Airway Instruments Airway Instruments Oropharyngeal / Guedel Airway • This is essentially a rigid, curved plastic tube. It is an airway adjunct • It is used to provide an airway for a patient where there is an impaired level of consciousness. • It is sized by measuring the distance from the angle of the mandible to the patient’s mouth. • It is inserted upside down into the mouth and rotated downwards when it is past the tongue within the oral cavity. Airway Instruments Airway Instruments Endotracheal Tube • Used to provide a definitive airway for patients. This means a cuff is inflated to prevent aspiration. Used for long operations, (laparotomy) and in cases of inhalation injury, (burns) • Indications: – Depressed consciousness – Hypoxemia – Airway Obstruction Airway Instruments Endotracheal Tube • Then check the tube is in the trachea by: – Auscultating: ensure bilateral breath sounds – Auscultate over the stomach (epigastric region) to ensure no gurgling (that would indicate oesophageal intubation) – Measure end tidal CO2 tension: since CO2 is produced in the lung, you can confirm that the tube is in the trachea by measuring the end tidal CO2 tension. If the tube is in the oesophagus, then the CO2 gas pattern would be absent. – Do CXR and look for metallic mark Airway Instruments Endotracheal Tube • Complications: – Broken Teeth, lacerations of the tissues of the upper airway, – Intubation of the Oesophagus Airway Instruments Airway Instruments Tracheostomy Tube • Definitive airway • Tracheostomy = surgical opening into the trachea. • Can be temporary or permanent. • It involves placing the tracheostomy in between the 2 and 4th tracheal rings. • Usually done in theatre under GA. Airway Instruments Tracheostomy Tube • Indications – Patients who require long term intubation (>2 weeks) – better tolerated than ETT – Severe maxillofacial injury (unable to intubate) – Post-laryngeal surgery (e.g. laryngectomy for malignancy) – Lung disease (e.g. COPD) to reduce dead space and allow effective ventilation – Obstructive sleep apnoea – Upper airway obstruction • Complications – – – – – Tracheostomy stenosis, Infection Blocked tube, Tracheoesophageal fistula Surgical emphysema. Airway Instruments Airway Instruments Laryngoscope • A laryngoscope has a handle and a curved blade, usually fitted with a light, it moves the tongue and epiglottis aside in order to inspect the larynx. • It is used to aid insertion of an endotracheal tube or for examination. Airway Instruments Airway Instruments Laryngeal mask Airway • Sits on top of the larynx and therefore does not intubate the trachea. • It is used to assist a patient with impaired breathing. It can also be used as an airway during short operations e.g. day cases. • It is inserted and then the inflatable cuff over the larynx can be pumped, by pushing air from a syringe, into the blue lumen. Surgical Instruments Surgical Instruments Proctoscope (Gabriel) • Used to visualise the anal canal and lower rectum • It is also used when injecting or banding haemorrhoids. • After explaining the procedure to the patient, the patient is placed in the left lateral position and a digital rectal examination is performed. • The proctoscope is then attached to a light source and lubricated prior to its insertion into the rectum. Surgical Instruments Surgical Instruments Shouldered Syringe • This a syringe used for the injection of haemorrhoids with 5% phenol in almond oil. • The injection is performed in conjunction with a proctoscope. • The injection is performed above the dentate line as it is insensitive Surgical Instruments Surgical Instruments Rigid Sigmoidoscope • • • • • • Used for the inspection of the rectum and lower sigmoid colon. After explaining to the patient what you are about to do, you must attach a light source and a air pumping device. The patient is placed in the left lateral position and a digital rectal examination is performed. The sigmoidoscope is then lubricated with jelly and inserted pointing towards the umbilicus. Air is pumped into the rectum to allow you see the direction of the rectal lumen. Biopsies