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4
 Contents

Preface

Acknowledgments

Introduction

1. Medical Terminology
Answers and Explanations

2. Microbiology
Questions
Answers and Explanations

3. Pharmacology and Anesthesia

Questions
Answers and Explanations

4. Blood Values
Questions
Answers and Explanations

5. Aseptic Technique
Questions
Answers and Explanations

6. Sterilization and Disinfection

Questions
Answers and Explanations

7. Operating Room Environment

Questions
Answers and Explanations

8. Transportation and Positioning

Questions

5
 Answers and Explanations

9. Counts
Questions
Answers and Explanations

10. Specimens
Questions
Answers and Explanations

11. Medical, Ethical, and Legal Responsibilities

Questions
Answers and Explanations

12. Diagnostic Procedures

Questions
Answers and Explanations

13. Consents
Questions
Answers and Explanations

14. Skin Preparation and Draping

Questions
Answers and Explanations

15. Instruments
Questions
Answers and Explanations

16. Sutures, Stapling Devices, and Drains

Questions
Answers and Explanations

17. Wound Healing and Dressings

Questions
Answers and Explanations

18. General Surgery

Questions
Answers and Explanations

19. Obstetrics and Gynecology

6
 Questions
Answers and Explanations

20. Ophthalmology
Questions
Answers and Explanations

21. Otorhinolaryngology
Questions
Answers and Explanations

22. Plastic and Reconstructive Surgery

Questions
Answers and Explanations

23. Genitourinary
Questions
Answers and Explanations

24. Thoracic
Questions
Answers and Explanations

25. Cardiac
Questions
Answers and Explanations

26. Vascular
Questions
Answers and Explanations

27. Neurosurgery
Questions
Answers and Explanations

28. Orthopedics
Questions
Answers and Explanations

29. Pediatrics
Questions
Answers and Explanations

7
30. Biomedical Science (Electricity, Hemostasis, Lasers, and Computers)
Questions
Answers and Explanations

31. Occupational Hazards/Fire Safety

Questions
Answers and Explanations

32. Endoscopy, Minimally Invasive Surgery, and Robotics

Questions
Answers and Explanations

Bibliography

Index

8
 Preface

Lange Q&A: Surgical Technology Examination, Seventh Edition, has been designed to assist surgical technicians
planning to take the National Certification Examination for Surgical Technologists. Although unable to
guarantee a perfect score, a study guide can provide a good deal of assistance in test preparation by enabling
the student to review relevant material while becoming familiar with the type of questions that will be
encountered on the examination.
The ever-growing body of knowledge necessary to prepare the surgical technologist for a professional role
in the operating room requires that competency be measured by an examination that tests both constant and
technologically up-to-date information. With this in mind, the authors have prepared a seventh edition of the
review book that has been extensively revised and updated to include those advances in technology that have
emerged since the previous edition.
The book contains over 1,900 questions that closely correlate in percentage the amount prescribed in the
Study Guide for Certification provided by the Liaison Council of the Association of Surgical Technologists.
The text is divided into 32 chapters. Following each chapter are questions. Each question has one answer and
a full-length explanation, a difficulty in a single area indicates a need for individual study emphasis.

9
 Acknowledgments

We would like to give special thanks to Mark Sherman and John Chmielewski for giving us their
overwhelming support throughout the process of writing this review book. We also would like to thank all
students past, present, and future for giving us the inspiration to write this review book.

10
 Introduction

ORGANIZATION OF THE BOOK

The book is organized into 32 chapters covering the major topic areas found on the Certifying Examination
for Surgical Technologists. Each chapter is designed to facilitate your review of the major content areas of
surgical technology. Each chapter ends with detailed explanations of each question for reinforcement of
knowledge.

HOW TO ANSWER A QUESTION INTELLIGENTLY

Unlike many examinations, which are a composite of several multiple-choice questions, the National
Certification Examination for Surgical Technologists uses only one major type of question. Each question will
have one correct answer and the other options are incorrect. However, the remaining three choices may be
partially correct, but there can only be one best answer.
When the question reads “EXCEPT’’ it is to remind you that the correct answer will be the exception to
the statement in the question.

Sample Question 1
A left subcostal incision indicates surgery of the:

(A) gallbladder
(B) pancreas
(C) spleen
(D) common bile duct

This question could be answered from rote memory, placing the term “subcostal” with the anatomic structure
“spleen.” It is more likely that the student will conjure up a picture of the human abdomen and discount
gallbladder (choice A) and common bile duct (choice D) immediately because they are located on the right
side of the abdominal cavity. Thus, two choices are ruled out as possible answers, improving the odds of
selecting the correct answer from 25% to 50%. Although the tail of the pancreas reaches over to the left side of
the body and is adjacent to the spleen, spleen is clearly the best choice and the only correct answer.

Sample Question 2
An elderly female, sleeping soundly, arrives in the OR via stretcher with siderails in place and safety strap
intact. She is placed alone outside her assigned OR. The woman awakes, climbs off the stretcher, and, falling,

11
receives a deep scalp laceration. The circulating nurse:

(A) can be charged with abandonment

(B) can be charged with simple assault
(C) can be charged with battery
(D) cannot be charged because safety devices were in place

This question is more difficult. Although we clearly see choices B and C as incorrect because the nurse had no
physical part in the injury to the patient, the difficulty is now in choosing between the remaining answers.
Choice D may seem correct because the stem of the questions tells us that all safety devices were intact. It is
only with knowledge of the legal aspect of OR procedure that we know that the key word alone signifies
culpability on the part of the nurse. Standard OR procedures claim that one is guilty of abandonment if a
patient is left alone at any time when in the care of OR personnel and may be charged as such in a court of
law.

Table 1. Strategies for Answering Questionsa

1. Remember that only one choice can be the correct answer.
2. Read the question carefully to be sure that you understand what is being asked.
3. Quickly read each choice for familiarity. (This important step is often not done by test takers.)
4. Go back and consider each choice individually.
5. If a choice is partially correct, tentatively consider it to be incorrect. (This step will help you lessen your
choices and increase your odds of choosing the correct choice/answer.)
6. Consider the remaining choices, and select the one you think is the answer. At this point, you may want to
quickly scan the stem to be sure you understand the question and your answer.
7. Select the appropriate answer. Even if you do not know the answer, you should at least guess—you are
scored on the number of correct answers, so do not leave any blanks.
aNote that steps 2 through 7 should take an average of 45–55 seconds total. The actual examination is timed
for an average of 45–55 seconds per question.

HOW TO USE THE BOOK

Read the chapter review followed by answering the questions at the end of the chapter. Continual notation in
this book will provide you with a quick review at the end of the chapter. This will help you determine those
areas that require the most emphasis for study and those areas that require additional review. Most of the
references are texts that are readily available at your nearest library, or that you may already own.
The official source of applications for and information about the surgical technology examination can be
obtained from The National Board of Surgical Technology and Surgical Assisting (http://nbstsa.org).

12
13
 ___________________ CHAPTER 1 ___________________

Medical Terminology

• This is the language spoken by health professionals in hospitals, surgicenters, clinics, and physicians’
offices.
• You must be able to identify the four basic word parts, construct medical terms by using the word parts
and use the correct pronunciation.
• The four word parts include: root words, prefixes, suffixes, and combining words.
Root Rword—primary meaning
Prefix—placed before the root word
Suffix—placed after the root word
Combining forms—usually an O but can be an I or E
• Example #1: Endocarditis
endo—prefix—meaning within
card—root word—pertaining to the heart
itis—suffix—meaning inflammation of
• Example #2: Osteoarthritis
oste—root—pertaining to bone
o—combining vowel
arthr—root—pertaining to a joint
itis—suffix—meaning inflammation of

14
15
16
17
18
Answers and Explanations

19
20
21
22
 ___________________ CHAPTER 2 ___________________

Microbiology

• ASEPSIS—absence of disease causing micro-organisms

• STERILE—free of all living microorganisms including spores
• SURGICALLY CLEAN—mechanically disinfected but not sterile
• AERATION—this is the method by which ethylene oxide (a type of sterilization process) is removed
from the ETO-sterilized items
• AEROBES—microbes that cannot live and reproduce without oxygen
• FACULTATIVE ANAEROBES—can live in both environments
• ANAEROBES—microbes living in the presence of oxygen
• FOMITE—inanimate object that contains microorganisms
• CELLS—smallest unit of living things
MITOCHONDRIA—they are the power house of the cell and provide energy
FLAGELLA—provides locomotion to the cell
CELL WALL—protects the cell
CYTOPLASMIC MEMBRANE—semipermeable membrane within the cell
• BACTERIA—all living cells are classified into two groups:
PROKARYOTES—less complex organisms. Single circular chromosome, without a nuclear membrane
or membrane-bound organelles
EUKARYOTES—complex cellular structure, they include fungi, algae, plant and animal cells. HAS A
NUCLEUS
• Bacteria divide by BINARY FISSION—this is the asexual reproduction of a cell by division into two
identical daughter cells
• Bacteria are shaped: rod shaped/spherical shaped/spiral shaped
• GRAM-POSITIVE—purple
• GRAM-NEGATIVE—red
• BACTERICIDE—kills gram-positive and gram-negative bacteria
• BACTERIOSTATIC—inhibits (to prevent something from developing) the growth of bacteria
• BIOBURDEN—the amount of microorganisms on an item before sterilization
• BIOLOGICAL INDICATOR—a sterilization monitoring system used to test the effectiveness of the
sterilization process used
GEOBACILLUS STEAROTHERMOPHILUS—is the microbes used in steam sterilization

23
 BACILLUS ATROPHIES/GEOBACILLUS SUBTILIS—are the microbes used for ETO
sterilization
• CONTAMINATION—presence of pathogenic microorganisms (disease-causing microorganisms) on
animate (living being) and inanimate (nonliving) objects
• DECONTAMINATION—process by which chemical or physical agents are used to clean inanimate
objects, NONCRITICAL surfaces
• SSI—SURGICAL SITE INFECTION
• DEEP INCISIONAL SSI—an infection involving deep soft tissue, fascia DISINFECTION—not used
on living tissue
• ANTISEPTIC—used on living tissue
• FUNGICIDE—kills fungi
• IMMUNITY—resistant to infection
NATURALLY ACQUIRED ACTIVE IMMUNITY—acquired when you get a disease and acquire
antibodies
ARTIFICIALLY ACQUIRED ACTIVE IMMUNITY—vaccination
NATURALLY ACQUIRED PASSIVE IMMUNITY—antibodies from mother to child through the
placenta
ARTIFICIALLY ACQUIRED PASSIVE IMMUNITY—a short-term immunization by the
injection of antibodies, such as gamma globulin, that are not produced by the recipient’s cells
• INFECTION—invasion and multiplication of microorganisms in body tissues, causing cellular damage.
• SKIN—it is the first line of defense against bacteria
• NOSOCOMIAL INFECTION—an infection that was acquired in the hospital
• PASTEURIZATION—this is not a method of sterilization but a heating process of destroying
pathogenic microorganisms such as in milk or wine
• PARASITES—microorganisms that reside on or within living organisms. Some are OBLIGATORY
(means they depend on living tissue) and others are FACULTATIVE (meaning they can live on dead
tissue)
• PATHOGEN—any disease-producing micro-organism
• RESIDENT MICROORGANISMS—these are microorganisms that live deep in the epidermis (outer
most layer of skin), they live in the folds and crevices of the skin
• TRANSIENT MICROORGANISMS—these are microorganisms that live on the surface of the
epidermis, they have a very short life span and can be removed with a good hand scrub
• VIRUCIDE—kills viruses
• MICROORGANISMS:
STAPHYLOCOCCUS AUREUS—commonly found in RESPIRATORY PASSAGES
ENTEROCOCCI—found in the normal flora of the GI tract. These organisms are associated with
surgical site infections (SSIs)
STREPTOCOCCI—found in the GI tracts, upper respiratory tracts, and genitourinary tracts.

24
 HELMINTHS—parasitic worms (round worms, tape worms). This is acquired by ingestion of
contaminated soil with fecal matter
RICKETTSIAE—they are parasites transmitted by insects
CLOSTRIDIA—produces virulent toxins
CLOSTRIDIUM PERFRINGENS—GAS GANGRENE (serious infection in body tissue, the
severe infection causes a buildup of gas)
C. TETANI—TETANUS (muscle twitching, cramps that are caused by a problem with the
parathyroid glands involving calcium)
C. DIFFICILE—the normal flora in the intestines is altered usually caused by the overuse of
antibiotics causing severe diarrhea and dehydration
MYCOBACTERIUM TUBERCULOSIS—it is transmitted directly from the respiratory tract,
causing TB.
VIRUSES—some examples of a virus include: HIV, herpes simplex, hepatitis B, C, and D
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)—this is a particular
strain of a virus that is resistant to most all antibiotics; the only antibiotic that works on this virus is
VANCOMYCIN
CREUTZFELDT–JAKOB DISEASE—this is a fatal neurodegenerative disease of the central
nervous system caused by a HUMAN PRION
• PRION/PROTEINACEOUS INFECTIOUS PARTICLE—is the smallest infectious particle; it is
neither viral, bacterial, nor fungal. Prions are also responsible for the disease known as mad cow disease.
This disease is important for the STSR because there is no sterilization process that kills these prions,
when surgery is performed on these patients, disposable instruments are used so they can be disposed of
• BIOTERRORIST AGENTS—
Anthrax
Smallpox
Plague (pneumonic, bubonic)
Tularemia (various types of insect bites)
Botulism
• MUTUALISM—when different organisms exist and benefits from the other
• COMMENSALISM—when one organism benefits and the other does not benefit and is not harmed
• PARASITISM—when one organism benefits from the other and is harmed
• OSMOSIS—a fluid, usually water passes through a membrane solution of higher concentration which
equalizes the concentrations of materials on either side of the membrane
• MITOSIS—division of a single cell into two identical cells. Each cell has an identical number of
chromosomes as the parent cell. They have the same genes
• MEIOSIS—cell division involving sexually reproducing organisms
• CHRONIC INFECTION—there is a continued presence of infection
• ACUTE INFECTION—a rapid onset of the disease but for a short time

25
• EPIDEMIC—it is a quick widespread infectious disease in a certain area, an example would be the flu
• PANDEMIC—it is a global outbreak of a disease, it affects many more people
• ENDEMIC—a disease connected to a particular group of people in a certain area
• MICROSCOPE—an instrument used to view microorganisms that cannot be seen by the naked eye.
Invented by Anton Von Leeuwenhoek
• JOSEPH LISTER—father of modern medicine. Discovered antiseptic techniques
• LOUIS PASTEUR—founded the science of microbiology and that diseases are caused by microorganisms

26
 Questions

1. The English surgeon who established the first principles of aseptic technique is?

(A) Ehrlich
(B) Madame Curie
(C) Alexander
(D) Lister

2. Passage of fluid through a cell membrane is called:

(A) mitosis
(B) meiosis
(C) osmosis
(D) symbiosis

3. Oxygen-dependent bacteria are said to be:

(A) anaerobic
(B) bacillic
(C) antibiotic
(D) aerobic

4. The destruction of bacteria by white cells during the inflammatory process is called:

(A) symbiosis
(B) mitosis
(C) lymphocytosis
(D) phagocytosis

5. Bacteriostatic means:

(A) inhibit growth of microorganisms

(B) destroy microorganisms
(C) control microorganisms
(D) inactivate microorganisms

6. Staphylococcus aureus would most likely be transmitted by:

(A) urine

27
 (B) feces
(C) nose and mouth
(D) sex organs

7. Microbial death occurs when an organism is:

(A) reproducing at a slower rate

(B) reduced in population
(C) no longer capable of reproduction
(D) exposed to heat

8. What immune protection is available to the fetus?

(A) Natural active

(B) Natural passive
(C) Active artificial
(D) Passive artificial

9. The clinical syndrome characterized by microbial invasion of the bloodstream is:

(A) superinfection
(B) septicemia
(C) cross infection
(D) cellulitis

10. The bodys first line of defense against the invasion of pathogens is:

(A) the immune response

(B) skin and mucous membrane linings
(C) cellular and chemical responses
(D) phagocytosis

11. Rod-like–shaped bacteria are identified microscopically as:

(A) bacilli
(B) cocci
(C) spirilla
(D) spirochetes

12. Herpes simplex is commonly called:

(A) cold sore

(B) shingles
(C) smallpox
(D) chicken pox

28
13. All of the following descriptors refer to the inflammatory process EXCEPT:

(A) heat
(B) pain
(C) vasoconstriction
(D) edema

14. Clostridium tetani causes:

(A) gangrene
(B) nosocomial infection
(C) lockjaw
(D) malaria

15. A laboratory procedure useful in classifying bacteria using a staining procedure is:

(A) gram stain

(B) iodine stain
(C) acid-fast stain
(D) differential stain

16. A fulminating infection arising from necrotic tissue and spreading rapidly is:

(A) rabies
(B) gas gangrene
(C) pasteurellosis
(D) tetanus

17. A severe allergic reaction possibly resulting in death is called:

(A) arthus reaction

(B) hypersensibility
(C) anaphylactic shock
(D) autoimmune disease

18. What organism is responsible for a boil?

(A) S. aureus
(B) Clostridium perfringens
(C) Escherichia coli
(D) Neisseria

19. The organism most frequently found in burns is:

(A) C. perfringens
(B) Pseudomonas aeruginosa

29
 (C) C. tetani
(D) Hemolytic streptococci

20. Which type of wound would favor the development of gas gangrene?

(A) Ischemic
(B) Necrotic
(C) Dry
(D) Both A and B

21. Gas gangrene is caused by:

(A) Fusobacterium
(B) C. tetani
(C) P. aeruginosa
(D) C. perfringens

22. The bacteria highly resistant to sterilization and disinfection is:

(A) spores
(B) fungus
(C) Gram-positive
(D) Pseudomonas

23. The bacteria found in the intestinal tract is:

(A) E. coli
(B) Bordetella pertussis
(C) Francisella tularensis
(D) Neisseria gonorrhoeae

24. The space caused by separation of wound edges is called:

(A) lag phase

(B) evisceration
(C) fibrous scarring
(D) dead space

25. Which body fluid is least likely to transmit HIV?

(A) Blood
(B) Semen
(C) Saliva
(D) Spinal fluid

26. What bacteria is the common cause for postoperative wound infections?

30
 (A) S. aureus
(B) Rickettsiae
(C) Haemophilus influenzae
(D) Candida

27. Hospital-acquired infections are known as:

(A) Antibiotic resistant

(B) Bacteremia
(C) Nosocomial
(D) MRSA

28. Methicillin-resistant S. aureus (MRSA) is a strain of S. aureus that is resistant to most antibiotics. What
is the only drug of choice to treat MRSA at this time?

(A) Vancomycin
(B) Penicillin
(C) Gentamicin
(D) Keflex

29. E. coli is part of the normal flora of the ______ of humans.

(A) skins
(B) hair
(C) intestinal track
(D) None of the above

30. The type of immunity that is acquired by a vaccination is:

(A) naturally acquired active immunity

(B) naturally acquired passive immunity
(C) artificial active acquired immunity
(D) artificial passive acquired immunity

31. What gram stain turns red at the end of the staining procedure?

(A) Gram-positive
(B) Gram-negative
(C) Acid-fast positive
(D) Acid-fast negative

32. What living cells are more complex, have nuclei and include protozoa, fungi, green, red, and brown
algae?

(A) Eukaryotic

31
 (B) Facultative
(C) Prokaryotic
(D) Passive

33. Universal precautions is a previous policy, it is now called:

(A) recommended precautions

(B) evidence-based practice
(C) occupational precautions
(D) standard precautions

34. Asepsis means:

(A) without infection

(B) destroys bacteria
(C) clean
(D) absence of microbes

35. The microbes that reside on the skin and are easily removed are referred to as:

(A) resident
(B) transient
(C) aseptic flora
(D) None of the above

36. All factors increase the surgical patient’s risk for infection EXCEPT:

(A) location of surgery

(B) health of the patient
(C) length of the procedure
(D) position of the patient

37. What is responsible for bacterial motility?

(A) Flagella
(B) Mitochondria
(C) Cell wall
(D) RNA

38. Rickettsia are transmitted by:

(A) S. aureus
(B) arthropod bites
(C) tape worms
(D) fungi

32
39. When there is a relationship between two organisms that occupy the same space but one organism
benefits and the other does not but is unharmed it is termed:

(A) mutualism
(B) commensalism
(C) parasitism
(D) none of the above

40. When there is a relationship between two organisms and one benefits from the expense of the other it is
termed:

(A) mutualism
(B) commensalism
(C) parasitism
(D) fungi

41. The basic structural and functional living unit of the body is known as:

(A) cell
(B) tissue
(C) organ
(D) mitochondria

42. The biological indicator for ETO is:

(A) subtilis
(B) stearothermophilus
(C) bacillus atrophaeus
(D) both A and C

43. Inflammation in the following gland may be used to diagnose the disease mumps is:

(A) sublingual
(B) submandibular
(C) thyroid
(D) parotid

44. What is the term for the division of a reproductive cell into two cells with chromosome cells?

(A) Binary fission

(B) Mitosis
(C) Meiosis
(D) Osmosis

45. An inanimate object that contains microorganisms is termed:

33
 (A) fomite
(B) prion
(C) obligatory
(D) flagella

46. Which of the following causes the disease “mad cow”?

(A) Virus
(B) Prion
(C) Spore
(D) Fungi

47. When there is a continued presence of an infection it is termed:

(A) acute
(B) pandemic
(C) chronic
(D) nosocomial

48. The definition of pandemic:

(A) disease that has spread throughout a school

(B) disease that has spread during the winter season
(C) disease that has spread throughout the world
(D) disease that has spread quickly and causes serious illness

34
 Answers and Explanations

1. (D) In 1867, Lister began the age of chemical control of the atmosphere. He used aqueous phenol to
disinfect instruments, soak dressings, and spray the air of surgical rooms.

2. (C) Osmosis allows the passage of a solvent, usually water, to pass through the membrane from the
region of lower concentration of solute to the region of higher concentration. This tends to equalize the
concentration of the two solutions.

3. (D) The majority of microbes are aerobes. This means they grow and flourish in the presence of oxygen.

4. (D) Leukocytes known as phagocytes rush to a wound to engulf and destroy the bacteria present.
Phagocytosis means “cell eating.”

5. (A) Agents that destroy or inactivate microorganisms are bactericidal. An agent that inhibits the growth
of bacteria is known as a bacteriostatic agent.

6. (C) S. aureus is commonly present on skin and mucous membranes, especially those of the nose and the
mouth. It is gram-positive and is the cause of such suppurative conditions as boils, carbuncles, and
internal abscesses.

7. (C) Microbial death occurs when an organism, or population of organisms, is no longer capable of
reproduction.

8. (B) In passive natural immunity, maternal antibodies cross the placenta. Infants are immune to the same
infectious diseases as their mothers for 6 to 12 months after birth. Breast-fed babies receive additional
protection from the breast milk.

9. (B) Microorganisms can multiply in the blood. Infection of bacterial origin carried through the
bloodstream is referred to as bacteremia or septicemia. Microorganisms invade from a focus of infection
in the tissue.

10. (B) The unbroken skin acts as a mechanical barrier to pathogens. Only when it is cut, scratched, or
burned can pathogens gain entrance. Mucous membranes entrap invaders.

11. (A) Bacteria generally appear in one of several shapes: bacilli are rod shaped, cocci are spherical, and
spirilla and spirochetes are corkscrew shaped.

12. (A) Herpes simplex, commonly called “cold sores” or fever blisters, is an example of a viral agent capable

35
 of latent periods where the virus is not multiplied. It remains intact until stress encourages growth. Its
appearance is associated with trauma, sun, hormonal changes, and emotional upset.

13. (C) Local irritation causes the small blood vessels to dilate and become more permeable. The tissue
spaces become engorged with fluid, and edema results. In inflammation there is pain, redness, heat,
swelling, vasodilation, and disturbance of function.

14. (A) C. tetani is the causative organism of tetany, or lockjaw. Commonly found in soil contaminated with
animal fecal waste. Protection is provided by receiving tetanus toxoid to stimulate antibodies against
tetanus toxins. A booster may be given when a dangerous wound is received.

15. (A) The gram stain is very useful because it classifies bacteria into two large groups: gram-positive and
gram-negative. This provides valuable treatment options. Gram-positive bacteria tend to be killed easily
by penicillins and cephalosporins. Gram-negative bacteria are generally more resistant.

16. (B) When the organisms of gas gangrene are introduced into tissues where conditions permit anaerobic
multiplication, they utilize amino acids and carbohydrates freed from dead or dying cells.

17. (C) Anaphylactic shock is the state of collapse resulting from injection of a substance to which one has
been sensitized. It is a severe allergic reaction. Death may occur if emergency treatment is not given.

18. (A) S. aureus is associated with skin infections such as boils, carbuncles, furuncles, and impetigo.

19. (B) P. aeruginosa most frequently found in burns, presents very difficult problems because the organism
is generally resistant to many clinically useful antibiotics.

20. (D) An ischemic necrotic wound caused by C. perfringens causes gas gangrene.

21. (D) Gas gangrene is caused by the microorganism C. perfringens.

22. (A) The most resistant form of microbial life is the endospore. Spores have a thick wall making them
difficult to destroy. This enables them to withstand unfavorable conditions such as heat. They require a
prolonged exposure time to high temperatures to destroy them.

23. (A) E. coli is by far the best known enteric bacterium and is found in the intestinal tract of animals and
humans.

24. (D) Serum or blood clots can form in this dead space and prevent healing by keeping the cut edges of
the tissue separated. It is the space caused by separation of wound edges that have not been closely
approximated.

25. (C) Hazardous body fluids include amniotic fluid, blood, pericardial fluid, peritoneal fluid, pleural fluid,
semen, spinal fluid, synovial fluid, and vaginal secretions. Saliva has not been implicated in HIV
transmission.

36
26. (A) The S. aureus is the common cause of boils, carbuncles, impetigo, toxic shock syndrome, and
postoperative wound infections.

27. (C) Hospital-acquired infections are known as nosocomial. They can be acquired due to improper
technique.

28. (A) Vancomycin destroys bacteria by inhibiting cell wall synthesis and is now the frontline antibiotic
therapy used against MRSA.

29. (C) E. coli is part of the normal flora of the intestinal track of humans, most strains are harmless.

30. (C) Artificial active acquired immunity is acquired immunity gained by getting a vaccination.

31. (B) Gram-negatives appear red from the safranin stain and gram-positives remain purple.

32. (A) Eukaryotes are more complex and include protozoa, fungi, green, red, and brown algae and all plant
and animal cells including human cells.

33. (D) Aseptic technique is among the behaviors and protocols specified in the standard precautions. These
evolved from a previous policy called universal precautions established by the CDC for control and
prevention.

34. (D) Asepsis means absence of microbes and infection.

35. (B) Transient flora are microbes which reside on the skin and are easily removed.

36. (D) Risk factors include location of the surgical site, the health of the patient, condition of tissues and
organs, resistance of body tissue, length of the preoperative stay, duration of the procedure, and surgical
technique.

37. (A) Flagella is responsible for bacterial motility. Mitochondria are known as the “power house of the
cell.” The cell wall gives shape to the cell and provides a barrier to the outside of the cell. Ribonucleic
acid (RNA) is manufactured in the nucleolus and controls cellular protein synthesis.

38. (B) Rickettsia are gram-negative bacteria, they reproduce in the host cell of arthropods (type of
invertebrate—insects, spiders, centipedes) and mammals. S. aureus is a gram-positive bacterium and is
frequently found in the respiratory tract and on the skin. Tape worms are flat worms that live in the
intestines of animals. Fungi are part of the group of eukaryotic organisms, they are unicellular, and
include yeasts and molds.

39. (B) Commensalism is the relationship between two organisms that occupy the same space. One
organism benefits and the other does not but neither is harmed. Mutualism is the relationship between
two organisms and both benefit. Parasitism is the relationship of two organisms and one benefits at the
expense of the other.

37
40. (C) Parasitism is the relationship of two organisms and one benefits at the expense of the other.
Mutualism is the relationship between two organisms and both benefit. Commensalism is the
relationship between two organisms that occupy the same space, one organism benefits and the other
does not but neither is harmed. Fungi are part of the group of eukaryotic organisms, they are
unicellular, and include yeasts and molds.

41. (A) The smallest structural and functioning unit of an organism is a cell. Tissues are made up of
specialized cells that perform a specific function. Organs are made up of tissues and are grouped into
systems. Mitochondria are known as the “power house” of the cell.

42. (D) The biological indicator for ETO is Bacillus atrophaeus/subtilis. Geobacillus stearothermophilus is
the biological indicator used for steam sterilization.

43. (D) The parotid gland is the primary gland that is affected by the mumps. This disease is caused by a
virus and is highly contagious. The thyroid gland is an endocrine gland and it is found in the neck.
Sublingual glands are salivary glands found in the mouth. The submandibular glands are salivary glands
located below the lower jaw.

44. (B) Mitosis is a type of cell division that results in two daughter cells each having the same number of
chromosomes. Binary fission is when the cell divides into two equal daughter cells. Meiosis is a type of
cell division that results in four daughter cells each with half the number of chromosomes of the parent
cell. Osmosis is when liquid passes from a lower concentration through a membrane into an area with a
higher concentration to balance them.

45. (A) Fomite is an inanimate object that contains microorganisms. Prion is a small proteinaceous
infectious disease-causing spore. It is neither bacterial, fungal, nor viral. They are responsible for
degenerative brain diseases. Obligatory is in regard to bacteria that can grow under aerobic or anaerobic
conditions. Flagella are responsible for bacterial motility.

46. (B) A prion is responsible for the disease “mad cow.” Virus—there is many diseases caused by viruses.
Examples include cold, chickenpox, meningitis, and many others. Spores—two of the major spore-
forming diseases include food poisoning caused by (Bacillus cereus), and (C. tetani) which is found in
soil.

47. (C) A chronic infection is considered a continued presence of infection. An acute infection is a serious
infection with an abrupt onset and progresses rapidly. Pandemic is an outbreak of a disease over a wide
geographic area infecting much of the population of that area. Nosocomial—is a hospital-acquired
infection.

48. (C) The definition of a pandemic disease is one that spreads throughout the world. Epidemic is the
rapid spread of an infectious disease to a large number of people in a short period of time.

38
39
 ___________________ CHAPTER 3 ___________________

Pharmacology and Anesthesia

• Drug sources include: plants, animals, lab synthesis, and biotechnology

• Pharmacodynamics—what the drug does to the body
• Pharmacokinetics—what the body does to the drug
• Antagonist—it is a chemical drug that counteracts or blocks the action of another drug
• Synergist agent—one drug works with another drug (boosts the result) to provide the same effect; however
by combining the two drugs the dose is lower and safer
• Therapeutic effect—the drug is intended to produce a desirable and beneficial effect to the patient
• Side effect—it is the secondary effect to a therapeutic drug. It is usually undesirable but tolerable
• Adverse effect—this is an undesirable and potentially harmful effect from a therapeutic drug
• Anaphylaxis—a severe allergic reaction, immediate attention is required or the patient could die
• Toxic effect—undesirable effect could cause cancer
• Toxic effect—undesirable effect could cause cancer
• Addiction—a dependency on the effect of the drug
• Onset—time required for the drug to work
• Peak effect—period of time when the maximum effect of the drug works
• Duration—how long the medication works

40
• FDA—food and drug administration—prescription drugs must go through a review process and an
approval process in order to be used in the United States

• Controlled substances—these are drugs that have the potential to cause dependence and abuse
• Medication information
Trade name/brand name—name assigned by the manufacturer. Example, Advil
Generic name—shortened name for the chemical name. This is the name on the medication label.
Example, ibuprofen
Chemical name—this is the chemical composition of the medication. Example, (RS)-2-[4-(2-
methylpropyl)phenyl]propanoic acid (this is not on package but on package insert)

41
• Concentration
How much drug is in a given amount of fluid
The concentration is found on the medication label
For medications that need to be reconstituted (powder mixed with a solution) the instructions will also
be on the label
• Dose
The dose of the medication is the amount delivered to the patient
• Application
This applies to the way the medication is being used and how it is delivered to the patient in surgery
Example, Lidocaine hcl is commonly used as a local medication to numb a specific area; however, it
could also be used to decrease abnormal heartbeats. This medication can be given for two different
reasons, and administered in two different ways.
• Conversions of temperature
Freezing point of water—32°F = 0°C
Boiling point of water—212°F = 100°C
Normal body temperature—98.6°F = 37°C
• The six rights of medication
The “right” patient
The “right” drug
The “right” dose
The “right” route of administration
The “right” time
The “right” labeling/documentation
• Medication identification
Ampule—a little glass container that requires the top to be broken off—contains liquid.
Vile—plastic or glass container that has a rubber top—may contain liquid or powder
Preloaded syringe—contains liquid
• Transferring medications onto the sterile field
The circulator and the STSR agree on the medication
The circulator holds the medication so the STSR can see the label; the circulator reads the medication
information out loud:
Name of drug
Strength of the drug
Expiration date
As soon as the STSR receives the medication, she must label the container
When she fills the syringe it must be immediately labeled
All basins and pitchers containing irrigation fluids, antibiotics, and/or sterile water must be labeled
Medications that need to be reconstituted are done by the circulator before transfer to the sterile field

42
 Medications can be poured, squeezed or ejected through a syringe
• All medical cups, glasses, emesis basins and pitchers are placed at the edge of the table by the STSR so the
circulator can dispense the fluid without reaching over the sterile field and contaminating the field.
The irrigation fluid should be held 12 in above the pitcher when pouring
Irrigation fluids are poured into a pitcher
Transferring medications from a vial onto the sterile field:
Procedure 1—the circulator removes the plastic cap, wipes the top of the vial with an alcohol wipe,
draws up the medication in a syringe and dispenses it on to the sterile field
Procedure 2—the circulator removes the plastic cap, wipes the top of the vial with an alcohol wipe
and holds the vial upside down. The STSR draws up the medication using a syringe. She then changes
the hypodermic needle before passing the syringe to the surgeon just in case there was any
contamination.
It is easier to draw up medication with a larger hypodermic needle.
Every time the STSR passes a syringe to the surgeon they must state:
Name of the drug
Strength and amount
If there is any question about the strength of the drug or name of the drug that has been placed on the
sterile field, the drug must be discarded and replaced

43
44
• Retrobulbar (this block is performed directly into the base of the eyelids or into the back of the globe of
the eye)

45
46
47
48
49
50
Hemostasis and blood replacement

• Hemostasis—it is the technique used to control bleeding during a surgical procedure

• Chemical methods of hemostasis
• Bone wax—a sterile mixture of beeswax used to seal off bleeding on bone
• Absorbable gelatin sponges
Made of callogen
Gelfoam
Gelfilm
• Microfibrillar callogen
Avitene—assists in the coagulating process. Must be applied with clean dry gloves or clean forceps
• Oxidized cellulose
Surgicel—blood clots and forms a gel. It is applied directly to the bleeding surface
• Silver nitrate
It comes in a stick form or like a pencil. Commonly used in the nose or cervix
• Epinephrine
It is a vasoconstrictor
Mixed with a local to prolong the effects and aid in hemostasis
• Thrombin
It is a topical hemostatic agent
It should never be injected—could cause death
Can be used by itself or with a gelfoam sponge and cottonoids
• Floseal
Used to control bleeding
It swells to provide a tamponade (compression) effect
It fills the space
• Blood loss in the operating room is monitored through:
Suction canisters—irrigation fluid is subtracted and you have an estimated blood loss. Also through

51
 sponges
• Blood components
Blood components are stored in the blood bank.
They must be refrigerated.
Before blood products are given they must be identified by two licensed personnel to identify the correct
blood product and the correct patient.
All information should match the information on the patient’s wrist band, blood bag and chart.
Always check for clots.

Blood is donated by the patient themselves prior to surgery (autologous), or by a donor (homologous).

• Common blood components:

• Autotransfusion
Blood products are used to:
increase blood volume
increase the number of red blood cells
increase the number of platelets for clotting
replace the clotting factor that was depleted during surgery
• Autologous blood retrieval system/Cell Saver
The Cell Saver is a machine that suctions the blood directly from the wound and filters it to remove
debris
Mixes with heparinized saline
Then separates the RBCs from the rest of the fluids
The RBCs are pumped into a separate blood bag and it is infused back into the patient
• Cell Saver blood cannot be used if it contains:
Cancer cells
Amniotic fluid

52
 Hemostatic agents, for example, Avitene
Certain antibiotics

General anesthesia
Methods of anesthetic administration

• The ways anesthetic agents are given:

Inhalation agents/gas
Injectable agents/IV
Instillation agents/the agent is absorbed in a mucous membrane, for example, rectum
• Hypnosis—altered state of consciousness
• Anesthesia—freedom from pain
• Amnesia—lack of recall, memory loss
• Muscle relaxation—neuromuscular blocking agents mixed with inhalation agents provide muscle relaxation
• Anesthesia agents, and techniques vary from patient to patient depending on:
Physiological status of the patient
Current medications
Allergies
History of substance abuse
Emergency conditions
• Phases of general anesthesia

53
54
 Questions

1. A drug that interferes with the blood clotting mechanism is:

(A) lidocaine
(B) fentanyl
(C) heparin
(D) cefazolin

2. An mg is a measurement of:

(A) length
(B) weight
(C) volume
(D) temperature

3. The solutions used intravenously to replace plasma when plasma is not available is:

(A) 0.9% NaCl

(B) dextrose 5% in water
(C) lactated Ringer’s solution
(D) dextran

4. How many milliliters are in 1 oz?

(A) 10
(B) 30
(C) 75
(D) 100

5. One gram equals:

(A) 100 mg
(B) 1,000 mg
(C) 100 mL
(D) 1,000 mL

6. A drug used to increase blood pressure is:

(A) Avitene

55
 (B) epinephrine
(C) heparin
(D) mannitol

7. The action of an anticholinergic drug is to reduce:

(A) heart rate

(B) anxiety
(C) nausea
(D) secretions

8. The total volume in a 30-cc syringe is:

(A) 1 oz
(B) 2 oz
(C) 3 oz
(D) 4 oz

9. Naloxone (Narcan) is an example of a/an:

(A) narcotic antagonist

(B) mydriatic
(C) histamine
(D) diuretic

10. Avitene is:

(A) hemostatic
(B) adrenergic
(C) cycloplegic
(D) mydriatic

11. An absorbable gelatin hemostatic agent that is often soaked in thrombin or epinephrine solution is:

(A) Avitene
(B) Oxycel
(C) Nu-knit
(D) Gelfoam

12. Each of the following agents must be applied using dry gloves or instruments EXCEPT:

(A) Gelfoam
(B) Collastat
(C) Avitene
(D) Helistat

56
13. An anticoagulant given subcutaneously, intravenously, or as a flush is:

(A) nitroglycerin
(B) dextran
(C) heparin
(D) thrombin

14. A drug that decreases the tendency of blood to clot is:

(A) warfarin sodium

(B) diazepam
(C) lorazepam
(D) midazolam HCl

15. An antibiotic used intraoperatively is:

(A) diazepam
(B) ketorolac
(C) Cyclogyl
(D) gentamicin

16. A topical antibiotic is:

(A) bacitracin
(B) ephedrine
(C) Ancef
(D) Keflex

17. Which item is used on cut edges of bone to seal off oozing of blood?

(A) Electrocautery
(B) Silver nitrate
(C) Bone wax
(D) Epinephrine

18. The most common diuretic is:

(A) Lasix
(B) Pronestyl
(C) Isoptin
(D) Cefadyl

19. An osmotic diuretic agent used to decrease cerebral edema and intraocular edema is:

(A) Diuril
(B) furosemide

57
 (C) papaverine
(D) mannitol

20. A systemic agent used to control uterine hemorrhage is:

(A) protamine
(B) Pitocin
(C) procainamide HCl
(D) phenylephrine

21. Steroids are used for:

(A) reduction of fluid in body

(B) reduction of body’s need for oxygen
(C) reduction of tissue inflammation and swelling
(D) reduction of uterine constriction and contraction

22. Solu-Medrol is a/an:

(A) antibiotic
(B) myotic
(C) mydriatic
(D) anti-inflammatory

23. An artificial plasma-volume expander is:

(A) mannitol
(B) dextran
(C) Ringer’s solution
(D) uromatic

24. An anticoagulant used in vascular surgery is:

(A) protamine sulfate

(B) heparin
(C) adrenalin
(D) papaverine

25. Heparin effects are reversed by:

(A) Pitocin
(B) phenylephrine
(C) protamine sulfate
(D) procainamide HCl

26. Normal saline is used for lap pad moistening and for intraperitoneal irrigation because it is:

58
 (A) hypotonic
(B) isotonic
(C) hypertonic
(D) hyperkalemic

27. The last sensation to leave the patient during general anesthesia induction is:

(A) hearing
(B) sight
(C) feeling
(D) smell

28. A short-acting drug useful during intubation to produce paralysis and also to produce muscle relaxation
is:

(A) Sublimaze
(B) Valium
(C) Versed
(D) Anectine

29. Neuroleptanalgesia combines:

(A) a narcotic and an anticholinergic

(B) a tranquilizer and narcotic
(C) an anti-inflammatory and a tranquilizer
(D) a muscle relaxant and a tranquilizer

30. A sedative/tranquilizer used to reduce anxiety and apprehension of the preop patient is:

(A) Valium
(B) Marzicon
(C) Anectine
(D) Demerol

31. An antimuscarinic:

(A) controls pain

(B) prevents nausea
(C) limits salivation
(D) reverses muscle relaxation

32. Anesthesia given in a combination of several agents to obtain optimum results is called:

(A) regional anesthesia

(B) general anesthesia

59
 (C) conduction anesthesia
(D) balanced anesthesia

33. A bolus is:

(A) a small, intermittent dose intravenously

(B) a dose injected intramuscularly
(C) a rapid dose, subcutaneously
(D) a dose injected all at once, intravenously

34. A drug used to soothe and relieve anxiety is a/an:

(A) cholinergic
(B) analgesic
(C) sedative
(D) narcotic

35. A Bier block provides:

(A) anesthesia to a distal portion of an extremity

(B) anesthesia below the diaphragm
(C) anesthetic block surrounding a peripheral nerve
(D) anesthetic block to a nerve group

36. Which inhalation agent is used for short procedures requiring no muscle relaxation?

(A) Nitrous oxide

(B) Halothane
(C) Ethrane
(D) Forane

37. Halothane is also called:

(A) Ethrane
(B) Penthrane
(C) Forane
(D) Fluothane

38. A method of anesthesia in which medication is injected into the subarachnoid space, affecting a portion
of the spinal cord, is called a:

(A) Bier block

(B) field block
(C) nerve block
(D) spinal block

60
39. The indication for an epidural would be:

(A) anorectal, vaginal, perineal, and obstetric procedures

(B) Bankart Procedure
(C) upper gastrointestinal procedures
(D) above the waist procedures

40. Compazine is:

(A) an antiemetic
(B) a sedative
(C) a tranquilizer
(D) an anticholinergic

41. Which technique can be employed to prevent pain during an operative procedure or to relieve chronic
pain?

(A) Local infiltration

(B) Bier block
(C) Nerve block
(D) Field block

42. The most widely used local anesthetic is:

(A) Carbocaine
(B) Marcaine
(C) prilocaine
(D) lidocaine

43. Another name for adrenalin is:

(A) ephedrine
(B) epinephrine
(C) lidocaine
(D) Levophed

44. A vasoconstrictor that, when added to a local anesthetic agent, extends its life is:

(A) ephedrine
(B) epinephrine
(C) Aramine
(D) Ethrane

45. The purpose of an LMA is:

(A) to establish and maintain a patent airway

61
 (B) to provide patient cooling
(C) to monitor body temperature
(D) to evaluate cardiac and venous status

46. Blood oxygenation can be monitored during surgery by means of a/an:

(A) blood pressure monitor

(B) arterial catheter
(C) pulse oximeter
(D) CVP catheter

47. A drug that could be used to reverse the effect of muscle relaxants is:

(A) Narcan
(B) protamine sulfate
(C) Prostigmin
(D) Valium

48. Arterial blood gases (ABGs) are commonly obtained by accessing the:

(A) femoral artery

(B) carotid artery
(C) radial artery
(D) renal artery

49. Which piece of equipment is of extreme importance when anesthesia induction begins?

(A) Oximeter
(B) Blood pressure apparatus
(C) Oxygen
(D) Suction

50. Tablets placed under the tongue for rapid absorption are called:

(A) oral
(B) transdermal
(C) subungual
(D) sublingual

51. Pharmacokinetics focuses on:

(A) rejecting drugs

(B) reacting to drugs
(C) process by which drugs move through the body
(D) response to drugs

62
52. Drug effects that occur predictably, and may not cause a problem are:

(A) adverse reaction

(B) toxicity
(C) side effect
(D) therapeutic effect

53. The patented name of medication is also its:

(A) chemical name

(B) proprietary name
(C) molecular name
(D) None of the above

54. A capnometer measures:

(A) O2 concentration
(B) CO concentration
(C) CO2 concentration
(D) PO2 concentration

55. Contrast media for radiographic studies include:

(A) barium sulfate

(B) Conray
(C) Isovue
(D) all of the above

56. The acronym MAC stands for:

(A) monitored anesthesia care

(B) managed airway control
(C) metabolic analgesia care
(D) none of the above

57. A drug that constricts the pupil during ophthalmic surgery is:

(A) Healon
(B) Miochol
(C) hyaluronidase
(D) atropine

58. During general anesthesia, exhaled CO2 is absorbed by:

(A) soda lime reservoir

(B) vaporizer

63
 (C) ventilator
(D) breathing bag

59. Cricoid pressure:

(A) paralyzes the patient

(B) produces complete anesthesia
(C) occludes the esophagus
(D) is done during extubation

60. Extubation occurs during which phase of anesthesia?

(A) Recovery
(B) Emergence
(C) Induction
(D) Maintenance

61. The drug used to treat malignant hypothermia is:

(A) dantrolene
(B) Levophed
(C) Depo-Medrol
(D) digoxin

62. An example of a depolarizing muscle relaxant is:

(A) Halothane
(B) Fentanyl
(C) Sufentanil
(D) Succinylcholine

63. During ophthalmic surgery, paralysis of the ciliary muscle is achieved by using:

(A) cycloplegics
(B) myotics
(C) mydriatics
(D) narcotics

64. Zofran is an:

(A) antiemetic
(B) sedative
(C) tranquilizer
(D) anticholinergic

65. Benzodiazepines produce _____ for up to 6 hours from the onset of the drugs action.

64
 (A) pain relief
(B) hallucinations
(C) amnesia
(D) relief from nausea

66. IV lines are preoperatively placed to:

(A) immediate intravenous access for medications

(B) maintain and manipulate fluid volume
(C) maintain electrolyte balance
(D) all of the above

67. The number of “Rights” to safe medication administration is:

(A) 3
(B) 4
(C) 5
(D) 6

68. The intensity of contractions is increased with the use of:

(A) oxytocin
(B) glucagon
(C) heparin
(D) Lugol’s

69. Drugs used to reduce the reabsorption of water, causing frequent urination:

(A) anticoagulants
(B) anticholinergics
(C) diuretics
(D) colloids

70. A medication that is placed between the lip and the cheek to be absorbed by mucous membranes is:

(A) parenteral
(B) buccal
(C) subungal
(D) oral

71. The most accurate method used to measure liquid medication is:

(A) syringe
(B) measuring cup
(C) tablespoon

65
 (D) teaspoon

72. Which name is derived from the molecular formula of a drug?

(A) Brand
(B) Proprietary
(C) Chemical
(D) Generic

73. An undesirable or intolerable reaction to a drug administered at the normal dosage, is defined as:

(A) toxicity
(B) allergy
(C) side effect
(D) adverse reaction

74. The process whereby the drug enters the bloodstream is known as:

(A) absorption
(B) elimination
(C) distribution
(D) metabolism

75. One liter is equal to:

(A) 1,000 mL
(B) 100 mL
(C) 10,000 mL
(D) none of the above

76. One gram is equal to:

(A) 1,000 mg
(B) 100 mg
(C) 10 mg
(D) 1 mg

77. Medications used to prevent post op infections are:

(A) antiemetics
(B) antipyretics
(C) antibiotics
(D) agonists

78. Drugs with the potential to lead to abuse are:

66
 (A) narcotic
(B) prescription
(C) controlled substances
(D) all of the above

79. Which organ is primarily responsible for excretion of drugs?

(A) Kidneys
(B) Liver
(C) Gallbladder
(D) Spleen

80. Anticoagulants such as heparin are used to prevent:

(A) fevers
(B) nausea
(C) allergic reactions
(D) blood clots

81. The generic name for Marcaine is:

(A) xylocaine
(B) bupivacaine
(C) oxytocin
(D) lidocaine

82. The phase of anesthesia occurring when surgery is in progress is:

(A) emergence
(B) induction
(C) preinduction
(D) maintenance

83. Benzodiazepines are categorized as:

(A) analgesics
(B) sedatives
(C) cholinergics
(D) anticholinergics

84. While under general anesthesia, the anesthesiologist monitors the rate, rhythm, and electrical
conduction by:

(A) electrocardiogram
(B) oximetry

67
 (C) ABGs
(D) blood pressure cuff

85. Drugs classified as antiemetics are used to prevent:

(A) hypertension
(B) hypotension
(C) tachycardia
(D) nausea

86. A warming blanket which contains warm air and is used on patients during surgery is called:

(A) Bair Hugger

(B) SCDs
(C) TEDs
(D) hypothermic unit

87. The trade name for xylocaine is:

(A) Pontocaine
(B) Marcaine
(C) Lidocaine
(D) Sensorcaine

88. The vasoconstrictor used with lidocaine to prolong the effects of the anesthetic is:

(A) epinephrine
(B) heparin
(C) protamine sulfate
(D) digoxin

89. Which drug is the antagonist to heparin?

(A) Depo-Medrol
(B) Papaverine
(C) Protamine sulfate
(D) Dantrolene

90. When the surgeon performs an intraoperative cholangiogram he uses:

(A) Renografin
(B) Conray
(C) barium sulfate
(D) gentian violet

91. Another name for Anectine is:

68
 (A) succinylcholine
(B) halothane
(C) fluothane
(D) fentanyl

92. Malignant hyperthermia can be triggered by:

(A) succinylcholine
(B) demerol
(C) morphine
(D) valium

93. Patient is receiving 1 litre of 5% dextrose in water as an IV fluid during her 1-hour surgery. The number
of grams of dextrose the patient has received during this infusion is:

(A) 5 g
(B) 50 g
(C) 500 g
(D) 0.5 g

94. The needed medication comes in 100 mg per 1 cc. The surgeon wants 50 mg. Your syringe will draw
up_______of the medication.

(A) 0.5 cc
(B) 1 cc
(C) 2 cc
(D) 3 cc

95. One ounce is equal to _______ cc.

(A) 60 cc
(B) 1 cc
(C) 30 cc
(D) 10 cc

96. The vial the circulating nurse is holding is labeled 75 mg per 1 cc. The surgeon wants 150 mg of the
medication. You will draw up:

(A) 0.75 cc
(B) 1.5 ccs
(C) 2 ccs
(D) None of the above

97. A synergist agent is:

69
 (A) One drug that works with another drug (boosts the result) to provide the same effect; however by
combining the two drugs the dose is lower and safer
(B) The drug is intended to produce a desirable and beneficial effect to the patient
(C) It is a chemical drug that counteracts or blocks the action of another drug
(D) This is an undesirable and potentially harmful effect from a therapeutic drug

98. An intrathecal injection is:

(A) placed between the cheek and gums

(B) placed in the adipose tissue
(C) placed into the subarachnoid space
(D) placed in a hollow cavity

99. Every time the STSR passes a syringe to the surgeon they must state all of the following except:

(A) name of the drug

(B) strength
(C) amount of the drug
(D) expiration date

100. A drug used to reverse an overdose of an analgesic is:

(A) Atropine
(B) Demerol
(C) Narcan
(D) protamine sulfate

101. The drug used to treat ventricular arrhythmias is:

(A) Lidocaine
(B) Marcaine
(C) Sensorcaine
(D) Bupivacaine

102. Which of the following symptoms is not a symptom malignant hyperthermia?

(A) Muscle contraction

(B) Bradycardia
(C) Rigid jaw
(D) Increased body temperature

103. The biggest risk associated with general anesthesia is:

(A) aspiration
(B) inflammation of the esophagus

70
 (C) breaking of teeth
(D) overdosing the patient

104. Symptoms of ventricular tachycardia include all of the following EXCEPT:

(A) changes in the EKG

(B) heart rate below 100
(C) heart rate above 120
(D) arrhythmia

105. Nitrous oxide should never be used on which procedure?

(A) Shoulder arthroscopy

(B) Circumcision
(C) Tympanoplasty
(D) Closed fracture

106. Which drug has a milky appearance and is sometimes referred to as “milk of amnesia”?

(A) Narcan
(B) Pentothal
(C) Sublimaze
(D) Propofol

107. A dissociative agent that provides complete unconsciousness and a catatonic state is:

(A) Ketamine
(B) Nitrous oxide
(C) Versed
(D) Anectine

108. Which IV solution is similar to plasma, is water based and contains sodium, potassium, and calcium?

(A) Dextrose 5% in water

(B) Ringer’s
(C) Normal saline
(D) Lactated Ringer’s

109. Induced hypothermia is not used on the following surgery:

(A) open heart surgery

(B) malignant hyperthermia crisis
(C) organ transplant
(D) liver biopsy

110. Which instrument aids in positioning the endotracheal, nasotracheal, and nasogastric tubes in the

71
 trachea?

(A) McGill forceps

(B) Bayonet forceps
(C) Transfer forceps
(D) Bozeman forceps

111. During intubation cricoid pressure is applied in order to occlude:

(A) hyoid bone

(B) trachea
(C) esophagus
(D) thyroid gland

112. An A-line is commonly inserted into the:

(A) jugular artery

(B) radial artery
(C) carotid artery
(D) brachial artery

113. Fast breathing for short periods of time, followed by apnea is termed:

(A) dyspnea
(B) tachypnea
(C) Cheyne—Stokes
(D) Eupnea

114. Which of the following refer to Kortokoff’s sounds?

(A) The first tapping sound heard when taking a blood pressure
(B) Soft whistling sound as cuff in deflated
(C) Rhythmic tapping sound as the cuff is deflated
(D) All of the above

72
 Answers and Explanations

1. (C) Heparin and warfarin are anticoagulant drugs that interfere with blood clotting mechanism.

2. (B) Kilograms, grams, milligrams, and micrograms are the metric weight designations.

3. (D) Dextran, artificial plasma, is used when plasma is not available.

4. (B) An ounce (fluid, apothecaries) is a measure for liquids. It is equal to 29.6 mL; thus, 30 mL.

5. (B) One gram (g) is equal to 1,000 mg.

6. (B) Epinephrine is an adrenergic which increases blood pressure.

7. (D) Anticholinergics block secretions, an example is atropine or scopolamine.

8. (A) One fluid ounce equals 29.573 mL. One milliliter equals 1 cc. Thus, 30 cc equals 1 oz.

9. (A) A narcotic antagonist is given to reverse the effects of a narcotic.

10. (A) Avitene is a microfibrillar collagen hemostatic agent. It is an adjunct to hemostasis when
conventional methods are ineffective. It is an absorbable topical agent of purified bovine collagen, and it
must be applied in its dry state. It is very expensive.

11. (D) Gelfoam is an absorbable hemostatic agent that aids in clot formation and absorbs 45 times its own
weight in blood. It is frequently soaked in thrombin or epinephrine solution and dipped in it before
handing to the surgeon.

12. (A) Gelfoam can be used wet or dry. Each of the others must be applied dry.

13. (C) Heparin prolongs clotting time and may be given simultaneously, intravenously, or as a flush to keep
IV lines open or to flush the lumen of a blood vessel (1 mL heparin in 100 mL normal injectable
saline).

14. (A) Warfarin sodium is a Coumadin derivative that depresses blood prothrombin and decreases
tendency of blood platelets to cling together, thus decreasing blood clotting. The others are either
sedatives or help provide a calm, hypnotic state preoperatively.

15. (D) An antibiotic used intraoperatively is Gentamicin.

16. (A) Bacitracin is a topical antibiotic.

73
17. (C) Bone wax, made from refined and sterilized bee’s wax, is used on cut edges of bone to seal off oozing
blood. Soften by kneading before use.

18. (A) Lasix (furosemide) increases the amount of urine secreted and is a common diuretic.

19. (D) Mannitol, an osmotic diuretic, is given prophylactically to prevent renal failure. It is also used to
decrease intracranial and intraocular pressure.

20. (B) Pitocin is a trademark for an oxytocic (oxytocin), a hormone produced by the pituitary gland, which
is prepared synthetically for therapeutic injection. In labor and delivery, it is given to contract the uterus
after placenta delivery or systemically to control uterine hemorrhage.

21. (C) Steroids reduce tissue inflammation and postoperative swelling. Examples are Decadron and
Cortisporin ophthalmic ointment. In eye surgery, they are applied topically to reduce postoperative
swelling. In plastic surgery, they are applied in and around the site in patients who tend to form keloids.

22. (D) Methylprednisolone (Medrol) is an adrenal corticosteroid drug. Corticosteroids prevent the normal
inflammatory response; thus, it is anti-inflammatory. In eye surgery, they reduce the resistance of the
eye to invasion by bacterial viruses and fungi.

23. (B) Dextran is an artificial volume expander that acts by drawing the fluid from the tissues. It remains in
the circulation for several hours. It is used in emergency situations to treat shock by increasing blood
volume.

24. (B) Heparin is the most common drug used in vascular surgery to anticoagulate the patient. Protamine
reverses heparin.

25. (C) Heparin is reversed by protamine. It should be given.

26. (B) Normal saline is used because it is isotonic (contains an amount of salt equal to that of intracellular
and extracellular fluid), thus will not alter sodium, chloride, or fluid balance.

27. (A) During the induction phase, the patient retains an exaggerated sense of hearing until the last
moment. Thus, it is essential that all personnel in the room remain as quiet as possible.

28. (D) Succinylcholine (Anectine) is an ultra-short-acting agent with rapid onset and is useful to produce
paralysis during intubation as well as continuing muscle relaxation when used in a dilute solution.

29. (B) The combination of a narcotic (potent analgesic) and a tranquilizer (neuroleptic) produces
neuroleptanalgesia. When these are reinforced with an inhalation anesthetic, it is call
neuroleptanesthesia.

30. (A) Valium and Versed are examples of Benzodiazepines (sedative tranquilizers) are used in two ways to
reduce the anxiety and apprehension of the patient and as an adjunct to general anesthesia to reduce the
amount and concentration of other more potent agents.

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31. (C) Antimuscarinics (formerly known as anticholinergics) act as blockers of the cholinergic effects thus
limit salivation and bradycardia, for example, atropine sulfate and glycopyrrolate.

32. (D) Balanced anesthesia is a technique whereby the properties of anesthesia (hypnosis, analgesia, and
muscle relaxation) are produced in varying degrees by a combination of agents.

33. (D) A bolus is a rapid medication dose injected all at once intravenously.

34. (C) Sedatives are drugs that soothe and relieve anxiety. The only difference between a hypnotic and a
sedative is one of degree. A hypnotic produces sleep; whereas, a sedative provides mild relaxation. It is
quieting and tranquilizing.

35. (A) A Bier block provides anesthesia to the distal portion of the upper extremity by injecting an
anesthetic agent into a vein at a level below a tourniquet (double cuffed). The limb is exsanguinated
with esmarch, and the cuff is inflated.

36. (A) Nitrous oxide has a rapid induction and recovery. It is used on short procedures, when muscle
relaxation is unimportant.

37. (D) A widely used halogenated hydrocarbon is Fluothane, also known as halothane. It is nonflammable
and provides smooth induction.

38. (D) Spinal anesthesia is an extensive nerve block, sometimes called a subarachnoid block. It affects the
lower spinal cord and nerve roots. It is used for lower abdominal or pelvic procedures.

39. (A) An epidural is used for anorectal, vaginal, perineal, and obstetrical procedures. Injection is made into
the space surrounding the dura mater within the spinal canal (the epidural space).

40. (A) Compazine is an antiemetic that minimizes nausea and vomiting.

41. (C) Nerve blocks may be used preoperatively, intraoperative, and postoperatively to prevent pain or
therapeutically to relieve chronic pain. In a field block, the surgical site is blocked off with a wall of
anesthetic drug.

42. (D) Lidocaine hydrochloride (Xylocaine) is a most widely used agent. It is potent, has rapid onset and
lacks local irritation effects. Allergic reactions are rare.

43. (B) Adrenalin is another name for epinephrine.

44. (B) Epinephrine is added to a local anesthetic when a highly vascular area is to be injected. It causes
vasoconstriction at the operative site. This holds the anesthetic in the tissue, prolongs its effect, and
minimizes local bleeding.

45. (A) LMA (laryngeal mask airway) is a device placed into the laryngopharynx through the mouth to form
a low pressure seal (with an inflated balloon) around the laryngeal inlet. It is a simple, effective way of

75
 establishing a patent airway.

46. (C) The pulse oximeter measures blood oxygenation. The fingertip is commonly used. It is a continuous,
rapid, and easy means of assessment.

47. (C) Neostigmine, also known as Prostigmin, reverses the effect of muscle relaxants.

48. (C) ABGs involve invasive monitoring of pH, oxygen saturation, and CO2 levels. A common site is the
radial artery (arterial line or a-line). Direct blood pressure monitoring may also be performed this way.

49. (D) Suction must always be available and ready, along with assistance to the anesthesiologist, as
induction begins for the safety of the patient.

50. (D) When a tablet is placed under the tongue, this is sublingual.

51. (C) Pharmacokinetics is the movement of a drug through the tissues and cells of the body including the
process of absorption, distribution, and localization in tissues.

