Introduction to the
Gastrointestinal System
Summary
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Anatomy & Physiology, Pathology and
Operative Considerations for:
GI System
Breast
IVAD
Care & Use of Endoscopes
Gastrointestinal Definitions
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Adhesion- tissue that is normally separate is bound together;
produced by inflammation, injury, or intentionally surgically
created
Anastomosis- joining of parts to create a union
Bile- yellow-green alkaline fluid produced by the liver that aids
in digestion and fat absorption
Biliary tract- system of the body involved with bile production,
secretion, and transport
Cholangiogram- injection of contrast media into the cystic duct
or a tube placed in the common bile duct to allow visualization
of the biliary ductal system
Cholecystitis- inflammation of the gallbladder
Cholelithiasis- stones in the gallbladder
Colon- large intestines
Gastrointestinal Definitions
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Diverticula- small pouches in the lining or wall of a canal or
organ, most commonly the colon
Dysphagia- difficulty swallowing
Fissure- crack or opening
Fistula- abnormal passage between two surfaces or two
hollow organs
Intussuseption- when part of the upper intestine slips into or
invaginates into a lower portion of the intestine/creates an
intestinal obstruction
Meckel’s diverticulum- congenital blind pouch usually
associated with the ileum and ileocecal valve
Mucosa- mucous membrane
Gastrointestinal Definitions
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Peptic ulcer- open lesion in the stomach or duodenum
Peritonitis- inflammation of the peritoneal cavity
Polyp- growth or tumor with a stalk or pedicle extending from a
mucous membrane
Pyloric stenosis- congenital narrowing between the stomach
and duodenum (pyloric orifice) due to thickening of circular
muscle surrounding it
Resection- excision of a structure and reconstruction of what
remains
Sphincter- ring-like muscle surrounding an orifice
Volvulus- twisting or torsion of the intestine causes obstruction
and possible strangulation
General Surgery
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Abdominal Wall
Abdominal Cavity
Abdominal Organs
Breast (excluding reconstructive
procedures)
Vascular Access (excluding dialysis
shunting access procedures)
Can include tracheotomy, thyroidectomy
and parathyroidectomy
Anatomy of the Abdominal
Wall
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Subcuticular (skin)
Subcutaneous (fatty/adipose layer)
Anterior fascia (thin or thick membrane over the
muscle)
Muscle
Posterior fascia (thin or thick membrane under the
muscle)
Peritoneum (shiny membrane covering the
abdominal cavity)
Omentum (lesser and greater)
Contents of abdominal cavity (organs/viscera)
Abdominal Cavity
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Diaphragm to pelvic base
Pelvic girdle
Ribs
Vertebrae
Abdominal Surgery
Landmarks
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Xiphoid process
Subcostals
Iliac crests
Symphysis pubis
Umbilicus
Linea alba
Serve as reference points for incisions and
internal organ access
Abdominal Divisions
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Four Quadrants
Nine Quadrants
Abdominal Division
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Anatomy of the Abdomen
RUQ (right upper quadrant) contents:
liver
gallbladder
duodenum
head of pancreas
right kidney and adrenal
part of ascending and transverse colon
Anatomy of Abdomen Continued
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LUQ (left upper quadrant) contents:
stomach
spleen
left lobe of liver
body of pancreas
left kidney and adrenal
part of transverse and descending colon
Anatomy of Abdomen Continued
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RLQ (right lower quadrant) contents:
cecum
appendix
right ovary and fallopian tube
right ureter
right spermatic cord
Anatomy of Abdomen Continued
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LLQ (left lower quadrant) contents:
part of descending colon
sigmoid colon
left ovary and fallopian tube
left ureter
left spermatic cord
Anatomy of Abdomen Continued
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Midline of Abdomen:
Aorta
Uterus
Bladder
Digestive Tract
Alimentary Canal
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Mouth to the Anus
Mouth>Pharynx>Pharyngoesophageal
Sphincter>Esophagus> Esophagogastric
Sphincter>Stomach>Pyloric Sphincter
>Duodenum>Jejunum>Ileum>Cecum
(appendix)>Ascending Colon>Transverse
Colon>Descending Colon>Sigmoid
Colon>Rectum>Internal Sphincter>External
Sphincter>Anus
Physiology of the Digestive
System
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Two major parts:
GI tract/alimentary Canal
-mouth to anus
-about 30 ft long
Accessory Organs
-outside of or to side of GI tract, but are
connected
-teeth, salivary glands, biliary system: liver,
gallbladder, pancreas
Physiology of the Digestive
System
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5 major processes:
Ingestion/eating
Mechanical and Chemical Digestion
Peristalsis
Absorption
Defecation
Mechanical and Chemical
Digestion
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Begins in mouth, teeth increases surface
area of food to allow enzymes to work on
Tongue pushes food underneath teeth and
flips food as a “bolus” to back of throat
(oropharynx)
Salivary Glands-primary salivary amylase
begins break down of carbohydrates
Mechanical and Chemical
Digestion
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Esophagus:
Begins at oropharynx
Mucous allows food to slide down
Mechanical and Chemical
Digestion
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1.
