persistent coughing
Chest pain
Trouble breathing or shortness of breath
Dizziness
Heartbeat abnormalities
Funny taste or numbness of the mouth
Other worrisome symptoms

Resources:

http://en.wikipedia.org/

http://www.thompsonhealth.com

Fundamentals of Nursing – Barbara Kozier et

al

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 COMMON SURGICAL INSTRUMENTS
The operating room contains a multitude of instruments fit for accomplishing a number of procedures. Note
that this is not an exhaustive list of instruments, but rather some that you will encounter frequently.

SCALPEL
Used for initial incision
and cutting tissue.
Consists of a blade and
a handle. Surgeons #10 Blade: Used primarily for #11 Blade: Used for making #15 Blade: Smaller version of
often refer to the making large skin incisions, precise or sharply angled #10 blade used for making finer
instrument by its blade e.g., in laparotomy. incisions. incisions.
number.

Pott’s Scissors:
Fine scissors used
for creating
SCISSORS incisions in blood
vessels.
Used for cutting tissue,
suture, or for Iris Scissors: Used
dissection. Scissors Mayo Scissors: Heavy scissors Metzenbaum Scissors: Lighter
for fine dissection
available in multiple varieties. scissors used for cutting delicate
can be straight or and cutting fine
Straight scissors are used for tissue (e.g., heart) and for blunt
curved, and may be cutting suture (“suture scissors”), dissection. Also called “Metz” in
suture. Originally
used for cutting heavy for ophthalmic
while curved scissors are used practice.
or finer structures. procedures, but
for cutting heavy tissue (e.g.,
now serves
fascia).
multipurpose role.

Bonney DeBakey Russian

Forceps: Forceps: Forceps:
Heavy Used for Used for
Tissue Forceps: Non-toothed atraumatic
FORCEPS forceps used for fine handling
forceps
used for tissue
atraumatic
tissue
Also known as non- of tissue and traction during holding grasping grasping
locking forceps, dissection. thick tissue during during
grasping forceps, (e.g., fascial dissection. dissection.
thumb forceps, or closure).
pick-ups. Used for
grasping tissue or
objects. Can be toothed
Adson Forceps: Forceps
(serrated) or non-
toothed at the tip used for
toothed at the tip. handling dense tissue, such as
in skin closures.

Crile Kelly Kocher Allis and

Hemostat: Clamp: Clamp: Babcock
aka “snap,” Larger size Traumatic Clamps:
CLAMPS atraumatic
and non-
variation of
hemostat
toothed
clamp
Slightly
rounded
Also called locking toothed with used to jaws,
forceps, these are clamp used to similar hold both are
ratcheted instruments grasp tissue function tissue used for
used to hold tissue or or vessels for that will grasping
objects, or provide that will be grasping be intestine.
hemostasis. Can be tied off. Also larger removed.
traumatic or atraumatic. used in blunt tissues or
dissection. vessels.

ACS Division of Education Student Resource Task Force

 COMMON SURGICAL INSTRUMENTS
Needle Types Suture Sizing Suture Types
Needles must dissect through tissue to pass Available in sizes between #5 There are two main types of
suture. They come in various sizes, types, and and #11-0. Higher numbers suture. The first is braided and
NEEDLES & shapes depending on the application. Here are a indicate larger suture non-braided, or monofilament.
few (though not all) examples:
SUTURE diameter (e.g., #3 is larger
than #2), and more zeros
The second is absorbable and
non-absorbable. Additionally,
Needles come in many indicate smaller suture suture can be made with
shapes and cutting diameter (e.g., #4-0, or natural or synthetic materials.
edges for various #0000, is smaller than #3-0, Some (brand) names and uses
applications. Suture or #000). are shown below.
can be absorbable, non Tapered Needle Conventional Cutting
Needle is round and Needle Suture Types
absorbable, and is tapers to a simple point. Needle is triangular with Absorbable Non-Absorbable
available in different Most commonly used in sharp edges, and one edge
Braided Monofilament Braided Monofilament
sizes. softer tissue such as faces the inside of the
intestine but may also be curved needle. Used for Vicryl® Monocryl® Silk Prolene®
used in tougher tissue tougher tissues such as Polysorb® Maxon® Surgipro®
such as muscle. skin. PDS® Monosof®
Needle Shape Chromic gut Nylon
The shape of the needle is also important. The
curvature of the needle allows for use in Internal Fascial closure Vessel ligation Skin closure
specialized applications. Curved needles are used Skin Glue and anastomosis Subcuticular Reapproximate
in most general surgical procedures, while straight Staplers skin closure lacerations
needles are used for skin and subcuticular suturing. For skin closures, in
particular, staplers
and skin glue may be
used in lieu of
suture. This is
usually based on
cosmetic outcome
and surgeon
preference.

RETRACTORS
In varying forms,
retractors are used to
hold an incision open,
hold back tissues or
other objects to
maintain a clear surgical
field, or reach other
structures. They can Deaver Retractor: Army-Navy Retractor: Weitlaner Retractor: Self- Richardson Retractor: Bookwalter Retractor:
Used to gain exposure retaining for exposing deep Used to hold back deep Self-retaining retractor
either be hand-held or Used to hold back
the abdominal wall. of skin layers. or smaller surgical sites. tissue structures. Also system that is anchored
self-retaining via a to the operating table.
Also called “Wheaty.” called “Rich.”
ratcheting mechanism.

SUCTION
Suction tips, combined
with a suction source,
help to remove debris
and fluid from the Malleable Retractor: Rake Retractor:
surgical field. It can Yankauer Suction Poole Suction Tube: Frazier Suction Tip: Can be bent and Hand-held retractor
also be used to clear Tube: Used Used to remove large Used primarily in customized. Also with sharp teeth
primarily for surface amounts of fluid from ENT and neurosurgery.
surgical smoke. used to protect used to hold back
suction and some the surgical field, as well Usually angled. intestines during surface structures.
intra-abdominal as intra-abdominal abdominal closure.
suction. suction.
ACS Division of Education Student Resource Task Force
 COMMON SURGICAL INSTRUMENTS

STAPLERS
AND CLIPS
Used for reanastomosis
of viscera, vessel
ligation, and excision of
specimens. Can be
one-time use,
reloadable, manual, or Linear Stapler: Creates a Linear Cutter: Creates a linear Circular Cutter: Performs Clips: Used in the ligation
electronically powered. linear staple line; no cutting cut and immediately staples circular cut and staple. Used of vessels, may be metal or
both free edges. Used in in reanastomosis of hollow absorbable material. Open
Staples come in function. Used in ligation and
anastomosis. May be curved. separation and anastomosis. viscera, e.g., large bowel. and lap applicators.
multiple sizes.

ENERGY
SYSTEMS
Broad term used to
describe various
methods of cutting
tissue or sealing
vessels. May use Electrosurgery: Instrument that Ultrasonic: (Harmonic®) uses high- Endostapler: Used in laparoscopic
cuts or cauterizes tissue via an frequency sound to concurrently procedures, provides simultaneous cutting
electricity or sonic
alternating electrical current. cut and seal tissue. Less thermal and stapling. May be manual or electronic.
waves. Available in Some feature articulating heads to
Open (shown) and laparoscopic spread than electrosurgery, but
open or laparoscopic more time consuming. accomplish more difficult placement.
(Ligasure®) applications.
forms.

LAPAROSCOPIC
INSTRUMENTS
Many instruments are
similar to those used in
open surgery, adapted to
fit through narrow ports
placed through the skin.
Laparoscopic work is then
conducted via the ports.
Camera: The camera is the hand-
held component and connects to
a variety of lenses. There are
usually settings for focus and
white balance.
Light Source: Fiber optic cable
Lens: Available in multiple viewing
connects to lens and illuminates
angles to achieve better
field of vision. Caution around
visualization of anatomical
internal structures as light
structures. May require occasional
output can be hot.
defogging.

Image attributed to Magnus 1313 at English Wikipedia Image attributed to Ignis

Insufflator: Injects carbon dioxide
into the abdominal cavity to
create a working space for trocar
placement and surgical
procedures.
Veress Needle: One method of
achieving pneumoperitoneum.
Consists of blind placement of
needle into abdomen and
subsequent injection of gas.
Trocars: Transabdominal working
ports where laparoscopic
instruments are inserted. Also for
insufflation or removal of
specimens. Available in multiple
sizes, e.g., 5, 10, and 12 mm.
Laparoscopic Instruments: Hand-
held and shafted implements
used to work through trocars.
Can perform grasping, retracting,
cutting, cauterizing, and other
functions.