52. (C) Anticipated effects of a drug other than those intended are side effects.

53. (B) The patented name given to the drug by its manufacturer is its proprietary name.

54. (C) Expired CO2, which is a product of ventilation, is measured. The exhaled gas is analyzed and the
results displayed in wave form on a monitor. This is capnography.

55. (D) These are all examples of radiopaque solutions introduced into body cavities to outline their inner
surfaces.

56. (A) MAC is monitoring of vital functions during regional anesthesia to ensure patients safety and
comfort.

57. (B) Miochol is a cholinergic, which rapidly constricts the pupil and is used in the intraocular space
during anterior segment surgery and is reconstituted immediately before surgery.

58. (A) Exhaled CO2 captured from the system is measured and absorbed by a soda lime reservoir.

59. (C) Cricoid pressure is digital occlusion of the esophagus by applying external pressure over the cricoid
cartilage during intubation.

60. (B) The emergence phase is the cessation of the anesthetic. Reversal drugs may be administered and the
patient regains consciousness.

61. (A) Dantrolene relieves symptoms of malignant hypothermia by acting on the SR to block calcium
release which relieves muscle spasticity.

62. (D) Succinylcholine is a neuromuscular blocking agent.

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63. (A) Cycloplegics are drugs that cause paralysis of the ciliary muscle.

64. (A) Zofran is an agent that blocks serotonin receptors and on afferent vagal neurons in the upper GI
tract.

65. (C) Benzodiazepines cause e amnesia which is loss of recall of events for up to 6 hours from the onset of
the drugs action.

66. (D) All of these are achieved by inserting an intravenous line.

67. (D) In addition to the right drug, the right dose, the right route, the right patient, and the right time,
there is a sixth right that applies to medications used on the surgical field. It is the right surgical label.

68. (A) Drugs that enhance uterine contractions are called uterotropics. The most common is oxytocin.

69. (C) A diuretic is an agent that promotes urine secretion. These drugs are prescribed to rid the body of
excess fluid.

70. (B) Buccal is defined as pertaining to or directed toward the cheek.

71. (A) A syringe is the most accurate instrument used when measuring and dispensing a liquid.

72. (C) Chemical names are derived from the molecular formula of a drug following the International
Convention.

73. (D) Adverse reaction is an undesirable or intolerable reaction to a drug administered at the normal
dosage.

74. (A) Absorption is the process in which a drug enters the bloodstream following administration.
Absorption usually involves chemical and physical breakdown of the drug.

75. (A) One liter is equal to 1,000 mL.

76. (A) One gram is equal to 1,000 mg.

77. (C) A chemical compound produced by and obtained from certain living cells especially bacteria, yeast
and mold or an equivalent synthetic compound which is an antagonist to some other form of life
especially pathogenic or noxious organisms.

78. (D) All of these have the potential for abuse. These are rated according to their risk potential.

79. (A) Drugs are mainly eliminated or cleared from the body through the kidneys.

80. (D) Anticoagulants are used to prevent the coagulation of blood.

81. (B) Bupivacaine is the generic name for Marcaine.

82. (D) Maintenance is the phase involving continuation of the anesthetic agent, unconsciousness is

77
 maintained with the inhalation agent and adjunct agents.

83. (B) Benzodiazepines are a group of drugs that prevent and relieve anxiety.

84. (A) Electrocardiography is the graphic recording from the body surface of the potential of electric
currents gathered and generated by the heart.

85. (D) An antiemetic is an agent that relieves vomiting.

86. (A) A Bair Hugger is a blanket, which connects to a hose, which blows hot air in order to maintain the
patient’s body temperature.

87. (C) Lidocaine is the trade name for xylocaine.

88. (A) The vasoconstrictor used with lidocaine to prolong the duration of Lidocaine is epinephrine.

89. (C) Protamine is given to reverse the effects of heparin.

90. (A) Renografin is a contrast medium used to outline hollow organs or vessels before radiographs are
obtained.

91. (A) Anectine or succinylcholine produces a state known as depolarizing neuromuscular blockage.

92. (A) Malignant hyperthermia is a rare potentially fatal condition that can be triggered by succinylcholine
and other inhalation anesthetics as well.

93. (B) Medications described by percentages describe grams per 100 cc. 5% = 5 g per 100 cc of fluid. This is
1 L of 1,000 cc total so this equal to 10 × 5.

94. (A) If 1 cc contains 100 mg, 50 mg equals one-half that amount or 0.5 ccs.

95. (C) One ounce is equal to 30 ccs.

96. (C) If 1 cc contains 75 mg then 2 cc equals 150 mg.

97. (A) A synergist is one drug that works with another drug to boost the result to provide the same effect;
however by combining the two drugs the dose is lower and safer.
A therapeutic affect is intended to produce a desirable and beneficial effect to the patient.
A chemical drug that counteracts or blocks the action of another drug is an antagonist. An adverse
effect is an undesirable and potentially harmful effect from a therapeutic drug.

98. (C) An intrathecal injection is placed into the subarachnoid space. Buccal is placed between the cheek
and gums. Subcutaneous is placed in the adipose under the skin. Instillation is placed in a hollow cavity.

99. (D) The expiration date is confirmed by the STSR and circulator. It is not necessary to repeat this to the
physician.

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100. (C) Narcan is the drug of choice used to reverse an overdose of an analgesic. Atropine is an
anticholinergic. Demerol is an analgesic. Protamine sulfate reverses heparin.

101. (A) Lidocaine is used to treat ventricular arrhythmias. Marcaine, sensorcaine, and bupivacaine are not
used because they cannot be given intravenously.

102. (B) Bradycardia is a heart rate below 60 bpm. Malignant hyperthermia causes muscle contraction, rigid
jaw, increased body temperature, and tachycardia.

103. (A) Although all are possible risks associated with general anesthesia, aspiration is the most severe.

104. (B) A heart rate below 100 is not a symptom of ventricular tachycardia. VT is an arrhythmia, there are
definitive changes in the EKG and a heart rate above 120 bpm.

105. (C) Nitrous oxide cannot be used on a tympanoplasty as it causes pressure in enclosed spaces. Nitrous
oxide can be used during any of the other procedures.

106. (D) Propofol has a white and milky appearance. Narcan, Pentothal, and Sublimaze are clear liquids.

107. (A) Ketamine causes a catatonic state while patient remains awake. Nitrous oxide is a sedative agent
mixed with O2 during anesthesia. Versed is a sedative used to relieve anxiety and providing an amnesic
affect. Anectine is a muscle relaxant.

108. (B) Ringers solution is a water-based solution similar to plasma containing sodium, potassium, and
calcium. Dextrose 5% in water is used to treat hypoglycemia. Normal saline is a salt solution commonly
used when blood products are given. Lactated Ringer’s is also a salt solution which contains electrolytes.

109. (D) Induced hypothermia is not necessary for a liver biopsy. It is commonly used during open heart
surgery, MH crisis, and organ transplant to lower the body temperature.

110. (A) McGill forceps is the instrument used to position the endotracheal, nasotracheal and nasogastric
tubes. Bayonet forceps are commonly used in neurosurgery. Transfer forceps are used to remove a sterile
item from the steam autoclave by a nonsterile person to place the item on the sterile back table.
Bozeman forceps are packing forceps used in GYN.

111. (C) Cricoid pressure is applied to the tracheal cartilage to occlude the esophagus to avoid aspiration.

112. (B) An A-line is commonly inserted into the radial artery. The Femoral artery is the second most
common site for cannulation.

113. (C) Cheyne–Stokes breathing consists of fast breathing for short periods of time followed by apnea.
Dyspnea is difficulty breathing. Tachypnea is rapid breathing and eupnea is normal breathing.

114. (D) Kortokoff’s sounds are the first tapping sound heard when taking a blood pressure. Kortokoff’s
sounds occur in five phases; a soft whistling sound as the cuff is deflated is one of the phases. As the

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cuff is deflated, you can hear a rhythmic tapping sound.

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 ___________________ CHAPTER 4 ___________________

Blood Values

• COMPLETE BLOOD COUNT—it is used as a general screening for your health and to diagnose
diseases. It includes:
WHITE BLOOD CELL COUNT—it is the total number of white blood cells in your blood. These
cells protect your body against infection
5,000–10,000 adult male/female
WHITE BLOOD COUNT DIFFERENTIAL—each of these white blood cells help protect your
body against disease and provide information about diseases by determining the correct numbers of these
cells. They include:
Neutrophils
Lymphocytes
Monocytes
Eosinophil’s
Basophils
RED BLOOD CELL COUNT—they carry oxygen from the lungs to the rest of the body and CO2
back to the lungs to be exhaled.
4.7–6.1 adult male
4.2–5.4 adult female
HEMOGLOBIN (HGB)—it gives blood it’s red color and carries oxygen
14–18 adult male
12–16 adult female
HEMATOCRIT (PACK CELLS)—this test measures the amount of volume red blood cells take up
in the blood
0.42–0.52 adult male
0.37–0.47 adult female
PLATELETS (THROMBOCYTES)—they are important in blood clotting
150–400 adult male/female
• BLOOD TYPES
O negative—UNIVERSAL DONOR
A—can donate to type A and AB
B—can donate to type B and AB

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 AB—UNIVERSAL PLASMA DONOR—can only donate to AB, but can receive from all others
RH factor/RHESUS FACTOR—these are antigens found on the surface of red blood cells. If you have
the antigen you are Rh positive, if you do not have the antigen you are Rh negative. This becomes very
important when involving blood transfusions and pregnancy.
• BLOOD TRANSFUSION—a blood transfusion is performed to replace blood loss. It can be the patient’s
own blood, donor blood, and/or blood products.
AUTOLOGOUS—patient’s own blood
HOMOLOGOUS—someone else’s blood

Table 4–1.

• ARTERIAL BLOOD GASES

Arterial blood gases (ABGs) are diagnostic tests performed on blood taken from an artery which
contains oxygen and carbon dioxide.
ABGs measure how well the lungs can provide adequate oxygen to the body and subsequently remove
carbon dioxide.

pH LEVELS

• A pH level below 7.35 indicates that acidosis is present, indicating a buildup of carbonic acid in the blood.
• A pH level above 7.45 indicates alkalosis is present, which indicates the buildup bicarbonate (bases) in the
blood

PCO2 LEVEL

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• Is the level of carbon dioxide in your blood
The condition of respiratory alkalosis is present if the PCO2 number is below 35 mm Hg. This indicates
that there is too little carbon dioxide in the blood. A person with this condition may be breathing very
fast (hyperventilating).
The condition of respiratory acidosis is present if the PCO2 number is above 45 mm Hg. This is an
indication that there is too much carbon dioxide in the blood. A person with this condition can be
confused or restless and have a low heart rate.

(HCO3) LEVEL

• It is the renal component in the acid-base balance

An HCO3 level below 24 mEq/l indicates metabolic acidosis. When in a state of metabolic acidosis, the
body cannot produce enough bicarbonates to keep up with the carbonic acid in the blood. It can be
caused by many conditions including dehydration and kidney disease.
An HCO3 level above 26 mEq/l indicates metabolic alkalosis. There are too many bicarbonates in the
blood. Hyperventilation is the common cause, but it is also seen in many other conditions including
Cushing’s disease and long term steroid therapy.
• PROTHROMBIN TIME (PT)
Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of
your blood to clot.
If you are taking warfarin/coumadin or plavix your health care provider will check your PT, or
prothrombin time, regularly.
The normal range is 11.0–13.5 seconds.
• CELL SAVER
Blood is suctioned directly from the surgical field into the machine; it washes the blood and prepares it
to be given back to the patient.
You should not use the cell saver in the presence of bacterial contamination, malignancy, or
anticoagulants.

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 Questions

1. Who is the universal blood donor?

(A) AB
(B) A
(C) B
(D) O negative

2. Who is the universal plasma donor?

(A) AB
(B) A
(C) B
(D) O

3. Type A positive blood can donate to:

(A) A positive
(B) B positive
(C) AB positive
(D) Both A and C

4. Homologous refers to:

(A) one’s own blood

(B) donated blood
(C) blood products
(D) synthetic blood products

5. If you are Rh positive:

(A) you do NOT have the antigen on the surface of red blood cells
(B) you can donate blood to all patients
(C) you do have the antigen found on red blood cells
(D) you CANNOT receive O negative blood

6. The test used to determine the total number of white blood cells in you blood is:

(A) platelet count

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 (B) white blood cell count
(C) white count differential
(D) CBC

7. Autologous refers to:

(A) your own blood

(B) recipient blood
(C) blood products
(D) a specific blood product

8. What gives red blood it’s color?

(A) Platelets
(B) Neutrophils
(C) Hemoglobin
(D) Hematocrit

9. All are types of white blood cells except:

(A) neutrophils
(B) lymphocytes
(C) astrocytes
(D) monocytes

10. What is the normal white blood cell count in an adult male?

(A) 5.0–6.0
(B) 5,000–10,000
(C) 14–18
(D) 150–400

11. When is the cell saver contraindicated?

(A) When there is a malignancy

(B) When anticoagulants are used
(C) When bacteria is present
(D) All of the above

12. Blood gas analysis is called:

(A) BGA
(B) SAT rate
(C) ABG
(D) ABO

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13. Cross-matching of blood:

(A) determines patient’s blood type

(B) determines Rh factor of both patient and donor
(C) determines suitability of donor by mixing donor RBC’s with recipient serum
(D) determines blood group of donor

14. The highly specialized blood cell whose function is oxygen transportation is:

(A) red blood cell

(B) white blood cell
(C) blood plasma
(D) fibrinogen

15. A differential count provides an estimate of:

(A) the amount of hemoglobin

(B) the volume percentage of red cells
(C) the percentage of each type of white cell
(D) electrolyte percentages

16. Mixing of incompatible bloods may result in:

(A) agglutination
(B) infectious hepatitis
(C) leukocytosis
(D) hyperglycemia

17. Platelets are essential for:

(A) coagulation of blood

(B) controlling of infection
(C) carrying oxygen
(D) combating histamine effect

18. In a normal adult, the average number of leukocytes per cubic millimeter of circulating blood is:

(A) 1,000–4,000
(B) 3,000–8,000
(C) 5,000–10,000
(D) 10,000–15,000

19. Blood or fluid can be quickly delivered to a patient via:

(A) rapid infusion pump

(B) SARA

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 (C) Bair Hugger
(D) Doppler

20. Blood oxygenation can be monitored during surgery by means of a:

(A) blood pressure monitor

(B) arterial catheter
(C) pulse oximeter
(D) CVP catheter

21. The universal donor blood that may be given in extreme emergencies until the patient can be typed and
cross-matched is:

(A) A
(B) B
(C) O
(D) AB

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 Answers and Explanations

1. (D) O negative is the universal blood donor. See reference chart above.

2. (A) AB is the universal plasma donor.

3. (D) A positive can donate to both A positive and AB positive recipients. See reference chart above.

4. (B) Homologous blood refers to blood donated from another person. One’s own blood is autologous.

5. (C) An antigen is found on red blood cells. Most people are Rh positive. If you are Rh positive, you do
have the antigen on your red blood cells. If you are Rh negative, you do not have the antigen on your
red blood cells.

6. (B) White blood cell count is the test used to determine the total number of WBC’s in the blood.
Platelets are needed for clotting. The differential white count determines correct numbers of a specific
white blood cell which can help to determine certain diseases. CBC is a general screening of blood
components.

7. (A) Autologous refers to one’s own blood.

8. (C) Hemoglobin carries the oxygen which gives blood its red color. Platelets are needed for clotting.
Hematocrit is the amount of volume of RBC’s take up in your blood. Neutrophils are a component of
WBC’s.

9. (C) An astrocyte is not a white blood cell. It is a glial cell of the nervous system. Neutrophils,
lymphocytes, and monocytes are three types of white blood cells.

10. (B) 5,000–10,000 is the normal white cell count for both adult males and females.

11. (D) The cell saver should not be used where there is a malignancy present, anticoagulants such as
Avitene are used, or when bacteria is present.

12. (C) Arterial blood gas assesses the oxygen and carbon dioxide in arterial blood, measured by various
methods to assess the adequacy of ventilation and oxygenation and the acid–base status.

13. (C) In a cross-match of blood, the donor RBCs are mixed with the recipient’s serum. If agglutination
does not occur, the recipient does not have antibodies that will attack the donor RBC’s. If no
agglutination (clumping) occurs, the donor’s blood may be safely transfused to the recipient providing

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 all the other criteria have been met.

14. (A) Red blood cells contain oxygen-carrying protein hemoglobin. They are called RBCs or erythrocytes.

15. (C) The differential white count (an estimate of the percentage of each type of white cell) is done using a
stained blood slide. Some blood diseases and inflammatory conditions can be recognized this way.

16. (A) Incompatibility of blood transfusions may be attributable to either the plasma or red cells of the
donor’s blood. The red cells of the donor’s blood may become clumped or held together in bunches.
This process is called agglutination.

17. (A) Platelets are formed by the red bone marrow and are essential for the coagulation of blood and in
maintenance of hemostasis.

18. (C) A normal adult has an average of 5,000 to 10,000 leukocytes per cubic millimeter of circulating
blood, or about 1 leukocyte to 700 erythrocytes. A high white blood count is indicative of infection.

19. (A) a rapid infusion pump aids in rapidly delivering blood or other fluids by means of a pressurized cuff
around the administration bag to exert external force. It may also have a fluid warmer component.

20. (C) The pulse oximeter measures blood oxygenation. The fingertip is commonly used.

21. (C) Type O blood is the universal donor blood. The four main types are A, B, O, and AB.

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 ___________________ CHAPTER 5 ___________________

Aseptic Technique

• Asepsis—without infection
• Sterility—completely free of all viable microorganisms including spores
• Sterility is maintained by aseptic technique
• Preoperative—all duties that are required prior to the incision
• Intraoperative—this phase is from the incision to closure
• Postoperative—all duties from the time the surgery is finished and the dressings are applied
• Masks should be changed between each case
• They cannot hang; they are either on or off
• Sterile people must always wear protective eyewear—either a mask with a face shield or goggles that
protect the eyes from contamination
• The gown is sterile from the midchest to the waist level; the sleeves circumferentially to 2 in above the
elbow
• The white cuffs of the gown are considered unsterile because they are permeable
• Due to evidence based practice, all operating room personnel must double glove on all cases. It also makes
it easier if you contaminate yourself and must change gloves. When double gloving; it is recommended to
wear ½ size larger for the first pair and normal size for the second
• Closed gloving is performed after the surgical scrub and after the gown has been donned
• If the STSR get contaminated during the procedure, the first choice is that another sterile team member
reglove the STSR
• Sterile gloves are also worn for other procedures, not just for surgery (e.g., urinary catheterization)
• When the STSR is standing at the operating room table, the top of the OR table and the top of the back
table are considered sterile. If anything falls below these areas, it is considered contaminated.
• You should not gown and glove off the back table. A separate surface should be used
• The STSR should never sit unless the procedure is performed sitting down
• When entering the OR, wipe down all horizontal surfaces and the overhead OR lights with a disinfectant
• Before opening sterile supplies, check integrity of the item for holes and water spots
• If the item falls to the floor, check for air implosion and make sure the area that touched the floor is clean
and dry. If the item is good, you may open it now for that case only. If you do not use it on that case, the
item must be discarded and not put back on the shelf
• If the item is double wrapped or in a case, check the chemical indicators (tape/plastic indicator) that there

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 has been a color change.
Steam tape—cream-colored lines turn brown when sterilized
ETO tape is green—the lines turn brown when sterilized
• If there is a color change, it still does not mean the item is sterile. It only means the sterilant has met the
parameters of the item. Once sterile, you must check the internal indicators before placing the item on
your sterile field
• It is recommended that the gown and gloves be opened on the Mayo stand, or small gown and glove table
• Check integrity for holes and moisture
• The inner edge of a peel pack is the line between sterile and unsterile
• When opening an envelope-type sterile wrapper, open the first flap away from you
• The inside of paper wrappers containing sterile items is considered sterile except for 1 in around the
outside edge of the wrapper
• Never reach over sterile field
• Two methods of the surgical scrub
Timed method (5–10 minutes depending on the institution)
Counted brush-stroke method
• Two types of microbes we are trying to control:
Transient—live only on the surface of the skin—we can remove these
Resident—live deeper in the skin—we cannot remove them but can only reduce the microbial count
• When rinsing hands, use a unidirectional motion
• The circulator will assist in turning the gown. Hand her the tie and she will proceed around you. You do
not want to turn your back to the sterile field
• The sterile field should be set up as close as possible to the procedure time
• The sterile solutions should be poured into the sterile container that has been placed towards the edge of
the table for easier access for the circulator. When pouring the solution, it must be held 12 in above the
sterile field. You may never recap a solution
• When opening sharps, they should be directly passed to the STSR. That is the correct thing to do. They
may be flipped onto another area, however, it must be stated to the STSR where the item is
• The sterile field must be broken down if the case has been canceled. You cannot cover the sterile field with
a sterile drape and move to another operating room
• When draping a nonsterile surface, always place hands inside a cuff
• When a STSR is draping a nonsterile surface the drape should be opened towards you first and the second
away from you
• The top of a sterile table is considered the only part sterile
• Sterile drapes can never be repositioned
• Strike through—moisture soaking through a sterile barrier
• When clamping a tubing with a metal clamp you must consider the tips of the clamp contaminated as well
as the drape it is attached to. They should not be removed until the end of the surgical procedure

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• A nonsterile person should remain 12 in from the sterile field
• Drapes are considered a physical barrier. Antiseptic prep solutions are considered chemical barriers
• Sterile team members should pass front to front, back to back
• When removing your gown and gloves, remove your gown first, followed by gloves and lastly, your mask
touching the ties only
• Sterile gloves should be removed glove to glove and skin to skin

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 Questions

1. The minimum distance a nonsterile person should remain from a sterile field is:

(A) 6 in
(B) 1 ft
(C) 2 ft
(D) 3 ft

2. Identify which of the following is NOT a safe practice.

(A) Discard opened sterile bottles

(B) Sterile persons drape first toward themselves, than away
(C) Sterile persons face sterile areas
(D) Sterile tables may be covered for later use

3. Tables are considered sterile:

(A) on the top and 2 in below the table level

(B) up to 2 ft off the ground
(C) on the top and in the area that has been pulled close to the sterile field
(D) only on the top

4. At the end of the case, drapes should be:

(A) pulled off and placed in a hamper

(B) rolled off and placed on the floor so they can be checked for instruments
(C) rolled off and placed in a hamper
(D) checked for instruments, rolled off, and placed in a hamper

5. If a solution soaks through a sterile drape:

(A) discard drape and replace it

(B) cover wet area with impervious sterile drape or towel
(C) cover wet area with at least two layers of fabric
(D) fill out an incident report at the end of the case

6. Which of the following is not an acceptable wrapper for gas sterilization?

(A) Nylon

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 (B) Muslin
(C) Paper
(D) Plastic

7. Which of the following is the only acceptable plastic that can be used for a steam sterilization wrapper?

(A) Polyethylene
(B) Polypropylene
(C) Polyamide
(D) Polyvinyl chloride

8. All of the following statements regarding muslin wrappers are true EXCEPT:

(A) muslin must be laundered, even if unused, in order to rehydrate it

(B) a 140 thread count of unbleached muslin is used for wrappers
(C) muslin is flexible and easy to handle
(D) small holes can be repaired by stitching on a patch

9. Packages wrapped in muslin must have:

(A) one thickness

(B) two thicknesses
(C) three thicknesses
(D) four thicknesses

10. The maximum storage life for a muslin wrapped item in a closed cabinet is:

(A) 7 days
(B) 14 days
(C) 21 days
(D) 30 days

11. An item dropped on the floor is considered safe only if:

(A) it is wrapped in woven material

(B) it is enclosed in an impervious material
(C) it is used right away
(D) it is inspected carefully

12. When using a pour solution:

(A) a portion may be poured and the cap replaced

(B) the contents must be used or discarded after the bottle is opened
(C) the cap may be replaced if it has not been placed on a nonsterile surface
(D) the solution may be used on the same case if the cap is not replaced

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13. What is the standard safety margin on package wrappers?

(A) Up to the edge

(B) Less than 1 in
(C) 1 in
(D) None of the above

14. When opening a wrapper, the circulator should open the top flap:

(A) toward self

(B) away from self
(C) after the sides
(D) over sterile field

15. When the scrub nurse drapes a basin stand:

(A) the side nearest the body is opened first

(B) the side nearest the body is opened last
(C) the lateral areas are done first
(D) Both A and B

16. When flipping a sterile item onto the field, the circulator may:

(A) lean over the sterile field to shake item out of package
(B) project item without reaching over the sterile field
(C) shake item into sterile basin stand
(D) lean over sterile linen pack and drop item onto it

17. Gowns are considered sterile only from:

(A) waist to neck level in front and back, and the sleeves
(B) waist to shoulder, front and back, and the sleeves
(C) neck to thighs in front and the sleeves
(D) only in front from chest to sterile field level, and sleeves from elbow to cuffs

18. An acceptable action when drying the hands and arms after the surgical scrub is to:

(A) dry from elbow to fingertip

(B) dry thoroughly, cleanest area first
(C) keep the hands and arms close to the body, at waist level
(D) dry one hand and arm thoroughly before proceeding to the next

19. All of the following statements regarding gowning another person are true EXCEPT:

(A) open the hand towel and lay it on the person’s hand
(B) hand the folded gown to the person at the neckband

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 (C) keep hands on the outside of the gown under a protective cuff
(D) release the gown once the person touches it

20. Which statement regarding the scrub procedure is NOT true?

(A) It reduces the microbial count

(B) It leaves an antimicrobial residue
(C) It renders the skin sterile
(D) It removes skin oil

21. If the scrub nurse needs to change a glove during an operation:

(A) the scrub must also regown

(B) the circulator pulls the glove off
(C) the scrub pulls the glove off
(D) the scrub uses closed gloved technique to reapply gloves

22. Which statement regarding the removal of gown and gloves does NOT meet safe criteria?

(A) The gloves are removed before the gown

(B) The gown is pulled off inside out
(C) The gown is untied by the circulator
(D) The gloves are removed inside out

23. An effective surgical scrub procedure is:

(A) Time method

(B) brush-stroke method
(C) 3-minute anatomic method
(D) Both A and B

24. Regarding the surgical scrub, which statement would violate acceptable practice?

(A) Fingernails that only reach the tip of the finger

(B) Nail polish may be worn if freshly applied
(C) It is okay to scrub with a cut or abrasion
(D) A non–oil-based hand lotion may be used to protect the skin

25. Eyewear, goggles, and/or face shields should be worn:

(A) on every case

(B) on orthopedic cases
(C) on vascular cases
(D) on positive HIV cases

26. The surgical scrub is:

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 (A) sterilization of the skin
(B) mechanical cleansing of the skin
(C) chemical cleansing of the skin
(D) mechanical washing and chemical antisepsis of the skin

27. Scrub technique ends

(A) 2 in below the elbow

(B) just below the elbow
(C) at the elbow
(D) 2 in above the elbow

28. Which statement regarding the surgical scrub indicates INAPPROPRIATE preparation by the scrub?

(A) Wearing artificial nails are acceptable

(B) Nail polish may be worn, if not chipped
(C) Finger nails should not reach beyond fingertips
(D) Skin should be protected with a non–oil-based product

29. Which statement best describes an effective surgical hand scrub?

(A) Time, no anatomical sequence

(B) Number of strokes, no anatomical sequence
(C) Time or number of strokes, hand to elbow sequence
(D) Number of strokes, elbow to hand sequence

30. The brush-stroke method of scrubbing prescribes the number of strokes required. Indicate the number
for each: nails, fingers, hand (back and palm), and arms.

(A) 40, 30, 30, 30

(B) 40, 40, 20, 20
(C) 30, 20, 20, 20
(D) 30, 20, 10, 10

31. Evidence-based practice (EBP) relies on:

(A) opinion and tradition

(B) past evident practices
(C) current practices
(D) science and evidence

32. Standard precautions evolved from a practice called:

(A) universal
(B) aseptic technique

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 (C) EBP
(D) the method of thinking and doing

33. When water comes in contact with a sterile drape or gown, it can cause:

(A) strike through contamination

(B) slippery surface
(C) resident flora
(D) create a potential fire hazard

34. Standards during surgery include all EXCEPT:

(A) nonsterile team members do not pass between two sterile fields
(B) sterile gowns are only considered sterile from the waist to the axillary lines, from hands to shoulders
(C) movement should be kept to a minimum
(D) if there is any doubt about the sterility of the item, consider it contaminated

35. When removing sterile attire, arrange following in proper order (1) remove your gloves, (2) remove your
gown, (3) remove your mask

(A) 1, 2, 3
(B) 1, 3, 2
(C) 2, 1, 3
(D) 3, 2, 1

36. When opening sterile supplies, all the following are proper techniques EXCEPT:

(A) do not readjust the table drape after it has been opened
(B) open the first flap away from you on an unwrapped item
(C) remember not to lean over the sterile field
(D) when opening items in a peel pouch, slowly allow the item to slide out of the package onto the
sterile field

37. When opening supplies for a case, what should be passed directly to the scrub or flipped in an area
where they are clearly visible?

(A) Medications
(B) 10-cc syringe
(C) Peanuts
(D) Blades

38. Sterile personnel must pass each other:

(A) right to left

(B) should never pass each other

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 (C) back to back, front to front
(D) does not really matter because gowns that wrap around are used

39. What is known as the center of your sterile field?

(A) Back table

(B) Mayo
(C) Surgeon
(D) Draped patient

40. If there is a break in sterile technique during the procedure, the STSR should tell:

(A) the surgeon

(B) the person who broke technique
(C) the circulator
(D) everyone in the lounge

41. Which condition regarding sterile technique is NOT recommended?

(A) Sterile tables are set up just before the operation

(B) Sterile tables may be set up and safely covered until time of surgery
(C) Once sterile packs are open, someone must remain in the room to maintain vigilance
(D) Sterile persons pass each other back to back

42. Which of the following conditions is NOT an acceptable aseptic technique?

(A) Scrub nurse standing on a platform or standing stool

(B) Scrub nurse keeps hands below shoulder level
(C) Scrub nurse folds arms with hands at axillae
(D) Scrub nurse’s hands are at or above waist level

43. When a sterile item is hanging or extending over the sterile table edge, the scrub nurse:

(A) must watch closely that no one comes near it

(B) does not touch the part hanging below table level
(C) should pull it back onto the table so it does not become contaminated
(D) may use the item

44. Which of the following is considered a break in technique?

(A) A sterile person turns his or her back to a nonsterile person or area when passing
(B) Sterile persons face sterile areas
(C) A sterile person sits or leans against a nonsterile surface
(D) Nonsterile persons avoid sterile areas

45. In which situation should sterility be questioned?

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 (A) If a sterilized pack is found in an unsterile workroom
(B) If the surgeon turns away from the sterile field for a brow wipe
(C) If the scrub drapes a nonsterile table, covering the edge nearest the body first
(D) If the lip of a pour bottle is held over the basin as close to the edge as possible

46. When handing skin towels to the surgeon, where should the scrub person stand in relation to the
surgeon?

(A) On the opposite side of the table

(B) On the same side of the table
(C) At the foot of the table
(D) Any position is acceptable

47. According to CDC guidelines, each of the following actions by a scrub person prevents wounds and
punctures EXCEPT:

(A) use an instrument to remove blades

(B) recap injection needles
(C) account for each needle as surgeon finishes with it
(D) protect sharp blades, edges, and tips

48. Which of the following is NOT an acceptable technique when draping a patient?

(A) Hold the drapes high until directly over the proper area
(B) Protect the gloved hands by cuffing the end of the drape over them
(C) Unfold the drapes before bringing them to the OR table
(D) Place the drapes on a dry area

49. The procedure to follow if a hair is found on the operative field is to:

(A) notify circulator

(B) complete an incident report
(C) remove it with a clamp, cover over area
(D) no action is necessary

50. If the floor or wall becomes contaminated with organic debris during a case, the circulator:

(A) calls housekeeping stat

(B) decontaminates promptly
(C) decontaminates after case is complete
(D) defers for terminal cleaning

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101
 Answers and Explanations

1. (B) All nonsterile persons should remain at least 1 ft from any sterile field.

2. (D) Sterile tables should be set up just before the surgical procedure. Covering of tables is not
recommended.

3. (D) A sterile draped table is considered sterile only on the top. The edges and sides extending below
table level are considered nonsterile.

4. (D) Check drapes for instruments. Roll drapes off the patient to prevent sparking and airborne
contamination. Wet areas should be placed in the center to prevent soaking through the laundry bag.

5. (B) If a solution soaks through a sterile drape to a nonsterile area, the wet area is covered with
impervious sterile drapes or towels.

6. (A) Nylon is not used for ethylene oxide (EO) sterilization because of inadequate permeability; however,
muslin, nonwoven fabric, paper, and plastic are safely used. Items wrapped for gas sterilization should
be tagged to avoid inadvertent steam sterilization.

7. (B) Polypropylene film of 1- to 3-mm thickness is the only plastic acceptable for steam sterilization. It is
used in the form of pouches presealed on two or three sides. The open sides are then heat sealed.

8. (D) Small holes can be heat sealed with double vulcanized patches; they can never be stitched because
this will leave needle holes in the muslin.

9. (D) Muslin wrappers must have two layers of double thickness (four thicknesses) to serve as a sufficient
dust filter and microbial barrier. A 140-thread count muslin is used for wrappers.

10. (D) The storage life for muslin is 30 days maximum in closed cabinets. Muslin wets easily and dries
quickly so water stains may not be obvious. On open shelving, the storage life is 21 days.

11. (B) If a sterile package is dropped, the item may be considered safe for immediate use only if it is
enclosed in an impervious material and the integrity of the package is maintained. Dropped items
wrapped in woven materials should not be used.

12. (B) After a sterile bottle is opened, the contents must be used or discarded. The cap cannot be replaced
without contamination of the pouring edges. The edges of anything that encloses sterile contents are
considered nonsterile.

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13. (C) A 1-in safety margin is usually considered standard on package wrappers. After a package is open,
the edges are nonsterile.

14. (B) The top flap is opened away from self, the sides turned under, and secured. The last flap is pulled
toward the person opening the package.

15. (A) When a scrub nurse is draping a ring stand, the side nearest the body is opened first. The portion of
the drape then protects the gown, enabling the nurse to move closer to the table to open the opposite
side.

16. (B) When flipping a sterile item onto a sterile field, the circulator may never reach over the sterile field
and shake the item from the package.

17. (D) Gowns are considered sterile only in front from chest to level of sterile field, and the sleeves from
elbow to cuffs.

18. (B) The STSR should bend forward slightly at the waist holding hands and elbows away from the body.
Dry both hands and arms independently starting at the fingertips which are the cleanest area, to 2
inches above the elbow.

19. (B) Before handing a gown, unfold it carefully, holding it at the neckband.

20. (C) The surgical scrub removes skin oil, reduces the microbial count, and leaves an antimicrobial residue
on the skin. The skin can never be rendered sterile (aseptic). It is considered surgically clean.

21. (B) To change a glove during an operation, the scrub nurse must turn away from the sterile field. The
circulator pulls the glove off inside out, and the open-glove technique is used to don a new pair of
gloves.

22. (A) The gown is always removed before the gloves. It is pulled downward from the shoulders, turning
the sleeves inside out as it is pulled off the arms. Gloves are turned inside out, using the glove-to-glove
then skin-to-skin technique as they are removed. The circulating nurse unfastens the gown at the neck
and waist.

23. (D) Either the time method or brush-stroke method is effective if properly executed. Studies have shown
that a vigorous 5-minute scrub with a reliable agent is as effective as the 10-minute scrub with less
mechanical action.

24. (C) Persons with an open wound/abrasion should not scrub.

25. (A) Eye protection or masks with face shields should be worn on all surgical cases to avoid direct contact
with blood and body fluids.

26. (D) The surgical scrub is the process of removing as many microorganisms from the hands and arms by
mechanical washing and chemical antisepsis.

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27. (D) The arm is scrubbed, including the elbow and the antecubital space to 2 in above the elbow.

28. (A) Artificial nails are never acceptable in the operating room.

29. (C) Time varies with the frequency of the scrub, the agent used, and the method used. The procedure
may be time method or counted brush stroke, each of which follows an anatomical pattern of scrub
ending 2 in above the elbow. All steps begin with hands and end with elbow, with the hands having
most direct contact.

30. (C) The nails are scrubbed 30 strokes; all sides of each finger, 20 strokes; the back of the hand and palm,
20 strokes; and the arms, 20 strokes to 2 in above the elbow.

31. (D) Scientific investigation and discovery supersede old practices; it considers only the best on current
study and proof. An example is double gloving in the old days was only done on orthopedic cases. The
current practice is for all surgical personnel to double glove for all cases. This is due to EBP.

32. (A) Standard precautions evolved from a policy called universal precautions. They were originally
established to prevent the spread of HIV and AIDS.

33. (A) This occurs when moisture from either side of the drape serves as a vehicle for bacteria to infiltrate
the drape from a nonsterile surface.

34. (B) Sterile gowns are considered sterile only in the front from the axillary lines to the waist, from the
hands to the elbows.

35. (C) Gown first, then gloves, and mask last.

36. (D) Items wrapped in peel pouches are delivered directly to the scrub.

37. (D) Scalpel blades and other sharps should be passed directly to the scrub or flipped on to an open area
where they are visibly seen.

38. (C) Sterile personnel pass each other back to back or front to front.

39. (D) The draped patient is the center of your sterile field during surgery.

40. (B) If there is a break in technique during a procedure, the person who broke technique should be told
and correct actions should be taken.

41. (B) Covering sterile tables for later use is not recommended because it is difficult to uncover a table
without contamination

42. (C) Hands are kept at or above waist level, away from the face and arms, and never folded, because there
may be perspiration in the axillary region.

43. (B) Anything falling or extending over a table edge is unsterile. The scrub person does not touch the part

104
 hanging below table level.

44. (C) Sitting or leaning against a nonsterile surface is a break in technique because a sterile person should
keep contact with nonsterile areas to a minimum.

45. (A) If sterility is doubtful, consider it not sterile. Do not use a pack, even if it appears to be sterile, if it is
found in a nonsterile workroom.

46. (B) The scrub who hands the drapes to the surgeon should stand on the same side of the table in order
to avoid reaching over the unsterile OR table.

47. (B) Do not recap used injection needles.

48. (C) Drapes should be carried to the OR table folded to prevent them from coming in contact with
unclean items in transport.

49. (C) A hair found on a drape must be removed with a hemostat; hand instrument off of field, and cover
the area with a suitable drape.

50. (B) Decontaminate floor and walls promptly during operation if contaminated by organic debris. Use a
broad-spectrum detergent disinfectant and wear gloves. This action helps prevent microorganisms from
drying and becoming airborne.

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 ___________________ CHAPTER 6 ___________________

Sterilization and Disinfection

• Asepsis—absence of disease causing microorganisms

• Sterile—free of all living microorganisms including spores
• Surgically clean—mechanically and disinfected but not sterile
• Strike through contamination—contamination of the sterile field with fluid through a puncture or
absorbing through the drapes
• Aeration—this is the way ethylene oxide is removed from the sterilized items
• Aerobes—microorganisms that cannot live without oxygen
• Anaerobes—microorganisms that are able to survive without oxygen
• Bacteria—all living cells are classified into two groups:
Prokaryotes—they divide by the process of binary fission. No nucleus
Eukaryotes—they include fungi, algae, plant and animal cells. Has a nucleus
Bacteria divide by binary fission
• Binary fission—the asexual reproduction of a cell by division into two identical cells
• Bactericide—kills bacteria
• Bacteriostatic—prevents the growth of bacteria
• Bioburden—the amount of microorganisms on an item before sterilization
• Biological indicator—a sterilization monitoring system used to test the effectiveness of the sterilization
process used
• Contamination—presence of microorganisms on animate living and nonliving objects
• Decontamination—process by which chemical or physical agents are used to clean inanimate objects,
noncritical surfaces
• SSI—surgical site infection. Factors that increase SSI infections include:
Age
Obesity
General health
• Shaving a patient should be performed the day before surgery to avoid SSI
• Using an electrical razor is preferred then using a razor to prevent cuts that can become infected
• Deep incisional SSI—an infection involving deep tissue
• Disinfection—not used on tissue. Chemical or physical process of destroying most forms of pathogenic
microorganisms, used for inanimate objects

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• High-level disinfection—the process that destroys all microorganisms if the contact time with the item is
sufficient
• Intermediate-level disinfection—the process that destroys inactive vegetative bacteria and most fungi and
viruses but not bacterial endospores
• Low-level disinfection—the process that destroys most bacteria, some viruses, and some fungi but not
bacterial endospores
Always use sterile distilled water to rinse items
• Flash sterilization—a sterilization process that is used for immediate patient use using the steam
sterilization method. It is usually done in the or in the substerile room autoclave
• Fungicide—kills fungi
• Immunity—resistant to infection
Naturally acquired active immunity—when you are exposed to the disease, you get it and as a result you
become immune
Artificially acquired active immunity—when you receive a vaccine and become immune
Artificially acquired passive immunity—when you receive an immunization such as a gamma globulin. It
is a short-term immunization
Naturally acquired passive immunity—this occurs during pregnancy when a pregnant woman passes the
antibodies to her fetus through the blood stream long
• Infection—invasion microorganisms in body tissues causing damage
• Nosocomial infection—an infection that was acquired in the hospital, they include:
UTI
SSI
Lung infection
Infection in the blood
• Pasteurization—this is a heating process of destroying pathogenic microorganisms such as in milk or wine
• Parasites—microorganisms that live on or within living organisms. Some are:
Obligatory—means they depend on living tissue
Facultative—meaning they can live on dead tissue
• Pathogen—any disease producing microorganisms
Resident microorganisms—these are microorganisms that live deep in the epidermis
Transient microorganisms—these are microorganisms that live on the surface of the epidermis
• Mutualism—when different organisms exist and benefits from the other
• Commensalism—when one organism benefits from the other and neither is harmed
• Parasitism—this is when one organism benefits from the other and harms the host
• Virucide—kills viruses
• Viruses—some examples of a virus include: HIV, herpes simplex, hepatitis B, C, D
• MRSA—Methicillin-Resistant Staphylococcus Aureus—this is a virus that is resistant to most all
antibiotics; the only antibiotic that works on this virus is vancomycin. MRSA is highly contagious

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• Creutzfeldt–Jakob disease—this is a fatal neurodegenerative disease of the central nervous system (brain)
caused by a human prion
• Prion—this is the smallest infectious particle; it is neither a viral, bacterial, nor fungal
Prions are also responsible for the disease known as mad cow disease. There is no known form of
transmission
This prion causes holes in the brain
There is no sterilization process that kills these prions. When surgery is performed on these patients we
use disposable instruments so they can be disposed of
They have no DNA/RNA
• Staphylococcus aureus—these microorganisms are found in respiratory tract, nasal passages, and skin. This
is a gram-positive microbe
• Gram-positive—purple
• Gram-negative—red
• Enterococci—found in the normal flora of the GI tract and female genital tracts
• Streptococci—found in the GI tracts, upper respiratory tracts, and genitourinary tracts
• Clostridia
Clostridium Perfringens—responsible for gas gangrene
C. Tetani—tetanus
C. Difficile—the normal flora in the intestines is altered usually caused by the over use of antibiotics
causing severe diarrhea, dehydration and in some cases death. Very contagious
• Mycobacterium tuberculosis—it is transmitted directly from the respiratory tract, causing TB
• The most common bioterrorist agents include:
Anthrax
Smallpox
Plague (pneumonic, bubonic)
Tularemia (types of insect bites)
Botulism
• New infectious diseases emerging in the United States include:
SARS—severe acute respiratory syndrome
West Nile virus
Avian influenza
H1N1 virus—flu
• Central Processing Department—central processing department is made up of a decontamination area,
instrument room, sterile processing area, and sterile storage area
Personnel in this department wear PPE (personal protective equipment) they include:
Waterproof aprons
Caps
Face-shields

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 Gloves that are used for chemical disinfection these are not surgical gloves or patient care gloves
• Spaulding’s classification of patient care items—Spaulding was a microbiologist who developed a method
of classifying the levels of processing equipment to be used on patient care items
Critical items—they must be sterile because they enter sterile body tissue and the vascular system,
examples include:
Surgical instruments
Endoscopic equipment that cut tissue
Catheters
Implants
Needles
Semicritical items—they require high-level disinfection because they come in contact with skin and
mucous membranes, they go into the mouth, and urinary tract. Examples include:
Respiratory equipment
Anesthesia equipment
Bronchoscopes
Colonoscopes
Gastroscopes
Cystoscopes
• Noncritical items—require low-level disinfection because they only come in contact with skin. Examples
include:
Blood pressure cuffs
Furniture
Linens
• Chemical disinfectants
Alcohol—used in housekeeping to damp dust lights, furniture, etc.
Intermediate-level disinfection
Used on semicritical items
Chlorine compounds—they are limited to housekeeping disinfection for spot cleaning of blood and
body fluids
Household bleach—sodium hypochlorite
Low-level disinfectant—can be high level depending on concentration and pH
Used on noncritical items
Formaldehyde—is a high-level disinfectant used for surgical instruments
Kills TB, and viruses when items soak for 10 minutes
Sporicidal when soaking for 12 minutes
Fumes irritate the eyes and mucous membranes. All items that come in contact with formaldehyde
must be rinsed with sterile distilled water
High-level disinfectant

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 Used on critical items
Glutaraldehyde—Cidex
Used on surgical instruments, can also be used on rubber and plastic
A 2% solution is considered a high-level disinfectant
Kills bacteria, fungi, virus, HIV
HBV when soaked for 10 minutes
Kills TB when soaked for 45–90 minutes
Kills spores in minimum of 10 hours
Odor and fumes are irritating to mucous membranes, eyes, respiratory tract
The solution can be reused, it is kept in a basin with a cover
It has a shelf life of 14–30 days (manufacturer instructions)
Instruments must be washed first, rinsed with sterile water, dried, and totally submerged in the
solution. All lumens must also be filled with the solution. After the appropriate time for disinfection
the instruments must be rinsed again with sterile water
High-level disinfectant
Used on critical/semicritical items
Iodophors—iodine compound, used for housekeeping
Low-level disinfectant
Used on noncritical items
Quaternary ammonium compounds—known as quats—they kill bacteria, fungi
Low-level disinfectant
Used on noncritical items
Hydrogen peroxide—kills bacteria, fungi, virus, TB
Low-level disinfectant
Noncritical items
• Instrument cleaning—combines manual, mechanical, chemical, and physical decontamination process
Washer-sterilizer/decontaminator:
All bioburden must be washed and rinsed from the instruments by hand
Instruments are then reassembled—all box locks on instruments are open, and instruments
disassembled such as the Balfour retractor, blade, and wing nuts
Instrument sets are placed in the washer-sterilizer and the cycle begins
Ultrasonic cleaner:
the ultrasonic cleaner works by cavitation (high frequency sound waves). This removes small organic
particles that the washer-sterilizer cannot reach
• Power equipment—should never be submerged in water or a cleaning solution, or placed in any of the
mechanical decontaminating machines Proper cleaning includes:
Keep cords attached to drill while cleaning to prevent any solutions from entering into the cord or drill
Wash cord and drill with neutral detergent. Never use alcohol on these items as it will harden and crack

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 the cord
Rinse all components with distilled water and dry
• Instruments with lumens—(trocars, nondisposable tonsil suction tips)
Flush the lumen with Hydrogen peroxide until it runs clear and rinse with distilled water
Hand clean the outside with neutral detergent
The inside with a brush
• Decontamination of endoscopes
Rigid
Clean all lumens as noted above and soak rigid scope in an enzymatic solution
Using a water pressure gun you rinse and dry the instrument
Do not hit the lens, and do not tightly wind or kink the light cord you will break the fibers in the cord
Flexible endoscope
ports are cleaned with a small brush
soak in enzymatic solution with the ports open
Wash the outside manually with neutral detergent
Be careful with lens and cords and scope itself
Dry all scopes before storing
Basins
Must be separated by a cloth towel when sterilized together
Never place sponges in the basin when sterilizing
Place basins on their sides when sterilizing
They should not weigh more than 7 lb
• Drape packs
Must not exceed a maximum of 12 × 12 × 20
Must not weigh more than 20 lb
They are placed on their side close to the edge when sterilizing
• Rubber and plastics
Tubing’s, catheters, and drains require a residual of distilled water in their lumens when sterilizing
Tubing’s should not be kinked
• Wood products—should be packaged and sterilized separately, an example would be:
An orthopedic instrument with a wooden handle
Repeated sterilization cracks the wood
• Oils/petroleum products/talc’s—sterilized by dry heat sterilizers. Examples include:
Convection oven
Gravity convection oven
• Rubber goods—tubing’s, catheters, and drains must have a residual of sterile distilled water in their lumen
All tubing’s that are coiled must not have kinks
Most of this equipment is disposable and is the preferred method

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• Peel packs
Choose the correct size wrapper
The pack should be heat sealed unless it has an adhesive tape. If it does, it may be used
Never use staples/rubber bands
Write only on the plastic
Instruments/equipment with sharp edges should have protective paper, foam sleeves to prevent the sharp
tip from coming through the pack
Peel packs are placed on their side in the autoclave
• Julian date indicates the date of sterilization
It is attached to the item with a labeling gun
Example—February 27, 2012 is the date of sterilization- the Julian date is 58 (count from January 1 to
February 27 = 58)
• Woven fabrics
Reusable, also called muslin or linen
Made of 100% cotton, muslin
After each use and wash they must be inspected for holes
You cannot stitch the material if there is a hole it will make more holes a patch is used
140 thread count is used
This is not moisture resistant and requires double wrapping
When using muslin wraps the recommended maximum size of a linen pack is 12 × 12 × 20 (12 in high ×
12 in wide × 20 in long)
• Nonwoven fabrics
These are disposable wrappers for single use only
They come in a variety of sizes to accommodate different items to be sterilized
Paper is a type of nonwoven material difficult to work with because it has extreme memory
• Chemical indicators
Autoclave tape on the outside of wrapped items (tape changes colors when exposed to the sterilent and
temperature)
Steam sensitive tape is tan and reveals dark stripes when exposed to steam sterilization
Gas sensitive tape is light green and reveals dark stripes when exposed to gas sterilization
Internal steam indicators are placed on the inside of the instrument sets
Rigid containers have a plastic indicator that is attached to the outside locking devices; a black dot
appears when exposed to the sterilent and temperature
• Biological indicator—this is the only true indication that all sterilization conditions have been met
The biological microorganism used in steam sterilizers is Geobacillus stearothermophilus
The biological microorganism used for ETO is Bacillus atrophaeus/Geobacillus subtilis
The biological indicator is placed in the most difficult area in the autoclave for the sterilent to reach
Incubation period is 48 hours

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• Chemical sterilization
ETO—ethylene oxide gas sterilization
Used to sterilize items that are sensitive to heat and moisture
The process interferes with the microorganisms metabolism and results in cell death
ETO must be carefully regulated because it is highly toxic, explosive, and flammable
Aeration is required after every cycle
• Radiation sterilization—gamma ray and beta particle sterilization
Cobalt 60 is a type of isotope that produces gamma rays used for sterilization
Back table covers and all manufactured packs are sterilized by cobalt 60
• Bowie–Dick test—chemical indicator used with a prevacuum sterilizer to test if the air has been removed
from the cycle
• Flash sterilization—a fast sterilizing process for unwrapped instruments that are to be used immediately
Minimum exposure time to the sterilization process is 270–275°F for 3 minutes for instruments, and 4
minutes for porous items
• Gravity displacement sterilizer—a steam sterilizer that uses a downward motion to remove air from the
sterilizing chamber. Air is pushed down near the front lower chamber
Air is heavier than steam and pushes the air out
Minimum exposure time to the sterilization process is:
15 minutes at 250–254°F
15–17 psi ( pounds per square inch)
Time/temperature/pressure
The total cycle is about 30 minutes
No living thing can withstand steam at 270°F for 15 minutes
• Indicators
Biological indicators—are the best and most effective indicators to prove sterility, they are living spores
The bacterial spore used in the biological indicator for steam sterilization is Geobacillus
stearothermophilus
This test is performed daily and when implants are used
The enzyme in the biological indicator will turn a fluorescent yellow within 60 minutes as the
endospores are killed
• Prevacuum sterilizer—a fast steam sterilizer that removes air by a vacuum before filling the chamber with
steam
Time/temperature/pressure are the three components needed for sterilization
The complete cycle time is less in the prevacuum sterilizer than in the gravity displacement sterilizer
Gravity displacement 30 minutes
Prevacuum is 15–20 minutes
Exposure time:
270–276°F for a minimum of 4 minutes

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 27 psi
• Ethylene oxide gas sterilization—used on items that cannot be sterilized with heat and moisture (e.g.,
plastics, some scopes, cameras)
Highly flammable, explosive, and toxic
ETO is mixed with carbon dioxide to reduce its flammability
For ETO to be highly effective it depends on 4 parameters:
Concentration of the gas
Temperature
Humidity
Time
Sterilization takes from 3–5 hours depending on the size of the chamber and load
Aeration is essential because ETO can be toxic to humans
The items must be aerated for 8 hours. at 140°F
The biological indicator must be incubated for 48 hours before it is read
• Dry heat sterilization—not used in the operating room
Used for oils (mineral oil is used for dressings), petroleum products, and talc
Biological indicator used for dry heat ovens are B. atrophaeus
Examples include:
Mechanical convection ovens
Gravity convection ovens
• Hydrogen peroxide plasma sterilization—a cloud or glow of pink plasma covers the items to be sterilized,
it kills all microorganisms including spores

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115
 Questions

1. The amount of pressure necessary in a steam sterilizer set at 250°F is:

(A) 15–17 lb
(B) 20–22 lb
(C) 22–25 lb
(D) 25–27 lb

2. Positive assurance that sterilization conditions have been achieved can only be obtained through:

(A) biological control test

(B) heat-sensitive tape
(C) color change monitor
(D) mechanical indicator

3. A wrapped tray of instruments is sterilized in a gravity displacement sterilizer at 250°F for:

(A) 10 minutes
(B) 15 minutes
(C) 30 minutes
(D) 40 minutes

4. The minimum exposure time for unwrapped instruments in a flash sterilizer that is set at 270°F (132°C)
is:

(A) 2 minutes
(B) 3 minutes
(C) 5 minutes
(D) 7 minutes

5. When steam is used to sterilize a rubber tubing or catheter:

(A) the lumen must be dried thoroughly before the process begins
(B) a rubber band may be placed around it so it does not unwind
(C) it should be fanfolded before wrapping
(D) a residual of distilled water should be left inside the lumen

6. To be sterilized effectively, a linen pack must not weigh more than:

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 (A) 12 lb
(B) 14 lb
(C) 16 lb
(D) 18 lb

7. Gravity displacement utilizes ________ to destroy microorganisms.

(A) gas
(B) radiation
(C) gamma rays
(D) steam

8. The process called cavitation occurs in the:

(A) moist heat sterilizer

(B) ultrasonic cleaner
(C) high-speed pressure sterilizer
(D) washer–sterilizer

9. All of the following statements regarding instrument sets are true EXCEPT:

(A) instruments must be placed in perforated trays

(B) heavy instruments are placed on the bottom
(C) all instruments must be closed
(D) all detachable parts must be disassembled

10. All of the following statements regarding steam sterilization are true EXCEPT:

(A) flat packages are placed on the shelf on edge

(B) small packages, placed one on top of the other, are crisscrossed
(C) basins are placed on their sides
(D) solutions may be autoclaved along with other items as long as they are on a shelf alone

11. Wrapped basin sets may be sterilized by steam under pressure at 250°F for a minimum of:

(A) 5 minutes
(B) 10 minutes
(C) 15 minutes
(D) 20 minutes

12. Which of the following statements regarding the sterilization of basin sets is TRUE?

(A) Basins must be separated by a porous material if they are nested

(B) Sponges and linen may be packaged inside the basin to be sterilized
(C) Basins are placed flat in the autoclave

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 (D) Basins must always be placed on the top shelf of the autoclave in a combined load

13. Why would gas sterilization be chosen over steam sterilization?

(A) It is less expensive

(B) It is less damaging to items
(C) It is faster
(D) It is more effective

14. The chemical agent used in gas sterilization is:

(A) ethylene glycol

(B) ethacrynate sodium
(C) ethyl chloride
(D) ethylene oxide

15. What chemical system uses peracetic acid as the sterilant?

(A) Ozone gas sterilization

(B) STERIS
(C) Sterrad
(D) Vapor phase sterilizer

16. The lumen of a tubing undergoing ethylene oxide (EO) sterilization is:

(A) well lubricated

(B) dried thoroughly
(C) prepared with a residual of distilled water
(D) prepared with a NaCl flush

17. The commercial name for glutaraldehyde is:

(A) peracetic acid

(B) phenol
(C) Quats
(D) Cidex

18. A 30-minute single-use sterilization system useful for endoscopes is:

(A) STERIS
(B) ETO
(C) steam under pressure
(D) cold sterilization

19. Which of the following is essential when using shelf of the autoclave in a combined load-activated
glutaraldehyde for sterilization?

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 (A) Items must be rinsed thoroughly in sterile water before use
(B) The solution must be heated in order to be effective
(C) The items must be thoroughly moistened before placement in solution
(D) The item must be air dried before use

20. What is the shelf life of Cidex?

(A) 14 days
(B) 7 days
(C) 1 month
(D) Indefinite

21. In which procedure would the use of a high-level disinfectant be acceptable instrument preparation?

(A) Suction lipectomy

(B) Tracheotomy
(C) Cystoscopy
(D) Mediastinoscopy

22. In a high-speed flash sterilizer, unwrapped instruments are exposed for a minimum of:

(A) 1 minute
(B) 3 minutes
(C) 5 minutes
(D) 10 minutes

23. To kill spores, an item must be immersed in a 2% aqueous solution of glutaraldehyde for:

(A) 20 minutes
(B) 2 hours
(C) 10 hours
(D) 24 hours

24. When placing tubing in an activated glutaraldehyde solution, one should:

(A) use a shallow container

(B) be certain that the interior of the tubing is completely filled
(C) moisten it thoroughly before submersion
(D) Both B and C

25. What is the role of moisture in EO sterilization?

(A) The items will dry out during the process if no humidity is added
(B) The sterilizer will deteriorate from gas over a period of time if no moisture is added
(C) Dried spores are resistant to the gas, so they must be hydrated

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 (D) Moisture is not an essential element in gas sterilization

26. “Slow exhaust” in a gravity displacement steam sterilizer is used for:

(A) plastics
(B) solutions
(C) rubber
(D) drape packs

27. What is the function of an aerator in EO sterilization?

(A) It is used to aerate items before sterilization

(B) It is a separate unit used to decrease the aeration time
(C) It is the last cycle in the EO sterilizer, which helps exhaust the gas and add air
(D) It adds air to the cycle, which is essential for obtaining item sterility

28. Ethylene oxide destroys cells by:

(A) interfering with the normal metabolism of the protein and reproductive processes
(B) coagulating cell protein
(C) converting ions to thermal and chemical energy causing cell death
(D) shrinking the cell

29. Activated glutaraldehyde is used to disinfect endoscopes for:

(A) 5 minutes
(B) 10 minutes
(C) 20 minutes
(D) 60 minutes

30. When using a high-level disinfectant, always:

(A) submerge items while wet

(B) rinse items with sterile distilled water before using
(C) soak items in saline before using
(D) add hot diluent to activated agent

31. The chemical sterilant used in the STERIS method of sterilizing is:

(A) formaldehyde
(B) Cidex
(C) ethylene oxide
(D) peracetic acid

32. How should basins be positioned in the autoclave for sterilization?

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 (A) Stacked on top of each other
(B) On their sides
(C) Upside down
(D) Does not matter

33. Gravity displacement, steam sterilizers operate on the principle that:

(A) air is heavier than steam

(B) air and steam have equal weight
(C) steam is heavier than air
(D) water is heavier than air

34. The process of terminal decontamination follows every surgical case. Decontamination of the walls
consists of:

(A) cleaning all walls up to 3 ft

(B) cleaning all walls up to 1 ft
(C) spot clean where soiled
(D) always clean with alcohol

35. Which of the following kills bacterial spores?

(A) Sterilant
(B) Germicide
(C) Antiseptic
(D) Fungicide

36. Instrumentation and equipment are processed according to their level of risk. This system is known as:

(A) evidence-based practice

(B) the Spaulding method
(C) reprocessing
(D) central monitoring

37. According to the Spaulding system, what risk is assigned to sterile body tissue including the vascular
system?

(A) Critical
(B) Semicritical
(C) Noncritical
(D) Intermediately critical

38. What method of sterilization is used on objects that cannot tolerate heat, moisture, and the presence of
steam sterilization?

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 (A) Gravity displacement
(B) ETO
(C) Hydrogen peroxide
(D) Cidex

39. Gluteraldehyde is a high-level disinfectant, that is, a sporicidal, a bacteriocidal, and a virocidal at a 2%
concentration for _______, it is also a tuberculocidal.