2.
3.
4.
Stomach
4 areas:
Cardiac (esophagus ends and cardiac or
esophageal sphincter empties into this region
Fundus/fundic area part that is rounded on left
side of body
Body-main part of stomach
Pyloric region or antrum=area before pyloric
sphincter which is where the duodenum begins
Mechanical and Chemical
Digestion
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1.
2.
3.
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Rugae (hills and valleys allow stomach to expand
3 basic cell types here that produce:
Pepsinogen
HCl
Mucous
HCl acid activates pepsinogen which then becomes pepsin
which begins protein breakdown
Vagus nerve stimulates tunica muscularis to create waves in
stomach from bottom up to allow for mixing of HCl and
pepsin
Vagus nerve tires easily, production of hormone gastrin by
the stomach sustains the action of stomach wave action
Food in stomach 1-6 hours
Food broken down into “chyme” (semi-solid or pasty material
Pancreas
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Head
Body
Tail
80% comprised of lobules
Lobules consist of exocrine and
endocrine glands
Mechanical and Chemical
Digestion
Pancreas
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Endocrine and exocrine gland
1. Endocrine portion = Islets of Langerhan
 No ducts, secrete into blood or lymph
 Secreting portion is Islets of Langerhans
 1% of pancreatic mass
 Receives 25% pancreatic blood supply
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Islets of Langerhan
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Two cell types:
Alpha cells secrete hormone glucagon (↑
blood sugar level)
Beta cells secrete hormone insulin (↓ blood
sugar levels)
Function maintenance of blood glucose
levels
Exocrine glands
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Secrete directly through a duct
Called acini
Functions: breakdown fats, proteins,
carbohydates and maintain pH
pH maintenance prevents excessive
acid production which prevents
duodenal ulcers
Mechanical and Chemical
Digestion
Pancreas
2. Exocrine portion:
1.
Produces enzymes: collectively called
pancreatic juices (Trypsin, chymotrysin,
carboxypeptidase) break down proteins
2.
Pancreatic amylase breaks down
carbohydrates
3.
Pancreatic lipase breaks down lipids
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All get to small intestine via pancreatic duct
(Duct of Wirsung) at Ampula of Vater
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Mechanical and Chemical
Digestion
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Liver
Functions:
Store excessive nutrients
Detoxify and filter toxins
Regulate nutrient levels
Destroy worn out RBCs, WBCs, bacteria
Produce heparin, prothrombin, fibrinogen, and
albumin
Store fat soluable vitamins (A,D,E,K)
Water soluable are excreted
Produces bile (function to emulsify lipids)
Mechanical and Chemical
Digestion
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Gallbladder
Stores bile
Sphincter of Oddi (hepatopancreatic
sphincter) opens to release bile and
pancreatic juices into the small
intestine
Bile released from gallbladder when
lipids (fats) are present
Mechanical and Chemical
Digestion
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1.
2.
3.