can also be taken of rectal mucosa through the sigmoidoscope eg in a case of ulcerative colitis Surgical Instruments Surgical Instruments Trucut Biopsy Needle • Used to take histological specimens from lesions – eg breast lumps or liver. • The procedure can be performed under local anaesthetic Surgical Instruments Surgical Instruments Sutures • • Sutures Used to hold a wound together in good apposition until such a time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary and redundant • • • Alternatives: Staples Steristrips – self adhesive tape, useful for superficial lacerations, useful if there is potential tension on a wound Tissue adhesive – based on cyanoacrylate manometer, wounds need to be clean and tension free • Surgical Instruments Suture material • Absorbable Synthetic • • • • Polyglycolic Acid (Dexon) Polyglactin (Vicryl) Polydioxone (PDS) Polyglyconate (Maxon) • Non-Absorbable – Natural • Silk • Linen • Stainless Steel Wire – Synthetic – Polyamide (Nylon) – Polyester (Dacron) – Polypropylene (Prolene) Surgical Instruments Surgical Instruments Needle Holder • These are special forceps • Designed to hold the needle to allow the surgeon to suture accurately Surgical Instruments Surgical Instruments Laparoscopic Port • Used during laparoscopic procedures eg Lap Chole • Ports allow the surgeon to insert telescopes/Cameras/instruments Surgical Instruments Surgical Instruments Dever’s retractor • Used in open abdominal surgery • Allows the surgeon to operate with more space Surgical Instruments Surgical Instruments Self Retaining retractor • Used to hold wounds open • Eg Hernia repair/appendectomy Fluids Fluids Hartmanns Solution • Used in Surgery, especially nil by mouth patients Fluids Fluids Dextrose • Dextrose is a solution made of sugar and water Fluids Fluids Saline Crystalloids are an electrolyte solution in water. It can pass through a semipermeable membrane (cell wall). NaCl saline 0.9% solution is an isotonic fluid as it has similar Na+ levels to the extracellular fluid in the body. Saline distributes throughout the ECF (not the ICF like dextrose does). The ECF consists of plasma, interstitial fluid and transcellular fluid (note colloids stay in the plasma). Saline is a good maintenance fluid. Fluids Dextrose Saline Dextrose Saline Dextrose Saline 1000ml 1000ml 1000ml 40g Dextrose 40g Dextrose 40g Dextrose Na 30mM Na 30mM Na 30mM K 20mM K 20mM K 20mM OR Normal Saline 5% Dextrose 5% Dextrose 1000ml 1000ml 1000ml 50g Dextrose 50g Dextrose K 20mM K 20mM Na 150mM K 20mM Fluids Fluids Gelofusine This is a colloid. Used in cases of volume loss: eg trauma, molecules cannot pass through semi permeable membrane. Remains in the intravascular space. Useful in increasing Blood Pressure. Use is controversial. Natural colloids: albumin Synthetic colloids: Gelofusine and Haemaccel (gelatine based infusions) Lines Lines Cannulas This is a an IV cannula. It is used to give IV fluids and IV drugs. If you wish to give the fluid quickly, the cannula must be short and large bore (Poiseuille’s law – flow is proportional to the fourth power of the internal radius of the tube and inversely proportional to the length). Emergencies (265ml/min) Generally insert a 18G (green) or higher when giving drugs. Emergency should be brown (14G) which has a flow rate of about 265ml/min. Use antecubital fossae in emergencies. If you cannot get it, use femorals. Lines Cannulas Blue 22G Pink 20G Green 18G White 17G Grey 16G Brown 14G Lines Lines Triple lumen Central Venous Pressure Catheter • Inserted into either the right subclavian vein or internal jugular vein. • Used for Central Venous Pressure monitoring and to administer drugs (chemotherapy drugs), taking blood, not good for fluids. • Single or triple lumen Lines Triple lumen Central Venous Pressure Catheter • • • • Inserted using Seldinger technique.: Lie patient flat. Infiltrate skin with LA 5ml of lignocaine Assemble the catheter and flush all the lumina Introduce needle and syringe 1cm below the junction of the middle and medial thirds of the clavicle. Aim the needle to the sternal notch and advance. Aspirate as