(A) 10 minutes
(B) 15 minutes
(C) 20 minutes
(D) 40 minutes

40. Chemical monitors are placed inside and outside of all packs to be sterilized. This monitor shows:

(A) the item is sterile

(B) proper packaging is achieved
(C) the parameters such as heat and pressure have been reached
(D) the proper time has been met

41. To achieve 270°F, the required pressure is:

(A) 15 psi
(B) 20 psi
(C) 27 psi
(D) 40 psi

42. Why is ethylene oxide diluted with an inert gas?

(A) It increases its effective sterilization

(B) It adds convenience and speed
(C) It adds humidity
(D) It helps with aeration

43. Bioburden refers to:

(A) the degree of microbial contamination

(B) a hospital acquired infection
(C) a chemical agent
(D) high-level disinfectant

44. Sterility was previously measured by time but is now considered invalid. The principle now used is:

(A) carefully checking sterile indicators

(B) event-related sterility

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 (C) terminal sterilization
(D) Both B and C

45. The following statements regarding wrapping materials are true EXCEPT:

(A) Disposable nonwoven wrappers are intended for one use only
(B) You can use two 140 thread count per square inch
(C) You can use one 280 thread count per square inch
(D) Peel pouches can be used on all instruments including large heavy instruments and micro
instruments

46. Gastrointestinal endoscopes are characterized _______ under the Spaulding sterilization system.

(A) critical
(B) noncritical
(C) semicritical
(D) scopes are not considered in the Spaulding system

47. All are environmental disinfectants used for low-level disinfection and terminal decontamination
EXCEPT:

(A) glutaraldehyde
(B) hypochlorite
(C) quaternary ammonium compound
(D) alcohol

48. Personal protective equipment (PPE) includes all of the following EXCEPT:

(A) protective eyewear

(B) facemask
(C) surgical and/or patient care gloves
(D) full protective body suit or gown

49. Most packaged sterilized equipment from a manufacturer such as sutures, sponges, and disposable
drapes are sterilized by means of:

(A) ETO
(B) Cobalt 60 (ionizing radiation)
(C) gravity displacement sterilizer
(D) quaternary ammonium compounds

50. Which is not a method of sterilization but is a heating process that destroys microorganisms at a
temperature and exposure time but does not alter their chemical makeup:

(A) decontamination

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 (B) pasteurization
(C) hydrogen peroxide plasma sterilization
(D) ETO gas sterilization

51. What is the immunity referred to when you are exposed to the disease and as a result you become
immune:

(A) naturally acquired active immunity

(B) artificially acquired active immunity
(C) artificially acquired passive immunity
(D) naturally acquired passive immunity

52. An obligatory parasite is:

(A) a type of prion

(B) a type of microorganism that depends on living tissue to survive
(C) a type of microorganism that depends on dead tissue to survive facultative parasite
(D) All of the above

53. The only antibiotic that works on MRSA is:

(A) gentamycin
(B) amoxicillin
(C) tobramycin
(D) vancomycin

54. All are true regarding a prion EXCEPT:

(A) Creutzfeldt–Jakob disease

(B) they contain DNA/RNA
(C) It is neither viral, bacterial, nor fungal
(D) When performing surgery on a patient that is infected with a prion, we should use disposable
instruments

55. ______ is when different organisms exist and benefit from the other. ______ is when one organism
benefits from the other and neither is harmed. _____ is when one organism benefits from the other and
harms the host:

1. Parasitism 2. Mutualism 3. Commensalism

(A) 1, 2, 3
(B) 3, 2, 1
(C) 2, 3, 1
(D) 1, 3, 2

56. Bioterrorist agents include all EXCEPT:

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 (A) anthrax
(B) botulism
(C) small pox
(D) bubonic plague

57. New infectious diseases emerging in the United States include:

(A) SARS
(B) West Nile virus
(C) avian influenza
(D) All of the above

58. The chemical name for common household bleach is:

(A) sodium hypochlorite

(B) quaternary ammonium compounds
(C) petroleum products
(D) hydrogen peroxide

59. Personal protective equipment includes all EXCEPT:

(A) goggles
(B) surgical and/or patient care gloves
(C) facemask
(D) protective body clothing

60. Instruments and equipment are processed according to their level of risk. This system is known as:

(A) ETO sterilization

(B) event related sterility
(C) the Spaulding method
(D) instrument cleaning and disinfection

61. What is the test that is used to check for air trapped in the prevacuum sterilizer?

(A) Biological indicator

(B) Bowie–Dick test
(C) Chemical indicator
(D) Prevacuum test

62. The bacterial spore used in the biological indicator for steam sterilization is Geobacillus
stearothermophilus when killed within 60 minutes, the enzyme in the biological indicator will turn
what color:

(A) fluorescent yellow

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 (B) red
(C) blue
(D) no specific color

63. All are true of dry heat sterilization EXCEPT:

(A) the indicator used for dry heat ovens are B. atrophaeus
(B) it is used only in an emergency in the operating room
(C) sterilization occurs in mechanical convection ovens
(D) sterilization occurs in gravity convection ovens

64. Hydrogen peroxide plasma sterilization utilizes:

(A) a cloud or glow of pink plasma sterilization utilizes:

(B) a chamber much like microwaves
(C) using a hydrogen peroxide solution
(D) All of the above

65. In a gravity displacement sterilizer, steam enters the chamber through:

(A) bottom
(B) bottom, back
(C) top, back
(D) top front

66. ETO is mixed with carbon dioxide to:

(A) increase antimicrobial effect

(B) reduce flammability of ETO
(C) reduce temperature requirement
(D) increase microbial killing rate

67. How long should the ETO biological indicator be incubated before the reading is recorded?

(A) 24 hours
(B) 48 hours
(C) 12 hours
(D) 3 hours

68. For ETO sterilization, how long must instruments remain in the aerator being operated at 140°F?

(A) 8 hours
(B) 6 hours
(C) 4 hours
(D) 2 hours

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69. What spore is used to test steam under pressure (steam sterilizer)?

(A) Clostridium perfringens

(B) Bacillus stearothermophilus
(C) Treponema pallidum
(D) Staphylococcus aureus

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 Answers and Explanations

1. (A) Fifteen to seventeen pounds of pressure is necessary in the steam sterilizer set at 250°F. It is 27 psi if
set at 270°F.

2. (A) Positive assurance that sterile conditions have been achieved by either steam, ethylene oxide, or dry
heat sterilization can be obtained only through a biological control test. These should be done at least
weekly. The most dependable is a preparation of living spores resistant to the sterilizing agent.

3. (C) Instruments wrapped as a set in double thickness wrappers are autoclaved at a setting of 250°F for 30
minutes.

4. (B) In a flash (high speed pressure) sterilizer set at 270°F, the minimum exposure time is 3 minutes for
unwrapped items. With this cycle, the entire time for starting, sterilizing, etc., is 6–7 minutes.

5. (D) Rubber tubing should not be folded or kinked because steam can neither penetrate it nor displace air
from folds. A residual of distilled water should be left in the lumen. Rubber bands must not be used
around solid items because steam cannot penetrate through or under rubber.

6. (A) Linen packs must not weigh more than 12 lb. Linen must be freshly laundered. Items must be
fanfolded or loosely rolled.

7. (D) Gravity displacement utilizes steam under pressure to effect moist heat sterilization.

8. (B) The ultrasonic cleaner (which is not a sterilizer) utilizes ultrasonic energy and high-frequency sound
waves. Instruments are cleaned by cavitation. In this process, tiny bubbles are generated by high-
frequency sound waves. These bubbles generate minute vacuum areas that dislodge, dissolve, or disperse
soil.

9. (C) Hinged instruments must be open with box locks unlocked to permit steam contact on all surfaces.
All detachable parts should be disassembled.

10. (D) Solutions are sterilized alone on a slow exhaust cycle to prevent them from boiling over. The
pressure gauge must read 0°F before opening the door. This is so the caps will not pop of.

11. (D) Wrapped basin sets are sterilized at 250°F for a minimum of 20 minutes. They are placed on their
sides to allow air to flow out of them. This also helps water flow out.

12. (A) Basins and solid utensils must be separated by a porous material if they are nested, to permit

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 permeation of steam around all surfaces, and condensation of steam from the inside during sterilization.
Sponges or linen are not packaged in basins.

13. (B) EO gas is an effective substitute for most items that cannot be sterilized by heat or that would be
damaged by repeated exposure to heat. It is noncorrosive and does not damage items. It completely
penetrates porous materials.

14. (D) Ethylene oxide gas is used to sterilize items that are either heat or moisture sensitive. It kills
microorganisms, including spores, by interfering with the normal metabolism of protein and
reproductive processes.

15. (B) A proprietary (STERIS) chemical formulation of peracetic acid, hydrogen peroxide, and water
causes cell death by inactivating the cell systems.

16. (B) Any tubing or other item with a lumen should be blown out with air to force dry before packaging,
as water combines with EO gas to form a harmful acid, ethylene glycol.

17. (D) Glutaraldehyde, a high-level disinfectant is known commercially as Cidex.

18. (A) Peracitic acid is used in a machine (STERIS) that heats the sterilant and can be used for endoscopes.
The cycle takes 30 minutes, and the sterilant can only be used for a single sterilization cycle, thus is
more expensive than other methods.

19. (A) Items must be thoroughly rinsed before use. Solution is reusable for the time set by the
manufacturer. Items must be clean and dry before submersion.

20. (A) Gluteraldehyde must be renewed after 14 days because it becomes ineffective after that time.

21. (C) In cystoscopy, sterilization of instruments with steam or EO provides the greatest elimination of the
risk of infection; however, it is not essential. High-level disinfection is recommended and provides
reasonable assurance that items are safe to use.

22. (B) The minimum exposure time at 270°F with 27 psi is 3 minutes for unwrapped nonporous items.

23. (C) Immersion in a 2% aqueous solution of activated, buffered alkaline glutaraldehyde is sporicidal (kills
spores) within 10 hours. It is chosen for heat-sensitive items that cannot be steamed or if EO gas is
unavailable or impractical.

24. (B) Lumens of instruments or tubing must be completely filled with solution. All items should be placed
in a container deep enough to completely immerse them. All items should be dry before immersion so
that the solution is not diluted.

25. (C) Moisture is essential in gas sterilization. Desiccated or highly dried bacterial spores are resistant to
EO gas; therefore, they must be hydrated in order for the gas to be effective.

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26. (B) Solutions are sterilized alone on slow exhaust so solutions will not boil over and so caps will not blow
off.

27. (B) Aeration following EO sterilization can be accomplished at room temperature; however, aeration of
exposed items at an elevated temperature (in an aerator) enhances the dissipation rate of absorbed gases,
resulting in faster removal. The aerator is a separate unit.

28. (A) EO or ETO is a chemical agent that kills microorganisms, including spores. It interferes with the
normal metabolism of protein and reproductive processes, resulting in cell death.

29. (C) A minimum of 20 minutes is used to kill vegetative bacteria, fungi, hepatitis B, and HIV. It is 45
minutes for tuberculocidal activity.

30. (B) Scopes and all accessories that are soaked in activated glutaraldehyde are rinsed well in sterile
distilled water to prevent tissue irritation from the solution.

31. (D) Peracetic acid or acetic acid mixed with a solution of salts (Bionox) kills microorganisms. It is used
only in the STERIS system for heat sensitive and immersible instruments. Processing is 20–30 minutes,
temperature is controlled at 131°F; it is cost effective, and environment friendly.

32. (B) Basins, jars, cups, or other containers should be placed on their sides with the lid ajar so that air can
flow out and steam can enter.

33. (A) Gravity displacement steam sterilizers operate on the principle that air is heavier than steam. Steam
is forced into the inner chamber. Any air in the inner chamber blocks the passage of pressurized steam
and prevents sterilization.

34. (C) Walls, doors, surgical lights, and ceilings are spot cleaned if they are soiled with blood tissue or body
fluids.

35. (A) Spores are not killed unless an item is sterilized.

36. (B) The Spaulding system assigns a risk category that is specific to the regions of the body in which a
device is to be used.

37. (A) Critical risk is assigned to sterile body tissues including the vascular system.

38. (B) ETO is used to sterilize objects that cannot tolerate heat, moisture, and the pressure of steam
sterilization.

39. (C) Two percent gluteraldehyde is a tuberculocidal when item is sterilized for 20 minutes.

40. (C) Subjecting items to the process of sterilization does not ensure that the item is sterile, but only that
the parameters such as heat and pressure have been met.

41. (C) The laws of physics tell us to raise the temperature of steam, we must also raise the pressure in the

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 closed sterilization chamber, to achieve 270°F, and the required pressure is 27 psi.

42. (A) When blended with inert gas, it produces effective sterilization by destroying DNA and the protein
structure of microorganisms

43. (A) Bioburden is the number and the type of live bacterial colonies on the surface before it is sterilized.

44. (D) Event-related sterility or terminal sterilization is based on the principles that sterilized items are
assumed sterile between uses unless environmental conditions or events interfere with the integrity of
the package.

45. (D) Peel pouches are intended for light-weight instruments and devices.

46. (C) Gastrointestinal scopes come in contact with mucous membranes or nonintact skin. They are
semicritical items.

47. (A) Environmental disinfectants that are used for routine low-level disinfection and terminal
decontamination include phenolics, quats, hypochlorites, and alcohol. Gluteraldehyde is a high-level
disinfectant known as Cidex commonly used on instruments.

48. (C) All staff members who work in the decontamination area must wear PPE in compliance with
government regulations. Only gloves approved for contact with chemical disinfectants are used. Surgical
gloves and patient care gloves are not permitted.

49. (B) Most equipment available that is packaged from the manufacturer has been sterilized by Cobalt 60
or ionizing radiation. This process is restricted to commercial use because of its expense.

50. (B) Pasteurization is a heating process that destroys microorganisms at a certain temperature and
exposure time but does not alter their chemical makeup.

51. (A) Naturally acquired active immunity is when you are exposed to the disease and as a result become
immune. Artificially acquired active immunity is when you receive a vaccine and become immune.
Artificially acquired passive immunity is when you receive immunization such as gamma globulin. It is a
short-term immunization. Naturally acquired passive immunity occurs during pregnancy when a
pregnant woman passes the antibodies to her fetus through the blood stream.

52. (B) An obligatory parasite is a type of microorganism that depends on living tissue to survive.

53. (D) Vancomycin is the antibiotic used to treat MRSA.

54. (B) Prions do not contain DNA/RNA.

55. (C) Mutualism, commensalism, and parasitism.

56. (D) Anthrax, botulism, and small pox are bioterrorist agents.

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57. (D) SARS, West Nile, and avian flu are all infectious diseases emerging in the United States.

58. (A) Sodium hypochlorite is the chemical name for household bleach.

59. (B) Personal protective equipment includes goggles, facemasks, and protective body clothing.

60. (C) The Spaulding method is used to rate the level of risk when processing equipment.

61. (B) The Bowie–Dick test is used to check for air trapped in the prevacuum sterilizer. The biological
indictor is the most effective indicator to prove sterility. A chemical indicator is tape used in the
autoclave.

62. (A) The enzyme in the biological indicator will turn fluorescent yellow.

63. (B) Heat sterilization is not only used in an emergency.

64. (A) Hydrogen peroxide plasma sterilization utilizes a loud or glow of pink plasma covering the items to
be sterilized.

65. (D) Steam enters the chamber in a gravity displacement sterilizer at the top front of the autoclave.

66. (B) ETO is mixed with carbon dioxide to reduce the flammability of the ETO.

67. (B) ETO biological indicators should be incubated for 48 hours before reading.

68. (A) Instruments must remain in the aerator cycle of the ETO at 140°F degrees for 8 hours.

69. (B) B. stearothermophilus is the spore used to test steam under pressure sterilizers.

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 ___________________ CHAPTER 7 ___________________

Operating Room Environment

Operating Room Environment/Specialty equipment/Furniture

• Electrical outlets—operating rooms use 110-volt and 220-volt outlets. They must be mounted off the
floor. They must be grounded and explosion proof
An example of a grounding system includes cords with a three prong plug:
Current comes from the two upper prongs and the third prong on the bottom is for grounding
• Suction—used during surgery and by anesthesia to remove blood, body fluids, and irrigation during
surgery, during intubation and extubation. It consists of:
Vacuum device—this can come from the ceiling, wall or a portable unit
Neptune mobile suction unit—to remove waste the unit can be relocated to a waste disposal area
through a docking station
Each operating room should have at least two suction outlets, one for surgery and one for anesthesia
Collection canisters come as single or double canisters that are positioned in a carousel. They are used to
collect and monitor the amount body fluids and irrigation during the surgical procedure
Tubing from the surgical field and anesthesia is connected to the canister, and an additional tubing is
connected to the suction device
The suction power can be adjusted according to what it is being used for
There are several types of suction tips and specialty equipment. They come nondisposable and
disposable
Poole suction tip—commonly used for suctioning large amounts of fluid and irrigation in the
abdomen
Yankauer/tonsil suction tip—commonly used by anesthesia, and also in other parts of the body
Frazier suction tip—this is an angled tip with a small hole on the hand piece used to control the
amount of suction needed. Fraziers also have a flexible stylet that is inserted into the lumen to clean
the inside of the suction tip if it gets clogged. They come in various sizes
Smith and Nephew Coblator—this instrument cauterizes, irrigates and has a suction device attached
to the instrument. Used on tonsils
Special long suction tips are used on endoscopic procedures
• Gas outlets—these lines are piped into the operating rooms and must have manual shut off valves outside
the or room
They can be wall mounted, ceiling mounted, and on a boom

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 Each line is specifically color coded, they include:
Vacuum for suction
Oxygen—green
Nitrogen—black
Nitrous oxide—blue
Compressed air—yellow
• Overhead operating room lights—they are designed to be nonglaring with a blue white beam to prevent
eye fatigue
The lights have an intensity control on the light themselves covered with a sterile light handle so the
light may be manipulated at the surgical field
They are adjustable to many positions
They should be damp dusted every morning prior to the first surgical procedure
• Ventilation systems—this system removes:
Airborne contamination
Toxic fumes
Anesthesia gas
• Laminar air flow
This is a positive air pressure, unidirectional air flow
The air pressure in the operating room is kept at a higher pressure than the hallways, when the
operating room door is opened, air is pushed out of the operating room instead of the air coming in and
spreading airborne contaminates
• HEPA filters—High efficiency particulate air
They remove dust particles and filter air
Air enters through the ceiling and exits from the grills near the floor
They remove bacteria particles in the air that are larger than 0.3 mm. It can remove bacteria as large as
0.5–5 mm
Air exchange should be:
between 20 and 25 air exchanges per hour
No less than 15 air exchanges per hour
20% should be fresh air from the outside that is filtered in
• X-ray viewing box—used to view patients films prior to and during surgery
• OR table—operating room beds—they should be positioned under the center of the operating room lights
and away from the doors to prevent contamination from the outside corridors.
They can be controlled manually or electrically
They have break points at the head, waist, knee and foot
Weight limits vary
Special tables are used for bariatric patients
Parts of the operating room bed include:

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 Headpiece/body/foot piece
Neuro/ortho attachments:
Mayfield headrest
Gardner Wells tongs
Horseshoe headrests
Special operating room tables
Orthopedic fracture table
Andrews—used for laminectomy procedures in the knee chest position
Jackson—used for cervical, thoracic and lumbar procedures
Wilson—used to support the patient’s upper body for laminectomies, discectomies, and bladder
stimulators.
Cystoscopy table—covered in GU
Hand table
• Pneumatic tourniquet—the tourniquet is used to create a bloodless surgical field by restricting blood flow
to the operative site.
The tourniquet cuff is inflated with nitrogen or air
The widest cuff should be used, and is determined by:
The size and weight of the patient
Size of the limb
Preexisting conditions of the patient
Type of surgery
The tourniquet should not be used on patients with:
Traumatic injury
Patient with peripheral vascular disease
An infected limb
DVT’s in the operative limb
Poor skin conditions on the operative limb
On a limb that has an AV fistula/AV shunt
Protect the patients skin by wrapping a lint free padding around the limb and make sure the padding is
free of wrinkles
Place the tourniquet cuff on the patient and connect the tubing to the inflation machine
The limb is exsanguinated first by elevating the limb for approximately 2 minutes and wrapping an
Esmarch bandage—distal to proximal
The extremity is prepped and draped
The tourniquet is inflated at the pressure the surgeon decides. Surgeon should be notified when the cuff
is inflated and notified after the first 60 minutes.
The cuff on an upper limb can be inflated for 60 minutes
The cuff on a lower limb can be inflated for 90 minutes

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 Once the time limit has been reached it is recommended practice that the tourniquet be deflated for
approximately 15 minutes before the limb is re-exsanguinated and the tourniquet reinflated
The recommended guidelines for tourniquet pressure is:
50 mm Hg above the patient’s systolic blood pressure for upper extremity
100 mm Hg above the patient’s systolic blood pressure for lower extremity
• Wall mounted clock should have a start–stop timer and second hand if they need to track time on arterial
occlusion, tourniquet or cardiac arrest
• Intercom system—this allows communication with the outside, examples include the front desk and
pathology
It should have a floor mounted intercom switch for the sterile members of the surgical team in the room
• Computers—computers, printers and fax machines are at the front desk, and each operating room has its
own computer. They are used to access patient records, films, lab work. The circulator and surgeon use for
patient charting, communication with other departments, to access surgeons preference cards, operating
room schedule, and the patient’s family can track the patients progress in the operating room
Switch on the computer, startup process is termed “booting”
Screen background is termed “wallpaper”
Surfing the internet—allows you to look at different web pages and switch them
Scrolling—the term used for moving up and down on a document
Word processing is the term for creating a document
Hard drive—is the internal part of the computer that stores information
CD-ROM/DVD
Modem—help send information
Task bar—shows documents, allows you to switch documents
Mouse—allows scrolling through documents, moves the cursor to different areas on the screen
Monitor—screen
Keyboard—enters characters, and commands into the computer
WWW—World Wide Web—allows browsing the internet
E-mail—allows you to send a message and receive a message or forward a message
Computers allow you to:
Create, save, and print a document
Check spelling
Cut, copy, paste—move words, documents to another place on the document or to another document
Fonts—different styles of letters—you can change their color, make them bold, and change their size.
The standard size 11/12
Bullets—they can be designs or letters they allow you to list words, sentences
• TV systems—(closed-circuit) TV’s can be mounted at the front desk and used to view what is going on in
each operating room
They are also used to view endoscopic procedures, communicate with other departments so that

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 procedures can be seen from other locations
• Microscopes—the microscope is used to magnify the surgical field
Microscopes can be floor mounted, ceiling mounted, wall mounted, and/or mounted to the operating
room bed
They should be damp dusted prior to surgery
The microscope is draped by the STSR and the circulator. A clear drape is placed over the top part of
the microscope and is secured to the oculars with sterile lens covers and rubber bands
The microscope has two types of lenses. They include:
Objective lens
Ocular lens
The objective lens—closest to the object
The ocular lens—is the eyepiece the surgeon looks through
Zoom lens—allows the surgeon to change the magnification at the surgical field, it is foot controlled
Illumination/lighting system
Coaxial illuminator—uses fiberoptics to transmit light. This light is cool to touch to protect patient
tissues
Paraxial illuminator—this uses light tubes, halogen bulbs and focusing lenses
Beam splitter—this allows the microscope to transmit the same image to the assistants field of vision
Magnifying power—the ability of the microscope to magnify the image
Resolving power—this allows the microscope to differentiate and clarify details at the surgical field
The surgeon uses a special chair when working with the microscope. The chair is on wheels, has
hydraulic foot pedals to raise and lower as needed and attached armrests to support his forearms for
stability
The STSR must carefully place instruments in the surgeon’s hands and guide towards the surgical field
because his/her field of vision is restricted. The surgeon does not want to take eyes off the surgical site
• C-arm—this is a mobile image intensifier used to take pictures
The fluoroscopy allows films to be taken still and with movement in real time. It is controlled by a foot
pedal
It is called a c-arm because of it’s obvious shape
X-rays can be taken in lateral or anterior positions
Both the patient and staff must wear a lead apron to protect the testicles and ovaries. A thyroid collar is
worn to protect the thyroid. Do not turn your unprotected back to the c-arm
Do not bend or twist lead aprons as that could damage the lead
The c-arm delivers high doses of radiation. The surgeon and staff should limit the time their hands are
exposed or wear lead gloves
All personnel working with fluoroscopy should be monitored for exposure time. An x-ray badge is worn
at the neck and routinely checked
While the fluoroscopy is in use, it is recommended to stand at least 1 ft from the machine. further if

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 possible
A special drape is used to protect the surgical field from contamination
• Mini c-arm—this is a smaller version of the original c-arm commonly used on hands and feet
• Head light—this is an adjustable head piece worn by the surgeon to provide a concentrated beam of light
to the surgical field. The head piece is connected to the light source by a fiberoptic cord. It is important for
those who handle this piece of equipment not to over bend the cord because you can damage the
fiberoptics
• ESU—Electro Surgical Unit. Bipolar Electro cautery/bipolar cautery—the current is delivered to the
surgical site and returned to the generator by forceps. The current passes between the tips of the forceps.
One tip is active the other is inactive
• Mono-polar electro surgery—current flows from the generator to the active electrode (Bovie hand piece) to
the patient, to the inactive dispersive electrode back to the generator
• Coagulating current—a current that passes through the active electrode (Bovie hand piece) with intense
heat to burn and control bleeding vessels
• Cutting current—the current used to cut tissue
• Blended current—a current that can be used to provide hemostasis to tissue and cut tissue
• Generator—the power source, the machine that produces the current by using high-frequency radio
• Inactive dispersive electrode—the pad used to return the current back to the generator. Also referred to as
the grounding pad, inactive electrode or return electrode
• Active electrode—the hand piece or active electrode directs the current to the target tissue.
• Smoke evacuator—are used to suction large amounts of smoke from ESU or laser.
It has a filtration system that can trap particles and toxic plumes. The filters should be changed between
patients because they are considered biohazard materials
The suction tip should be held as close to the target area (2 in) for effectiveness
• Doppler—is used to access blood flow through a vessel by sound. It can be used pre-, intra- or
postoperatively. A sterile drape is used to cover the probe when used during a surgical procedure
• Booms—ceiling mounted arms that contain surgical equipment
• Cabinets—they contain operating room supplies. They should always remain closed. Patient care gloves
should be removed before entering the cabinet for additional supplies
• Doors—they should always be kept closed except when the patient is entering or exiting the operating
room to prevent traffic and outside contamination

Operating room furniture:

• Back table—it is used to create the sterile field for the surgical procedure. The sterile pack is opened on the
back table and operating room sterile supplies and instruments are set up on the back table. They come in
various sizes and heights some being double tiered
• Mayo stand—this is used for instruments and supplies that are being used immediately for the surgical
procedure. It is moved to the operative field and is placed over the patient. It has an adjustable height and
can be raised simply by pulling it up

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• Utility table, prep table, gown and glove table—used for all of the above mentioned
• Kick bucket—used for sponges that have been used during the surgical procedure—not garbage. They are
low on the floor and are maneuvered with your foot
• Ring stand—they come single or double and they hold basins that contain solutions used during the
surgical procedures
• Standing stool/sitting stool—they should be positioned before opening the sterile field to avoid
contamination
• Trash containers and linen hampers—have a foot control pedals so the STSR can open them
• IV poles
• Lead door—this is used to protect staff from x-rays
• Cautery machine—explained in the Electricity chapter

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 Questions

1. The room temperature in an operating room (OR) should be:

(A) below 50°F

(B) below 60°F
(C) between 68°F and 76°F
(D) between 80°F and 86°F

2. The most effective protection from the radiation of x-rays is a:

(A) lead apron

(B) double thick muslin apron
(C) 3-ft distance from machine
(D) 3-ft distance from patient

3. It is considered good technique to:

(A) change your mask only if it becomes moistened

(B) hang the mask around the neck
(C) crisscross the strings over the head
(D) handle the mask only by the strings

4. Electrical cords should be:

(A) removed from outlets by the cord

(B) wrapped tightly around equipment
(C) removed from pathways so equipment is not rolled over them
(D) disconnected from the unit before disconnection from the wall

5. Scatter radiation effects are directly related to:

(A) amount of radiation

(B) length of exposure
(C) accumulation of radioactive substances in operating room (OR)
(D) amount of radiation and length of exposure time

6. Room temperature for infants and children should be maintained as warm as:

(A) 70°F

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 (B) 80°F
(C) 85°F
(D) 95°F

7. Areas needing special cleaning attention on a weekly or monthly routine would include:

(A) furniture
(B) air-conditioning grills and walls
(C) ceiling mounted and wall-mounted fixtures and tracks
(D) kick buckets

8. A glass suction bottle should ideally be:

(A) rinsed with tap water between each case

(B) cleaned with a disinfectant solution and autoclaved before reuse
(C) rinsed with sterile distilled water between each case
(D) autoclaved daily

9. Storage shelves must be cleaned with a germicide:

(A) each case

(B) each day
(C) each week
(D) each month

10. While a surgical case is in progress:

(A) doors remain open so that staff can easily move in or out
(B) doors should remain closed
(C) doors remain open to circulate air
(D) doors may be opened or closed

11. When cleaning the floor between cases:

(A) a clean mop head must be used each time

(B) a two-bucket system, one detergent and one clear water, is used
(C) buckets must be emptied and cleaned between each case
(D) All of the above

12. A dropped sterile item may only be used if the:

(A) wrapper is muslin

(B) wrapper is impervious and the contact area is dry
(C) wrapper is impervious with the contact area wet or dry
(D) wrapper is dusted off thoroughly

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13. The following comply with protocol for protective eyewear EXCEPT:

(A) impervious face shields can be worn

(B) goggles can be worn
(C) prescribe eyeglasses
(D) All eye covers must extend from the front to the side

14. What statement regarding OR attire applies?

(A) Head caps and hoods must be worn to reduce contamination from hair and dander to the field
(B) Long sleeve, nonsterile cover jackets are worn by nonsterile personnel to prevent contamination by
bacterial shedding of their arms
(C) The scrub suit is worn by both sterile and nonsterile personnel
(D) All of the above

15. All are true in preparing nonsterile equipment EXCEPT:

(A) make sure the OR table is positioned directly under surgical lights
(B) arrange the room according to how the surgical tech likes it
(C) place furniture so that draped sterile tables are no closer than 12–18 in to a nonsterile surface.
(D) pretest suction lines for adequate pressure

16. All are recommendations for opening a case EXCEPT:

(A) when opening packages sealed with tape, break the tape rather than tearing it
(B) open the scrub gown on to the back table
(C) never unwrap a heavy item while holding it in mid air
(D) when opening instruments in closed sterilization trays, break the seal and lift top straight up and
away from the tray

17. Excessive exposure to radiation can affect the:

(A) integumentary system

(B) brain
(C) reproductive organs
(D) stomach

18. Radiation exposure of the staff is monitored with:

(A) a homing device

(B) a Holter monitor
(C) film badges
(D) a notation on each operative record

19. Ionizing radiation protection is afforded by the use of:

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 (A) iron
(B) ebonized coating
(C) zinc
(D) lead

20. An OR hazard that has been linked to increased risk of spontaneous abortion in female OR employees is
exposure to:

(A) x-ray control

(B) radium
(C) sterilization agents
(D) waste anesthetic gas

21. While using this mixture, a scavenging system is used to collect and exhaust or absorb its vapors. It is
called:

(A) glutaraldehyde
(B) polypropylene
(C) methyl methacrylate
(D) halon

22. How is inhalation of the laser plume best prevented?

(A) Double mask worn by scrub team

(B) Filter on suction
(C) Laser on standby whenever possible
(D) Mechanical smoke evacuator on field

23. A Cavitron unit is used for:

(A) cyclodialysis
(B) photocoagulation
(C) phacoemulsification
(D) cryotherapy

24. The power source for Hall’s power equipment is:

(A) carbon dioxide

(B) nitrous oxide
(C) nitrogen
(D) electricity

25. The power source for air-powered dermatomes is:

(A) compressed nitrogen

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 (B) nitrous oxide
(C) air
(D) Either A or C

26. Suction tubing should be processed in the following way:

(A) residual of distilled water in lumen, steam sterilize, tubing coiled

(B) residual of saline in lumen, ethylene oxide sterilization (ETO), tubing coiled
(C) lumen dried thoroughly, ETO, tubing banded
(D) Either A or B

27. The suction tip that is right angled and is used for small amounts of fluid such as in brain surgery is:

(A) Poole
(B) Ferguson–Frazier
(C) Yankauer
(D) Tungsten

28. Which suction tip has an angle and is used in the mouth or throat?

(A) Ferguson
(B) Ferguson–Frazier
(C) Poole
(D) Yankauer

29. A tourniquet is utilized:

(A) only in lower extremity bleeding

(B) only when hemorrhage is not controlled by other methods
(C) in all venous bleeding
(D) in all arterial bleeding

30. Exsanguination of a limb before tourniquet inflation is accomplished with wrapping the elevated
extremity with:

(A) Kling
(B) Esmarch
(C) Stockingette
(D) Webril

31. The amount of pressure used to inflate a tourniquet depends on all of the following EXCEPT:

(A) patient’s age

(B) size of extremity
(C) depth of surgical incision

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 (D) systolic blood pressure

32. A regional block that uses the tourniquet is a/an:

(A) Bier block

(B) intrathecal block
(C) peridural block
(D) field block

33. The tourniquet is contraindicated if:

(A) patient’s circulation to distal part of extremity is poor

(B) patient is elderly
(C) patient is obese
(D) patient has epidural anesthesia

34. At what point should the surgeon be informed of the time of tourniquet application?

(A) After 15 minutes, then every 5 minutes

(B) After 1 hour, then every 15 minutes
(C) After 2 hours, then every hour
(D) After 3 hours, then every 15 minutes

35. When would the use of Esmarch be contraindicated?

(A) Patient has had previous anesthesia

(B) Patient has had recent injury
(C) Patient has had recent cast
(D) Both B and C

36. Which agent is NOT used to inflate a pneumatic tourniquet?

(A) Nitrous oxide

(B) Air
(C) Oxygen
(D) Freon

37. A precaution necessary when using a pneumatic tourniquet is:

(A) limb must be continually elevated

(B) tourniquet time must not exceed 20 minutes
(C) solutions must be prevented from pooling under tourniquet
(D) inflation is done before prep and draping

38. In which procedure would a tourniquet be contraindicated?

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 (A) Tendon repair, child
(B) Arthroscopy, adult
(C) Bunionectomy
(D) Gangrenous toe amputation

39. The following statements regarding a grounding plate for electrosurgery are true EXCEPT:

(A) the plate must have good contact with the patient’s skin
(B) the plate must be lubricated with electrosurgical gel
(C) the plate must be placed directly over a bony prominence
(D) the grounded pathway returns the electrical current to the unit after the surgeon delivers it to the
operative site

40. A grounding pad is not required for the electrocautery in:

(A) a cutting current setting

(B) a coagulation current setting
(C) a monopolar unit
(D) a bipolar unit

41. The inactive electrode of the cautery is the:

(A) grounding pad

(B) electrocautery pencil
(C) cable connecting pad to pencil
(D) blade tip pencil

42. The electrical circuit of the electrocautery is complete when:

(A) current flows from generator to inactive electrode, through tissue, and back to generator
(B) current flows from active electrode to generator, to tissue, and return
(C) current flows to and from the generator to patient via the active electrode
(D) current flows from the generator to active electrode, through tissue, and back to generator via the
inactive electrode

43. Why must the electrocautery tip be kept clean?

(A) To ensure electrical contract effectiveness

(B) To avoid fire via accidental drape ignition
(C) To prevent burn injuries to staff
(D) To prevent circuit overload

44. In electrosurgery, “buzzing” refers to:

(A) coagulation of vessel via a metal instrument touching the active electrode

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 (B) coagulation of tissue via a metal instrument touching the inactive electrode
(C) cutting current
(D) blended current (cutting and coagulating simultaneously)

45. Which electrosurgical unit provides precise control of the coagulated area?

(A) Monopolar
(B) Blended
(C) Bipolar
(D) Bovie

46. Which condition is MOST acceptable when using electrocautery?

(A) Ground pad placed on scar or hairy area

(B) Ground pad placed on patient’s forearm
(C) Ground pad placed on skin over metal implant
(D) Ground pad placed close to operative site

47. The active electrode on the electrocautery is the:

(A) dispersive electrode

(B) power unit
(C) grounding pad
(D) tip

48. A cautery would not be used:

(A) when Betadine skin prep is used

(B) in cases requiring irrigation
(C) in neck or nasopharynx surgery if nitrous oxide is used
(D) in hernia repair if an epidural is used

49. Why are only moist sponges utilized during electrocautery use?

(A) To prevent snagging of sponges on a cautery tip

(B) To prevent fire
(C) To reflect beam
(D) None of the above

50. When working in the bladder, why is more or higher electrical current necessary during cautery use?

(A) More current is needed when working in solution

(B) Bladder tissue is tougher
(C) High voltage arcing requires it
(D) Eschar formation is to be avoided

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51. Fulguration via the resectoscope is accomplished by the use of a/an ______ tip.

(A) electrode
(B) ball
(C) blade
(D) needle

52. Fiberoptic lighting is

(A) a cool light

(B) made of plastic fibers
(C) of low intensity
(D) powered by battery

53. All are precautions when handling fiberoptic cables EXCEPT:

(A) light cables should be dropped or swing free when carried

(B) cables are coiled loosely, no kinking
(C) heavy items are not laid on cables
(D) cables are only gas sterilized

54. Fiberoptic cable integrity is questionable when:

(A) illumination is bright

(B) dark spots are evident
(C) tubing has been coiled
(D) tubing is scratched

55. When using a fiberoptic, burns and fires are prevented by:

(A) cable is kept away from drapes when disconnected from endoscope
(B) personnel should not lean on cable end that is disconnected but is still on
(C) cable end is kept on a moist towel when disconnected from endoscope
(D) All of the above

56. Loupes are used for:

(A) tissue retraction

(B) magnification
(C) hemostasis
(D) patient transfer

57. Resolving power of an operating microscope means:

(A) the ability to discern detail

(B) the ability to enlarge the image

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 (C) the adaptation of operative procedure to individual patient requirements
(D) the ratio of image size on viewer’s retina with and without magnification

58. Which item in the optical lens system is responsible for magnification?

(A) Oculars
(B) Paraxial illuminators
(C) Objective lens
(D) Both A and C

59. The range of focal lengths of the objective lenses in the operating microscope is:

(A) 0–100 mm
(B) 100–200 mm
(C) 100–400 mm
(D) 5–25 mm

60. A continuously variable magnification system is afforded to the eye surgeon by the:

(A) broadview viewing lens

(B) microadapter
(C) zoom lens with foot control
(D) couplings

61. The purpose of the “slit” lamp in eye surgery is:

(A) defining depth perception

(B) focusing ability
(C) magnifying power
(D) discerning detail

62. The operating microscope that visually employs fiberoptics for its light source is:

(A) halogen
(B) tungsten
(C) coaxial illuminators
(D) paraxial illuminators

63. Care of the microscope would include all of the following EXCEPT:

(A) damp dust external surfaces with detergent–disinfectant before use

(B) damp dust lenses with detergent–disinfectant before use
(C) enclose in an antistatic plastic cover when not in use
(D) clean casters before each use

64. The purpose of the beam splitter in an operating microscope is to:

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 (A) coincide the assistant’s field of view with the surgeon’s
(B) increase light intensity
(C) decrease vibration
(D) narrow the beam of light

65. The colpomicroscope affords a view of the:

(A) fallopian tube

(B) intraperitoneal structures
(C) cervix
(D) uterine endometrium

66. The procedure employing the use of a self-retaining laryngoscope and microscope is called a ______.

(A) indirect laryngoscopy

(B) direct laryngoscopy
(C) suspension microlaryngoscopy
(D) laser microlaryngoscopy

67. The binocular microscope provides stereoscopic vision. This refers to:

(A) the view afforded by double eyepieces

(B) the color projected on the field
(C) the magnification capability
(D) the illumination process

68. Which magnifying powers are available for the microscope eyepieces?

(A) 1×, 2×, 3×, and 4×

(B) 10×, 20×, 30×, and 40×
(C) 10×, 12.5×, 16×, and 20×
(D) 300 mm, 400 mm, 500 mm, and 600 mm

69. Which procedure is inappropriate when caring for optic lenses?

(A) Blood, water, and irrigating solutions are removed with cotton tipped applicators and distilled
water
(B) Lens is always cleaned in a circular motion, beginning at the center
(C) Oil or fingerprints are removed by soaking in solvent for 10 minutes and drying with a cotton ball
(D) Lint or dust are removed with a lens brush or rubber bulb syringe

70. The OR bed may have a metal crossbar between the two upper sections which may be raised to elevate
the:

(A) kidney

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 (B) breast
(C) gallbladder
(D) Both A and C

71. The smallest diameter on a French scale is a:

(A) 3
(B) 5
(C) 7
(D) 9

72. A motorized device whose action prevents venous stasis and reduces risk of deep-vein clotting in high
risk patients is:

(A) pneumatic antishock garment

(B) military antishock trousers (MAST)
(C) Thrombo-embolic-deterrent stockings
(D) sequential pneumatic compression boots

73. A blood flow detector is a:

(A) Doppler
(B) Gruentzig
(C) Moretz
(D) Warren

74. A secondary video monitor is referred to as a/an:

(A) MAC
(B) SMA
(C) CAM-2
(D) “slave”

75. The mobile suction unit is called:

(A) Neptune
(B) Smith and nephew
(C) Andrews
(D) Saturn

76. What is the all in one instrument used to cauterize, irrigate and suction simultaneously?

(A) Yankauer
(B) Coblator
(C) Neptune

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 (D) Poole

77. What color is the gas outlet used for oxygen?

(A) Blue
(B) Yellow
(C) Black
(D) Green

78. All pertain to laminar air flow EXCEPT:

(A) maintains positive pressure

(B) maintains negative pressure
(C) has unidirectional airflow
(D) maintains a higher pressure in the OR

79. HEPA filters remove bacterial particles that are:

(A) Larger than 0.3 mm

(B) Smaller than 0.3 mm
(C) 0.3–0.5 mm
(D) Both A and C

80. HEPA filters exchange the air in the OR how many times per hour?

(A) Between 20 and 25

(B) Between 10 and 15
(C) 10
(D) Less than 10

81. All are facts regarding operating room tables EXCEPT:

(A) they have break points at head, waist, knee, foot

(B) they can be controlled manually or electrically
(C) there is no weight limit
(D) they are positioned under the OR lights and away from main door

82. Neurosurgery attachments include all EXCEPT:

(A) Mayfield
(B) Gardner wells
(C) Horseshoe
(D) Alvarado

83. Special operating room tables used for spine surgery include all EXCEPT:

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 (A) Andrews
(B) Fracture table
(C) Jackson
(D) Wilson

84. When is the standing stool positioned?

(A) Should be positioned before the opening of the sterile field to avoid contamination
(B) Should be positioned after the surgical prep and prior to draping
(C) Should be positioned prior to incision
(D) There is no specific time to position the stool

85. Chest rolls are used to:

(A) to help secure the patient

(B) assist with respirations
(C) prevent pressure wounds
(D) assist patients with back injuries

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 Answers and Explanations

1. (C) Room temperature is maintained within a range of 68–76°F.

2. (A) Lead-lined aprons should be worn to protect the staff from radiation, especially during the use of an
image intensifier. Thyroid collars are also particularly useful for protection.

3. (D) Masks should be handled only by the strings, thereby keeping the facial area of the mask clean. The
mask should never be worn around the neck. Upper strings are tied at the top of the head; lower strings
are tied behind the neck because crisscrossing distorts mask contours and makes the mask less efficient.

4. (C) Electrical cords should not be kinked, curled, or tightly wrapped. They should be handled by the
plug, not the cord, when disconnecting. Always remove cords from pathways before rolling in
equipment because this can break the cord.

5. (D) The effect of radiation is directly related to the amount and length of time of exposure. Exposure is
cumulative.

6. (C) Infants and children are kept warm to minimize heat loss and prevent hypothermia, 85°F should be
maintained.

7. (B) Ceiling- and wall-mounted fixtures are cleaned daily. Walls are spot cleaned as necessary but should
be regularly cleaned along with air-conditioning grills. All furniture, room equipment, floors, and waste
receptacles are cleaned between cases and at the end of the day.

8. (B) Glass suction bottles should be thoroughly cleaned with a disinfectant solution and autoclaved before
reuse.

9. (C) Storage areas should be cleaned at least weekly to control dust.

10. (B) Doors should be closed during and in between cases to reduce the microbial count.

11. (D) A wet vacuum system is the best. However, if mopping is to be utilized, a clean mop is used. Each
time the mop is used, a two-bucket system is recommended (detergent germicide and clear water), and
the buckets must be emptied and cleaned between uses.

12. (B) If a sterile package wrapped in a pervious muslin or other woven material drops to the floor or
unclean area, do not use it. If the wrapper is impervious and contact area is dry, the item may be used.
Dropped packages should not be put back into sterile storage.

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13. (C) Protocol for the eyes say eyes must be covered from the brow to the top of the surgical mask and
must extend over the temples. Prescription eyeglasses are not protocol.

14. (D) All of the above statements are true.

15. (B) OR furniture should be arranged in a manner that prevents contamination of sterile surfaces by
traffic and by nonsterile equipment and also to prevent clutter.

16. (B) The scrub person’s gown and gloves should be opened on a small table or Mayo stand not back table.

17. (C) Exposure to radiation can cause genetic changes, cancer, cataracts, injury to bone marrow, burns,
tissue necrosis, and spontaneous abortion and congenital anomalies.

18. (C) Film badges are the most widely used monitors measuring total REMS of accumulated exposure.
Data are reviewed.

19. (D) Shielding with lead is the most effective protection against gamma rays and x-rays in the form of
lead-lined walls, portable lead screens, lead aprons, lead-impregnated rubber gloves, lead thyroid–sternal
collars, and lead glasses.

20. (D) Waste anesthetic gas is gas and vapor that escape from the anesthesia machine and equipment, as
well as gas released through the patient’s expiration. The hazards to personnel include an increased risk
of spontaneous abortion in females working in the OR, congenital abnormalities in their children as
well as in the offspring of unexposed partners of exposed male personnel, cancer in females
administering anesthesia, and hepatic and renal disease in both males and females. This problem can be
reduced by a scavenging system that removes waste gases.

21. (C) Methyl methacrylate, bone cement, is mixed at the sterile field. Vapors are irritating to eyes and
respiratory tract. It may be a mutagen, a carcinogen, or toxic to the liver. It can cause allergic dermatitis.
A scavenging system is used to collect vapor during mixing and exhaust it to the outside or absorb it
through activated charcoal.

22. (D) A mechanical smoke evacuator or suction with a high-efficiency filter removes toxic substances
including carcinogens and viruses from the air. Personnel should not inhale the fumes.

23. (C) Phacoemulsification (the fragmentation of a lens by use of ultrasonic energy and its subsequent
aspiration from the capsule) is accomplished by the use of a Cavitron unit.

24. (C) The power source is inert, nonflammable, and explosion-free gas. Compressed nitrogen is the power
source for all air-powered equipment.

25. (D) Dermatomes may be electric or air-powered with compressed nitrogen or air.

26. (A) A residual of distilled water should be left in the lumen of any tubing to be sterilized by steam.
Tubing should be coiled without kinks and disassembled from suction tips. Rubber bands prevent steam

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 penetration.

27. (B) A right-angled tube with a small diameter used for small amounts of fluid such as in brain, spinal,
plastic, or orthopedic surgery is Ferguson–Frazier.

28. (D) the Yankauer tonsil tip is a hollow tube, with an angle, used in the mouth and throat.

29. (B) Apply a tourniquet only as a last resort when hemorrhage cannot be controlled by any other means.
Tourniquets can cause irreparable vascular or neurologic damage.

30. (B) While elevated, the extremity is wrapped distally to proximally with an Esmarch rubber bandage to
exsanguinate the limb. The tourniquet is then inflated.

31. (C) The patient’s age, the size of extremity, and the patient’s systolic pressure are all factors to be
considered when applying a tourniquet. The depth of the incision is of no consequence.

32. (A) A Bier is a regional intravenous injection of a local to an extremity below level of the tourniquet.
The extremity remains painless as long as the tourniquet is in place.

33. (A) A tourniquet should never be used when direct circulation in the distal part of an extremity is
impaired. It could cause tissue injury, shutting off of blood supply to the part below causing gangrene
and loss of the extremity.

34. (B) Tourniquet application and removal time is recorded. The surgeon is informed when it has been on
for 1 hour and then every 15 minutes.

35. (D) If the patient has had a traumatic injury or casting, danger exists that thrombi might be in vessels
because of injury or stasis of blood. These could become dislodged and result in emboli.

36. (A) Air, oxygen, Freon, or ambient air is used. Nitrous oxide is an anesthetic gas.

37. (C) Caution must be taken to prevent solution from pooling under a tourniquet. Apply tourniquet and
drape position before tourniquet is inflated.

38. (D) Tourniquets are not used if circulation is compromised. Arthroscopy, bunionectomy and tendon
repair on a child would be indications for use.

39. (C) The ground plate or inactive electrode is lubricated with an electrosurgical gel and is placed in good
contact with a fleshy, nonhairy body surface. It should not be placed over a bony prominence. The
grounded pathway returns the electrical current to the unit after the surgeon delivers it to the operative
site.

40. (D) Bipolar units provide a completely isolated output with negligible leakage of current between the
tips of the forceps. The need for a dispersive pad is eliminated.

41. (A) The dispersive pad is the inactive electrode. It is placed as close to the operative site as possible, on

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 the same side of the body as the operative site and over a large muscle if possible. Bony prominences
and scar tissue should be avoided. Good contact is essential.

42. (D) To complete the electric circuit to coagulate or cut tissue, current must flow from a generator (power
unit) to an active electrode, through tissue, and back to generator via the inactive electrode.

43. (A) The tip is kept clean, dry, and visible. Charred or coagulated tissue is removed by wiping with a tip
cleaner or scraping with the back of a knife blade. Charred tissue on the electrode absorbs heat and
decreases effectiveness of current.

44. (A) Vessels are coagulated when any part of the metal instrument is touched with the active electrode. It
is known as buzzing.

45. (C) The bipolar cautery provides extremely precise control of the coagulated area.

46. (D) The ground plate should be as close as possible to the site where the active electrode will be used to
minimize current through body.

47. (D) The sterile active electrode directs the flow of current to the operative site. Style of the electrode tip
may be blade, loop, ball, or needle. It may be attached to a pencil-shaped handle or incorporated into
either a tissue-forceps or suction tube.

48. (C) Electrosurgery is not used in the mouth, around the head, or in the pleural cavity when high
concentrations or oxygen or nitrous oxide are used because of fire and explosion hazards.

49. (B) Only moist sponges should be permitted on a sterile field while the electrosurgical unit is in use, to
prevent fire.

50. (A) More electric current is needed when working in solution, as in the bladder, than in the air. During
bladder surgery, continuous irrigation is necessary to distend bladder for visualization and wash out
debris.

51. (A) Fulguration of a tumor is accomplished by use of a cutting electrode to destroy tissue. It both cuts
and coagulates.

52. (A) Fiberoptic lighting is an intense cool light that illuminates body cavities via a bundle of thousands of
coated glass fibers. It is nonglaring.

53. (A) Light cables should never be dropped or swung while carrying.

54. (B) A simple test for the integrity of the cable is to hold one end of the cable to a bright light and inspect
the opposite end. Dark spots are an indication that some of the fibers are broken.

55. (D) Light is cold, meaning that the heat is not transmitted throughout scope and tissue is not damaged.
The ends, however, can get hot and should be kept out of contact with patient and personnel skin. Keep

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 cable away from drapes or place on moist towel to prevent burns and fires.

56. (B) Loupes are glasses with telescopic lenses used for magnification in microvascular surgery and nerve
repair.

57. (A) The ability to discern detail is known as resolving power or resolution.

58. (D) The optical combination of the objective lens and the oculars determine the magnification of the
microscope.

59. (C) Objective lenses are available in various focal lengths ranging from100 to 400 mm with intervening
increases by 25-mm increments. The 400 mm provides the greatest magnification.

60. (C) A continuously variable system of magnification for increasing or decreasing images is possible with
zoom lens, usually operated with a foot control to free surgeon’s hands from the task.

61. (A) The slit aperture permits a narrow beam of light to be brought into focus on the field. This slit
image assists the surgeon in defining depth perception (relative distance of objects within the field).

62. (C) Usually fiberoptic, coaxial illumination provides intense, cool light. Paraxial illuminators contain
tungsten or halogen bulbs.

63. (B) Microscopes should be damp dusted before use. All external surfaces, except the lenses, are wiped
with detergent–disinfectant solution. Casters are also cleaned. It is kept dust free with an antistatic
cover.

64. (A) A beam splitter takes the image from one of the surgeon’s oculars and transmits it through an
observer tube; thereby, providing the assistant with an identical image of the surgeon’s view.

65. (C) The culpomicroscope illuminates and permits identification of abnormal cervical (ectocervical, lower
cervical canal, and vaginal wall) epithelium to target for biopsies.

66. (C) The laryngoscope becomes self-retaining by suspension in a special appliance placed over the
patient’s chest, thus enabling the surgeon freedom of his or her hands to use a microscope and perform
procedures.

67. (A) A microscope is a monocular or binocular. The binocular has two telescopes mounted side by side
that gives stereoscopic vision.

68. (C) Eyepieces are interchangeable and are available in four magnifying powers: 10×, 12.5×, 16×, and
20×.

69. (C) A, B, and D are appropriate techniques. Oil or fingerprints are removed with a solvent or lens-
cleaning solution or 50% denatured alcohol; however, solvents should be used sparingly so that
cemented surfaces are not destroyed.

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70. (D) some tables have a metal crossbar or body elevator between the two upper sections that can be raised
to elevate a gallbladder or kidney.

71. (A) Instruments and catheters are measured on a Fr scale; the diameter (in millimeters) is multiplied by
3. The smallest is 1 mm in diameter times 3, or 3 French.

72. (D) Inflatable, double-walled vinyl boots use alternating compression and relaxation to reduce risk of
deep-vein clotting in legs of high-risk patients undergoing general anesthesia.

73. (A) The Doppler is a blood flow detector. Ultrasonic imaging records flowing blood.

74. (D) A secondary monitor is called a “slave.”

75. (A) The mobile suction unit is called the Neptune. It removes waste and can be relocated to a waste
disposal area through a docking station.

76. (B) Smith and nephew coblator cauterizes, irrigates and suctions simultaneously. Commonly used on
tonsil surgery.

77. (D) The tubing for oxygen is green. Nitrous oxide is blue. The tubing for compressed air is yellow and
the tubing for the nitrogen is black.

78. (B) Laminar maintains positive pressure not negative. It has a unidirectional flow and maintains a higher
pressure in the OR.

79. (D) HEPA filters remove dust particles and bacteria as small as 0.3 mm to 5 mm in the OR.

80. (A) The air exchange per hour with HEPA filters is 20–25 exchanges.

81. (C) There is a weight limit for OR tables. All tables in the OR have weight limits.

82. (D) The Alvarado is not a neuro attachment but used as a foot holder in total joints.

83. (B) The fracture table is used for hip and leg fractures.

84. (A) It should be positioned before opening the sterile field to avoid contamination.

85. (B) Chest rolls are used to allow the patient to expand their lungs/chest.

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 ___________________ CHAPTER 8 ___________________

Transportation and Positioning

Patient transport, transfer to the operating room table, operating table attachments and positioning prior to
surgery: vital signs/blood pressure/urethral catheterization/sequential compression devices (SCDs)

• Patient transport to the operating room (OR)

The patient should be transported through the hallways feet first and enter the elevator head first
Side rails should be up and patient advised to keep hands and feet in
• Transfer and positioning
Four people are required to move an immobile patient
Two people for an ambulatory/mobile patient
The stretcher should always be locked before moving the patient
Anesthesia determines when it is time to move the patient. They are also responsible for moving the
head/neck
Once the patient is centered on the OR bed, a safety strap is placed 2 in above the knee
Arms are placed on arm boards not to exceed 90 degrees. This prevents nerve damage to the brachial
plexus
The patients feet should not extend beyond the end of the operating room bed to avoid foot drop
The patient should always be covered when possible to protect the patients privacy and keep them warm
• Once the patient is properly positioned on the operating room bed, we want to provide normothermia to
keep the patient comfortable, this includes:
Warming of the OR suite until the prep is performed and dries
Blankets from the warmer
Bair Hugger—air forced warming blankets
They should never be placed directly next to the patients skin because it can cause burns
Warming lamps
Blanketrol warmers that contain water or alcohol
Used to circulate warm or cool water through the coils to control the patient’s body temperature
Fluid warmers are used to warm IV solutions
Irrigation fluid warmer is used to warm irrigation fluids
• Heat loss in the operating room occurs four ways, they include:
Radiation—patient loses heat through the surrounding environment. The patient is brought from a
warm environment to a cold operating room

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 Convection—patient loses heat through air currents
Conduction—the patient loses heat by direct contact with the patients skin
Evaporation—the liquid on your skin evaporates and causes heat loss, loss through perspiration
• Hypothermia—this is a drop in normal body temperature where your body loses heat faster than it can
produce heat. When your body temperature drops, your heart, nervous system and other organs cannot
function properly which can cause failure to the heart and respiratory system. Symptoms include:
Increased oxygen—shivering
The cardiovascular and nervous system are compromised
Increased blood pressure
Bradycardia
• When a patient is having cardiac surgery hypothermia is a desired effect
• Antiembolic device/SCD—sequential compression device
These are stockings placed on the patient prior to surgery in order to pump blood back up to the heart
while the patient is immobile. This avoids blood clots. Venous stasis occurs due to long periods of
immobility. the superficial and deep veins in the legs do not get a normal blood flow and can develop
pooling of the blood and clots
The SCD massage the legs and move the blood in an upward direction to prevent venous stasis
SCDs come in various sizes
The SCDs are placed on the patient, after the patient is transferred to the OR table
The device should never be turned off or removed without permission from the anesthesiologist or
surgeon
• Vital signs include:
Temperature
Pulse
Respiration
Blood pressure
• Temperature
Noninvasive temperature monitors include:
Temperature monitoring disc—this is placed on the patients forehead to monitor temperature during
surgery
Invasive temperature monitors include:
Oral, rectal
Esophageal—used during radiofrequency ablation of atrial fibrillation
Bladder—commonly used in ICU. It is a heat sensitive indwelling urinary catheter
Normal body temperature
Oral—98.6°F (37°C)
Rectal—99.6°F (37.6°C)
Axillary—97.6°F (36.4°C)

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 Pulse
Pulse is taken at the radial artery 1 in proximal to the thumb
Apical pulse—this is a pulse taken at the apex of the heart with a stethoscope
Measure the pulse rate for 15 seconds and multiply by four to get the heart rate
Normal heart rates
Birth—130–160 bpm
Infant—110–130 bpm
Children—80–120 bpm
Adults—60–80 bpm
Tachycardia—heart rate over 100 bpm can be caused by:
Stress
Drugs
Exercise
CHF (congested heart failure)
Bradycardia—less than 60 bpm, this includes:
Athletes
Cerebral hemorrhage
Heart block
Drugs
Hypoxia (decrease in oxygen reaching body tissues)
Respirations—breathing is the exchange of oxygen and carbon dioxide in the cells.
A pulse oximeter (oxygen saturation device)—measures the amount of oxygen in the hemoglobin
portion of blood. The device clips onto the patient’s finger or toe.
Apnea—cessation of breathing
Brought on by anesthesia
Foreign body stuck in the airway
Bradypnea—decreased rate of breathing
Cheyne–Stokes—the patient’s breath is deeper and faster followed by decrease in breathing. They can
sometimes stop breathing for a short time. This pattern repeats itself. It is commonly found in patients
with heart failure or brain damage
Dyspnea—shortness of breath and/or difficulty breathing. This can occur during exercise or if the
patient has a history of heart/lung disease
Tachypnea—rapid breathing. Occurs in patients with a high fever
Kassumaul’s—fast, deep labored breathing
• Blood pressure—when your heart beats, it contracts and pushes blood through the arteries to the rest of
the body. This force is called systolic blood pressure or the top number. Diastolic blood pressure is the
bottom number. It is the pressure in the arteries when the heart is at rest
Blood pressure can be taken manually or with an electric recording sphygmomanometer

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 Blood pressure is measured in millimeters of mercury (mm Hg)
The cuff is placed around the upper portion of the arm and inflated and arterial blood flow is stopped
A stethoscope is placed on the brachial artery and the air in the cuff is slowly released
Korotkoff’s sounds—these are the first tapping sounds you hear. These sounds take place in five
phases:
Systolic pressure—the first tapping sounds you hear
Soft whistling sound as the cuff is deflated
Rhythmic tapping sound as the cuff is deflated
Fading tapping sound as the cuff is deflated
Diastolic pressure—the point where the sounds disappear altogether
Normal BP—less than 120/less than 80
Hypertension—140,159/90,99
An arterial line/art-line/A-line—is a thin catheter inserted into an artery. It is most commonly used in
intensive care and during surgery where the anesthesiologist can monitor the patient’s status with a
blood sample. The blood pressure is also monitored
This can also be used to obtain blood gases
An arterial line can be inserted in:
Wrist-radial artery
Elbow brachial artery
Groin femoral artery
Foot dorsalis pedis artery
• Bispectral index monitor—used to monitor of the depth of anesthesia in the surgical patient.
Urethral catheterization—performed by nonsterile team members, however, it is a sterile procedure
requiring aseptic technique to prevent a UTI. Always check for patient allergies to latex
Performed to drain the bladder and for irrigation the bladder is drained to:
Prevent injury
Better visualization
Monitor urine output
To obtain a sterile specimen
To relieve urinary retention
They are made of latex, silicone, and teflon
Foley catheter is commonly used and comes in various sizes (8–30 Fr)
16-French 5-cc Foley balloon catheter is commonly used on adults
The catheter balloon is tested with 10 cc of sterile water. Saline breaks down the catheter and air can
leak. Not commonly done anymore because the catheter can lose its integrity (always follow
manufacturer’s instructions)
Coude catheter (this catheter has a bend at the tip)—it can be used as an indwelling catheter or a
straight catheter. This is used on male patients with an enlarged prostate

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 A Robinson catheter is a straight catheter use on a D&C procedure
Urinary drains by gravity. The catheter bag must be kept below bladder level
When performing a urethral catheterization on a female patient:
Female patient—frog leg position
Open the catheter pack by using sterile technique (four-quadrant)
Put on sterile gloves
Test the catheter—follow manufacturer’s instructions
Use the nondominant hand to hold the labial fold open
Prep the area—urethra down
Place the tip of the catheter in lubricant and insert catheter
Connect the catheter to the drainage bag. When urine begins to flow, you know the catheter is in the
bladder
When performing this procedure on a male patient:
The patient is positioned in supine
Procedure same as above except the catheter is inserted into the male urethra
• Patient positioning—patient positioning takes place following anesthesia induction. Everyone involved in
patient positioning should have the knowledge of positioning to prevent damage to skin, nerves, joints,
cardiovascular system, respiratory system and other body parts
• Patient positioning provides visualization of the surgical site and provides the best access to the surgical
site
You must slowly and carefully position when the patient is asleep, they cannot tell you what is hurting
them or react to pain
You must keep the range of motion within the body’s limits to avoid damage to a limb
You must be aware of the position of the IV, Foley catheter, and other patient care devices so as not to
accidently pull them out
Protect pressure points and boney prominences by using padding
The patient’s skin should not come in contact with metal parts of the table as it can cause burns from
the ESU
Confirm that patient’s legs are not crossed
• Positioning aids include:
Operating room beds—they should be positioned under the center of the operating room lights and
away from the doors to prevent contamination from the outside corridors.
Weight limits vary
Special tables are used for bariatric patients
Parts of the operating room bed includes:
Headpiece/body/foot piece
Neuro/ortho attachments:
Mayfield headrest

164
 Gardner–Wells tongs
Horseshoe headrests
Special operating room tables
Orthopedic fracture table
Andrews—used for laminectomy procedures, knee chest
Jackson—used for cervical, thoracic and lumbar procedures
Wilson—used to support the patient’s upper body for laminectomies or disc removal
Hand table
Arm boards
Shoulder braces
Foot boards
Stirrups
Candy cane
Allen
Patient transfer devices
Roller
Toboggan
Flexible air mattress for bariatric patients
• Ergonomics—using proper body mechanics when moving or positioning the surgical patient This is
important to prevent injury to the health care worker
• Supine position—dorsal recumbent
The patient is always in supine position when anesthesia is induced
Patient is flat on their back with their legs straight
Arms on arm boards palms facing up not extending 90°. Overextension can cause injury to the brachial
plexus
Elbows must be carefully positioned to avoid damage to the ulnar nerve
Arms can be positioned at the patient’s sides if needed; arms and hands must be positioned carefully to
avoid injury. When tucking the patients arms at their side with a draw sheet, you must not tuck the draw
sheet under the mattress but under the patient themselves
Padding is placed under the head. There are several varieties of head rests
Safety strap is placed 2 in above the knee
Supine position is used on surgery of:
Chest/breast
Abdomen
Pelvis
Anterior extremities
• Trendelenburg position—is a modification of the supine position where head and upper body are tilted
downward

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 Used to displace the pelvic organs for better exposure
This position is a used in treatment for shock
Shoulder braces can be used to prevent the patient from sliding off the table
• Reverse Trendelenburg—is a modification of the supine position where the head and upper body are
positioned upward
Displaces the abdominal organs
Foot board can be used to prevent the patient from sliding off the table
• Fowler’s/sitting position—the upper body is at a 90-degree angle
• Semi-Fowler’s—same as above except the upper body is at about an 85° angle
This position reduces blood flow from the upper body, and facilitates respiration. A major concern is an
air embolism
Used for surgery on the breast, head/neck, and shoulder
Arms may be positioned on arm boards or across the abdomen
Padded foot board is used to prevent the patient from sliding off the table
• Lithotomy position
Various positioning devices can be used
Candy cane stirrups
Yellofins/Allen stirrups
Stirrups must be equal height and length
Arms are on arm boards or at patient’s side tucked under the patient using a draw sheet that is tucked
under the patient
Raise and lower legs slowly and simultaneously. Two people are required to avoid blood pressure
changes
Buttocks must be positioned on the edge of the bed. Do not have legs hanging off the bed as this can
cause a back injury
Return the patient to supine position as soon as possible to avoid cardiovascular and respiratory
problems
Surgery includes—vagina, perineum, anus, rectum, and urethra
• Prone position
The anesthesiologist induces the patient while they are in supine position before positioning in prone
You need padding to prevent compression on the venacava and abdominal aorta
Use padding: axillary rolls, chest rolls to provide expansion of chest for lungs to expand
Position the breasts and male genatilia carefully
Be careful positioning the arms to prevent injury to the shoulder
Lower and rotate arms for placement on an arm board with palms facing downward or tuck along the
side of the body with palms facing inward
Surgerys performed—posterior cranium, dorsal body, spine, and/or posterior extremities
• Sims position

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 This is a modification of left lateral position
Used for—endoscopies (colonoscopy)
The left leg is straight, and the right leg is bent.
Usually the patient can position themselves
• Kraske/jackknife
This is a modification of prone position
Used for surgery on the anus and rectum
Patients hips (iliac crest) are positioned at the table break
Safety strap is placed proximal to the knees
Same applies to positioning the arms as with prone position
• Lateral position/lateral recumbent/lateral decubitus
Right lateral position—the right side of the body is down exposing the left side of the body. Same for
the left lateral position
Same precautions as prone position
Use padding: axillary rolls or chest rolls to provide expansion of chest to ease with respirations
Lower leg is bent/upper leg is straight with a pillow between them
Blood pressure should be measured from the lower arm
A Mayo stand is used to support the upper arm
The lower arm on the arm board the palm is facing up and the upper arm positioned on the mayo-stand
the palm is facing downward
A bean bag can be used to stabilize the upper body
• Kidney position
Modification of lateral position
The kidneys must be properly placed on the kidney bar/rest so it is able to be elevated
• Knee–chest position
Similar to the jackknife position but the legs are bent at the knee at a 90° angle
Used for spine surgery

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 Questions

Transportation
1. When using a patient roller, how many people are necessary to move the patient safely and efficiently?

