An introduction to surgical techniques and practical procedures

Published on 10/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

This article have been viewed 2364 times

CHAPTER 2 An introduction to surgical techniques and practical procedures

This chapter will describe various techniques which are part of the ‘stock-in-trade’ of the surgeon and therefore the student training in surgery. It will also describe some practical procedures with which the surgical trainee should be familiar.

Surgical incision

When choosing an incision, the following points should be considered:

• Access: the incision must be appropriately placed, large enough and capable of extension

• Orientation: if possible in the lines of skin tension (Langer’s lines) or skin creases. This leads to minimal distortion and better healing

• Healing potential of tissues

• Anatomy of underlying structures, e.g. the avoidance of nerves

• Good cosmetic result

• Abdominal incision: the common abdominal incisions are shown in Figure 2.1 and the indications for such incisions are indicated on the diagram. Paramedian incisions are rarely used nowadays but are included as their scars are still seen on the abdominal wall of the older patient.

Figure 2.1 Abdominal incisions.

Sutures

Students are usually introduced to suturing in a Clinical Skills Laboratory and during their A&E attachment. There is a wide range of suture materials, broadly divided into absorbable and non-absorbable, natural and synthetic, braided and monofilament.

Absorbable

These are plain catgut (natural monofilament); chromic catgut (natural monofilament); polyglycolic acid (synthetic braided – Dexon); polyglactin (synthetic braided – Vicryl); polydioxanone (PDS – synthetic monofilament). The strength of absorbable sutures declines according to the material, catgut being the quickest to lose strength. (Catgut sutures are no longer available in the UK because of their theoretical potential for transmitting spongiform encephalopathy and the fact that there are adequate supplies of acceptable alternative synthetic sutures.)

Non-absorbable

These include silk (natural braided); linen (natural braided); wire (stainless steel, usually monofilament); nylon (synthetic monofilament – Ethilon); polypropylene (synthetic monofilament – Prolene); expanded polytetrafluoroethylene (ePTFE – expanded monofilament). Non-absorbable sutures retain strength indefinitely and are used where strength is needed until repair is completed naturally, e.g. abdominal incisions and hernia repair. Non-absorbable sutures are often used for skin closure – synthetic monofilament used in subcuticular fashion giving the best cosmetic result.

Natural sutures

These are catgut, silk, linen, but their use is declining. Catgut is cheap but of variable strength. Silk handles well but, as with linen, it excites a strong inflammatory reaction.

Synthetic sutures

Types include Dexon, Vicryl, PDS, nylon, polypropylene and ePTFE. They are more expensive than natural sutures, but cause little tissue reaction. The degree of strength and absorbability can be controlled in manufacture.

Monofilament

These include catgut, polydioxanone, wire, polypropylene and nylon. They are smooth and pass easily through tissues and cause less tissue reaction. The disadvantage is that they are stiff, slippery and difficult to knot.

Braided (polyfilament)

These include polyglycolic acid, polyglactin, silk, nylon and linen. They handle well, but interstices harbour bacteria.

Wire

This is useful for closing the sternum in cardiac procedures and for orthopaedic procedures. It is strong, inert, but subject to breakage and handles poorly.

Gauge

Gauge (G) is the calibre of the suture and is expressed in numbers. Originally, the finest gauge was ‘1’ and the heaviest ‘4’ but with the development of finer sutures a scale of ‘0s’ was developed, the more 0s, the finer the suture, e.g. ‘0’, ‘00’ (2/0), ‘000’ (3/0). The finest suture is 10/0, used in eye surgery. The gauge used depends on the strength required, number of sutures, type of suture material being used and cosmetic requirements.

Needles

Needles are cutting or round-bodied. They come in a variety of shapes and lengths and may be straight or curved. Cutting needles are usually triangular in cross-section, and are useful for skin, tendon, and breast tissue. Round-bodied needles are oval or round in cross-section. Round-bodied needles are useful for GI tract and vascular anastomoses.

Methods of suturing

Sutures may be interrupted, continuous, vertical mattress, horizontal mattress or subcuticular. The choice depends on the site and nature of the operation and surgeon’s preference. Interrupted sutures may be used if there is a risk of infection, where some individual sutures may be removed to allow drainage. Subcuticular sutures may be used to give good cosmetic results, especially when using synthetic monofilament. Synthetic absorbable subcuticular sutures (e.g. Vicryl) may be used in children to avoid the trauma of suture removal.

