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Advanced surgical nursing

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Abstract

Successful theatre management is vital for the efficient and effective running of a surgical list in a busy veterinary practice/hospital. Theatre management is usually the responsibility of a veterinary nurse and can provide a defined career path for a qualified, dedicated and experienced nurse. This chapter cover the role of the theatre team, along with more specific duties of theatre nurses. Minor surgical procedures such as haemostasis, tissue handling and suturing are explored. The chapter also considers advanced surgeries such as: thoracic surgery, abdominal surgery, upper respiratory tract surgery, neurosurgery and orthopaedic surgeries.

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Figures

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8.1 A theatre team. Left to right: circulating nurse; scrubbed nurse; surgical assistant; primary surgeon; and anaesthetist. (© A Young)
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8.2 Holding a scalpel. The pencil grip allows more precise control of the blade and is most suitable for short, controlled incisions. The finger tip grip is recommended for longer incisions, as it maximizes the contact of the blade with the tissue. (© A Young)
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8.3 Monopolar diathermy handpiece and plate. (© A Young)
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8.4 A selection of scissors. Left to right: general purpose blunt/blunt; Mayo; Metzenbaum; suture/ligature-cutting scissors. (© A Young)
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8.5 A selection of thumb forceps. Left to right: rat-toothed; Adson; Gene’s; DeBakey. (© A Young)
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8.6 Mayo–Hagar needle-holders, showing the thumb and third finger grip. (© A Young)
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8.7 Needle in position in needle-holders. The needle is held perpendicular and is grasped two-thirds of the way from the point. (© A Young)
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8.10 Simple interrupted skin sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and are printed with her permission.
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8.11 Horizontal mattress skin sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and are printed with her permission.
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8.12 Ford interlocking suture. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and are printed with her permission.
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8.13 Continuous intradermal or subcuticular suture. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and are printed with her permission.
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8.15 A selection of instruments for cardiac surgery. (© A Young)
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8.17 A right lateral thoracotomy performed for removal of a tumour affecting the right middle lung lobe in a dog. The ribs are being held apart with Finochietto retractors. (© M Tivers)
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8.18 Thoracostomy tubes and connectors: (1) silicone tube; (2) polyvinylchloride drain with trocar; (3) plastic gate clamp; (4) metal gate clamp; (5) Christmas tree connector; (6) needle-free drain connector. (© A Young)
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8.19 Thoraseal unit for continuous drainage. The drain attaches directly to the thoracostomy tube and the gate clamp remains open. (Top photograph: © M Tivers; bottom photograph: © A Young)
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8.21 Thoracostomy tube following lateral thoracotomy. Note the dressing covering the surgical incision to the right of the picture. The thoracostomy tube is being drained in an aseptic manner using a three-way tap attached to the tube. (© M Tivers)
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8.22 Removal of a lung lobe affected by a tumour, using a TA30 stapler. The lung lobe is held in the surgeon’s hand whilst the stapler is placed across the pedicle of the lung. (© M Tivers)
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8.23 Diaphragmatic rupture. The cat’s diaphragm is at the top of the picture and the large defect is being held up by the veterinary surgeon’s fingers. The liver and other abdominal contents have been reduced prior to repair of the diaphragm. (© M Tivers)
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8.24 Cat with diaphragmatic rupture, with head and thorax elevated whilst being clipped and prepared for surgery. (© M Tivers)
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8.25 Selection of abdominal retractors. Left to right: Balfour; Gossett; Possey. (© A Young)
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8.26 Selection of surgical staplers with single-use cartridges: (1) Surgiclip; (2) ligate and divide stapler (LDS); (3) gastrointestinal anastomosis (GIA) stapler; (4) thoracoabdominal (TA) stapler. (© A Young)
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8.27 An exploratory laparotomy for splenic torsion. The congested and enlarged spleen is held in the veterinary surgeon’s hands. The splenic vascular pedicle can be seen to be twisted (arrowed). (© M Tivers)
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8.28 Portovenography. Loop of intestine which has been exteriorised and a catheter has been placed into a mesenteric vein. This allows contrast medium to be injected and also allows the measurement of portal blood pressure. Ventrodorsal portovenogram images taken via fluoroscopy before and after ligation of an extrahepatic portosystemic shunt. The images have been digitally subtracted to remove the ribs and other structures to allow the vessels to be seen clearly. (b) The initial portovenogram shows the contrast medium flowing through the shunt (S) and into the vena cava (VC). The contrast medium does not flow down the portal vein (PV) to the liver. (c) The second portovenogram (after the shunt has been ligated) shows the contrast medium flowing down the portal vein and into the liver. Note the branching of the blood vessels within the liver, which indicates that good perfusion of the liver is present in this case. (© M Tivers)
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8.29 Exploratory laparotomy in a dog with a linear foreign body. Note how the intestine appears corrugated where it has become ‘bunched up’ along the foreign body. The foreign body was successfully removed and was an elastic toy! (© M Tivers)
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8.30 The main surgical instruments kit is shown in the background, with a separate gastrointestinal kit in the foreground ready for ‘dirty’ procedures. (© A Young)
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8.31 Dog undergoing open peritoneal drainage for management of septic bile peritonitis. Abdominal incision. The central part of the incision has been left open with loose non-absorbable sutures, whilst the cranial and caudal parts of the incision have been closed normally. Following placement of an absorbent abdominal dressing. Patient in the critical care unit. (© M Tivers)
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8.32 Tracheostomy tubes. The bottom, cuffed, tube would be used when anaesthetizing or ventilating patients with a tracheostomy tube in place. (© A Young)
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8.33 Tracheostomy tube placement (see text for details). (© SJ Baines)
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8.34 The spinal cord during a hemilaminectomy; note the compression of the cord by disc material. The cord after decompression. (© A Young)
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8.35 A Dachshund following spinal surgery. A sling is used to aid walking. (© M Tivers)
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8.36 Ventrodorsal radiograph of the pelvis of a dog with bilateral cemented total hip replacements. (© AP Moores)
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8.37 A selection of surgical instruments for total hip replacement. (© A Young)
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8.38 Postoperative radiograph following TPLO. The top of the tibia has been cut and rotated to level the tibial plateau. The osteotomy has been stabilized with a TPLO plate. The skin has been closed with staples. (© M Tivers)
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8.39 Craniocaudal (left) and lateral (right) views of the radius and ulna, showing a fracture of the distal diaphysis of the radius of a dog. Craniocaudal (left) and lateral (right) views postoperatively, showing a 3.5 mm modified dynamic compression plate applied to the cranial aspect of the radius. (© M Tivers)
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8.40 Dynamic compression plate. (© A Young)
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8.41 Left to right, in order of use when placing a screw: drill bit and drill guide; depth gauge; tap and tap sleeve; screw forceps; screwdriver with sleeve. (© A Young)
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8.42 Cat with a fracture of the right femur following a road traffic accident. The femur has been repaired with an external skeletal fixator and intramedullary pin. The clamps have been covered with pink bandaging material. (© M Tivers)
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8.43 Cat with multiple mandibular fractures repaired using an external fixator constructed with epoxy putty. (© M Tivers)

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