ACS Division of Education Student Resource Task Force

 SPECIAL SURGICAL CONSIDERATIONS
Most surgical subspecialties have specialized equipment specific to the procedures they commonly perform.
This guide provides a brief overview of some of that equipment for familiarity.

Cardiopulmonary

CARDIO- Bypass: Pump circuit

that diverts blood
THORACIC away from heart,
oxygenates blood, and
SURGERY removes wastes, with
a separate circuit for
Cardiopulmonary
cardioplegic solution.
bypass, bronchoscopy, Operated by a cardiac Image attributed to Cancer Research UK Image attributed to Cancer Research UK

and equipment for perfusionist. Adequate Bronchoscope: Endoscope Video-Assisted Thorascopic

minimally invasive anticoagulation narrow enough to view, Surgery (VATS): Minimally
thoracic procedures are required for proper aspirate, or remove specimens invasive surgical technique for
frequently encountered. function. from airway and branches procedures in the thorax.
Image attributed to Pfree2014

Cystoscope:
Endoscope, either
Ureteral Stent: Semirigid
flexible or rigid, that
tube that is used to
UROLOGIC is used for
visualization of the
maintain patency of ureter.
SURGERY genitourinary system
May be used as temporary
measure for obstruction or
Minimally invasive for either diagnosis or
placed prior to abdominal
cystoscopic equipment procedures.
surgery to identify ureters.
Combined with saline
is frequently used for Usually placed with
circulation to create
both visualization and viewing space in
cystoscopy.
performing procedures. bladder.
Image attributed to Cancer Research UK Image attributed to Hildpeyi at English Wikipedia

ORTHOPAEDIC
SURGERY
Joint replacements and Image attributed to Arthroscopist Image attributed to Netha Hussain Image attributed to Bszsurgico
other procedures Arthroscope: Endoscopic Orthopaedic Implants: Rongeur: Sharp-edged Bone Saw: Battery
require specialized technique to diagnose and Synthetic pins, nails, or other and sturdy instrument powered and used for
equipment. treat joint, ligament, and prostheses used to fix broken used for removing cutting bone, either free
tendon disorders. Combined bones or replace worn joints. bone or creating a hand or with the
with saline circulation to Usually implanted using window in bone. assistance of a jig.
create joint space. special surgical equipment.

Robotic Surgical
System: Electronically-
powered instrument
ROBOT- usually with multiple
arms and
ASSISTED interchangeable
SURGERY surgical tools. Surgeon
works from a console
Increasingly used for while surgical Surgeon Console: Operation Robotic Arm: Apparatus
procedures in urology, technicians replace center for surgical system, holding surgical instruments.
gynecology, endocrine instruments as needed. consisting of controls for Allows for increased range of
surgery, and other System usually robotic arms and stereotactic motion over laparoscopy
specialties. operates via video offering three- through articulating
laparoscopic approach. dimensional view of field. instrument heads.

ACS Division of Education Student Resource Task Force

Suture Materials
Home / Basic Surgical Skills / Surgical Equipment / Suture Materials

Last updated: March 10, 2021

Revisions: 23

Surgical suture materials are used in the closure of most wound types. The ideal suture should allow the healing tissue to recover su!iciently to keep the
wound closed together once they are removed or absorbed.

The time it takes for a tissue to no longer require support from sutures will vary depending on tissue type:

Days: Muscle, subcutaneous tissue or skin

Weeks to Months: Fascia or tendon

Months to Never: Vascular prosthesis

It is worth noting that regardless of suture composition, the body will react to any suture as a foreign body, producing a foreign body reaction to varying
degrees.

In this article, we shall look the classification of suture materials, suture size, and the components of the surgical needle.

Classification of Suture Materials

Broadly, sutures can be classified into absorbable or non-absorbable materials. They can be further sub-classified into synthetic or natural sutures, and
monofilament or multifilament sutures.

The ideal suture is the smallest possible to produce uniform tensile strength, securely hold the wound for the required time for healing, then be absorbed. It
should be predictable, easy to handle, produce minimal reaction, and knot securely.

© By TeachMeSurgery (2020)

Figure 1 – The di!erent classifications and sub-classifications of suture materials.

The suture type chosen vary much depends on the clinical scenario. For example, as a rough guide, a mass closure of a midline laparotomy may warrant use
of PDS, a vascular anastomosis will probably require prolene, a hand-sewn bowel anastomosis may need vicryl, and securing a drain may need a silk suture.

Absorbable vs Non-Absorbable
Absorbable Sutures

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Absorbable suturesuses cookies.
are broken down by the body via enzymatic reactions or hydrolysis. The time in which this absorption takes place varies between
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Absorbable sutures are commonly used for deep tissues and tissues that heal rapidly; as a result, they may be used in small bowel anastomosis, suturing in
the urinary or biliary tracts, or tying o! small vessels near the skin.

For the more commonly used absorbable sutures, complete absorption times will vary:

Vicryl rapide = 42 days

Vicryl = 60 days

Monocryl = ~100 days

PDS = ~200 days

Non-Absorbable Sutures

Non-absorbable sutures are used to provide long-term tissue support, remaining walled-o! by the body’s inflammatory processes (until removed
manually if required).
Uses include for tissues that heal slowly, such as fascia or tendons, closure of abdominal wall, or vascular anastomoses.

Synthetic vs Natural
Suture materials can be further categorised by their raw origin:

Natural – made of natural fibres (e.g. silk or catgut). They are less frequently used, as they tend to provoke a greater tissue reaction. However, suturing silk
is still utilised regularly in the securing of surgical drains.

Synthetic – comprised of man-made materials (e.g. PDS or nylon). They tend to be more predictable than the natural sutures, particularly in their loss of
tensile strength and absorption.

Monofilament vs Multifilament
Suture materials can also be sub-classified by their structure:

Monofilament suture – a single stranded filament suture (e.g nylon, PDS*, or prolene). They have a lower infection risk but also have a poor knot security
and ease of handling.

Multifilament suture – made of several filaments that are twisted together (e.g braided silk or vicryl). They handle easier and hold their shape for good
knot security, yet can harbour infections.

Suture Type Absorbable Non-absorbable Monofilament Multifilament

Vicryl ✓ ✓

PDS* ✓ ✓

Monocryl ✓ ✓

Nylon ✓ ✓

Prolene ✓ ✓

Silk ✓ ✓

Table 1 – Suture type and structure *PolyDioxanone Suture

Suture Size
The diameter of the suture will a!ect its handling properties and tensile strength. The larger the size ascribed to the suture, the smaller the diameter is,
for example a 7-0 suture is smaller than a 4-0 suture.

When choosing suture size, the smallest size possible should be chosen, taking into account the natural strength of the tissue.

© By TeachMeSurgery (2020)

Figure 2 – Sutures come in a variety of sizes; the larger the number, the smaller the suture
Surgical Needles
The surgical needle allows the placement of the suture within the tissue, carrying the material through with minimal residual trauma.

The ideal surgical needle should be rigid enough to resist distortion, yet flexible enough to bend before breaking, be as slim as possible to minimise trauma,
sharp enough to penetrate tissue with minimal resistance, and be stable within a needle holder to permit accurate placement.

Commonly, surgical needles are made from stainless steel. They are composed of:

The swaged end connects the needle to the suture

The needle body or shaft is the region grasped by the needle holder. Needle bodies can be round, cutting, or reverse cutting:
Round bodied needles are used in friable tissue such as liver and kidney

Cutting needles are triangular in shape, and have 3 cutting edges to penetrate tough tissue such as the skin and sternum, and have a cutting surface on
the concave edge

Reverse cutting needles have a cutting surface on the convex edge, and are ideal for tough tissue such as tendon or subcuticular sutures, and have
reduced risk of cutting through tissue

The needle point acts to pierce the tissue, beginning at the maximal point of the body and running to the end of the needle, and can be either sharp or
blunt:
Blunt needles are used for abdominal wall closure, and in friable tissue, and can potentially reduce the risk of blood borne virus infection from
needlestick injuries.

Sharp needles pierce and spread tissues with minimal cutting, and are used in areas where leakage must be prevented.

The needle shape vary in their curvature and are described as the proportion of a circle completed – the ¼, ⅜, ½, and ⅝ are the most common curvatures
used. Di!erent curvatures are required depending on the access to the area to suture.

