Surgery

Published on 05/05/2017 by admin

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Last modified 22/04/2025

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FIG. 7.12 Organization of the male reproductive organs. Sagittal section of pelvis showing placement of male reproductive organs. (From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby.)
 
Surgical Mapping
Cystoscopic TURP (transurethral prostatectomy)

Instruments Important Anatomy Involved Pathophysiology
Cystoscopy instrumentation:
Irrigation,
tubing & pump
Camera
Light source & cable
Resectoscope
Three-way Foley catheter
Ellik evacuator
Van Buren sounds
Electrocautery
Urethra
Prostate
Bladder
BPH (benign prostatic hypertrophy)
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Indigenous microorganisms
concentrated in the external urethral orifice and navicular fossa, basically consisting of gram-positive aerobic bacteria
Class II (clean contaminated)
Prep: perineal prep & drape
Position: lithotomy or low lithotomy
Incision: none
Spinal/general anesthesia
Omniopaque/Renografin (radiopaque solutions for KUB x-ray series)
image

FIG. 7.13 Urinary bladder. Male bladder cut to show the interior. In the male, a large prostate gland surrounds the urethra as it exits from the bladder. (From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby.)
 
Surgical Mapping
Ureteroscopy

Instruments Important Anatomy Involved Pathophysiology
Ureteroscopy instrumentation
irrigation, tubing & Pump
Camera
Light source & cable
Three-way Foley catheter
Ureteral stent
Van Buren sounds
Electrocautery
Laser
Urethra
Bladder
Ureter
Kidney
Urinary calculi
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Indigenous microorganisms
concentrated in the external urethral orifice and navicular fossa, basically consisting of gram-positive aerobic bacteria
Class II (clean contaminated)
Prep: perineal prep & drape
Position: lithotomy
Spinal/general anesthesia
Omnipaque/Renografin
(radiopaque solutions for KUB x-ray series)
Go ahead and use the template available on the Evolve Resources site to try mapping the remaining procedures:
• Cystoscopy
• Cystoscopy TURBT (transurethral resection of bladder tumor)
• Urethrotomy

Penile and Testicular Procedures

Procedures

• Hydrocelectomy
• Orchiopexy
• Circumcision (Fig. 7.14)
• Orchiectomy
• Hypospadias and epispadias repair
• Penile prosthesis placement
• Vasvasotomy
• Vasectomy
• Varicocelectomy

Basic Equipment Required

• Genitourinary minor instrument set
• Electrocautery (needle tip)
• Two #15 knife blades

Additional Facts to Remember

• Repair of hypospadias, in which the urethral opening of the penis is on the underside rather than at the tip, may require multiple procedures performed in stages.
• In epispadias, the urethra ends in an opening on the upper aspect (dorsum) of the penis.
• Because of the importance of preserving skin for use as grafts in repair procedures, circumcision is not performed in infants with defects.
• Hypospadias repair also involves the release of chordee to straighten the penis.

image

FIG. 7.14 Circumcision. A, Initial incision made in the shaft. B, Second incision made in subcoronal sulcus. C, Amount of tissue to be removed. D, Removal of tissue. E, Shaft skin sutured to subcoronal skin. (From Holcomb GW, Murphy JP: Pediatric surgery, ed 5, Philadelphia, 2010, Saunders.)
• Urethral catheters of 10 to 12 Ch/F for adult women and 10 to 16 Ch/F for adult men are generally chosen; hence, any size smaller than 8F is used for pediatric patients when avoiding damage to the urethra is of major concern.

Mapping

Here’s the mapping on two GU procedures that you’re likely to encounter in the operating room:
 
Surgical Mapping
Hypospadias repair

Instruments Important Anatomy Involved Pathophysiology
Minor instrument tray
Pediatric Foley catheter
Urethra
Bladder
Hypospadias
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Indigenous microorganisms
concentrated in the external urethral orifice and navicular fossa, basically consisting of gram-positive aerobic bacteria
Class II (clean contaminated)
Prep: perineal prep, external genitalia (retracting foreskin as needed)
Incision: slit-like adjusted Mathieu (SLAM) on dorsal side of penis
Position: supine
Warm normal saline
General anesthesia
And now it’s your turn; try mapping the remaining procedures, using the template available on the Evolve Resources site:
• Hydrocelectomy
• Orchiopexy
• Circumcision
• Orchiectomy
• Penile prosthesis insertion
• Vasvasotomy
• Vasectomy
• Varicocelectomy

Kidney, Ureter, and Bladder Procedures

See Fig. 7.15 for more information on the urinary system.

Procedures

• Wilms tumor excision
• Nephrectomy (Fig. 7.16)
• Kidney transplant
• Pyelolithotomy
• Cystectomy/ileal conduit procedure
• Marshall-Marchetti-Krantz procedure
• Endoscopic suburethral sling
• Stamey procedure

Basic Laparoscopic Equipment Required

• Light cord
• Camera
• Insufflation or irrigation tubing
• Trocars
• Laparoscopic instruments
• Minor soft instruments
• Fluid to induce distention

Basic Endoscopic Equipment Required

• Light cord
• Camera
• Irrigation tubing
• Trocars
• Cystoscopic instruments

Additional Facts to Remember

• Depending on the surgery, an open or laparoscopic approach may be required.

