Setup for an Exploratory Laparotomy with Possible Splenectomy (South College, Knoxville, TN)

CHAPTER 1

I'm Chris Blevins, and I am the senior department chair for the surgical technology programs at South College, and I am so excited you're watching. Today, I am gonna talk about an exploratory laparotomy and a splenectomy. And this is an important combination of procedures because if you're doing this, you're probably in a trauma. So knowing what you need to do next and doing it quickly is pretty important.

CHAPTER 2

So let's get started. All right, so we have our back table, our Mayo stand, ring stand, and our instruments, right? So first thing we need to do is double drape our back table, which has already been done, sweet. All right, so look, working end, middle for our instrumentation, non-working end, this is gonna be the end closest to my patient, that's where all my supplies are gonna go. My instruments go in the middle and then any of my extras like gowns, and towels, and things, that's gonna go at the end farthest away from my patient. So let's get all of our gowns. This is a big case. You're probably gonna have a lot of extra hands, so you wanna make sure that you have your gloves for your surgeons and your assistants ready to go. Go ahead and separate 'em out, that way you don't have to fiddle with them. Double glove, super important. We're gonna have our blue towels, we are gonna drape out our patient. So I'm gonna go ahead and set my blue towels right here. We'll show our four towels that we're gonna square off with later. That's gonna go here. And our laparotomy drape, very big, important. So when we're doing exploratory laparotomy, that means we're gonna make an anterior abdominal incision. Since the splenectomy is involved with it too, we're not making a midline incision that's gonna go ventral, we're actually gonna make a transverse incision because the spleen sits on top of your left kidney, so we need more lateral access, so you want to think about it that way. And then, of course, our fish, that is for closure. We're just gonna set it aside. This is your bag for your trash. I like to put it on my mayo stand, so we'll deal with that later. All this other stuff, magnet pad, that's gonna go on your mayo as well. This is getting handed off 'cause we don't need it.

CHAPTER 3

Next, I'm gonna get my instruments out, so they're ready to go in case we need to count. It's a trauma, we're gonna go fast. Your person that's helping you needs to check that bottom filter and make sure that there aren't any holes or any condensation. So that's very important, even though it's a trauma. So I'm gonna get my ring and get my strand ready to go, so I'm gonna form my towel. And in a trauma, we don't really care if it's pretty, just get it done. There's that. I'm gonna get my stringer. In your stringer, you want your clamps facing your working end. So get that and your stringer goes that way with the curves facing your working end. Once we've done that, I wanna organize all of my retractors, so like with like. This is a Balfour self-retaining retractor, our Richardson, our Deaver. We're gonna have a malleable. Sometimes that's used for closure if you don't have a fish. Bladder blade because the bladder and the bowel are narcissists, they're gonna get in your way. We've gotta protect them so that this trauma doesn't get any more complicated. There's our sweetheart retractor, and our two Army-Navies. And then we'll talk about suction here in a minute. So I get my suction out of the way. Here's all my retractors. I'm gonna find all my forceps, put those here. All my knife handles are gonna go towards my working end. These are towel clips. I'm gonna go ahead and put those here just to get them out of the way. And more clamps, all right. So, sweetheart's going there. Deaver... I go biggest to smallest because the deeper you go in your patient, the bigger your retractor needs to be. And then remember, like with like, right? So my Army-Navies are here, my S-retractors, you're really not gonna use those, but you need to be able to see them so that you and your circulator can both count at the same time, so put those there. And then here's another clamp. These are vascular clamps. We are gonna use those, but we need to keep 'em on our back table until we've counted. And I'll talk to you about what those are here in a minute. And then, of course, our little Weitlaner. I wish we were gonna use that, we're not. So we're gonna put that there for counting. All right, so I've got it organized. I'm gonna take a blue towel because we always wanna protect anything that we have sharp. So take your blue towel, put it here on your working end, and that's where all of our knife handles are gonna go. We'll load those here in a minute. And then let's organize our forceps. So I always put our atraumatic forceps closest to my working end, my traumatic forceps, those with teeth, go away from my working end, that way, just in case you accidentally grab one in a hurry, you're gonna grab something that's gonna protect the bowel, right? Making a hole in a bowel is a bad day. So here's rat-tooth, here's Russians, those aren't really considered traumatic. Here's a big ugly, a Ferris-Smith, definitely traumatic. We have DeBakeys, we have smooth forceps. Here's another forceps with teeth, and then we have Adsons with teeth, right? Typically, you're gonna push those up in pairs. All right, lastly, here's that malleable. I'm gonna put the malleable right here on the side. And then here's the rest of our clamps and our stringer. Don't take your stuff off your stringer until you've counted, that way it's easier to count. So there we are, I'm ready for my instrument count if my circulator is ready for me.