© By TeachMeSurgery (2020)

Figure 3 – The parts of a surgical needle

+
Key Points
Suture materials can be classified in a variety of ways

Choice of suture material is dependent on numerous factors, such as tissue type, infection risk, and personal preferences

The surgical needle allows for the correct positioning of the suture material within a tissue
 GENERAL SURGERY (/SURGERY/GENERAL-SURGERY/NOTES)

Abdominal incisions
NOTES

Overview
A surgical incision refers to a cut made through the skin to access deeper tissue or
facilitate an operation.

An abdominal incision refers to a surgical cut made anywhere on the abdomen. This enables
access to deeper tissue to facilitate an operation by gaining access to the intra-abdominal or intra-
pelvic cavities. There are a number of characteristic incisions that are completed on the abdomen
to facilitate open surgery. Many of these have eponymous names.

Knowledge of abdominal incisions is important for exams.

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Kocher
This is a subcostal incision that is completed to gain access to the upper abdomen.

A Kocher (subcostal) incision is commonly performed in the right upper quadrant for open
cholecystectomy. The skin incision is placed approximately 3 cm below and parallel to the costal
margin.

Chevron
 A chevron incision is more commonly known as a 'rooftop' incision.

A Chevron incision is essentially an extension of the Kocher incision across the midline to involve
the other side of the abdomen. It is important for gaining good access to the upper abdomen for
major surgery (e.g. liver transplantation, duodenal surgery, adrenalectomy).

The rooftop incision may be combined with a sternotomy incision during cardiac or liver surgery.
This combined incision is known as a 'Mercedes-Benz' incision.

Laparotomy
A midline laparotomy incision involves a longitudinal cut in the middle of the abdomen.

A laparotomy is a very common surgical incision to gain access into the intra-abdominal cavity. It is
often performed in an emergency (e.g. trauma) as it provides the most rapid entry into the
abdomen. It may be a full incision from the xiphoid process to pubic symphysis or limited to the
upper or lower abdomen by halting the incision at the umbilicus.

A laparotomy incision provides excellent exposure into the abdomen and provides excellent access
to many organs including abdominal viscera, liver, spleen, major vessels (inferior vena cave, aorta),
kidneys, and pelvic organs.

Variations of this longitudinal incision may be performed, which include:

Paramedian incision: cut 2-5 cm left or right of the midline

Pararectus incision: cut at the lateral border of the rectus muscle

NOTE: these incisions are less commonly performed as they take longer to complete and risk injury
to surrounding structures (e.g. epigastric vessels, nerves)

Transverse
Several transverse incisions may be made across the abdomen for both abdominal and
pelvic surgery.

Transverse incisions will usually follow the natural skin tension lines leading to a better cosmetic
result during closure. A variety of incisions can be made to perform both abdominal and pelvic
surgery. They may be performed above or below the umbilicus.

The Pfannenstiel incision is an example of a commonly employed transverse incision for

gynaecological and obstetric procedures that is discussed below. Small transverse incisions may be
used to form/close stomas or to extract laparoscopic resection specimens.

Rutherford-Morrison
The Rutherford-Morrison is an extension of the gridiron incision that is commonly
performed for transplant surgery.

The Rutherford-Morrison incision is commonly completed for renal transplants. It may be used on
the left or right-hand side.
The incision begins ~2 cm above the anterior superior iliac spine (ASIS) and extends obliquely
down and medially through the skin and deeper tissue cutting them along the line of the skin
incision.

A shorter version of this incision that is centred over McBurney's point (two thirds from the
umbilicus to the ASIS) is known as the Gridiron incision that is used in conventional open
appendicectomy. Extension of the Gridiron laterally and medially leads to a Rutherford-Morrison
incision that is more colloquially known as a 'Hockey-stick' incision.

Pfannenstiel
The Pfannenstiel incision is a commonly used transverse incision to perform pelvic
surgery.

Pfannenstiel's incision refers to a low transverse incision (10-15 cm) that is 2-5 cm above the pubic
symphysis. It provides excellent access into the intra-pelvic cavity.

Lanz
A Lanz incision is a commonly performed abdominal incision for open appendicectomy.

The Lanz incision is an oblique incision made along Langer's lines. It is also known as the Rockey-
Davis incision and it is essentially a modification of the traditional Gridiron incision (also known as
McBurney's incision).

It is a transverse incision centred over McBurney's point (two-thirds from the umbilicus to the
ASIS). The incision extends medially to the lateral border of the rectus abdominis and laterally the
same distance. It is commonly completed or open appendicectomy and is considered to have a
better cosmetic result compared to the Gridiron incision.

Last updated: July 2022

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FURTHER STUDY:

VIEW VIDEO TA K E E X A M ( / E X A M ? E X A M % 5 B T O P I C _ I D S % 5 D % 5 B % 5 D = 8 1 7 )

Author
The Pulsenotes Team
A dedicated team of UK doctors who want to make learning medicine beautifully simple.
 PATIENT – Patient J.B.V.B. (Jowie Benedict Velasquez Bonite) is a 16-year-old male born on August 5, 2006, admitted in PPS 310B with
a case number 2023 2155. He has a Pre Op and Post Op Diagnosis of Acute Suppurative Appendicitis. The operation performed was
Appendectomy that was started at 9:27 PM and finished at 10:40 PM with a duration of 1 hour and 13 minutes. The surgeons were
Dr. Robert James Gacayan and Dr. Maris Ting tio. The assistants were Dr. Ken Anatorio and PGI Litara. The anesthesiologist was Dr.
Jose Marie Villarosa. The Circulating nurse was Ms. Xandria Maureen Del Rosario, RN together with Circulating Student Nurse Jewel
Ngujo. The Scrub tech was Ms. Mary Jane Canoy assisted by Scrub Student Nurses Ryan Kuizon and Mary Katherine Loma.

Anesthesia started: 9:10 PM; Ended: 10:40 PM

Anesthesia Used: Bupivacaine

a. Generic Name: Marcaine, Sensorcaine

b. Classification: Central Nervous System Agent
c. Type of Anesthesia: Local Anesthesia
d. Route of Administration: Spinal Anesthesia L3-L4

Adjunctive Drugs Given: Midazolam, Nalbuphine, Dexketoprofen trometamol

Operation Position: Supine

Type of Incision: Rocky-Davis Incision (Transverse) Lanz Incision
Illustration:

Instruments Used:
A. Cutting
1. Cautery Pen with Tip
2. Blade handle #4
3. Blade #15
4. Blade handle #3??
B. Clamping
1. 5 pcs regular round
nose forceps
2. 6 pcs Kelly forceps
curved
3. 6 pcs mosquito
straight forceps
C. Grasping
1. 2 pcs regular tissue
forceps with teeth
2. 1 pc regular tissue
forceps without teeth
3. 3 pcs regular allis
forceps
4. 3 pcs regular Babcock
forceps
 D. Exposing
1. 2 pcs big Richardson’s
retractors
2. 2 pcs baby
Richardson’s
retractors
3. 2 pcs army navy
retractors
E. Suturing
1. VIcryl-0
2. Vicryl 3.0
3. 2 pcs Needle holders
(regular and big)
Others
1. Kidney basin
2. 1 pc small bowl
3. 1 pc big bowl
4. 10 pcs OS 4x8
with liner
5. 1 pc lap pack
6. 1 pc square pack

Sutures and Needles Used:

Layer Suture Needle
Fascia Vicryl-0 ATR (Round)
Muscle Vicryl-0 ATR (Round)
Organ PERMA-HAND 3. ATR (Round)

Acute Suppurative Appendicitis

Epidural
Spinal
Appendix –
4 types of Anesthesia: local monitored sedation, general, regional, spinal – main anes; epidural – maintenance
Instruments
CAICAN
Incision
Draw different blade handle or blades?
What Is an Appendix?
The appendix is a 4 inches long finger-shaped pouch present at the junction of the small and large intestine. It is normally
present in the lower right abdomen.
The exact function of the appendix is unknown. Some believe it harbors good bacteria, which helps to reboot the digestive
system after diarrhea. And some believe it to be a vestigial organ (organs which do not have any apparent function). But
surgical removal of the appendix does not cause any noticeable health problem.
What Is Appendicitis?
Inflammation or infection of the appendix is called appendicitis. It is one of the most common causes of abdominal pain.
The pain is accompanied by nausea and vomiting. The pain becomes worse as the inflammation increases and the appendix
ruptures. Anyone can get appendicitis, but it is more common in people between 10 and 30 years of age. It is usually
caused either by stomach infection moving to the appendix or when stool gets trapped in the appendix.
What Are the Types of Appendicitis?
The two types of appendicitis depending on the onset, which are:
1. Acute Appendicitis - It develops very fast within a few days to hours, and requires prompt medical treatment or
surgery.
2. Chronic Appendicitis - Here, the inflammation lasts for a long time. It is a rare condition.
And depending on the complications:
1. Simple Appendicitis - Cases with no complications.
2. Complex Appendicitis - Cases that involve complications like appendix rupture or abscess.
What Are the Signs and Symptoms of Appendicitis?
Appendicitis causes pain around the belly button and mild fever d uring the initial stages. As the condition progresses, the
signs and symptoms seen are:
• The pain worsens and moves to the lower right side of the abdomen.
• Pain increases on coughing, walking, and making sudden movements.
Related Topics

Appendicitis
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• Nausea.
• Vomiting.
• The fever might go up.
• Constipation or diarrhea.
• Stomach gets bloated.
• Inability to pass gas.
• Painful urination.
• Loss of appetite.