Endoscopic Procedures

Fluid is used as the medium for distention; input and output must be monitored closely so it does not run out.
Allen or candy cane stirrups are used to put the patient in lithotomy position.
• The Stamey procedure is a retropubic urethropexy approach in which sutures are used to raise the urethra and bladder neck and secure them to the surrounding tissue and bone.

Pyelolithotomy

• If the pleural cavity is to be entered, a chest tube may be necessary, because the 12th rib is removed to permit full visualization of the renal pelvis.
• The left kidney is larger than the right.
• The right kidney is located slightly lower than the left to accommodate the liver.

Ileal Conduit Procedure

• Be prepared for specimens to be taken for frozen sections.
• Seeding must be prevented in the case of tumor excision through isoslation of instruments that have come into contact with cancer cells.
• The patient will have a stoma (ileostomy).

Mapping

Here are a couple of example procedures for you:
 
Surgical Mapping
Pyelolithotomy

Instruments Important Anatomy Involved Pathophysiology
Major laparotomy set
Abdominal retractors
Vascular tray
Long instrument tray
Thoracic tray & chest instruments (available)
Kidney/area of kidneys
Ureter
Liver, colon, pancreas
Calculus of the renal pelvis
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Class I (clean)
Prep: axilla to midthigh
Position: lateral with kidney rest (affected side up)
Incision: flank
General anesthesia
image

FIG. 7.15 Urinary system. A, Anterior view of urinary organs. B, Surface markings of the kidneys, 11th and 12th ribs, spinous processes of L1 to L4, and lower edge of pleura viewed from behind. C, Horizontal (transverse) section of the abdomen showing the retroperitoneal position of the kidneys. D, Colorized x-ray film of the urinary organs. (A, C, D, From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby. B, From Abrahams P, Hutchings RT, Marks SC: McMinn’s color atlas of human anatomy, ed 5, St Louis, 2003, Mosby.)
image

FIG. 7.16 Intraoperative photograph of a right radical nephrectomy. An automatic clip applier is being used to control the renal artery. Note the renal vein to the left of the instrument. (From Becker JM, Stucchi AF: Essentials of surgery, ed 1, Philadelphia, 2006, Saunders.)
 
Surgical Mapping
Ileal conduit procedure

Instruments Important Anatomy Involved Pathophysiology
Major laparotomy tray
Intestinal tray
Bookwalter retractor
Stapling devices for bowel
Vascular tray
Stoma bag
Ureteral stents
Bladder
Prostate
Ileum
Kidneys
Ureters
Malignancy of the bladder and nearby tissues
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Class IV
Prep: midchest to both thighs
Incision: midline vertical abdominal
Position: supine with laparotomy draping
General anesthesia
Try mapping the remaining procedures using the template available on the Evolve Resources site:
• Wilms tumor excision
• Nephrectomy
• Kidney transplant
• Marshall-Marchetti-Krantz procedure
• Endoscopic suburethral sling
• Stamey procedure

Prostate Procedures

These surgeries may be performed endoscopically (laparoscopically) or as open procedures.

Procedures

• Prostatectomy (Fig. 7.17)
• Suprapubic prostatectomy
• Laparoscopic robot-assisted prostatectomy
• Implantation of radioactive seeds into the prostate

Basic Laparoscopic Equipment Required

• Light cord
• Camera
• Insufflation tubing
• Trocars
• Laparoscopic instruments
• Minor soft Instruments

Additional Facts to Remember

• In endoscopic procedures, fluid is used as the medium for distention.
• Allen or candy cane stirrups are used to place the patient in the lithotomy position.
• A Foley catheter is inserted and maintained on the sterile field.

image

FIG. 7.17 Sectional view illustrating removal of portion of hypertrophied middle lobe of prostate gland with Iglesias resectoscope. (From Rothrock JC: Alexander’s care of the patient in surgery, ed 15, St Louis, 2015, Mosby.)

Mapping

Here’s how one of these procedures looks when mapped:
 
Surgical Mapping
Suprapubic prostatectomy

Instruments Important Anatomy Involved Pathophysiology
Major laparotomy set
Abdominal retractors(Judd-Mason)
GU instrument tray
Long instrument tray
Electrocautery
Hemoclips
Suprapubic & Foley catheters
Ureter
Bladder
Urethra
Prostate
Prostate cancer
Microbiology/Wound Classification Skin Prep/Incision/Patient position Pharmacology
Class II (clean contaminated)
Prep: axillae to midthigh, perineal prep; laparotomy draping in combination with perineal draping of scrotum
Incision: low transverse
Position: supine/frog leg shoulder brace for Trendelenburg rotation
General anesthesia
The remaining procedures are yours to map!
• Prostatectomy
• Laparoscopic robot-assisted prostatectomy
• Implantation of radioactive seeds into the prostate