(A) Two
(B) Three
(C) Four
(D) Five

2. When moving the patient from the operating room (OR) table, who is responsible for guarding the head
and neck from injury?

(A) Circulating nurse

(B) Scrub nurse
(C) Anesthesiologist
(D) Surgical technician

3. To move the patient from the transport stretcher to the OR table:

(A) one person stands at the head, one at the foot, while the patient moves over
(B) one person stands next to the stretcher, one adjacent to the OR table, while the patient moves over
(C) one person stands next to the stretcher, stabilizing it against the OR table, while the patient moves
over
(D) one person may stand next to the OR table and guide the patient toward him if stretcher wheels
are locked

4. When moving a patient with a fracture in the OR, all of the following are true EXCEPT:

(A) extra personnel are necessary

(B) support of the extremity should always be from below the site of fracture
(C) lifters on the affected side support the fracture
(D) the surgeon should be present

5. Which statement is false regarding the position on the OR table?

(A) Elbow should not rest against the metal table

(B) Feet should be uncrossed
(C) Pillows provide support and comfort to prevent strain

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 (D) Safety strap is 4 in below the knee

6. To avoid compromising the venous circulation, the restraint or safety strap should be placed:

(A) at knee level

(B) at the mid thigh area
(C) 2 in above the knee
(D) 2 in below the knee

7. A patient with a fractured femur is being moved to the OR table. Who is responsible for supporting and
protecting the fracture site?

(A) The nurse assistant

(B) The physician
(C) The circulating nurse
(D) The scrub nurse

Positioning
8. Crossing the patient’s arms across his or her chest may cause:

(A) pressure on the ulnar nerve

(B) interference with circulation
(C) postoperative discomfort
(D) interference with respiration

9. A precaution always taken when the patient is in the supine position is to:

(A) place the pillows under the knees for support

(B) place the safety strap 3–4 in below the knee
(C) place the head in a headrest
(D) protect the heels from pressure on the OR table

10. During lateral positioning:

(A) pillow is placed between the legs

(B) sandbag is placed between the knees
(C) rolled towel is placed under the bottom leg
(D) sheet is folded flat between the legs

11. To prevent strain to the lumbosacral muscles and ligaments when the patient is in the lithotomy
position:

(A) the buttocks must not extend beyond the table edge
(B) the legs must be placed symmetrically
(C) the legs must be at equal height

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 (D) a pillow should be placed under the sacral area

12. The lithotomy position requires each of the following EXCEPT:

(A) patient’s buttocks rest along the break between the body and leg sections of the table
(B) stirrups are at equal height on both sides of the table
(C) stirrups are at the appropriate height for the length of the patient’s legs to maintain symmetry
(D) each leg is raised slowly and gently as it is grasped by the toes

13. All of the following are requirements of the Kraske position EXCEPT:

(A) patient is prone with hips over the break of the table
(B) a pillow is placed under lower legs and ankles
(C) a padded knee strap is applied 2 in above knees
(D) arms are tucked in at sides

14. When using an armboard, the most important measure to take is to:

(A) support the arm at the intravenous site

(B) strap the patient’s hand to it securely
(C) avoid hyperextension of the arm
(D) avoid hypoextension of the arm

15. Anesthetized patients should be moved slowly in order to:

(A) prevent fractures

(B) prevent circulatory overload
(C) allow the respiratory system to adjust
(D) allow the circulatory system to adjust

16. If the patient is in a supine position, the circulator must always:

(A) place a pillow between the knees

(B) place a pillow under the knees
(C) confirm that ankles and legs are not crossed
(D) pad the thoracic area adequately

17. Extreme positions of the head and arm can cause injury to the:

(A) cervical plexus

(B) radial nerve
(C) ulnar nerve
(D) brachial plexus

18. Ulnar nerve damage could result from:

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 (A) poor placement of legs in stirrups
(B) hyperextension of the arm
(C) using mattress pads of varying thickness
(D) placing an arm on an unpadded table edge

19. In the prone position, the thorax must be elevated from the OR table to prevent:

(A) compromised respiration

(B) pressure areas
(C) circulatory impairment
(D) brachial nerve damage

20. The anesthesiologist closes the eyelids of a general anesthetic patient for all of the following reasons
EXCEPT:

(A) prevent drying of the eye

(B) prevent the patient from seeing the procedure
(C) prevent eye trauma
(D) protect the eye from anesthetic agents

21. Which position would be the most desirable for a pilonidal cystectomy or a hemorrhoidectomy?

(A) Lithotomy
(B) Kraske
(C) Knee–chest
(D) Modified prone

22. A position often used in cranial procedures is called:

(A) Fowler’s
(B) Kraske
(C) Trendelenburg
(D) lithotomy

23. In positioning for laminectomy, rolls or bolsters are placed:

(A) horizontally, one under the chest and one under the thighs
(B) longitudinally to support the chest from axilla to hip
(C) longitudinally to support the chest from sternum to hip
(D) below the knees

24. The position used for a patient in hypovolemic shock is:

(A) modified Trendelenburg

(B) reverse Trendelenburg

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 (C) supine
(D) dorsal recumbent

25. A Mayfield headrest would be used for which type of surgery?

(A) Ophthalmic
(B) Gynecological
(C) Neurological
(D) Urological

26. Good exposure for thyroid surgery is ensured by all of the following EXCEPT:

(A) modified dorsal recumbent with shoulder roll

(B) hyperextension of the neck
(C) utilization of skin-stay sutures
(D) firm retraction of the laryngeal nerve and surrounding structures

27. A procedure requiring the patient to be positioned supine in modified lithotomy is:

(A) colonoscopy
(B) abdominoperineal resection (APR)
(C) marsupialization of pilonidal cyst
(D) ileostomy

28. In which procedure may the patient be placed in a supine position with the right side slightly elevated by
a wedge to tilt the patient to the left?

(A) Cerclage
(B) Marsupialization of Bartholin’s cyst
(C) Shirodkar
(D) Cesarean section

29. The position for most open-bladder surgery would be:

(A) lithotomy
(B) supine, bolster under pelvis
(C) reverse Trendelenburg
(D) Fowler’s, modified

30. In which position could the patient sustain injury to the pudendal nerves?

(A) Positioned on the fracture table

(B) Positioned in lateral chest
(C) Positioned in lithotomy
(D) Positioned on the urological table

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31. Which factor is important to consider when positioning the aging patient?

(A) Skeletal changes

(B) Limited range of motion of joints
(C) Tissue fragility
(D) All of the above

32. When positioning the patient for a procedure, which of the following provides maximum patient safety
and maximum surgical site exposure?

(A) Patient’s body does not touch metal on table

(B) Equipment, Mayo stand, or personnel are not resting on the patient
(C) Bony prominences are padded
(D) All of the above

33. Changing a patient’s position, can result in severe:

(A) hypotension
(B) ischemia
(C) elevated cerebral pressure
(D) Both A and C

34. All are ways to identify a patient EXCEPT:

(A) address patient by their full name and state the surgery they are having
(B) examine the patient’s identification band and compare with the name and number on the chart
(C) ask the patient to state their full name, do not call the patient by their name before asking
(D) ask the patient to tell you what procedure they are having

35. To assist a falling patient, you should:

(A) support the patient’s weight with your body

(B) ease the patient to the floor while protecting their head
(C) once the patient is down, run and get assistance
(D) None of the above

36. Intravenous (IV) lines and fluids should be:

(A) lower than the patient’s body

(B) level with the patient’s arm
(C) higher than the patient’s body
(D) it really does not matter

37. What is the position called when the OR bed is tilted with feet down?

(A) Trendelenberg

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 (B) Low lithotomy
(C) Hyperflexion
(D) Reverse Trendelenberg

38. Antiembolism or SCDs are placed on the patient’s legs prior to surgery to prevent:

(A) thromboembolus
(B) cramping
(C) protection from metal parts of the OR table
(D) to assist in the range of motion

39. Another name for the supine position is:

(A) prone
(B) anteriolateral
(C) dorsal recumbent
(D) Trendelenberg

40. When the patient is positioned in supine position, the armboard must not ______ be more than
________ degrees.

(A) flexed, 90
(B) there is no specific criteria
(C) adducted, 90
(D) abducted, 90

41. The position that allows greater access to the lower abdominal cavity and pelvic structures due to gravity
is:

(A) reverse Trendelenberg

(B) lithotomy
(C) Trendelenberg
(D) supine

42. The orthopedic fracture table provides:

(A) circumferential access

(B) horizontal traction
(C) exposure to the ankle
(D) Both A and B

43. What position is occasionally used for facial, cranial, or reconstructive breast surgery?

(A) Sims
(B) Fowler’s position

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 (C) Reverse Trendelenberg
(D) Anteriolateral

44. Another name for the jackknife position is:

(A) prone
(B) posterolateral
(C) Kraske
(D) low lithotomy

45. Thoracic outlet syndrome can occur when there is pressure on:

(A) the thoracic artery

(B) the brachial plexus
(C) subclavian artery
(D) Both B and C

46. Ulnar neuropathy results from:

(A) improper padding

(B) continuous pressure from the edge of the OR table
(C) when the elbow is tightly flexed
(D) All of the above

47. The following is a risk when positioning the patient on the OR table:

(A) hyperextension of limbs

(B) pressure on bony prominences
(C) improper padding
(D) All of the above

48. When transferring an unconscious or immobile patient from the stretcher to the OR table, ideally how
many people are required?

(A) Two or three

(B) Four to six
(C) One or two
(D) None of the above

49. When removing a patient from lithotomy position:

(A) lower the legs separately

(B) lower the legs quickly
(C) lower the legs together
(D) lower stirrups, then remove legs

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50. All of the following help to maintain normothermia during surgery EXCEPT:

(A) warm the OR until the prep is performed and dries

(B) blankets from the warmer are used
(C) SCD is applied
(D) fluid warmers are used to warm IV solution

51. Heat loss caused by convection occurs when:

(A) patient loses heat through the surrounding environment. From warm environment to a cold
operating room
(B) the liquid (due to perspiration) on their skin evaporates and causes heat loss
(C) patient loses heat by direct contact with the patient’s skin
(D) patient loses heat through air currents.

52. Symptoms of hypothermia include all EXCEPT:

(A) tachycardia
(B) increased oxygen shivering
(C) compromised cardiovascular and nervous systems
(D) increased blood pressure

53. The device used by the anesthesiologist to measure the amount of oxygen in the hemoglobin component
of the blood is:

(A) pulse oximeter

(B) oxygen saturation device
(C) sphygmomanometer
(D) Both A and B

54. Cheyne–Stokes breathing is defined as:

(A) shortness of breath and breathing difficulty

(B) breaths are deeper and faster followed by a decrease in breathing. The breathing can sometimes
stop for a short time.
(C) rapid breathing as in patients with a high fever
(D) fast deep labored breathing

55. Korotkoff’s sounds are:

(A) observed during Cheyne–Stokes breathing

(B) are the first tapping sounds heard when taking a blood pressure
(C) observed when using the bispectral index monitor
(D) the sound noted when using a Doppler

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56. An arterial line can be inserted into the:

(A) radial artery

(B) brachial artery
(C) femoral artery
(D) All of the above

57. Bispectral index monitor is used to:

(A) monitor the depth of anesthesia in the surgical patient

(B) used to monitor blood pressure
(C) measure the amount of oxygen in blood
(D) monitors body temperature

58. The neuro/ortho headrest attachments include all EXCEPT:

(A) Mayfield headrest

(B) Gardner–Wells tongs
(C) horseshoe headrest
(D) Andrews headrest

59. OR tables commonly used in spinal surgery include:

(A) Andrews
(B) Wilson
(C) Jackson
(D) All of the above

60. Which statement is incorrect when the patient is in Fowler’s position?

(A) The upper body is at a 90° angle

(B) Blood flow from the upper body is reduced and facilitates respirations
(C) A padded shoulder board is used to prevent the patient from sliding off the table
(D) Used for surgery on the breast, head, neck, or shoulder

61. Positioning aids used for lithotomy position include:

(A) candy cane stirrups

(B) yellofin stirrups
(C) Allen stirrups
(D) All of the above

62. All of the following statements are true regarding the Sims’ position EXCEPT:

(A) used for spine procedures

(B) left leg is straight, and right leg is bent

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 (C) this is a modification of left lateral position
(D) used for endoscopic procedures

63. All apply to a lateral position EXCEPT:

(A) padding, axillary rolls, and chest rolls are used to improve respirations
(B) a Mayo stand should not be used to support the upper arm
(C) lower leg is bent/upper leg is straight with a pillow in between
(D) blood pressure should be measured from the lower arm

64. The desirable position for better visualization in the lower abdomen or pelvis is:

(A) Fowler’s
(B) reverse Trendelenburg
(C) Trendelenburg
(D) Kraske

65. Another name for the Kraske position is:

(A) prone on an adjustable arch

(B) lateral
(C) knee–chest
(D) jackknife

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 Answers and Explanations

Transportation
1. (C) Four people are needed to move the patient safely when using a roller. One lifts the head, one lifts
the feet, one is beside the stretcher, and one is beside the OR table.

2. (C) It is the responsibility of the anesthesiologist to guard the neck and head. It also puts him or her in a
better position to observe the patient. Four people are needed, and the action must be synchronized.

3. (B) There should be an adequate number of personnel to safely transfer the patient to the OR table. One
person should stand next to the stretcher to stabilize it against the adjacent OR table. Another receives
the patient from the opposite side of the table.

4. (B) Fractures should be handled gently. Support should be both above and below the fracture site when
moving the patient. Adequate personnel should be available. The lifters on the affected side support the
fracture site.

5. (D) The safety strap is 2 in above the knee, not too tight but secure.

6. (C) The safety strap should be applied securely but loosely about 2 in above the knee. This is to avoid
compromise of venous circulation or pressure on bony prominences or nerves.

7. (B) The physician is responsible for supporting and protecting the fracture site when moving the
orthopedic patient. A fracture is handled gently with support above and below the fracture site.

Positioning
8. (D) Patient’s arms should not be crossed on the chest in order to prevent hindrance of diaphragmatic
movement and airway. This is essential to maintain respiratory function, to prevent hypoxia, and to
facilitate inhalation anesthesia induction.

9. (D) In the supine position, heels must be protected from pressure on the table by a pillow, ankle roll, or
doughnut. The feet must not be in prolonged flexion; the soles are supported to prevent foot drop.

10. (A) When a patient is positioned on his or her side, a pillow is placed lengthwise between the legs to
prevent pressure on blood vessels and nerves.

11. (A) The buttocks should be even with the table edge but should not extend over the edge; otherwise, it
could cause strain to the lumbosacral muscles and ligaments because the body weight rests on the

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 sacrum.

12. (D) Legs are raised simultaneously by two people who grasp the sole of a foot in one hand and support
the knee area with the other. Stirrups must be of equal height and appropriate for the size of the
patient’s leg.

13. (D) The requirements of the Kraske position are as follows: patient is prone with hips over break of
table, wide armboard is under head of mattress to support arms, pillow is under lower legs and ankles,
padded knee strap is 2 in above knees, table is flexed to acute angle, and small rolled towel is under each
shoulder.

14. (C) When using an armboard, caution should be taken so that the arm is not hyperextended or the
infusion needle dislodged. Hyperextension can cause nerve damage.

15. (D) The anesthetized patient and the elderly patient must be moved slowly and gently. This allows the
circulatory system to adjust. This is for patient safety.

16. (C) The patient must not have ankles or legs crossed as this could create pressure on blood vessels and
nerves. A normal reaction is for a supine patient to cross his or her legs before going to sleep.

17. (D) Injury to the brachial plexus can result from extreme positions of the head and arm. This can be
avoided with proper care and careful observation.

18. (D) Ulnar nerve damage can occur from pressure from the OR table edge. The arm resting on an
unpadded surface places pressure on the ulnar nerve as it transverses the elbow. This can be prevented
by the use of padding, by fastening the arm securely with a lift sheet, or by placing the arms on
armboards.

19. (A) The thorax is elevated when the patient is in the prone position in order to facilitate respiration.
This is accomplished with supports, rolls, elevating pads, body rests, or braces.

20. (B) The patient’s eyes may remain open even when the patient is under anesthesia. This exposes them to
drying or trauma from drapes or instruments. They can be protected with ophthalmic ointment or taped
closed.

21. (B) The Kraske (jackknife) position is used for procedures in the rectal area such as pilonidal sinus or
hemorrhoidectomy. Feet and toes are protected by a pillow. The head is to the side and the arms are on
armboards.

22. (A) In the Fowler’s position the patient lies on his or her back with knees over the lower break in the
table. A footboard is raised and padded. The foot of the table is lowered slightly, flexing the knees. The
body section is raised. Arms rest on a pillow on the lap. This position is used in some cranial procedures
with the head supported by a headrest.

23. (B) The patient is in prone position with lumbar spine over the center break of the table; two

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 laminectomy rolls (or other firm padding) are placed longitudinally to support the chest from axilla to
hip. Additional padding protects bony prominences.

24. (A) A modified Trendelenburg position is used for patients in hypovolemic shock. This may aid in
venous return and cardiac output.

25. (C) A Mayfield is a special neurosurgical overhead instrument table.

26. (D) The patient is in modified dorsal recumbent position with a rolled sheet to extend the neck and raise
the shoulders. Skin flaps may be held away with stay sutures. The laryngeal nerve is identified and
carefully preserved.

27. (B) For an abdominoperineal resection, the patient is initially positioned supine in modified lithotomy
providing simultaneous exposure of both abdominal and perineal fields.

28. (D) In a C-section, uterine displacement to the left in order to shift the uterus away from the pelvic
vessels is done to avoid maternal hypotension and maintain fetal well-being.

29. (B) For most open bladder surgery, the patient is placed in the supine position with a bolster under the
pelvis. Trendelenburg may be desired to allow viscera to fall toward the head, allowing excellent pelvic
organ exposure.

30. (A) On the orthopedic fracture table, the patient is positioned supine with the pelvis stabilized against a
well-padded vertical post. Pressure on the genitalia from the perineal post can injure the pudendal
nerves.

31. (D) The aging patient’s skin integrity is very important. Aging decreases range of motion of joints.
Elderly people cannot fully extend the spine, neck, or upper and lower extremities. Pillows, padding,
and support devices compensate for the skeletal changes to ensure patient comfort and ensure against
postoperative pain or injury.

32. (D) Maximum patient safety is accomplished by padding all bony prominences, protecting the brachial
plexus in the axillary region from strain or pressure, ensuring that the legs are not crossed to prevent
pressure on nerves and blood vessels, supporting and securing extremities to prevent them from falling
off the bed, ensuring that no part of the patient’s body touches metal on the OR bed, and making
certain no equipment, Mayo, or personnel rests on the patient.

33. (D) Changes in posture can result in hypotension and elevated cerebral pressure. Even when transfers
are slow and deliberate, accidents can occur.

34. (A) All are ways to identify a patient except addressing by their full name and stating the surgery they
are having.

35. (B) If a patient is walking unsteadily, you should use a wheelchair. If he or she is falling down, ease the
patient to the floor while protecting their head, immediately call for assistance while remaining with the

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 patient. Do not abandon the patient under any circumstances.

36. (C) IV lines and fluids should always be higher than the patient’s body.

37. (D) Reverse Trendelenberg or foot down position is used when the surgeon requires unobstructed access
to the upper peritoneal cavity and the lower esophagus.

38. (A) SCDs reduce the risk of blood pooling or stasis and thrombus formation.

39. (C) Dorsal recumbent is also known as supine position.

40. (D) To protect the brachial plexus, armboards must not be abducted more than 90 degrees.

41. (C) Trendelenberg provides greater access to lower abdominal cavity and pelvic structures by allowing
gravity to retract the organs.

42. (D) The fracture allows circumferential access and horizontal traction during the surgical procedure.

43. (B) The position used for facial, cranial, or reconstructive breast surgery is the Fowler’s position.

44. (C) Jackknife is also known as Kraske. The patient is in the prone position with the table flexed
downward to achieve simultaneous head down and foot down position.

45. (D) Thoracic outlet syndrome is a rare condition in which the brachial plexus and the subclavian artery
are compressed.

46. (D) The ulnar nerve passes through the condylar groove of the elbow. It is only covered by skin and
subcutaneous tissue. The nerve is subject to compression injury when the elbow is tightly flexed or there
is direct pressure from the edge of the OR table.

47. (D) All of the above. The patient can be seriously and permanently injured as a result of improper
positioning. Only personnel specifically trained and competent to position the patient should assist in
this task.

48. (B) Transferring the patient who is unable to control movement to the OR table requires four to six
people.

49. (C) Sudden shifts in blood pressure and spinal injury can occur during positioning and removal from
stirrups. To prevent this injury, both legs must be lowered together slowly.

50. (C) SCDs do not provide warmth to the patient. They are used to prevent DVT.

51. (D) Convection is when the patient loses heat through air currents. Radiation is when the patient loses
heat through the surrounding environment. The patient is brought from a warm environment to a cold
operating room. conduction is when the patient loses heat by direct contact with the patient’s skin and
evaporation is when the liquid on the patient’s skin from perspiration evaporates and causes heat loss.

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52. (A) Bradycardia is a symptom of hypo-thermia.

53. (D) The pulse oximeter or oxygen saturation device both measure the amount of oxygen in hemoglobin.

54. (B) Cheyne–Stokes is when the patient’s breathing is deeper and faster followed by a decrease in
breathing. They can stop breathing for a short time. This pattern repeats itself. Dyspnea is shortness of
breath or difficulty breathing. Tachypnea is rapid breathing and Kassumaul’s is fast deep labored
breathing.

55. (B) Korotkoff’s sounds are the first tapping sound that is heard during blood pressure reading and take
place in five phases.

56. (D) An arterial line can be inserted into the radial artery, brachial artery, femoral or dorsalis pedis artery.

57. (A) A bispectral index monitor is used to monitor the depth of anesthesia in the surgical patient. A pulse
oximeter measures the amount of oxygen in the hemoglobin.

58. (D) The Andrews table is used for spinal surgery.

59. (D) All mentioned tables can be used for spinal surgery.

60. (C) A padded foot board is used to prevent the patient from sliding off the table.

61. (D) Yellofins and Allen stirrups are used when the patient is in lithotomy position.

62. (A) Sims’ position is not used for spinal surgery, it is commonly used for patients undergoing a
colonoscopy.

63. (B) A Mayo stand is used to support the upper arm with proper padding and with the palm facing
downward.

64. (C) The Trendelenburg position is used for procedures in the lower abdomen or pelvis in which it is
desirable to tilt the abdominal viscera away from the pelvic area for better exposure. The entire table is
tilted downward (about 45 degrees at table head) while the foot is also lowered the desired amount.

65. (D) The Kraske position is also called the jackknife position. The patient is anesthetized in supine
position. He or she is turned to the abdomen with the hips over the center break in the table.

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 ___________________ CHAPTER 9 ___________________

Counts

• The scrub tech and circulating nurse are responsible for counting items before, during, and after the
surgical procedure because the surgeon relies on their accuracy for patient safety and legal reasons
• Counts are performed:
Before the skin incision is made
Before closing a hollow organ, example: uterus
Any time there is a change of shift in the room
When additional supplies are added to the sterile field, they must be counted
When closing the peritoneum
When closing skin
• When counting, the scrub tech will touch each item and count out loud with the circulating nurse
watching
• When performing a closing count, the order is as follows:
Surgical field
Mayo stand
Back table
• The only time a count may be omitted is in an extreme emergency situation
The omitted count must be documented
The surgical technologist and circulator individually do the best they can to keep track of everything
At the end of the case there will be a final count and if requested by the surgeon, an x-ray can be taken

SPONGES

• All sponges on the sterile field should be radiopaque

• Bar Coding—radiofrequency sponges that are counted with a scanner have a small black encoded tag
attached
• 4 × 4’s—come in packs of 10—they should be individually separated and counted
• Laparotomy pads/lap pads
They come square and oblong in packs of five with a radiopaque blue twill tape sewn on one corner
They may also come with five plastic or radiopaque rings. When using the lap pad with rings in the
abdominal or thoracic cavities, the rings must remain outside of the body
• Peanut sponge—they are small radiopaque rolled gauze sponges

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 Commonly used for blunt dissection, and absorption of fluid
Come in packs of five
They are attached to the tip of a clamp using a Kelly or an Adson
• Kittner dissector—similar to a peanut, made from heavy cotton dental tape
Commonly used for blunt dissection
• Tonsil sponges—They are soft cotton filled gauze in the shape of a ball with a cotton string attached
They come in groups of five
Commonly used on T&A surgery
• Cottonoid patties—they are small square- or rectangle-shaped strips of compressed cotton or rayon used
for hemostasis
Commonly used on neurological procedures of the spine and brain
They are moistened with various solutions including topical thrombin
The surgeon used Bayonet forceps to pick up the patty
• Cloth towels—they are not commonly counted but when used to pack the abdomen it is the responsibility
of the surgical technologist and circulator to keep count of them going in and out of the abdomen
• All of the above types of sponges should be handled and counted one by one by the surgical technologist
and circulator

SPECIAL CONSIDERATION WHEN USING SPONGES

• Secure sponges in a safe area away from other supplies so not to accidently grab one and drag into the
wound
• Never cut sponges on the surgical field
• Never remove the radiopaque marker
• Never pass off a specimen on a surgical sponge Use a piece of Telfa
• Pass off the dirty sponges into the kick bucket Do not keep on your field
• Once the abdomen is opened, all small sponges should be removed from the Mayo stand
• Use Raytec sponges on sponge forceps if used on an open abdomen
• Lap pads should be counted going into the abdomen and when coming out of abdomen
• They should be handed to the surgeon on an exchange basis

COUNTING SHARPS
Needles
• When counting needles, they are counted while in the package. As they are opened for use, the count is
verified
• Needles should be left in their package until the surgeon requests the suture
• No needle should be on the Mayo stand without a needle holder attached
• Needles are handed on an exchange basis with the neutral zone/no-hand technique

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 • When the surgeon returns the needle to the surgical technologist, it should be placed on the needle board
immediately
• All hypodermic needles should be counted
• The ESU tip should be counted

Blades
• Blades should be handed directly to the STSR, or told immediately where the blade has been flipped to
• Blades should be loaded onto the handle with a heavy needle holder
• If a blade breaks, all parts must be counted
• The skin blade should only be used for skin. Once handed back, it should be isolated
• The scalpel should be passed to the surgeon by the neutral zone technique or the no-hand technique

INSTRUMENT CONTAINERS

• Instruments are first counted and documented on a count sheet in sterile processing
• When counting the instruments in the OR, the STSR hands the count sheet off the sterile field to the
circulator
• Instruments should be counted on the back table before they are placed on the Mayo stand
• They should be counted one instrument at a time
• All instruments should be visually and verbally counted by the surgical technologist and the circulator
• The surgical technologist should touch each instrument when counting
• Instruments that have multiple parts are counted individually

POTENTIAL PROBLEMS WITH COUNTS

• If the count sheet does not match the actual number of instruments, change the numbers on the count
sheet
• Always count twice if there is a discrepancy
• If the patient is not yet in the operating room and you have an incorrect sponge count, remove them from
the sterile field, bag the sponges and remove from the room
• If the patient is in the OR and you have an incorrect sponge count you must remove them from the sterile
field, bag them and isolate them in the room
• The Mayo stand and back table should remain sterile until the patient has left the room
• The correct steps when experiencing an incorrect closing count:
Notify the surgeon immediately
Count again
Check drapes and incision
The circulator looks through all garbage’s, linen hampers, under the OR furniture, and floor
After all search efforts are complete and the item is still missing call for x-ray
The incident must be documented and an incident report completed

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DOCTRINE OF RES IPSA LOQUITUR
• This means “The thing speaks for itself”
• This doctrine applies to a negligent act in the operating room. An example is a retained foreign object in
the patient

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 Questions

1. When are counts done in the OR?

(A) At beginning and end of case

(B) Before beginning of case, at beginning of wound closure, and at skin closure
(C) As case begins and when case is in progress
(D) Before beginning of case and at end of case

2. Soiled sponges are:

(A) never touched with bare hands

(B) left in the kick bucket until the count begins
(C) removed from the room once the peritoneum is closed
(D) counted and stacked on a towel or sheet on the OR floor

3. The initial count requires:

(A) a count of both plain and radiopaque sponges

(B) that counts be done in the right-hand corner on the back table
(C) that the count be done aloud by circulator and scrub
(D) the scrub to count each item and report to the circulator for recording

4. If a sponge pack contains an incorrect number of sponges, once the patient is in the room, the
circulating nurse should:

(A) isolate the pack, put in bag, do not remove from the room
(B) no documentation needed
(C) use after adding or subtracting the correct number
(D) remove it from the room

5. In an instrument count:

(A) all instruments and parts must be counted

(B) precounted sets eliminate the need for precase count
(C) large bulky instruments need not be counted
(D) count only instruments that will be used

6. Which of the following statements concerning sponges are true EXCEPT:

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 (A) only radiopaque sponges should be used on the sterile field
(B) sponges should be counted from the folded edge
(C) a pack containing an incorrect number of sponges is discarded
(D) a count is unnecessary in a vaginal procedure

7. The following statements regarding counts are true EXCEPT:

(A) the relief scrub or circulator does not need to repeat count if only one of them is relieved
(B) all counts are verified before person being relieved leaves room
(C) persons taking final count are held accountable
(D) persons taking final count must sign the count record

8. During the closure count a discrepancy:

(A) is noted on patient’s chart

(B) is reported to surgeon
(C) is reported to supervisor
(D) is reported to anesthesiologist

9. The following statements regarding counting sponges are true EXCEPT:

(A) sponges are counted at folded edge

(B) fan pack to separate sponges
(C) separate each sponge and number aloud while placing it in a pile on table
(D) an incorrect number of sponges in a pack should be compensated for on count sheet with a
notation

10. Instruments added to the sterile field after the case is in progress are counted by:

(A) STSR and circulator

(B) STSR and first assist
(C) Does not need to be counted
(D) Included in final count

11. Counted items include:

(A) sponges
(B) umbilical tapes
(C) suture reels
(D) All of the above

12. The closing counts are done in what order?

(1) Mayo stand

(2) Back table

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 (3) Sterile field
(4) Items discarded from the sterile field
(A) 1, 2, 3, 4
(B) 3, 2, 1, 4
(C) 3, 1, 2, 4
(D) 2, 3, 1, 4

13. If the count is incorrect the proper order or procedural steps are: 1. Radiograph is taken 2. Search is
initiated 3. Notify surgeon and count repeated:

(A) 3, 2, 1
(B) 1, 2, 3
(C) 2, 3, 1
(D) 1, 3, 2

14. When performing a C-section, the first count is initiated:

(A) before closing the body cavity

(B) before closing the uterus
(C) before the closing suture is given
(D) when the shift change occurs

15. The first closing count is performed on which abdominal layer?

(A) Skin
(B) Sub q
(C) When the surgeon requests
(D) Peritoneum

16. What action should be taken when there is an incorrect sponge count and the patient is on the operating
room table?

(A) Document the correct amount and proceed with procedure

(B) Place sponges in a bag and isolate them in the operating room until the case is completed
(C) Place the sponges in a bag and immediately remove them from the operating room
(D) Discard them in the garbage in the operating room

17. What is the correct way to count radiopaque 4 × 4 sponges?

(A) Keep the tab on the 4 × 4’s, give a slight shake and count while holding
(B) Remove the tab and count by 2’s
(C) Remove the tab and count each sponge individually
(D) Lay them out and let the circulator count them and proceed with your setup

18. Prior to the beginning of the surgical procedure, the ideal situation to count instruments is:

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(A) from the back table when all instruments and their parts are all in one area
(B) once you have set up your back table and mayo stand
(C) after you have assembled all instrument parts to assure all are working properly
(D) at any time prior to the incision

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 Answers and Explanations

1. (B) The first count is done by the instrument wrapper at assembly. The second count is done
immediately before the operation begins by the scrub and the circulator. A third count is done when
wound closure is started. A fourth is done for any discrepancy and at skin closure. An additional count
may be done when a cavity within a cavity is closed, for example, uterus.

2. (A) Soiled sponges should never be touched with bare hands. Sponges should be counted in units and
bagged in a waterproof plastic bag or transferred to a moisture-proof surface until the final count is
completed. This is done to avoid hepatitis or pathogenic organism transmission.

3. (C) The scrub nurse and the circulator count each item aloud and together. The nurse then records the
number. Count additional items away from already counted items. Counting should be uninterrupted.

4. (A) If a pack contains an incorrect number of sponges, it is the responsibility of the circulator to isolate
it, and it is not used. The danger of error is great if attempts are made to correct or compensate for
discrepancies.

5. (A) Each item used must be considered a foreign object that can cause unnecessary harm should it be left
inside the patient. Detachable parts of instruments must be counted. This ensures that part of an
instrument does not remain in the wound.

6. (D) Sponge and instrument counts are very important in vaginal procedures. Sponges should be secured
on sticks in deep areas. This prevents loss in hard-to-see areas.

7. (A) The relief of either the scrub or the circulator by another person necessitates the verification of all
counts before person being relieved leaves room. Persons taking final counts are held accountable and
must sign record.

8. (B) During the closure count, the scrub person reports counts as correct or incorrect to the surgeon.

9. (D) If a pack contains an incorrect number of sponges, scrub hands pack to circulator. Attempts should
not be made to correct errors or compensate for discrepancies. Pack is isolated and not used.

10. (A) Recommended procedure for counts including sponges, sharps, instruments, and special equipment
which requires at least a licensed registered nurse and an STSR.

11. (D) Counted items include sponges, sharps, instruments, retraction devices (umbilical tapes, vessel loops,
bolsters, sutures, reels), and any other small item that is used on the sterile field.

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12. (C) The closing count begins with the sterile field then to the Mayo stand, back table, and, finally, to
items that were discarded from the field.

13. (A) When the count is incorrect, the surgeon is notified and the count is repeated. A search is initiated
and finally, an x-ray is taken.

14. (B) The first count performed during a C-section is done before closing the uterus which is a hollow
organ.

15. (D) The first closing count is performed when the peritoneum is being closed.

16. (B) If the patient is already in the operating room and the count is incorrect, you must bag the sponges
and isolate them in the OR room until the end of the case. If the patient is not yet in the room, you
may bag the sponges and remove them from the room.

17. (C) The tab holding the Raytec 4 × 4 sponges should be removed and each sponge counted individually.

18. (A) The ideal time to count your instruments is when all instruments and supplies are still on the back
table.

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 ___________________ CHAPTER 10 ___________________

Specimens

• Biopsy—excision of tissue or aspirated fluid

• Histology—study of tissue
• Cytologic—study of cells
• All tissue and objects removed from the patient are considered specimens and must be sent to pathology
• Permanent specimens are sent in formalin or saline. The fluid is drained and replaced with paraffin. This is
a type of wax that helps to keep the tissue hard or together so it can be cut and viewed under a microscope
at a later date
• Frozen sections are sent immediately to the lab and placed in a dry container
• Urine specimens
• Clean catch—urethral meatus is cleaned and the patient urinates in a sterile specimen cup midstream upon
voiding
• Urine specimens are obtained under sterile conditions and sent in a sterile specimen container
• The STSR must confirm the specimen with the surgeon before handing it off the field
• The circulator must confirm with the STSR and surgeon to confirm proper labeling before sending it out
of the room. “Write down and read back”
• The surgeon may mark specimens with suture/clips/margin markers to identify the correct orientation of
the specimen when taken from the body
• Bullets—must be handled with gloved hands not instrumentation because instruments can leave a scratch
or indentation in the bullet and forensics will not be able to make an accurate match. All guns have
markings in the barrel and the bullet should have identical markings and instrument will alter this
• Removed prosthesis—are kept clean and dry before sending to pathology
• Amputated limbs are sent dry to pathology
• Breast specimens—are sent frozen (dry)
• Gall stones and kidney stones should go dry to pathology as the preservative can alter the specimens
• Smear and brush biopsy specimens are commonly used for endoscopic procedures (bronchoscopy)
• Fluid and cells are obtained with a small brush and placed on a slide for the cells to be examined
• Specimens are placed on Telfa, or in a basin never on a surgical sponges
• Incisional biopsy—this is removal of a portion of the lesion for frozen section
• Gram stain—used to identify bacteria. Stains used include:
Blue/purple—gram positive

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 Red/pink—gram negative
• CSF—cerebral spinal fluid is obtained by performing a spinal tap. CSF is withdrawn from the lumbar
region of the spinal column for analysis
• Thoracentesis—a needle is placed into the pleural space and fluid is withdrawn for diagnosis
• Lukens tube—collection tube used to obtain specimens from the lungs and stomach during procedures

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 Questions

1. Who is directly responsible for receiving and handling the specimen on the sterile field?

(A) STSR
(B) Circulator
(C) Anesthesiologist
(D) Surgeon

2. Damage to or loss of specimens results in:

(A) an incorrect diagnosis

(B) repeat or needless surgery
(C) delayed treatment
(D) All of the above

3. What type of biopsy is performed during a flexible endoscopic procedure?

(A) Incisional biopsy

(B) Needle biopsy
(C) Brush biopsy
(D) Fine-needle aspiration

4. Stones are sent to pathology in:

(A) formalin
(B) dry container
(C) sterile saline
(D) not sent to pathology

5. Which of the following is considered a foreign body?

(A) A nontissue item

(B) Wood
(C) An implant
(D) All of the above

6. An amputated limb is sent:

(A) to the morgue

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 (B) pathology
(C) in formalin
(D) it is discarded

7. What type of specimen requires immediate analysis?

(A) Stones
(B) Foreign body
(C) Frozen section
(D) All of the above

8. Bacteria cultures obtained during surgery are:

(A) ABGs
(B) aerobic
(C) anaerobic
(D) Both B and C

9. The term describing the specimen removal in one piece is:

(A) in situ
(B) en bloc
(C) colon resection
(D) None of the above

10. Bacteria cultures obtained during surgery include:

(A) aerobic
(B) anaerobic
(C) urine
(D) Both A and B

11. What is considered a foreign body:

(A) bullett
(B) femoral implant
(C) wood
(D) All of the above

12. Loss of specimens can result in all except:

(A) the patient requiring additional surgery or treatment

(B) an incorrect diagnosis
(C) not a problem another specimen can be obtained
(D) treatment can be delayed

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13. Specimens should never be placed on:

(A) Raytec 4 × 4
(B) Telfa
(C) emesis basin
(D) None of the above

14. Stones are sent to pathology in:

(A) sterile water

(B) dry container
(C) saline solution
(D) formalin

15. What is considered improper procedure for handling a bullet specimen:

(A) handle as little as possible

(B) use tissue forceps to gently grasp the bullet
(C) do not drop bullet into metal basin or bowl
(D) do not use an instrument to grasp the bullet

16. When sending a frozen specimen to the lab:

(A) send immediately for analysis

(B) send in a dry container
(C) verify with the surgeon before handing it off the sterile field
(D) All of the above

17. Permanent specimens are sent to pathology:

(A) immediately for a diagnosis

(B) dry container
(C) in a container with formalin or saline
(D) they do not need to go to pathology and can be discarded

18. A femoral implant removed from the patient’s body is sent:

(A) clean in formalin

(B) clean in a dry container
(C) discarded
(D) clean wrapped in a lap and placed in a dry container

19. What is an incisional biopsy?

(A) The entire mass with surrounding tissue

(B) A small portion of tissue is incised and sent for examination

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 (C) Sent as a permanent specimen
(D) Sent in formalin

20. Thoracentesis

(A) A needle is placed into the pleural space and fluid is withdrawn for diagnosis
(B) A Lukens is used to obtain a thoracentesis specimen
(C) A brush instrument is used to obtain the specimen
(D) Is a VATS procedure

21. A specimen obtained in one piece is termed:

(A) in situ
(B) en bloc
(C) frozen
(D) None of the above

22. The color of a gram-positive bacteria stain is:

(A) red/pink
(B) green
(C) blue/purple
(D) yellow

23. When obtaining CSF for a specimen:

(A) termed a spinal tap

(B) retrieved from the lumbar region
(C) sent as a frozen specimen
(D) Both A and B

24. Cultures obtained during surgery:

(A) are handled as any other specimen

(B) are passed off the sterile field into a bag or container held by the circulator
(C) should be kept warm or sent to the laboratory immediately
(D) should be handled only by the scrub nurse

25. How is a frozen section sent to the laboratory?

(A) In formalin
(B) In saline
(C) In water
(D) Dry

26. Which of the following specimens is NOT placed in preservative solution?

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(A) Stones
(B) Curettings
(C) Tonsils
(D) Uterus

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 Answers and Explanations

1. (A) The STSR is directly responsible for receiving the specimen on the sterile field.

2. (D) If a specimen is lost or damaged, the result can be an incorrect diagnosis, repeat or needless surgery,
and delayed treatment.

3. (C) A brush biopsy is performed during a flexible endoscopic procedure. A fine brush is used to collect
cells on the surface of mucous membranes.

4. (B) Stones removed from the urinary tract, salivary ducts, and the gallbladder are sent in a dry container
to pathology.

5. (D) A nontissue item, wood, or an implant are all considered foreign bodies.

6. (B) Initially, the limb must be sent for analysis to pathology like any specimen and then sent to the
morgue.

7. (C) Frozen section requires immediate analysis. This is accomplished by freezing the tissue and making
fine sectional slices that can be examined microscopically.

8. (D) The two types of bacteria cultures taken intraoperatively are aerobic and anaerobic.

9. (B) En bloc is when the specimen is removed all in one piece.

10. (D) Aerobic and anaerobic cultures are taken to culture for bacteria.

11. (D) A foreign body is any object that is found in the body that does not belong there.

12. (C) Loss of specimens can result in additional surgery or treatment, an incorrect diagnosis and treatment
can be delayed.

13. (A) Specimens can never be placed on a Raytec sponge because it is a counted item and cannot leave the
room.

14. (B) Stones must go to pathology dry because solutions can change the composition of the specimen.

15. (B) Instruments can damage the bullet. Marks on the bullet need to be examined to match the gun. Any
alteration to the bullet can distort that test.

16. (D) All of the above facts are true regarding frozen sections.

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17. (C) Permanent specimens go to pathology in formalin or saline.

18. (B) After removal of a prosthesis, the item must go in a clean dry container.

19. (B) An incisional biopsy is a small portion of tissue that is removed. Excisional biopsy is removal of the
entire mass. This biopsy is never sent as permanent or in formalin.

20. (A) A needle is inserted into the pleural space to remove fluid. A Lukens is used for peritoneal washings.
Brush instruments are used in cytology. This procedure is done without video assistance.

21. (B) En bloc refers to all pieces of specimen to remain attached when it is removed. In situ is a specimen
that is in its original position. Frozen specimen is tissue that is sent immediately to pathology.

22. (C) The color of the stain in gram-positive specimens is blue/purple. Gram-negative specimens turn
red/pink.

23. (D) Obtaining CSF is done through a spinal tap and is taken from the lumbar region.

24. (B) Cultures are obtained under sterile conditions. The tips must not be contaminated by any other
source. The circulating nurse can hold open a small bag for the scrub nurse to drop the tube into if it is
handled on the sterile field. This protects personnel and prevents the spread of microorganisms.

25. (D) Frozen section specimens are not placed in solution because they can react with tissue and affect the
pathologist’s diagnosis. A frozen section is the cutting of a thin piece of tissue from a frozen specimen.
This permits examination under a microscope.

26. (A) Stones are placed in a dry container to prevent dissolving. Stones are sent for additional study to
determine their composition.

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 ___________________ CHAPTER 11 ___________________

Medical, Ethical, and Legal Responsibilities

MEDICAL/ETHICAL/LEGAL FOR THE REVIEW BOOK

• We are all responsible for our own actions

• Scope of practice—this is a term given that identifies the knowledge and skills required for the professional
(STSR) to provide effective and reliable care. This is based on:
Education
Experience
National credentialing
• The STSR performs tasks in the OR under the authority of the surgeon
We can only do what we are legally trained to do. If someone asks us to do something we were not
trained to do—do not do it!!!!! Many times in the OR you will see people performing tasks that they
shouldn’t do, and you will be asked to do tasks you shouldn’t do either. Politely say “ I’m sorry I can’t do
that . . .”
• When faced with a task that you may feel is not in your scope of practice ask yourself this question?
“Was the task taught in our surgical technology program?” If the answer is yes than you may do it. If the
answer is no then do not do it.
“Am I willing to take full responsibility for what I am about to do?”
• Licensure
Most restrictive
Registered nurses are licensed
• Certification—surgical technology students are credentialed by certification
NBSTSA—the national board of surgical technology and surgical assisting—they administer the
national certification examination
Surgical technologists must pass the examination in order to work in New Jersey, Texas, Illinois,
Indiana, South Carolina, and Tennessee
Accreditation—in order to sit for the national certification examination you must come from an
accredited program
CAAHEP—Commission on Accreditation of Allied Health Education Programs—they set the
standards for the surgical technology program
Core Curriculum—this is the guide that outlines the mandatory curriculum for the surgical technology
program

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 ARC/STSA—The Accreditation Review Council on Education in Surgical Technology and Surgical
Assisting—they directly oversee the educational part of the program. They assist accredited programs
prepare for site visits
• Legal terms
Accountability—to be held responsible for your action
Affidavit—sworn written statement of facts (confession)
Allegation—a claim that someone has done something illegal or wrong, usually made without any proof
Bonafide—sincere without intention to deceive
Guardian—court appointed guardian to care for someone who cannot take care of themselves
Minor children
Incapacitated adults
Iatrogenic injury—an injury caused by a health care worker
Liability—obligation to do something or not to do something. Being responsible for doing something or
not doing something
Malpractice—this is when a medical professional does something or doesn’t do something that causes
injury to the patient.
Abandonment—leaving the patient at any given time without proper protection for them
Negligence—carelessness but not meant to do harm. Failure to use reasonable care, another professional
would not do the same thing in the circumstance. Examples include:
Something left in the body during surgery
Poor positioning that injured a patient
Patient burns from prep solution or the cautery
Performing surgery on the wrong side, site
Standard of care—this is the conduct that is expected of a health care professional in given
circumstances.
Health professionals must recognize responsibility to patients first and to other health professionals
Provide competent medical care
Respect human dignity and human rights
• Tort—a wrongful act that results in injury to another’s person, property, reputation, and the injured party
is entitled to compensation. Torts can be intentional or unintentional
Intentional torts
Assault—it is a threat of bodily harm with the intent to actually cause bodily harm
Battery—the intentional unlawful touching of someone without their consent. You actually want to
cause harm
Defamation—oral or written statement about someone that is untrue and can damage to their
reputation
Invasion of privacy—discussing private information about a patient without their consent
Unintentional torts

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 Patient misidentification
A patient’s wrist band should never be removed until they leave the hospital.
Transport should check the ID bracelet before bringing the patient into the operating room
The preoperative nurse in the holding area should check the name on the bracelet with the name on
the chart
The patient is requested to state their name and it should match the ID bracelet
Circulator, anesthesiologist should do the same
The last is the surgeon in the operating room
Aeger primo—the patient first
Primum non nocere—above all do no harm
Res ipsa loquitor—the thing speaks for itself
Respondeat superior—let the master answer
• Time out
Anyone can initiate the time out; however, it is usually the circulator
Everyone in the room must stop and pay close attention to the time out
Everyone in the room should be in agreement with the information and verbally agree to it
• Time out includes:
Confirming the patients name/procedure/and where the incision will be made (specific right, left side)
Allergies
Anesthesia has addressed any patient concerns
Have antibiotics been given prophylactically
Estimated blood loss
All films, supplies, equipment ready
Are there any patient specific concerns
All agree?
• Foreign bodies left in the patient—counts must be completed between the STSR and the circulator
verbally and visually:
Before the case begins
When closing a hollow cavity (e.g., uterus, C-section)
Peritoneum
Skin
• Patient burns—burns in the operating room include:
Hot instruments—cool off instruments from the autoclave with cool sterile water
Placing the return electrode improperly
The ESU should be placed in its holder when not in use. Do not clamp the ESU cord with a metal
instrument because if the electrical cord has a cut or tear in it in the current will travel and cause a burn.
Electrical equipment should be tested prior to use
Improper use of lasers and neglect of laser safety

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 Pooled prep solutions under the patient
Hot irrigation solutions
Anesthesia flammable gases
Light cords that are placed on the patients drapes
• Falls or improper patient positioning
Side rails should be up when transferring the patient and all extremities should be kept inside the bed
rails
The stretcher and operating room table should be locked when transferring the patient
Proper amount of people when moving the patient include:
Two—mobile patient
Four—immobile patient
Anesthesia controls the head and time of transfer
Immediately place safety strap 2 in above the knee as soon as the patient is on the operating room table
Insure proper padding
Understand positioning techniques and work together
• Incorrect administering of drugs
The STSR and the circulator should verify verbally and visually the correct drug, expiration date, and
amount
The STSR should label the med cup/pitcher/syringe as soon as the drug is received and the syringe is
filled
When passing the syringe to the surgeon the STSR should state the medication and the percentage
• Always check equipment before use and follow manufacturer’s directions
• Loss or damage of patient property—the RN in the holding area should remove patient’s personal
property, place it in a labeled bag and keep with the patients chart. If it gets past her, the circulator in the
operating room should follow protocol
• Be responsible for any breaks in sterile technique you make. SSI infections are caused by breaks in
technique. They can be traced back to someone who does not follow sterile technique.
• The STSR is under the direct authority of the surgeon; however we should not do anything that is out of
our scope of practice. It is illegal.

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 Questions

1. A patient was burned on the lip with a hot mouth gag. Which of the following actions would have
prevented this incident?

(A) The circulator cooled the item in the sterilizer

(B) The scrub nurse warned the surgeon that the item was hot
(C) The scrub nurse cooled the item in a basin with sterile water
(D) The surgeon had checked the item before using it

2. A patient signs a permission form for surgery, but because of a language barrier he or she does not fully
understand what she or he has signed. This could constitute a liability case for:

(A) assault and battery

(B) lack of accountability
(C) improper documentation
(D) invasion of privacy

3. If a patient falls because he or she was left unattended, the OR team member could be cited in a lawsuit
for:

(A) misconduct
(B) assault
(C) doctrine of respondeat superior
(D) abandonment

4. The legal doctrine that mandates every professional nurse and technician to carry out their duties
according to national standards of care practiced throughout the country is the:

(A) doctrine of res ipsa loquitor

(B) doctrine of respondeat superior
(C) Nurse Practice Act
(D) doctrine of reasonable man

5. The doctrine of respondeat superior refers to:

(A) the legal terms for assault and battery

(B) invasion of privacy
(C) employer liability for employee’s negligent conduct

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 (D) professional misconduct

6. Liability is a legal rule that:

(A) applies only in criminal actions

(B) holds the hospital responsible for its personnel
(C) holds each individual responsible for his or her own acts
(D) has no significance in malpractice suits

7. A criteria that identifies, measures, monitors, and evaluates patient care is:

(A) audits
(B) automated information systems
(C) quality control circles
(D) quality assurance programs

8. Failing to observe or act in a situation that the individual should have known about and acted on is
called:

(A) negligence
(B) abandonment
(C) guilt
(D) defamation

9. A document which a person gives instructions about his or her medical care in the event that the
individual cannot speak is:

(A) hospital policy

(B) administrative law
(C) ethical deposition
(D) advanced directive

10. The legal document signed by the patient before surgery is:

(A) operative report

(B) safe medical act
(C) ethical policy
(D) informed consent

11. The operative paperwork completed by the RN contains:

(A) sponges, sharps, and instrument counts

(B) specimens
(C) medications given
(D) All of the above

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12. The Latin phrase “aeger primo” refers to:

(A) patient first

(B) do no harm
(C) breathe
(D) it speaks for itself

13. Events requiring an incident report include:

(A) bullying
(B) equipment failure
(C) incorrect count
(D) All of the above

14. Accreditation for surgical technology programs is:

(A) ARC/STSA
(B) CAAHEP
(C) AORN
(D) JACHO

15. The code of ethics of the Association of Surgical Technologists include:

(A) to follow the principles of asepsis

(B) to report any unethical conduct or practice to proper authorities
(C) to respect and practice the patients legal and moral rights for quality patient care
(D) All of the above

16. The American Hospital Association (AHA) Patient’s bill of rights was adopted in what year?

(A) 1972
(B) 1985
(C) 1990
(D) 1960

17. Ethics is defined as:

(A) legal obligation that one person owes another person

(B) moral obligation that one person owes another person.
(C) laws
(D) what the patient requests

18. When you pass the CST exam, the certification is described as:

(A) formal process by which qualified individuals are listed in a registry

(B) legal right granted by a government agency which complies with a statute that authorizes the

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 activities of the profession
(C) recognition by an appropriate body that an individual has met a predetermined standard
(D) perform according to the facility guidelines

19. The health insurance portability and accountability act (HIPPA):

(A) gives patients the right to have elective surgery

(B) privacy standards to protect the patient’s medical records
(C) gives the patient the right to sue their doctor
(D) allows patients to see any physician they chose

20. Risk management objectives for a hospital include:

(A) minimize risks to patients and employees

(B) control financial loss
(C) collecting data to decrease harm to patients and staff
(D) All of the above

21. When a negligence suit is filed against the hospital who is named?

(A) The surgeon

(B) The RN
(C) The STSR
(D) Every person that has played a part in that surgery

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 Answers and Explanations

1. (C) It is the responsibility of the scrub nurse to cool an instrument in cool sterile water before handing it
to the surgeon. Burns are one of the most frequent causes of lawsuits.

2. (A) Lack of consent is an aspect of assault and battery. Consent must be given voluntarily with full
understanding of the implications. The procedure must be explained fully, in understandable language,
so that the patient fully comprehends what will be done.

3. (D) Abandonment may be a cause for a lawsuit if an unattended patient falls from a stretcher or an OR
table. It is the responsibility of a staff member to stay with the patient at all times.

4. (D) The doctrine of reasonable man means that a patient has the right to expect all professional and
technical nursing personnel to utilize knowledge, skill, and judgment in performing duties that meet the
standards exercised by other reasonable, prudent persons involved in a similar circumstance.

5. (C) An employer may be liable for an employee’s negligent conduct under the Respondeat Superior
master–servant employment relationship. This implies that the master will answer for the acts of the
servant.

6. (C) An unconditional general rule of law is that every person is liable for the wrongs he or she commits
that cause injury, loss, or damage to any person’s property. Liability means to be legally bound,
answerable, and responsible. A patient or family member may institute a civil action against the person
who caused the injury, loss, or damage.

7. (D) Quality Assurance (QA) establishes the criteria for measuring, monitoring, and evaluating patient
care as well as setting standards for improvement.

8. (A) Negligence is legally defined as “the omission to do something which a reasonable person, guided by
those ordinary considerations which regulate human affairs, would do, or do something which a
reasonable and prudent person would not do.

9. (D) An advanced directive is a document giving someone instructions pertaining to medical care in the
event the person cannot make decisions on their own.

10. (D) Informed consent is a legal document that states the patient procedure, risks, consequences, and
benefits of the surgery.

11. (D) This paperwork includes patient assessment, care plan, equipment, and devices used during the

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 procedure. It counts specimens, medications, and the names of all perioperative personnel who
participated in the procedure.

12. (A) The Latin term “aeger primo” means patient first.

13. (D) Many events require an incident report. They also include medication errors, bullying, equipment
failure as well as incorrect counts.

14. (B) CAAHEP accredits programs upon recommendation of the ARC/STSA. The ARC/STSA
provides educational standards and recommendations required for the accredited program of surgical
technology and surgical first assisting.

15. (D) All of the above are part of the code of ethics and many more.

16. (A) The AHA adopted the bill of rights in 1972.

17. (B) Ethics is defined as the moral obligation one person owes to another.

18. (C) Certification is described as being recognized by an appropriate body stating that the person has met
the required standards.

19. (B) HIPPA assures privacy standards in regard to a patient’s medical condition and medical records.