Removal of sutures

The timing is a balance between strength of healing and a good cosmetic result. Some areas are better vascularized, under less tension, and therefore heal quicker than others. The following is a rough guide for the time of removal for different areas: face and neck (3–4 days); scalp (5–7 days); limbs (5–7 days); hands and feet (10–14 days); abdomen (8–10 days).

Alternatives to sutures

Alternatives include clips and staples. Michel clips appose the skin edges but do not penetrate the skin, and cosmetic results are good. Preloaded disposable staples have largely replaced Michel clips. Cosmetic results are excellent. Stapling devices are also available for GI anastomoses. Simple wounds in children can be closed with adhesive strips (Steri-Strips). Scalp lacerations in children can be closed using hairs adjacent to the wound edges as ‘sutures’. The hairs are knotted across the wound.

Drains

Drains are used prophylactically to drain anticipated collections, e.g. haematomas, bile leaks, urine leaks, or therapeutically to remove collections of pus, blood or other body fluids. Most drains consist of latex-based material or silicone. Red rubber tube drains are still used occasionally. Red rubber and latex drains form better tracks than silicone by exciting more tissue reaction. Drainage may be open or closed, suction or non-suction.

Open drainage

This is drainage by capillary action or gravity into dressings or stoma bags. Drainage may depend on position of patient. Sepsis is commoner with open drains.

Closed drainage

This is drainage into a bag or bottle attached to the drain. Usually, it is a suction system although it may be passive, working on the syphon system. Sepsis is less common with closed systems.

Suction drains

These help collapse down potential spaces as well as draining blood and other fluids. They are usually closed systems and therefore the risk of sepsis is less. Sump drains are open drains used in connection with suction. Sump drains contain an air inlet lumen to prevent blockage with soft tissue. Sepsis is a risk with sump drains.

Non-suction drains

These are used mainly intraperitoneally to drain gastrointestinal and biliary anastomoses. They are usually left for up to 5 days. They are usually rubber, PVC or silastic. If prolonged drainage is necessary and there is need for a tract to be established, rubber drains should be used as they stimulate fibrosis.

Complications of drains

• Sepsis: commoner with open drains

• Failure: especially suction drains which draw fat or omentum into the side holes

• Pressure or suction necrosis of the bowel leading to leakage of the intestinal contents with peritonitis

• Rarely, erosion into a vessel with haemorrhage.

Stomas (-ostomies)

Colostomy

A permanent colostomy usually opens onto the anterior abdominal wall in the left iliac fossa (LIF). It is flush with the skin and the contents of the bag are usually formed faeces. It is most commonly created following an operation for abdominoperineal resection of the rectum. A temporary colostomy in this position is usually consequent on a Hartmann’s procedure. Colostomies may occasionally be seen in the upper abdomen, either to the right or left of the midline, when they are defunctioning colostomies fashioned in the transverse colon to protect a distal anastomosis, although defunctioning ileostomies are preferred nowadays.

Ileostomy

An ileostomy is usually in the right iliac fossa (RIF). It is not flush with the skin but overhangs as a ‘spout’ for about 2.5 cm. This is so that the liquid small bowel content, rich in pancreatic enzymes, does not come into contact with the skin of the abdominal wall, resulting in tryptic digestion of the skin. The contents of the bag are fluid and are of the consistency of porridge. An ileostomy usually results from total colectomy with excision of the rectum (panproctocolectomy) for ulcerative colitis. Defunctioning loop ileostomies are used to protect distal anastomoses.

Urostomy (ileal bladder)

A urostomy is usually in the RIF. It is a blind-ended loop of ileum and looks not dissimilar to an ileostomy, i.e. it is not flush with the skin edge but looks like a ‘spout’. The ureters have been transplanted into the ileal loop. Urine drains from the ileal loop. It is usually created following total cystectomy for carcinoma of the bladder.

Mucous fistula

In some operations it may be necessary to bring out both ends of bowel, e.g. ischaemic bowel to assess viability. One end will be the functioning draining stoma (either ileostomy or colostomy) and the other end will be the functionless stoma termed a mucous fistula.

Local anaesthesia

Techniques with local anaesthetics include topical (surface) anaesthesia, local infiltration, regional nerve block, spinal or epidural anaesthesia. Only local anaesthetic infiltration will be described here since regional nerve blocks, spinal and epidural anaesthesia are the province of the anaesthetist.