Small Intestine
Begins at pyloric sphincter, ends at ileocecal valve
About 21 feet long
Where 90% of digestion and absorption occur
Other 10% in stomach and large intestines
3 parts:
Duodenum-(12 inches long)
Jejunum (8 feet long)
Ileum (12 feet long)
Mechanical and Chemical
Digestion
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Large intestine
Parts of: Ascending, transverse, descending,
sigmoid, rectum
Functions:
Absorption of water, electrolytes, proteins into
amino acids, and bacterial products
Feces formation
Food in large intestine 3-10 hours for absorption
purposes
Undigested food is expelled via “mass peristaltic
movement” out the anus
Esophagus
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Esophagitis
Ulceration
Neoplasms
Foreign bodies
Zenker’s diverticulum located in
esophagus – dx w/ esophagoscopy 1°sx dysphagia
Esophageal varices - esophagus
erodes due to severe alcoholism
Pathology of The Stomach
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Ulcers
Gastritis
Polyps
Bezoar (hairball in animals/fiber ball in
humans)
Carcinoma
Lymphoma (benign or malignant)
Small Intestine
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Duodenum
Jejunum
Ileum
Pathology of the Small
Intestine
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Ulcer (duodenum most common site)
Neoplasm (benign or malignant)
Obstruction
Crohn’s Disease (Surgical intervention
needed with perforation, abscess or
hemorrhagic fistula formation)
Colon Pathology
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Appendicitis
Adhesions
Herniation
Polyps
Diverticulosis or Diverticulitis
Tumor (benign or malignant)
Ulcerative Colitis
Obstruction
Volvulus
Intussusception
Impaction
Anorectal Pathology
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Fistula
Fissure
Pilonidal Cyst
Hemorrhoids
Pathology of the Pancreas
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Cyst
Tumor (Benign or Malignant)
Chronic Pancreatitis
Trauma
Spleen
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Largest lymphatic mass in body
Composed of:
75% red pulp (vascular)
25% white pulp (lymphatic/immune
response)
Functions: RBC and Plt storage
Excision of renders liver and other
lymphatic tissues to pick up the slack
Pathology of the Spleen
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Trauma
Hematologic Disorders
Tumor (Benign or Malignant)
Cyst
Splenomegaly
Liver
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Largest organ in the body
Comprised of 4 lobes
Functions:
*Bile production
*Metabolism of fats, proteins and carbohydrates
*Glycogen storage
*Storage of fat soluable vitamins (A, D, E, K) and Fe,
Cu
*Detoxification
*Prothrombin and fibrinogen synthesis
Pathology of the Liver
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Carcinoma
Trauma
FYI:
Cirrhosis is related to hepatic cancer
Cirrhosis results from hepatitis and
chronic alcohol abuse
Biliary Tract
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Gallbladder, cystic duct, common bile duct, and common
hepatic duct
Function: transport bile, store bile and release bile into the
duodenum
Aids in digestion and absorption of fats
Gallbladder divided into fundus, body and Hartman’s pouch
Hartman’s pouch: most common site of gallstones (clog and
prevent passage of bile into cystic duct)
Sphincter of Oddi: where CBD empties into
duodenum/controls release of bile into duodenum
Ampulla or papilla of Vater is an enlarged area where the
duodenum joins CBD
Biliary Pathology
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Acute Cholecystitis
Cholelithiasis
Chronic Cholecystitis
Gallbladder calcification
Tumor (benign or malignant)
Pre-Operative Testing &
Diagnosis
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Family History
Symptomatic
Liver Function Blood Tests
Pancreatic Function Blood Tests
Barium Studies
Endoscopic Studies (Visualization, Biopsy, ERCP
with C-Arm)
Ultrasound
CT Scan
MRI
Medications
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Contrast Media (Hypaque)
Dye
Antibiotic Irrigation
Topical Hemostatics
Local
Anesthesia
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General
MAC (IV Sedation)
MAC (IV Sedation with Local)
Spinal
Epidural
Local
Instrumentation
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Minor tray
Major Tray
Intestinal Tray
Gallbladder Tray
Laparoscopic Tray
Laparoscopic Accessories
Extra Long Instrument Tray
Scopes
Equipment
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X-Ray Table
Laparotomy
Endoscopic Tower (video monitor,
insufflation tubing, insufflator, light
cord, light source, camera box,
camera, scope, scope warmer)
Supplies
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Laparotomy Pack
Basic Pack
Laparotomy Sheet
Universal Sheet
Minor Basin Set
Suture of Surgeon choice
Kittners
Gloves
Blades
Cholangiogram Supplies (Sterile specimen cup,
stopcock, IV tubing, 30cc syringes x 2)
Positioning
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Supine
trendelenburg
reverse trendelenberg
Kraske
Lateral
Prepping
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Betadine Scrub
Betadine Paint
Duraprep
Alcohol
Hibiclens
Surgeon Preference
Draping
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Towels
Stapler or towel clips
Optional Ioban or Vi-Drape
Laparotomy Sheet
Universal Sheet
Surgeon Preference
Procedure for Opening Abdominal
Cavity
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Skin incised
Blood vessels cauterized
Fascia incised
Muscle layers divided or separated
Fascia incised
Omentum displaced (intestinal bag prn)
Peritoneum incised
Abdominal cavity contents exposed
Abdominal Incision Type
Considerations
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Surgeon selects incision that will best
expose the structure to be operated on
Surgeon selects incision that will create
minimal trauma and post-operative pain
Surgeon selects incision that will allow