20. (D) The risk management department is responsible for minimizing risks to the patients and employees,
avoiding or minimizing the financial loss of the institution and to collect data to avoid future injuries.

21. (D) When a negligence suit is filed, everyone in contact with that patient will be named in the suit.

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 ___________________ CHAPTER 12 ___________________

Diagnostic Procedures

DIAGNOSTIC IMAGING

• Radiography/roentgenography—term used to produce images of internal structures of the body, they

include:
• Portable x-ray machine—this can be used in the operating room. It uses:
Cassette—this can placed under the patient, or on a wheel mounted machine that can be placed
alongside the patient covered with a sterile drape sheet
Once the film is taken it is processed to be viewed
• Contrast media—these are chemical substances used in x-ray. When the contrast media is injected, it
makes the images on the film look dense and the target structure stands out. They include:
Renografin
Hypaque/sodium diatrizoate
Cystografin
These chemical substances can be introduced into the body by:
Intravenously
Intra-arterial,
Intrathecal—injected into the spine
Intra-abdominally
• C-arm—is a mobile image intensifier used to take pictures.
Contrast media can be used
The fluoroscopy allows films to be taken still and with continuous movement in real time. It is
controlled by a foot pedal
It is called a C-arm because of it’s obvious shape
X-rays can be taken in lateral or anterior positions
Both the patient and staff must wear a lead apron to protect the testicles and ovaries; and a thyroid collar
to protect the thyroid. Do not turn your unprotected back to the C-arm
Lead apron thickness: 0.5 mm of lead
Do not bend and twist lead aprons it could damage the lead
The C-arm delivers high doses of radiation. The surgeon and staff should limit the time there hands are
exposed or wear led gloves
All working with fluoroscopy should be monitored to the amount of exposure, an x-ray badge called

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 Dosimeters is worn at the neck and routinely checked
While the fluoroscopy is being used it is recommended to stand at least 1 ft from the machine even
further if possible
A special drape is used to protect the surgical field from contamination
• Mini C-arm—this is a smaller version of the original c-arm, commonly used on hands and feet
• Mammography—this is an x-ray taken of the soft tissue of the breast to diagnose breast tumors. The x-ray
can take many different angles to view the breast tissue
• Myelography—this is an x-ray of the spine. Contrast media is used
• Angiography—is an imaging technique used to view the inside of vessels. Contrast media is injected and
the vessels outlined.
• Cardiac catheterization—this procedure is the process of injecting the contrast medium whereby the
coronary arteries are outlined. The invasive cardiologist can now diagnose which of the coronary arteries
are obstructed. A stent may be placed in the coronary artery that is obstructed. This stent keeps the artery
open.
A cut-down procedure is performed and a catheter is introduced into the vessel and contrast media is
injected, depending on which part of the heart they are focusing on, they can use the:
Femoral vessel
Brachial vessel
• ECG/Electrocardiogram—this is performed to test the electrical activity of the heart. Electrodes are
placed on the skin—trunk, arms, and legs
• Pulmonary angiography is primarily performed to detect pulmonary embolism or pulmonary artery
aneurysms
• Cholangiography—this procedure can be performed preoperatively or intraoperatively, the contrast media
is injected preoperatively through an IV, and intraoperatively directly into the common bile duct to
visualize stones or an obstruction
• Ventriculography—this is an x-ray of the ventricles in the brain
• Arthrography—this is an x-ray of the inside of a joint using contrast media or gas (air or carbon dioxide)
• Gastrointestinal x-ray
Upper GI track—a barium drink is used as the contrast media while fluoroscopy is used to visualize the
esophagus, stomach, and small intestines
Lower GI track—a barium is given while fluoroscopy is used to visualize the large intestines
• X-rays of the genitourinary (GU) track
Cystography—x-ray of the bladder
Cystourethrography—x-ray of the urethra and bladder
KUB—x-ray of the kidneys, ureters and bladder to obtain information regarding the size, shape and
position of the structures
IVP/IVU/intravenous urogram—contrast media is injected through an IV and x-rays are taken of the
entire GU system

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• CAT/CT/computed axial tomography scan—this is a specialized x-ray machine that takes pictures in
cross-sections or slices. The CT scan uses radiation, and contrast media can be used via an IV
• MRI/magnetic resonance imaging—this type of x-ray does not use radiation. It uses radiofrequency waves
and a magnetic field. The patient is slid into a tubular magnetic type of machine also tales pictures of the
body in slices but they can be taken from any direction and provides a detailed picture. Contrast media can
also be used by introducing through an IV
• PET/positron emission tomography—this type of x-ray uses a radioactive substance called “tracer” which
is introduced into the body through a vein. The organs in your body absorb the tracer and the physician
can interpret how your organs and tissues are working
• Ultrasound—this uses high-frequency sound waves to create an image of organs inside of the body. A
water-soluble gel is placed on the skin to provide an airtight connection and a transducer probe transmits
images to the screen. This is commonly used for images of:
Stomach
Liver
Heart/echocardiogram—this type of ultrasound provides a two dimensional image of the structures and
function of the heart
Tendons
Muscles
Joints
Blood vessels
Fetus
This cannot be used on the lungs because it cannot pass through organs with air
• Radionuclide scan—this type of scan by oral ingestion or through an IV. A radioactive chemical (an
example could be Iodine) to produce an image of the structure and function of body organs. This is
performed in nuclear medicine
• Biopsy—this is performed to diagnose a disease by excising tissue and/or fluids for examination with a
microscope. Types of biopsy’s include:
Incisional biopsy—a portion of the target tissue is excised and sent to pathology for a diagnosis. They
can be sent:
Frozen—immediate diagnosis
Permanent—this study will be performed at a later time
Specimens are covered more in depth in the specimen chapter
Aspiration biopsy—fluid is removed from target tissue through a syringe and sent to pathology for
diagnosis
Smear or brush biopsy—cells are placed on a microscope slide and sent for examination
• Gram stains—this procedure is performed to identify bacteria for examination. A dye is applied and the
bacteria are cultured
Gram positive—retains a violet/blue dye

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 Gram negative—retains a pink/red dye
• Spinal tap—this procedure is performed to remove CSF through a lumbar puncture for diagnosis
• EMG/electromyography—this is performed to study the electrical activity of muscles. A probe is inserted
through the skin and an electrical impulse is introduced to see how the muscles contract and relax
• Doppler—this is used to access blood flow through a vessel by sound. It can be used
pre/intra/postoperatively. A sterile drape is used to cover the probe when used during a surgical procedure
• Plethysmography—this procedure is performed to measure changes in vessels. A pressure sensitive
instrument or a pressure cuff is placed around a limb and records the changes. It does not measure blood
flow in a particular vessel but blood flow of the entire area that the cuff is placed on
• Thoracentesis—is performed to remove fluid from the pleural cavity for diagnosis and/or therapeutic
treatment
• EEG/Electroencephalography—this is performed to measure the electrical activity of the brain. Leeds are
placed on the scalp and they measure brain waves and determine how the brain functions
• Blood work—discussed in blood values chapter
• Urinalysis—discussed in GU

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 Questions

1. Contrast media includes all except:

(A) Renografin
(B) sodium hypochlorite
(C) Hypaque
(D) Cystografin

2. Contrast media can be introduced into the body by route of:

(A) IV
(B) injected into the spine
(C) intrathecal
(D) All of the above

3. All pertain to c-arm procedures except:

(A) a Dosimeter is used to monitor the amount of x-ray exposure from the fluoroscopy machine
(B) the x-ray badge is worn at the bottom hem area of the lead apron
(C) it is recommended to stand at least 6 feet from the fluoroscopy x-ray beam
(D) lead apron thickness: 0.5 mm of lead

4. An x-ray of the spine is termed:

(A) mammography
(B) ECG
(C) myelography
(D) IVU

5. During a cardiac catheterization the vessels used to introduce the catheter and inject the contrast media
are:

(A) femoral
(B) popliteal
(C) carotid
(D) cephalic

6. When performing a cholangiogram, the contrast media is introduced into the:

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 (A) cystic artery
(B) cystic vein
(C) CBD
(D) cystic duct

7. A ventriculography is an x-ray of the:

(A) ventricles in the brain

(B) vessels of the body
(C) cross sections of the body
(D) varicosities

8. What type of x-ray uses high frequency sound waves to create an image of organs inside of the body?

(A) CT Scan
(B) PET Scan
(C) Ultrasound
(D) All of the above

9. A Biopsy is performed to diagnose a disease by excising tissue and fluids for examination, the type of
biopsy that requires an immediate diagnosis is termed:

(A) permanent
(B) frozen
(C) brush
(D) None of the above

10. Gram stains are performed to identify bacteria for examination, a stain that is gram positive is:

(A) violet/blue
(B) red
(C) pink/blue
(D) pink

11. When performing a spinal tap to retrieve CSF the puncture is performed in which space?

(A) Cervical
(B) Thoracic
(C) Lumbar
(D) Sacral

12. The first step in determining the origin of a patient’s illness is:

(A) x-rays
(B) history and physical

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 (C) ultrasound
(D) PET scan

13. The test used to evaluate the entire spine, neck, back or leg pain is:

(A) electrocardiogram
(B) cystogram
(C) myelogram
(D) spinal tap

14. The procedure performed to measure changes in blood vessels is termed:

(A) plethysmography
(B) ventriculography
(C) radionuclide scan
(D) ECG

15. Thoracentesis:

(A) is performed to remove fluid from pleural cavity

(B) a test to visualize whether the tumor is hard or fluid filled
(C) uses ultrasonic sound waves to produce an image containing fluid
(D) is performed to remove fluid from the abdominal cavity

16. An x-ray performed of the entire mouth in one film is termed:

(A) EEG
(B) panoramic
(C) audiometry
(D) basic x-ray

17. ECG is:

(A) stress test of the heart

(B) used to assess blood flow through a vessel
(C) used to measure electrical activity of the brain
(D) used to measure electrical activity of the heart

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 Answers and Explanations

1. (B) Sodium hypochlorite is household bleach.

2. (D) Contrast media can be introduced into the body by all routes.

3. (B) The x-ray badge is called a dosimeter. It is recommended to be worn at the neck level.

4. (C) Myelography is an x-ray of the spine.

5. (A) During a cardiac catheterization, the vessels used to introduce the catheter to inject contrast are the
femoral vessels.

6. (D) The cystic duct is the area where the contrast is introduced.

7. (A) Ventriculography is an x-ray of the brain. Angiography is x-ray of vessels. A CT produces cross
sections of the body. Varicosities are thrombosed veins.

8. (C) An ultrasound uses high frequency sound waves to create an image. PET scan uses a radioactive
substance called “tracer.” CT scan uses radiation and contrast media

9. (B) A specimen that is sent to pathology for an immediate diagnosis is a frozen section.

10. (A) Gram stains that are gram positive turn violet/blue.

11. (C) A spinal tap retrieves CSF from the lumbar space.

12. (B) A history and physical is the first thing a physician does prior to ordering any diagnostic tests.

13. (C) A myelogram is done to view and evaluate the entire spine, neck, back or leg pain.

14. (A) Plethysmography is used to measure changes in blood flow.

15. (A) Thoracentesis is performed to remove fluid in the pleural cavity.

16. (B) Panoramic views include the entire mouth.

17. (D) ECG is done to measure the electrical activity of the heart.

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221
 ___________________ CHAPTER 13 ___________________

Consents

• Informed consent—this is an oral and written consent that is signed before a patient has a surgical
procedure
The informed consent is obtained by the surgeon. The information regarding the consent includes:
Patient’s name
Surgeon’s name
Procedure
Signature of the patient and witness
Date of the signatures
• The surgeon is responsible for obtaining the consent, he should clearly explain:
The procedure
Risks involved
Benefits
Alternatives
Complications
• The patient must receive this information in terms that they understand. If the patient does not fully
understand what the physician informed them about the procedure because they have a language barrier
and something goes wrong this could constitute assault and battery
• Information prior to the patient signing the consent includes:
Exactly who will perform the procedure, who will assist
The consent must be signed before the patient has received any preoperative medication
The circulating nurse should ensure that this process has taken place before the patient is admitted to
the operating room
• The patient should sign the consent themselves unless:
They are minors
Unconscious
Mentally incompetent
In a life threatening situation, if this be the case the next closest relative is authorized to sign
If a minor has a child they may sign for the child
Illiterate person—may sign with an x
Unconscious person—a responsible relative or guardian

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 Mentally incompetent—the legal guardian
If the patient is incompetent because they are under the influence of alcohol or drugs the closest relative
may sign if it is an emergency, if not an emergency they will wait for the patient to detox
• General consent form—is signed upon admission to the health care facility.
This is signed to perform generalized day-to-day treatment
An additional informed consent is required for surgery
• Consent in an emergency
Phone consent—two nurses must monitor the call and sign a legal form
Two surgeon’s (not part of the patient’s care) may be called in to witness that the patient is in a life-
threatening situation and needs the surgery, they sign a legal form.
• Witnessing the consent—may be a nurse, other facility employees. The witness must verify:
Patient’s signature
The signature was made voluntarily
The patient had a sound mental state
• Every patient has the right to refuse a surgical procedure at any time. The surgeon and nurse document the
patient’s refusal for surgery, and all sign. This will relieve the hospital and health care team from any
liability
• Advanced directives—is a document that allows the patient to give instructions about their medical care in
the event they become incapacitated and cannot speak for themselves. Additional information can include
information on organ donation
• Living will—this document specifies the type of medical intervention that the patient does not want,
examples include:
Feeding tubes
Ventilator
• Power of attorney—this document authorizes a designated person to make decisions for a patient if they
are incapacitated and cannot make decisions for themselves
• DNR—do not resuscitate. No CPR
• Incident report—is a written statement regarding an accident involving a patient or employee. The details
should be written as statement, and facts without your opinion
This should be reported to the nurse manager. Examples include:
Needle sticks
Falls
Loss of instruments

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 Questions

1. In the event that a child needs emergency surgery, and the parents cannot be located to sign the
permission:

(A) no permission is necessary

(B) permission is signed by a court of law
(C) permission is signed by the physician
(D) a written consultation by two physicians other than the surgeon will suffice

2. The patient is scheduled for an appendectomy. After completing this procedure, the surgeon decides to
remove a mole from the shoulder while the patient is still under anesthesia. No permission was obtained
for this. The circulating nurse should:

(A) report it to the anesthesiologist

(B) report it to the chief of surgery
(C) report it to the supervisor or proper administrative authority
(D) let the surgeon proceed because it is his or her responsibility to obtain the consent

3. The surgical consent form can be witnessed by each of the following EXCEPT:

(A) the surgeon

(B) a nurse
(C) an authorized hospital employee
(D) the patient’s spouse

4. The patient is premedicated and brought to the operating room (OR) for a cystoscopy and an open
reduction of the wrist. Upon arrival in the OR, it is observed that the patient has only signed for the
cystoscopy. The correct procedure would be to:

(A) cancel surgery until a valid permission can be obtained

(B) have the patient sign for the additional procedure in the OR
(C) ask the patient verbally for consent and have witnesses attest to it
(D) let the surgeon make the decision as to whether surgery could be done

5. A general consent form is:

(A) a form authorizing all treatments or procedures

(B) a form for all patients having general anesthesia

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 (C) a form for all patients having hazardous therapy
(D) another name for an operative permit

6. The ultimate responsibility for obtaining consent lies with the:

(A) OR supervisor
(B) circulating nurse
(C) surgeon
(D) unit charge nurse

7. The surgical consent is signed:

(A) before induction

(B) in the holding area
(C) the morning of surgery
(D) before administration of preoperative medications

8. An informed consent:

(A) authorizes routine duties carried out at the hospital

(B) protects patient from unratified or unwanted procedures
(C) protects the surgeon and the hospital from claims of an unauthorized operation
(D) Both B and C

9. Implied consent:

(A) is the preferred option for consents

(B) is allowed by law in emergencies when no other authorized person may be contacted
(C) is never legally valid
(D) is the permission for surgical action

10. Which statement regarding the withdrawal of a consent by a patient is NOT true?

(A) The surgeon informs the patient of the dangers if the procedure is not carried out
(B) The surgeon informs the hospital administration of the patient’s refusal
(C) The surgeon obtains a written refusal from the patient
(D) The surgeon may do the procedure if he documents that it is necessary as a lifesaving measure

11. Conditions of signing a consent form include:

(A) signed voluntarily

(B) patient must be competent
(C) patient must sign before preoperative medications are given
(D) All of the above

12. Consents are required for:

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 (A) anesthesia
(B) blood and blood products
(C) experimental treatments
(D) All of the above

13. The patient must receive information regarding consent, the patient must understand the procedure. If
the patient does not fully understand what the physician informed them about due to language barrier,
and something gorse wrong during the procedure, this could constitute:

(A) assault and battery

(B) atonement
(C) neglect
(D) defamation of character

14. Which document allows the patient to give instructions regarding their medical care in the event they
become incapacitated and cannot speak for themselves:

(A) living will

(B) power of attorney
(C) advanced directive
(D) DNR

15. What is the protocol for an illiterate person who cannot write and the consent form:

(A) the closest relative can sign for them

(B) explain the situation and omit a signature
(C) two physicians unrelated to the case but in agreement surgery is required
(D) they can sign with an X

16. Examples of a living will include:

(A) feeding tube

(B) ventilator
(C) IV
(D) All of the above

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 Answers and Explanations

1. (D) In a dire emergency, the patient’s condition takes precedence over the permit. Permits may be
accepted from a legal guardian or responsible relative. Two nurses should monitor a telephone consent
and sign the form; it is then signed by the parent, guardian, or spouse upon arrival. A written
consultation by two physicians, not including the surgeon, will suffice until the proper signature can be
obtained.

2. (C) If the surgeon intends or wants to perform a procedure not specified on the permission or consent
form, the OR nurse assumes the responsibility of informing the surgeon and/or the proper
administrative authority of the discrepancy.

3. (D) The patient’s (or suitable substitute’s) signature must be witnessed by one or more authorized
persons. They may be physicians, nurses, or other hospital employees authorized to do so. The witness
is attesting to the proper identification of the patient and the fact that the signing was voluntary.

4. (A) The patient giving his or her consent must be of legal age, mentally alert, and competent. The
patient must sign before premedication is given and before going to the OR. This protects the patient
from unratified procedures as well as protecting the surgeon and the hospital.

5. (A) The general consent form authorizes the physician in charge and hospital staff to render such
treatments or perform such procedures as the physician deems advisable. It applies only to routine
hospital procedures. The consent document for any procedure possibly injurious to the patient should
be signed before the procedure is performed.

6. (C) The ultimate responsibility for obtaining permission is the surgeon’s. The circulating nurse (RN or
charge nurse) and the anesthesiologist are responsible for checking that the consent is on the chart,
properly signed, and that the information on the form is correct.

7. (D) All consent forms must be signed before the administration of preoperative medications. This is to
ensure that the patient fully understands what the procedure is. If the permission is signed incorrectly, it
may not be revised until the preoperative medication has worn off.

8. (D) An informed consent (operative permit) protects the patient from unratified procedures and protects
the surgeon and the hospital claims of an unauthorized operation. A general consent authorizes the
physician and staff to render treatment and perform procedures which are routine duties normally
carried out at the hospital.

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 9. (B) Implied consent is never the preferred action. Law allows it in emergency situations when no other
authorized person can be contacted or when conditions are discovered during a surgical procedure.

10. (D) The patient has a right to withdraw written consent if it is voluntary and if he or she is in a rationale
state. The surgeon explains consequences, obtains a written refusal and informs hospital and
administration. The surgery is postponed.

11. (D) All of the above are conditions for signing a consent.

12. (D) All of the above including placing central venous catheters and other vascular devices and patients
undergoing elective sterilization process must sign written consent.

13. (A) The physician can be charged with assault and battery.

14. (C) Advanced directives give instructions on how to proceed should the patient become incapacitated.

15. (D) The patient may sign with an “X” if they cannot write due to illiteracy.

16. (D) Living wills include statements regarding the feeding tube, ventilator, or whether they want an IV
started

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 ___________________ CHAPTER 14 ___________________

Skin Preparation and Draping

Prepping and draping the patient for the Review Book

• Skin prep is performed to remove transient flora and reduce the amount of resident flora and hinder the
growth of microbes during the surgical procedure to prevent infection
• Prep solutions include:
Povidone-iodine/Betadine—this must be allowed to dry at least for 2 minutes prior to draping
Less irritating to skin than other prep solutions
It should not be used on the patient with allergies to iodine and shell fish
Betadine can be used on the face, around the eyes and ears
When used as a hand scrub the iodine compounds are mixed with a detergent and should be rinsed
off the skin unlike the prep solution which is left to dry on the skin
Chlorhexidine gluconate/Hibiclens—this can be used for a surgical had scrub and a skin prep
When applying as a skin prep it should be applied properly for approximately 2 minutes and towel
dried and repeat the step
It has a residual effect for 5–6 hours following application
It is an eye irritant and ototoxic
Alcohol—these solutions should contain 70% isopropyl alcohol as an effective prep solution
Works fast
It should not be used on mucous membranes, the eyes, and open wounds
It should be dry prior to placing the drape sheets
It is extremely flammable
Dura-Prep—this solution contains 70% isopropyl alcohol and iodophor solution
Fast acting and lasts for 12 hours on the skin
Should be dry prior to draping
This comes in self-contained applicators
You must follow manufacturer’s instructions before warming a prep solution. It is not recommended
because warming can change the chemical properties of solutions and reduce its effectiveness on
destroying microbes

Prior to performing the surgical-prep

• Hair removal—If a shave prep is ordered it should be performed as close to the time of surgery as possible

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 in order to reduce the risk for microbial growth in the case of a break in the skin and cause an infection
The shave prep should be performed in the patient holding area not the operating room
It is recommended that an electric clipper be used not a razor to prevent cutting the patients skin
Eyebrows should never be shaved
Long eyelashes should be carefully trimmed using small scissors and a water soluble jelly
When hair is removed for a craniotomy procedure the patients hair should go into a secure bag and
labeled with the patients name and identification #. This is property of the patient and should be kept
with the chart.
• Surgical prep
The night before or in the morning prior to surgery the patient should shower/bathe, the surgeon may
order a special antiseptic wash be used
The skin prep is performed using sterile technique
This should always be performed from clean to dirty
The skin prep begins at the planned incision site and carried to the periphery, using a circular motion,
never return over the clean area with a sponge
The boundaries of the skin prep should be much wider than the planned incision to allow the incision to
be extended if needed
Sterile towels should be placed to prevent pooling of the prep solution and prevent a chemical burn and
a burn from ESU
Each sponge must be discarded once used
You must avoid contamination when performing the prep
When holding a limb during a prep always don sterile gloves to prevent contamination
• Preps that require two separate preps
Abdominal perineal prep—the perineal area should be prepped first and covered with a sterile towel to
avoid contamination of the abdominal area, and the abdominal area is prepped last
Preps for donor and recipient sites—the donor site is prepped first usually using a colorless solution so
the surgeon can see the skin clearly, the recipient site is prepped next
• Special considerations when performing the skin prep for contaminated areas include:
Umbilicus—even though the umbilicus is considered contaminated it should be cleaned first with a
cotton tipped applicator and antimicrobial solution and discarded
Cancer prep—the prep should be applied gently to avoid spreading the cancer cells
Stomas
If the stoma is included in the surgical procedure it should be covered with an adhesive drape, the
incision site is prepped and the drape is removed and the stoma is prepped last
If the stoma is not part of the surgical procedure an adhesive drape should be placed and left until the
procedure is complete
Vagina/perineal area/anus—these areas should be prepped last, each sponge should be used once and
discarded

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 Traumatic wounds/open wounds
Sometimes an I&D is performed first
The wound is then packed with sterile saline soaked gauze sponges and the area around the wound is
prepped
Axilla/hair line—these areas have a high microbial count and need to be prepped last

Anatomical Boundaries, Preps

• Abdominal
Nipple line to symphysis pubis
Lateral to sides of the bed
• Thoracoabdominal—patient is in lateral position
Chest/axilla down to the iliac crest
Beyond the midline anterior and posterior
• Breast
From the incision site to anterior neck to OR table on affected side, arm is elevated and the shoulder,
and upper arm to the elbow is prepped circumferentially
prep continues down to the to the symphysis pubis and lateral to the OR table on the affected side
axilla prepped last
• Face
Place cotton balls in the ears
Hairline to behind the ears
Neck to both sides of the OR table
• Eyes
Be careful not to allow the prep solution to enter the patients eyes
Center of the lid to the eyebrow to the cheek
• Neck
Neck laterally to both sides of the OR table
Up to the chin and
Down to the chest and shoulders laterally to both sides of the OR table
• Shoulder
Patients head is turned to the opposite direction of affected shoulder
The arm is held and the shoulder is elevated off the OR table and the prep begins at the shoulder to the
base of the neck
Over the shoulder, scapula, and chest to the midline
Upper arm to below the elbow circumferentially
Axilla last
• Elbow and Forearm
The arm is held by the hand

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 Prep extends from the hand to the shoulder circumferentially
The axilla prepped last
• Hand
The arm is held above the elbow, also can be placed on a bolster and supported
The hand to above the elbow is prepped circumferentially
• Ankle/foot
The leg is held at the knee
Prep extends from the foot to the knee circumferentially
• Leg—lower leg and knee
The leg is held by the foot
Prep includes the foot to the upper thigh, circumferentially
• Thigh
The leg is held at the foot
The entire leg is prepped circumferentially from the foot to above the hip and buttocks laterally to the
OR table on the affected side
Groin area last
• Hip
The leg is elevated at the knee
Prep begins at the hip up to the abdomen on the affected side
Over the buttock laterally to the OR table on the affected side
Down to the knee
Groin area last
• Vaginal and Perineal prep
The prep begins at the pubic symphysis down over the genitalia area
Anus is last
• Always remember when the surgery involves the abdominoperineal areas
The perineal area is prepped first and covered
The abdominal area is prepped last to prevent contamination from below
They are considered two separate preps

Drapes

• Drapes are used to preserve the sterile field and create a sterile barrier
• Draping sequence varies from hospital to hospital and surgeon to surgeon
• Drapes must be:
Fluid and blood resistant
Antistatic and flame resistant
Lint free
Tear and puncture proof

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 Porous so that the patient’s body temperature is not affected
Nonreflective to operating room lights
Toxic free

Drape materials

• Nonwoven disposable
Synthetic made of nylon, rayon, and polyester
• Woven fabric—reusable drapes
These drapes must be hospital laundered
Inspected routinely for wear and tear and holes
270–280 thread count
• Fenestrated drape—drape with an opening (hole), placed over the incision site, they include:
Laparotomy drape sheet—this has a large opening, commonly used on the abdomen
Laparoscopy drape sheet—this is a combination of a laparotomy sheet and a lithotomy, perineal drape
sheet, commonly used in GYN procedures
Transverse drape sheet—rectangle sheet commonly used for pelvic GYN and kidney procedures
Pediatric drape sheet—sheet with a smaller fenestration
Lithotomy/Perineal drape sheet—used for the patient in lithotomy position
Leg drapes accompany this drape sheet, there is a folded cuff to protect your hands from
contamination
• Aperture drape—this is a fenestrated drape sheet with adhesive that surrounds the opening to help secure
the drape
• Incise drape—the entire drape is a clear plastic sticky drape that is applied to the skin. The incision is
made directly through the drape
These drapes can also be impregnated with an iodophor-containing adhesive
• Split sheet/U-drape—(these drape sheets are very similar and used the same way) this drape is split-up the
middle with adhesive tape along each side of the slit, used to wrap around a limb or body part
• Drape sheets—this is a sheet without a fenestration that come in various sizes:
Used as additional drapes for multiple parts of the body
It provides an extra thickness to the fenestrated drape sheet
Can be used to drape operating room furniture or be used as reinforcement to the furniture drapes
• Towel drape/utility drape—small drape with a straight adhesive band

Rules of draping

• Always check the surgeons preference card for draping instruction

• Organize drapes on your back table in order of use prior to the surgical procedure to be more efficient
• Never hand a drape across the sterile field
• Always keep a distance when maneuvering around the sterile field to avoid contamination

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• Don’t let the drape fall below table level
• Never adjust a drape sheet that has been improperly placed
The circulator will remove the drape by peeling it from the sterile field without contaminating any other
drapes
If contamination occurs the patient should be prepped and draped again
• Utility drapes (disposable)—the order to be handed to the surgeon is:
First drape is handed on the same side as the surgeon
Second drape is handed and placed superior
Third drape is handed and placed inferior
Fourth drape is placed opposite the first drape
• Cloth towels—principles apply same as above
Towel clips are to carried with the towels
Folded edge goes down
Nonperforating towel clips should be used to secure the drapes
If sutures are used to secure a drape the needle holder, suture, and scissor should be discarded
Once a towel clip or clamp has been fastened to a drape and goes through the drape it cannot be
removed until the end of the case to avoid contamination
If the clip must be removed it should be immediately handed off the field and cover with another drape
sheet
• If a hole is discovered it should be immediately be covered with another drape sheet
• If a hair is found on the sterile drape it should be removed with a clamp and handed off the sterile,
immediately cover the area with another drape sheet

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 Questions

1. The main purpose of the skin prep is to:

(A) remove resident and transient flora

(B) remove dirt, oil, and microbes, and to reduce the microbial count
(C) remove all bacteria from the skin
(D) sterilize the patient’s skin

2. Which is the antiseptic solution of choice for a skin prep?

(A) Cipex
(B) Staphene
(C) Povidone-iodine
(D) Zephiran

3. When preparing a patient for a breast biopsy, a breast scrub is either eliminated or done very gently
because of:

(A) patient anxiety

(B) dispersal of cancer cells
(C) contamination
(D) infection

4. The ideal place to do the shave prep is in the:

(A) patient’s room

(B) operating room (OR) suite
(C) holding area of the OR
(D) room where the surgery will be performed

5. Any area that is considered contaminated:

(A) should be scrubbed last or separately

(B) should not be scrubbed at all
(C) should be scrubbed first
(D) needs no special consideration

6. In preparation for surgery, skin should be washed and painted:

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 (A) from the incision site to the periphery in a circular motion
(B) from the periphery to the incision site in a circular motion
(C) in a side-to-side motion
(D) in an up-and-down motion

7. Preliminary preparation of the patient’s skin begins:

(A) with a preoperative shower

(B) with the shave preparation
(C) in the OR
(D) in the holding area

8. Suction tubing is attached to the drapes with a/an:

(A) towel clip

(B) nonperforating clamp
(C) Kocher clamp
(D) Allis clamp

9. All of the following statements regarding sterility are true EXCEPT:

(A) wrapper edges are unsterile

(B) instruments or sutures hanging over the table edge are discarded
(C) sterile person pass each other back to back
(D) a sterile person faces a nonsterile person when passing

10. When draping a table, the scrub nurse should drape:

(A) back to front

(B) front to back
(C) side to side
(D) Either A or B

11. A seamless, stretchable material often used to cover extremities during draping is:

(A) Esmarch
(B) ace bandage
(C) Kling
(D) stockinette

12. Drapes are:

(A) adjusted after placement for correct position

(B) unfolded before being carried to OR table
(C) passed across the table to surgeon along with towel clips

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 (D) placed on a dry area

13. Which statement demonstrates a break in technique during the draping process?

(A) Gloved hands may touch the skin of the patient

(B) Discard a drape that becomes contaminated
(C) Discard a sheet that falls below table level
(D) Cover or discard a drape that has a hole

14. A head drape consists of:

(A) medium sheet, towel, towel clip

(B) two medium sheets, towel clip
(C) one small sheet, one medium sheet, towel clip
(D) towel, fenestrated sheet

15. When the scrub person is draping a nonsterile table, he or she must:

(A) cover the back edge of the table first

(B) use a single-thickness drape
(C) be sure the drape touches the floor
(D) cuff the drape over his or her gloved hands

16. When covering a Mayo stand, the scrub person should:

(A) use a wide cuff

(B) use no cuff
(C) open the cover fully before placement
(D) ask the circulator to pull on the cover

17. If a sterile field becomes moistened during a case:

(A) nothing can be done

(B) extra drapes are added to area
(C) the wet sections are removed and replaced with dry sections
(D) the wet sections are covered with a plastic adherent drape

18. Which of the following actions by the scrub person is NOT an acceptable sterile technique principle?

(A) Discarding tubing that falls below sterile field edges without touching the contaminated part
(B) Reaching behind sterile team members to retrieve instruments so they do not collect on the patient
(C) Facing sterile areas when passing them
(D) Stepping away from the sterile field if contaminated

19. What antiseptic agent is safe for ophthalmic and in a face prep?

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 (A) Alcohol
(B) Betadine
(C) Chlorhexidine
(D) Triclosan

20. When prepping a contaminated such as a colostomy, the procedure includes:

(A) contaminated area is prepped first and covered with sterile gauze and clean prep sponges are used
to clean surrounding area
(B) contaminated area is prepped first, clean sponges are used to prep the surrounding area
(C) prep the clean surrounding area first then with clean sponges, prep the contaminated area
(D) All of the above can be done

21. Why should prep solutions dry before applying drapes?

(A) To prevent strike through contamination

(B) They stick better
(C) It enhances the antiseptic effect
(D) Does not stain the drapes

22. Risks associated with prep solutions pooling under a patient include:

(A) causes no harm to patient

(B) chemical burn
(C) blistering and skin loss
(D) Both B and C

23. Betadine is categorized as a/an:

(A) alcohol
(B) chlorhexidine gluconate
(C) iodophor
(D) sterilant

24. A prep that includes from the chin to the nipple line or the waist and around the side of the body to the
OR table on each side is indicated for what type of surgery?

(A) Breast
(B) Neck (radical)
(C) Shoulder
(D) All of the above

25. Rectal surgery prep is done:

(A) Patient is prepped in supine then positioned in prone

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 (B) Surrounding area is prepped first, anus last
(C) Anus first, surrounding area last
(D) Before the buttock tape is placed

26. During prepping and draping if the STSR contaminates their hand they should:

(A) finish draping and change

(B) change glove immediately
(C) remove all drapes and start over
(D) do nothing, it does not matter

27. Drapes that are self-adhering and transparent and provide an impervious barrier over an incision are
called:

(A) incise drapes

(B) nonwoven drapes
(C) fenestrated drapes
(D) woven drape

28. Arrange the following procedure of removing drapes at the end of the procedure in proper order:

1. remove all instruments and equipment from sterile field

2. roll drapes from the head proceeding to the patients feet
3. place dressings and hold dressings in place while removing drapes
4. dispose of drapes in garbage

(A) 1, 3, 2, 4
(B) 1, 2, 3, 4
(C) 2, 3, 4, 1
(D) 2, 4, 1, 3

29. A sterile barrier between the face and head used in nose and throat procedures is a:

(A) fenestrated
(B) self-adherent drape
(C) head drape
(D) incise drape

30. What is the body’s primary defense against infection?

(A) Hair
(B) Skin
(C) Proper prepping and draping
(D) Good hygiene

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31. The word “fenestrated” refers to:

(A) an opening
(B) length of drape
(C) width of drape
(D) transparent

32. All prep solutions are different and should be used according to manufacturer’s instructions, however,
they all have one thing in common which is:

(A) they should not be used on the patient with allergies to iodine and shell fish
(B) the have a residual effect for 5–6 hours following applications
(C) they should be dry prior to placing the drape sheets
(D) they should be placed in hot sterile water to warm them prior to prepping.

33. Alcohol prep solutions should contain what percentage of isopropyl alcohol to be considered an effective
prep solution

(A) 70%
(B) 10%
(C) 50%
(D) None specific

34. If a shave prep is ordered, when is it performed?

(A) Two days prior to surgery

(B) As lose to the time of the surgical procedure as possible
(C) The morning of the procedure
(D) They are no longer performed

35. All apply to hair removal prior to surgery EXCEPT:

(A) the shave prep should be performed in the patient holding area not the operating room
(B) eyebrows should be shaved with an electric razor
(C) when hair is removed for a craniotomy procedure the patients hair should go into a secure bag and
labeled with the patients name and identification number. This is the property of the patient and
should be kept with the chart
(D) it is recommended that an electric clipper be used not a razor to prevent cutting the patients skin.

36. Preps that require two separate preps include:

(A) abdominal perineal prep

(B) donor and recipient sites
(C) mastectomy with reconstruction surgery
(D) All of the above

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37. Special considerations when performing the skin prep for contaminated areas include all EXCEPT:

(A) prepping the umbilicus first

(B) cancer preps should be applied gently to avoid seeding
(C) prepping the umbilicus last
(D) no need to prep the umbilicus

38. The prep that involves the anatomical boundaries from the nipple line to symphysis pubis and lateral to
both sides of the bed is:

(A) abdominal
(B) shoulder
(C) pelvic
(D) uterus

39. When prepping for an abdominoperineal procedure:

(A) the perineal area is prepped first and covered

(B) the abdominal area is prepped last to prevent contamination from below
(C) they are considered two separate preps
(D) all are true regarding an abdominoperineal prep

40. The drape sheet that has a hole with adhesive that surrounds the opening to help secure the drape is
termed:

(A) fenestrated sheet

(B) transverse sheet
(C) aperture sheet
(D) split sheet

41. The drape that is a clear plastic sticky drape that is applied directly to the skin and the incision is made
directly through the drape is termed:

(A) incise
(B) U drape
(C) split sheet
(D) disposable drape sheet

42. When using utility drapes what is the correct order of handing them to the surgeon: (1) drape handed
and placed superior, (2) drape is handed and placed inferior, (3) drape is handed on the same side as the
surgeon, (4) drape is placed opposite the first drape.

(A) 1, 2, 3, 4
(B) 2, 1, 3, 4
(C) 3, 1, 2, 4

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 (D) 4, 3, 1, 2

43. All apply to the sterile technique of draping EXCEPT:

(A) once a towel clip or clamp has been fastened to a drape and goes through the drape, it cannot be
removed until the end of the case to avoid contamination
(B) if a hair is found on the sterile drape, it should be removed with your hand and handed off the
sterile field and cover the area with another drape sheet
(C) if a hole is discovered, it should be immediately be covered with another drape sheet
(D) towel clips are handed with the towels

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 Answers and Explanations

1. (B) Methods of skin prep may vary, but the objectives are the same—to remove dirt, oil, and microbes
from the skin so the incision can be made through the skin with a minimal danger of infection. It also
reduces the resident microbial count and prevents the growth of microbes.

2. (C) The current trend is toward a surgical scrub of antiseptic solution containing povidone- iodine. This
reduces the number of bacteria on the skin and inhibits the growth. This process is eliminated in some
ORs.

3. (B) When a breast is prepped for suspected malignancy, it is done gently or not at all. Scrubbing the
breast with the usual amount of pressure could cause cancer cells to break loose from the lesion and
spread the disease.

4. (C) The patient should be shaved immediately before surgery, preferably in a holding area of the OR.
This is thought to reduce the infection rate. The amount of time between the preoperative shave and
the operation has a direct effect on wound infection rate.

5. (A) Contaminated areas (which can include draining sinuses, skin ulcers, vagina, or anus) should be
scrubbed last or with separate sponges. This prevents dragging pathogens into the incisional area and,
thus, reduces the possibility of infection.

6. (A) Skin should be washed from the incision site to the periphery in a circular motion. This keeps the
incision site cleaner and prevents wound contamination.

7. (A) Patients may be advised to begin bathing with a 3% hexachlorophene solution before admission for
an elective procedure. Patients should shower or be bathed before coming to the OR suite. This action
is bacteriostatic and reduces microbial contamination.

8. (B) Suction tubing is attached to the drapes with a nonperforating clamp.

9. (D) A sterile person turns his or her back to a nonsterile person or area when passing.

10. (B) When draping a table, open the drape toward the front of the table first. This establishes a sterile
area close to the scrub.

11. (D) Stockinette may be used to cover an extremity. It is a seamless, stretchable tubing material which
contours snugly to skin. It may be covered with plastic. Some has vinyl on outside layer.

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12. (D) Drapes are placed on a dry area. The scrub nurse takes towel clips and skin towels to the side of the
OR table from which the surgeon will apply them. Folded drapes are carried to the OR table. Drapes
are held high enough to avoid touching nonsterile areas. Once a drape is placed, it may not be adjusted.

13. (A) B, C, and D are acceptable techniques. Gloved hands should not touch the skin of the patient.
Protect gloved hands by cuffing end of sheet over them.

14. (A) The surgeon places a drape under the head while the circulator holds up the head. This drape
consists of a towel placed on a medium sheet. Center of towel edge is 2 inches in from center of sheet
edge. Towel is drawn up on each side of face, over forehead or at hairline and fastened with a clip.
Additional towels surround operative site.

15. (D) In draping a nonsterile table, the scrub nurse should cuff the drape over his or her gloved hand in
preparation for opening it. The side of the drape toward him or her is done first to minimize the
possibility of contaminating the front of the gown.

16. (A) A wide cuff is used on the Mayo cover to protect the gloved hands.

17. (B) The table and sterile field should be kept as dry as possible. However, extra towels may be spread if a
solution has soaked through a sterile drape.

18. (B) Scrub persons should not reach behind a member of the sterile team. They may go around the
person, passing back to back.

19. (D) Triclosan is an antiseptic agent safe for ophthalmic use and in a face prep. The other agents are not
safe for use on these areas.

20. (C) The clean area is prepped first and with clean sponges, the contaminated area is cleaned.

21. (C) Prep solutions should be dry prior to applying drapes in order to enhance the antiseptic effect.

22. (D) Chemical burns result when prep solution is allowed to pool under the patient. Pressure and contact
with the chemical over time can cause severe blistering and skin loss.

23. (C) Betadine is categorized as an iodophor.

24. (B) Prep for a neck procedure includes the chin to the nipple line to the waist and around the side of the
body to the OR table on each side.

25. (B) The area is prepped cleanest to dirtiest areas.

26. (B) The STSR should change glove immedi- ately.

27. (A) Incise drapes are self-adhering transparent and provide an impervious barrier over an incision.

28. (A) At the end of the procedure, the STSR should remove all instruments and equipment from sterile

244
 field, place dressings on incision and hold with hand while removing drapes from head to toe and place
in garbage.

29. (C) A head drape is the sterile barrier between the face and head used during nose and throat
procedures.

30. (B) Skin is the body’s primary defense against infection.

31. (A) The word fenestrated refers to an “opening” in a drape.

32. (C) All prep solutions should dry prior to placing drape sheets.

33. (A) 70% is the percentage of isopropyl alcohol to be considered an effective prep solution.

34. (B) If a shave prep is ordered, it should be performed as close to the time of surgery as possible in order
to reduce the risk for microbial growth in the case of a break in the skin and cause an infection.

35. (B) Eyebrows should never be shaved.

36. (D) All of the above require two separate setups.

37. (C) Even though the umbilicus is considered contaminated, it should be cleaned first with a cotton
tipped applicator and antimicrobial solution and discarded.

38. (A) The abdominal prep involves the anatomical boundaries from the nipple line to the symphysis pubis
and lateral to both sides of the bed.

39. (D) All are true.

40. (C) The aperture drape sheet is a fenestrated drape sheet with adhesive that surrounds the opening to
help secure the drape.

41. (A) Incise drape is a plastic sticky drape that is applied to the skin. The incision is made directly through
the drape. These drapes can also be impregnated with an iodophor containing adhesive.

42. (C) The order of handing the utility drapes to the surgeon is: first drape is handed on the same side as
the surgeon. Second drape is handed and placed superior. Third drape is handed and placed inferior.
Fourth drape is placed opposite the first drape.

43. (B) If a hair is found on the sterile drape, it should be removed with a clamp and handed off the sterile
field and immediately cover the area with another drape sheet. You should not use your gloved hand.

245
___________________ CHAPTER 15 ___________________

Instruments

246
 Questions

1. A surgical treatment for scoliosis could employ the use of:

(A) skeletal traction

(B) external fixation
(C) compression plate and screws
(D) Harrington rods

2. During surgery, towel clips:

(A) may be removed only by the circulator

(B) may not be removed once fastened
(C) may be removed and discarded as long as the area is covered with sterile linen
(D) may be removed and discarded from the field

3. As grossly soiled instruments are returned to the scrub, they should be:

(A) placed in a basin of sterile saline to soak off debris

(B) wiped off with a sponge moistened with water or soaked in a basin of sterile distilled water
(C) wiped off with a dry sponge
(D) discarded so that the circulator can clean them thoroughly

4. The sterile component of the electrosurgical unit (ESU) is the:

(A) grounding pad

(B) generator
(C) foot pedal
(D) active electrode

5. Deaver and Richardson retractors have an advantage over the Balfour and O’Connor/O’Sullivan
retractors in that they provide:

(A) less exposure

(B) less fatigue
(C) greater adjustability
(D) more fatigue

6. Which suction tip is meant to be used during abdominal surgery?

247
 (A) Poole
(B) Yankauer
(C) Frasier
(D) Tonsil

7. What kind of retractor is generally used in areas near viable nerves or blood vessels?

(A) Sharp rakes

(B) Skin hooks
(C) Dull rakes
(D) Sharp Weitlaner

8. All of the following instruments have teeth EXCEPT:

(A) Allis
(B) Heaney
(C) Kocher
(D) Babcock

9. All of the following are self-retaining retractors EXCEPT:

(A) O’Connor–O’Sullivan
(B) Balfour
(C) Weitlaner
(D) Richardson

10. What is the term that refers to separating tissue layers on a vertical plane using dissecting scissors?

(A) Incision
(B) Undermining
(C) Transecting
(D) Blunt dissection

11. The following surgeries do not require the use of a trocar EXCEPT for:

(A) laparoscopy
(B) cystoscopy
(C) proctoscopy
(D) bronchoscopy

12. The safest method for loading a blade on a knife handle is to use:

(A) gloved hand

(B) needle holder
(C) mixter

248
 (D) Adson forceps

13. What is a Lebsche used for?

(A) Open the sternum

(B) To retract spinal nerves
(C) To elevate the periosteum
(D) To separate the ribs

14. A rongeur used extensively in surgery of the spine and in neurosurgery is the:

(A) Adson
(B) Cobb
(C) Kerrison
(D) Cloward

15. A rib retractor is a:

(A) Weitlaner
(B) Finochietto
(C) Harrington
(D) Beckman

16. A Doyen is a:

(A) rib shears

(B) rib cutter
(C) rib spreader
(D) rib raspatory

17. The instrument used to enlarge the burr hole made during a craniotomy is a:

(A) rongeur
(B) periosteal elevator
(C) Gigli saw
(D) Cloward punch

18. Westcott scissors are used in:

(A) plastic surgery

(B) ophthalmic surgery
(C) vascular surgery
(D) orthopedic surgery

19. The instrument used in a splenectomy is a:

249
 (A) Doyen
(B) Allen
(C) Jacobs
(D) pedicle clamp

20. Bowman probes are used in:

(A) common bile duct surgery

(B) lacrimal surgery
(C) kidney surgery
(D) bladder surgery

21. A Hurd dissector and pillar retractor is used for:

(A) appendectomy
(B) plastic surgery
(C) nasal surgery
(D) tonsillectomy

22. The Lempert elevator is used in surgery of the:

(A) eye
(B) nose
(C) ear
(D) bones

23. A Scoville retractor is used in a:

(A) total knee replacement

(B) meniscectomy
(C) laminectomy
(D) carpal tunnel release

24. A Bailey is a:

(A) clamp
(B) rongeur
(C) dissecting forceps
(D) rib approximator

25. A Sauerbruch is a/an:

(A) elevator
(B) raspatory
(C) retractor

250
 (D) rongeur

26. An Auvard is a:

(A) forceps
(B) dissector
(C) speculum
(D) sound

27. A Babcock is used to:

(A) grasp bone

(B) grasp delicate structures
(C) clamp vessels
(D) retract soft tissue

28. Nasal cartilage is incised with a:

(A) Ballenger swivel knife

(B) Freer elevator
(C) Duckbill rongeur
(D) Hurd dissector

29. A self-retaining retractor is a:

(A) Weitlaner
(B) Lincoln
(C) Hibbs
(D) Deaver

30. A rectal speculum is a:

(A) Percy
(B) Hirschmann
(C) Pennington
(D) Hill

31. A small fine needle holder used in plastic surgery is a:

(A) Ryder
(B) Heaney
(C) Webster
(D) Castroviejo

32. A kidney pedicle clamp is a:

251
 (A) Lincoln
(B) Herrick
(C) Love
(D) Little

33. Uterine dilators are:

(A) Hanks
(B) Van Buren
(C) Bakes
(D) Graves

34. A technique utilizing the insertion of a needle or wire through a needle in order to identify suspicious
breast tissue is a/an:

(A) incisional biopsy

(B) wire localization
(C) Silverman needle biopsy
(D) magnetic resonance imaging (MRI)

35. A forceps used to remove stones in biliary surgery is a:

(A) mixter
(B) Lahey gall duct
(C) Potts–Smith
(D) Randall

36. Right-angled pedicle clamps would be found on a setup for:

(A) splenectomy
(B) cholecystectomy
(C) hemorrhoidectomy
(D) thyroidectomy

37. Blunt nerve hooks are selected for a________ setup.

(A) vagotomy
(B) colostomy
(C) gastrojejunostomy
(D) abdominal–perineal resection

38. In which procedural setup would a T-tube be found?

(A) Exploration of the common bile duct

(B) Cholecystectomy

252
 (C) Cholelithotripsy
(D) Choledochoscopy

39. Stapedectomy requires all of the following items EXCEPT:

(A) small microsuction

(B) speculum
(C) prosthesis
(D) autograft

40. Cochlear implants utilize an electrode device:

(A) to restore hearing

(B) to aerate the mastoid
(C) to allow drainage
(D) to relieve vertigo

41. All of the following are required for repair of a nasal fracture EXCEPT:

(A) bayonet forceps

(B) Ballenger swivel knife
(C) splint
(D) Asch forceps

42. A forceps used in nasal surgery is a/an:

(A) bayonet
(B) Russian
(C) rat–tooth
(D) alligator

43. All of the following instruments can be found on a nasal setup EXCEPT:

(A) Freer elevator

(B) bayonet forceps
(C) Potts forceps
(D) Frazier suction tube

44. On which setup would bougies be found?

(A) Tonsillectomy
(B) Esophagoscopy
(C) Radical neck
(D) Parotidectomy

45. All of the following can be found on a tonsillectomy setup EXCEPT:

253
 (A) Yankauer suction
(B) Hurd dissector and pillar retractor
(C) tongue depressor
(D) Jameson hook

46. Tissue expanders are used in:

(A) augmentation mammoplasty

(B) reduction for gynecomastia
(C) transrectus myocutaneous flap
(D) breast reconstruction

47. The fracture treated with arch bars is:

(A) nasal
(B) mandibular
(C) zygomatic
(D) orbital

48. Rib removal for surgical exposure of the kidney requires all of the following EXCEPT a/an:

(A) Alexander periosteotome

(B) Doyen raspatory
(C) Heaney clamp
(D) Stille shears

49. Stone forceps on a kidney set are:

(A) Lewkowitz
(B) Randall
(C) Satinsky
(D) Mayo

50. A Sarot is a:

(A) bronchus clamp

(B) scapula retractor
(C) lung retractor
(D) lung grasping clamp

51. Which item would not be included on a setup for a transvenous (endocardial) pacemaker?

(A) Tunneling instrument

(B) Intra-aortic balloon pump
(C) Fluoroscopy

254
 (D) Defibrillator

52. The most frequent conditions requiring the use of a permanent pacemaker are:

(A) coronary or mitral insufficiency

(B) pulmonary artery or vein stenosis
(C) heart block, bradyarrhythmia
(D) pulmonary stenosis, ventricular septal defect

53. Which setup would include distraction and compression components?

(A) Harrington rods

(B) Intramedullary nail
(C) Arthrodesis
(D) Tibial shaft fracture

54. Traction applied directly on bone via pins, wires, or tongs is:

(A) internal
(B) closed
(C) skeletal
(D) counter pressure

55. Skeletal traction of a lower leg is accomplished with the use of a/an:

(A) Kirschner wire

(B) Knowles pin
(C) Eggers plate
(D) Smith–Peterson nail

56. In orthopedic surgery, the viewing of the progression of a procedure on a television screen is known as:

(A) image intensification

(B) radiography
(C) portable filming
(D) x-ray

57. A neurological study in which a radiopaque substance is injected into the subarachnoid space through a
lumbar puncture is called a/an:

(A) cerebral angiography

(B) myelogram
(C) encephalogram
(D) diskogram

58. A neuro headrest skull clamp is called a/an:

255
 (A) Sachs
(B) Frazier
(C) Adson
(D) Mayfield

59. Maintenance of acceptable blood pressure and prevention of the development of air emboli in the
neurosurgical patient can be effected by preoperative utilization of:

(A) an antigravity suit

(B) ace bandages
(C) thromboembolic device (TED) stockings
(D) adequate body support

60. Specialized instruments for a cleft lip repair would include:

(A) Cupid’s bow

(B) Logan’s bow
(C) arch bar
(D) wire scissors

61. Cloward instrumentation would be included for surgery of the:

(A) hip
(B) femur
(C) cervical spine
(D) lumbar spine

62. On which setup would a Beaver knife handle be found?

(A) Orthopedic
(B) Pediatric
(C) Gynecological
(D) Eye

63. Which procedure requires a sterile setup?

(A) Manual skin traction

(B) Skin traction
(C) Skeletal traction
(D) Closed reduction

64. A craniotomy may employ the use of a/an ___________ for exposure.

(A) Mayfield
(B) Sugita

256
 (C) Heifetz
(D) Leyla–Yasargil

65. On which setup would either a Pereyra or a Stamey needle be found?

(A) Urological
(B) Eye
(C) Orthopedic
(D) Thoracic

66. Disintegration of kidney stones through a liquid medium is accomplished with a/an:

(A) nephroscope
(B) extracorporeal shock wave lithotripter
(C) laser
(D) cystoscope

67. A urology perineal retractor system is called:

(A) Bookwalter
(B) O’Sullivan–O’Conner
(C) Omni–Tract
(D) Lowsley

68. Which procedure would utilize a Mason–Judd retractor?

(A) Bladder
(B) Uterus
(C) Hip
(D) Nose

69. A Furlow inserter is used in:

(A) penile implantation

(B) femoral–popliteal bypass
(C) total hip replacement
(D) intraocular lens (IOL) implant

70. A Millin is a/an:

(A) prostatic enucleator

(B) urological needle holder
(C) stone forceps
(D) retropubic bladder retractor

71. Which setup would include a Gomco clamp?

257
 (A) Colostomy
(B) Breast augmentation
(C) Circumcision
(D) Femoral popliteal bypass

72. In which surgical specialty would a Humi Cannula be used?

(A) Gynecological
(B) Ophthalmic
(C) Orthopedic
(D) Vascular

73. An instrument used in laparoscopy to manipulate the uterus for increased structure visibility is the:

(A) Veress
(B) Pratt
(C) Mayo–Hegar
(D) Hulka

74. A central venous pressure (CVP) catheter insertion requires:

(A) a sterile setup

(B) a crash cart
(C) an IV technician
(D) None of the above

75. The purpose of a set of Bakes would be:

(A) anal dilation

(B) esophageal dilation
(C) common duct dilation
(D) cervical dilation

76. A Steffee plate is a:

(A) shoulder replacement

(B) knee joint replacement
(C) femoral implant
(D) spinal implant

77. Skeletal traction is accomplished with:

(A) Sayre sling

(B) Minerva jacket
(C) Crutchfield tongs

258
 (D) Steffee system

78. The Bookwalter is a _________ instrument.

(A) clamping
(B) holding
(C) suturing
(D) retracting

79. Which instrument is a retractor?

(A) Harrington
(B) Doyen
(C) Crile
(D) Allen

80. A long thoracic forceps is a:

(A) Semb
(B) Debakey
(C) Sauerbruch
(D) Doyen

81. A Bougie is a:

(A) clamp
(B) dilator
(C) retractor
(D) grasper

Questions 82 through 84: The following group of questions is preceded by a group of instrument images
(Figure 15–1). For each question, select the one-lettered option that is the best answer.

259
Figure 15–1.

82. If arch bars remain in the patient postoperatively, which instrument must accompany the patient to
postanesthesia care unit (PACU) in order to open the mouth in case of emergency?

(A) B
(B) A
(C) C
(D) None of the above

260
 83. What instrument would be used to extend the incision on a carotid?

(A) A
(B) B
(C) C
(D) None of the above

84. Which instrument is used for a blepharoplasty?

(A) B
(B) C
(C) A
(D) None of the above

85. The name of the instrument below (Figure 15–2) is _______, which is also known as uterine dilators.

Figure 15–2.

(A) Bakes dilators

(B) Hanks dilators
(C) Hegar dilators
(D) Van Buren dilators

86. What is the instrument below (Figure 15–3) called?

261
Figure 15–3.

(A) Vanburen sound

(B) Bougies
(C) Bakes dilators
(D) Garrett dilators

Questions 87 through 90: The following group of questions is preceded by a group of instrument images
(Figure 15–4). For each question, select the one-lettered option that is the best answer.

262
263
Figure 15–4.

87. Which instrument is the Bookwalter?

(A) A
(B) B
(C) C
(D) D

88. Which instrument is a chest spreader/rib spreader?

(A) B
(B) C
(C) D
(D) Both B and D

89. What retractor is used in abdominal procedures and commonly used in pelvic procedures?

264
 (A) A
(B) B
(C) D
(D) None of the above

90. Which instrument is the Balfour retractor?

(A) A
(B) B
(C) C
(D) D

91. The name of the instrument Figure 15–5 is:

Figure 15–5.

(A) Toomey
(B) Microvasive evacuator
(C) Bulb
(D) Ellik

Questions 92 through 94: The following group of questions is preceded by a group of instrument images
(Figure 15–6). For each question, select the one-lettered option that is the best answer.

265
Figure 15–6.

92. Which catheter is used for intermittent or continuous bladder irrigation?

(A) A
(B) B
(C) Both A and B
(D) None of the above

93. What catheter is also called a retention indwelling catheter?

(A) A
(B) B
(C) Both A and B
(D) None of the above

94. Figure 15–6A is a two-way Foley 5-cc balloon used for:

(A) urinary drainage

(B) tamponade
(C) irrigation and aspiration
(D) common nonretaining catheter

95. What is the name of the instrument in Figure 15–7?

Figure 15–7.

266
 (A) Luer lock syringe
(B) Toomey
(C) Asepto
(D) Ellik

Questions 96 through 101: The following group of questions is preceded by a group of instrument images
(Figure 15–8). For each question, select the one-lettered option that is the best answer.

267
268
Figure 15–8.

96. What instrument provides retraction of the posterior vaginal wall?

(A) B
(B) D
(C) E
(D) F

97. What is the name of the instrument in Figure 15–8C?

(A) Jarit
(B) Heaney
(C) Jorgenson
(D) Westcott

98. What instrument is used as a uterine manipulator?

(A) A
(B) B
(C) E
(D) F

99. What is the name of the instrument in Figure 15–8F?

(A) Simpson
(B) Heaney
(C) Bozeman
(D) Ochsner

100. The name of the instrument in Figure 15–8A is called:

(A) Jacobs
(B) Schroeder
(C) Graves
(D) Phaneuf

101. Another name for the instrument in Figure 15–8E is the duckbill. What is the proper name for this

269
 instrument?

(A) Eastman
(B) Graves
(C) Young anterior
(D) Auvard

102. What is the name of the electrode in Figure 15–9?

Figure 15–9.

(A) Ball loop

(B) Loop
(C) Bugbee
(D) The working element

103. What is the name of the electrode in Figure 15–10?

Figure 15–10.

270
 (A) Ball loop
(B) Working element
(C) Randall
(D) Loop electrode

104. What is the name of the instrument in Figure 15–11?

Figure 15–11.

(A) Nephrostomy tube

(B) Fogarty
(C) T-tube
(D) Cigarette drain

105. Instrument in Figure 15–12 would commonly be found on which setup?

Figure 15–12.

(A) Orthopedic
(B) Vascular
(C) Ophthalmology
(D) Plastic

Questions 106 through 108: The following group of questions is preceded by a group of instrument images
(Figure 15–13). For each question, select the one-lettered option that is the best answer.

271
Figure 15–13.

106. What instrument is used to grasp the lung?

(A) A
(B) B
(C) C
(D) None of the above

107. What is the name of the instrument in Figure 15–13A?

(A) Sarot
(B) Cooley

272
 (C) Potts–Smith
(D) Javid

108. What is the name of the instrument in Figure 15–13C?

(A) Glover
(B) Cooley
(C) Javid
(D) Statinsky

Questions 109 and 110: The following group of questions is preceded by a group of instrument images
(Figure 15–14). For each question, select the one-lettered option that is the best answer.

273
Figure 15–14.

109. The instrument used to cut rib bone is:

(A) A
(B) B

274
 (C) C
(D) Both A and C

110. The instrument in Figure 15–14B is:

(A) Allison lung retractor

(B) Cooley arterial retractor
(C) Davidson scapula retractor
(D) Finochietto retractor

111. The instrument in Figure 15–15 would commonly be found on what procedure?

Figure 15–15.

(A) Colon resection

(B) Laparoscopic cholecystectomy
(C) Common duct exploration
(D) Hysterectomy

Questions 112 and 113: The following group of questions is preceded by Figure 15–16. For each question,
select the one-lettered option that is the best answer.

275
Figure 15–16.

112. The catheter in Figure 15–16 would be used on:

(A) CBD
(B) Artery
(C) Vein
(D) Both B and C

113. The instrument in Figure 15–16 is called:

(A) Red Robinson catheter

(B) Fogarty embolectomy catheter
(C) Malecot
(D) Fogarty biliary catheter

114. The instruments in Figure 15–17 would commonly be found on what procedure?

Figure 15–17.

(A) Arch bars

(B) Dental extraction
(C) Tracheostomy
(D) Tonsillectomy

276
Questions 115 through 118: The following group of questions is preceded by a group of instrument images
(Figure 15–18). For each question, select the one-lettered option that is the best answer.