Many minor surgical procedures are carried out under local anaesthetic. Some require very small amounts, while others may reach the maximum safe dose, e.g. repair of an inguinal hernia. Local anaesthetics reversibly block nerve conduction by inactivating sodium channels, blocking electrical depolarization. Smaller nerve fibres are more sensitive than larger so that pain and temperature sensation are lost first, followed by proprioception, touch and pressure and motor impulses. This explains why the patient may feel pressure but no pain, and loss of motor function occurs later.

Types of local anaesthetic

Three main types of local anaesthetic are available: lidocaine, bupivacaine and prilocaine – lidocaine being the most widely used.

Lidocaine

Rapid onset, short duration. Comes in three strengths: 0.5% (5 mg/mL), 1% (10 mg/mL), 2% (20 mg/mL). The upper dose limit for lidocaine is 3 mg/kg (plain), 7 mg/kg (with 1:200 000 adrenaline).

Bupivacaine

Slower onset, longer duration. Comes in two strengths: 0.25% (2.5 mg/mL), 0.5% (5 mg/mL). Upper dose limit is 2 mg/kg (both plain and with adrenaline).

Prilocaine

Rapid onset, shorter duration than lidocaine. Comes as 1% solution (10 mg/mL). Upper dose limit is 6 mg/kg.

Local anaesthetics may be mixed with 1 in 200 000 adrenaline. Adrenaline is included as a vasoconstrictor. It diminishes local blood flow, slows the rate of absorption of the local anaesthetic and prolongs its local effect. Adrenaline should be used in low concentration, e.g. 1 in 200 000 (5 μg/mL). The total dose of adrenaline should not exceed 500 μg.

Adrenaline must not be used where there are ‘end’ arteries, i.e. never on the digits or penis. It is also inadvisable to use it on other extremities, i.e. the nose, nipple or lobe of the ear. Addition of adrenaline does not increase the safe dose of bupivacaine and there is little point in using it for infiltration with bupivacaine except to reduce bleeding. The total dose of adrenaline should not exceed 500 μg. Local anaesthetic techniques should only be performed where adequate resuscitation facilities are available. Local anaesthetics should not be injected into inflamed or infected tissues where they are largely ineffective and may be responsible for further spread of infection.

Complications

• Injection site: pain, haematoma, direct nerve trauma (with delayed recovery of sensation), infection

• With adrenaline: ischaemic necrosis (digits and penis)

• Systemic effects: idiosyncratic or allergic reactions (rare)

Toxicity

This may be due to excess dosage, inadvertent intravenous infection, or premature release of a Bier’s block (intravenous regional anaesthesia) cuff. Toxic effects include: lightheadedness, tinnitus, circumoral and tongue numbness, nausea, vomiting, visual disturbances, fits, CNS depression leading to coma, arrhythmias, cardiovascular collapse.

Tourniquets

Tourniquets are used in limbs where a bloodless field is required or to limit blood loss. They can also be used for a Biers Block (i.v. local anaesthetic for the manipulation of upper limb fractures). The principles of use of tourniquets include:

• Empty the limb of blood (this can be performed by elevation, Esmarch bandage or rubber ‘sleeve-like’ appliances which both aim to empty the limb of blood)

• The tourniquet is placed at the proximal end of the limb (layers of crepe bandage are used underneath the cuff to protect the skin)

• For upper limb surgery an inflation pressure of 200 mmHg (or 50–75 mmHg above patient’s systolic blood pressure) and for lower limb surgery 250–350 mmHg (100–150 mmHg above patient’s systolic blood pressure).

• One hour is the recommended inflation time for upper extremity surgery and 1.5–2 h for lower extremity surgery. The tourniquet should be deflated for 10 min after the maximum recommended time, after which the tourniquet may be re-inflated for another full period.

Complications of tourniquet use include:

• Nerve injury – associated with pressure

• Emboli – use of tourniquet may lead to formation of a DVT and PE

• Sickle crisis – in susceptible patients the build up of potassium, lactate, etc. may precipitate a sickle crisis

• Compartment syndrome – prolonged ischaemia may lead to reperfusion injury and swelling of muscles

• Post-tourniquet syndrome – consists of non-pitting oedema, sensory loss, muscle weakness and stiffness. This may last up to a month

• Burns – can occur if alcohol containing skin preparations get under the tourniquet

• Raised core temperature and increased plasma viscosity – these events are known to occur after tourniquet use but their clinical significance is uncertain

• Increased postoperative pain.