What Are the Causes of Appendicitis?

When the lining of the appendix gets blocked, it results in an infection causing appendicitis. Things that can cause this
blockage are:
• Hard stools.
• Swollen lymph nodes in the intestine.
• Parasitic infection.
What Are the Risk Factors for Appendicitis?
Some of the risk factors include:
• People between ages 15 and 30 years.
• More common in males.
• Family history.
How Is Appendicitis Diagnosed?
If the doctor suspects that your symptoms are caused by appendicitis, he or she will check for tenderness or swelling and
rigidity in the lower right side of your abdomen. To rule out conditions like gastroenteritis, urinary tract infections, ectopic
pregnancy, Crohn’s disease, and kidney stones, the doctor might suggest you get the following tests:
• Complete Blood Count (CBC) - CBC is done to look for signs of infection. Bacterial infection of the urinary tract and
abdominal organs also cause similar symptoms.
• Urine Test - Urinalysis is done to rule out urinary tract infection and kidney stones.
• Pregnancy Test - To rule out an ectopic pregnancy.
 • Pelvic Exam - For females, a pelvic exam is done to rule out conditions affecting the reproductive organs like pelvic
inflammatory disease.
• Imaging Tests - To rule out abdominal abscess or fecal impaction, imaging tests like an abdominal ultrasound, X-
ray, CT (computed tomography) scan, or MRI (magnetic resonance imaging) scan is done.
• Chest Imaging - Chest imaging like a chest X-ray or CT scan is done to check for pneumonia
What Are the Treatment Options for Appendicitis?
Usually, surgical removal of the appendix (appendectomy) is done to remove the inflamed appendix. To prevent the spread
of infection, antibiotics are given before the surgery.
1) Surgery:
Appendectomy can be performed by:
• Laparotomy - Open surgery is done after placing an incision about 2 to 4 inches long.
• Laparoscopic - Surgery is done after placing a few small abdominal incisions with the help of special surgical tools
and camera.
2) Draining the Abscess Before Surgery:
In case the appendix has burst and an abscess has formed around it, the abscess is drained before appendectomy. The
abscess is drained by placing a tube through the skin.
What Is the Recovery Time for Appendectomy?
The recovery time depends on the type of surgery and appendicitis. It usually takes 1 to 3 weeks to recover from
laparoscopic surgery and 2 to 4 weeks for open surgery. If the appendix burst, then you would have to wait for the pus and
infection to be drained out first, which will take a longer time. Some tips for recovering fast after surgery are:
• Avoid strenuous activity for the first couple of weeks.
• To reduce pain, place a pillow on your abdomen and apply pressure before you laugh, cough, and change position.
• Tell your doctor if you experience pain even after taking painkillers.
• Take rest when you feel tired.
What Are the Complications of Appendicitis?
The complications are:
• Abscess - Collection of pus in the appendix.
• Ruptured Appendix - It spills fecal matters and bacteria in the abdominal cavity.
• Peritonitis - Bacteria can cause inflammation of the abdominal lining, which can be fatal.
• Spread of Infection - The infection can travel through the bloodstream and infect other organs.
Conclusion
As of now, there is no sure way to prevent appendicitis, as the cause is still not clear. But its prevalence is less common i n
people who eat a fiber-rich diet. So there is a chance that consuming foods rich in fiber like fruits, vegetables, lentils, and
whole wheat, might help prevent inflammation of the appendix.
After an appendectomy, if you have uncontrolled vomiting, severe abdominal pain, dizziness, pus in the wound, and fever,
get immediate medical attention, as it can be a sign of infection.
Frequently Asked Questions

1.
How Do You Rule Out Appendicitis?
Appendicitis can be ruled out by using brief case history, physical examinations, computed tomography scan, urine analysis,
ultrasound abdomen, anal examinations, an x-ray of the abdomen, and blood examination.
2.
How Long Can You Have Appendicitis Before It Bursts?
The duration taken for bursting depends on the type of appendicitis. In the case of chronic appendicitis, it lasts for a long
period, whereas in the case of acute conditions, symptoms will appear suddenly and immediate surgery is needed.
3.
What Does Appendicitis Feel Like?
Appendicitis pain might be mild or severe. There will be fever, abdominal pain, navel pain, difficulty in moving around, loss
of appetite, and anal pain in some cases. There may also be vomiting, diarrhea, and nausea.
4.
How Bad Is Appendicitis Pain?
There will be sharp pricking pain in the abdomen and the pain worsens by pressing the painful area, moving around.
Sometimes, even coughing, and sneezing worsens the pain. There will be difficulty in sitting in a particular place for a long
time. There will also be difficulty in passing urine.
5.
How Do You Check for Appendicitis at Home?
There are no standard methods for the examination of appendicitis at home, but we can check for any swelling in the
abdominal area. If we have basic knowledge and ideas about appendicitis we can palpate the abdomen and rule out in
some cases.
6.
How Does Someone Get Appendicitis?
Any blockages in the lining of the appendix lead to appendicitis. This is mainly due to the food items we consume and seeds
of fruits that block the passage. It may lead to infection and rupture in the appendix region and sometimes pus discharges
also.
7.
Should You Feel for Appendicitis?
Appendicitis treated at an early time is easily curable but in cases where it is left untreated leads to fatal conditions. So, it
is necessary to start the treatment faster. This will make the condition simple.
8.
How Does Appendicitis Pain Start?
The pain usually comes and goes for a short period of time in the belly and navel region. It starts with pain around the
navel region which makes it difficult in sitting and moving. If you are feeling too much pain, you should consult your doctor
immediately.
9.
What Is the Recovery Time for Appendicitis?
Usually, it takes around one to three days for recovery for laparoscopy. It usually takes two to four weeks after surgery to
return to our routine life. Depending on the severity of the surgery, and the patient the recovery time may be extended.
You should ask your doctor for instructions that are to be followed.
10.
How Quickly Does Appendicitis Come On?
Appendicitis comes so quickly that symptoms appear within the first 24 hours. Later on, any disturbance and food items
lead to further signs and rupture. Any disturbance to the regions leads to further signs.
11.
How Long Are a Patient Stays in the Hospital for Appendicitis?
The patient stays in the hospital just for three days. The patient is admitted to the hospita l one day before the surgery. This
is done so that the patient can adapt to the environment before the surgery. The next day surgery is performed. The
patient is asked to stay in the hospital for another day and then they can be discharged if the doctor ad vises them to do so.
12.
How Quickly Does Appendicitis Develop?
The degree of pain and the duration it takes to show the symptoms might vary. Appendicitis usually develops in teenagers,
the symptoms appear very early in addition some food items lead to rupture of the appendix. Symptoms and signs appear
in an early stage. However, you should consult your doctor if you experience pain for more than one day.
13.
Where Does Your Stomach Hurt With Appendicitis?
Initially, the pain starts near the belly and in the navel region, and later on the pain travels to the abdominal region, mainly
to the right abdomen. There will be swelling in the stomach region which can be identified by palpation by the doctors.
Palpation is the procedure of investigation done by touching and pressing.
14.
What Is Appendicitis Surgery?
For severe cases of appendicitis, appendectomy is done. It is the surgical removal of the appendix. This is usually done by
open surgery. Nowadays, it is done using a laser. The surgery that is done usi ng a laser is known as laparoscopy. In which
three holes are made and the further procedure is carried out.
15.
What Foods Make Appendicitis Worse?
Undigested food makes the condition of the appendix to worsen. Seeds of fruits and vegetables are also harmf ul.
Medications that are taken to relieve pain leads to the rupture of the appendix. This makes the condition even worsen.
Some doctors say that spicy food items also worsen the condition of appendicitis.
16.
What are the early signs and symptoms of appendicitis?
The signs and symptoms of appendicitis are:
- Nausea.
- Vomiting.
- Loss of appetite.
- Sudden and severe pain in the right side of the lower abdomen.
- The pain begins in the navel that shifts to the right side of the abdomen.
- Severe pain will be experienced while walking, coughing, and movements.

