(Box 2.2, Figures 2.1 and 2.2).
Rectal Prolapse
A prolapsed rectum can be reduced and retained in its normal position by applying a purse‐string suture around the circumference of the anus. Nylon suture (3‐0) on a straight needle is ideal for this purpose. Prior to reducing the prolapse, white granulated sugar can be applied to the prolapsed tissue to alleviate some of the tissue edema. A routine soft tissue instrument set should be sufficient, with the addition of a culturette due to the location of the surgery and concern for contamination. The patient is positioned in sternal recumbency in Trendelenburg position if the surgery table tilts. Alternatively, a rectal stand to elevate the caudal end of the patient to approximately shoulder level of the surgeon can be used.
Hemoabdomen
When preparing an operating room for a patient with a hemoabdomen, the first step upon entering the abdomen will be to remove the accumulated blood to visualize the source of hemorrhage. See Figure 2.1 for suction and lavage instrumentation. In addition to the routine soft tissue instrument set, sterile suction tubing to connect to wall‐mounted or portable suction and additional suction canisters should be available, depending on the volume of fluid to be removed. A Balfour retractor will be helpful for abdominal wall retraction while the surgeon completes a thorough examination of the abdomen to identify the source of hemorrhage. Monopolar cautery and a bipolar vessel‐sealing device (LigaSure™) are helpful in controlling hemorrhage and expediting the surgical procedure.
Box 2.1 Routine Soft Tissue Instrument Set
3 straight and 1 curved carmalt forceps
4 Allis tissue forceps
8 Kelley forceps
6 mosquito forceps
4 large Backhaus towel clamps
10 small Backhaus towel clamps
2 needle drivers
Poole suction tip
2 Army Navy retractors
2 Parker retractors
2 basins
#3, #4 scalpel handles
Debakey thumb forceps
Brown–Adson thumb forceps
Rat‐tooth forceps
20 4 × 4 gauze sponges
Box 2.2 Instruments for Gastrointestinal Surgery
Routine soft tissue instrument set
Balfour retractor (used for ventral midline abdominal approach)
Sterile suction tubing
Suction canister
Monopolar and bipolar cautery (bipolar cautery should be available for esophageal surgery)
Doyens intestinal clamps
Lap sponges
Suture for enterotomy closure
25‐gauge needle and 5–10 cc syringe for performing a leak test after enterotomy closure
See Box 2.12 for additional instruments necessary for a lateral thoracotomy approach and closure.
Biliary Emergencies
In cases of biliary obstruction due to choleliths, cholecystitis, pancreatitis, neoplasia or gallbladder mucocele, either biliary duct stenting for reversible obstruction or cholecystectomy or cholecystoenterostomy for non‐reversible obstruction can be performed. Instruments recommended for biliary emergencies are listed in Box 2.3.
Liver Lobectomy
For a liver lobectomy procedure in which there is potential for significant hemorrhage, a bipolar vessel sealing device (LigaSure) can be beneficial in providing hemostasis in areas where ligations by hand would be difficult. The LigaSure handpieces come in a variety of shapes, such as the Precise, Impact, and Atlas. The Atlas comes in an assortment of lengths, diameters and with blunt and tapered tips. In addition, Hemoclips, Ligaclips®, and Surgiclips are valuable additions to your operating room instrumentation when there is high risk for hemorrhage because they can be applied quickly and securely to vessels. Removal of the affected liver lobe can be achieved using a stapling device, such as the TA™ or GIA™ vascular stapler, which applies two to four rows of interlaced staples. For reference, the TA Auto Suture vascular stapler by Covidien comes in cartridge lengths of 30 mm, 55 mm, or 90 mm, with staple widths ranging from 3–4 mm and staple height ranging from 2.5–4.8 mm. For larger tissue resections, the GIA stapler comes in cartridge lengths of 50 mm, 60 mm, 80 mm, and 90 mm, with staple widths from 3–4 mm and staple heights ranging from 2.5–4.8 mm. Other hemostatic agents include Vetspon® absorbable hemostatic gelatin sponge (gel foam) and oxidized regenerated cellulose (Surgicel®). Both are applied to a site of hemorrhage to aid in clot formation and can be left in place indefinitely until eventually absorbed or removed during surgery once hemostasis is achieved. The instruments needed are listed in Box 2.4.
Figure 2.1 Balfour retractor (bottom left), Poole suction tip (top left), sterile suction tubing (bottom right), and suction canister (top right) for abdominal lavage.
Figure 2.2 Portable suction machine.
Box 2.3 Instruments for Biliary Surgery
Routine soft tissue instrument set
Monopolar and bipolar cautery
Balfour retractor
Sterile suction tubing
Suction canister
Lap sponges
Culturette
Hemoclips® or Surgiclips™
± Covidien™ feeding tube and red rubber urethral catheter (Kendall™) for common bile duct stenting
Urinary System
Ureteral Surgery
Instruments