CHAPTER 4

So let's go ahead and do our supplies and get all of those situated. So lots of supplies, but really, what do you need? You can't operate on something if you don't see it, right? So we're gonna have to really have a lot of laps. So there's one pair of laps. Go ahead and just start with two sets, that's a total of 10. Our Ray-Tecs, we're really only gonna use those to create a sponge stick, and I'll show you how to do that in a minute. Pitchers are really important because lots of irrigation, as I said, so you're gonna have that warm irrigation that we're gonna constantly flood the abdomen with. And then, of course, our kidney basin, that's really like our trash can. And then we have lots and lots of goodies, all right? So our stapler is gonna be used for skin closure. We have things for hemostasis. Our drain. You're gonna have Surgicel or Avitene, maybe surgical foam, anything, because if you're in here, the spleen is bleeding, the spleen's super vascular, and so you need to be able to control that bleeding so that you can see it, so that we can then proceed to remove the spleen. So be able to have all of those things to control bleeding, and I usually put it in my kidney basin so that way it stays dry, and just in case we get a little splashy. I'm not gonna use that. And then we have all of our different suture, and I'll kind of walk through that. So you're definitely gonna have a lot of ties, but our suture, I'm gonna go ahead and organize it in my kidney basin while we have it. So pop-offs, you're gonna need for our dissection down, and we have our 3-0 suture. Vicryl is usually used for our peritoneal stitching. You're gonna have more 3-0. I've got my fascial stitches, which is usually a really big one on a TPS. You can use PDS, you can use Vicryl, it's whatever the surgeon wants. Check out that preference card, it's going to be your best friend. Sometimes we have Kittners. Kittners are loaded at the tip of a Pean or a Kelly, and that's for blunt dissection, especially if they're adhesions that are maybe part of the trauma. If we do that, we're gonna take the sticky off and we're gonna put it right here at the top of our needle box, and then get rid of this trash. So here's my needle box. I'm gonna put it right next to where my sharps are. We don't need an Asepto, and we don't need our ruler. The more stuff you can get out that you don't have to count the better, 'cause remember, this is a trauma, you gotta go fast. So, get rid of that. Our patients are probably gonna be a repeat offender, so we are gonna put a drain in. You may have to put a wound vac in at the end of this case. So be prepared for either, and then we're not gonna do a running closure for the skin. You're probably just gonna staple them closed. Because once we've stabilized that patient, remove that spleen, we're probably gonna get them to ICU and then bring 'em back. So staples are a heck of a lot easier to remove than suture is. So have that drain stitch ready to go. Here's my grenade. And then other countable items. So when we remove the spleen, the last thing that we do before we close those vessels off is remove the hilum. And a lot of surgeons either use a vascular clamp to do that, and then a stick tie or they use a GIA stapler. So look on your preference card. If your surgeon's gonna staple it, you wanna make sure you have plenty of reloads, and those always go here on our working end, I usually just put it here on my needle box. Also, when we're doing an exploratory laparotomy and a splenectomy, or one or the other, you're gonna be using either a Ligaclip or Hemoclips to really close those vessels that you're kind of ligating as you go down. So remember, the process is clamp, clamp, cut, tie, tie. Just remember that in your sleep. So you wanna make sure that if you don't have a disposable Hemoclip, you wanna make sure that you have these boats to go with your clip appliers, and these are countable. So make sure that you keep those in the same working end as well. And I'm gonna put them next to my Kittners. So, of course, your skin marker. It's a trauma, you're probably not gonna mark your incision. Here's your medicine cups, your light handles, a syringe for local, and then we have big vessels like your splenic artery, your splenic vein, and then, of course, if there is any other trauma as you do the exploratory laparotomy and run the bowel, and see if there are any other lacerations. So it's a good idea to go ahead and have some vessel loops or maybe umbilical tape. And anytime we give these to the surgeon, we want them moistened. So a good rule of thumb is to extend them out and then go ahead and put them in your basin where your saline is gonna go, that way they're easily countable and they're easily handable, and they're already moistened, so you removed a step. So that just leaves in my ring basin, you have your suction tubing, you have your light handle, and, of course, you have your Bovie. And here's the kicker, as we go down, remember, the spleen is very lateral and it's towards the back posterior portion of your patient. So to begin with, in the exploratory laparotomy part, you are gonna have a Bovie, but you may have to then switch as we get deeper to the extended Bovie tip. So you wanna be able to have both. So remember, we count the Bovie, but then also you need to have this to be able to count. Don't forget to take off any protective coverings from anything on your field. These are not X-ray detectable, they don't need to go anywhere near your Mayo or your patient. So I'm gonna put that over here in between my sharps, and this little protector, guess what? It's getting tossed off. All right, so I'm ready to count. Everything else I can do either as we're making that first incision after our timeout or as I'm, you know, in between gowning and gloving, everybody and their dog that's coming into the case. So let's go ahead and get started with our count.