Appendicitis NCLEX Review

What is Appendicitis? inflammation of the appendix
Where is the appendix? It is found on the right lower side of the abdomen and connects to the cecum of the large intestine. It looks
like a protruding worm or finger-like structure coming out of the large intestine, specifically the ascending colon.
The role of the appendix: it plays a role in storing the “good” bacteria in your GI tract while the tract is recovering from a diarrhea
illness (so it helps maintain healthy GI flora).
Cause of Appendicitis
• OBSTRUCTION of some form:
o most common fecalith (hard stool that blocks the appendix)
o parasites (worms)
o foreign body that may have been ingested
o swollen lymph nodal tissue in the mucosal lining of the appendix can swell….these lymph nodes help
fight viral and bacterial infections…people who have Crohn’s Disease, mononucleosis, measles, or
gastroenteritis are at risk.
• TRAUMA/Injury
Pathophysiology of Appendicitis
Let’s look at appendicitis due to a blockage of some kind that is blocking the lumen of the appendix (which is the inside of the
appendix):
The blockage in the lumen of the appendix causes major INCREASE PRESSURE inside the appendix.
What is causing the increased pressure? Inside the appendix is mucosal lining, which is continuously secreting mucus and fluids.
There are also bacteria that normally live in the appendix that start to increase in production due to the blockage. All this “material”
(mucous, fluids, bacteria) continue to grow and it can NOT move anywhere due to the blockage. This causes major pressure in the
lumen of appendix that can lead to perforation (rupture) of the appendix.
Note: if appendicitis is not treated within 48-72 hours there is a risk for rupture which will lead to abscess and peritonitis.
What happens as the pressure continues to build? It leads to major venous obstruction of the veins of the appendix. Therefore,
there is occlusion of blood flow and the stagnant blood can’t go anywhere.
What happens when blood stays stagnant? It coagulates, hence leads to the development of a clot formation. This further
complicates everything and leads to ISCHEMIA. Therefore, the appendix will start to slowly die.
As the appendix dies, the walls of the appendix break down and start to leak all of its contents (bacteria etc.) into the abdominal
cavity. This leads to an abscess forming at the site of rupture and PERITONITIS, which is life-threatening.
Treatment for appendicitis? Appendectomy which is the surgical removal of the appendix. It may be performed as an open surgery
or laparoscopic.
Signs and Symptoms of Appendicitis
 McBurney’s Point Location
Remember “Appendix”
Abdominal pain (will be dull at first with pain at or around the belly button that radiates to the right lower quadrant and it will
localize at this spot)
Point of McBurney’s will have the most pain (found one-third distance between the belly button and anterior superior iliac spine)
Poor appetite
Elevated temperature
Nausea/vomiting
Desire to be in the fetal position to relieve pain (side lying with knees bent)
Increased WBC, inability to pass gas or have a bowel movement (constipation..can have diarrhea too)
eXperiences rebound tenderness (when pressure is applied to the right lower quadrant it hurts but it HURTS MORE when the
pressure is released) and abdominal rigidity on palpation (involuntary stiffening of the abdominal muscle when abdomen
palpated).
Pre-Opt Nursing Care
Care for a patient waiting for an appendectomy
Monitoring:
• Vital signs
• Signs the appendix may have rupture (perforated) : patient’s pain is suddenly relieved which will be followed by
intense abdominal pain
• Signs of Peritonitis
o Increased HR, Increase Respiration, Increased Temperature, and status of abdominal pain (very
intense) and abdominal distention/bloating
Maintain nothing by mouth
Pain relief (especially non-pharmacology with positioning)…watch pain medications because they can mask pain and it is important
the patient notifies you if the pain is suddenly gone
NO HEAT (can use ice application to abdomen if needed) increases risk of rupture
NO ENEMAS (may have constipation or inability to expel gas) or LAXATIVES…increases risk of rupturing appendix
Post-Opt Nursing Care
Care for monitoring a patient after an appendectomy
Monitor:
• Vital Signs (especially temperature which can indicate infection)
• Surgical incision site for infection (extreme redness or purulent drainage)
Maintain drain after surgery, if present. Most sites will have a drain if the patient’s appendix ruptured. The drain will drain excessive
drainage due to the irrigation used to wash out the abdomen and remove the infection. Maintain the drain per MD order. It will be
removed when it stops draining. To help will drainage to escape the abdomen, try to keep the patient on the right side which will
allow gravity to help with drainage (don’t want drainage staying in the abdomen).
Ambulating (getting out of bed), incentive spirometer usage, coughing and deep breathing (splinting wound)…prevent blood clots
and developing pneumonia
Administering IV antibiotics per MD order (usually ordered if the appendix ruptured)
Maintain NG tube if present (remove stomach fluids and swallowed air). It will be removed when bowels start to work…keep NPO
until tube is removed.
Diet will start out slow with clears, then fulls, and solids as tolerated. Encourage patient to eat a high fiber diet (decreases straining
during bowel movements).
Monitor bowel sounds (are they present?), patient passing gas?, and when last bowel movement was (should have a BM within 2-3
days after surgery…if not notify doctor).
Surgery may be open or laparoscopic….If done laparoscopic: patient may experience shoulder pain for a couple of days after
surgery. It is due to the gas, “carbon dioxide”, used to expand the abdominal wall away from the internal organ so the surgeon could
see the appendix and GI tract during surgery.
Administering pain relief as ordered by MD.
ACUTE SUPPURATIVE APPENDICITIS
Suppurative

• Suppurative is a term used to describe a disease or condition in which a purulent exudate (pus) is formed and discharged.
• Suppurative appendicitis has traditionally been considered a later stage of appendicitis, in which bacteria and inflammatory
fluids accumulated in the lumen of the appendix enter the wall of structure and subsequently cause intense pain when the
inflamed membrane rubs against the parietal peritoneum lining the abdominal cavity.
• Accordingly, for many years incidence of suppurative appendicitis was utilized as a measure of medical care since, according
to this view, delays in diagnosis or treatment increase the likelihood of suppuration. Recent research, however, indicates
that acute appendicitis and suppurative appendicitis may develop through discrete processes. For instance, one intriguing
study found that the incidence of acute appendicitis is greatest among teenagers, but that incidence of suppurative
appendicitis does not vary by age. Also, according to some researchers, acute appendicitis is more frequently linked to
mucosal ulceration than suppurative appendicitis, which is more often caused by obstruction of the appendix. It has even
been suggested that small epidemics of acute appendicitis could be associated with a viral agent, though more studies must
be carried out on the subject to more fully understand such occurrences.

TYPES OF APPENDICITIS

• Chronic appendicitis can have milder symptoms that last for a long time, and that disappear and reappear. It can go
undiagnosed for several weeks, months, or years.
• Acute appendicitis has more severe symptoms that appear suddenly within 24 to 48 hours. Acute appendicitis requires
immediate treatment.

Diagnosis:
Since the symptoms are very vague and are like those of other ailments of the bladder, intestinal infections, and gastroenteritis, it is
often tricky to accurately diagnose Appendicitis at once. Following are the tests for diagnosing Appendicitis:
1. Abdominal examination to check inflammation
2. Blood test to check if there is any infection
3. An ultrasound to examine swelling in the appendix
4. A CT scan

APPENDECTOMY
Removal of vermiform appendix.