Important safety points for tourniquet use include:

• Correct size with adequate padding

• Keep duration of inflation to a minimum (2 h is considered the absolute maximum)

• Use minimum pressure needed to achieve desired effect

• Time the period accurately of tourniquet inflation

• Avoid multiple inflation and deflation

• Contraindicated in patients with a history of DVT and/or PE, peripheral vascular disease and sickle cell disease.

Diathermy

Surgical diathermy is an invaluable tool in providing haemostasis but can also be used to cut tissues. It involves high frequency alternating current (AC). There are a number of important points to understand regarding surgical diathermy:

• Diathermy used in surgery is very high frequency (400 kHz–10 MHz) and uses high current intensity (as high as 500 milliamps (mA) can be used). However, home electricity is capable of inducing VF (as much as 100 mA is sufficient); this is due to the much lower frequency of around 50–60 Hz.

• Monopolar. This is the most common type of diathermy. An AC is produced and passed to an electrode with a small surface area (the diathermy tip). Current is passed to the tissues as heat. The current passes through the body tissue and completes the circuit by returning to a much larger surface plate, i.e. the indifferent electrode plate which is usually placed on the patient’s thigh (Fig. 2.2A). Good contact is essential. Current recommendations to improve contact include shaving hair from the skin where the plate is placed and using disposable self-adhesive diathermy plates. Monopolar diathermy is most widely used for operative haemostasis but there is wide dispersion of coagulating and heating effects, which makes it unsuitable for use near nerves and other delicate structures.

• Bipolar. There is no need for a plate and uses much less power. The two active electrodes are the tips of a pair of forceps. Current flows between the tips of the forceps and thus only affects the tissues between them (Fig. 2.2B). Bipolar diathermy is used for finer surgery where greater precision is required. There is minimal tissue damage around the point of coagulation and therefore safety in relation to nearby nerves and blood vessels.

• Coagulation. This involves sealing blood vessels. The AC output is pulsed and haemostasis occurs by a combination of cellular dehydration and protein denaturation.

• Cutting. In this form, the AC output is continuous and forms an arc between the diathermy and the tissue. The heat generated is sufficient to cause water to explode into steam. A combination of cutting and coagulation is often referred to as ‘blend’. Cutting diathermy is mainly used for dividing large muscle masses, e.g. thoracotomy and transverse abdominal incisions.

• Fulguration. A form of coagulation in which a higher voltage is used that creates sparks which arc from the diathermy to the tissues and create charring of the tissue.

Figure 2.2 (A) Monopolar diathermy. Current passes through the fine instrument tip (a), through the patient (b) and returns via the large indifferent electrode (c). (B) Bipolar diathermy. Current passes between the tips of the forceps (a) and coagulates tissue grasped between the tips. It does not pass through the patient.

Complications of diathermy include:

• Electrocution. Very low risk with modern equipment.

• Explosion. Rare can occur with pooling of alcohol based skin preparations or with colonic gases.

• Burns. Most common problem. Can occur with faulty application of the patient plate. Patient is earthed by touching a metal object (e.g. drip stand), faulty insulation on the diathermy wires, accidental activation and accidentally touching another metal object while activating diathermy (e.g. retractor).

• Interference with pacemakers. Diathermy activation may result in no pacing or the pacemaker may revert to a fixed rate. Bipolar diathermy is considered safe to use. If monopolar diathermy must be used, then the patient plate should be sited as far away as possible from the pacemaker.

• Channelling. The use of diathermy in tissues with narrow channels or pedicles can lead to the current being ‘channelled’ through a short surface area and thus high heat production. Examples of this would be in a child’s penis during circumcision or along the spermatic cord with operations on the testicle. Bipolar diathermy is safe to use.

• Direct coupling. The active diathermy comes into contact with another metal instrument (e.g. camera) that is touching tissues (e.g. bowel) and results in a burn.

• Capacitance coupling. Very rare with modern ports. Occurred when ports had a plastic portion to anchor them into the abdomen. When a current is applied through an insulated instrument within a metal tube (e.g. port), some electrical charge is transferred to the cannula. If the port is entirely metal, then there is no problem as the charge will dissipate through the abdominal wall over a large area of contact. If a plastic collar is present, then this will prevent discharge and potentially lead to burns on adjacent tissue. Diathermy injury during laparoscopic surgery may also occur with accidental activation, faulty insulation of equipment and retained heat in the instrument.