you advance the needle. • Once blood enters the syringe, remove the syringe keeping the needle still in its position. • Insert the guide wire, remove the needle, feed the dilator over the guide wire, remove dilator, insert central line, remove guide wire • Stitch in place, Order CXR to check position and exclude pneumotharax Lines Triple lumen Central Venous Pressure Catheter • Complications of a central line insertion: • • Immediate: pneumothorax, haemothorax, damage to adjacent vessels e.g. carotid arteries, primary haemorrhage • • Early: infection (skin commensals), secondary haemorrhage, haematoma formation • • Late: thrombosis, catheter blockage. Lines Lines Nasogastric Tube • This is a feeding NG tube. It is used for enteral nutrition in patients. • It has a fine bore and is soft (comfortable for patients), unlike the Ryle’s NG tube which is wide bore. Note the end has a cap (not present in Ryle’s NG tube). It is made from silastic, which tends to block less often. • Another indication is oesophageal obstruction. • DO NOT use is patients with basal skull fractures, facial trauma or if patient refuses it. Lines Lines Single Lumen Central Venous Catheter Lines Lines Hickmann Line • This is a Hickman line. It is a modified central line that is tunnelled under the skin to make it more secure. It is used as a long term central vascular access device. It is usually inserted into the right subclavian vein. • The Hickmann line is a central line as it is inserted into a central vein (therefore making it a central venous access device). It is used mainly for long term access to the central line. This can be for providing patient with TPN or for taking blood or administering drugs long term. • The line is tunnelled under the skin, therefore you will see subcutaneous swelling under the skin along the path of the catheter (CVP catheters are not tunnelled and they are used for short term only). Lines Lines Peripherally Inserted Central Catheter (PICC) These lines are inserted into a peripheral vein, usually the cephalic vein in the antecubital fossa and 'unwound' upwards into the subclavian vein/superior vena cava. They are firmly secured with tape or sutures. They tend to be used for relatively short-term venous access, e.g. a prolonged course of antibiotics, but can be used for periods of up to several months. Lines Lines Swan-Ganz Catheter Inserted into pulmonary artery, this is a diagnostic catheter used to detect heart failure, sepsis, monitor pressures in right atrium, right ventricle and pulmonary artery Lines Lines Tesio Line For Renal Dialysis Drains • A surgical drain is a tube used to remove pus, blood or other fluids from a wound. •Broadly classified as: – Tube Drains – Corrugated Drains • Types of drainage systems –Closed –Open –Passive –Active Drains Drains Chest Drain Bottle •Bottle to which the chest drain is attached. • There is a line called prime level which is filled with sterile water. • The chest drain tubing is connected to a tube which is under the sterile water and therefore acts as a water seal. •After a chest drain has been inserted you can see bubbling in the water as the air leaves the pleural space. •The chest drain bottle can be used to collect air, blood, fluid and pus from the pleural space. •The system can be driven by attaching suction to the top of the bottle making it an example of a active closed drainage system Drains Drains Yates Tissue Drain • Row of tubes • For big cavity drains • It is an open drainage system Drains Drains Vacuum Drain bottle (Redivac) •Used to drain areas where fluid or blood may collect or where the surgery has left a cavity which is closed by the suction from the vacuum drain. •This is an example of an active closed drainage system. T-tube Radioopaque Q1: Indications: 1 following eradication of C.B.D 2 splint for C.B.D 3 feeding jejunostomy 4 drainage for oesoph. perforation Q2:Time of removal: Remove after 10-15 days when there is no charcot’s triad (pain-jaundicefever) Q3:Complications: -Occlusion (blood, biliary mud) -Dislodgment biliary peritonitis -Pancreatitis, Cholangitis Q4:Treatment of