CHAPTER 5

All right, so we're ready to count, right? First thing we're gonna do is our softs and we're gonna get our sponges started. So one, two, three, four, five. One, two, three, four, five. I'm gonna go ahead and take these and put them on my Mayo 'cause time is of the essence. Then one, two, three, four, five. One, two, three, four, and five. And these are gonna go back on my back table. Ray-Tecs. One, two, three, four, five, six, seven, eight, nine, 10. One, two, three, four, five, six, seven, eight, nine, and 10. And these are staying on my back table as well. And then don't use your bare hand to ever count sharps, period. All right, so suture. I have one. Always show the needle. Two. Three, four, five. And pop-off, six, seven, eight, nine, 10, 11, 12, 13. And then these are ties. You don't have a needle, so we're not gonna count them, right? I have boats, I have one, two. Kittners, one, two, three, four, five For blades, I have one, two, three. For loads, I have one, two. Bovie tips, I have one, two. And then let's see, marker, I have one, two, because we will count the tip, as well as the handle. And let's see, then we're gonna count my vessel loops, I have one, two, three, and four. See how easy it is when you already have it laid out? And then we'll start with our instrumentation, and we'll go from there. Okay, we're ready, start counting our stringer. So straight mosquito, one, two. Curved mosquito, one, two. Straight Crile, one, two, three, four. Curved Crile, one, two, three, four. Straight Kelly, one. Curved Kelly one, two, three, four, five, six. Allis, one, two, three, four. Kocher, one, two. Babcock, one, two, three, four. Tonsil, one, two. Right-angle, one. Sponge stick, one, two. One Glassman, curved. This is the Mixter gall duct, one. This is a DeBakey vascular, one, two, and we have a third that was pulled. We have needle drivers, one, two, three, four. I have a Metz, one. Curved Mayo, one. Straight Mayo, one. And then Ligaclip applier, one, two. And then I have a Satinsky vascular clamp and a Cooley vascular clamp. And that's our stringer, plus the extra vasculars that we pulled. So we'll go to forceps. I have one Russian, one DeBakey forcep, one smooth forcep, one Adson forcep, one rat-tooth. I have one Bonney, and one Ferris-Smith. So that makes one, two, three, four, five, six, seven forceps total. And then we'll move to retractors. I have one, two, S-retractors. One, two, Army-Navies. I have one Weitlaner retractor. I have one Richardson retractor. One Deaver retractor. One sweetheart retractor. One malleable. And then let me get these guys outta there. Towel clips, I have one, two, three, four, and five total. And we will just leave those right there. Knife handles, I have one, two, and three. And then we'll go to suction. I have one, two. We count that tip 'cause it can come off. Yankauer, and then our abdominal Poole section with guard is important 'cause this is a one, two as well. You'll need to go back and forth with those. Then I have one bladder blade, and this is our Balfour retractor, and there are many parts to this because everything can come apart. So we count one, two. We count three for the bar, four, 'cause this comes off, five, six, for the nuts, seven, for the part that connects it, and then eight, for the loop that tightens it. Lots to count and you gotta go fast. So don't forget anything that's disposable, but we still wanna count 'cause it goes in the patient, right? So we need to count our fish. And then, of course, double check with your circulator. Take another look around, you may have missed something, but that's why we have two sets of eyes. Okay, so once you've gotten that initial count over, that's great, go ahead and do your stringer. Undo that, and then we're gonna hide it and get that out of the way.