Anesthesia Used: Bupivacaine

a. Generic Name: Marcaine, Sensorcaine

b. Classification: Central Nervous System Agent
c. Type of Anesthesia: Local Anesthesia
d. Route of Administration: Spinal Anesthesia L3-L4

Adjunctive Drugs Given: Midazolam, Nalbuphine, Dexketoprofen trometamol

Bupivacaine
C – CENTRAL NERVOUS SYSTEM AGENT; LOCAL ANESTHETIC (AMIDE-TYPE)
A – Anesthetic of the amide type. Decreases sodium flux into nerve cell, inhibiting initial depolarization, and prevents propagation
and conduction of the nerve impulse. Progression of anesthesia, related to diameter, myelination, and conduction velocity of
affected fibers is manifested clinically as sequential loss of nerve function. May stimulate or depress the CNS or do both.
- Primary depressant effect is in medulla and higher centers affecting patient's reaction to pain, temperature, and touch, as well as
proprioception and skeletal muscle tone.
I – Infiltration anesthesia; peripheral, sympathetic nerve, and epidural (including caudal) block anesthesia; 0.75% bupivacaine
solution in dextrose is used for spinal anesthesia.
C – Known sensitivity to bupivacaine, local anesthetics, other amide-type anesthetics. Parabens, or metabisulfites; acidosis; heart
block; severe hemorrhage; hypotension and shock; hypertension, cerebrospinal diseases; obstetrical paracervical anesthesia or
spinal anesthesia in septicemia; topical or IV regional anesthesia; intercurrent use with chloroprocaine; history of malignant
hyperthermia. Safety during pregnancy (category C) other than during labor, lactation, or children <12 y is not established.
A – Body as a Whole: Hypersensitivity [cutaneous lesions, urticaria, sneezing, diaphoresis, syncope, hyperthermia, angioneurotic
edema (including laryngeal edema), anaphylaxis, anaphylactoid reaction]. CNS: Nervousness, unusual anxiety, excitement,
dizziness, drowsiness, tremors, convulsions, unconsciousness, respiratory arrest. Special Senses: Pupillary constriction; blurred or
double vision; tinnitus. GI: Nausea, vomiting. Other: Inflammation or sepsis at injection site, chills, pupillary
constriction. Associated with Epidural Anesthesia, Body as a Whole: Total spinal block, persistent analgesia,
paresthesia. Urogenital: Urinary retention, fecal incontinence, loss of perineal sensation and sexual function. Other: Slowing of
labor, increased incidence of forceps delivery, cranial nerve palsies (with inadvertent intrathecal injection).
N – Monitor for signs of inadvertent intravascular injection, which can produce a transient "epinephrine response" (increased
heart rate or systolic BP or both, circumoral pallor, palpitations, nervousness) within 45 seconds in the unsedated patient and an
increase by 20 bpm or more in heart rate for at least 15 seconds in sedated patient.
• Vasoconstrictor-containing solution should be administered cautiously, if at all, to areas with end arteries (e.g., digits,
penis) or to areas that have a compromised blood supply; ischemia and gangrene can result. Inspect areas for evidence of
reduced perfusion because of vasospasm: pale, cold, sensitive skin.
• Note: Systemic reactions (toxicity) are more apt to occur in children or older adults and may develop rapidly or be
delayed for as long as 30 min after administration.
• Monitor for toxicity: CNS stimulation (unusual anxiety, excitement, restlessness) usually occurs first, followed by CNS
depression (drowsiness, unconsciousness, respiratory arrest). However, because stimulation is apt to be transient or
absent, drowsiness may be the first sign in some patients (especially children and older adults).
• Monitor BP and fetal heart rate continuously during labor because maternal hypotension may accompany regional
anesthesia. Place mother on left side with legs elevated.
• Monitor cardiac and respiratory status continuously in patients receiving retrobulbar and dental blocks.
Patient & Family Education
• After spinal anesthesia, sensation to lower extremities may not return for 2.5–3.5 h.
Midazolam
C – CENTRAL NERVOUS SYSTEM AGENT; BENZODIAZEPINE ANXIOLYTIC; SEDATIVE-HYPNOTIC
A – Short-acting parenteral benzodiazepine. Mechanism of action unclear. Intensifies activity of gamma-aminobenzoic acid
(GABA), a major inhibitory neurotransmitter of the brain, by interfering with its reuptake and promoting its accumulation at
neuronal synapses. This calms the patient, relaxes skeletal muscles, and in high doses produces sleep.
- CNS depressant with muscle relaxant, sedative-hypnotic, anticonvulsant, and amnestic properties.
I – Sedation before general anesthesia, induction of general anesthesia; to impair memory of perioperative events (anterograde
amnesia); for conscious sedation prior to short diagnostic and endoscopic procedures; and as the hypnotic supplement to nitrous
oxide and oxygen (balanced anesthesia) for short surgical procedures.
C – Intolerance to benzodiazepines; acute narrow-angle glaucoma; shock, coma; acute alcohol intoxication; intraarterial injection.
Safety in pregnancy (category D), labor and delivery, or lactation is not established.
A – CNS: Retrograde amnesia, headache, euphoria, drowsiness, excessive sedation, confusion. CV: Hypotension. Special
Senses: Blurred vision, diplopia, nystagmus, pinpoint pupils. GI: Nausea,
vomiting. Respiratory: Coughing, laryngospasm (rare), respiratory arrest. Skin: Hives, swelling, burning, pain, induration at
injection site, tachypnea. Body as a Whole: Hiccups, chills, weakness.
N – Inspect insertion site for redness, pain, swelling, and other signs of extravasation during IV infusion.
• Monitor for hypotension, especially if the patient is premedicated with a narcotic agonist analgesic.
• Monitor vital signs for entire recovery period. In obese patient, half-life is prolonged during IV infusion; therefore,
duration of effects is prolonged (i.e., amnesia, postoperative recovery).
• Be aware that overdose symptoms include somnolence, confusion, sedation, diminished reflexes, coma, and untoward
effects on vital signs.
Patient & Family Education
• Do not drive or engage in potentially hazardous activities until response to drug is known. You may feel drowsy, weak, or
tired for 1–2 d after drug has been given.
• Be prepared for amnesia to prevent an upsetting postoperative period.
• Review written instructions to assure future understanding and compliance. Patient teaching during amnestic period may
not be remembered. Even if dose is small and depth of amnesia is unclear, relearn information.
Nalbuphine
C – CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC; NARCOTIC (OPIATE) AGONIST-ANTAGONIST
A – Synthetic narcotic analgesic with agonist and weak antagonist properties. Analgesic potency is about 3 or 4 times greater than
that of pentazocine and approximately equal to that produced by equivalent doses of morphine. On a weight basis, produces
respiratory depression about equal to that of morphine; however, in contrast to morphine, doses >30 mg produce no further
respiratory depression. Antagonistic potency is approximately one fourth that of naloxone and about 10 times greater than that of
pentazocine.
Therapeutic Effects
Analgesic action that relieves moderate to severe pain with apparently low potential for dependence.
I – Symptomatic relief of moderate to severe pain. Also preoperative sedation analgesia and as a supplement to surgical
anesthesia.
C – History of hypersensitivity to drug. Safety during pregnancy (category C) or lactation is not established. Prolonged use during
pregnancy could result in neonatal withdrawal.
A – CV: Hypertension, hypotension, bradycardia, tachycardia, flushing. GI: Abdominal cramps, bitter taste, nausea, vomiting, dry
mouth. CNS: Sedation, dizziness, nervousness, depression, restlessness, crying, euphoria, dysphoria, distortion of body image,
unusual dreams, confusion, hallucinations; numbness and tingling sensations, headache, vertigo. Respiratory: Dyspnea,
asthma, respiratory depression. Skin: Pruritus, urticaria, burning sensation, sweaty, clammy skin. Special Senses: Miosis, blurred
vision, speech difficulty. Urogenital: Urinary urgency.
N – Assess respiratory rate before drug administration. Withhold drug and notify physician if respiratory rate falls below 12.
• Watch for allergic response in persons with sulfite sensitivity.
• Administer with caution to patients with hepatic or renal impairment.
• Monitor ambulatory patients; nalbuphine may produce drowsiness.
• Watch for respiratory depression of newborn if drug is used during labor and delivery.
• Avoid abrupt termination of nalbuphine following prolonged use, which may result in symptoms similar to narcotic
withdrawal: nausea, vomiting, abdominal cramps, lacrimation, nasal congestion, piloerection, fever, restlessness, anxiety.
Patient & Family Education
• Do not drive or engage in potentially hazardous activities until response to drug is known.
• Avoid alcohol and other CNS depressants.
• Do not breast feed while taking this drug without consulting physician.
Dexketoprofen trometamol
C – Nonsteroidal Anti-Inflammatory Drugs (NSAIDs);
Dose: 25mg diluted in 10cc diluent to be given slow IVTT now then q 8H RTC with BP precaution
Brand name: Ketesse
A – A propionic acid derivative with analgesic, anti-inflammatory, and antipyretic properties. It is an NSAID that reduces
prostaglandin synthesis by inhibiting the cyclooxygenase pathway.
I – Management of moderate to severe pain and inflammation.
C – Patient in whom aspirin or another NSAID induces asthma, urticaria, bronchospasm, severe rhinitis, shock. Safety during
pregnancy (category B), lactation, or in children <12 y is not established.
A – CNS: Trouble in sleeping, nervousness, headache, dizziness; depression, drowsiness, confusion, migraine,
vertigo. CV: Peripheral edema, palpitations, hypertension, tachycardia. Special Senses: Visual disturbances, conjunctivitis, eye
pain, retinal hemorrhage, pigmentation changes; Dry nose or throat, tinnitus, hearing impairment. GI: Dyspepsia, drug-induced
peptic ulcer, GI bleeding, nausea, vomiting, diarrhea, constipation, flatulence, stomach pain, anorexia, dry mouth, gingivitis, rectal
burning and hemorrhage, melena, jaundice, elevated ALT, AST. Hematologic: Prolonged bleeding time, anemia,
purpura, agranulocytosis, thrombocytosis. Urogenital: Gynecomastia, changes in libido, urinary tract irritation (dysuria,
frequency/urgency), renal impairment. Respiratory: Laryngospasm, bronchospasm, laryngeal edema, pharyngitis. Skin: Rash,
pruritus, urticaria, erythema, photosensitivity. Endocrine: Aggravation of diabetes mellitus.
N – Lab tests: Monitor baseline and periodic evaluations of hemoglobin, renal and hepatic function.
• Monitor for and report tinnitus, hearing impairment, and visual disturbance, especially during prolonged or high-dose
therapy.
• Monitor for S&S of GI ulceration (e.g., stool for occult blood, persistent indigestion).
Patient & Family Education
• Report promptly signs of jaundice as well as the following: blurred vision, tinnitus, urinary urgency or frequency,
unexplained bleeding, weight gain with edema.
• Note: Possible CNS adverse effects (e.g., light-headedness, dizziness, drowsiness).
• Do not drive or engage in potentially hazardous activities until response to drug is known.
• Note: Alcohol, aspirin, or other NSAIDs may increase risk of GI ulceration and bleeding tendencies and therefore should
be avoided.
• Tell dentist or surgeon that you are taking ketoprofen.
• Do not breast feed infants while taking this drug without consulting physician.
 A. Cutting
1. Cautery Pen with Tip A cautery pen, also known as the cautery pencil or simply as cautery is a medical device doctors
use to stop bleeding. A direct or alternating current is passed through a metal wire to generate
heat. The heat is then conducted through the pen's tip, to seal off tiny blood vessels.
2. Blade #15
3. Blade handle #3?? #3 and #4 (far right) scalpel handles are used most frequently with #3 being used more often than
And 4 #4. The #4 handle is larger than the #3 and has a larger fitment for large blades such as #20. The
#7 handle (long and skinny) is used frequently for more delicate incisions.