complications: -Reopen and suck bile -Reoperation Q5: Contraindication of removal: -Charcot's triad -Pain or leakage after clamping -Abnormal T tube cholangiogram Q1: Indications: -control of bleeding esophageal varices -preparing for endoscopy surgery Q2: Complications: -Aspiration pneumonia -Ulceration, stricture -Suffocation -Pressure on nose -Perforation of esophagus Q3: Describe Senkstaken Tube -3 lumens -2 inflatable balloons; gastric balloon (spherical when inflated) esophageal balloon (tubular when inflated), which obliterate varices while allowing gastric suction and tube feeding. Q1: indications: مهم -Drainage of urine in chronic retention e.g. :SEP -Monitor urine outflow -Hemostasis after prostatectomy -Peritoneal drainage in biliary peritonitis Foley's catheter Q2: complications: -False passage -Bleeding -Infection -Rupture urethra -Obstruction of catheter Rectal deflation tube Q1: Indications: -Drain fluid & blood leakage after perforation -After laparotomy for peritonitis corrugated rubber drainage No more used – highly complicated It’s open cystic drain Describe – uses Q2: Removal: After it stops drainage Q3: Complications: -Infection -Incisional hernia -Bleeding -Pressure necrosis -Loss it in drained cavity Indications: for varicose vein surgery Vein stippler Allis forceps Uses: 1- hold tough structures as fascia, sheath , tendon 2- hold duodenum for duodenal closure during gasterectomy Can hold delicate structure (X) hold fascia & aponeurosis Toothed - locked - box - crushed Artery Forceps (mosquito forceps) Uses: 1- Hold peritoneum, viscous, soft tissue, bleeding vessels 2- Facilitate tying of ligature Babcock forceps Uses: Hold: 1-intestine during resection 2-thyroid gland 3-mesoappendix 4-uterine tube 5-ureter 6-C.B.D Toothed forceps Uses: *Hold tough layer such as skin, fascia, aponeurosis, fat & muscles *Give firm grip Scalpel Uses: *Surgical knife used to incise skin & SC tissue and also divide major vascular pedicle after ligation Intestinal clamp (non crushing clamp) Non crushing – Box – Locked – Non toothed Uses: * Occlude intestinal lumen to prevent slippage of contents & Control bleeding during intestinal anastomosis * Occlude portal vein * Coapitation of intestine Kocher’s forceps Uses: *hold tough structures Curved –Toothed – screwCrushing *strap muscles thyroidectomy *crush base of appendix *clamp vascular bands or omentum *dissect in tissue planes Lahey's forceps (right angled clamp) *Right angle – crushing – long – box *Used to ligating major vascular pedicles example superior thyroid pedicle - cystic artery – lumbar vein (lumber sympathectomy) Satinsky vena cava clamp (vascular clamp) *Non crushing – box – locked *Used to isolate part of wall of IVC to anastomose to portal vein during portocaval anastomosis Used to hold renal pedicle to control haemorrhage while doing partial nephrectomy Bulldog Has spring handle Occlude blood vessel temporary Used during direct arterial surgery example anastomosis & grafting Sponge Forceps Used to hold gauze squares or sponge to “mop up” the surgical site Jaws are serrated Transfer Forceps When sterile, transfer forceps; • arrange items on sterile tray • transfer items to sterile field Needle Holder • Used to hold and pass a suturing needle through tissue • Has groove to hold needle within jaws Towel Clamp • Adds weight to drapes and towels to ensure they stay in place • Allow exposure of the operative site Skin Hook • Flat end is a blunt retractor • Three-prong end may be sharp to dull • Used to retract small incisions or secure a skin edge for suturing Iris Suture Scissors • Used to remove sutures • Blade has beak or hook to slide under sutures Sharp/Sharp Scissors • Used to cut and dissect tissue • Both blade tips are sharp Sharp/Blunt Scissors • Used to cut and dissect fascia and muscle • One blunt tip and one sharp tip Nasal Speculum • Used to spread nostrils during examination Vaginal Speculum • Used during gynecological exam or procedure • Dilates the opening of the vaginal cavity, allowing for inspection of the vagina and cervix • Facilitates access for observation and treatment