Chapter 19
Minor Surgical
Procedures
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Review Tip
Chapter 17, “Microorganisms and Asepsis,” has direct application to
surgical procedures—be sure you understand those concepts
before reviewing this chapter. Minor surgery is another area of the
national exams that contains questions requiring identification,
care, and usage of surgical instruments.
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Overview
Most states define and regulate types of surgery that are considered
appropriate for the medical office. Medical malpractice insurance
carriers also play a role. Refer to Chapter 4, “Law and Ethics,” for
issues concerning licensure, scope of practice, patient rights, informed
consent, malpractice, and confidentiality. As in all areas of medical
assisting, patient education is an important component (see Chapter
8).
General anesthesia is not usually administered for surgery in the medical
office and is not covered in this book.
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Preparation
Surgical asepsis must be maintained throughout the preparation and
performance of surgical procedures.
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Sterile field—a pathogen-free area containing sterile instruments,
solutions, sponges, and other items that will come in direct contact
with another sterile item or the surgical field; this includes the
hands and anterior neck to waist of the surgical team
• Ensure sterile indicators and dates on instruments and solutions
are intact and current before opening and placing on a sterile
field
• Examine sterile items for signs of break in packaging or
presence of moisture (discard item if either is noted)
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Preparation, cont’d.
• Open the sterile package(s)
- Open the top flap first; open away from you to avoid
reaching over sterile field
- Open the right and left flaps to the sides
- Open the last flap toward you
• Allow only sterile items to come into contact with other sterile
items
• Keep all sterile items and hands above the waists of the surgical
team
• Maintain a border of 1 inch between nonsterile and sterile areas
• Do not turn your back to a sterile field or leave it unattended
• Do not lean or reach over sterile field
• Do not pass contaminated or nonsterile items over a sterile field
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Preparation, cont’d.
• Pour liquids such as sterile saline or an antiseptic into a sterile
waterproof container on the sterile field
• Do not touch the container with the nonsterile bottle
• Do not drip or spill liquid on the sterile field
• Do not talk, cough, or sneeze over a sterile field
■ Surgical handwashing (scrub)—remove all jewelry; use foot- or
knee-controlled faucet; wash hands, wrists, and forearms for 10
minutes (first surgical scrub of day); hold hands in upward position
while rinsing; use brush and cuticle stick on nails; do not apply
lotion; dry with sterile towel; apply sterile gloves
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Preparation, cont’d.
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Personal protective equipment (PPE) for surgery
• Gloves—sterile
• Goggles or eye shields—nonsterile
• Masks—nonsterile
• Gowns—sterile
• Aprons—sterile if worn over surgical gown
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Preparation, cont’d.
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Surgical site preparation
• Hair removal—shave or cut hair at surgical site only with
physician order (usually in procedure file); use only disposable
blades; sterile instruments should be covered during hair
removal; all loose hair should be removed before application of
antiseptic
• Skin cleansing—using an antiseptic cleansing solution (check
for patient allergies) such as Betadine® or Hibiclens®, cleanse
the surgical site using a circular motion from the point of the
incision outward; use a clean sponge to repeat
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Preparation, cont’d.
• “Painting” and draping—after performing the previous steps, a
sterile member of the surgical team will use a sterile sponge
stick and sterile sponges to apply, or “paint,” an antiseptic
solution on the surgical site, using circular motions beginning
with the incision site and working outward (one sponge per
layer of antiseptic); fenestrated drapes (a drape with a hole or
opening) or sterile towels, held in place by sterile towel clips,
are applied, as well as any other drapes (sterile coverings)
required by the size of the sterile field
• When local anesthetic is required on a sterile field, the physician
will hold the sterile syringe with sterile gloved hands; the
medical assistant shows the physician the label on the vial and
holds the vial upside down for the physician to draw out the
required amount of medication
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Instrumentation
All instruments or parts of instruments that enter the sterile field must be
sterile. Chapter 17 covered the two common procedures for
sterilization: autoclaving and cold or chemical sterilization. Safety (e.g.,
the use of sharps containers and other biohazard receptacles) was
also addressed in Chapter 17.
Common Instruments
Curette—sharp or smooth spoon-shaped instrument used to scrape
tissue or other substances from a body orifice or organ; the most
common types are ear and uterine
■ Dilator—solid instrument used to stretch or widen the opening to an
anatomic structure
■ Forceps—a two-handled instrument used to grasp, move, or crimp
tissue; may be with or without “teeth”
■
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Instrumentation, cont’d.