for wound closure strength as closed
by primary wound healing
Abdominal Incision Types
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Right Subcostal
gallbladder, biliary system
Left Subcostal
spleen
Median Upper Abdominal
stomach, duodenum, pancreas
Median Lower Abdominal
uterus, adnexa (ovaries, fallopian tubes),
bladder
Abdominal Incision Types
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Right Upper Paramedian
stomach, duodenum, pancreas
Left Lower Paramedian
pelvic structures, colon
McBurney
appendix
Left Oblique Inguinal
hernia repair
Lower Transverse (Pfannensteil)
uterus, ovaries, and fallopian tubes
Dressings
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Packing prn
4 x 4s
ABD Pad
Tape
Will vary with Surgeon and Procedure
Drains
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Penrose
Jackson Pratt
Snyder
Blake
May use grenades or hemovac
Varies with Surgeon Preference and
Procedure
Postoperative Care &
Considerations
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PACU or ICU
Minor procedures may D/C to home
Possible complications: hemorrhage,
infection, recurrence of pathology,
bowel obstruction, wound dehiscence
or evisceration,
atelectasis>pneumonia,
The Breast
Anatomy of the Breast
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Mammary Gland
Modified Sweat Glands
Anterior to the Pectoralis Major Muscle
15 to 20 lobes
Reproductive System (accessory)
Secrete milk for infant
Functionless in the male
Well vascularized
Pathology of the Breast
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Abscess
Fibroadenoma (benign lesion)
Cyst
Lump (Benign or Malignant)
Mass/Tumor (Benign or Malignant)
Diagnosis R/T Breast
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Self-Breast Exam
Mammogram
Ultrasound
Chest X-ray
Bone Scan
Surgical Breast Procedures
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Biopsy
Lumpectomy
Segmental Resection
Simple Mastectomy (preservation of
pectoralis muscles and axillary nodes)
*Modified Radical Mastectomy
(preservation of pectoralis muscles)
Radical Mastectomy
Equipment/Instruments/
Supplies
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Routine (armboards)
Minor tray
Breast Retractors
Extra hemostats
Plastic Tray (prn)
Laparotomy pack
Minor basin set
Suture of surgeon choice
Blades
Gloves
Dressing
Drain of surgeon choice
Medications & Anesthesia
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Local
Antibiotic irrigation
Dyes:
Marking pen
Isosulfan Blue (Vital Blue)
Technetium
Biopsies will be done under Local
General with local anesthesia
Sentinel Nodes
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May hear or see “Sentinel node”
associated with a breast procedure
This just refers to the first lymph nodes
along the lymphatic channel from
where the tumor originates
Not in the same place in every patient
Helpful in determining extensiveness
of malignancy
Sentinel Node Biopsy
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Isosulfan Blue (Vital Blue)
“Rule of 5’s”
5ml, 5cm area, 5 sites, 5 minute
massage
Remove blue stained nodes
Await pathology results
May involve further breast or axillary
dissection
Sentinel Node Biopsy
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Technetium
Injected in nuclear medicine department
Is radioactive material
“Rule of 6’s”
6ml, 6 sites, 6cm area, 6 minute massage
prior to exploration of nodes
Wand passed over that detects “hot” areas
Surgeon will mark site with a marking pen
and proceed with dissection of nodes or
further intervention
Positioning
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Supine
Affected arm on armboard
Prep
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Performed extensive in event need to
extend excision
Anterior chest from neck to umbilicus,
upper affected arm to affected axilla
Prep should be gentle particularly if
open breast biopsy with needle (wire)
localization in place
Draping
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Laparotomy sheet or universal drape
May use split sheet for affected arm
Dressing/ Drains/Post-op Care
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Fluffy dressing
Drains of surgeon choice
PACU
Post-operative complications:
Hematoma, hemorrhage, infection,
cellulitis, impaired arm movement,
anesthesia of anterior chest wall
Chemotherapy and/or Radiation
Vascular Access Procedures
Vascular Access Procedures
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Cannulation of arteries and veins
General surgeons primarily will do venous
access procedures (IVAD)
Performed percutaneous or via cut-down
Indicated for chemotherapy, nutrition (TPN),
blood product infusion, needle phobia,
pediatric patients, CVP monitoring needed,
exhausted peripheral venous access)
Types: Broviac, Groshong, Hickman, and
Port-A-Cath
Complications of IVAD
Insertion
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Thrombosis
Infection
Nerve Damage
Pneumothorax
Hemorrhage due to inadvertent arterial
puncture
Dressing/Postoperative Care
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Prior to placing port caps on lumens need to flush ports with
1.5ml to 3ml of Heparin 5,000ut per ml or heparin mixture of
surgeon choice (refer to package insert)
Betadine or Neosporin ointment on site where catheter
penetrates skin (surgeon preference
2 x 2 (surgeon preference)
Tegaderm of appropriate size
Surgeon may want you to cover patient with sterile drape until
chest x-ray performed to verify placement and intactness of
pleura around lungs
If not, do not breakdown table until line placement verified
Carefully remove drapes so as not to dislodge catheter (place
a towel over entire area prior to drape removal)
CARE & HANDLING
OF
ENDOSCOPES
Endoscopes
Diagnostic
2. Operative
(channeled)
 Rigid
Visualization:
Direct (0°)
Angled (30, 70, 120°)
 Semi-rigid
 Flexible
Visualization:
Panoramic
1.
