Setup for an Open Total Thyroidectomy (South College, Knoxville, TN)

CHAPTER 1

Hi, guys. My name is Melissa Yearwood and I am an adjunct lab instructor here at South College in Knoxville, Tennessee for the surgical technology program. And what I wanna do today is show you how to do a basic setup for an open thyroid procedure. So as you can see, the majority of my supplies are already out and I've also already popped my tray. I'm also already in my gown and gloves.

CHAPTER 2

So before I come into the OR for the day, I would actually have already also performed my surgical hand scrub, whether it be the water-based scrub or the waterless alcohol-based scrub. After I perform that, I would come in, put my gown and gloves on. I like to double-glove personally for every procedure. So what that means is I have an indicator glove as my under glove, and then just your normal white glove on the top. So your indicator glove is typically gonna be a different color. In this instance, mine is green and the benefit of that is if I was to have a needle stick injury or while I'm setting up, if I was to accidentally poke a hole in my top gloves, if I was to get it in any fluid or anything like that, the green of that glove would show through, indicating that I have punctured that. So it would make me aware that I need to change either just my top set of gloves or both set of gloves completely.

CHAPTER 3

Now you can see that I have my supplies open, I'm gonna go ahead and start organizing my back table. So the goal is to move things as little as possible, preferably only one time. So we're gonna get started. So on top of my pack, I have my surgeon's gown. I'm gonna move that over here. My nurse has already opened my surgeon's gloves. Again, we have that indicator set, which is in this case green. I like to put them in the order that they're gonna put them on. So I'm gonna have my white gloves on the bottom and then my green or whatever color indicator gloves you have on top. And I'm gonna set that right on top of my surgeon's gown. Next, we have, this is just an absorbent pad in the pack. You can use this on the patient when you're performing the procedure if you have a lot of fluid loss, like say you're using a lot of irrigation or things like that. But for this instance, I'm just gonna set this on the bottom over here in the corner. Next, you have a 3/4 sheet. Again, this is gonna be for the patient. So sometimes we have really tall patients or if there's an area exposed after we drape our patient with the patient drape that is left still being seen, we can use this drape just as an extra level of protection to make sure that we do a really good job covering all of the exposed areas of our patient. So I'm just gonna set that right there as well. Next, I have a magnet pad. So I'm actually gonna go ahead and set this on my Mayo stand because we will lay this over the patient's abdomen. This is really good for magnetizing instrumentation because we do use quite a bit throughout this procedure. So the surgeon can just place this on this magnet pad and it will prevent it from sliding off throughout the procedure. And then we just have some surgical towels I'm gonna set over here beside my drape. And now this is our patient drape. So since this is gonna be the first drape I'm gonna use, I'm actually gonna set it on top over here in the corner with all of my other drapes. And this is just a clear drape. I'm not gonna use it for this procedure 'cause not every surgeon is gonna use it. Also, this is just a suture bag. Again, I don't use these, I typically just use my kidney basin if I have any trash just to kind of keep things more contained. So I'm just gonna set both of these off to the side. Now, my ring basin, I'm just gonna grab this whole thing and bring it up to my table. So these little guys right here, these are called utility drapes. The good thing about these is this little white strip right here pulls straight off and it exposes an adhesive side. So these are really good to use. Whenever you're squaring off the incision side, you can just peel off that white strip exposing the adhesive and place it in the appropriate spot. So these I like to go ahead and set on top of my patient drape because our sequence for draping is going to be, we're gonna square off with four towels or four utility drapes. Then we're gonna put our patient drape on. And then if anything else is exposed, we can use that additional 3/4 sheet or other drapes to cover those areas.

CHAPTER 4

And then this, I just have a basin and my pitcher, so this is gonna be for any fluids that I'm gonna use for irrigation throughout the procedure. I also have a bulb syringe. Again, this is just gonna be used to put the fluid in that we're gonna be using for irrigation. I have my laparotomy sponges and my Ray-Tec sponges. I like to put those over here because when you're setting up your table, you really wanna keep in mind, kind of divide it into sections. So this section over here is gonna be what's called my working end. This is gonna be the area that I reach for most of the time. I'm gonna have this side of the table pulled up to my patient. And the instruments that I'm gonna use most throughout my procedure are gonna be on this side. This side over here is my non-working end. So this is gonna be where I have my surgeon's gown and gloves, all of my drapes, any extras that I may need throughout the procedure, but I'm not gonna need as much as I would the things over here. I've got my kidney basin, which does have medicine cups in it. So if you are gonna have any local anesthetic for the procedure, you would put that in here. I have a skin marker so we can refine any skin incision marks. Sometimes after we prep, those markings can go away. So we always like to have a sterile marker so we can refine those if we need to. I have a pack of silk ties that we can use. These are really good to tie around blood vessels to help occlude flow. I have a 10-cc control syringe. So the good thing about these, this has finger rings on them. So a lot of times surgeons will like to use these because they feel it gives them better control when they're injecting local anesthetic. I have just a simple plastic ruler. It has inches and centimeters on it. So depending on what the surgeon wants to measure, they can use this ruler. And then I have Kittners or peanuts. Depending on where you are at, people call these different things. These are a countable item. We don't wanna leave these in the patient. We will use these for blunt dissection. And whenever we start setting up our instrumentation on our Mayo stand, I can show you how we load these. I also have just your standard suture box, and that will have inside, I have some of my sharps already. We'll count those here in just a few moments. I also have a pink pad. This is known as a no-pass or a neutral zone. So these are really useful whenever you have your blade handle loaded with your scalpel on it. If you have your syringe that has your hypodermic needle on it, if you have sutures loaded that are ready to pass, this is a really good area to put it on. You can announce that you have sharps on this no-pass zone, so nobody's grabbing it and they're risking any potential sharps injury. And in my bucket, what I'm gonna leave is I have my Bovie, my electrocautery for cutting and coagulating. I have a suction tubing, and I also have just a disposable light handle. So we can actually take this, place it on our surgical light so we can sterilely manipulate the light throughout surgery. And then I'm just gonna set this back over here in my ring basin.

