Surgical Safety Checklist, Surgical Blades, Energy Sources, Sutures and Needles, Foley’s Catheter, IV Cannulas😊

Surgical Safety Checklist

• Note: Time out is before skin Incision

Sign in (Before anesthesia induction)

• Confirm: Patient ID, site, procedure.

• Written consent.

• Surgical site marking.

• Inquire allergies.

• Confirm pulse oximeter function.

• Evaluate risk of blood loss.

Time out (Before skin incision)

• Verbal confirmation: Patient, site & procedure name.

• Surgeon confirms:
• Operative duration.
• Anticipated blood loss.

• Anaesthetist: Antibiotic prophylaxis (given within 60 minutes of procedure).

Sign out (Before patient leaves OR)

• Nurse confirms: Gauze + instrument count.

• Surgeon confirms: Specimen labelling.

• Anaesthetist confirms: Actual blood loss.

OT Zones

Zone 1: Protective zone:

• Change rooms,

• Trolley bay

• Transfer bay,

• Pre & post-op rooms,

• ICU/PACU.

Zone 2: Clean zone:

• Equipment store room,

• Pre OP & Recovery room

• Plaster room

• Staff lounge

• Maintenance workshop.

Zone 3: Sterile area/Aseptic zone:

• Operation

• Anasthesia room

Zone 4: Disposal area:

• Waste disposal area

OT Positions

• Lithotomy:



• Obstetric, gynaecological, urological procedures.
• Risk: Common peroneal nerve injury (if legs not properly supported).

• Lateral/Kidney position:



• Thoracotomy,
• Kidney surgeries (e.g. Nephrectomy).
• Risk: Brachial plexus injury due to hyperextension of arms.

• Sitting/Fowler's position:



• Posterior cranial fossa procedures.
• Advantage: Better exposure, bloodless field.
• Disadvantage: ↑ Risk of air embolism.

• Jack-knife:



• Not preferred (d/t positional asphyxia).

Boyce Position :

• AKA Chevalier Jackson/Barking dog/Sniffing morning air position.

• Flexion at cervical spine & extension at atlanto-occipital joint

• Used in MLS & direct laryngoscopy (Intubation).

NOTE:

• Rose position
• Boyce position + pillow placed below shoulders
• Extension at cervico-thoracic joint

Surgical Blades

• No. 11 (Pointed/stab blade):
• Incision and drainage
• Arteriotomy.

• No. 12 (Curved blade):
• Suture removal.

• No. 10, 15, 20, 21, 22, 23 (Blades with a belly):
• Making incisions
• 15 blade
• plastic surgery
• dermatosurgery
• ocularsurgery
• corn excision in foot/hand
• 20 blade
• Abdominal incisions

Blade Handling

• Blades passed in kidney tray.

• Mounted on BP handle.

• Incision made far to near.

Langer's Lines

 

• AKA relaxed tension lines.

• Appearance: Mostly straight, can be oblique, not curved.

• Nature: Lines of orientation of collagen muscle fibres.

• Constancy: Not constant, change with age.

• Clinical Relevance: 
• Surgery
• Important for surgical incisions
• Better healing
• Better scars
• Muscle action perpendicular to lines
• Forensic
• Stab wound parallel to Langer’s line:
• Decreased gaping.
• Stab wound perpendicular to Langer’s line:
• Increased gaping.

• Mnemonic: Langer's lines has "anger" (not constant, momentary).

Energy Sources

Monopolar Cautery:

• Flow: Tip → Body → Cautery pad → Machine.

• Uses: Cutting/coagulating.

• Cautery pad:
• Placed over well-vascularized area.
• Wide contact required.
• Small pad → Burns at attachment site.

• Disadvantages:
• Thermal damage to nearby nerves/vitals.
• Interference with cardiac conduction.

• Buttons:
• Yellow → Cut 
• Blue → Coagulate.

Bipolar Cautery:

• Advantage:
• Safe with pacemakers,
• used near vital structures/end arteries.

• Flow: Prong 1 → Body → Prong 2 (local circuit).

• No cautery pad required.

• Uses: Only coagulation.

• Used in: Thyroid, parotid, penile, CNS sx, ear lobule surgeries.

Modes of Currents (Electrosurgery)

• Cutting: 
• Low voltage, continuous current → Cuts tissue.

• Coagulation: 
• High voltage, alternating current → Stops bleeding.
• Cut needs current, Coag needs Voltage

• Other Modes:
• Blend mode, Fulguration mode.

Harmonic Scalpel

 

• Working principle:
• Ultrasonic coagulation without heat production.
• Uses oscillatory blade (20,000-50,000 Hz).

• Advantage:
• Precise cut, cuts through scar tissue, used close to vital structures.

Sutures

Skin Suturing

• Edge should be everted.
• (Bowel: Inverted)

• Needle entry: 90° with skin.

• Bite on each side: X.

• Distance b/w 2 sutures: 2X (X: depth of wound).

Types of Skin Sutures

Simple sutures:

• Fail to cause edge eversion.

Mattress suture: 

• Hemostatic, causes eversion of edges

• Better approximation

• (Vertical & Horizontal)

Subcuticular sutures:

• No needle marks on skin.

• Suture buried from inside.

• Cosmetically better.

• Suture material: 3-0/4-0 monocryl (Absorbable) on cutting needle.