277
278
Figure 15–18.

115. The instrument in Figure 15–18A is called:

(A) Leksell
(B) Pituitary
(C) Scoville
(D) Kerrison

116. The instrument in Figure 15–18B is:

(A) Leksell
(B) Pituitary
(C) Scoville
(D) Taylor

117. The instrument in Figure 15–18C is a Leksell rongeur. It is used:

(A) to remove pieces of bone and soft tissue surrounding the bone
(B) to remove the spinous processes
(C) to extract teeth
(D) Both A and B

118. The instrument in Figure 15–18D is:

(A) Scoville
(B) Cobb
(C) Pituitary
(D) Cloward

Questions 119 through 127: The following group of questions is preceded by a group of instrument images
(Figure 15–19). For each question, select the one-lettered option that is the best answer.

279
280
281
Figure 15–19.

119. Which instrument is used to put traction on the gallbladder?

(A) D
(B) B
(C) F
(D) E

120. Which instrument is used to peel adhesions while to visualize the cystic duct and cystic artery?

(A) C
(B) E
(C) G
(D) H

121. Which instrument is used to ligate the cystic artery?

(A) C
(B) B
(C) D
(D) G

122. Which instrument is used to divide the cystic following the ligation?

(A) D
(B) E
(C) H
(D) G

123. Which instrument is used for hydrodissection?

(A) C
(B) D
(C) E
(D) F

124. Which instrument is used to cauterize fallopian tubes?

(A) B
(B) C
(C) G
(D) All of the above

125. Which instrument is used to retract the liver from obscuring the view of the gallbladder?

282
 (A) A
(B) H
(C) I
(D) F

126. Which instrument is used to expand the abdomen during a TEP (total extra peritoneal) inguinal hernia
repair?

(A) I
(B) A
(C) G
(D) F

127. The instruments in Figure 15–19J are used for:

(A) laparoscopic hernia repair

(B) laparoscopic cholecystectomy
(C) laparoscopic bowel resection
(D) All of the above

Questions 128 through 130: The following group of questions is preceded by a group of instrument images
(Figure 15–20). For each question, select the one-lettered option that is the best answer.

283
Figure 15–20.

128. What stapling instrument is used to join two arms of the intestines together, shown in Figure 15–20B?

(A) thorocoabdominal (TA)

(B) gastrointestinal intestinal anastomosis (GIA)
(C) end-to-end anastomosis (EEA)

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 (D) ligate, divide and staple (LDS)

129. The instrument in Figure 15–20C is used:

(A) to ligate and divide tubular structures and vessels

(B) to provide end to end or side to side anastomosis
(C) to provide the same function as a purse string suture
(D) for resection and transaction

130. The instrument in Figure 15–20A is used for:

(A) resection and transection

(B) resection and creation of an anastomosis
(C) resect tubular structures and vessels
(D) perform the same function as a purse string suture

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 Answers and Explanations

1. (D) Harrington Rods are internal splints that help maintain the spine as straight as possible until
vertebral body fusion becomes solid.

2. (C) Once a clip has been fastened through a drape, do not remove it because the points are
contaminated. If it is necessary to remove one during a case, discard it from the field and cover the area
with a piece of sterile linen.

3. (B) Old blood and debris should be removed from instruments as soon as possible with water so that it
does not dry on surfaces or crevices. Saline can damage surfaces, causing corrosion and pitting.

4. (D) With the ESU, electrical energy flows from the generator through a sterile active electrode to the
patient including both bipolar forceps and monopolar forceps.

5. (C) Self-retaining retractors, such as the Balfour, can cause the potential for bruising and nerve and
muscle damage more than the hand held retractors.

6. (A) The Poole’s suction tip has a guard which protects intestinal organs.

7. (C) Dull hooks and rakes are used in areas close to viable nerves and blood vessels, and sharp rakes are
designed to grasp superficial tissue.

8. (D) Heaney and Kocher contain teeth and/or serrations in order to grasp, facilitate in dissection, and
suturing.

9. (D) A Richardson retractor must be hand-held and self-retaining retractors use mechanical action, they
have many attachments and they hold tissue against the walls of the surgical wound.

10. (B) With this technique, scissors are inserted between the two tissue planes and opened. This separates
the layers rather than cutting them.

11. (A) Trocars are used to create an opening in which endoscopic instruments can be exchanged where
there is no natural opening.

12. (B) Blades must be loaded and removed from the handle with an instrument. Most commonly used is a
needle holder and never with your hands.

13. (A) A Lebsche sternum knife is used in chest surgery to open the sternum.

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14. (C) Kerrison refers to a rongeur. It is available in many angles and is used extensively in surgery of the
spine and neurosurgery.

15. (B) A Finochietto is a rib retractor.

16. (D) A Doyen is a rib raspatory.

17. (A) An electric drill or a hand perforator is used to make the burr holes. A rongeur is used to enlarge the
burr holes and increase exposure.

18. (B) Westcott tenotomy scissors are fine scissors with a spring action used in eye surgery.

19. (D) For splenectomy, prepare a basic laparotomy set plus two large right-angled pedicle clamps and long
instruments and hemostatic materials.

20. (B) Bowman probes are used to probe the lacrimal duct in a dacryocystorhinostomy and in lacrimal
probing to open a closed lacrimal drainage system.

21. (D) The tonsil lobe is freed from its attachments to the pillars with a Hurd dissector and pillar retractor.

22. (C) The Lempert elevator is used in delicate ear surgery.

23. (C) The Scoville is a retractor used in a laminectomy.

24. (D) The Bailey rib approximator is used to approximate the ribs for closure of a thoracic incision before
closure of the chest with interrupted suture.

25. (D) A Sauerbruch is a rib rongeur used to resect a rib and is found in a thoracotomy rib instrument bone
set.

26. (C) An Auvard is a speculum that is weighted for use in the vagina. It is placed in the posterior vagina.

27. (B) A Babcock forceps is a curved fenestrated blade clamp without teeth that grasps or encloses delicate
structures such as the ureter, appendix, or fallopian tube.

28. (A) A Ballenger swivel knife is used in rhinologic surgery. The nasal cartilage is incised with a Ballenger
knife.

29. (A) A Weitlaner is a self-retaining retractor.

30. (D) A Hill is a rectal retractor.

31. (C) A Webster needle holder is found in a basic plastic surgery instrument set.

32. (B) The kidney pedicle containing the major blood vessels is isolated and doubly clamped with a
Herrick, Satinsky, or Mayo pedicle clamp.

33. (A) Uterine dilators are Hank uterine dilators.

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34. (B) A lesion detected by a mammogram can be localized by the insertion of a needle(s) or a wire that is
inserted through a needle. Once the suspected area is identified, the patient is sent to the OR for a
biopsy. After biopsy, the specimen can be sent back for mammography validation before pathological
examination.

35. (D) Randall stone forceps are available in various angles and are used to remove stones from inaccessible
areas.

36. (A) Instrumentation for splenectomy is a basic laparotomy plus two, large right-angled pedicle clamps,
long instruments, and hemostatic materials or devices.

37. (A) Two blunt nerve hooks are required on a vagotomy setup.

38. (A) In an exploration of the common bile duct, a drainage T-tube is placed into the common bile duct.
It is used to confirm successful evacuation and patency of the ducts and stays in place as a drain.

39. (D) Prosthetic devices are of stainless steel and Teflon. Microsuctions are used. A speculum provides
view.

40. (A) Cochlear implantation is the placement of an electrode device in the cochlea in deaf people.
Candidates should have a history of lingual skills before becoming deaf. The device receives sound and
emits electrical impulses into the cochlea and along the acoustic nerve. Sound interpretations are taught
to the patient postoperatively.

41. (B) A Ballenger swivel knife is used in nasal surgery. An anesthesia setup, bayonet forceps, an Asch
septum-straightening forceps, a straight hemostat, impregnated gauze, packing, a splint, and adhesive
tape are prepared for a nasal fracture, closed reduction.

42. (A) A bayonet forceps is used to introduce sponges into the nose.

43. (C) The Potts tissue forceps is a fine forceps associated with vascular and fine intestinal surgery. Nasal
surgery requires, intranasally, an angled forceps such as the bayonet forceps, a Freer elevator, and a fine
Frazier suction tube.

44. (B) Esophageal dilators (Bougies) may be on an esophagoscopy setup.

45. (D) A Jameson hook is used in eye surgery. The Yankauer suction, Hurd dissector and pillar retractor,
and tongue depressor are all found in a tonsil set.

46. (D) A tissue expander stretches normal tissue to accommodate a breast prosthesis, used postmastectomy.
The expander is placed in a created pocket and exchanged for a permanent prosthesis after desired
expansion has occurred.

47. (B) Mandibular and maxillary fracture reduction is most often accomplished by applying arch bars to the
maxillary and mandibular teeth for immobilization in order to restore the patient’s preinjury dental

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 occlusion.

48. (C) The Alexander periosteotome, Doyen raspatory, and Stille shears are all instruments required to
remove a rib. A Heaney clamp is a hemostatic clamp used in gynecological surgery.

49. (B) Randall stone forceps are part of a kidney instrument set.

50. (A) A Sarot is a bronchus clamp.

51. (B) An intra-aortic balloon pump (IPB) is not necessary. Fluoroscopy and a defibrillator are required
plus vascular dissecting instruments, tunneling instrument, pacemaker and electrodes, introducer set,
and an external pacemaker.

52. (C) A permanent pacemaker initiates atrial or ventricular contraction or both. The most common
indications are complete heart block bradyarrhythmias.

53. (A) Harrington rods are internal splints—the distraction rods placed concave to the curve and the
compression rods on the convex side.

54. (C) Skeletal traction is the pulling force exerted to maintain proper alignment or position. It is applied
directly on the bone following insertion of pins, wires, or tongs placed through or into the bone.
Traction is applied by pulleys and weights to establish and maintain direction until fracture reunites.

55. (A) For a forearm or lower leg, a Kirschner wire or a Steinmann pin is drilled through the bone distal to
the fracture site. Traction is applied.

56. (A) During orthopedic surgery, the mobile image intensification, also referred to as fluoroscopy or x-ray
image, allows viewing of the case progression.

57. (B) The myelogram outlines the spinal subarachnoid space and shows distortions of the spinal cord or
dura sac by means of an injection of contrast media.

58. (D) Sachs, Frazier, and Adson are metal suction tips that suck and also conduct coagulation. Gardner
and Mayfield are skull clamps and part of a neuro headrest setup.

59. (A) An antigravity suit applied before positioning may help prevent air embolism and assist in
maintaining blood pressure.

60. (B) After wound closure, a Logan’s bow is applied to the cheeks with tape strips to relieve tension on the
incision and to splint the lip. It is a curved metal frame.

61. (C) A Cloward is the removal of anterior cervical disk with fusion using Cloward instruments. It entails
removal of disk fusion of the vertebral bodies and the use of bone dowels for the fusion obtained from
the patient’s iliac crest.

62. (D) A Beaver knife handle is found on the instrumentation for lens procedures in the eye.

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63. (C) Skeletal traction requires the use of sterile supplies (traction bow, pins, and drills).

64. (D) A Leyla–Yasargil is a self-retaining retractor. The others are aneurysm clips.

65. (A) A Pereyra or a Stamey are used for bladder neck suspensions to correct urinary stress incontinence. It
is a ligature carrier and is inserted through a suprapubic incision.

66. (B) Extracorporeal shock wave lithotripter (ESWL), a noninvasive procedure, utilizes the lithotripter,
which introduces shock waves through a liquid medium to disintegrate stones. Fluoroscopy and the
image intensifier are used for visualization.

67. (C) The Omni–Tract is an adjustable urology perineal retractor system.

68. (A) A Mason–Judd is a bladder retractor.

69. (A) The Furlow inserter is used to place a penile implant.

70. (D) A Millin is a retropubic bladder retractor.

71. (C) The Gomco is a circumcision clamp used for infants. For adults, a plastic instrument set is used.

72. (A) A Humi cannula is used in gynecological surgery for placement into the uterine cavity via the cervix
for intraoperative chromotubation with diluted methylene blue or indigo carmine solution.

73. (D) The Hulka forceps may be introduced into the cervix to manipulate the uterus for better visibility.

74. (A) A central venous pressure catheter insertion is a minor operative procedure requiring sterile gloves,
drapes, and instruments.

75. (C) Bakes are a set of common duct dilators.

76. (D) A Steffee plate is an internal spinal implant fixation system used for treatment of fractures,
spondylolisthesis, and idiopathic scoliosis of the thoracolumbar spine.

77. (C) Crutchfield tongs are for skeletal traction.

78. (D) The Bookwalter is a self-retaining retractor system.

79. (A) A Harrington is a large retractor.

80. (B) A Debakey is a long thoracic forceps.

81. (B) Bougie dilators are available in graduated sizes for esophageal dilation.

82. (C) The wire cutter scissor needs to accompany the patient to PACU post operatively in case of
emergency and the mouth needs to be opened.

83. (B) Potts–Smith scissors are used to extend the arteriotomy incision during a carotid endarterectomy.

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84. (C) Figure 15–1A. A Stevens scissor is used for delicate plastic surgery such as a blepharoplasty.

85. (B) Hanks dilators are used on the uterus to dilate the cervix. Hegar dilators are also used to dilate the
cervix (they are not pictured). Van Buren dilators are used to dilate the male urethra.

86. (C) Bakes dilators are used on the common bile duct to open and expand the duct to allow passage of
bile from the live. Bougies are esophageal dilators and Garrett dilators are used to dilate vessels.

87. (A) The Bookwalter is used to retract large abdominal wounds. It is a self-retaining retractor that
attaches to the OR table. All individual pieces need to be included in the count.

88. (C) Figure 15–4D is the finochietto. It is a chest/rib spreader. Other chest spreaders include the
Burford, the Ankeney. They are not pictured but look very similar.

89. (B) The retractor commonly used in abdominal surgery and mostly pelvic procedures (GYN) is the
O’Connor/O’Sullivan retractor.

90. (C) The Balfour is a self-retaining retractor used for retraction of a large abdominal wound. It has
multilateral blades and a wide center blade. The set also includes the frame and a wing nut.

91. (D) The Ellik evacuator is a double glass bowl and bulb with an adapter tip. It is used to remove tissue
segments/blood clots from the bladder. A microvasive evacuator does the same thing but is disposable.

92. (B) The three-way Foley catheter is used for intermittent or continuous bladder irrigation.

93. (C) Both the two-way and the three-way Foley catheters are the most common indwelling catheters.
The Foley has a balloon at one end and is used to hold the catheter in place. A large-mL Foley catheter
would be used postoperatively for a tamponade (used to apply pressure against a tissue opening)
example would be following a TURP.

94. (A) Two-way Foley 5 cc is used for urinary drainage. One port is used to inflate the balloon and the
other hooks to the drainage bag. A common nonretaining urinary catheter is a Robinson red rubber
catheter.

95. (B) Figure 15–5B is a Toomey syringe. It aspirates specimens and blood clots from the bladder. It is
often used to check for bleeding following a TURP. Fluid is injected into the bladder with a Toomey
syringe and then aspirated out of the bladder with the Toomey syringe checking the color of the fluid.

96. (B) The Auvard speculum provides retraction of the posterior vaginal wall. The blade is placed into the
vaginal vault and the weight of the speculum allows it to hang in place.

97. (C) The instrument in Figure 15–6C is a Jorgenson dissecting scissor commonly found on the GYN
tray. A Jarit is a retractor used to retract small shallow wound edges.

98. (B) Figure 15–6B is the Hulka tenaculum. It is used for grasping and holding. It is used to manipulate

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 the uterus during laparoscopic examination of pelvic structures. The probe is inserted into the cervical
os and the sharp prong penetrates the anterior cervical lip.

99. (C) The instrument in Figure 15–6F is a Bozeman uterine dressing forceps. It is used to place vaginal
packing in the vagina following vaginal procedures. A Simpson forceps is used to facilitate the fetal
decent when the fetus is lodged in the birth canal. The Ochsner is a curved Kocher, a grasping
penetrating clamp.

100. (D) A Phaneuf is a hysterectomy instrument used to clamp vessels and uterine ligaments used during a
hysterectomy. The Jacobs Vulsellum is used to grasp the anterior lip of the cervix for manipulation. The
Schroeder is a single toothed tenaculum used to grasp the cervix.

101. (B) The instrument in Figure 15–6E is the Graves vaginal speculum. It is used to retract the anterior
and posterior walls. The Eastman is a lateral vaginal retractor and the Young anterior retractor is a
prostate retractor used in prostate surgery.

102. (C) A Bugbee electrode is used to coagulate small areas usually following a bladder biopsy. It is also the
working element.

103. (D) Figure 15–7B is the loop electrode. It is used for resection and coagulation of the prostate and
bladder tissue during transurethral procedures. The ball loop electrode is used for coagulation of a larger
surface area. Example is the bladder. Randall forceps are used to grasp renal stones and common bile
duct stones.

104. (C) A T-tube is inserted into the bile duct for drainage of bile. The T-tube is a type of passive drain.

105. (B) A Fogarty embolectomy catheter would commonly be found on a vascular setup. It is the method of
removing thrombi.

106. (B) The instrument in Figure 15–9B is a Duval lung forceps. It is used to grasp and hold lung tissue.

107. (A) The instrument in Figure 15–9A is a Sarot bronchus clamp. Is used to hold and occlude the
bronchus while stapling during a lung procedure. A Cooley is used to clamp deep anatomical vessels.
The Javid carotid artery clamp is used to secure the Javid shunt in the carotid artery and Potts–Smith
are used to grasp and hold tissue.

108. (D) The Statinsky vena cava clamp has the jaws of the Debakey design. It is used to encircle the superior
and the inferior vena cava before placement of umbilical tape around the vessel.

109. (D) Figure 15–10A is a Bethune rib cutter. This heavy shear has straight cutting blades. Figure 15–10C
is the Gluck rib shear. The outside blade covers the rib and the inside blade cuts down. Another
common rib cutter is the Sauerbruch (not pictured) A patient’s anatomy as well as which rib is being
excised determines which rib cutter will be used.

110. (C) The instrument in Figure 15–10B is the Davidson scapula retractor. It is used to retract the scapula

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 and expose the ribs during thoracic entry and closure. The Allison lung retractor looks like a whisk and
is used to retract lung tissue (not pictured). The Cooley arterial retractor is used to retract the atrium
during a mitral valve procedure.

111. (C) The forceps in Figure 15–11A are Randall stone forceps. They are used to grasp stones in the biliary
system. They come in different intensities of curvature.

112. (A) This biliary catheter is used to retrieve stones from the common bile duct.

113. (B) A Fogarty embolectomy catheter is used to remove thrombus from vessels and a Malecot is a self-
retaining urethral catheter. Instead of using a balloon, the tip of the Malecot has either two or four
wings that expand out to hold it in place.

114. (D) The instrument in Figure 15–12A is a Hurd dissector. It is used to retract the soft palate for oral
procedures and to dissect tonsil tissue. Figure 15–12B is a mouth gag used to retract the mouth open for
exposure of the oral cavity. Another commonly used mouth gag used is the Jennings mouth gag.

115. (D) The instrument in Figure 15–13A is a Kerrison rongeur. It is used to excise the lamina and create
access to the disc. It is used during a spine procedure. They come up biting, straight, and down biting.

116. (B) The pituitary is used to remove the herniated disc. A Taylor spinal retractor is used for wound
retraction during lumbar spine procedures.

117. (D) The Leksell rongeur is used to remove pieces of bone and soft tissue and is also used to remove the
spinous process during a laminectomy.

118. (A) This instrument is called the Scoville nerve root retractor. It is used to retract the dura and the nerve
root. The shaft can be straight or angled. Cobb curettes are used to scrape bone during spine surgery.
Cobb ring curettes are used to strip muscle and peritoneum off the bone.

119. (B) Figure 15–14B is a blunt grasper which is used for grasping and manipulating organs causing
minimal trauma and these graspers are often used on tissue that is going to be removed.

120. (A) The Maryland dissector is a curved with fine tapered jaws with horizontal serrations running the
length of its jaws. It is used for fine dissection and separation of thin adventitial.

121. (C) Figure 15–14D is the endoclip applier. It is used for occluding vessels or other tubular structures. It
comes in various titanium clip sizes from 5 to 10 mm and in different size lengths.

122. (B) Endoscopic scissors are used to cut and dissect tissues, ducts, vessels, and suture material. They have
a rounded blunt tip with curved blades.

123. (D) Figure 15–14F is a suction irrigator, which is used to irrigate and aspirate fluid and debride from the
surgical site. It is a hollow suction tube attached to a combination tubing that has a suction valve and an
irrigation valve.

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124. (C) The Kleppinger is a paddle tip forceps that attaches to a bipolar cord used to grasp tissues and
vessels between the jaws and stepping on the foot pedal during laparoscopic procedures.

125. (B) The endo-fan retractor is used for elevation, retraction, and mobilization of organs and tissues and
provides optimal visualization of the surgical field.

126. (A) During a repair of an inguinal hernia, using the TEP approach, the instrument used is a balloon
expander. It is inserted into an incision and inflated with air or normal saline. The balloon dissector is
then removed and is maintained with gas insufflations.

127. (D) Figure 15–14J shows common laparoscopic instruments that are commonly used on all laparoscopic
surgeries.

128. (C) EEA or end-to-end stapler has a circular double row of staples and a knife blade within the
instrument which resects excess tissue, and creates a circular anastomosis. The LDS is used for ligation
and division of blood vessels and other tissues during abdominal GYN and thoracic procedures. It is
commonly used in gastrointestinal surgery to ligate and divide the greater omentum and mesentery (not
pictured).

129. (D) The thorocoabdominal staple gun is used to transect and resect. It has a double or triple staggered
row of staples commonly used in lung and abdominal surgery.

130. (B) The gastrointestinal anastomosis stapling device is used for resection and anastomosis. It provides
two rows of double staggered staples and simultaneously divides tissue between them.

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 ___________________ CHAPTER 16 ___________________

Sutures, Stapling Devices, and Drains

SUTURES

• The choice of suture depends on the health of the patient, surgeons preference, and preexisting conditions
• Types of suture material
Absorbable—absorbed by the body. Never used on vessels and arteries
Nonabsorbable—resists enzymatic breakdown and absorption by human tissue
Monofilament—one single strand which glides through tissue
Multifilament—several strands braided together
• When working with chromic and plain sutures do not pull on the suture to reduce their memory because
handling weakens the suture
• Nylon sutures are held between gloved hands to remove the memory. Suture is held on each end away
from needle. Commonly used in neurosurgery
• Do not crush or clamp suture, including stainless steel with an instrument as it can put a crimp in the
suture causing it to create a larger hole when going through tissue which causes bleeding
• Keep silk suture dry—if wet is decreases its tensile strength

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• Sutures should be passed using the “neutral zone” technique
• Information on the suture pack includes:
Surgical application
Product code #
Suture length and color
Suture size
Diagram of the size and shape of the needle
Needle point
Lot #
Expiration date
• Gauge—refers to the diameter of the suture
The larger the suture gauge, the smaller the diameter of the thread.

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 The higher the #, the finer the suture
• Knot tensile strength
This is the amount of force or pull that a suture strand can withstand before breaking
• Ligatures/ties are used to occlude vessels, ducts and also to retract
• Free tie—this type of suture is handed as a single strand
Ligature reel—used on superficial bleeders
The ligareel is radiopaque. the suture material is wrapped around the reel
You pull the suture to make a 2 in tail prior to handing the reel with tail to surgeon
• Instrument tie/tie-on-a-passer—this is used to occlude deeper vessels
Single strands of suture are clamped to the tip of the instrument—Adson or a Mixter and handed to the
surgeon
pass the instrument the same way as usual while holding the tip of the suture with your other hand
• Suture ligature/stick tie—this is used to occlude deeper vessels. There is a swaged needle attached
Figure-of-eight stick tie—this is used with a clamp. When the surgeon clamps off a bleeder he may
prefer to use a stick tie instead of a ligareel.
• Loading the suture-the needle should be clamped one third of the way from the swaged end of the needle

CUTTING SUTURE

• You should use your dominant hand for best control

• Your ring finger and thumb are placed in the rings and your index finger on the box lock/screw joint for
control
• Use the tip of the scissors to cut the suture. Slightly open the scissors, slide the one blade down the suture,
and cut above the knot unless otherwise instructed by the surgeon

NEEDLES

• Needles are made of steel

• Eye of the Needle—the part of the needle where the suture is attached/swaged on. There are three types of
needles including:
Closed eyed—the holes in the needle are round or square. These needles cause more damage to tissue
than eyeless needles because the holes are larger
French eyed—this needle is easier to load than a closed needle because there is an opening on the top so
the suture thread can be pulled through quicker
Eyeless and double armed—the needle may be swaged on or can be control release needles (pack
contains eight needles—suture easily pulls off)

Needle points

• Needles can be:

Cutting
Conventional cutting needle—has three razor sharp edges—they place a small cut in the tissue

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 Reverse cutting—opposite cutting edges as a conventional cutting needle. These are commonly used
for skin
Side cutting/spatula—used for eye procedures
Tapered
Taper needle—they do not have a cutting edge. The needle punctures the tissue. Commonly used on
the gastrointestinal tract-delicate tissue
Blunt
It has a round shaft and a blunt tip. Commonly used on the kidney and liver-delicate friable tissue
Keith needle
Straight needle—comes free or swaged on

HYPODERMIC NEEDLES

• These are used to inject medications into tissue and IV tubing

• To withdraw blood from the patient
• They come in various sizes and lengths

ARTERIAL OR VENOUS/CANNULA NEEDLES

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 • This needle is used to place an indwelling catheter for IV fluids or blood
• Angio-Cath is commonly used for IV fluids

Arterial needles

• These needles are used to guide catheters used for angioplasty over guide wires into the arterial system,
they include:
Potts
Cournand
Venous needles—with an aspirating syringe is used to puncture large veins to introduce monitoring
catheters (Swan–Ganz)

• Swan–Ganz catheterization—is the passing of a (catheter) into the right side of the heart and the arteries
leading to the lungs. It is done to monitor the heart’s function and blood flow

IRRIGATION NEEDLES—used for irrigating

VERESS NEEDLE—used for laparoscopic cases to introduce CO2 into the abdomen to create a
pneumoperitonium
Biopsy needles

• Dorsey cannulated needle for brain tissue biopsy

• Chiba—biopsy needle used for lung tissue
• Franklin–Silverman cannulated biopsy needle—used for liver and other internal organs
• Tru-Cut biopsy needle—they are commonly used for the liver
• Bone biopsy needles—used to retrieve bone marrow or for biopsy of the spine
• Spinal needles—they are used to introduce anesthetic medication into the epidural space, subdural space as
well as to obtain spinal fluid

Suturing techniques

• Dr. Halsted developed the principles of suture technique

Continuous/running suture
Single strand of suture that runs the entire length of the wound
As the surgeon is suturing the assistant follows by holding tension and keeping the suture out of the
surgeons line of sight
Continuous running locking/blanket stitch
Same as continuous except after each stitch a technique is used to lock the stitch in place
Subcuticular—stitches are hidden under the skin layer
The suture runs along the tissue below the skin. There is no visible suture
Steri-Strips and Dermabond are used to reinforce the wound
Purse-string—this is a draw string suture around a tubular structure
Commonly used on an appendectomy

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 Interrupted suture—used on tissues under tension and infected tissue
There are many variations of the interrupted stitch
Buried suture—the knot of the suture is burried under the tissue layer and not sticking out
Traction sutures—used to retract tissue. Commonly used on the eye, heart, CBD, tongue
Retention sutures—these are large sutures, nonabsorbable and interrupted that are placed through all
layers of tissue for wound reinforcement when needed
Bridges/bolsters—are used with the retention suture to prevent the heavy suture from cutting into the
patient’s skin
They are tubular pieces of plastic or rubber
Endoscopic sutures—used in laparoscopic procedures. There are two types of techniques used:
Extracorporeal—the knot is tied outside the body and slipped back in
Intracorporeal—the suture is tied inside the body
Endoloop and Endo stitch are two types of suture used

Alternative skin closure methods

• Wound zipper—leaves no suture holes

• Dermabond—(cyanoacrylate)— liquid glue
• Fibrin glue—biologic adhesive that can be used on deep tissue. Approximates wounds and helps control
bleeding
• Button suture—used on tendon repair—the button helps eliminate tissue damage
• Umbilical tape
It was originally used to tie off the umbilical cord on an infant
• Vessel loops—they are elastic strips used for retraction. They come in different colors for identification
Red—arteries
Blue—veins
White and yellow—nerves or ducts
• Suture anchors—they are used in orthopedic surgery to attach ligaments to
• Suture boots—they are small silicone covers that go on the end of mosquito clamps
They are used to identify and hold suture material
They are clamped on one end of the suture where the needle is. Used to keep track of the second needle
but also used for traction
Booties prevent the suture material from becoming kinked and causing a larger hole in the vessel
• Steri-Strips—are used with tincture of benzoin so that they stick better
• Skin staples—can be stainless steel or titanium. They are quicker to place than suture, cause minimal
scaring and are a choice for skin. Not used on plastic surgery cases. Staples are never used in the presence
of infection. Two people are required to place staples (1) places staples and (2) uses forceps to approximate
the skin

DRAINS

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• They are used to drain fluids and air from a wound
• Drains can be active or passive
• Passive drains—air and fluids drain from high pressure to low pressure. There is no suction involved.
These drains include:
Penrose drain
A type of latex tubing placed in the wound
They drain by capillary action
Cigarette drain
It is a Penrose drain with a gauze strip inside
It works by wicking action
T-tube
This tubing is placed in a tubular structure for drainage
Most commonly used in the common bile duct
One side is placed in the duct and the other brought out to the skin and connected to a bile bag
Gastrostomy tube/feeding tube/PEG tube (percutaneous endoscopic gastrostomy feeding tube)
Inserted through the abdominal wall into the stomach for drainage and nutritional feeding
Cystostomy tube
Inserted through the abdomen into the bladder for drainage
Nephrostomy tube
This tube is inserted percutaneously into the kidney for drainage
Tympanostomy tube—Myringotomy tubes—a small incision is made in the tympanic membrane and
the tiny tube is placed into the incision with alligator forceps. This procedure is performed to equalize
pressure in the middle ear and for drainage from chronic otitis media.
• Active drains—drainage occurs by suction mechanically or manually. They include:
Hemovac—used when a moderate amount of drainage is expected. Commonly used in orthopedic
surgery
Jackson–Pratt drain—commonly used on thyroid, breast, orthopedics, and abdominal procedures with
minimal drainage. It uses a tube and a grenade
Stryker—this drain works off a battery evacuation pump—mainly used in hips and knees. It is very
effective in eliminating dead space
Gastrointestinal decompression—a plastic or rubber nasogastric tube—NG tube is inserted through a
nostril down into the stomach or intestine to remove gas, fluids and other contents to decompress the
gastrointestinal tract. Types of tubes used include:
NG tubes are Levin tube (stomach)
Miller–Abbott tube (intestines)
Salem Sump (Nasogastric suction)
Urinary drainage—urinary catheters provide constant drainage of the bladder and kidneys during
surgical procedures to provide decompression of the bladder.

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 Pleur-Evac chest drainage system—closed water-seal drainage system—this consists of a chambered
collection system and a connecting hose. One end attaches to the patient’s chest tube and the other end
to the collection unit. This can be used as a gravity drain and vacuum.
This provides drainage of the pleural cavity and expansion of the lungs after surgery.
You always want to maintain negative pressure in the pleural space or the lungs will collapse
When it is not attached to suction, the collection unit must be kept below the chest level of the
patient because gravity will allow the fluid contents to go back into the plural space and collapse the
lung.
Chest tubes—they are clear plastic drains that are inserted into the chest cavity—the tubing from the
Pleur-Evac is connected to the chest tube.

STAPLING DEVICES

• Staples are made of various materials they include:

Stainless steel
Titanium
Absorbable materials

Skin stapler

• They are used to approximate skin edges

• One staple is fired at a time
• Adson forceps are used to approximate the skin edges. The gun is lined up with the skin edges and the
staple is released
• Depending on the manufacturer, the average gun hold from 28–36 staples

Linear stapler

• There are two basic types, they include:

GIA—gastrointestinal anastomosis
TA—thoracoabdominal
• GIA
This gun places two double rows of staggered staples and has a blade that ligates and divides the tissue
This is commonly used to join tubular segments together side by side
Commonly used in the GI track and the thoracic cavity
• TA
This gun places two double rows of staggered staples. Same as above but does not have a blade within
the gun
The target tissue is placed in the jaws of the TA gun, closed and fired. The staples are released. The
target tissue is sealed and a free scalpel blade is used to ligate the tissue
Commonly used to close a side or end of bowel or lung tissue
• LDS—ligating and dividing stapler

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 A double row of staples are released side by side for a one time staple and cut.
This is commonly used to ligate small vessels and small tubular structures. An example would be the
omentum
• EEA—end to end anastomosis/intraluminal staple gun
This is a circular staple gun with a double row of staggered staples and a blade attached
Commonly used on tubular structures of the lower GI track, distal colon, or rectum
When the gun is fired, it staples and ligates tissue leaving behind two pieces of tissue shaped like a
doughnut. They are sent to pathology separately to determine that both pieces of tissue are intact,
contain no cancerous margins, and assuring that a proper seal from the gun has been made
• Endoscopic stapler
These staple guns are endoscopically inserted through a trocar system
They are used to ligate and divide
Same principle as discussed above
• Ligating clip applier/Hemoclip applier
They are used to occlude small vessels, ducts, and tissue
Two clips are placed. One proximally and one distally on a structure. The structure can be divided with
a blade or scissor

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 Questions

1. Which of the following is a monofilament suture?

(A) Prolene
(B) Silk
(C) Polyester
(D) Vicryl

2. The size of the suture is based on its diameter. An example of a suture with the same diameter is a 2-0
silk and

(A) 3-0 silk

(B) 2-0 nylon
(C) 4-0 silk
(D) Both A and C

3. Which term refers to the amount of force needed to break the suture?

(A) Multifilament
(B) An absorbable quality
(C) Tensile
(D) Nonabsorbable

4. Which needle would be used on a liver resection?

(A) Cutting
(B) Tapered
(C) Keith
(D) Blunt

5. Which suture needle is contraindicated for a repair of nerve tissue?

(A) Taper
(B) Cutting
(C) Reverse cutting
(D) Both B and C

6. When using a skin gun, the staples go through which two layers?

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 (A) The epidermis and the dermis
(B) Cuticular and subcuticular
(C) Subcuticular and muscle
(D) Cuticular and muscle

7. In an appendectomy, a purse string suture is used to:

(A) tie off the appendix

(B) invert the stump of the appendix
(C) use to retract the appendiceal stump
(D) All of the above

8. A cutting needle would not be used on:

(A) the skin

(B) the bowel
(C) the tendon sheath
(D) the eye

9. If the surgical technician in the scrub role receives a broken needle back from the surgeon, they should:

(A) order an x-ray

(B) report it to the circulator
(C) remember to add to the final count
(D) tell the surgeon immediately

10. All of the following are absorbable sutures EXCEPT:

(A) polyglactin 910

(B) chromic
(C) nylon
(D) plain gut

11. What suture would be used on a coronary artery bypass and an aortic valve replacement?

(A) Polypropylene
(B) Silk
(C) Dexon
(D) Vicryl

12. Chromic and plain gut suture originate from:

(A) sheep intestine

(B) beef intestine
(C) pig intestine

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 (D) Both A and B

13. Which of the following sutures would commonly cause the least tissue reaction?

(A) Chromic
(B) Silk
(C) Stainless steel
(D) Vicryl

14. What term is used for a suture thread preattached to a needle?

(A) Swaged
(B) Tensile strength
(C) French eye
(D) Continuous

15. Retention sutures with bolsters would be used in what type of incision?

(A) Pfannenstiel
(B) Abdominal midline
(C) Oblique
(D) Transverse

16. What type of suture technique is used for a cosmetic closure?

(A) Purse string

(B) Detach
(C) Retention
(D) Subcuticular

17. A Keith needle is:

(A) straight needle with a tapered point

(B) straight needle with a cutting point
(C) another name for a spatula needle
(D) extremely large curved needle

18. The name given to suture material that is passed around a vessel or a duct for ligation is:

(A) tie on a passer

(B) control release
(C) swaged needle
(D) Ligareel

19. A strand of suture material attached to the top of an Adson clamp or a right angle is:

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 (A) stick tie
(B) Keith
(C) tie on a passer
(D) ligareel

20. The technique used to reduce suture memory is:

(A) hold needle in one hand with thread in the other and lightly tug on suture strand
(B) hold suture thread between gloved hands and lightly tug on thread
(C) either of the above will work but you must stretch the suture until the memory is gone
(D) none are acceptable techniques to reduce memory

21. The reason for using suture boots on a suture thread instead of just a clamp is:

(A) the clamp is part of the count and should not be used
(B) once you clamp the suture, it should not be removed until the end of the case
(C) if you use a clamp on suture it will crimp suture altering the integrity of the suture
(D) they are yellow and easy to identify

22. Another name for Polyglactin 910 is:

(A) Vicryl
(B) PDS
(C) nylon
(D) None of the above

23. Silk suture must be kept dry because moisture causes:

(A) a crimp in the suture

(B) contamination
(C) decreases its tensile strength
(D) hardness of the suture

24. Which information is included on each suture packet?

(A) Lot #
(B) Product code #
(C) Suture length and color
(D) All of the above

25. The type of needle commonly used for skin is:

(A) reverse cutting

(B) side cutting
(C) tapered

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 (D) hypo

26. Arterial needles used to guide angioplasty catheters over the guide wires include:

(A) Potts
(B) Cournand
(C) Angio-Cath
(D) Both A and B

27. The needle used to obtain tissue from the brain for specimen is:

(A) Dorsey cannulated needle

(B) Preaya needle
(C) Spinal needle
(D) Tru-cut biopsy needle

28. Who developed the principle of suture technique?

(A) Pasteur
(B) Lister
(C) Halstead
(D) Debakey

29. Suture techniques include all EXCEPT:

(A) Keith
(B) continuous running locking
(C) interrupted
(D) subcuticular suture

30. Retention sutures are:

(A) used to retract tissue

(B) used for tendon repair
(C) it was originally used to tie off the umbilical cord of infants
(D) large sutures, nonabsorbable, interrupted and placed through all layers to reinforce closure

31. All of the following pertain to drains EXCEPT:

(A) they drain fluids and air from a wound

(B) can be active
(C) can be passive
(D) are never removed from the patient

32. The drain commonly used after thyroid surgery is:

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 (A) Hemovac
(B) Jackson–Pratt
(C) Stryker
(D) All of the above

33. When loading the suture, the needle should be placed:

(A) ⅓ the distance from the swaged end

(B) ½ the distance from the swaged end
(C) ¼ the distance from the swaged end
(D) on the area of the needle that the swaged end attaches to the thread

34. The suture code RB on the package means:

(A) renal artery bypass

(B) retro bulbar
(C) retinal blunt
(D) reverse blunt

35. The suture code for the CTX needle is:

(A) cardiac transplant

(B) circle taper extra large
(C) cutting
(D) None of the above

36. Arterial needles used to guide angioplasty catheters over guide wires include:

(A) Potts
(B) Cournand
(C) Dorsey
(D) Both A and B

37. The biopsy needle commonly used on the liver is:

(A) Chiba
(B) Franklin–Silverman
(C) Tru-cut
(D) Both B and C

38. Suture techniques include:

(A) continuous running

(B) blanket stitch
(C) sub cuticular

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 (D) All of the above

39. Which of the following sutures are nonabsorbable, placed interrupted and placed through all layers of
tissue for wound reinforcement:

(A) traction
(B) buried
(C) bridges
(D) retention

40. All apply to a Penrose drain EXCEPT:

(A) it is a passive drain

(B) it works by a wicking action
(C) drains by capillary action
(D) can be used for retraction

41. Where is a T-tube commonly placed for drainage purposes?

(A) Cystic artery

(B) Cystic duct
(C) CBD
(D) Hepatic artery

42. Active Drains include:

(A) Stryker
(B) Hemovac
(C) gastrointestinal decompression
(D) All of the above

43. Gastrointestinal decompression drainage tubes include:

(A) Levin tube (stomach)

(B) Miller–Abbott tube (intestines)
(C) Salem Sump (Nasogastric suction)
(D) All of the above

44. All apply to closed chest drainage system except:

(A) This provides drainage of the pleural cavity and expansion of the lungs after surgery
(B) You always want to maintain a positive pressure in the pleural space or the lungs will collapse
(C) When it is not attached to suction the collection unit must be kept below the chest level of the
patient because gravity will allow the fluid contents to go back into the plural space and collapse the
lung

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 (D) Chest tubes—they are clear plastic drains that are inserted into the chest cavity—the tubing from
the Pleur-Evac is connected to the chest tube.

45. All apply to the skin stapler except:

(A) They are used to approximate skin edges

(B) One staple is fired at a time
(C) Adson forceps are used to invert the skin edges, the gun is lined up with the skin edges and the
staple is released
(D) Depending on the manufacturer the average gun hold from 28 to 36 staples

46. All are false in regards to linear staple guns except:

(A) The GIA gun places two double rows of staggered staples and has a blade that ligates in between
the staples and divides the tissue
(B) This is commonly used to ligate small vessels, small tubular structures and example would be the
omentum
(C) Commonly used on tubular structures of the lower GI track, distal colon or rectum
(D) Two clips are placed proximal and distal on a structure and can be cut with a blade or scissors to
divide the structure

47. What are two basic types of abdominal/thoracic linear staple guns?

(A) LDS and EEA Staple guns

(B) Endoscopic Staplers and Hemoclip appliers
(C) Skin Stapler
(D) GIA and TA

48. LDS is the acronym for?

(A) It is a ligating and dividing stapler device

(B) Used for ligating ducts and small vessels
(C) Lysis of duct structures
(D) All of the above

49. In what type of surgical procedure are you most likely to use an EEA stapler device to create an end to
end anastomosis?

(A) Hysterectomy
(B) Distal colon resection
(C) Ovarian cystectomy
(D) Hemorrhoidectomy

50. A CDC guideline that addresses the care of “sharps” includes all of the following EXCEPT:

(A) needles should always be recapped

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 (B) needles should not be bent or broken by hand
(C) needles should not be removed from disposable syringes
(D) needles should be discarded in puncture resistant containers for disposal

51. In a gastrointestinal closure, the mucosa of the intestinal tract is closed with:

(A) chromic 4-0 or 3-0

(B) silk 4-0 or 3-0
(C) Dacron 3-0 or 2-0
(D) Novafil 3-0 or 2-0

52. Which type of suture would be used to invert the stump of an appendix?

(A) Buried
(B) Purse-string
(C) Mattress
(D) Tension

53. Why are bumpers or bolsters used on retention sutures?

(A) To prevent the suture from cutting into the skin surface
(B) To facilitate easy removal
(C) To identify the order of suture removal
(D) To prevent unequal tension on the wound edges

54. Which procedure would not require a pressure dressing?

(A) Plastic surgery

(B) Knee surgery
(C) Radical mastectomy
(D) Hysterectomy

55. A closed-wound suction system works by:

(A) positive pressure

(B) negative-pressure vacuum
(C) air displacement
(D) constant gravity drainage

56. Mersilene is a/an:

(A) wire mesh

(B) absorbable suture
(C) nonabsorbable suture
(D) synthetic mesh

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57. All the following drains are considered active postoperative drains that are attached to an external force
EXCEPT:

(A) sump
(B) chest
(C) Penrose
(D) Hemovac

58. A continuous suture placed beneath the epidermal layer of the skin in short lateral stitches is called a:

(A) mattress suture

(B) transfixion suture
(C) retention suture
(D) subcuticular suture

59. Which procedure is followed if the scrub is pricked with a needle?

(A) Change glove only

(B) Discard needle, change glove
(C) Place new glove over old
(D) Change gown and gloves

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 Answers and Explanations

1. (A) Prolene is a single continuous fiber made of a polymer chemical (i.e., chains of the same molecule
strung together) that is extruded and stretched.

2. (B) A 2-0 silk has the same diameter as a 2-0 nylon suture. A numbering system indicates the sutures
outside diameter and ensures that a stated size is the same regardless of the material.

3. (C) Tensile strength refers to the amount of force needed to break the suture.

4. (D) A blunt needle is the least traumatic and the safest needle point. It is used on friable tissue and
organs that are soft and spongy.

5. (D) The taper needle has a round body that tapers to a sharp point. Its primary use is for suturing soft
tissue such as the biliary track, the dura, gastrointestinal (GI), muscle, and nerve.

6. (B) When using a skin gun, the cuticular and subcuticular are penetrated.

7. (B) A purse string suture is used to invert the stump of the appendix into the cecum.

8. (B) A cutting needle is not used on the bowel because it lacerates the bowel.

9. (D) When the STSR receives a broken needle back from the surgeon they should immediately tell him.

10. (C) All are absorbable except nylon which is a nonabsorbable suture.

11. (A) The polypropylene is commonly used on soft tissue and cardiovascular surgery.

12. (D) Chromic and plain gut is protein collagen derived from the sub mucosal layer of sheep or beef
intestine.

13. (C) Surgical stainless steel is the strongest of suture materials. It has no significant inflammatory
properties. It is available in monofilament, twisted and commonly used in the presence of infection.

14. (A) The suture is inserted into the eye end of the needle and is crimped and sealed. This is referred to as
swaged on.

15. (B) Retention sutures provide additional support to wound edges in abdominal surgery.

16. (D) In subcuticular stitching, the needle is placed within the dermis from side to side. This technique
brings the skin edges together and no suture material is visible from the outside. This technique

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 produces a very fine scar or no scar.

17. (B) A Keith needle is a straight needle with a cutting point frequently used in GYN and used on
superficial tissue.

18. (A) A tie on a passer is a piece of suture attached to a clamp that is passed around a vessel or a duct for
ligation and is commonly used in deeper cavities.

19. (C) A tie on a passer is a strand of suture material attached to the top of an Adson or right angle clamp.

20. (B) You can only hold the suture. If you grasp the needle, you may pull it off. You can never get all the
memory out without causing damage to the suture.

21. (C) Suture boots are used to identify and hold one end of a double armed suture but ideally used to
prevent a kink in the thread which can lead to vessel damage.

22. (A) Another name for Polyglactin 910 is Vicryl.

23. (C) When silk becomes wet it compromises its tensile strength.

24. (D) All of the above are included on a suture package.

25. (A) A reverse cutting needle is commonly used for skin closure. A side cutting is commonly used for eye
procedures. Tapered needles are used in the GI tract and for delicate tissue. Hypodermic needles are
used to inject medications into tissue and IV fluids.

26. (C) A Potts and Cournand are types of arterial needles. An Angio-Cath is used to introduce IV fluids.

27. (A) The Dorsey cannulated needle is used to obtain tissue for a brain biopsy. A Preyea needle is used for
stress incontinence. A spinal needle is used to introduce anesthetic medication into the epidural space,
subdural space and to obtain spinal fluid. A Tru-cut needle is used for a liver biopsy.

28. (C) Dr. Halstead developed the principles of suture technique. Lister contributed to antiseptic
technique. Debakey is known for his contributions to cardiac surgery.

29. (A) A Keith is a straight needle and has nothing to do with sewing technique.

30. (D) Retention sutures are large sutures. They are nonabsorbable and placed interrupted through all
layers of tissue for wound re- inforcement.

31. (D) Active drains are removed from the patient.

32. (B) Jackson–Pratt drain is commonly used following thyroid surgery. A Hemovac is used when a
moderate amount of drainage is expected. They are commonly used in orthopedic surgery. A Stryker
drain works off of a battery. It is an evacuation pump mainly used on hips and knees. It is very effective
in eliminating dead space.

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33. (A) When loading the suture, the needle should be placed ⅓ of the distance from the swaged end.

34. (A) The RB suture code stands for renal artery bypass.

35. (B) The CTX suture code stands for circle taper extra-large needle. C/CV is a cardiovascular needle.

36. (D) Potts and Cournand are two types of angioplasty catheters. A Dorsey needle is a cannulated needle
used for brain biopsies.

37. (D) the Tru-cut biopsy needle is commonly used for a liver biopsy. The Franklin Silverman biopsy
needle can be used for a liver biopsy along with other organs. The Chiba biopsy needle is commonly
used for lung tissue.

38. (D) All of the above are suture techniques.

39. (D) Retention sutures are large nonabsorbable interrupted sutures that are placed through all layers of
tissue for wound reinforcement. Traction suture are used to retract tissue commonly during eye, heart,
CBD, or tongue surgery. Buried suture is when the knot of the suture is buried under the tissue layer
and not sticking out. Bridges and bolsters are used with the retention suture to prevent the heavy suture
from cutting into the patient’s skin.

40. (B) All apply to the Penrose drain except it does not work by wicking action. The cigarette drain is a
Penrose drain with a gauze strip inside that works by wicking.

41. (C) The t-tube is commonly used for drainage of the CBD.

42. (D) Stryker—this drain works off a battery evacuation pump and is mainly used in hips and knees, it is
very effective in eliminating dead space. Hemovac is used when there is a moderate amount of drainage.
Commonly used in orthopedic surgery. Gastrointestinal decompression is a plastic or rubber nasogastric
tube-NG tube and is inserted through a nostril down into the stomach or intestine to remove gas fluids
and other contents to decompress the gastrointestinal tract.

43. (D) The Levin tube is used for stomach decompression. The Miller–Abbott is used to decompress the
intestines, and the Salem Sump is used for nasogastric suction.

44. (B) You always want to maintain a negative pressure in the plural cavity or the lungs will collapse.

45. (C) Adson forceps are used to evert the skin edges and the gun is lined up with the skin and the edges of
the skin and the staple is released.

46. (A) The GIA gun places two double rows of staggered staples and has a blade that ligates in between the
staples and divides the tissue. The LDS—ligating and dividing staple gun is commonly used to ligate
small vessels, small tubular structures and example would be the omentum. The EEA gun is used on
tubular structures of the lower GI track, distal colon or rectum. Hemoclips are two clips are placed
proximal and distal on a structure and can be cut with a blade or scissors to divide the structure.

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47. (D) GIA and TA linear staple guns are stapling devices that are commonly used to divide and join
tubular segments back together side by side for intestinal (GI) or thoracic procedures. All other choices
are NOT basic types of linear staple guns.

48. (A) Ligating and diving stapler is the acronym for an LDS stapler device. This is a double row of two
staples that are released side by side for a one time staple and cuts between with a blade within the gun.
This is also commonly used to ligate small vessels, small tubular structures.

49. (B) The EEA stapler device is a circular staple gun with a double row of staggered staples and a blade
attached to cut around this circular lumen within the tissue. Commonly used on tubular structures of
the lower GI track, such as distal colon or rectum surgical procedures.

50. (A) Precautions must be taken to prevent injuries. To prevent needle stick injuries, needles should not be
recapped, purposely bent or broken by hand, removed from the disposable syringes, or otherwise
manipulated by hand. Sharps should be place in a puncture-resistant container for disposal.

51. (A) In a gastrointestinal closure, the mucosal layer is closed with chromic 4-0 or 3-0; the seromuscular
layer is closed with chromic 3- 0 or 2-0 and silk 4-0 or 3-0.

52. (B) A purse-string suture is a continuous suture placed around a lumen and tightened, drawstring
fashion, to close the lumen. This is used, for example, when inverting the stump of an appendix or
when closing the anus in the perineal stage of an abdominoperineal resection.

53. (A) A bumper is passed over or through the exposed portion of suture in a retention suture to prevent
the suture from cutting into the skin surface.

54. (D) Pressure dressings are used frequently following extensive operations, especially in plastic surgery,
knee operations, and radical mastectomies.

55. (B) This portable system is used to apply suction to a large closed-wound site postoperatively. A
constant, negative vacuum evacuates tissue fluid and blood to promote healing by reducing edema and
media for microbial growth.

56. (D) Synthetic meshes, such as Mersilene or Martex, are helpful in repair of recurrent hernias requiring a
strong repair.

57. (C) Sump, chest, and Hemovac drains are all active drains attached to an external force of vacuum to
create suction. The Penrose exits the wound and provides a path of least resistance for drainage into the
dressing.

58. (D) A subcuticular suture is a continuous suture placed beneath the epithelial layer of the skin in short
lateral stitches. It leaves a minimal scar.

59. (B) Change a glove at once and discard needle or instrument if a glove is pricked by a needle or snagged
by an instrument.

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 ___________________ CHAPTER 17 ___________________

Wound Healing and Dressings

Factors that affect wound healing include:

• Age
• Obesity
• Nutritional status
• Smoking
• Immunocompromised patients
• Radiation exposure

Complications of wound healing include:

• Infection
• Hemorrhage
• Dehiscence—the wound separates after it has been closed
• Evisceration—the contents of the abdomen protrude out from the wound
• Dead space—separation of wound layers where air and/or blood accumulate and cause infection
• Fistula—an abnormal tube-like passage from a normal cavity or tube to a free surface or to another cavity
• Sinus tract—a tract that is open at one end only. It runs between two epithelial-lined structures. It causes
infection and drainage
• Suturing material and technique used

Types of Wounds

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 • Contusion—bruise
• Laceration—tear or cut
• Thermal—can be caused by heat, cold, or chemicals
• Abrasion—scrape
• Closed wound—skin remains intact. Some damage to underlying tissue
• Open wound—skin is cut/open
• Clean wound—clean cut, skin edges can be approximated
• Contaminated wound—open wound with bacteria and infection
• Complicated wound—a foreign body may remain in the wound, the edges of the wound cannot be
approximated because of tissue loss
• Chronic wound—a wound that takes an extended period of time to heal

Dressing is used to:

• Immobilize
• Apply even pressure over the wound
• Collect drainage
• Provide comfort for the patient
• Protect the wound

Biologic dressings

• Integra
• Dermagraft

Integra

• It is a bilayer matrix wound dressing made of bovine tendon and collagen matrix

Dermagraft

• It is manufactured from human fibroblast cells derived from newborn foreskin tissue

Skin grafts

• Autologous skin graft—taken from the patient’s own body

• Homograft—taken from a cadaver donor
• Xenograft/heterograft—a graft taken from another species
• Porcine—pigs

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321
Pressure Dressing/Bolster Dressing/Tie-Over Dressing

• This is a type of three-layer dressing

• Commonly used in plastic surgery following skin grafts
• It is applied tightly to:
Immobilize an area
Absorb excessive drainage
Provide even pressure
Eliminated dead space
Reduces edema
Reduces hematoma formation
• Stent dressing—this is a type of pressure dressing
The primary layer usually consists of Xeroform gauze
The secondary layer is fluffs
Tertiary layer consists of silk suture securing the dressing in place
• Wet-to-dry dressing
The dressing is soaked in saline, applied wet to the wound, and allowed to dry. The dressing is then
removed with a layer of the wound tissue
• Wet-to-wet dressing
Wet sponges are applied to the wound and removed before they dry. This type of dressing also debrides
the wound but with less pain than the wet to dry dressing.
• Thyroid collar/Queen Anne collar—a circumferential wrap is used to secure dressing
• Ostomy bag—dressing applied over a stoma
• Drain dressing—surgical dressing cut in the shape of a “Y” to wrap around a drain
• Tracheostomy dressing—surgical dressing used to secure a tracheostomy
• Eye pad—oval-shaped gauze pad used to cover the eye and keep the eyelid closed
• Eye shield—rigid oval-shaped shield used to cover the eye pad and protect the eye from trauma
• Perineal/Peri-Pad—this is a pad used to absorb vaginal and perineal drainage

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 • Packing material—long strips of gauze used to:
Provide hemostasis
Pressure, eliminate dead space
Support a wound
Comes plain or impregnated with an antiseptic (iodoform) and a radiopaque mark
Burns—can be caused by:
• Heat
• Chemicals
• Electricity
• Gases
• Radiation

Burns are classified by four degrees:

• Burns are assessed by:

The rule of nines—this is the method used to calculate the body surface area involved in burns using the
value of “9”
The head and neck = 9%
The front of the body trunk = 9%
The back of the body trunk = 9%
Arms—4.5 right arm/4.5 left arm = 9%
Legs—9 right leg/9 left leg = 18%

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 Perineal area = 1%
Lund and Browder—is a method used for estimating the extent of the burns to the body surface relating
to different ages. Commonly used for children

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 Questions

1. A surgical wound that is sutured together heals by:

(A) granulation
(B) primary intention
(C) inflammatory means
(D) second intention

2. Which classification of wound healing is involved with perforated bowel?

(A) Secondary intention

(B) Primary intention
(C) Third intention
(D) Fourth intention

3. Which wound is assigned to tissue healing by granulation?

(A) Secondary intention

(B) Third intention
(C) Fourth intention
(D) Inflammatory intention

4. Which type of wound healing requires debridement and continuous irrigation?

(A) Primary
(B) Secondary
(C) Third
(D) Fourth

5. What will be the correct order of wound healing process: (1) remodeling, (2) proliferation, and (3)
inflammatory?

(A) 1, 2, 3
(B) 2, 3, 1
(C) 3, 2, 1
(D) 2, 1, 3

6. Which of the following is associated with secondary intention wound healing?

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 (A) Wound that is sutured together
(B) Infected contaminated wound
(C) Wound space that is packed
(D) Wound that is not sutured

7. During which phase of healing is a scab formed?

(A) Inflammatory
(B) Proliferation
(C) Remodeling
(D) Primary

8. Conditions that affect wound healing include:

(A) surgical technique

(B) obesity
(C) age
(D) All of the above

9. A sunburn is classified as a:

(A) second-degree burn

(B) first-degree burn
(C) third-degree burn
(D) Not classified

10. Which of the following burns cause destruction of the entire thickness of skin?

(A) First degree

(B) Second degree
(C) Third degree
(D) Fourth degree

11. Which burn classification is characterized by dry white skin and generally have little pain associated with
this burn?

(A) First degree

(B) Second degree
(C) Third degree
(D) Fourth degree

12. Another name for a scar is:

(A) fibrin
(B) keloid

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 (C) hydrocolloid
(D) infection

13. Which nonadherent surgical dressing is used for a clean surgical wound and also care of specimens?

(A) Sterile gauze

(B) Telfa
(C) ABD
(D) Xeroform

14. What type of dressing is most often used on a skin graft?

(A) Pressure
(B) Stent
(C) Flat
(D) Both A and B

15. What type of pressure dressing is molded into a thick pad that fits into the graft area and is secure with
sutures?

(A) Supportive
(B) Stent
(C) Flat
(D) Tegaderm

16. Gauze packing is used:

(A) on a small incision

(B) wrapping a limb
(C) in nose or open wound
(D) when compression is needed

17. A strong thin transparent liquid useful in sealing certain wound edges is:

(A) Dermabond
(B) tincture of benzoin
(C) collodion
(D) Both A and C

18. The main purpose of Webril is:

(A) cast padding

(B) under pneumatic tourniquet
(C) pressure dressing
(D) Both A and B

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19. What type of gauze dressing is used on a circumcision?

(A) Sponge
(B) Tegaderm
(C) Vaseline gauze
(D) Roll gauze

20. What is the correct order of dressing a surgical wound? (1) Place dressings, (2) wash the incision, (3)
cover sterile dressing with a towel, and (4) remove drapes.

(A) 1, 2, 3, 4
(B) 2, 1, 3, 4
(C) 3, 4, 1, 2
(D) 3, 4, 2, 1

21. A circumferential bandage should be applied to an extremity:

(A) distal to proximal

(B) proximal to distal
(C) anterior to lateral
(D) medial to anterior

22. The classification of the wound without infection including a hernia, CABG or craniotomy is:

(A) class I
(B) clean wound
(C) class II
(D) Both A and B

23. Dead space is termed:

(A) separation of wound layers

(B) the contents of the abdomen protrude outside the incision
(C) the separation of the wound after healing
(D) space where an organ has been removed

24. A tract which is open at both ends that runs between two epithelial line structures:

(A) fissure
(B) dead space
(C) fistula
(D) Both A and C

25. A one-layered dressing include all EXCEPT:

(A) a small wound with minimal drainage

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 (B) Opsite
(C) Tegaderm
(D) ABD

26. Another name for a scrape is:

(A) laceration
(B) contusion
(C) abrasion
(D) open wound

27. In a three-layer dressing, the non permeable layer creates an air tight and a water tight seal to avoid
sticking to the wound. All are types of three-layer dressings EXCEPT:

(A) Xeroform gauze

(B) Vaseline
(C) Band-Aid
(D) tape

28. A circumferential wrap used to secure dressings commonly used following a thyroid procedure is:

(A) stockinette
(B) a Queen Ann collar
(C) Coban
(D) All of the above

29. The type of cast used to immobilize the hip or thigh including the trunk and one or both legs:

(A) walking cast

(B) spica cast
(C) Minerva
(D) body jacket

30. An item used for padding that has smooth and clingy layers is called:

(A) Webril
(B) stockinette
(C) Telfa
(D) gypsum

31. A temporary biologic dressing is:

(A) porcine
(B) Telfa
(C) collagen

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 (D) mesh

32. Which of the following is NOT a reason for a pressure dressing?

(A) Prevents edema

(B) Conforms to body contour
(C) Absorbs extensive drainage
(D) Distributes pressure evenly

33. Adherent, occlusive dressings that are used when slight or no drainage is expected are transparent
polyurethane film such as:

(A) Telfa
(B) Bioclusive
(C) Opsite
(D) Both B and C

34. A method of applying dressings to an unstable area, such as the face or neck, utilizing long sutures tied
over the dressing for stability is known as:

(A) pressure
(B) stent
(C) one-layer
(D) three-layer

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 Answers and Explanations

1. (B) In a primary intention wound, the cut tissue edges are in direct contact. This is an aseptic wound
with minimum tissue damage and reaction.