Laser

Laser stands for Light Amplification Stimulated Emission of Radiation. Lasers work by energy being directed at a lasing medium. This excites atoms into a higher energy state. Photons are emitted as electrons fall from the excited to a ground state. These photons are amplified by being reflected between two mirrors. A small amount of laser light is allowed to emerge and this forms the laser beam. This beam vaporizes tissues and coagulates small vessels. A number of lasing mediums are used, usually gaseous (e.g. carbon dioxide, argon) but crystals are also used (neodymium, yttrium, aluminium and garnet – NdYAG). The lasing medium determines the wavelength and the wavelength determines the depth of absorption and thus clinical effect. Lasers are used in a number of surgical specialities such as destroying tumours of the GIT (e.g. oesophageal) urinary bladder and female genital tract. They are used in ophthalmology to destroy thickened lens capsules with cataracts. They are classified according to the degree of danger in their use (class I to class IV).

Potential risks involved with lasers include:

• Risks to patient – burning of normal tissue can lead to perforation, e.g. in the oesophagus

• Risk to operator – the laser can damage the eyes or skin.

A number of safety measures should therefore be adhered to:

• Appropriate local personnel. A laser safety officer and laser protection advisor should be nominated to draft safety protocols and ensure that they are followed

• All lasers should be labelled with their hazard category

• All personnel using or involved in the use of lasers should wear eye protection

• An appropriate environment with minimal reflective surfaces should be provided for laser use.

Laparoscopic surgery

Laparoscopy has been in use by gynaecologists for many years in diagnosing pelvic disorders and for sterilization by tubal ligation. It is now being used more widely in other branches of surgery, particularly for minimally invasive surgery. Laparoscopy may be either diagnostic or therapeutic.

Diagnostic laparoscopy:

For biopsy of lesions, staging of cancers, e.g. gastric and pancreatic; and increasing diagnostic accuracy in the acute abdomen.

Therapeutic laparoscopy:

Widely practiced, the most common operation being cholecystectomy. Other procedures include appendicectomy, inguinal hernia repair, division of adhesions, colonic resection, Nissen fundoplication for gastro-oesophageal reflux disease, nephrectomy, splenectomy. Laparoscopic operations may need to be converted to ‘open’ surgery if difficulties are encountered, e.g. gross adhesions, poor visualization of the operation site, slow progress with the operation, uncontrollable haemorrhage.

Technique

Usually performed under general anaesthesia. A pneumoperitoneum is created by introducing carbon dioxide under controlled pressure. This may be done by direct visualization of the peritoneal space by an open cut down technique made below the umbilicus (Hassan technique). The use of a Veress (insufflation) needle is still popular but it requires gas to be insufflated without confirmation of the correct location of the needle tip. The first port is inserted at the umbilicus for the telescope and camera. To perform procedures, additional puncture sites are required (secondary ports). Trocars are inserted at these sites under direct laparoscopic vision to prevent injury to the viscera. Various instruments are then introduced through these port sites. Basically, these instruments may be divided into those for visualization, grasping, retraction, dissection, ligation/suturing and retrieval.

Instruments introduced through port sites include scissors, diathermy hooks, clip applicators. Some operations are described as ‘laparoscopic assisted’, where the major dissection is performed laparoscopically and subsequently a small incision made in the abdomen to deliver the specimen. ‘Hand assisted’ laparoscopy requires a small incision to insert the operator’s hand to assist with dissection and delivery of the specimen. Retrieval bags may be introduced into the peritoneal cavity to aid the delivery of specimens, the aim being to prevent the spread of infection, seeding of tumours, or to prevent disruption of the specimen when it is pulled out through an abdominal incision. The operation is performed by the operator with one or more assistants who control the camera or manipulate the ports, the progress of the operation being observed on video monitors.

Complications

• Dangers of pneumoperitoneum; needle/trocar injury to bowel or blood vessels; compression of venous return predisposing to DVT and PE; subcutaneous emphysema; shoulder tip pain (irritant effect of carbon dioxide producing carbonic acid locally and irritating the diaphragm with referred pain to the shoulder tip); pneumothorax (rare); pneumomediastinum (rare)

• Inadvertent injury to other structures either by dissection or diathermy or inappropriate application of clips, e.g. damage to the bile duct in cholecystectomy; uncontrollable haemorrhage

• Complications related to duration of anaesthesia, which may be longer for laparoscopic procedures than for open procedures. The diaphragm is splinted by abdominal inflation and this may result in cardiorespiratory complications

• Herniation at port sites with possible subsequent strangulation.

