Indication for surgical procedure	Example
Incision	Open tissue or structure by sharp dissection
Excision	Remove tissue or structure by sharp dissection
Diagnostics	Biopsy tissue sample
Repair	Closing of a hernia
Removal	Foreign body
Reconstruction	Creation of a new breast
Palliation	Relief of obstruction
Aesthetics	Facelift
Harvest	Autologous skin graft
Procurement	Donor organ
Transplant	Placement of donor organ
Bypass/shunt	Vascular rerouting
Drainage/evacuation	Incision of abscess
Stabilisation	Repair of a fracture
Parturition	Caesarean section
Termination	Abortion of a pregnancy
Staging	Checking cancer progression
Extraction	Removal of a tooth
Exploration	Invasive examination
Diversion	Creation of a stoma for urine

Phillips (2007)

Surgical procedures are carried out in hospitals, day surgery units or surgeons’ rooms. A surgical procedure may be invasive, minimally invasive, minimal access or non-invasive in nature. Any invasive or minimal access procedures involve entry into the body through an opening in the tissues or a body orifice (Phillips, 2007). Non-invasive procedures are frequently diagnostic and do not enter the body. Advances in diagnostic methodologies and drug therapies enable more individuals to be considered for surgery; however, each patient and each procedure is unique. Surgery cannot be considered always completely safe, patient outcomes are not constantly predictable and the surgical team must, at all times, be prepared for the unexpected.

Surgery and surgical techniques continue to evolve along with technology; the result is increasingly less invasive procedures and more rapid patient recovery. Improvements in technology in perioperative patient care are attributed to:

• surgical specialisation of surgeons and teams

• sophisticated diagnostic and intraoperative imaging techniques

• minimally invasive equipment and technology

• ongoing research and technological advancements (Phillips, 2007).

All surgery has clearly defined principles of the operative technique (Phillips, 2007).

These principles are listed below.

1. Plan the incision.

2. Make the skin incision with one stroke of evenly applied pressure.

3. Handle tissue carefully and as little as possible.

4. Provide haemostasis.

5. Preserve blood supply.

6. Debride necrotic and devitalised tissue.

7. Keep tissue moist.

8. Carefully and accurately approximate tissues.

9. Immobilise the wound.

Sequence of surgery

Every surgical procedure, no matter how simple or complex, will follow a defined surgical sequence. This generalised sequence is then adapted to the specific surgical procedure being performed. Knowledge of the stages of surgical intervention, instrumentation and suture material assists the perioperative nurse in ensuring safe patient outcomes. A working knowledge is required of the sequential steps for a specific surgical procedure based on four concepts that should be considered for any surgical event:

1. approach

2. procedure

3. possible complications

4. closure.

Additional knowledge required by the surgical team includes:

• understanding the anatomy involved

• knowing the surgeon’s approach (position and incision)

• recognising accepted techniques for a given institution (e.g. counts, usage of equipment)

• general condition of the patient

• possible complications related to the proposed surgery (intraoperative, post- operative).

Stages of the surgical procedure

Every surgical procedure, whether invasive or minimally invasive, and regardless of the rocedure undertaken, will follow a set sequence that can be broken down into five stages, as shown in Table 8-2 (Richardson-Tench & Martens, 2005).

Table 8-2 Five stages of the surgical procedure

Stage	Procedure
I	Open
II	Dissection and exposure
III	Exploration and isolation
IV	Repair—revise, excise or replace
V	Close

The instrument nurse must have an in-depth knowledge of each stage of the surgical sequence in order to anticipate the surgeon’s requirements. The focus for the circulating nurse is the provision of support to the surgical team, and management and coordination of the operating room. A laparotomy procedure is used below to outline the five stages in the operative procedure.

Procedure	Rationale
Providing exposure	• Adequate traction required for surgical procedure. • Overly aggressive traction may cause injury to patient.
Stabilisation of anatomical structures	• Wet or dry packs and/or Raytec gauze are used to hold back tissue/push it out of the way. • Gentle handling prevents bruising, tearing and puncturing; firm handling prevents slippage. • Tapes, ties, vessel loops, Penrose drains or sutures may be used.
Use of retractors, grasping instruments and other devices	• Hand-held or self-retaining retractors move and hold tissue/organs. • Clamps, swabs on sticks and suction cannulae push tissue and organs away or towards the surgeon. • A misplaced retractor can compress, tear or stretch blood vessels, nerves and organs. • A grasping instrument can puncture delicate tissue. • Self-retaining retractors are normally used on muscle; smooth blades prevent tearing; toothed blades hold fasciae, subcutaneous tissue, skin. • Swabs on sticks—peanuts—are used for blunt dissection/haemostasis. • Poole and Yankauer suckers are used as exposure devices.
Clamping tissue	• Artery forceps are used to grasp superficial vessels. • Vascular clamps provide haemostasis or partial occlusion until vessel is sutured. • Non-crushing clamps are used for intestinal surgery.
Grasping tissue	• Use fingers/forceps to lift tissue. • Use non-toothed forceps on tissue that may bleed/perforate. • Toothed forceps are used on skin, dense tissue, scar tissue.