2. (C) Third intention or a delayed closure is a process in which an infected or a contaminated wound is
treated. An example is perforated bowel.

3. (A) This type of wound heals from the base. The healing process involves filling the tissue gap with
granulation tissue.

4. (C) A delayed closure may be performed when the wound is infected or requires continuous irrigation
and debridement.

5. (C) The phases of wound healing are inflammatory, proliferation, and remodeling.

6. (D) A wound that is not sutured must heal by secondary intention.

7. (A) During the inflammatory phase, platelet aggregation and the formation of a scab are followed by the
cellular phase.

8. (D) All of the above including the immune system, chronic disease, and nutrition are all factors in
wound healing.

9. (B) Burns are classified by the depth of the burn. First-degree burns involve only the outer layer of the
epidermis, for example, sunburn.

10. (C) Burns that cause the destruction of the entire thickness of skin is a third-degree burn.

11. (C) Third-degree burns are characterized by dry white skin and generally have little pain.

12. (B) When the proliferation of collagen is excessive, the scar is a keloid.

13. (B) A Telfa is a nonadherent flat fabric pad used for clean surgical wounds and also used in surgery for
the care of specimen.

14. (D) A stent dressing is a type of pressure dressing. They are used to apply slight pressure on the graft
site. This prevents serous fluid from lifting the skin graft away from the recipient site.

15. (B) A stent dressing is molded into a thick pad that fits into the graft area. Sutures are placed around the

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 graft site. The long suture ends are tied over the pad to secure it in place.

16. (C) Gauze packing is used in a cavity such as the nose or an open wound. It is available in long thin
strips and packaged in a bottle or a similar container.

17. (D) Dermabond and collodion are liquid self adhesives and occlusive dressings.

18. (D) Webril is a soft felt padding used under a pneumatic tourniquet and cast padding.

19. (C) Vaseline gauze is used to cover delicate incisions where tearing of tissue would disrupt repair.
Examples are minor burns, skin grafts, and circumcisions.

20. (B) The correct order of dressing the surgical wound is wash the incision, place dressings, cover sterile
dressing with a towel, and remove drapes.

21. (A) The bandage should be applied from distal to proximal as this prevents blood from pooling at the
surgical site.

22. (D) A class I wound is also defined as a clean wound. There is no presence of infection nor break in
aseptic technique. A class II which is a clean contaminated wound, there is no spillage of contents.
Example is a gallbladder or appendix. A class III contaminated wound is an open trauma wound.
Example would be a gunshot. Class IV is a dirty wound which can include perforated bowel.

23. (A) Dead space is the separation of wound layers where air and/or blood accumulate causing infection.
Evisceration is when the contents of the abdomen protrude out form the incision. Dehiscence is when
the wound separates following closure.

24. (C) A fistula is defined as a tract open at both ends that runs between two epithelial-lined structures.

25. (D) An ABD is an example of a secondary type of dressing used in a three-layer dressing. This is the
absorbent layer that is placed over the contact layer.

26. (C) Abrasion is the term used for a scrape. Laceration is a cut or tearing of the skin. A contusion is a
bruise. An open wound is when the skin is cut.

27. (D) Xeroform gauze, Vaseline gauze, and a Band-Aid are examples of nonpermeable dressings. Tape is
considered the outer layer used to secure the dressing.

28. (B) A Queen Anne collar is commonly used following thyroid surgery along with a Jackson-Pratt drain.
A stockinette is a tubular elastic type of dressing commonly used in orthopedics. Coban is an elastic
pressure wrap that adheres to itself and is also commonly used in orthopedics.

29. (B) A hip spica cast is used to immobilize the hip or thigh including the trunk and one or both legs. A
walking cast is a cylindrical cast used for the lower extremity. The Minerva Jacket is used to immobilize
the body from the head to the hips. It immobilizes the cervical and upper thoracic vertebrae and the

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 lower part of the body jacket is used to immobilize the thorax and lumbar area from the axilla to the
hips.

30. (A) Webril is a soft, lint-free cotton bandage. The surface is smooth but not glazed, so that each layer
clings to the preceding one and the padding lies smoothly in place.

31. (A) Pigskin (porcine) is used as a temporary biologic dressing to cover large body surfaces denuded of
skin.

32. (C) A pressure dressing does not absorb excessive drainage. A pressure dressing prevents edema,
distributes pressure evenly, gives extra wound support, and provides comfort to the patient
postoperatively.

33. (D) Sterile, transparent occlusive dressings, such as Bioclusive and Opsite, are made of transparent
polyethylene and may be used when slight or no drainage is expected. They are usually removed after
24–48 hours.

34. (B) Stent fixation is a method of applying pressure and stabilizing tissues when it is impossible to dress
an area such as the face or neck.

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 ___________________ CHAPTER 18 ___________________

General Surgery

GENERAL SURGERY: GASTROINTESTINAL

TRACT/BILIARY/LIVER/PANCREAS/SPLEEN/HERNIA/BREAST/SURGICAL INCISIONS

GASTROINTESTINAL TRACT

• Gastrointestinal tract is also called the alimentary tract.

• The GI tract includes:
Esophagus
Stomach
Small intestines
Large intestines
Rectum
• The basic functions of the GI tract include:
Ingestion
Secretion
Digestion
Absorption
• ESOPHAGUS—it transport ingested material by peristalsis from the pharynx to the stomach.
• ESOPHAGOGASTRODUODENOSCOPY—EGD—also referred to as GASTROSCOPY—scoping
of the esophagus, stomach, and duodenum.
Endoscopes are considered semicritical, and must undergo high level disinfection before each use.
Endoscopic accessories such as biopsy forceps, cytology brushes, and fine-needle aspiration
instrumentation are considered critical devices because they enter the mucosa and must be sterile.
• GASTROESOPHAGEAL REFLUX DISEASE (GERD)—is a condition of backflow of gastric or
duodenal contents into esophagus causing pain, heartburn, coughing, and respiratory distress.
• BARRETT’S ESOPHAGUS—Barrett’s esophagus is an abnormal growth or development of cells of the
mucosal lining of the distal esophagus. This could be a precurser for cancer.
• ESOPHAGECTOMY—removal of a portion of the esophagus. This can be performed by several
different approaches and procedures, they include:
Transthoracic
Transhiatal

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 VATS—video-assisted thoracic surgery
• ZENKER’S DIVERTICULUM—this is a weakening in the wall of the esophagus that collects food and
causes a feeling of fullness in the neck.
• ESOPHAGEAL HIATAL HERNIA/DIAPHRAGMATIC HERNIA—it is a defect in the diaphragm
where a part of the stomach protrudes up into the thoracic cavity.
• LAPAROSCOPIC NISSEN FUNDOPLICATION —performed to restore the function of the lower
esophageal sphincter (the valve between the esophagus and the stomach) by wrapping the stomach around
the esophagus. This procedure prevents reflux of the acid and bile from the stomach into the esophagus.
• ESOPHAGEAL DILATION—is performed to dilate the esophagus due to strictures caused by scaring
of past surgeries, chemical or thermal burns, and anomalies.
Instruments needed include a gastroscopy and video equipment and BOUGIE DILATORS.
• STOMACH—lies between the esophagus and the duodenum. It is located in the upper left abdominal
cavity, beneath the diaphragm. The stomach is divided into:
Cardia (below the esophageal sphincter)
Fundus (upper portion)
Body
Pyloric antrum (above the pylorus)
• It is connected to the lower portion of the esophagus, by the esophageal sphincter and the duodenum by
the pyloric sphincter
• The lower margin of the stomach is known as the “greater curvature” and the upper margin is the “lesser
curvature”
• Attached to the greater curvature is the OMENTUM (it is a double fold of peritoneum containing fat that
covers the intestines)
• The MESENTERY—connects the intestines with the posterior abdominal wall
Functions of the stomach include:
Storage of ingested material
Chemical and mechanical digestion (peristaltic waves—which mix and push stomach contents (chime
—semifluid mass of partially digested food) into the duodenum
• VAGOTOMY—is a surgical procedure in which one or more branches of the vagus nerve are cut to
reduce gastric secretions into the stomach
• PYLOROPLASTY/PYLOROMYOTOMY—this procedure is performed to create a larger passageway
between the pyloric area of the stomach and a portion of the duodenum
More common in infants—symptoms are projectile vomiting
• PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)—PEG is the most common
gastrostomy tube used. PEG uses a flexible gastroscope and a gastrostomy tube for placement through the
abdominal wall
It is used for gastric decompression and external feedings
• GASTROJEJUNOSTOMY—this is performed to treat a benign obstruction in the pyloric end of the

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 stomach, or an inoperable lesion of the pylorus of the stomach when a partial gastrectomy cannot be done.
This provides a larger opening without sphincter obstruction. This procedure makes a permanent
communication between the proximal jejunum and stomach, without removing any portion of the GI tract
• PARTIAL GASTRECTOMY—BILLROTH I and BILLROTH II
BILLROTH I is a gastrectomy resection of the diseased portion of the stomach, and an anastomosis
between the stomach and duodenum
BILLROTH II is a gastrectomy resection of the distal portion of the stomach, and an anastomosis
between the stomach and the jejunum
• TOTAL GASTRECTOMY—this is complete removal of the stomach
• PARTIAL GASTRECTOMY—partial removal of the stomach
• BARIATRIC SURGERY—bariatric surgery is also known as weight loss surgery. This is performed for
the surgical treatment of obesity
MORBID OBESITY—is defined as a BODY MASS INDEX (BMI) of 40 kg (kilograms) or more
45 kg = 100 lb
This procedure reduces the size of the stomach. Food is digested and absorbed normally, and because
the stomach is smaller it has a feeling of fullness, and the patient eats less. Examples include:
ADJUSTABLE GASTRIC BAND/LAP-BAND
LAP-BAND—it is a silicone strip and an elastic ring placed around the top of the stomach. A fold of
stomach is wrapped around the band to secure it in place. The band has a port that is inflated with
saline 4 weeks postoperatively. This procedure is adjustable and reversible
• LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS—this procedure is a gastric bypass, it reroutes
the passage of food from a small pouch created with surgical staples or sutures in the proximal stomach to
a segment of the proximal small bowel. It is commonly performed laparoscopically
• SMALL INTESTINE—is the longest part of the digestive tract. It begins at the pylorus of the stomach
and ends at the ileocecal valve
• It is divided into three parts:
Duodenum
Jejunum
Ileum
• LIGAMENT OF TREITZ—it is the duodenojejunal flexure where the duodenum and jejunum connect
• MECKEL’S DIVERTICULUM—this is an out-pouching from the small intestine. It is failure of a
congenital duct to be eliminated. The diverticulum can become inflamed, ulcerated, bleed, perforate, or
cause an obstruction
• INTUSSUSCEPTION—is a telescoping of a part of the intestine; this can lead to intestinal obstruction
• LARGE INTESTINES—they begin at the ileocecal valve and ends at the anus. It is divided into the:
Cecum
Colon
Rectum

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• CECUM—forms a pouch from which the APPENDIX projects
• COLON—the colon is divided into four parts:
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
• RECTUM—begins at the sigmoid colon and ends in the anus
• ANUS—the anal canal is a narrow passage, it is controlled by two muscle groups which form the:
Internal anal sphincter
External anal sphincter
• LAYERS/WALL OF THE INTESTINE:
Serosa—outer layer
Muscularis
Submucosa
Mucosa—inner layer
• HAUSTRA—outpunching’s on the intestines, they give them the bubble appearance.
• The primary function of the large intestine is to:
Reabsorb water and electrolytes
Breakdown vitamin K and B complex vitamin’s
Help eliminate solid food and waste through defecation
• APPENDECTOMY—this is removal of the appendix. This procedure is performed to remove an acute
inflamed appendix, and prevent the spread of infection and peritonitis (inflammation of the peritoneum)
McBurney incision is used
Bowel technique is used here on any instruments that come in contact with the appendix should be
isolated
PURSE-STRING suture commonly used on an appendix
• INTESTINAL STOMAS—this is a surgically created opening or stoma that extends from a portion of
the bowel to the outside of the abdominal wall. This is performed for:
Diverting intestinal contents so the bowel can heal
Bypass an obstruction or a tumor
Stomas include:
Ileostomy—performed for removal of the colon
Cecostomy
Colostomy—creating an opening anywhere along the colon
• POLYPECTOMY—polyps are small growths, typically benign they protrude from a mucous membrane
• HEMICOLECTOMY/TRANSVERSE COLECTOMY/ANTERIOR RESECTION/AND TOTAL
COLECTOMY. These procedures are performed for:
Colitis

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 Diverticulitis
A new and abnormal growth of tissue in some part of the body
• WHIPPLE PROCEDURE—PANCREATICODUODENECTOMY—removal of:
HEAD OF THE PANCREAS
DISTAL 1/3 OF THE STOMACH
ENTIRE DUODENUM
PROXIMAL JEJUNUM
GB
CYSTIC AND COMMON BILE DUCTS
PANCREATIC LYMPH NODES
• BOWEL TECHNIQUE/ISOLATION TECHNIQUE
All items that come in contact with the GI tract are considered contaminated
There should be two set-ups. One for the clean part and one for the dirty
Instruments from the contaminated set up should be isolated from the clean
The STSR should not touch anything that is dirty and then go back to the clean part of the case until
the case is over and their gown and gloves have been changed
Once the GI tract is closed the STSR should replace the suction and cautery tips, contaminated
instruments, and the sterile towels that were placed at the beginning of the case
All surgical team members should change gown/gloves
• ABDOMINAL PERINEAL RESECTION—an APR is performed to remove malignant lesions and to
treat inflammation of the:
Sigmoid colon
Rectum
Anus
• ADHESIONS—are fibrous bands of tissue that cause organs and tissues to adhere to one another
• HEMORRHOIDECTOMY—surgical removal of dilated veins or prolapsed mucosa of the anus and
rectum. They can be external or internal or both. They can be ligated with:
Silastic band sutures
Bovie or laser
• FISTULOTOMY/FISTULECTOMY—this is an abnormal or surgically made passage between a hollow
or tubular organ and the body surface, or between two hollow or tubular organs. The procedures
performed include:
Fistulotomy—this is an opening into the tract for drainage. The wound heals from the inside out
Fistulectomy—the tract is excised
Procedure includes dye (Methylene blue) injected into the fistula tract and a probe and grove director
are used to identify the tract/follow it/and open it using a blade
• PILONIDAL CYST- A pilonidal cyst is a cyst or abscess near or on the cleft of the buttocks that often
contains hair and skin

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• LAPAROTOMY—a surgical opening into the peritoneal cavity
• LAYERS OF THE ABDOMINAL WALL:
Skin
Sub-q
Fascia
External oblique
Internal oblique
Transverse abdominis
Fascia
Peritoneum
• LAPAROSCOPY
Also referred to as MIS—minimally invasive surgery
Laparoscopic GYN procedures were originally called: Band-Aid, keyhole, belly button procedures
• LAPAROSCOPIC-ASSISTED PROCEDURES—this procedure is performed with a laparoscope.
Additionally, one port site is enlarged in order for the surgeon to bring the tissue outside of the wound for
repair. The surgeon may bring the operative tissue out of the body to repair (EXTRACORPOREAL
REPAIR) or reach his hand into the opening and perform a (INTRACORPOREAL) repair
• SIL—SINGLE PORT LAPAROSCOPIC SURGERY—one port is used to gain access to the
abdominal cavity. The port placed through the umbilicus
HASSON CUT-DOWN TECHNIQUE—this is performed with a cut-down technique using a blade
and blunt trocar instead of a sharp trocar system
EQUIPMENT and INSTRUMENTATION include:
Veress needle—provides access for CO2 to create a pneumoperitoneum.
CO2 intra-abdominal pressure is between 12 and 15 mm Hg and should not exceed 18 mm Hg.
10-, 11-, 12-, and 5-mm trocar and cannulas are introduced into the abdomen according to surgeon’s
preference

BILIARY SYSTEM

• GALLBLADDER-BILIARY SYSTEM
It is located in the right upper quadrant, under the right lobe of the liver
The main function of the GB is to store bile
Removal of the GB, this is performed for:
Cholecystitis—acute or chronic inflammation of the GB
Cholelithiasis—stones in the GB (Gallstones are sent to pathology in a dry container)
In both open and laparoscopic cholecystectomies, the surgeon stands and operates from the left side of
the patient
• CHOLECYSTECTOMY—subcostal/Kocher incision.
• LAPAROSCOPIC CHOLECYSTECTOMY—removal of the gallbladder endoscopically

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 Biliary instruments include:
Randall Stone forceps—they are used to remove stones from the GB. (look like polyp forceps they
come in various angles)
Bakes dilators—they are used to dilate the common bile duct
T-tube—is a type of drain is inserted into the CBD for additional drainage
Fogarty biliary catheter—this is used to remove stones in the CBD
Harrington—used to retract the liver
Potts scissors—are used to extend the incision in the CBD
• CHOLANGIOGRAM—this is an x-ray using fluoroscopy of the bile ducts (cystic/common bile ducts)
DIATRIZOATE SODIUM/HYPAQUE, RENOGRAFIN—is the types of dyes that are injected
into the bile ducts through a catheter called a CHOLANGIOCATHETER and a picture is taken
It is also important to clear all bubbles from cholangiocatheter tubing when doing a cholangiogram
because the bubbles may show up as stones on the x-ray
• When removing the GB specimen from the abdomen you can use these techniques:
The GB specimen is removed in an endo-catch bag to prevent spillage
Kelly clamps are used to extend the port opening to remove the GB
The GB can also be decompressed with suction
• ERCP—ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY—this is an
endoscopic procedure used to identify the presence of stones, tumors, or narrowing in the biliary and
pancreatic ducts
• CHOLEDOCHODUODENOSTOMY—this is performed to bypass an obstruction in the distal end of
the CBD. The anastomosis is between the CBD and the duodenum
• CHOLEDOCHOJEJUNOSTOMY—the anastomosis is between the CBD and the JEJUNUM
• CHOLEDOCHOTOMY—a T-tube is inserted into the CBD after stones have been removed from the
duct to provide drainage
• TRANSDUODENAL SPHINCTEROPLASTY—this is performed because the SPHINCTER ODDI
(the Sphincter of Oddi is the muscle that controls the pancreatic/gastric/bile juices into the ampulla of
Vater that empties into the duodenum) does not function properly

LIVER
Located in the right upper abdominal quadrant of the abdominal cavity beneath the diaphragm and
directly above the stomach
It is divided into right and left lobes by the falciform ligament
Glisson’s capsule—the outer covering of the liver
Bile is manufactured in the liver
• LIVER NEEDLE BIOPSY
Performed for liver disease
A Silverman or True-Cut needle is used for the biopsy
• SUBPHRENIC ABSCESS

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 This is an abscess in or around the liver
• LIVER RESECTION
This is performed for primary tumors benign and metastatic
The entire liver cannot be removed without a transplant
This procedure can be performed open/laparoscopic/robot assisted
Instruments used are:
Laparotomy set
Biliary instruments
Vascular instruments
Blunt needles are always used on the liver.
Self-retaining retractors—Bookwalter retractor.
CUSA—cavitron ultrasonic surgical aspirator.
Dissects tissue using ultrasonic waves incorporated with fluid and suction
The hand piece similar to the ESU cuts through the tissue emulsifying it and thinning the tissue with
fluid so it can be suctioned
Intraoperative ultrasonography—the ultrasonic probe is draped and used inside the body in conjunction
with the surgery
Right subcostal incision
• LIVER TRANSPLANTATION
This is an implantation of a liver from a donor patient to a recipient patient
This procedure is performed only after the donor patient is pronounced brain dead and the family
consent for organ donation has been obtained
The procedure:
Retrieving the liver from the donor patient
Performing a hepatectomy on the recipient patient
Implant the donor liver
Instrumentation:
Basic laparotomy instruments
Cardiovascular instruments
Sternal saw
Nephrectomy instruments
The procurement team provides special solutions to flush the organs to procure them They include:
Collins solution
University of Wisconsin solution
There are two or rooms one set up for each patient
Supine position
Bilateral subcostal incisions/midline incision

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SPLEEN

• The spleen is located in the upper left abdominal cavity, protected by the 10th/11th/12th rib, and directly
beneath the dome of the diaphragm
• SPLENECTOMY—this is performed for:
HYPERSPLENISM—splenomegaly—(this is an enlarged spleen with a decrease in red blood cells,
white blood cells, and platelets
Also performed for tumors and trauma
HODGKIN’S DISEASE (a type of cancer that starts in the cells of lymphocytes) one of the places it
can start is the spleen
SICKLE CELL DISEASE—in this inherited form of anemia, abnormal red blood cells block the flow
of blood through vessels and can lead to organ damage, including damage to the spleen. People with
sickle cell disease need immunizations to prevent illnesses their spleen helped fight
THROMBOCYTOPENIA—(low platelet count): an enlarged spleen sometimes stores excessive
numbers of the body’s platelets. Splenomegaly can result in abnormally few platelets circulating in the
bloodstream where they belong
This procedure can be performed open or laparoscopic
Supine position
General anesthesia
Incisions include:
Left rectus paramedian
Midline
Subcostal
Hemorrhage is the main intraoperative complication

Pancreas

• The pancreas is located behind the stomach in the back of the abdomen. It is spongy and shaped like a fish
The head of the pancreas is the largest part and lays on the right side of the abdomen where the stomach
is attached to the first part of the duodenum
The tail or the body of the pancreas is its narrowest part, it is next to the spleen
The pancreatic is also known as the duct of Wirsung
• AMPULLA OF VATER—this is formed by the pancreatic duct and the common bile duct
• SPHINCTER OF ODDI—this is the muscular valve that controls the flow of gastric juices through the
ampulla of Vater
• There are two main types of tissue found in the pancreas:
Exocrine—tissue that produces pancreatic enzymes to aid digestion.
Endocrine—tissue that produces cells known as islets of Langerhans. These grape-like cell clusters
produce important hormones that regulate pancreatic secretions and control blood sugar
Insulin

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 Glucagon
• PANCREATICOJEJUNOSTOMY—this procedure is performed for obstructed ducts and pseudo cysts
this is associated with chronic alcoholic pancreatitis
Pancreatic pseudo cyst—is a collection of fluid around the pancreas. The fluid in the cyst is usually
pancreatic juice that has leaked out of a damaged pancreatic duct
A loop of the jejunum is anastomosed to the pancreatic duct
• PANCREATICODUODENECTOMY/WHIPPLE procedure—this procedure is performed on
patients with cancer on the head of the pancreas or the ampulla of Vater. Usually there is distant
metastasis to the lymph nodes/liver/lungs, the prognosis is usually poor
• Whipple—removal of:
Head of the pancreas
Entire duodenum
A portion of the jejunum
Distal third of the stomach
Gallbladder
Lower half of the common bile duct
• PANCREATECTOMY
This procedure is performed for:
Cancer of the pancreas
Benign tumors
Chronic pancreatitis
Trauma
This can be a total and partial removal of the pancreas
• TOTAL PANCREATECTOMY—is a surgical procedure performed to treat chronic pancreatitis when
other treatment methods are unsuccessful
This procedure involves the removal of the entire pancreas, as well as the gallbladder, common bile duct,
and portions of the small intestine and stomach, and most often, the spleen
• PANCREATIC TRANSPLANTATION—this procedure is performed to replace a diseased pancreas
with a healthy pancreas
The best candidates are:
Between 20 and 40 years old
Are able to regulate their glucose levels
Have few complications with diabetes
Those who are in good cardiovascular health

HERNIA

• Hernia—Latin word for rupture

Hernia—is a protrusion of viscus through an opening in the wall of a cavity

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 It can be a congenital defect or an acquired defect
• Hernia types
INGUINAL HERNIAS
DIRECT INGUINAL HERNIA
This hernia is acquired
Commonly found in men
It occurs in Hesselbach’s triangle which involves:
Rectus abdominus muscle
Inguinal ligament
Deep epigastric vessels
• INDIRECT INGUINAL HERNIA
Congenital hernia
The main focus in this type of hernia is caused by a weakness or tear in the transversalis fascia
The defect is in the internal inguinal ring and protrudes into the scrotum
Femoral hernia
Most common in women
Can be misdiagnosed as a lymph node
• VENTRAL HERNIA
Occurs anywhere on the abdominal wall other than the groin
Incisional hernia
This occurs at a previous incision site (where previous surgery was performed)
• UMBILICAL HERNIA
Commonly found in children—congenital
In adults usually acquired
Hernia protrudes through the umbilical ring
• DIAPHRAGMATIC/HIATAL HERNIA
Occurs more often in women, overweight people, and people over 50
Occurs at the level of the stomach where it joins the esophagus
Symptoms include heartburn and GERD (Gastroesophageal reflux disease)
• PANTALOON HERNIA
Both direct and indirect hernias are present
French word meaning pants
• EPIGASTRIC HERNIA—above the umbilicus.
• HYPOGASTRIC HERNIA—below the level of the umbilicus
• SPIGELIAN
Difficult to diagnose
The defect is usually between muscle layers not between two muscles
Intestinal obstruction is associated with this hernia

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 It is usually diagnosed because of the obstructed intestines
Surgery is immediately required
Commonly found in the left lower quadrant

CLASSIFICATIONS OF HERNIAS

• REDUCIBLE HERNIA
The hernia sac can be manipulated back into its normal position in the abdomen
• IRREDUCIBLE/INCARCERATED
The hernia cannot be manipulated back into its normal position
The hernia contents (intestines) become trapped and cause an intestinal obstruction
Immediate surgery required
• STRANGULATED HERNIA
The hernia contents become trapped and the viscera becomes necrotic
This is a surgical emergency—the hernia cannot be repaired without requiring a bowel resection
Richter’s hernia is a type of strangulated hernia

OPEN HERNIA REPAIR

• MCVAY/COOPER REPAIR
Performed on an indirect inguinal hernia
Transversalis fascia involved
Penrose on a Kelly
Mesh graft
• MESH GRAFT
The hernia is reduced and mesh placed on the weakened area, it is secured with sutures.
Mesh comes in various sizes and shapes—surgeons choice
Mesh material includes:
Gore-Tex
Teflon
Dacron
Marlex
Prolene
• BASSINI/SHOULDICE HERNIA REPAIR—not often used anymore
Tension repair—this type of repair involves reducing the hernia and pulling the muscles together and
suturing them with heavy suture or wire
• LITTRE HERNIA REPAIR
This type of hernia that involves a Meckel’s diverticulum
What is a Meckel’s diverticulum? This is a congenital defect in the distal ileum, it is a pouch on the wall
of the ilium

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• MAYDL HERNIA REPAIR
This type of hernia involves two loops of bowel
• LAPAROSCOPIC HERNIA REPAIR
Laparoscopy—is a way of performing a surgery. Instead of making a large incision, 5–10 mm incisions
are made and instruments are inserted including a scope attached to a camera to view the internal organs
and repair or remove tissue
• HASSON TROCAR AND CANNULA SYSTEM
Cut-down is used to insert this trocar and cannula (this is when they create a small incision using a
blade/scissors/forceps . . . instead of a puncture)
• There are two basic techniques used for a laparoscopic hernia repair. The difference between these two
approaches is the way they enter the preperitoneal space
TEP—totally extraperitoneal patch—a dissecting balloon is used to enter the preperitoneal space
without entering the peritoneal cavity
TAPP—transabdominal preperitoneal patch —they use standard trocars, Veress needle, or a cut-down
with the Hasson system

BREAST

• BREAST
The nipples are at the level of the 5th rib
Areola—this is the pigmented skin around the nipple
There are no muscles in the breast, but muscles lie under each breast and cover the ribs
• ARTERIAL BLOOD SUPPLY to the breast includes:
Internal thoracic
Lateral mammary
Intercostal

LYMPH GLANDS AND THE LYMPHATIC SYSTEM

• LYMPH NODES
Are found in the area of breast tissue, under the skin that leads into the axilla. The armpits have many
lymph glands, also known as lymph nodes
The lymph glands are part of the natural drainage system of the body called the lymphatic system. The
lymphatic system is made up of a network of lymph glands, connected throughout the body by tiny
vessels called lymph vessels
Lymph is a yellow fluid that flows through the lymphatic system and drains into veins. This helps to get
rid of waste products from the body and also is responsible for spreading malignant disease to other
organs of the body
• Lymphatics drain into two main areas:
AXILLARY NODES
INTERNAL THORACIC NODES (there are very few of these but they drain the inner half of the

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 breast)
• The most common forms of breast cancer are:
Intraductal carcinoma in-situ—originating from the ducts
Lobular carcinoma—originating from the lobules
• There is an increased risk if your mother, sister, or aunt had breast cancer (two or more people on your
mother’s side)
• MAMMOGRAM
This is the most common screening tool used today
Mammography and ultrasound are used to detect breast masses that are too small to detect on a clinical
examination
MAMMOGRAPHY is the study of the breast using x ray. The actual test is called a mammogram
Mammograms detect:
Abnormal densities (lumps/masses)
MICRO-CALCIFICATIONS—commonly found in intraductal carcinoma in-situ (they are course
calcium deposits). They appear on a mammogram as bright white tiny spots. More common in the
aged breast
• ULTRASOUND
Uses sound waves to make a picture of the tissue inside the breast. A breast ultrasound can show all
areas of the breast, including the area closest to the chest wall, which is hard to study with a
mammogram
A breast ultrasound is used to see whether a breast lump is filled with fluid (a cyst) or if it is a solid
lump. An ultrasound does not replace the need for a mammogram, but it is often used additionally to
check abnormal results from a mammogram
• DIGITAL STEREOTACTIC
This is performed after a mammogram/ultrasound to further diagnose a possible breast cancer
This is a minimally invasive procedure performed to locate and remove tissue from the tumor for
diagnosis. A needle is passed into the suspicious area in the breast and specimen is removed for the
pathologist
• MRI—MAGNETIC RESONANCE IMAGING
A breast MRI captures multiple images of your breast. Breast MRI images are combined using a
computer to generate detailed pictures
• POSITRON EMISSION TOMOGRAPHY (PET) SCAN
This is used to find out whether the cancer has spread to organs beyond the breast
• Terms used to describe the stages of breast cancer.
LOCAL—the cancer is confined within the breast
REGIONAL—the lymph nodes, primarily those in the armpit, are involved
DISTANT–the cancer is found in other areas of the body as well
• BRCA 1, BRCA 2 GENES—GENE TESTING

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 These are mutations in the genetic code of a gene that affects its function
• CORE BIOPSY—NEEDLE BIOPSY
A disposable cutting needle is introduced into the mass to core out a plug of tissue, the specimen is sent
to pathology for a diagnosis
• NEEDLE ASPIRATION
This is performed to aspirate fluid for diagnosis
• BREAST BIOPSY
Incisional biopsy—a portion of the mass is excised and sent to pathology
Excisional biopsy—the entire portion of the mass and surrounding normal tissue is removed
• LUMPECTOMY
This is removal of a mass with a margin of normal tissue included, to make sure they cleared all the
potential cancerous margins. Surgical clips are sometimes put in the spot where the specimen was
removed
• NEEDLE- WIRE LOCALIZATION
This procedure is performed when a mass is detected on a mammogram and is too small to palpate, or
the breasts are too dense. A biopsy is recommended
The patient goes to radiology and a wire is inserted into the mass under x-ray
• SENTINEL LYMPH NODE BIOPSY
The sentinel node chain is the first set of nodes closest to the cancerous tumor site. It is believed that
when cancer cells travel they settle in the first set of nodes
The sentinel node is not the same in every patient (because cancer tumors are not the same in every
patient)
Blue dye/isosulfan blue dye/Lymphazurin
Can be used alone to identify the sentinel nodes or it can be used with technetium 99—(this is a
radioactive dye.) This is injected in the nuclear medicine department
A gamma tracer probe is draped by the STSR and used like a Geiger counter to trace and follow the dye
to the sentinel node
• LYMPHEDEMA following breast surgery is caused by the excision of lymph nodes followed by radiation
therapy to the area. The lymphatic system works as a drainage system of fluid away from tissues back to
the heart. If too many lymph nodes are removed there is no drainage and the patients arm may fill with
fluid
• SUBCUTANEOUS MASTECTOMY
All breast tissue is removed and the skin and nipple are left intact
• SIMPLE MASTECTOMY
Removal of the entire breast without lymph node dissection
• MODIFIED RADICAL MASTECTOMY
The entire breast and axillary lymph nodes are removed
• RADICAL MASTECTOMY

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 Breast
Lymph nodes
Muscles—pectoralis major and minor

INCISIONS

• LAYERS OF THE ABDOMINAL WALL: INCLUDE:

Skin
Fascia (Camper’s and Scarpa’s)
Muscle—linea alba
Transversalis fascia
Extraperitoneal fat and
Peritoneum.
• VERTICAL INCISIONS
• MIDLINE INCISIONS
It offers good exposure to any part of the abdominal cavity
The incision can be extended from just below the sternal notch, around the umbilicus, back to the
midline and down to the symphysis pubis
• EPIGASTRIC INCISION
The incision is above the umbilicus to the xiphoid process at the midline
• SUBUMBILICAL INCISION
Below the umbilicus
• PARAMEDIAN INCISION
The paramedian is a vertical incision placed 2–4 cm laterally to the midline on either side of the upper
and lower abdomen

TRANSVERSE INCISION

• UPPER TRANSVERSE is used for the pancreas

• LOWER TRANSVERSE/PFANNENSTIEL
Used for access to the pelvic organs
Maylard and Cherney are also two lower transverse incisions.
Pfannenstiel/Maylard/Cherney—they are slightly different but all are used for access to pelvic organs
• SUBCOSTAL/KOCHER INCISION—the subcostal incision starts at the midline about 2–5 cm below
the xiphoid and can extend downward/outwards/or parallel to the costal margin
RIGHT SUBCOSTAL—biliary tract
LEFT SUBCOSTAL—spleen
• OBLIQUE INCISIONS—NEAR THE GROIN.
USED FOR INGUINAL HERNIA REPAIRS
THE INCISION IS THROUGH THE EXTERNAL OBLIQUE MUSCLE

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• MCBURNEY
THIS IS A TYPE OF OBLIQUE INCISION
USED FOR AN APPENDECTOMY
• THORACOABDOMINAL INCISION
ACCESS TO THE PLEURAL CAVITY
RIGHT CAN BE USED FOR A HEPATIC RESECTION
LEFT CAN BE USED FOR THE ESOPHAGUS, STOMACH, AND LIVER RESECTION

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 Questions

1. A Nissen fundoplication procedure is done to correct:

(A) repeated attacks of volvulus

(B) antireflux disease
(C) bladder prolapse
(D) gastroesophageal stenosis

2. A dissecting sponge that is a small roll of heavy cotton tape is a:

(A) Kittner
(B) peanut
(C) tonsil
(D) Both A and B

3. Peanuts and dissecting sponges are generally:

(A) used dry

(B) moistened with saline
(C) moistened with water
(D) moistened with antibiotic solution

4. Intra-abdominally, lap pads are most often used:

(A) dry
(B) moistened with saline
(C) moistened with water
(D) moistened with glycine solution

5. Specimens may be passed off the sterile field by the scrub person on all of the following items
EXCEPT:

(A) sponge
(B) towel
(C) basin
(D) paper

6. A catheter commonly used in a gastrostomy is a:

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 (A) mushroom
(B) Rehfuss
(C) Cantor
(D) Sengstaken–Blakemore

7. Before handing a Penrose drain to the surgeon,

(A) place it on an Allis clamp

(B) attach a safety pin to it
(C) cut it to the desired length
(D) moisten it in saline

8. The disposable circular staple designed to hold two tubular structures together after resection is known
as:

(A) TA linear
(B) LDS
(C) EEA
(D) GIA

9. Transduodenal sphincterotomy refers to the incision made into the ——— to relieve stenosis.

(A) cardiac sphincter

(B) ileocecal sphincter
(C) sphincter of Oddi
(D) pyloric sphincter

10. In surgery, cancer technique refers to:

(A) the administration of an anticancer drug directly into the cancer site
(B) the discarding of instruments coming in contact with tumor after each use
(C) the use of radiation therapy at the time of surgery
(D) the identification of the lesion

11. Why are gowns, gloves, drapes, and instruments changed following a breast biopsy and before incision
for a mastectomy?

(A) To respect individual surgeon’s choice

(B) To follow aseptic principles
(C) To accommodate two separate incisions
(D) To protect margins of healthy tissue from tumor cells

12. A postoperative complication attributed to glove powder entering a wound is:

(A) granulomata

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 (B) infection
(C) inflammation
(D) keloid formation

13. The correct procedure for sterile dressing application is:

(A) apply dressing after drape removal

(B) apply dressing before drape removal
(C) apply Raytec sponges in thick layer
(D) apply dressing in recovery room

14. When bowel technique for an intestinal procedure is utilized:

(A) two Mayo stands are used

(B) drapes and gloves do not need to be changed
(C) contaminated instruments are discarded, gloves are changed
(D) a separate setup is used for the closure

15. The Sengstaken–Blakemore tube is used for:

(A) esophageal hemorrhage

(B) tonsillar hemorrhage
(C) uterine hemorrhage
(D) nasal hemorrhage

16. Dark blood in the operative field may indicate that the patient is:

(A) hyperkalemic
(B) hypovolemic
(C) hypotensive
(D) hypoxic

17. The term transduodenal sphincterotomy indicates surgery of the:

(A) hepatic duct

(B) proximal end of the common bile duct
(C) distal end of the common bile duct
(D) pyloric sphincter

18. McBurney is an incision used for:

(A) appendectomy
(B) cholecystectomy
(C) herniorrhaphy
(D) pilonidal cystectomy

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19. The simplest abdominal incision offering good exposure to any part of the abdominal cavity is the:

(A) right subcostal

(B) Kocher’s
(C) midabdominal transverse
(D) vertical midline

20. During an appendectomy, a purse-string suture is placed around the appendix stump to:

(A) amputate the appendiceal base

(B) retract the appendix
(C) tie off the appendix
(D) invert the stump of the appendix

21. Gastrointestinal technique is required in all of the following procedures EXCEPT:

(A) cholecystectomy
(B) low anterior colon resection
(C) appendectomy
(D) hemicolectomy

22. A hernia occurring in Hesselbach’s triangle is called:

(A) indirect
(B) spigelian
(C) direct
(D) femoral

23. Pathologic enlargement of the male breast is called:

(A) subcutaneous adenoma

(B) gynecomastia
(C) hypoplasia
(D) cystic mastitis

24. Sutures placed in a wound to prevent wound evisceration are called:

(A) stent
(B) fixation
(C) retention
(D) traction

25. Surgical enlargement of the passage between the pre-pylorus of the stomach and the duodenum is a:

(A) duodenectomy
(B) pyloroplasty

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 (C) Billroth I
(D) Billroth II

26. A Whipple operation is surgically termed a:

(A) pancreatectomy
(B) pancreaticoduodenectomy
(C) pancreatic cyst marsupialization
(D) transduodenal sphincterotomy

27. A left subcostal incision indicates surgery of the:

(A) gallbladder
(B) pancreas
(C) spleen
(D) common bile duct

28. A lower oblique incision is a/an:

(A) Pfannenstiel
(B) inguinal
(C) paramedian
(D) midabdominal

29. The curved transverse incision used for pelvic surgery is:

(A) midabdominal transverse

(B) Poupart
(C) Pfannenstiel
(D) McVay

30. Which breast procedure removes the entire breast and axillary contents but preserves the pectoral
muscles?

(A) Lumpectomy
(B) Wedge resection
(C) Modified radical mastectomy
(D) Radical mastectomy

31. The breast procedure performed to remove extensive benign disease is a/an:

(A) axillary node dissection

(B) simple mastectomy
(C) radical mastectomy
(D) modified radical mastectomy

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32. What incision is indicated for an esophagogastrectomy?

(A) Left paramedian

(B) Upper vertical midline
(C) Thoracoabdominal
(D) Full midabdominal

33. In which incision could retention sutures be used?

(A) Vertical midline

(B) McBurney
(C) Transverse
(D) Thoracoabdominal

34. In which hernia is the blood supply of the trapped sac contents compromised and in danger of
necrotising?

(A) Direct
(B) Indirect
(C) Strangulated
(D) Reducible

35. In which hernia does the herniation protrude into the inguinal canal but NOT the cord?

(A) Incisional
(B) Femoral
(C) Direct
(D) Indirect

36. Which hernia leaves the abdominal cavity at the internal inguinal ring and passes with the cord
structures down the inguinal canal?

(A) Direct
(B) Umbilical
(C) Spigelian
(D) Indirect

37. In a cholecystectomy, which structures are ligated and divided?

(A) Cystic duct and cystic artery

(B) Common bile duct and hepatic duct
(C) Cystic duct and common bile duct
(D) Hepatic duct and cystic artery

38. All of the following statements refer to pilonidal cyst surgery EXCEPT:

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 (A) it is performed with an elliptical incision
(B) the wound frequently heals by granulation
(C) probes are required on setup
(D) the cyst is removed, but the tract remains

39. An important consideration during cholangiogram is to:

(A) irrigate with distilled water

(B) remove all air bubbles from the cholangiocath
(C) flash sterilize the choledocoscope
(D) dip the catheter in lubricating jelly

40. The intestinal layer in order, from inside to outside, is:

(A) serosa, mucosa, musculature

(B) mucosa, submucosa, serosa
(C) serosa, musculature, mucosa
(D) mucosa, serosa, musculature

41. A common postoperative patient complaint following a laparoscopic procedure is:

(A) headache
(B) diarrhea
(C) gastric upset
(D) shoulder pain

42. A subphrenic abscess occurs in the:

(A) pancreas
(B) spleen
(C) lung
(D) liver

43. Portal pressure measurement is indicated in:

(A) liver transplant

(B) splenectomy
(C) hepatic resection
(D) Whipple operation

44. Which organ is removed either because of trauma, a blood condition, or as a staging procedure for
malignancy?

(A) Adrenals
(B) Spleen

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 (C) Liver
(D) Pancreas

45. Following a hemorrhoidectomy,

(A) dry dressing of 4 × 4 s is packed in the rectum

(B) petroleum gauze packing is placed in the anal canal
(C) stent dressing is applied
(D) Steri-Strip dressing is used

46. Which term is used when requiring intraoperative X-rays during a cholecystectomy?

(A) Choledochoscopy
(B) Cholelithotripsy
(C) Choledochoduodenostomy
(D) Cholangiogram

47. In a pilonidal cystectomy, the defect frequently is too large to close and requires use of a/an:

(A) skin graft

(B) traction suture
(C) implant
(D) packing and pressure dressing

48. The instrument most commonly used to grasp the mesoappendix during an appendectomy is a:

(A) Kelly
(B) Kocher
(C) Babcock
(D) Allis

49. Vaporization and coagulation of hemorrhoidal tissue can be accomplished with:

(A) cautery, bipolar

(B) cautery, monopolar
(C) CO2 laser
(D) cryosurgery

50. An entire breast tumor/mass removal is termed:

(A) needle biopsy

(B) staging biopsy
(C) excisional biopsy
(D) incisional biopsy

51. Thrombosed vessels of the rectum are known surgically as:

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 (A) polyps
(B) hemorrhoids
(C) fistulas
(D) anorectal tumors

52. A procedure done to give the colon a rest and is then reversed is:

(A) temporary colectomy

(B) temporary colostomy
(C) abdominoperineal resection
(D) McVay procedure

53. A device that may obviate the need for an abdominoperineal resection because a low anterior
anastomosis can be performed is a/an:

(A) end-to-end anastomosis (EEA)

(B) GIA
(C) TA 55
(D) LDS

54. An advanced inflammation of the bowel could be conservatively treated with which procedure?

(A) Temporary colostomy

(B) Anterior resection
(C) Hemicolectomy
(D) Abdominal perineal resection

55. Blunt dissection of the gallbladder from the sulcus of the liver requires the use of a:

(A) Metzenbaum
(B) Kelly
(C) tampon
(D) peanut

56. Direct visualization of the common bile duct is accomplished with a:

(A) cholangiocath
(B) cholangiogram
(C) choledochoscope
(D) trocar

57. Fogarty biliary catheters are used to:

(A) drain the gallbladder

(B) drain the common bile duct

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 (C) instill contrast media
(D) facilitate stone removal

58. Bariatric surgery treats:

(A) ulcers
(B) obesity
(C) thyroid disease
(D) carcinoma of the pancreas

59. Which incision would require cutting through Scarpa’s fascia?

(A) Subcostal
(B) Inguinal
(C) Pfannenstiel
(D) McBurney

60. A gastroplasty:

(A) reduces stomach size

(B) corrects gastric junction stenosis
(C) releases adhesions
(D) provides avenue for hyperalimentation

61. Which item retracts the spermatic cord structure in herniorrhaphy?

(A) Army–navy retractor

(B) Penrose drain
(C) Green retractor
(D) Silk suture

62. An irreducible hernia whose abdominal contents have become trapped in the extra-abdominal sac is
called a/an:

(A) incarcerated hernia

(B) sliding hernia
(C) spigelian hernia
(D) strangulated hernia

63. Which type of endoscopy camera produces the truest color?

(A) One-chip
(B) Two-chip
(C) Three-chip
(D) Four-chip

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64. White balancing a video camera in endoscopy requires the scrub person to focus the camera on:

(A) a white sponge

(B) a white wall
(C) a glove wrapper
(D) Any of the above

65. Defogging the video camera is usually the responsibility of the:

(A) circulator
(B) surgeon
(C) scrub person
(D) camera operator

66. A palliative invasive procedure done to prevent malnutrition or starvation is known as:

(A) Roux-en-Y
(B) gastrotomy
(C) gastrostomy
(D) gastrojejunostomy

67. The use of noninvasive high-energy shock waves to pulverize gallstones into small fragments for easy
passage through the common bile duct and out of the body is called:

(A) choledochoscopy
(B) cholelithotripsy
(C) choledochostomy
(D) choledochotomy

68. Intraoperative cholangiograms can be performed either through open abdominal or laparoscopic
procedures using a contrast medium directly into the common bile duct through a:

(A) cystocath
(B) cholangiocath
(C) T-tube
(D) red rubber catheter

69. Intra-abdominal pressure during the instillation of CO2 for creation of pneumoperitoneum is 10–15
mm Hg. A pressure reading higher than this may indicate that the needle may be:

(A) buried in fatty tissue

(B) buried in the omentum
(C) in a lumen of intestines
(D) All of the above

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70. The proper method of removing the gallbladder specimen after complete dissection and irrigation of the
operative site in a laparoscopic cholecystectomy is to:

(A) utilize an Endobag

(B) pull gallbladder through the largest port
(C) decompress the gallbladder by suctioning bile before removal
(D) All of the above

71. During a laparoscopic cholecystectomy, the surgeon generally stands:

(A) at the right side of the patient

(B) at the bottom of the patient’s table
(C) at the left side of the patient
(D) in front of the first assistant

72. Gastrointestinal decompression during a general surgical procedure can be effected by the use of a:

(A) Levine tube

(B) Miller–Abbott tube
(C) Vari-Dyne
(D) Both A and B

73. A selected alternative to a conventional ileostomy that denies spontaneous stool exiting from the stoma
and requires catheterization of the stoma daily to evacuate the contents is a/an:

(A) cecostomy
(B) ileoanal pull-through
(C) ileal conduit
(D) Kock pouch

74. When both direct and indirect hernias occur in the same inguinal area, the defect is termed:

(A) sliding
(B) pantaloon
(C) femoral
(D) spigelian

75. An inguinal hernia containing a Meckel’s diverticulum is called a:

(A) Richter’s
(B) Littre’s
(C) Maydl’s
(D) spigelian

76. Drainage of an incision following a simple or modified radical mastectomy is accomplished by a:

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 (A) Penrose
(B) sump
(C) closed-wound drainage
(D) cigarette drain

77. During laparoscopic cholecystectomy, the camera operator usually stands

(A) across from the surgeon

(B) to the right of the surgeon
(C) to the right of the first assistant
(D) behind the Mayo stand

78. The maximum pressure allowed to prevent the possible intraoperative complications of bradycardia,
blood pressure changes, or potential gas emboli during a laparoscopic procedure is:

(A) 8 mm Hg
(B) 10 mm Hg
(C) 15 mm Hg
(D) 20 mm Hg

79. Place tissue layers of the abdominal wall in their correct order from the outside in: (1) fascia, (2) skin, (3)
peritoneum, (4) subcutaneous, (5) muscle.

(A) 1, 2, 3, 4, 5
(B) 2, 3, 4, 5, 1
(C) 2, 4, 1, 5, 3
(D) 3, 5, 1, 4, 2

80. What is the technique used on a laparoscopic direct inguinal hernia repair where the peritoneal space is
inflated with a balloon dissector?

(A) TEP (total extraperitoneal)

(B) Hasson
(C) TAPP (transabdominal preperitoneal laparoscopy)
(D) Open

81. When viscera have protruded outside of the body, this condition is called:

(A) dehiscence
(B) evisceration
(C) ischemia
(D) fistula

82. The position which facilitates a symmetrical outcome during a mastopexy is:

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 (A) supine
(B) dorsal recumbent
(C) Fowler’s
(D) lateral

83. Which breast reconstruction procedure reconstructs the breast without the use of implants?

(A) TRAM
(B) TEP
(C) PPE
(D) Augmentation

84. The procedure where a hooked wire is inserted under fluoroscopy into the suspicious tissue is called:

(A) a hook wire

(B) wire localization
(C) staging
(D) frozen section

85. What procedure involves injection of dye and/or a radioactive material into the breast mass to track the
lymph nodes?

(A) Stereotaxis
(B) Excisional biopsy
(C) Staging
(D) Sentinel node biopsy

86. What is the correct order from the outermost to the innermost tissue layers that make up the wall of the
stomach: (1) serosa, (2) mucosa, (3) muscularis, (4) submucosa.

(A) 1, 2, 3, 4
(B) 4, 3, 2, 1
(C) 3, 2, 1, 4
(D) 2, 3, 4, 1

87. The pancreatic duct (the duct of Wirsung) and the common bile duct from the liver drain their contents
into this section of the intestine:

(A) jejunum
(B) ileum
(C) cecum
(D) duodenum

88. A sheet of vascular tissue that supplies blood and lymph to the lower section of the small intestines is:

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 (A) omentum
(B) stoma
(C) mesentery
(D) cecum

89. Arrange the large intestine in correct order from proximal to distal is: (1) rectum, (2) transverse colon,
(3) ascending, (4) sigmoid, (5) descending.

(A) 1, 2, 3, 4, 5
(B) 3, 2, 5, 4, 1
(C) 2, 3, 4, 1, 5
(D) 2, 3, 4, 5, 1

90. A condition that causes bowel obstruction when one section of intestine telescopes over another and
most common in children is:

(A) evisceration
(B) Crohn’s disease
(C) gastroschisis
(D) intussusceptions

91. What kind of tube is used to decompress the stomach or as a means of feeding the patient?

(A) Nasogastric tube

(B) Esophageal tube
(C) Gastrostomy tube
(D) T-tube

92. During a laparotomy, the surgeon packs the abdominal contents away from the diseased area with:

(A) Raytec 4 × 4 s
(B) moist laps
(C) Gelfoam and thrombin
(D) Dry laps

93. During a laparotomy procedure, the duties of the STSR include:

(A) 4 × 4 s and needles must be kept on the back table

(B) keep the ESU free of debris and in its holster
(C) keep surgical field free of instruments not in use
(D) All of the above

94. An esophageal diverticulum is also known as:

(A) hiatal hernia

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 (B) GERD
(C) Hirschsprung disease
(D) Zenker’s diverticulum

95. In what procedure is a portion of the stomach removed with an anastomosis created between the
stomach and a jejunum?

(A) Billroth I
(B) Billroth II
(C) Jejunectomy
(D) Gastrectomy

96. The procedure traditionally performed to treat gastric ulcers and gastric carcinoma and is currently used
to treat morbid obesity is:

(A) Roux-en-Y
(B) band gastroplasty
(C) Billroth I
(D) None of the above

97. Morbid obesity is defined as BMI (body mass index) greater than:

(A) 30
(B) 40
(C) 10
(D) 25

98. A common staple gun used to transect the stomach is ______ and the ______ gun is used to transect
and anastomose the jejunum during a Billroth II procedure.

(A) EEA, LDS

(B) TA, GIA
(C) Hemaclip, GIA
(D) Purse-string, LDS

99. The portion of the small intestine where a Meckel’s diverticulum arises is the:

(A) duodenum
(B) jejunum
(C) pylorus
(D) distal ileum

100. Twisting of the bowel is known as:

(A) strangulation

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 (B) intussusception
(C) volvulus
(D) paralytic ileus

101. The procedure to treat venous distention causing pain, bleeding, and a prolapse outside the anal canal is
known as:

(A) anorectal fistulectomy

(B) pilonidal cystectomy
(C) hemorrhoidectomy
(D) proctoscopy

102. The pancreatic duct is also known as:

(A) ampulla of Vater

(B) duct of Wirsung
(C) sphincter of Oddi
(D) circle of Willis

103. Which tube may be inserted to produce a continuous postoperative drainage of the common bile duct?

(A) Nasogastric tube

(B) Levine tube
(C) T-tube
(D) Foley

104. A choledochoduodenostomy is an anastomosis between the:

(A) pancreas and common bile duct

(B) common bile duct and duodenum
(C) gallbladder and duodenum
(D) Both B and C

105. A Whipple procedure consists of removal of:

(A) pancreas, duodenum, jejunum, stomach, and common bile duct

(B) head of pancreas, duodenum, portion of jejunum, gallbladder, distal stomach, cystic duct and distal
portion of common bile duct
(C) duodenum, jejunum, distal stomach, and gallbladder
(D) head of pancreas, portion of liver, gallbladder, and common bile duct

106. The passageway for foods and liquids into the digestive system, and for air into the respiratory system, is
the:

(A) trachea

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 (B) larynx
(C) epiglottis
(D) pharynx

107. Which of the abdominal muscles originates at the pubic bone and ends in the ribs?

(A) Rectus abdominis

(B) Transversus abdominis
(C) External oblique
(D) Internal oblique

108. The spleen filters:

(A) antibodies
(B) tissue fluid
(C) lymph
(D) blood

109. The spleen is located:

(A) in the left hypochondriac region

(B) behind the liver
(C) behind the left kidney
(D) behind the right kidney

110. All of the following are parts of the lymphatic system EXCEPT the:

(A) thyroid
(B) tonsils
(C) spleen
(D) thymus

111. The S-shaped bend in the lower colon is called the:

(A) hepatic flexure

(B) splenic flexure
(C) rectum
(D) sigmoid

112. The reabsorption of water and electrolytes is the main function of the:

(A) sigmoid colon

(B) large intestine
(C) small intestine
(D) liver

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113. The terminal portion of the large intestine is the:

(A) sigmoid
(B) rectum
(C) anus
(D) anal canal

114. Which structure lies retroperitoneally?

(A) Sigmoid colon

(B) Spleen
(C) Liver
(D) Kidney

115. The first portion of the large intestine is the:

(A) sigmoid
(B) cecum
(C) colon
(D) ileum

116. The appendix is attached to the:

(A) ascending colon

(B) transverse colon
(C) cecum
(D) descending colon

117. The primary function of the gallbladder is:

(A) storage of bile

(B) production of bile
(C) digestion of fats
(D) drainage of the liver

118. When the gallbladder contracts, bile is ejected into the:

(A) liver
(B) duodenum
(C) jejunum
(D) pancreas

119. The area in the duodenum where the common bile duct and the pancreatic duct empty is called:

(A) the duct of Santorini

(B) the ampulla of Vater

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 (C) Wirsung duct
(D) the islet of Langerhans

120. Which structure is also known as the “fatty apron”?

(A) greater omentum

(B) lesser omentum
(C) mesentery
(D) falciform ligament

121. The common bile duct is the union of the:

(A) cystic duct and cystic artery

(B) cystic duct and hepatic duct
(C) cystic artery and hepatic duct
(D) hepatic vein and cystic duct

122. The yellow tinge in the skin symptomatic of obstructive jaundice is caused by the accumulation of what
substance in the blood and tissue?

(A) Cholesterol
(B) Bile salts
(C) Enzymes
(D) Bilirubin

123. The head of the pancreas is located:

(A) in the curve of the duodenum

(B) by the spleen
(C) on the undersurface of the liver
(D) in the curve of the descending colon

124. The sphincter at the junction of the small and large intestines is the:

(A) sphincter of Oddi

(B) ileocecal sphincter
(C) pyloric sphincter
(D) duodenal sphincter

125. The portion of the small intestine that receives secretions from the pancreas and the liver is the:

(A) ileum
(B) jejunum
(C) duodenum
(D) pylorus

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126. The region of the stomach that connects to the duodenum is the:

(A) fundus
(B) body
(C) pylorus
(D) cardia

127. The mesentery is:

(A) a double-layered peritoneal structure shaped like a fan

(B) a word synonymous with “fatty apron”
(C) the membrane covering the surface of most abdominal organs
(D) a structure that supports the sigmoid colon

128. The large central portion of the stomach is called the:

(A) pylorus
(B) body
(C) fundus
(D) cardia

129. The muscle serving as a valve to prevent regurgitation of food from the intestine back into the stomach
is known as the:

(A) sphincter of Oddi

(B) ileocecal sphincter
(C) cardiac sphincter
(D) pyloric sphincter

130. The digestive passageway that begins at the pharynx and terminates in the stomach is the:

(A) larynx
(B) trachea
(C) windpipe
(D) esophagus

131. The point at which the esophagus penetrates the diaphragm is called the:

(A) hiatus
(B) meatus
(C) sphincter
(D) fundus

132. The liver has:

(A) two lobes

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 (B) three lobes
(C) four lobes
(D) five lobes

133. The cell saver is contraindicated for:

(A) the cancer patient where the tumor is resected en-bloc

(B) if avitene is used
(C) orthopedic procedures
(D) diabetic patients

134. An enteroscopy is the scoping of the:

(A) large intestine

(B) small intestine
(C) sigmoid
(D) stomach

135. Chronic gastroesophageal reflux disease can cause:

(A) dysphasia
(B) aspiration
(C) Barrett’s esophagus
(D) All of the above

136. Cellular changes of the mucosal lining of the distal esophagus that is known to be a precursor for
esophageal cancer is termed:

(A) Meckel’s diverticulum

(B) Zenker’s diverticulum
(C) Barrett’s esophagus
(D) GERD

137. The Ligament of Treitz supports:

(A) ascending colon and transverse colon

(B) duodenum and jejunum
(C) transverse colon and decending colon
(D) splenic flexure and hepatic flexure

138. A hiatal hernia is also termed:

(A) diaphragmatic
(B) pantaloons
(C) Meckel’s

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 (D) direct

139. The procedure performed for an esophageal diaphragmatic hernia is termed:

(A) TAPP
(B) laparoscopic Nissen fundoplication
(C) McVay
(D) Bassini

140. A balloon catheter that is inserted into the esophagus and into the stomach and provides pressure to
control bleeding from esophageal varices is termed:

(A) Bougie
(B) Bakes
(C) Sengstaken–Blakemore
(D) Hank

141. What procedure is performed to reduce gastric secretions?

(A) Total gastrectomy

(B) Percutaneous endoscopic gastrostomy
(C) Both A and B
(D) Vagotomy

142. All are true regarding a pyloromyotomy EXCEPT:

(A) it is more common in infants and the symptoms are projectile vomiting
(B) it is performed for treatment of peptic ulcers and removal of bands around the pyloric ring that
relieves spasms and permits emptying of the stomach
(C) establishes a permanent connection between the anterior and posterior portion of the stomach and
the jejunum without removing any portion of the GI tract
(D) special equipment includes an NG tube

143. All are true regarding placement of a PEG tube EXCEPT:

(A) a PEG tube uses a flexible gastroscope for placement through the abdominal wall
(B) it is used for internal feedings
(C) moderate sedation or local is used
(D) this can be performed in the endoscopy suite, the operating room or the patient’s bedside

144. Adhesions are caused by all EXCEPT:

(A) radiation
(B) previous surgeries
(C) foreign body reaction

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 (D) too much irrigation

145. Billroth I is a resection of the diseased portion of the:

(A) stomach with anastomosis between the stomach and duodenum

(B) stomach with anastomosis between the stomach and jejunum
(C) proximal duodenum with anastomosis between distal duodenum and jejunum
(D) stomach and distal esophagus

146. The common hepatic duct becomes the common bile duce when the common hepatic duct joins the:

(A) hepatic artery

(B) cystic artery
(C) cystic duct
(D) hepatic vein

147. The retractor used to life the edge of the liver is:

(A) Harrington
(B) Senn
(C) Sweetheart
(D) Both A and C

148. The instrument used to extend the CBD incision is (blank). (Blank) are used to remove stones from the
CBD. (Blank) arte used to dilate the common bile duct. And (blank) is used to drain the CBD

(A) Potts, Randal, Bakes, T-tube

(B) Potts, Bakes, Randal, T-tube
(C) Metz, Pennington, Hagar, Red Robinson
(D) Metz, Bakes, van Buren, T-tube

149. The procedure performed to drain the common bile duct is called a:

(A) choledochotomy
(B) cholecystectomy
(C) choledochoduodenotomy
(D) None of the above

150. All are true regarding bariatric surgery EXCEPT:

(A) performed for obesity

(B) procedure reduces the size of the stomach
(C) is also called a lap band
(D) performed for BMI below 25

151. All are true regarding the liver EXCEPT:

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 (A) located in the left upper quadrant
(B) produces bile
(C) is encased by Glisson’s capsule
(D) right and left lobes are divided by falciform

152. What instrument is used to obtain a liver biopsy?

(A) Silverman needle

(B) Tru-Cut needle
(C) Both A and B
(D) Blunt needle

153. Hodgkin’s disease and sickle cell disease patients may require:

(A) hepatectomy
(B) splenectomy
(C) pancreatectomy
(D) cholecystectomy

154. Which hernia occurs between the muscle layers of the abdomen and is difficult to diagnose?

(A) Richter’s
(B) Maydl’s
(C) Bassini
(D) Spigelian

155. Which type of hernia involves the stomach protruding through the diaphragm?

(A) Hiatal
(B) Diaphragmatic
(C) Both A and B
(D) Spigelian

156. The mesh used to repair a hernia is made of:

(A) Gore-Tex
(B) Prolene
(C) Teflon
(D) All of the above

157. When doing a cut-down procedure for laparoscopic surgery, which type of trocar and cannula system is
used?

(A) TEP
(B) TAPP

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(C) Hasson
(D) None of the above

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 Answers and Explanations

1. (B) An antireflux procedure, which prevents reflux of gastric juices back into the esophagus. The three
most frequently performed procedures are Nissen, Hill, and Belsy Mark IV.