MOST COMMON: 11, 12, 15, 20

B. Clamping
1. 5 pcs regular round Bigger compared to mosquito and Kelly; very dull;
nose forceps
2. 6 pcs Kelly forceps used during surgery to compress the artery, clamp and seal small to medium size blood vessels or
curved hold the artery out of the way.
3. 6 pcs mosquito Frequently used for small blood vessels.
straight forceps Type of Hemostatic Forceps commonly used to control bleeding.
Robust locking ratchet and serrated jaws for holding tissue in place.
C. Grasping
1. 2 pcs regular tissue They pierce tissues and allow them to be grasped firmly with the application of less pressure than
forceps with teeth is required with non-toothed forceps. This reduces the risk of crush injury. Toothed forceps are
2. 1 pc regular tissue used for tougher tissues which can tolerate being punctured, such as skin, subcutaneous fat,
forceps without teeth fascia, muscle and tendons.
3. 3 pcs regular allis Allis forceps are used to firmly grasping dense tissue during surgery. Teeth curve to the inside and
forceps are designed to help decrease general pressure applied to the area
4. 3 pcs regular Babcock Babcock Forceps are similar to Allis forceps; however, may be considered less traumatic due to
forceps their wider, rounded grasping surface. The jaws are circumferential, and the tips are triangular and
fenestrated with horizontal serrations. They are particularly useful for grasping tube-shaped
structures.
D. Exposing
1. 2 pcs big Richardson’s retract abdominal or chest incisions. Used for holding back multiple layers of deep tissue. This is
retractors one of the most common general retractors.
 2. 2 pcs baby
Richardson’s
retractors
3. 2 pcs army navy Used to retract shallow or superficial incisions. From small wounds to abdominal operations.
retractors
E. Suturing
1. VIcryl-0 Thickest suture is given the number 6
<6 = smaller diameter
Sutures having smaller diameter indicated by 0 (“aught”) smallest suture is designated 12-0
(twelve-aught).
Synthetic = nylon, or natural = silk or gut.
Some absorbed by the body during the healing process, nylon removed after woiund heals, usually
7-10 days.
2. Vicry 3.0
3. 2 pcs Needle holders Hemostat like devices that hold needles used to suture wounds closed.
(regular and big)
Others
1. Kidney basin
2. 1 pc small bowl
3. 1 pc big bowl
4. 10 pcs OS 4x8 Gauze pads: sponges used for soaking up blood and other fluids from the surgical site.
with liner
5. 1 pc lap pack
6. 1 pc square pack

Types of Blades
Based on the surgeries, location of an incision and usage there are various types of blades with different sizes and
shapes which are labeled with numbers. The list of blades commonly used are described below.
Each of them has a compatible BP Handles. BP Handles are also numbered based on their size.
• Handle No. 3 is compatible with Blade No. 10, 11, 12 and 15. It is the most common handle used in making
incisions. A subtype No. 3G has a graduated scale present over the handle to measure structures. Another
subtype No. 3L is a longer version of No. 3
• Handle No. 4 is compatible with Blade No. 20, 21, 22, 23 and 26. It is similar to No. 3 but has a larger tip for
accommodation of large blades. No. 4G has graduations along the handle No. 4L is a longer version of No.
4.
• Handle No. 7 is compatible with Blade No. 10, 11, 12 and 15. It is a long and slender handle with is useful in
making incisions in deep and tight spaces.

Table 2.1 Types of Blades.

 Table 2.2 Types of Blades.

Table 2.3 Types of Blades.

How is scalpel used?
The scalpel as said before is used in making the incisions, one of the first and the essential instruments used in the
Operation Theater. It can be held in different ways based on the type of incision needed.
• Palmar Grip – Here it is held between the thumb and the middle, ring and 5th fingers with the index finger
over the upper border of the handle. The handle lies clutched in the palm. This grip is used while making
incisions on tough tissues. A Periosteal Elevator is also held in a similar manner. The movement in this
position arises from the shoulder.
• Pencil Grip – Here it is held as a pencil which is used in making small, precision cuts where handle lies over
the palm. In this position movement is given from the fingers to make fine cuts.
Finger-Tip Grip – A modification of Palmar grip where the scalpel is held with the fingertips and the handle lies under the
palm. Here more length of blade lies in contact with the skin hence used in making long incisions, usually the on the skin.
Stab Grip – A modification of Pencil grip where the scalpel is held at a 90o angle to the skin surface. This position help in
allowing maximum control over penetration into the surface. It is used while making ports for laparoscopic surgeries.

Fig. 1 Pencil Grip (Left) and Finger-Tip Grip (Right)

One always needs to keep in mind to pass the scalpel in a Kidney Tray or by keeping the sharp side towards
him/herself.
 • Blades being sharps need to be discarded carefully, an attempt must be made to segregate them as soon as
their purpose is completed. They must be put in a white plastic container with a black lid which would be
sent to incineration. The handles may be reused after adequate sterilization.
Summary
The most important act done during the surgery is to create an incision to proceed further, this has been done using the
oldest surgical instrument known to the medical field, a Scalpel. Though the name of the instrument has changed and
evolved to what it is called today, it has had the same use.