CHAPTER 5

And now that I have all of my softs and sharps kind of organized, I'm gonna go ahead and go grab my instrument tray. Again, I've already checked my sterile indicators so I know that my sterile indicators are good. I am gonna go ahead and double check though. So there are two sterile indicators. You're gonna grab on the inside. Make sure you're maintaining that distance. You always wanna be 12 to 18 inches away from anything that's unsterile. So you're gonna grab these handles, making sure not to touch anything on the outside and pull it straight up. Now, what you're gonna wanna do from here, hold this tray out from your body. Reason being you wanna make sure your circulating nurse checks the inside of that tray to make sure that it's not contaminated. So what they're looking for in that is any type of moisture, debris, anything that could cause these instruments to be compromised because if that happens, these instruments are no good, we can't use those. If I have this tray out from my body, all I have to do is change my gloves. However, if I pull this instrument tray to me and my nurse tells me that that is contaminated, I have to take my gown and gloves off and regown and glove, so... They have said that's good. So I'm gonna go ahead and put that on my table. And then I'm immediately going to make a roll towel. And this will be for my instruments. So another fun fact about thyroid surgery, most facilities in our area, you do not have to count instrumentation because you're not going into a body cavity. Now, you may work somewhere where you have to count it, but in our area you do not. So I will be counting my softs and sharps though because whether you're doing a thyroid, any other type of surgery, you always wanna count your softs and sharps because what goes in your patient, we have to make sure that it comes out. So I have my instruments out and I'm just gonna go ahead and start organizing some of my instrumentation and I'll kinda walk you through the names of some of these as I'm doing so. So, let's see. To start, I have some knife handles. So I have right here, this is a number seven knife handle. I'm gonna set it on my no-pass zone. I also have a number three knife handle. This is the main one that we're gonna be using during the procedure today. My retractors, I have a self-retaining Weitlaner retractor. This one is blunt. Keep in mind, these instruments do come in sharp and blunt. So it's just gonna be dependent on the procedure that you're doing and your surgeon's preference, which one that they want. For this specific procedure, we're gonna be using a blunt one. I also have a Harrington, or a sweetheart retractor. I have a Richardson retractor, and I have two Army-Navy retractors. I also have towel clips in here, but since we have the sticky utility drapes, I'm not gonna need these for towels. Now, if you don't have sticky utility drapes and you're gonna be using normal towels to towel out your patient, you would need these to secure those towels down. I also have two S-shaped retractors. I have a Yankauer suction, which I'm gonna go ahead and also place that up here on my Mayo stand 'cause I do know that I'm gonna be using that for this procedure. And then our pickups. So on our pickups, we like to organize those. We like to have atraumatic or non-penetrating pickups on our working end and traumatic or penetrating pickups or forceps on our non-working end. So I have a pair of smooth pickups, I have a pair of rat tooth pickups, I have a pair of Debakey pickups, and I also have a pair of Adson with teeth pickups.

CHAPTER 6

So now that I have everything organized, I would be ready to count my softs and sharps with my circulator. So I'm gonna go ahead and do that at this time. You always start with your sponges whenever you start with your softs and sharps. So I will start with my laps. Now you see how these have a band around them? You never wanna remove that band until you're ready to count. And the reason being is because sometimes you will have multiples of these and you never wanna get 'em mixed up because everything is tracked by lot number. So you always wanna keep 'em separate until you know the count is accurate. And I also like to fan my sponges when I count them so they can be easily seen because we do wanna see them one at a time. So starting with my laps, I have one, two, three, four, five laps. And I'll put those back in their area. Next, I have my Ray-Tec sponges. Again, taking the band off when I'm ready to count. Fan those out a little bit. And I have one, two, three, four, five, six, seven, eight, nine, and 10 Ray-Tec sponges. Again, I'll bring those over here back to their little area. And next, I'm gonna start on my sharps. So I always like to use a knife handle when I'm counting my sharps just to add an extra level of protection to hopefully prevent me from getting any needle sticks while I'm counting. So first, I have scalpel blade, one. Bovie tip, I have one and two. I have one hypo. I have one and two sutures. Peanuts, I have one, two, three, four, and five. Ink, I have one, two. We always wanna count the ink with however many pieces like there are. So if there's one marker and one lid, that would be one, two. Some markers have two lids. So in that case your marker would be one, but each lid would also be a piece. So that would actually be a total of three. You also wanna count your plastic ruler. Again, this could get left in somebody. There's no radiopaque material in here. So if for some reason this accidentally did get left in the patient, X-ray wouldn't be able to pick that up and that could potentially cause a serious infection.