• Splinter forceps—fine-pointed, tweezer-like forceps without teeth
used to remove splinters and other foreign objects
• Thumb forceps—smooth (without teeth) forceps; the generaluse forceps
• Adson forceps—tweezer-like forceps, with or without teeth, with
a smaller tip for smaller areas
• Bayonet forceps—tweezer-like forceps shaped like a bayonet
used for packing in areas (e.g., the nostrils)
• Ring (sponge) forceps—long, two-handled forceps with open
ovals on the ends to grasp tissue, hold sponges, or transfer
sterile instruments
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Instrumentation, cont’d.
• Hemostat—sometimes referred to as a forceps; straight or
curved instrument used to compress or crimp capillaries and
other blood vessels to stop bleeding; also referred to as a
clamp or a crile; types are
- Kelly hemostat—a medium-size hemostat; may be curved or
straight
- Mosquito hemostat—a small hemostat used for pediatric,
plastic, or microsurgery; may be curved or straight
■ Needle holder—a two-handled instrument that clasps a suture
needle, allowing the physician to push and pull the needle with
suture material through various anatomic structures
■ Probe—a straight instrument with ends of various shapes, used
primarily to explore ducts, canals, and other anatomic structures
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Instrumentation, cont’d.
Retractors—instruments of various shapes used to hold back tissue
and organs to facilitate exposure to the operative site
■ Scalpels—knives of various blade shapes and sizes, used to make
surgical incisions; the blade is always disposable; the knife handle
may or may not be disposable
■ Scissors—two-bladed instrument used to cut tissue and materials
during surgical procedures
• Surgical/operating scissors—scissors used during surgery to cut
and dissect tissue; may be curved or straight, blunt or sharp
(e.g., Mayo scissors)
• Suture scissors—scissors used to cut suture material; straightbladed suture scissors are used in suturing; suture scissors with
a hook on the end of one side are used to remove sutures
• Bandage scissors—angled scissors with a blunt knobbed end to
insert under dressings to remove them without injuring tissue
■
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Instrumentation, cont’d.
■ Sound—a straight or curved instrument used to explore body
cavities for measurement of depth and presence of masses or
foreign bodies
■ Tenaculum—a long, two-handled instrument with pointed ends used
to grasp tissue during surgery; a cervical tenaculum is commonly
used in well-woman exams
■ Towel clamps (clips)—small instruments of various shapes used to
keep sterile towels used as drapes in place during surgery
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Instrumentation, cont’d.
Figure 19-1. Common surgical instruments.
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Instrumentation, cont’d.
Common Surgical Tray Instruments
Each office maintains a file of all instruments, supplies, and equipment needed for
each surgical procedure. The following are select surgical trays and their
instruments:
■ General minor surgery tray used for procedures such as removal of
lesions—towel clips (four), scalpel and blade, curved and straight
hemostats (two each), surgical scissors, thumb forceps, forceps with teeth,
suture scissors, needle holder (retractors and other instruments may be
added as needed), specified type of surgical sponge; sutures and sizes
may be on the file card or requested by the physician during the procedure
■ Suture tray—towel clips (four), curved hemostat, forceps with teeth, thumb
forceps, suture scissors, needle holder, sterile 4 × 4 gauze; sutures
identified by the physician and added to the setup
■ Suture or staple removal tray—suture scissors or staple remover, thumb
forceps, sterile 4× 4 gauze
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Instrumentation, cont’d.
Endoscope
An endoscope is a special instrument used to examine the interior of canals and
hollow viscus; the specific design and name is dependent on the organ (e.g.,
gastroscope, bronchoscope). The instrument usually contains fiberoptic
technology that allows lighting, video transmission, and other technologic
procedures; biopsies and select surgical procedures may be performed
through the endoscope, eliminating or minimizing a surgical incision.
Other Common Instrumentation with Power Sources
■ Electrosurgery—a method of dissection and cauterization using an electric
current directed to a specific anatomic area to cut, destroy, or coagulate;
the power source is initiated and controlled through a boxlike unit that
transmits to a hand piece with sterile removable tips that come in direct
contact with the surgical site; the patient must be grounded and safety
precautions enforced
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Instrumentation, cont’d.