CHAPTER 6

And the first thing you wanna do before you go continue on is just get your scalpel ready to go. Just in case you've gotta go fast before you can get everything else organized. So the first blade we're gonna get ready is your skin knife. Don't load a blade with your fingers. So we're gonna get that skin knife ready to go, and we're gonna go ahead and set it on our Mayo stand. I like to set the blade closest to the lip of the Mayo, that way you're protected in case you reach for it and you don't hurt yourself. So that's ready to go, we can get everything else ready just in case the surgeon needs to be a little autonomous, all right?

CHAPTER 7

So, in your ring basin you're gonna have your suction tubing, you're gonna have your Bovie, we're gonna go ahead and start with a Yankauer, but know that once you get past the fascia into the peritoneum, you may have a lot of bleeding, so you may have to go ahead and switch to your Poole suction. So get our Yankauer tip ready to go. Your light handle is in there, and then we're gonna have our laparotomy drape, and then we're gonna be ready to towel off. So sticky drapes are great 'cause they're really quick. So we like to do three up, which means that the fold that comes to you is facing you. And then the last one, the fold down, 'cause that's gonna be the way that you hand it to the surgeon, right? So three, up, one, down. And I just kind of fold that so we don't contaminate. And that's gonna go there. And then we're gonna protect it by putting it over here next to our Mayo stand. All right, now our drapes are ready to go. I have my magnet board. If you're lucky enough to have one of these, it's gonna be great 'cause it'll catch anything that they're throwing off of the patient. So go ahead and put that down there.

CHAPTER 8

This fish is for closing. So we're gonna keep it on our non-working end down here now, that we've made some room. This stapler, like I said, some people use a stick tie to dissect the hilum from the patient, some people use a stapler. Now, that we've made room, know that it's here, we're gonna go ahead and just put it here just to keep it out of the way. Here's your trash bag. It's not necessary, but hey, if you have time, use it. We're gonna stick that there. Remember, you already put that scalpel up here, so be careful. So we have all of our sponges. Another tip and trick is go ahead and get some of those sponges moistened, because we may have to pack the bowel or push the bladder aside as we do the exploratory laparotomy to expose the spleen, and we wanna do that with moistened sponges. So you might go ahead and take some of those and put them into your saline just to be safe. Lastly, remember the first step is our exploratory laparotomy, so you gotta get down there. You also need, after we've done the skin incision, you're going to take that skin knife, put it back on your back table, but you do need a deep knife for other things that are going on in the procedure. So go ahead and load that second 10 blade, and have that on maybe a longer knife handle, ready to go. I also pulled, as you may have noticed, a #11 blade, and that's for that drain. I told you earlier, once you've taken the spleen out, there may be a lot of peripheral bleeding afterwards, and so you're gonna wanna prepare that. So you don't have to load it now, but you may need to load an 11 blade in order to make the drain incision later. So I'm gonna go ahead and load that other #10. All right. Another thing you can do is take one of the ring forceps and we're gonna make a sponge stick out of it. This just helps with any blunt dissection that you're gonna have to do. So I make a little diaper if you will, shove that in there. And then I like to keep my sponge sticks here, that way it's out of the way, but it's easy for me to get whenever I'm doing the incision. So the first layers of the incision, we don't need a deep retractor, although we might need one later. So you can pull up something small like your Army-Navies, but remember, you're not gonna need it for long. So lots of clamps. Remember, clamp, clamp, cut, tie, tie, is gonna be the name of the game. So you want to bring up your tonsils and a right-angle. Anything that goes onto your Mayo from your back table needs to be closed at least one click, 'cause we never have an open clamp or any instrument that we give our surgeon. And then, of course, lots of hemostats. To begin, I'm just gonna put two up at a time. The whole point of an exploratory laparotomy is you're exploring what in the world's going on. So you don't really know what to be prepared for, but as long as you know what you have on your back table and what's available, then that's kind of the most important. I have an acronym I always use and teach my students. It's called P-R-I-C-K-S, right? So pick up, retractor, ink, clamp, knife, suction. So as long as you remember those things and you have that up here, then you're good to go. So I've mentioned several times, ties, you wanna keep those organized because here you're gonna have two different kinds of ties. And here's another little tip. Take your blue towel, it already comes folded in different ways, right? So in one fold, I'm just gonna open it one direction, and I'm gonna take the 2-0 ties that we're gonna use to close off any of those vessels. And I'm gonna lay those out neatly into that fold in my blue towel. And I'm gonna go ahead and close it. Then I'm gonna flip that open to another fold, and I'm gonna take maybe my 0 ties. You got have 2-0, 3-0, just give them options. And we're gonna put those ties in this fold. Don't worry if they're not neat, it's okay, they just need to not get tangled. Now, you can take that and you can always take your skin marker and write on your blue towel. Like this is 0 or this is 2-0. And then you take that, and if you take it and you put it right here next to your end, right, where you're gonna stand, right, which is the post, then you will always be able to load your tonsils quickly with one of those. And when we load it, remember, it's an extension of the instrument, right? So you can go ahead and load an 0 tie, you can load a 2-0, and you're ready to go the second that they need it. And now, whenever you have to go and get more, you just unfold that particular fold, add the extra ties in there, and refold it again. But it's a great way to have easy access to your ties, be able to load 'em on your Mayo, and keep going with the case. Same thing with your clip appliers. You wanna go ahead and have your clip applier ready to go. So, you're gonna take the clip applier that matches the boat, and you wanna go ahead and at least load one. But remember, it's clamp, clamp, cut, tie, tie. So this would be the same thing as tying, so you wanna always have two clip appliers ready to go because we use them in tandem. And so, you can either put them here, now, that we know we're not gonna use our towel clips and they have already been counted. You can put your clips here, your sponge sticks there. It's important to be organized this whole time, that way at least you know where everything is and you can grab it quickly.