There were many naturally available sources which were crafted to serve the purpose, such as bamboo sticks, shark
teeth, fingernails and obsidian. In the recent times the invention of alloys has taken over the use of the age-old
sources. Stainless steel, titanium and various metals are being used, in order to make them durable and strong they are
being coated with diamond or chromium too.

The blades are compatible with a Bard Parker Handle when combined make a Scalpel. The blades are of various sizes
and are numbered. Each of them has a special use.

The BP handle is also available in various sizes and are numbered. They may be reused after sterilization.

Blades being sharps need to be discarded with utmost care and sent to incineration.

Appendicitis
The appendix is a small, finger-like appendage attached to
the cecum just below the ileocecal valve. Because it empties
into the colon inefficiently and its lumen is small, it is prone
to becoming obstructed and is vulnerable to infection (appendicitis). The obstructed appendix becomes inflamed
and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower
quadrant of the abdominal cavity and the most common
cause of emergency abdominal surgery. Although it can
occur at any age, it more commonly occurs between the ages of 10 and 30 years.

Clinical Manifestations
• Lower right quadrant pain usually accompanied by lowgrade fever, nausea, and sometimes vomiting; loss of appetite
is common; constipation can occur.
• At McBurney’s point (located halfway between the umbilicus and the anterior spine of the ilium), local tenderness
with pressure and some rigidity of the lower portion of the
right rectus muscle.
• Rebound tenderness may be present; location of appendix
dictates amount of tenderness, muscle spasm, and occurrence of constipation or diarrhea.
• Rovsing’s sign (elicited by palpating left lower quadrant, which paradoxically causes pain in right lower quadrant).
• If appendix ruptures, pain becomes more diffuse; abdominal
distention develops from paralytic ileus, and condition worsens.

Assessment and Diagnostic Findings

• Diagnosis is based on a complete physical examination and
laboratory and imaging tests.
• Elevated WBC count with an elevation of the neutrophils;
abdominal radiographs, ultrasound studies, and CT scans
may reveal right lower quadrant density or localized distention of the bowel.

Gerontologic Considerations
In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague and suggestive of bowel obstruction or
another process; some patients may experience no symptoms until the appendix ruptures. The incidence of perforated appendix is
higher in the elderly because many of these people do not seek health care as quickly as younger people.

Medical Management
• Surgery (conventional or laparoscopic) is indicated if appendicitis is diagnosed and should be performed as soon as possible to
decrease risk of perforation.
• Administer antibiotics and IV fluids until surgery is performed.
• Analgesic agents can be given after diagnosis is made.
Complications of Appendectomy
• The major complication is perforation of the appendix,
which can lead to peritonitis, abscess formation (collection
of purulent material), or portal pylephlebitis.
• Perforation generally occurs 24 hours after the onset of pain.
Symptoms include a fever of 37.7
C (100
F) or greater, a
toxic appearance, and continued abdominal pain or tenderness.

Nursing Management
• Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection due to
the potential or actual disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition.
• Preoperatively, prepare patient for surgery, start IV line,
administer antibiotic, and insert nasogastric tube (if evidence of paralytic ileus). Do not administer an enema or
laxative (could cause perforation).
• Postoperatively, place patient in high Fowler’s position, give
narcotic analgesic as ordered, administer oral fluids when
tolerated, give food as desired on day of surgery (if tolerated). If dehydrated before surgery, administer IV fluids.
• If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal obstruction, secondary
hemorrhage, or secondary abscesses (eg, fever, tachycardia,
and increased leukocyte count).

Promoting Home- and Community-Based Care

Teaching Patients Self-Care
• Teach patient and family to care for the wound and perform
dressing changes and irrigations as prescribed.
• Reinforce need for follow-up appointment with surgeon.
• Discuss incision care and activity guidelines.
• Refer for home care nursing as indicated to assist with care
and continued monitoring of complications and wound
healing.

What is the difference between wound dehiscence and wound evisceration?

What is wound dehiscence?
Wound dehiscence is the separation of wound edges at the suture line. A healthy, healing wound should be well-approximated,
meaning that the edges meet neatly and are held closely together by sutures, staples or another method of closure. A wound is at
the greatest risk of dehiscence in the first 6-8 days after surgery, when the wound is still fresh and very fragile. In all cases
dehiscence should be reported to the surgeon.

What causes wound dehiscence?

1. A sudden increase in abdominal pressure. This is due to coughing, sneezing, vomiting, bearing down to have a bowel movement
or lifting a heavy object, causes an abdominal wound to open.
2. Infection. The infection delays healing and can also weaken the newly formed tissue as the body works to close the incision.
3. Malnutrition. A patient who is malnourished or unable to eat may not be able to heal their wound quickly.
4. Obesity. Obese patients are more likely to have problems with wound closure and healing, as the wound has more difficulty
closing and the healed incision must be stronger to support the additional weight of the fatty tissue.
What is wound evisceration?
Wound evisceration is the protusion of the internal organs (usually abdominal) through an incision. Evisceration is a rare but severe
surgical complication, it is an emergency and should be treated immediately.
What to do if evisceration occurs at home?
1. Call 911 or go to the nearest hospital.
2. Cover the opening and organs with cleanest WET sheet or bandage to prevent it from adhering to tissue and also prevent
infection. Sterile saline should be used but if not, bottled or tap water is used.
3. Calm down and seat low or lie down to prevent abdominal tension.
Section for Nurses:
WOUND DEHISCENCE
Assessment:
-Increased drainage.
-Opened wound edges.
-Appearance of underlying tissues through the wound.
Interventions:
-Place the patient in a low-fowler's position with the knees bent to prevent abdominal tension on an abdominal suture line.
-Notify the physician.
-Prevent wound infection through strict asepsis.
-Administer antiemetics as prescribed to prevent vomiting and further strain on the abdominal incision.
-Instruct the patient to splint the abdominal incision when coughing.
WOUND EVISCERATION
Assessment:
-Discharge of serosanguineous fluid from a previously dry wound.
-The appearance of loops of bowel or other abdominal contents through the wound.
-Patient reports feeling a popping sensation after coughing or turning.
Interventions:
-Place the patient in a low Fowler's position with the knees bent to prevent abdominal tension.
-Cover the wound with a sterile normal saline dressing.
-Notify the physician.
-Prevent wound infection through strict asepsis.
-Administer antiemetics as prescribed to prevent vomiting and further strain on the abdominal incision.
-Instruct the patient to splint the abdominal incision when coughing.
-Monitor signs and symptoms of shock.

ATR – Atraumatic Suture

This procedure allows atraumatic surgical needles to penetrate through the hardest tissues without causing trauma. Also, it is
important to ensure biocompatibility between tissue and product during surgical operations. A perfect penetration comfort is
provided during tissue transition with the sharpening process.

The Surgical Needle

In modern medicine the closure of wounds is typically performed with a surgical suture (thread) connected to a surgical needle.
There are many different kinds of suture and as many different needles. Surgical needles have been made of many materials
including bone (early on) and later from metals such as silver and copper, and wire material comprised of bronze or aluminum

Needles can be traumatic which means they have holes or eyes and are supplied to the hospital separate from their suture thread.
The suture must be threaded on site, as is done when sewing at home. Needles can also be atraumatic with the suture pre-attached
to an eyeless needle. The suture manufacture swages the suture thread to the eyeless atraumatic needle at the factory. There are
several advantages to having the needle pre-mounted on the suture. The doctor or the nurse does not have to spend time threading
the suture on the needle. More importantly, the suture end of a swaged needle is smaller than the needle body and causes
minimal trauma when passing through tissue – hence the name atraumatic needles. In modern medicine we primarily use
atraumatic needles when performing surgery.

There are several shapes of surgical needles. These include straight, 1/4 circle, 3/8 circle, 1/2 circle, 5/8 circle, compound curve, half
curved (also known as ski), and half curved at both ends of a straight segment (also known as canoe). Needles may also be classified
by their point geometry; examples include: taper (needle body is round and tapers smoothly to a point), cutting (needle body is
triangular and has a sharpened cutting edge on the inside), reverse cutting (cutting edge on the outside), trocar point or tapercut
(needle body is round and tapered, but ends in a small triangular cutting point), blunt points for sewing friable tissues, side cutting or
spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery

Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp
straight tug. These “pop-offs” are commonly used for interrupted sutures (individual bites rather than a continuous suture), where
each suture is only passed once and then tied.

We can’t perform good surgery without the right surgical needles. Understanding these needles, and how the various types work is
critical to getting good results.