■ Cryosurgery—a method of destroying tissue by freezing (cryogenics) using
liquid nitrogen applied from a tank with a gauge and removable hand
pieces (e.g., for removal of cervical lesions), or other cryomaterials
requiring simple spray canisters (e.g., for removal of skin lesions)
■ Laser surgery—a method using high concentrations of electromagnetic
radiation in narrow beams for surgical and diagnostic applications (e.g.,
coagulation of retinal hemorrhage); uses vary and are dependent on the
color spectrum; common terms associated with laser surgery are argon,
continuous wave, pulsed wave, excimer, krypton, KTP, YAG, and Qswitched; goggles should be worn and special training provided before
assisting in laser surgery
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Closure Materials
The type of material used for closure is dependent on several factors. Is
the closure on an internal anatomic structure or on the skin? What are
the depth, thickness, and length of the closure site? What are the
healing capacity factors of the patient (e.g., nutritional status, diabetes,
recent history of steroid administration, smoking)?
■
Suture—derived from Latin, meaning “a sewing”; threadlike
materials (ligature) and needle used to close a wound; the needle
and ligature used in the medical office are usually mechanically
attached (swaged) by the manufacturer
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Closure Materials, cont’d.
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Ligature
• Absorbable—material that dissolves in the body (e.g., catgut);
used for internal suturing
• Nonabsorbable—material that does not dissolve (e.g., silk, nylon
and other synthetics, wires); generally for external use,
although some wires may be used internally; most
nonabsorbable sutures are removed after healing takes place
• Size—determined by the thickness of the diameter; the range is
approximately from 7, the largest, to 11-0, the smallest
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Common Assessment
Measurements, cont’d.
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Closure Materials, cont’d.
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Needle
• Cutting—needle with sharp, flat edge used on tough tissue (e.g.,
skin)
• Noncutting—needle with sharp, smooth, rounded edge used on
finer tissue, such as peritoneum
• Curved—the shape of the needle; may have cutting or
noncutting edge; needle holder used
• Straight (Keith)—the shape of the needle; may have cutting or
noncutting edge; no needle holder required
• Size—determined by the size of the ligature to be used;
physician will ask for ligature size on a cutting or noncutting,
curved or straight needle
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Closure Materials, cont’d.
■ Staples—metal clips used to approximate skin edges during healing
or occlude internal structures; materials vary per use (e.g.,
stainless steel used on skin, silver used for neurosurgery); external
staples must be removed with a staple remover
■ Steri-Strips—adhesive strips of material used in minor lacerations
or as a follow-up to sutures to hold wound edges together during
healing
■ Glue—bonding material used externally to approximate skin edges
or internally to affix structures; often used in neurologic or
orthopaedic surgeries
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Wounds
Wounds are traumas to body tissues caused by physical means. The
trauma may be unintentional, such as a fall, or intentional, such as
surgery. The type of wound determines the treatment and the potential
for healing. Surgical wounds are considered clean wounds because
they are initiated under sterile conditions. Dirty wounds are those
sustained under contaminated conditions (e.g., a knife wound while
preparing a meal).
■ Abrasion—outer
layers of skin scraped off, resulting in a small
amount of sanguineous or serosanguineous drainage, such as a
“skinned” knee
■ Contusion—bleeding below unbroken skin caused by blunt trauma;
a bruise
■ Incision—a smooth cut as in surgery or as made with a razor; the
amount of bleeding depends on the location and depth
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Wounds, cont’d.
Laceration—a jagged traumatic cut resulting in irregular wound
edges
■ Puncture—a hole in the skin made by a sharp pointed object
■ Healing—physiologic process of wound closure; there are two
predominant types
• First intention (primary)—wound edges are approximated and
healing process occurs in all layers (e.g., incision, laceration)
• Secondary intention (granulation)—wound edges do not
approximate and healing begins at wound bottom, forming
granular projections on the wound surface (e.g., a wound from
a drain)
■
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Wounds, cont’d.
■ Dressings—defined as sterile coverings placed over a wound but
often used synonymously with bandaging; types of dressing include
gauze, occlusives (e.g., Vaseline gauze), nonstick (e.g., Telfa),
nonopaque (e.g., BioDerm), and commercial gauze impregnated
with medication (e.g., NuGauze); dressings should be applied
using sterile technique
■ Bandages—sterile or nonsterile materials that splint or protect
injured tissue (e.g., Kerlix, Ace bandages, triangular slings, tube
gauze [frequently used on digits]), maintain pressure over an area
(such as abdominal pads, Coban), and hold sterile dressings in
place (e.g., Montgomery straps, rolled gauze)
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