Setup for an Exploratory Laparotomy with Possible Splenectomy (Ivy Tech Community College, Indianapolis, IN)

CHAPTER 1

Hi, my name is David Wiseman. I'm the clinical coordinator for the surgical technology program at Ivy Tech Community College in Indianapolis. And today I'm gonna be showing you how I set up for an exploratory laparotomy with a possible splenectomy.

CHAPTER 2

So the first thing that I would do after I've scrubbed in and opened all my supplies and instrumentation is I would go ahead and drape my warmer. I would have a warmer in the room and a drape for it on the sterile field. I'm gonna go ahead and get that draped and then have my circulator pass irrigation to me. Probably normal saline would be the preferred irrigation and at least two liters, maybe three liters. And I'm gonna want to go ahead and get that plugged in and begin warming so that we're ready with warm irrigation when the patient comes into the room. At the point that she passed that, I would also go ahead and label it. So I make sure that I clearly have my medications labeled on the back table. So then next, I'm gonna go ahead and set up my table. You may notice this table's a little different than some you've seen. We call this a Fehling table or a straddle table. It is a square design rather than a rectangle. It's height-adjustable, and what I like about it is it's a shorter length, so you don't have as far to go. I can reach everything on the table from one position. I'm gonna go ahead and try to move things minimally. I like to put a towel underneath my instruments so that the heavy instruments don't tear through the back table drape. A lot of back table drapes now have a built-in towel, so if you have that already, you're gonna be okay.

CHAPTER 3

I'm gonna go ahead and place my patient drapes on the Mayo stand so that they're ready to go. And your surgeon is gonna have a preference for what type of drape they like for an exploratory laparotomy. The drapes we have here today are a universal style system with a top, a bottom, and two sides. You want to stack 'em in order of use, which I always tell everybody that it's just like jumping in a pool with draping, you want to go feet first, so you always have your bottom drape on top and the top drape below that, and then the two sides to follow.

CHAPTER 4

When you're setting up, you wanna be careful of any supplies that you may have passed during the setup. So, I did pass a couple of sharp items, so I wanna make sure that I find those and locate 'em so I don't hurt myself during the case. So in this instance, I did pass a blade, so I'm just gonna go ahead and put that over here in the corner. This item is called a fish. This is used for closing. It covers the abdominal contents so that when they're closing the fascia, they don't injure your bowel or anything like that. It is a countable item, and you want to make sure to keep an eye on it. I like to put my sharps box in the bottom left corner. I keep it pretty close to the edge and I would go ahead and peel off the stickies and stick it down so it stays there. I'm gonna keep my blade close to there and put my other countable items close to the sharps box as well. When you're draping, you're gonna need at least four towels to square off, so I'm gonna put those on top of my drapes. And then kind of situate my other towels. I like to do a rolled towel for my stringer. And I like to flip it around, kinda roll it tight, tighten it up a little bit, hold those instruments a little bit better. The stringer itself, I always put underneath the pan. Check with your facility; some facilities like to count that. I always put it underneath the pan so there's no possibility of anybody grabbing it during the procedure. I like to keep all my scissors right next to my sharps box, so they're there for cutting suture or anything like that. I'm gonna go ahead and position things. I've got my Asepto, maybe one, a second one, being that it's an exploratory laparotomy, you may be using a lot of irrigation, and it's a lot easier if you have two of these to kind of fill 'em up quickly. But I'm just gonna put that in my warmer. Suction tubing, I'm gonna go ahead and load a Yankauer on there, but I do have a Poole suction as well, and I would keep that out and know where that's at because that may be something I'm using really quickly into the case. Get all my sponges out, get everything ready for a count with my circulator. The goal here being, I wanna be ready to count as quickly as possible in case that patient needs to come in here quickly and we need to get moving with the procedure.