Purse string sutures:

 

• Rectal prolapse surgery (Thiersch wiring).

• Cervical cerclage in cervical incompetence.

• Bury appendicular stump.

• Hydrocele → Processess vaginalis

• Herniotomy

Needle: Terms and Types

Swaged end:

• End of needle where suture material attached.

• Needle held at: 
• 1/3rd from swaged end and 2/3rd from pointed end.

Types of Needles

• Round body (RB) needle:
• Rounded cross-section; 
• atraumatic.
• Used for:
• Delicate structures (GIT, Bowel, Bladder, CBD, blood vessels).

• Cutting/Reverse cutting needle:
• Triangular cross-section.
• Used for:
• Tough structures (All S/C: Skin, Sheath, Fascia).

Numbering of Sutures

• No. 1 suture → Thickest.

• No. 11-0 → Finest

Types of Suture Materials

Absorbable Suture

• Dexon: Polyglycolic acid
• Maximum risk of infection
• Braided

• Polyglactin → PG → Victor (Vicryl) → PGs get bowel and bladder suture with braided → but high infection rate

• Polydioxanone → PD → Diploma → also get bowel and bladder suture → nut with monofilaments

• Poliglecaprone → prone people → HS → get only subcuticular suturing with monofilaments

Non-absorbable Sutures

Natural:

• More tissue reaction/inflammation.

• Silk:
• Skin (S-O/cutting),
• Fix drains (No. 1/cutting),
• Bowel anastomosis (3-0/RB).
• Braided
• Mnemonic: Silky () skin () and belly (bowel) kand drained (drain) ayipoi

Synthetic:

• Polyester:
• Tendon repair.

• Steel sutures:
• Sternotomy wound closure (Post CABG).

• Prolene
• Blue suture
• (Polypropylene monofilament):
• Rectus sheath closure (Jenkins theory → holds for 4x wound length).
• Vascular repair/anastomosis (RB needle: 4-0 Aorta, 4-0 Femoral, 6-0 Popliteal).
• Mesh (hernia repair).
• Diaphragm repair in trauma
• Mnemonic: Pro → used for Pro procedures → like etc rectus, vascular, mesh…

• Nylon - Polyamide/Ethilon:
• Monofilament.
• Uses: Skin, fixing drains, nerve & tendon repair, cataract
• Mnemonic: Night (Ny) il ethi (ethi) tendon repair () cheyyan

Suture Removal in Non-absorbable Sutures

Open Drains

 

• Corrugated rubber drain:
• Used in abscess cavities.
• Rarely used.
• Disadvantage: Pus drains out, soaks dressing.

• typically relies on gravity for drainage

Closed Drains

• Romovac suction drain:



• Uses negative pressure.
• Post-mastectomy, thyroidectomy, neck dissection.

• Mini-vac drain:



• Smaller Romovac version.

• Jackson Pratt drain:



• Uses negative pressure.
• Flat tubing and a bulb.

• Abdominal drain:



• Placed in abdomen, no negative pressure.

• Under water seal bag:



• Connected to chest tubes.
• Submerged tube end → Prevents air getting sucked in.

Surgical Knots

Square/Reef knot: 

• Secure knot, does not open.

• (2 throws f/b a single throw).

Granny's knot/Slip knot: 

• Not secure,

• opens up (avoided).

Surgeon's knot: 

• 2 throws f/b single throw.

Bowel Anastomosis & Staplers

Bowel Anastomosis

• Strongest layer: Submucosa

• Inverted edges suturing.

• 3 methods: All give similar results.
1. Single layer extramucosal
2. Two layer
1. Outer → non absorbable → seromuscular
2. Inner → absorbable → all layer
3. Staplers

Surgical Staplers

• Linear:





• Bowel anastomosis,
• Sleeve gastrectomy, 
• Zenker's diverticulum surgery.

• Circular:



• Hemorrhoidopexy,
• Low anterior resection (LAR) for rectal cancer.

IV Cannulas

Superficial thrombophlebitis

• M/C cannula complication:

• Presentation: 
• Cord-like tender swelling.
• Resolves in few weeks.

• Mx: Topical heparinoids (Thrombophobe).

Colour-Coding

• Orange is used in shock

• Violet: 26G
• At 26 yr old → Violent avum last

• Yellow: 24G (13 ml/min)
• At 24 yr old → Starts yelling

• Blue: 22G (30 ml/min)
• At 22 yr old → have baby → blue

• Pink: 20G (67 ml/min)
• At 20 yr → get a girl → pink

• Green: 18G (96 ml/min)
• At 18 → Green light for everything → and 100 Rs (96 with tax)

• White: 17G
• At 17 → starts figuring out → white

• Gray: 16G (240 ml/min)
• At 16 yr old → Grey area

• Orange: 14G (270 ml/min)
• We can give 1 pint fluid in 2 mins

Equipment for cannulation of neonates:

1. Non-sterile gloves

2. Tourniquet

3. Antiseptic wipes

4. 5 ml syringe

5. Sterile gauze

6. Cannula - appropriate size (24G size, yellow colour)

7. Saline

8. Adhesive plaster

Foley’s Catheter

French (Fr) Scale

• Relates to outer diameter.

3-Way Foley’s

• Has 3 channels.

• Used in clot retention.

• Used for irrigation following surgeries like TURP.