Two Types of Flexible:
1. Fiberoptic
Visualization through
eyepiece
Connect to light source
2. Videoscope
Visualization on
monitor
Connect to light source
and camera
Diagnostic Endoscopes
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Diagnostic purposes (looking around)
No operating channels
Can be used if more than one port will
be utilized (cholecystectomy,
thoracoscopy, etc.) for visualization
during utilization of other laparoscopic
instrumentation for operative puposes
Operative Endoscopes
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Channeled: irrigation, suction,
insertion of biopsy forcep or needle,
connection of accessory instruments
such as cautery or laser
Normally involves one port access
(cystoscopy)
Can always use another port
Use & Care of Endoscopes
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Light Cords/Source
Incandescent first used
Problem: patient tissue damage due
to the intense heat that was
transferred through the light source
and cord
Use & Care of Endoscopes
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Light Cords/Source
Fiberoptics used today
“Cold Light”
Heat is not transferred through the
scope
No patient tissue damage
Use & Care of Endoscopes
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Light Cords/Source
Cord ends DO get HOT
Light source should be off prior to connection and
disconnection from the scope
Avoid looking into light beam from light source or
cord
Light cords may not have universal fitting
Are adaptors
Light cords usually specifically made to fit the scope
Do not bend cord/coil loosely due to multiple glass
fragments (hence fiber optics) contained in the cord
Use & Care of Endoscopes
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Scopes
Should keep scope in a scope warmer until ready to
use on the field to avoid fogging of the scope as a
cold scope passing into a warm patient’s body WILL
fog
DO NOT place “Operative Scopes” in a scope
warmer
Avoid bending the scope where eye piece attaches
to scope itself (If loose have poor visibility)
Avoid slamming or scratching the scope
Use & Care of Endoscopes
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Connection of scope, camera, light cord = “White Balancing”
Prior to passing to surgeon for use must white balance the
scope
Cannot do this until all parts are connected and all tower
sources are turned on
Allowance of camera to pick up white so it will be able to
differentiate primary colors for optimal visualization
Hold scope close to a white sponge, lap, towel
May be done on the field by pressing balance button on newer
cameras or by the circulator pressing the balance button on
the camera box
Use & Care of Endoscopes
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Cleaning:
Keep endoscopic instruments as clean as
possible on the field
Post-op clean per manufacturer’s
recommendations with proper enzymatic
cleaning agent
Rinse thoroughly with water
Dry thoroughly including ports and channels
Use & Care of Endoscopes



High-Level
Disinfection
Intact mucous
membranes
Esophagoscope,
colonoscope,
bronchoscope,
laryngoscope,
cystoscope




Sterilization
Sterile/Intact tissue
Vasculature
Laparoscope,
thoracoscope,
arthroscope,
angioscope
Use & Care of Endoscopes


High Level Disinfection
Gluteraldehyde
FDA: soak 45 minutes
Other: soak 20 minutes
Rinse with sterile water
(copious)
*follow institution’s
policy



Sterilization
Ethylene Oxide
Peracetic Acid (Steris)
30 minutes
Should use soon after
processed due to poor
shelf life
Gastrointestinal Endoscopic
Procedures








Anoscopy- examination of the anal mucosa
Choledochoscopy- examination of the common bile
duct
Colonoscopy- examination of the entire colon
Esophagogastroduodenoscopy- (EGD)examination of the esophagus, stomach and
duodenum
Esophagoscopy- examination of the esophagus
Gastroscopy- examination of the stomach
Proctoscopy- examination of the rectum
Sigmoidoscopy- examination of the sigmoid and
rectum
Summary





Anatomy & Physiology, Pathology and
Operative Considerations for:
GI System
Breast
IVAD
Care & Use of Endoscopes