CHAPTER 5

So, I'm gonna do my small count first, so it's gonna be my sponges, my sharps, and things like that. You're always gonna wanna start with your largest sponges first, work your way down. So I've got lap sponges. Make sure my circulator is ready to count. And they are. 1, 2, 3, 4, 5. You wanna be careful to rip the tab when you're counting with the circulator so they know that these haven't been handled or anything prior to that. 1, 2, 3, 4, 5 for 10. 1, 2, 3, 4, 5 for 15 laps, and 1, 2, 3, 4, 5 for a total of 20 laps. And at this point, I'm probably gonna take a couple of these laps and put 'em into my warmer, at least a couple to have some warm laps ready, some moist laps ready for retractor blades for the Bookwalter, or anything else the surgeon might need. Ray-Tecs, always easiest to find the folded edge when you count these. 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 Ray-Tecs. Blades, I have one. Bovie tip, I have one short one on the Bovie and one extended Bovie tip. You always want to have an extended Bovie tip because as you work your way into the abdomen, you're gonna get lower and deeper down and the surgeon's gonna need to be able to get there with the Bovie. I have vessel loops, 1, 2. Normally you would take these off, but I'm gonna leave 'em on here today. And suture, I have one. The suture that I passed is a 3-0 PDS. This is basically an emergency suture. Your surgeon's gonna have their own preferences as to what type of suture they want to use during the case, but you're gonna need something for bleeding or anything like that. And a 3-0 PDS is an excellent choice for that. I have some silk ties for vessel ligature throughout the case. And then I also have a Penrose drain if they need to isolate the splenic artery or splenic vein or any other vessels to retract 'em out of the way. So that would do it for our soft count. Some facilities I know do count the Yankauer suction tip, so check with your facility if that's something that needs to be counted as well. Next, at this point, I would move on to my major pan and then I'm gonna count my Bookwalter last. So when I'm counting my major pan, I'm gonna go ahead and situate the stringer as I already have. I like to put my forceps on the side of the pan and I separate those forceps by toothed and smooth forceps so that I know quickly which direction are the smooth and which direction are the toothed forceps. You don't want to hand a surgeon a toothed forceps when they're grabbing a blood vessel. I like to use the Ferris-Smith or big Joe as a divider 'cause it's easy to see that quickly and tell the difference. So I put my smooth on one side of it and my toothed on the other side. And a lot of times I'll leave my retractors just kind of in the pan. So, I like to count with a knife handle. I prefer the long knife handle. It brings my hands further away from the instruments so that the circulator can clearly see what I'm counting as I'm counting it. Whenever you're counting instruments or anything, it's always a good idea to state what you're counting first. That gives the circulator time to identify what they're gonna be counting. They know what to be looking at to follow you. Mosquitoes, 1, 2, 3, 4. Curved Crile, 1, 2, 3, 4. Curved Kelly, 1, 2, 3, 4. Pean, 1, 2. Tonsil or Schnitt, 1, 2. Allis, 1, 2, 3, 4. Babcock, 1, 2. Kocher, 1, 2. Sponge stick, 1, 2. Mixter right angle, 1, 2. And needle driver, 1, 2. For retractors, I have Richardson retractors, 1. Army-Navy, 1, 2. Malleable, 1. Deaver, 1. And a Weitlaner, 1. For forceps, I have 1, 2, 3, 4, 5, 6, 7, 8, 9. And penetrating towel clamps, or Backhaus towel clamps, I have 1, 2, 3, 4. My knife handles, I have a number three long and a number three short, one of each. And scissors, I have a curved Mayo, I have one straight Mayo, and one curved Metzenbaum. Now when we get to the Bookwalter, it's important to know how your facility counts the Bookwalter and what type of Bookwalter you have. So today we have a segmental Bookwalter that has a large oval ring and then a segmental ring. And there are a lot of different attachments to this. So in some instances, you may count this as one total number. At some facilities, they may want you to count each individual piece. Some of these pieces have potentially removable parts, so you wanna find out if they expect this to be counted as two separate pieces or just one piece. You wanna make sure you understand that ahead of time and that your communication between you and your circulator is very clear when you're counting this to make sure that there is no, you know, room for confusion. So here we're gonna count a collective total number. So I have 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20. And that is your setup for an exploratory laparotomy.