CHAPTER 7

So now that I have all of my softs and sharps counted, I'm gonna go ahead and start setting up my Mayo stand. And because I have so much room left in my tray, I just like to keep my stringer directly in here. Some people will put theirs underneath, which is completely fine. You just wanna put it in a place where you know where it's at so after the procedure you can access it so you can restring your instruments or whatever your facility requires to help aid in turnover. So for this particular procedure, I'm gonna start with usually about two of everything that I put up there because what the surgeon likes to do, the assistant will also do. So I'll do two curved Criles. Some places call these hemostats, some places call them snaps. So just have two of those. I will then place two Kelly clamps. Kellies are a little bit thicker than hemostats, so they work really well on denser, thicker tissue. I will do two Allis clamps. We will use these on the thyroid gland itself. So when we expose the thyroid gland, this can get a really good bite of that area. We can use that to retract. I'm then gonna get one right angle. This will do really good with dissecting around blood vessels or nerves. So if we need to put ties on, we can kind of put this under that area, put a tie on, tie it down, and then make, you know, cut in between those ties. Same thing with our tonsils. Tonsils are, they have a lot finer of a tip. They're a little bit longer than your Kellies and your Criles. They're really good to be used for blunt dissection. They can also kind of get down in there, kind of like your right angle, get around those blood vessels and those nerves. And sometimes what they'll do is they'll get down in there with the tips, they can actually spread those tips and Bovie in between the tips if they need to. So right now, since I have quite a few instruments in my hand, I'm gonna go ahead and start setting up my Mayo and then I can always go back and get anything else that I need. And then for my scissors, I'm gonna get a pair of Metzenbaum scissors, and a pair of straight Mayo scissors. Metzenbaums again are really good for fine dissection. They can really kind of get in there, get underneath the thyroid gland or get underneath the skin. They can get under there, spread those tips out so they can dissect. Also, we're gonna be using silk ties in this case. So they will put ties around the vessel and they'll actually use Metzenbaums to cut in between those ties. And the straight Mayo scissors that I have right here, you can see they have blunt tips. These are strictly gonna be used to cut suture at the end of the case. They can also be used to actually cut the ties. So when your surgeon ties them, you can cut that strand of material. Most surgeons for this procedure, they're gonna want some type of nerve monitoring system. So they may use a NIM's ET tube that hooks up to something. They may use regular nerve monitoring leads that kind of stick into the skin. But you're gonna want some type of nerve monitoring during this procedure because risk of injuring the recurrent laryngeal nerve is very high when you're removing a thyroid. So we want to eliminate that or reduce the risk as much as possible. Some surgeons also will use something known as a LigaSure device. It's a handheld device that kind of cauterizes and cuts through tissue. So when they're dissecting in the neck, they can use that. For my setup, instead of having a handheld LigaSure device, I have silk ties.

CHAPTER 8

And then I'm just gonna put a towel up here for my no-pass zone 'cause again, this is just an extra level of safety. So say, for instance, if I'm busy grabbing something for the surgeon off my back table, and they are suturing or if they have a scalpel or they have the needle because they're injecting local, they can put that on that white towel and they can say, "Hey, I have a sharp down on the no pass zone." That way I can immediately turn my attention to this and move it back to my neutral zone on my back table to just help keep everybody safe.

CHAPTER 9

And now what I'm gonna do is I'm actually gonna load my knife handle. So this right here is a 15 blade, and I'm gonna load it on a number three knife handle. And there's grooves on the side and there's grooves on this knife handle as well. So you can kind of fill it and get it down in there. And then it'll snap once it's into place. And what I like to do is I like to hold onto this while I have a really good hold onto my needle driver. And I'll actually kind of pull just to make sure that my blade is secure on there because the last thing you want is your surgeon to go to make an incision and your blade come off. So then I'm gonna place that on my no-pass zone. I'm gonna keep this pair of needle drivers over here on my no-pass zone on my back table because I know eventually I will need that for suture.

CHAPTER 10

And as far as these Kittners that I was telling you guys about, we will also use these for blunt dissection. It's really good whenever they're in there around really delicate tissues, nerves, blood vessels, they can actually load these onto a Kelly and they'll load it like this. And say they make an incision and they're down there and there's some nerves, they don't wanna damage anything. They can just use this really rolled up tight piece of cotton and just kind of brush it along those areas, and it does a really good job at bluntly dissecting around structures. So I'll go ahead and have one of those loaded up there, and I'll keep my other ones back here. Well, this is my setup for a basic open thyroid. I hope you enjoyed watching and thank you so much.