CHAPTER 9

So as we're going through, I don't have pairs of everything, but remember, we do everything in pairs. So when you're putting anything up on your Mayo, you know, put two atraumatic forceps up there, put two traumatic forceps up there. If you have to grab something off of your back table because they've asked for it and you didn't have it up there, go ahead and grab a second one, because there's always gonna be another one asked for it. These are just little tips that are gonna help you run through the case successfully. Fluid management - there's gonna be a lot of bleeding and you're going to have to irrigate a lot. So keep track of your pitcher. You see that we have two buckets, right? As the case goes on, you're gonna put your vessel loops, or your umbilical tape in your blue one, but we're gonna keep this full of warm irrigation. In these cases, we need to keep track of blood loss. So every time you fill this up, you're gonna need to keep track of how much was put in the patient so that you can communicate this to your circulator. So that good communication with your circulator is really important. If they are giving you other medications onto your back table, make sure that you are labeling them appropriately, both in your syringe, and your medicine cup, and in your pitcher. That's really, really important, 'cause a lot of our medications are all clear, they look exactly the same. So your stick ties, anytime that we are ligating, you wanna make sure that you not only just load one, but that you are ready to go with the next one. So, bleeding management is really important in these cases. Anytime we're gonna have a suture loaded, anytime you have one ready to go, you wanna make sure that when you hand it off, that you go ahead and load the next one. That's why you have so many needle drivers in a major set. So, I like to keep my pop-offs, once we've gotten into the abdomen, into the peritoneal cavity, I like to have my pop-offs on my Mayo stand up there the whole time. But if you do, then a good tip is to break your needle board in two, and to actually have the magnet up on the Mayo stand with you, because you're still responsible for keeping track of everything that's in and out of that patient. And so, just in case you don't have a free arm to get back to your back table to load those used needles, you at least can get them safe and sound, away from your patient, onto the magnet board, so that you don't have to worry about it from then on. And, of course, get that 11 blade off of there first.

CHAPTER 10

So, those are little tips as you go, but remember, slow down, it's a trauma, but you can't help them if you don't remain calm the entire time, and then stay organized, always. Keep your Mayo organized, manage your sharps, protect yourself, and then communicate really well with your circulator, because in an exploratory laparotomy, with a splenectomy or without one, anything can change in the blink of an eye and you need to be ready to pivot. So the more organized you are, and the more ready you can be to accept other instruments or other team members, the better you're gonna be and the better your patient's gonna be taken care of.