Venous access

Venous access may be required for simple venepuncture or insertion of a cannula. Suitable sites are veins on the back of the hand or the antecubital fossa. The foot veins may also be used if there are no suitable veins in the arm. Injections should not be given into veins in the antecubital fossa however, in case of accidental puncture of the brachial artery, which is immediately deep to the veins separated from them only by the bicipital aponeurosis. In children and patients with needle phobia, EMLA cream may be applied and left for 45–60 min to anaesthetize the skin. It should be wiped off before cannulating. The following steps are required in the procedure:

• Choose the site

• Place a tourniquet or sphygmomanometer (inflated to just below diastolic pressure) above the site

• Swab with alcohol

• Advance cannula until flashback of blood

• Release tourniquet or sphygmomanometer

• Withdraw needle leaving cannula in vein

• Connect infusion.

When removing the needle or cannula, raise the arm and compress the site for about 1 min to prevent bruising.

If no other site is available for venous access in an emergency, a venous cut-down may be required. This should only be used if it is not possible to gain venous access elsewhere. A cut-down is usually carried out at the ankle where there is a constant vein, i.e. the great saphenous vein lying immediately anterior to the medial malleolus. The steps in the procedure are as follows:

• Prepare skin and drape

• Infiltrate with local anaesthetic

• Make an incision over the vein

• Dissect the vein from other structures, e.g. the saphenous nerve in association with the great saphenous vein at the ankle

• Ligate the distal end of the vein and put a suture sling around the proximal end

• Make an incision in the vein

• Insert a large bore cannula into the vein and ligate proximally to secure cannula in vein

• Attach infusion

• Close wound and apply dressing.

Central venous catheterization – internal jugular vein

Indications for internal jugular vein cannulation include the determination and monitoring of central venous pressure and establishing a route for intravenous therapeutic agents. Complications include pneumothorax, carotid artery damage and haematoma. A clotting screen should be checked before starting the procedure.

The following are the steps in the procedure:

• Patient is prepared with head tilt 15° down and head turned to the opposite side

• Infiltrate the skin with local anaesthetic at the level of the thyroid cartilage (three fingers breadth above the medial end of the clavicle) lateral to the carotid artery pulse

• Site of entry is at the apex of the triangle formed by the two heads of sternocleidomastoid and the clavicle

• Using an 18G ‘finder’ needle, enter the apex of the triangle keeping lateral to the pulse of the carotid artery. (Most CVP lines are inserted under ultrasound guidance.)

• Insert the needle at 30° angle and aim for the ipsilateral nipple

• Once in the vessel, remove the syringe, hold the thumb over the needle to avoid air embolism

• Insert guidewire

• Make a small nick in the skin where the guidewire enters

• Advance dilator over guidewire

• Remove dilator

• Place catheter over guidewire

• Remove guidewire and aspirate blood and flush all three ports of cannula

• Suture to skin

• Arrange CXR to check position.

Blood gas sampling

Vessels of choice are the radial artery (immediately lateral to the tendon of flexor carpi radialis just above the wrist), the brachial artery (immediately medial to the biceps tendon at the elbow) or the femoral artery at the mid-inguinal point (halfway between the anterior superior iliac spine and the pubic symphysis). For radial artery cannulation, always check the patency of the ulnar artery (Allen test).

The following are the steps in the procedure:

• Swab site the alcohol

• Use a 2 mL heparinized syringe (usually pre-filled syringes are available)

• Expel air from syringe

• Advance at 60–90° into the artery (it may help to rest the wrist on a bag of saline). The artery may have been transfixed so it may be necessary to withdraw the needle slowly until blood fills the syringe

• Obtain 2 mL of blood and cap the syringe immediately

• Compress puncture site for 3–5 min

• Empty syringe of any air bubbles and send to laboratory immediately for analysis. If there is any delay, place the syringe on ice.

Urinary catheterization (male)

A Foley catheter is inserted into the bladder. For adults a 12–14F gauge should be used. For children an 8–10F gauge should be used.

The following are the steps in the procedure:

• Wash hands, put on sterile gloves and arrange contents of catheter pack on sterile tray

• Position patient flat

• Drape with sterile towels with penis exposed

• Grasp penis with sterile swab, retract foreskin and clean the urethral opening and glans with antiseptic solution

• Squeeze lignocaine gel into urethra and allow time for it to work

• Remove catheter from pack and insert fully into bladder to ensure balloon is in bladder. Do not use force

• Check that there is urine flow from catheter

• Inflate balloon with sterile water 5–10 mL

• Withdraw catheter to lodge against bladder neck

• Remember to replace foreskin to avoid paraphimosis

• Attach drainage bag.

Related

Churchills Pocketbook of Surgery