Phillips (2007)

The division of tissues is explained below in relation to a laparotomy.

Wound closure

The body is made of many different tissue layers, each having individual characteristics and roles. Historically, every layer was sutured closed. However, with research and the advent of synthetic materials, this practice has been deemed unnecessary in the majority of patients (Phillips, 2007).

Abdominal and visceral peritoneum

The first layer to be closed is that of the abdominal and visceral peritoneum. This is the serous membrane that lines the abdominopelvic cavity. The abdominal peritoneum divides at the posterior midline and surrounds the abdominal organs, creating the visceral peritoneum. The closure of either the visceral or abdominal peritoneum is dependent on the surgeon and the surgery being undertaken. The majority of surgeons will close either the abdominal peritoneum or fascia using either a continuous absorbable suture or interrupted non-absorbable sutures. However, occasionally, depending on their past experience, a surgeon may choose to close both these layers.

The second surgical count commences upon closure of the peritoneal cavity. In anticipation of this closure, the instrument nurse ensures that the surgeon has all the necessary instruments and equipment to continue surgery without interrupting the second surgical count. Clamps can be used to grasp the edges of the peritoneum during closure.

Muscle

The next layer of tissue encountered is muscle. Three layers of muscles—the rectus abdominis, internal and external obliques, and the transverse abdominis—cover the abdominal cavity. The layering effect provides greater strength. The muscle may or may not be sutured upon closure (Phillips, 2007).

Fascia

The external oblique fascia lies directly below the subcutaneous layer and is considered extremely important upon closure as the suture material must hold the wound together while resisting intra-abdominal pressure. An absorbable, monofilament suture that provides long-term wound support is the suture material of choice.

Subcutaneous layer

Closure of the subcutaneous layer will be dependent on the surgeon and the patient’s physical characteristics. One of the objectives of wound closure is to remove dead space and, in doing so, achieve better wound closure, as discussed in Chapter 7. The subcutaneous layer is one layer that, if left unsutured, will provide dead space, the presence of which allows tissue fluids to accumulate, which can delay wound healing. Absorbable suture material that is broken down by hydrolytic action is preferred for suturing of the subcutaneous or subcuticular tissues.

Skin

The final surgical count commences upon closure of the skin. As before, the instrument nurse ensures that the surgeon has access to all the necessary instruments, including suture scissors, tissue forceps, moistened sponges to clean the wound, dry sponges to dry the wound area and a dressing.

An absorbable monofilament suture material with a cutting needle using a subcuticular suturing technique is the preferred option for skin closure as the sutures do not require removal and there is less associated tissue reaction. The skin may also be closed by interrupted sutures using an absorbable or non-absorbable suture material. Skin staples or skin glue can also be used, despite not belonging to the absorbable, monofilament group. In conjunction with these skin closure materials, sterile adhesive strips may be added to provide extra support to the skin edges. Tension sutures may be required to provide additional support and relieve undue strain on the wound for patients in whom wound healing may be compromised; for example, in elderly or obese patients or those on chemotherapy (see Ch 7) (Dunscombe, 2007).

Application of dressing/tape

The skin around the operative site is cleansed prior to the application of the wound dressing. The choice of dressing is dependent upon the area to be dressed and the preference of the surgeon. After its application, the instrument nurse assists with the removal of the drapes from around the surgical site. Finally, tape or other fixative is applied to the dressing by the instrument nurse, the surgeon or surgeon’s assistant.

Instruments

Surgical instruments are critical to the surgical procedure. There are many elements to learn regarding instrumentation, such as names, handling, function, intended use, cleaning and sterilisation. All are very important; however, for many new nurses the most important element is to follow the progression of an operation and, through observation, learn which instruments are required for the various steps in the procedure, their names and function. This knowledge enhances the performance of the instrument nurse and leads to the ability to anticipate the requirements of the surgeon throughout the operative procedure. In preparing instrumentation for an operation, the instrument nurse should check sterility, working condition and completeness of the instruments being used.

Instrument categories

Some basic manoeuvres are common to all surgical procedures. The surgeon dissects, resects or alters tissue and/or organs to restore or repair body functions or body parts (Phillips, 2007). Surgical instruments are designed to act as the tools that the surgeon needs for each manoeuvre and are commonly categorised into five major groups. Although different labels may be attributed to these groups, they are generally categorised as:

1. cutting and dissecting instruments

2. grasping and holding instruments

3. clamps

4. retractors

5. miscellaneous/ancillary/accessory.

Cutting and dissecting instruments

Cutting and dissecting instruments have sharp edges and are used to dissect, incise, separate or excise tissues.

Scalpels

Various scalpel blades are available with configurations for different uses. The Bard Parker and Beaver scalpel handles hold disposable scalpel or knife blades. The Fischer tonsil, Smillie cartilage and Myringotome scalpel handles incorporate the blade into the handle.

Scalpel blades are a potential sharps hazard and, therefore, scalpels are passed in a receptacle (AORN, 2005a). In certain surgical specialties, such as cardiac, vascular and neurosurgery, it is not possible to pass the scalpel blade in this manner. In these circumstances, the instrument nurse should grasp the top of the handle, passing the handle towards the surgeon with the actual blade pointing downwards.