2. (D) Kittner and peanuts are dissecting sponges that are small rolls of heavy cotton tape that are held in
forceps/clamps.

3. (B) Peanuts are moistened with saline and pressed out flat on a metal surface.

4. (B) Normal saline is usually used to moisten sponges because it is an isotonic solution.

5. (A) Specimen may be passed from the field in a basin, on a piece of paper wrapper, or on a towel. Never
place specimen on a sponge that may leave the OR and disrupt the sponge count.

6. (A) Mushroom, Malecot, or Foley catheters are frequently used in the anterior gastric wall and are held
in place by a purse-string suture.

7. (D) Moisten the drain in saline before handing it to the surgeon.

8. (C) The end-to-end anastomosis stapler, the (EEA) is designed to hold two tubular structures, to join
the structures with staples, and to cut the structures internally so proper lumen is provided.

9. (C) The sphincter of Oddi is located at the most distal end of the ampulla of Vater. It may become
scarred because of biliary obstruction, stones, or disease. Transecting the duodenum at the site of the
sphincter allows the surgeon to reduce the stenosis and encourage the flow of bile and pancreatic juices
into the gastrointestinal system.

10. (B) To minimize the risk of disseminating malignant tumor cells outside the operative area, some
surgeons follow a special technique in which instruments in contact with tumor cells are discarded after
use.

11. (D) Gown, gloves, drapes, and instruments are changed. The tumor is incised during biopsy for
diagnosis. However, margins of healthy tissue surrounding a radical resection must not be inoculated
with tumor cells.

12. (A) The postoperative complication of powder granulomata can result from powder that is not properly
removed from gloves before surgery. This can be avoided by rinsing gloves before approaching the
operative site.

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13. (B) Sterile dressings should be applied before drapes are removed to reduce risk of the incision being
touched by contaminated hands or objects.

14. (C) In bowel technique, the contaminated instruments are discarded in a single basin. Gloves (and
possibly gowns) are changed by the surgical team, and the incisional area is redraped with clean towels.

15. (A) A Sengstaken–Blakemore tube is used to control esophageal hemorrhage. Pressure is exerted on the
cardiac portion of the stomach and against bleeding esophageal varices by a double balloon tamponade.

16. (D) Hypoxia is lack of adequate amounts of oxygen; if prolonged, it can result in cardiac arrhythmia or
irreversible brain, liver, kidney, and heart damage. The treatment is immediate adequate oxygen intake
to stimulate the medullary centers and prevent respiratory system failure. Dark blood on the operative
field is a symptom of hypoxia.

17. (C) The distal end of the common bile duct is called the sphincter of Oddi and is located where the duct
enters the duodenum. A transduodenal sphincterotomy is done to treat recurrent attacks of pancreatitis.
It is at this junction that the pancreatic duct enters and can be obstructed because of obstruction of the
common bile duct.

18. (A) The McBurney muscle-splitting incision is used for appendix removal. It is an 8-cm oblique incision
that begins well below the umbilicus, goes through McBurney’s point, and extends upward toward the
right flank.

19. (D) The vertical midline is the simplest abdominal incision to perform. It is an excellent primary incision
offering good exposure to any part of the abdominal cavity.

20. (D) A purse-string is a continuous suture placed around the lumen of the appendiceal stump to invert it.
It is tightened, drawstring fashion, to close the lumen.

21. (A) whenever a portion of the gastrointestinal tract is entered, gastrointestinal technique must be carried
out. Any instrument used after the lumen of the stomach or intestines has been entered cannot be used
after it is closed. A cholecystectomy does not enter the gastrointestinal tract. An appendectomy,
hemicolectomy, and an anterior resection of the sigmoid all require bowel technique.

22. (C) Hesselbach’s triangle is formed by the boundaries of the deep epigastric vessels laterally, the inguinal
ligament inferiorly, and the rectus abdominis muscle medially. Hernias occurring here are direct.

23. (B) Gynecomastia is a relatively common pathologic lesion that consists of bilateral or unilateral
enlargement of the male breast. Surgery consists of removal of all subareolar fibroglandular tissue and
surgical reconstruction of the resultant defect.

24. (C) Retention sutures may be used as a precautionary measure to prevent wound disruption and possible
evisceration of the wound.

25. (B) Pyloroplasty is the formation of a larger passage between the pylorus of the stomach and the

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 duodenum. It may include the removal of a peptic ulcer if one is present.

26. (B) A Whipple operation or pancreaticoduodenectomy is a radical surgical excision of the head of the
pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower
half of the common bile duct. There is then reestablishment of continuity of the biliary, pancreatic, and
gastrointestinal systems. This is done for carcinoma of the head of the pancreas and is a hazardous
procedure.

27. (C) A left subcostal incision is generally used for spleen surgery. The right subcostal is used for
gallbladder, common bile duct, and pancreatic surgery.

28. (B) A lower oblique incision, either right or left, is an inguinal incision. This incision gives access to the
inguinal canal and cord structures.

29. (C) The Pfannenstiel incision is frequently used for pelvic surgery. It is a curved transverse incision
across the lower abdomen, 1.5 in above the symphysis pubis. It provides a strong closure.

30. (C) A modified radical mastectomy involves removal of the involved breast and all three levels of axillary
contents. The underlying pectoral muscles are not removed.

31. (B) Simple mastectomy is removal of the entire breast without lymph node dissection, performed to
remove extensive benign disease or a confined malignancy.

32. (C) The diseased portion of the esophagus and stomach are removed through a left thoracoabdominal
incision, including a resection of the seventh, eighth, or ninth ribs. Here, an anastomosis is
accomplished between the disease-free ends of the stomach and the esophagus.

33. (A) Retention or tension sutures may be used in a vertical midline incision to ensure strength of closure
and support.

34. (C) The great danger of an incarcerated hernia is that it may become strangulated—the blood supply of
the trapped sac contents becomes compromised, and eventually the sac contents necrose.

35. (C) Direct hernias protrude into the inguinal canal but not into the cord.

36. (D) Indirect hernias leave the abdominal cavity at the internal ring and pass with the cord structures
down the inguinal canal, thus the indirect hernia sac may be found in the scrotum.

37. (A) In cholecystectomy there is exposure of the neck of the gallbladder, the cystic duct, and the cystic
artery. The cystic artery and duct are doubly ligated and divided, facilitating gallbladder removal.

38. (D) In a pilonidal cystectomy, the cyst and sinus tract must be completely removed to prevent
recurrence.

39. (B) A cholangiocatheter is prepared using a 20-cc syringe of saline and a 20-cc syringe of contrast

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 medium using a stopcock and Luer lock ports. All air bubbles are removed because they may be
misinterpreted as gall stones on x-ray. The cholangiocath is irrigated with saline before and during the
catheter insertion into the cystic duct and CBD.

40. (B) The layers of the large intestine from inside to outside are mucosa, submucosa, and serosa. Mucosa
suture closure is most frequently absorbable suture, while the serosa layer is closed with non-absorbable
silk.

41. (D) Postoperative shoulder pain may follow use of pneumoperitoneum. This is referred pain caused by
pressure on the diaphragm, which is somewhat displaced by CO2 during the procedure.

42. (D) A subphrenic abscess is a liver abscess that may require incision and drainage.

43. (C) For hepatic resection, supplies, and equipment should be available for hypothermia, electrosurgery,
measurement of portal pressure, thoracotomy drainage, and replacement of blood loss.

44. (B) Splenectomy is removal of the spleen, usually performed for trauma to the spleen, for specific
conditions of the blood such as hemolytic jaundice or splenic anemia, or for tumors, cysts, or
splenomegaly.

45. (B) Petroleum gauze packing is placed in the anal canal. A dressing and a T-binder are applied.

46. (D) An intraoperative cholangiogram is usually performed in conjunction with cholecystectomy to

visualize the common bile duct and the hepatic ductal branches and to assess patency of the common
bile duct.

47. (D) The defect resulting from recurrences may become too large for primary closure. In this case, the
wound is left opened to heal by granulation. The wound is packed and a pressure dressing is applied.

48. (C) After the abdomen is opened through a McBurney’s incision, the mesoappendix is grasped with a
Babcock and the appendix is gently dissected away from the cecum.

49. (C) The CO2 laser may be used for vaporization and coagulation of hemorrhoidal tissue.

50. (C) In an excisional biopsy, the entire tumor mass is excised. In a needle biopsy, a plug of tissue is
removed. In an incisional biopsy, a portion of the mass is excised.

51. (B) Varicosities of veins in the anus and rectum are called hemorrhoids. They may occur externally or
internally. They must be ligated and ligatured after the sphincter of the anus is dilated.

52. (B) A temporary colostomy is performed to decompress the bowel or give the bowel a rest and time to
heal after inflammation.

53. (A) A low colon lesion may require an abdominoperineal resection and colostomy. The EEA (end-to-
end anastomosis) is a stapling device that allows a very low anastomosis and thus avoids a colostomy.

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54. (A) Advanced inflammation of the colon is frequently treated with a temporary colostomy, often done to
decompress the bowel or give the bowel a rest.

55. (D) Blunt dissection, using a Kittner or peanut, is employed when removing the gallbladder from the
infundibulum up to the fundal region.

56. (C) Choledochoscopy is direct visualization of the common bile duct by means of an instrument
(choledochoscope) introduced into the common bile duct. This takes the place of cholangiography in
difficult cases.

57. (D) A Fogarty-type balloon-tipped catheter is used to facilitate the removal of small stones and debris as
well as to demonstrate patency of the common bile duct through the duodenum.

58. (B) Morbid obesity and bariatric surgery have been developed for people who weigh more than 100 lb
over ideal weight.

59. (B) The groin area contains the superficial group of muscles, the obliques, and Scarpa’s fascia. An
inguinal herniorrhaphy requires incision of Scarpa’s fascia.

60. (A) A gastroplasty treats obesity by resecting the stomach to reduce its capacity.

61. (B) A Penrose drain is used to retract the spermatic cord structures for better exposure.

62. (A) An irreducible hernia is one in which the contents of the hernia sac are trapped in the extra-
abdominal sac is called incarcerated.

63. (C) With a three-chip camera, each chip picks up only one of the primary colors. Since each chip sees
the entire image, there is no need to infer the color that should appear on the screen. Three-chip
cameras provide truer color.

64. (D) To balance a video camera, the scrub person must focus the camera on a white wrapper, wall, or
sponge to create a fixed point of reference for all other colors.

65. (C) Fogging occurs when the light going through the scope warms the air between the eyepiece and the
coupler and causes trapped air to evaporate. To avoid fogging, the scrub person must make sure that the
entire area is dry before assembling and uses an antifogging agent on the lens.

66. (C) Gastrostomy is a palliative procedure performed to prevent malnutrition or starvation. These may be
caused by a lesion or stricture situated in the esophagus or cardia of the stomach.

67. (B) Cholelithotripsy is a noninvasive procedure done generally under IV sedation using spark-gap
shockwaves generated by an electrode and passed on through the fluid medium into the body focused at
the stone with an ultrasound probe until they reach the stone.

68. (B) T-tubes are used to stent a common bile duct after common duct exploration. Red rubber catheters

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 can be used to irrigate postoperatively. Cholangiocaths are plastic catheters used to insert dye into the
common bile duct before x-ray or fluoroscopy.

69. (D) Gas flow is initiated at 1–2 l/min. The intra-abdominal pressure is normally in the 10–14 mm Hg
range and is used as an indicator for proper Veress needle placement. If the gauge indicates a higher
pressure, the needle may be in a closed space such as fat, buried in omentum, or in a lumen of intestines.

70. (D) Following irrigation of the liver bed, the scope and camera are moved to the upper midline sheath.
Large grasping forceps are inserted into the umbilical sheath, and the gallbladder is pulled through. An
Endobag may be used to contain the specimen. If the gallbladder is too large to be extracted, the neck is
brought to the surface, incised, and decompressed with a suction before removal.

71. (C) The surgeon performing the laparoscopic procedure stands at the patient’s left, while his or her
assistant stands at the patient’s right.

72. (D) Both the Levine tube and the Miller–Abbott tube effect gastrointestinal decompression. The Levine
tube is placed through the nasal passageway into the stomach, while the Miller–Abbott tube reaches
into the small intestines.

73. (D) An alternative to a conventional ileostomy for selected patients is the Kock pouch, or continent
ileostomy. The internal pouch is constructed of small intestine with an outlet to the skin. When it is
functioning properly, no stool spontaneously exits from the stoma. A catheter is inserted several times a
day to evacuate the contents.

74. (B) When both direct and indirect hernias are present in the same patient, the defect is called a
pantaloon hernia after the French word for pant, which the situation suggests.

75. (B) An inguinal hernia containing Meckel’s diverticulum is called Littre’s hernia; one containing two
loops of bowel is called Maydl’s hernia. A special type of strangulated hernia is Richter’s hernia. A
spigelian hernia is usually located as a peritoneal sac that is between the different muscle layers of the
abdominal wall.

76. (C) Following meticulous hemostasis of the operative site, the wound is irrigated with normal saline, and
closed wound drainage is instituted through a stab wound and secured to the skin with nonabsorbable
suture and a cutting needle.

77. (C) The camera operator stands to the right of the first assistant, across from the scrub person. He or she
must closely follow the surgeon’s actions.

78. (C) During the procedure, the perioperative nurse should set the insufflation unit to a maximum
pressure of 15 mm Hg. When intra-abdominal pressure reaches 15 mm Hg, the flow will stop. Pressure
higher than 15 mm Hg may result in bradycardia, a change in blood pressure, or may force gas emboli
into an exposed blood vessel during the procedure.

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79. (C) The correct order from the outside in is the skin, subcutaneous tissue, fascia, muscle, and
peritoneum.

80. (A) TEP approach to the peritoneal space is when a balloon dissector is used to expand tissue planes.

81. (B) Evisceration is when the viscera have protruded outside of the body.

82. (C) The Fowler’s position assists the physician with assuring symmetrical breasts.

83. (A) A transverse rectus abdominus myocutaneous (TRAM) flap is a tissue flap containing skin,
subcutaneous, and muscle, and is raised from the lower abdomen and transferred to the mastectomy
site.

84. (B) A wire localization is a procedure where a hooked wire is inserted under fluoroscopy into the tissue
suspected of being cancerous. The tissue surrounding the hook wire is removed.

85. (D) During a sentinel node biopsy, both materials, the dye and the gamma ray emission, may be used to
track the lymph nodes. The technetium 99 is tracked with a device similar to a Geiger counter (gamma
ray detecting probe).

86. (A) The correct order from outermost to innermost layers of the stomach are the serosa, mucosa,
muscularis, and submucosa.

87. (D) The duodenum is the first section of the small intestines and the pancreatic and common bile duct
drain here from the liver.

88. (C) The sections of the duodenum and jejunum are suspended from the abdominal wall by a sheet of
vascular tissue known as the mesentery.

89. (B) The large intestine from proximal to distal is ascending, transverse, descending, sigmoid, rectum.

90. (D) Intussusception is a condition that causes bowl obstruction because one section of intestine
telescopes another.

91. (A) A nasogastric tube is used to decompress the stomach or as a means of feeding the patient.

92. (B) Moist lap pads are used to pack the abdominal contents away from the diseased area of the bowel.

93. (D) All of the above are proper techniques.

94. (D) An esophageal diverticulum, sometimes called Zenker’s diverticulum is mucosa and submucosa that
have herniated through the cricoid pharyngeal muscles. Food particles become temporarily trapped and
cause problems.

95. (B) In a Billroth II, a portion of the stomach is removed and an anastomosis is created between the
stomach and the jejunum.

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 96. (A) A Roux-en-Y is done to bypass the distal stomach and reestablish continuity from the stomach to
the jejunum. A large portion of the stomach is bypassed and a gastric pouch is created.

97. (B) When the BMI is at least 40, this condition is known as morbid obesity. BMI is a formula of weight
and height calculated by a specific formula.

98. (B) The TA is used to staple the stomach and the GIA is used to transect and anastomose the jejunum
during the Billroth II.

99. (D) The Meckel’s diverticula occur at the distal ileum. It arises from a congenital remnant of the
umbilical duct.

100. (C) Twisting of the bowel is known as a volvulus.

101. (C) Hemorrhoids is defined as venous distention causing pain, bleeding, and a prolapse outside the anal
canal.

102. (B) The duct of Wirsung is the central duct of the pancreas. It communicates with the duodenum at the
ampulla of Vater, a location shared with the common bile duct.

103. (C) A T-tube is inserted to produce continuous drainage of bile following a common duct exploration.

104. (B) A choledochoduodenostomy is an anastomosis between the common bile duct and the duodenum.

105. (B) A Whipple involves removal of the head of the pancreas, duodenum, portion of jejunum, distal
stomach, and the distal portion of the common bile duct.

106. (D) The muscular pharynx serves as a passageway for food and liquids into the digestive tract. It is also
the path for air into the respiratory system. The throat runs from the nares and runs partway down the
neck, where it opens into the esophagus (posterior) and the larynx (anterior).

107. (A) On the anterior portion of the abdominal wall, the rectus abdominis forms a strap-like mass of
muscle. It runs from the pubic bone at the floor of the abdominal cavity straight up to the xiphoid
process of the sternum and the lower margins of the rib cage.

108. (D) The spleen is an organ containing lymphoid tissue designed to filter blood. It is frequently damaged
in abdominal trauma, causing it to rupture. This causes severe hemorrhage, which requires prompt
splenectomy.

109. (A) The spleen is located in the upper left hypochondriac region of the abdomen and is normally
protected by the rib cage. It is between the fundus of the stomach and the diaphragm.

110. (A) Lymph, lymph vessels, lymph nodes, tonsils, the thymus, and the spleen make up the lymphatic
system. Its function is to drain protein-containing fluid that escapes from the blood capillaries from the
tissue spaces. It also transports fats from the digestive tract to the blood.

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111. (D) The S-shaped bend where the colon crosses the brim of the pelvis and enters the pelvic cavity
(where it becomes the rectum) is the sigmoid colon. It begins at the left iliac crest, projects toward the
midline, and terminates at the rectum.

112. (B) The large intestine has little or no digestive function. It serves to absorb water and electrolytes. It
also forms and stores feces until defecation occurs.

113. (D) The narrow, distal part of the large intestine is called the anal canal. The rectum is the last 8 in of
the gastrointestinal tract. The terminal 2 in is the anal canal.

114. (D) Some organs lie on the posterior abdominal wall and are covered by peritoneum on the anterior
surface only. Such organs, including the kidney and pancreas, are said to be retroperitoneal.

115. (B) The beginning (proximal) portion of the large intestine is the cecum. It hangs below the ileocecal
valve. It is a blind pouch 2.5 in long.

116. (C) To the cecum is attached a small blind tube known as the appendix. It is a twisted, coiled tube, 3 in
in length.

117. (A) The gallbladder stores bile between meals and releases it when stimulated by gastric juice, fatty
foods, and the hormone cholecystokinin. Bile is produced in the liver. The gallbladder stores and
concentrates bile.

118. (B) When the gallbladder contracts, it ejects concentrated bile into the duodenum. Bile is forced into the
common bile duct when it is needed.

119. (B) Pancreatic juice leaves the pancreas through the pancreatic duct, the duct of Wirsung. The
pancreatic duct unites with the common bile duct from the liver and gallbladder and enters the
duodenum in a small raised area called the ampulla of Vater.

120. (A) The greater omentum is the largest peritoneal fold and hangs loosely like a “fatty apron” over the
transverse colon and coils of the small intestine.

121. (B) The hepatic duct joins the slender cystic duct from the gallbladder to form the common bile duct.
The common bile duct and the pancreatic duct enter the duodenum in a common duct, the
hepatopancreatic.

122. (D) The bile pigments, bilirubin, are products of red blood cell breakdown and are normally excreted in
bile. If their excretion is prevented, they accumulate in the blood and tissues, causing a yellowish tinge
to the skin and other tissues. This condition is called obstructive jaundice.

123. (A) The pancreas is an oblong, fish-shaped gland that consists of a head, tail, and body. The head rests
in the curve of the duodenum, and its tail touches the spleen. It is linked to the small intestine by a
series of ducts.

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124. (B) The ileocecal sphincter or valve joins the large intestine to the small intestine.

125. (C) The duodenum receives secretions from the pancreas and the liver. The duodenum originates at the
pyloric sphincter and extends 10 in, where it merges with the jejunum.

126. (C) The pylorus is the region of the stomach that connects to the duodenum.

127. (A) A broad fan-shaped fold of peritoneum suspending the jejunum and the ileum from the dorsal wall
of the abdomen is the mesentery.

128. (B) The stomach has four main regions: cardia, fundus, body, and pylorus. The large central portion is
the body.

129. (D) At the end of the pyloric canal, the muscular wall is thickened, forming a circular muscle called the
pyloric sphincter. Pyloric stenosis is a narrowing of the pyloric sphincter, which prevents food from
passing through.

130. (D) The esophagus is a straight, collapsible tube about 10 in long. It lies behind the trachea. It pierces
the diaphragm at the esophageal hiatus.

131. (A) The esophagus penetrates the diaphragm through an opening, the esophageal hiatus, which then
empties into the stomach.

132. (A) The liver is the largest gland in the body. It is divided into left and right segments or lobes. It is
located under the diaphragm. Bile is one of its chief products.

133. (B) The cell saver is not used on procedures where avitene is used because it cannot always be washed
out of the cells. This can cause DIC or ARDS. It is beneficial to use with cancer patients but only when
the cancer is resected en-bloc. It can be used on orthopedic procedures and patients with diabetes.

134. (B) Enteroscopy is the scoping of the small intestines. A colonoscopy is scoping of the large intestines. A
sigmoidoscopy is scoping of the sigmoid colon.

135. (D) Chronic GERD can cause dysphasia, aspiration and Barrett’s esophagus.

136. (C) Barrett’s esophagus is a condition caused by GERD. It is cellular changes in the mucosal lining of
the distal esophagus. A Meckel’s diverticulum is an out pouching of the distal ileum and a Zenker’s is
an out pouching in the esophagus.

137. (B) The ligament of Treitz supports the duodenal jejunal flexure and is also used as a surgical landmark
for the end of the duodenum and the beginning of the jejunum.

138. (A) Diaphragmatic hernia is also termed hiatal/esophageal hernia. A pantaloons hernia is both a direct
and indirect hernia. A Meckel’s is a diverticulum in the distal ileum. A direct hernia occurs in
Hesselbach’s triangle.

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139. (B) Laparoscopic Nissen fundoplication is a procedure used to repair a diaphragmatic hernia. A TAPP
hernia repair is a laparoscopic hernia repair. McVay and Bassini are also types of inguinal hernia repairs.

140. (C) Sengstaken–Blakemore tube is used to insert pressure in the esophagus. Bougie dilators are used to
dilate the esophagus. Bakes dilators are used to dilate the common bile duct. Hank dilators are used to
dilate the cervix.

141. (D) A vagotomy is performed to reduce gastric secretions in patients with duodenal ulcers. A
gastrectomy is removal of the stomach. A PEG tube is used for gastric decompression and external
feedings.

142. (C) A gastrojejunostomy is performed for a benign obstruction or an inoperable tumor. It creates a
permanent connection between the stomach and jejunum without removing any part of the distal
stomach of duodenum.

143. (B) A PEG tube is used for external feedings.

144. (D) Adhesions can be caused by radiation, PID, Crohn’s disease, abdominal surgeries and a reaction to a
foreign body.

145. (A) Billroth I is a resection for a diseased portion of the stomach and the anastomosis is between the
distal stomach and duodenum. A Billroth II is resection of diseased portion of the distal stomach with
anastomosis of stomach to jejunum.

146. (C) The hepatic duct joins with the cystic duct to form the common bile duct.

147. (D) The Harrington is also called the sweetheart. They are commonly used to retract the liver. A Senn
retractor is a small rake retractor.

148. (A) A Potts scissor is used to extend the CBD incision, Randal stone forceps are used to remove stones
from the CBD, Bakes dilators are used to dilate the CBD, and a T-tube is used to drain the CBD.

149. (A) The procedure performed to drain the CBD is called a choledochotomy, cholecystectomy is removal
of the gallbladder, and a choledochoduodenostomy is an anastomosis between the CBD and the
duodenum.

150. (D) The patient must have a BMI of 40 or greater to be approved for the surgery. Bariatric surgery is
performed for morbid obesity. The stomach is reduced in size. A lap band is an example of a procedure
performed.

151. (A) The liver is located in the left upper quadrant. It produces bile and is covered by Glisson’s capsule
and the right and left lobes are divided by the falciform ligament.

152. (C) A Silverman and a Tru-Cut needle can be used for liver biopsies. A blunt needle is used when
suturing the liver.

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153. (B) Splenectomy is performed for Hodgkin’s disease and sickle cell anemia. A hepatectomy is removal of
the liver. Pancreatectomy is removal of the pancreas and a cholecystectomy is removal of the
gallbladder.

154. (D) A spigelian hernia occurs between the muscles of the abdomen. A Maydl hernia involves two loops
of bowel. A Bassini is a hernia repair. The Richter hernia is a strangulated hernia.

155. (C) A hernia where the stomach protrudes through the diaphragm is a hiatal hernia which is also called
a diaphragmatic hernia. A spigelian hernia occurs between two muscle layers in the abdomen.

156. (D) Mesh materials include Gore-Tex, Teflon, Dacron, Marlex, and Prolene.

157. (C) A cut-down procedure is used when using a Hasson trocar. A TEP is a laparoscopic hernia repair
using the balloon preperitoneal dissector. A TAPP is a laparoscopic hernia repair.

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 ___________________ CHAPTER 19 ___________________

Obstetrics and Gynecology

• Skene’s glands/periurethral glands—located on the anterior wall of the vagina. They drain into the urethra
• Bartholin’s glands—they are glands located at the lower end of the vagina they secrete a fluid that
lubricates the vulva
• Marsupialization of Bartholin’s cyst—performed for obstruction of the Bartholin’s gland
• Marsupialization—this refers to the type of closure used. The cyst is opened, an I&D is performed and the
edges are sutured to the edges of the incision
• The uterus is lined with a membrane called the endometrium. When a woman does not become pregnant,
the lining is shed, resulting in a woman’s period (menstruation)
• The uterine tube (fallopian tube) carries an egg from the ovary to the uterus. At the end of the tube is
fimbria. They are finger like projections that help guide the egg into the fallopian tube
• Ectopic pregnancy—pregnancy anywhere outside of the uterus
• Tubal pregnancy is a pregnancy that takes place within the fallopian tube
• Ovaries—a pair of reproductive glands in women. The ovaries are located in the pelvis, one on each side of
the uterus. The ovaries produce eggs (ova) and female hormones estrogen and progesterone
• A female baby is born with all the eggs that she will ever have
• Cervix—is a cylinder-shaped tissue that connects the vagina and uterus. The opening in the center of the
cervix is known as the external os. It is the passage between the uterus and vagina
• Uterine ligaments include:
Broad
Round
Cardinal
Uterosacral
• GYN procedures can be performed:
Vaginal approach—with the vaginal approach the patient is in lithotomy position, a major complication
is thrombosis (blood clot)
Abdominal approach
Both—vaginal and abdominal
• Diagnostic procedures include:
Laparoscopy
Pelvic ultrasound

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 MRI
CT scan
• Hysterosalpingogram—is an x-ray of the uterus and fallopian tubes; usually performed for diagnosing
infertility
• Colposcopy—this is a procedure to closely examine your cervix, vagina and vulva for signs of disease.
During colposcopy, your doctor uses a special instrument called a colposcope
• Hysteroscopy—this is performed endoscopically to visualize the uterus for diagnostic and operative
procedures. The scope is inserted transvaginally/transcervically
• To distend the uterus the medium used is a nonelectrolytic fluid, they include:
Sorbitol
Glycine
Dextrose
• Cone biopsy of the cervix—this is to rule out cervical cancer, instruments used include:
Laser
Scalpel
Cervitome (cold knife conization)
LEEP (loop electrosurgical excision procedure)
• Culdocentesis—is a procedure to extract fluid from the rectouterine pouch posterior to the vagina with a
needle that is inserted transvaginally. It is a diagnostic procedure used in identifying pelvic inflammatory
disease and ectopic pregnancy
• PID—pelvic inflammatory disease—inflammation of the female genitalia. It can result in sterility and can
be caused by several microorganisms including:
Chlamydia
Gonococci
• D&C/fractional curettage—performed for histological studies. Tissue may be taken from the cervix
(endocervical) or the uterine lining (endometrial)
• Menorrhagia—is an abnormally heavy and prolonged period monthly
• Menometrorrhagia—prolonged or excessive bleeding that occurs irregularly and more frequently than a
normal period
• Dysmenorrhea—abnormally painful periods
• Amenorrhea—an abnormal absence of menstruation
• Chromopertubation—performed to test patency of the fallopian tubes. Methylene blue or indigo carmine
dye is injected into the uterine cavity through a uterine manipulator (zumi/humi) and the patency of the
tubes are confirmed by an abdominal laparoscope
• Laparoscopy—performed for direct visualization of the pelvic organs
• Tubal ligation—this is performed to prevent pregnancy. This can be done with:
Electrocoagulation (bipolar)
ESU with partial resection

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 Falope ring
Filshie clip
• Salpingostomy for ectopic pregnancy—salpingostomy is an opening into the fallopian tube to remove the
products of conception. Usually the tube is not sutured but left to close on its own. If reconstruction is
required fine sutures and Bowman’s lacrimal probes are used
• Salpingectomy—removal of the fallopian tube
• Excision of condylomata—this is a type of wart caused by the HPV virus. It can increase a woman’s chance
of cancer. They can be removed by ESU/laser/excision
• You must always use suction/smoke evacuator when using the ESU/laser to remove genital warts because
it is proven that the smoke plume that travels into the air still contains DNA from the virus and prolonged
exposure could cause the virus to travel to the throat and lungs
• Vulvectomy procedures are performed for carcinoma
Simple vulvectomy—removal of the labia majora, minora/clitoris
Total vulvectomy—wide excision is performed.
Radical vulvectomy—the vulva and if the nodes are positive, vagina, urethra, and anus may be removed.
Abdominal and perineal dissection is performed
• Vaginectomy/vaginoplasty—this is performed for cancer of the vagina
• An amnion graft (inner layer of a fetal membrane) or skin can be used for a vaginal graft
• Cystocele—this is a type of hernia. The bladder protrudes into the vaginal wall, symptom includes stress
incontinence
• Marshall–Marchetti–Krantz—the Marshall–Marchetti-Krantz procedure surgically reinforces the bladder
neck in order to prevent urinary incontinence
• Rectocele—performed for a herniation of the rectum into the vaginal wall
• Anterior posterior repair—this is performed to treat a cystocele/rectocele
• Enterocele—a herniation involving a portion of the intestine
• Vesicovaginal fistula—a fistula is a small opening (tubular connection) that develops between the bladder
and the vagina
• Urethrovaginal fistula—a fistula between the urethra and the vagina
• Ureterovaginal fistula—fistula between the ureter and the vagina
• Rectovaginal fistula—fistula between the rectum and the vagina
• Trachelorrhaphy—this is performed for reconstruction of the cervix, caused by lacerations due to the
trauma of childbirth
• Episiotomy—this procedure is performed to extend the perineal area upon delivering the baby to prevent
tearing of the perineum
• Uterine ablation—endometrial ablation is a procedure that burns the uterine lining to treat abnormal
uterine bleeding. This can be performed by laser, radiofrequency ablation (balloon filled with saline
solution that has been heated) and electricity (using a resectoscope with a loop or rolling ball electrode)
• Vaginal hysterectomy—this is removal of the uterus through an incision in the vaginal wall

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• Suprapubic catheter—this is a catheter that is inserted into the bladder percutaneous or with a cut down
procedure. This is a urinary diversion catheter; it diverts the urine away from the vaginal area where the
incision is
• LAVH/laparoscopic-assisted vaginal hysterectomy—this is a procedure using laparoscopic equipment to
dissect the uterus and it removed through the vagina
• Total abdominal hysterectomy—removal of the uterus and cervix through an abdominal incision
• TAH BSO—total abdominal hysterectomy, bilateral salpingo-oophorectomy—this is removal of the
uterus/fallopian tubes/ovaries. This is performed for malignant tumors
Uterus
Tubes
Ovaries
Ligaments
Upper part of the vagina
Bilateral pelvic lymph nodes
Some arteries and veins
• En bloc—removal of a tumor and/or organs involved without dissection of one, the entire tumor and
organs are removed together in one piece
• Seeding—when removing cancerous tissue you want to be extra careful not to drop tissue/cells into the
abdominal cavity and prevent the spread of cancer
• Pelvic exenteration—this is performed or malignant cancer. The procedure is performed en bloc The
organs removed include:
All reproductive organs
Distal ureters
Bladder
Vagina
It can involve the rectum
Perineum
Pelvic lymph nodes
• Oophorectomy—removal of an ovary
• Oophorocystectomy—removal of an ovarian cyst on the ovary, not the ovary itself. The most common
include:
Dermoid cyst/teratoma—this cyst contains embryonic cells containing epidermis, hair follicles, and
sebaceous glands
Follicular cyst
• Myomectomy—removal of fibroid tumors of the uterine lining
• Leiomyoma—this is a common tumor of the uterine lining
• Salpingo-oophorectomy—this is removal of the fallopian tube and part or the entire ovary
• Cervical cerclage—cervical cerclage is used for the treatment of cervical incompetency. This prevents the

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 fetus from miscarrying when the fetus gets larger and weighs heavy on the cervix. A strong suture or
Dacron tape is sutured around the cervix around weeks 12–14 and removed near the end of the third
trimester. Two common procedures include:
Shirodkar/McDonald
• Abortion—an abortion is a pregnancy that ends before the baby can survive outside the womb because it
has not yet reached viability
• Spontaneous abortion—the abortion occurs naturally
• Induced abortion—the pregnancy is terminated artificially or with medication
• Threatened abortion—this is when there is a problem with the pregnancy with symptoms that include
bleeding and pelvic pain. The cervix remains closed and under ultrasound it shows the pregnancy is still
viable
• Complete abortion—the pregnancy is terminated and the uterus completely empties itself
• Incomplete abortion—miscarriage with some products of conception retained that must be removed with a
D&C
• Missed abortion—the fetus is not viable but has not expelled itself from the uterus. A D&C for complete
elimination of retained products of conception
• Suction curettage—vacuum or suction with aspiration to remove uterine contents through the cervix
• Meconium—this is the first bowel movement of the fetus
• Amniotic fluid—the fluid surrounding the fetus in the womb
• Vernix—vernix caseosa—is the waxy white substance found on the skin of the newborn
• A common reason to perform a C-section is cephalopelvic disproportion. The infants head is too large to
fit through the birth canal
• Placental abruption—placental abruption is when the placenta separates from the wall of the uterus prior
to the birth of the baby
• Placenta previa—a condition in which the placenta blocks the opening of the uterus interfering with
normal delivery of a baby
• Pregnancy induced hypertension—high blood pressure that occurs during pregnancy
• Eclampsia—this can occur when the pregnant woman has high blood pressure which could cause a
convulsion, coma, and death if not treated
• Nuchal cord—this is when the umbilical cord is wrapped once or more around the baby’s neck
• Cord prolapse—this is when the umbilical cord comes before the baby’s head out into the vagina during
birth
• Breech—this occurs when the baby’s feet/buttocks/knees come before the baby’s head into the birth canal
• Gravida—is the number of times that a woman has been pregnant
• Para gravida—is the number of times that a woman has given birth to a fetus with a gestational age of 24
weeks or more
• Prima gravida—first pregnancy
• Oxytocin/Pitocin—medication used to induce labor, continue labor, and contract the uterus following the

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 birth to help the uterus expel blood
• Hemabate—this medication is used to induce an abortion by dilating the cervix and producing uterine
contractions which causes delivery
• Methergine—this medication is used to help control hemorrhage following birth
• Dextran—irrigation fluid left in abdomen to prevent adhesions
• Positioning for OB/GYN procedures includes supine, and lithotomy position
• Complications of lithotomy position are damage to the peroneal nerve damage or an embolus
• Prep for OB/GYN procedures include:
Clean to dirty—prep the clean area with a Betadine prep stick and then follow to the anal area and
discard. Repeat the step
• Chloraprep should never be used on the mucous membranes which includes the vagina
• Draping for OB/GYN procedures includes:
A buttock drape is placed
Leggings
Fenestrated abdominal drape
• DeLee suction—this is attached to the fetal head and assists in delivery of the fetus
• Common incisions that allow access to the pelvic organs include Pfannenstiel, Cherney, and Maylard
• Radical hysterectomy/Wertheim—this is performed for cervical cancer and endometrial cancer. Organs
removed include:

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 Questions

1. When handling uterine curettings,

(A) never place them in preservative

(B) keep the endometrial and the endocervical curettings separate
(C) send the endometrial and the endocervical curettings to the laboratory in one container
(D) send them on a 4 × 4 to the laboratory because it is too difficult to remove them

2. Labor can be induced using:

(A) ergotrate
(B) diazoxide
(C) Pitocin
(D) magnesium sulfate

3. The needle used to instill the gas during a laparoscopy is a:

(A) Silverman
(B) Crile
(C) Hegar
(D) Veress

4. A Hulka tenaculum forceps is used in:

(A) gynecological surgery

(B) urological surgery
(C) thoracic surgery
(D) neurological surgery

5. Which drug is given to aid in placental expulsion?

(A) Oxytocic
(B) Anticholinergic
(C) Antihistamine
(D) Hypoxic

6. A Humi cannula is used in:

(A) eye surgery

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 (B) vascular surgery
(C) urological surgery
(D) gynecological surgery

7. The aim of stress incontinence operations includes all of the following EXCEPT:

(A) to improve performance of a dislodged or dysfunctional vesical neck

(B) to restore normal urethral length
(C) to tighten and restore the anterior urethral vesical angle
(D) to repair a congenital defect

8. A procedure done on young women who have been diagnosed with benign uterine tumors but who wish
to preserve fertility is a:

(A) subtotal hysterectomy

(B) Wertheim procedure
(C) myomectomy
(D) Le Fort procedure

9. A procedure to prevent cervical dilatation that results in release of uterine contents is a:

(A) Shirodkar
(B) Le Fort
(C) Wertheim
(D) marsupialization

10. An endoscopic investigation of the uterus and tubes is a:

(A) Rubin’s test

(B) hysterogram
(C) hysterosalpingogram
(D) hysteroscopy

11. Sterility can be accomplished by all of the following procedures EXCEPT:

(A) laparoscopy
(B) minilaparotomy
(C) posterior colpotomy
(D) culdoscopy

12. An endoscopic approach to pelvic and intra-abdominal examination is:

(A) culdocentesis
(B) hysteroscopy
(C) pelviscopy

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 (D) salpingogram

13. The procedure that provides visualization of the internal contour of the uterus is a:

(A) laparoscopy
(B) pelviscopy
(C) hysteroscopy
(D) colposcopy

14. Extrauterine pregnancies can occur in the:

(A) abdominal cavity and tube

(B) ovary and pelvic ligaments
(C) abdominal cavity and corpus luteum
(D) pelvic ligaments and tube

15. What gynecological setup would include various sizes of sterile cannulas?

(A) Cesarean
(B) Hysterectomy
(C) Oophorectomy
(D) Suction curettage

16. A Foley catheter is placed into the presurgical hysterectomy patient to:

(A) record accurate intake and output

(B) distend the bladder during surgery
(C) avoid injury to the bladder
(D) maintain a dry perineum postoperatively

17. What would an anterior and posterior repair accomplish?

(A) Repair of cystocele and rectocele

(B) Repair of vesicovaginal fistula
(C) Repair of vesicourethral fistula
(D) Repair of labial hernia

18. An incision made during normal labor to facilitate delivery with less trauma to the mother is a/an:

(A) colpotomy
(B) colporrhaphy
(C) episiotomy
(D) celiotomy

19. Cervical carcinoma in situ can be classified as:

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 (A) limited to the epithelial layer, noninvasive
(B) micro-invasive
(C) clinically obvious
(D) vaginal extension limitations

20. The fallopian tube is grasped with a:

(A) Kocher
(B) Babcock
(C) Kelly
(D) Lahey

21. Reconstruction of the fallopian tube setup would include:

(A) Bowman lacrimal probes

(B) Bakes dilators
(C) Hegar dilators
(D) Van Buren sounds

22. To confirm the diagnosis of ectopic pregnancy, it is sometimes necessary to perform a:

(A) Rubin’s test

(B) culdocentesis
(C) paracentesis
(D) laparotomy

23. Cervical conization is accomplished using all of the following EXCEPT:

(A) scalpel
(B) cautery
(C) laser
(D) sclerosing solution

24. The most commonly identified ovarian cyst is the:

(A) chocolate
(B) follicle
(C) serous cyst adenoma
(D) dermoid

25. A herniation of the cul-de-sac of at the Pouch of Douglas is a/an:

(A) cystocele
(B) rectocele
(C) hydrocele

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 (D) enterocele

26. A vesicourethral abdominal suspension is known as a:

(A) Le Fort
(B) Wertheim
(C) Marshall–Marchetti
(D) Shirodkar

27. A condition causing leakage of urine into the vagina is a/an:

(A) ureterovaginal fistula

(B) cystocele
(C) vesicovaginal fistula
(D) rectovaginal fistula

28. What special technique is employed during a hysterectomy?

(A) Discard instruments used on cervix and vagina

(B) Use second set for closure
(C) Re-drape for closure
(D) Remove Foley before uterus is removed

29. Papanicolaou indicates:

(A) removal of small pieces of cervix for examination

(B) cytological study of cervical smear
(C) staining of the cervix for study
(D) direct visualization of pelvic organs

30. A technique employed for cervical biopsy is:

(A) random punches

(B) multiple punches at 3, 6, 9, and 12 o’clock
(C) one central punch at os
(D) one inferior and one superior punch

31. In a cesarean birth, the uterus is opened with a knife and extended with a/an:

(A) Metzenbaum
(B) Heaney
(C) iris scissor
(D) bandage scissor

32. At which point in a cesarean is a bulb syringe used?

399
 (A) When the membranes are incised
(B) When the fetal head is delivered
(C) When the entire infant is delivered
(D) After placental delivery

33. Oxytocics are given in a cesarean after the baby’s shoulders are delivered:

(A) to contract the uterus

(B) to relax the uterus
(C) to prolong the contraction
(D) to facilitate membrane rupture

34. When closing a uterus in a cesarean, the edges of the uterine incision are clamped with which of the
following?

(A) Allis
(B) Kocher
(C) Pennington
(D) Babcock

35. Intraoperative chromotubation can be affected by all of the following surgical cannulae EXCEPT:

(A) Humi
(B) Rubin
(C) Hui
(D) Hulka

36. What suture would be placed into the wall of a large ovarian cyst before aspiration of its contents and
final removal?

(A) Mattress
(B) Suture ligature
(C) Purse-string
(D) Figure-of-eight

37. What is the preferred procedure for recurrent or persistent carcinoma of the cervix after radiation
therapy has been completed?

(A) Wertheim’s
(B) Pelvic exenteration
(C) Abdominal perineal resection
(D) Low-anterior resection

38. Which of the following instruments would be used to grasp the anterior cervix of the uterus just before
dissection from the vaginal vault during a total abdominal hysterectomy?

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 (A) Allis
(B) Heaney
(C) Phaneuf
(D) Kelly

39. Laparoscopic tubal occlusion may utilize all of the following methods of effecting sterilization
EXCEPT:

(A) bipolar coagulation

(B) Silastic bands
(C) Surgitie ligating loop
(D) spring clip

40. A holding instrument not found in a vaginal procedure is a:

(A) Jacobs
(B) Lahey
(C) Staude
(D) Skene

41. Conization of the cervix may be accomplished by all of the following EXCEPT:

(A) scalpel
(B) Thomas uterine curette
(C) laser
(D) electrosurgery

42. An enterocele differs diagnostically from a rectocele by its contents and its position in the perineum. Its
location is in the:

(A) Pouch of Douglas

(B) anterior vaginal wall
(C) posterior vaginal wall
(D) pelvic floor

43. Pelviscopy differs from laparoscopy in the:

(A) utilization of a larger trocar and scope

(B) utilization of auxiliary ports for ancillary instrumentation
(C) utilization of a 30-degree angled scope
(D) Both A and C

44. A Stamey endoscopic procedure is performed to:

(A) suspend the vesicle neck

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 (B) correct anterior wall prolapse
(C) correct posterior wall prolapse
(D) repair a bladder laceration

45. What is the name given to a radical vaginal hysterectomy?

(A) Exenteration
(B) Schauta
(C) Wertheim’s
(D) Le Fort

46. What surgical procedure provides obliteration of the vagina by denuding and approximating the anterior
and posterior walls of the vagina?

(A) Vaginoplasty
(B) Colpocleises
(C) Colpoperineorrhaphy
(D) Colporrhaphy

47. The hysteroscope may be used to identify or remove all of the following EXCEPT:

(A) fallopian adhesions

(B) lost intrauterine devices (IUDs)
(C) intrauterine adhesions
(D) submucosa fibroids

48. Needle aspiration of the cul-de-sac is surgically termed:

(A) colpocleisis
(B) culdocentesis
(C) culdotomy
(D) colpotomy

49. An alternative to abdominal hysterectomy utilizing an endoscope is surgically termed a/an:

(A) laparoscopic-assisted vaginal hysterectomy (LAVH)

(B) LEEC
(C) pelviscopic-assisted vaginal hysterectomy (PAVH)
(D) Both A and C

50. What procedure cannot be performed through a pelviscope?

(A) Ovarian cystectomy

(B) Hysterectomy
(C) Oophorectomy

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 (D) Adhesiolysis

51. Endometrial ablation is performed to correct:

(A) amenorrhea
(B) metrorrhagia
(C) menorrhagia
(D) endometriosis

52. Endoscopic visualization of the uterine cavity is called:

(A) pelviscopy
(B) laparoscopy
(C) hysteroscopy
(D) colposcopy

53. Marsupialization of a Bartholin’s cyst involves the:

(A) suturing the posterior wall of the cyst to the skin edges
(B) removal of anterior wall of cyst
(C) draining cyst contents
(D) Both A and B

54. What is the self-retaining retractor used in vaginal procedures?

(A) O’Sullivan–O’Conner
(B) Gelpi
(C) Graves
(D) Auvard

55. Extrauterine disease of the female reproductive system may utilize any of the following lasers via a
colposcope or laparoscope EXCEPT:

(A) CO2
(B) Nd:YAG
(C) Candela
(D) argon

56. A postoperative complication of the GYN patient in lithotomy position for an extended period of time
is:

(A) emboli
(B) hypertension
(C) ulnar nerve damage
(D) hemorrhage

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57. A benign smooth muscle tumor of the uterus which causes abnormal uterine bleeding lead to anemia is:

(A) dermoid
(B) endometriosis
(C) leiomyoma
(D) cystocele

58. What incision is commonly used for a C-section?

(A) McBurney
(B) Upper midline
(C) Lower paramedian
(D) Pfannenstiel

59. Premature separation of the placenta from the uterine wall is:

(A) placenta prolapsed

(B) placenta previa
(C) nuchal cord
(D) placental abruption

60. The graft used for a vaginoplasty is:

(A) full thickness skin graft

(B) biological skin graft
(C) split thickness skin graft
(D) subcutaneous connective tissue

61. When all products of conception are expelled and surgical intervention is NOT necessary, it is a:

(A) incomplete abortion

(B) complete abortion
(C) missed abortion
(D) D&C

62. A cyst that is formed from the germ layer from the developing embryo is called a:

(A) teratoma (dermoid)

(B) leiomyoma
(C) fibroid
(D) endometrial cyst

63. Hypertension and seizure during pregnancy are known as:

(A) preeclampsia
(B) placenta abruption

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 (C) malignant hypertension
(D) eclampsia

64. Electrocoagulation, cryoablation, and radio frequency ablation are procedures performed for:

(A) dysfunctional uterine bleeding

(B) malignant fibroids
(C) benign fibroids
(D) cervical cancer

65. LAVH is removal of the uterus by combined approach using:

(A) laparoscopic and vaginal

(B) abdominal and vaginal
(C) pfannenstiel and vaginal
(D) lower midline and vaginal

66. The term describing the specimen removal in one piece is:

(A) in situ
(B) en bloc
(C) colon resection
(D) None of the above

67. The umbilical cord proceeding the fetal head is:

(A) placenta abruption

(B) placenta previa
(C) cord prolapsed
(D) nuchal cord

68. All of the following are uterine ligaments EXCEPT:

(A) broad
(B) round
(C) cardinal
(D) transcervical

A 29-year-old pregnant presents to the emergency room complaining of severe abdominal pain, referred pain
to the shoulder and bleeding. The transvaginal ultrasound shows an absence of an intrauterine pregnancy.

69. The tests show that the fertilized egg implanted itself outside the uterus. She is diagnosed with:

(A) ectopic pregnancy

(B) incompetent cervix
(C) complete abortion

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 (D) ovarian cyst

70. She is scheduled for:

(A) laparoscopic removal of ectopic

(B) exploratory laparotomy for ectopic
(C) ovarian cystectomy
(D) Both A and B

71. The position when the surgeon chooses an open approach for emergent surgery for ectopic pregnancy is:

(A) lithotomy
(B) supine with a wedge under the affected side
(C) supine
(D) reverse Trendelenburg

72. The surgery performed to remove the embryo while preserving the tube is:

(A) salpingo-oophorectomy
(B) salpingectomy
(C) salpingostomy
(D) oophorectomy

73. The affected tube is grasped with:

(A) Babcock
(B) Allis
(C) mixter
(D) Kocher

74. Pathology of an ectopic pregnancy includes all EXCEPT:

(A) an STD
(B) previous tubal surgery
(C) exercising during first trimester
(D) smoking

75. Tubal patency may be tested by the installation of _______ into the uterine cavity.

(A) balanced salt solution

(B) Chymar
(C) methylene blue
(D) gentian violet

76. In laparoscopy, tubal patency is checked by:

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 (A) irrigating with normal saline
(B) injecting Renografin into the tube
(C) injecting methylene blue into the cervical canal
(D) irrigating tube with Lugol’s solution

77. After removal of uterus in a hysterectomy,

(A) cervical and vaginal instruments are isolated from the instrument set in a discard basin
(B) the cervix is cauterized
(C) new instruments are used on the cervical closure
(D) cervical instruments are returned to the basket

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 Answers and Explanations

1. (B) The endometrial curettings should be kept separate from the endocervical curettings. Fractional
curettage specimens differentiate between the endocervical and the endometrium of the corpus, which
helps to locate a lesion more specifically.

2. (C) Pitocin is used to induce active labor or to increase the force or rate of existing contractions during
delivery. It may be given postpartum to prevent or control hemorrhage. It acts on the uterus.

3. (D) A Veress needle is inserted into the peritoneal cavity to instill the CO2 to achieve a
pneumoperitoneum.

4. (A) In laparoscopy, a D&C may be done when indicated. After the cervix is exposed, and the position
and depth of the uterus are confirmed, a Hulka forceps and uterine dilator may be introduced into the
cervix to manipulate the uterus during the laparoscopy so the surgeon has better visibility.

5. (A) As soon as the shoulders are delivered, about 20 units of oxytocic per liter of fluid are given
intravenously so the uterus contracts, aiding in expulsion of the placenta and membranes.

6. (D) A Humi cannula may be placed in the uterine cavity for intraoperative chromotubation with diluted
methylene blue during microscopic reconstruction of the fallopian tube.

7. (D) The aim of any operation for urinary stress incontinence is to improve the performance of a
dislodged or dysfunctional vesical neck, to restore normal urethral length, and to tighten and restore the
anterior urethral vesical angle.

8. (C) Myomectomy is usually done on young women with symptoms that indicate the presence of benign
tumors who wish to preserve fertility.

9. (A) The postconceptional Shirodkar operation is placement of a collar-type ligature of Mersilene,

Dacron tape, heavy nylon, or plastic-covered stainless steel at the internal os to close it when there is
cervical incompetence characterized by habitual, spontaneous abortion.

10. (D) A hysteroscopy is an endoscopic visualization of the uterine cavity and tubal orifices for evaluation of
uterine bleeding, location and removal of IUDs, diagnosis, and so forth.

11. (D) Laparoscopy, minilaparotomy, and posterior colpotomy are viable methods to create sterility.
Culdoscopy cannot be used for this purpose.

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12. (C) Pelviscopy is an endoscopic approach to pelvic and intra-abdominal examination and/or surgery.
Many procedures can be performed through the pelviscope.

13. (C) Hysteroscopy is an endoscopic visualization of the uterine cavity and tubal orifices (internal).

14. (A) The abdominal cavity and the fallopian tube are sites of extrauterine pregnancies (ectopic). A
salpingostomy done before rupture may preserve the tube.

15. (D) A, D, and C set plus added extras, including sterile cannulas for suction curettage, is used (for early
pregnancy termination and for missed and incomplete abortions). The cannula is inserted into the
uterus and suction is turned on to disrupt the sac and aspirate contents.

16. (C) Because pelvic procedures involve manipulation of the ureters, bladder, and urethra, an indwelling
Foley or suprapubic cystostomy catheter may be placed before or during operation to avoid injury to the
bladder.

17. (A) Cystoceles (bulging bladder) and rectoceles (bulging rectum) occur because of weakened vaginal
mucosa. Usually, the cause is traumatic childbirth, and the cure is an anterior and posterior vaginal
repair.

18. (C) An episiotomy is an intentionally made perineal incision executed during a normal birth to facilitate
delivery and prevent perineal laceration.

19. (A) Carcinoma in situ is limited to the epithelial layer with no evidence of invasion.

20. (B) The fallopian tube is grasped with either an Allis or Babcock forceps.

21. (A) Tuboplasty requires a basic gynecological instrument set plus iris scissors, Adson forceps, mosquitos,
Bowman lacrimal probes, Webster needle holder, and Frazier suction. A microsurgical set and laser may
also be used.

22. (B) Aspiration of fluid or blood from the cul-de-sac of Douglas (culdocentesis) confirms intraperitoneal
bleeding caused by ectopic pregnancy.

23. (D) Cervical conization may be performed by scalpel resection and suturing, by application of the cutting
of cautery, or by use of a laser.

24. (B) Functional cysts comprise the majority of ovarian enlargements. Follicle cysts are the most common.

25. (D) An enterocele is a herniation of Douglas’ cul-de-sac and almost always contains loops of the small
intestine. It herniates into a weakened area between the anterior and posterior walls.

26. (C) A Marshall–Marchetti procedure is an abdominal approach to repairing and elevating the fascial and
the pubococcygeal muscle surrounding the urethra and the bladder neck for the correction of stress
incontinence.

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27. (C) A vesicovaginal fistula may vary in size from a small opening that permits slight leakage of urine into
the vagina to a large opening that permits all urine to pass to the vagina.

28. (A) Once the cervix is dissected away from and is amputated from the vagina, all of the potentially
contaminated instruments used on the cervix and vagina are placed in a discard basin and removed from
the field (includes sponge sticks and suction).

29. (B) Papanicolaou is a cytological study of smears of the cervical and endocervical tissue. Characteristic
cellular changes can be identified.

30. (B) Multiple punch biopsies of the cervical circumference (at the 3, 6, 9, and 12 o’clock positions) may
be taken with a Gaylor biopsy forceps.

31. (D) The uterus is opened with a knife and extended by cutting laterally with a large bandage scissor or
by simply spreading with the fingers.

32. (B) As soon as the head is delivered, a bulb syringe is used to aspirate the infant’s exposed nares and
mouth to minimize aspiration of amniotic fluid and its contents.

33. (A) As soon as the shoulders are delivered, about 20 units of oxytocin per liter of fluid is administered
intravenously so that the uterus contracts. This minimizes blood loss and aids in placenta and
membrane expulsion.

34. (C) The edges of the uterine incision are promptly clamped with Pean forceps, ring forceps, or
Pennington clamps.

35. (D) Once the vagina has been prepped and an indwelling catheter is placed into the bladder,
chromotubation can be effected by placing a Kahn, Calvin, Hui, Humi, or Rubin cannulae into the
cervical opening using diluted methylene blue dye to identify a nonpatent fallopian tube as visualized
through a laparoscope.

36. (C) For removal of a large ovarian cyst, a purse-string suture may be placed into the cyst wall, and a
trocar is introduced into the center to aspirate its contents before the suture is tied.

37. (B) Pelvic exenteration is a preferred treatment for recurrent or persistent carcinoma of the cervix. It is
considered the only surgical alternative after a thorough investigation of the patient and disease status to
determine if there is a reasonable chance for a cure.

38. (A) After the vaginal vault is incised close to the cervix during the removal of the uterus, an Allis,
Kocher, or tenaculum may be used to grasp the anterior lip of the cervix.

39. (C) Preknotted suture loops are used to ligate pedicle tissues. Bipolar coagulation, spring clips, and
Silastic bands effect occlusion of fallopian tubes.

40. (B) The Lahey vulsellum clamp is used to elevate the thyroid lobe during dissection. All of the others are

410
 holding instruments used to manipulate the cervix during vaginal surgery.

41. (B) A Thomas uterine curette is used to remove endocervical as well as endometrial tissue scrapings from
the internal lining of the uterus. All other options can be used to remove the endocervical cone to treat
diseased tissue and preserve fertility.

42. (A) An enterocele is a herniation of Douglas’ cul-de-sac and almost always contains loops of the small
intestine. An enterocele herniates into a weakened area between the anterior and posterior vaginal walls.

43. (D) Pelviscopy differs from laparoscopy in two aspects: a 10-mm pelviscope with a 30-degree angle
replaces the 7-mm laparoscope with a zero-degree angle. The larger lumen allows a wider field of range.

44. (A) Known as a Stamey procedure for female incontinence, the bladder neck is suspended by placing
sutures on both sides of the vesicourethral junction from the anterior rectus fascia into the vagina. This
is aided by insertion of a cystoscope to ascertain correct needle placement through an incision into the
rectus fascia.

45. (B) An operative approach to early carcinoma of the cervix is a radical vaginal hysterectomy called a
Schauta operation. It is useful in obese patients and removes the uterus, upper third of the vagina,
parametria, fallopian tubes, and ovaries.

46. (B) Colpocleisis (Le Fort) is obliteration of the vagina by denuding and approximating the anterior and
posterior walls of the vagina and is generally reserved for elderly high-risk patients with uterine
prolapse.

47. (A) The hysteroscope is used most commonly for endometrial laser ablation. The hysteroscope also may
be used to identify and remove polyps and submucous fibroids, retrieve lost uterine devices, or lyse
intrauterine adhesions.

48. (B) Blood, fluid, or pus in the cul-de-sac is aspirated by needle via the posterior vaginal fornix for
suspected intraperitoneal bleeding or ectopic pregnancy, or tubo-ovarian abscesses.

49. (D) Laparoscopic-assisted vaginal hysterectomy (LAVH) or pelviscopic-assisted vaginal hysterectomy

(PAVH) offers an alternative to total abdominal hysterectomy and vaginal hysterectomy.

50. (B) Procedures performed through a pelviscope include adhesiolysis, ovarian biopsy, ovarian cystectomy,
oophorectomy, fimbrioplasty, and removal of ectopic pregnancies. Hysterectomies cannot be performed
because of the solid size of the viscus.

51. (C) Endometrial ablation is done to treat abnormal uterine bleeding. The overall goal is to create
amenorrhea or to reduce menstrual bleeding to normal. It may be an alternative to hysterectomy in
some patients with chronic menorrhagia.

52. (C) Hysteroscopy is endoscopic visualization of the uterine cavity and tubal orifices. Laparoscopy may be
done in association with hysteroscopy to assess the external contour of the uterus.

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53. (D) True marsupialization of the Bartholin’s cyst involves the removal of the anterior wall of the cyst and
suturing the cut edges of the remaining cyst to adjacent sides of the skin.

54. (C) A Graves self-retaining speculum frequently is known as a duckbill speculum and is used for vaginal
and cervical exposure.

55. (C) The Candela laser is valuable to disintegrate stones in the urinary tract because it is tunable, and the
wavelength can be adjusted. The CO2, argon, and Nd:YAG are used to treat pelvic endometriosis,
cervical dysplasia, condylomata, and premalignant diseases of the vulva and the vagina.

56. (A) SCD or antiembolic stockings are placed on the patients legs to prevent embolism.

57. (C) A leiomyoma is a benign smooth muscle tumor of the uterus.

58. (D) A low transverse, pfannenstiel or midline incision is used to perform a C-section.

59. (D) Placentia abruption is premature separation of the placenta from the uterine wall after 20 weeks’
gestation and before the fetus is delivered.

60. (C) During the first stage of the vaginoplasty, a split thickness skin graft is taken from the buttocks or
the thigh.

61. (B) A complete abortion is the expulsion of all products of conception. Surgical intervention is not
necessary.

62. (A) A teratoma is a common ovarian tumor that arises from one of the germ layers of the developing
embryo. It may contain hair, teeth, sebaceous material, and skin.

63. (D) Eclampsia is also referred to as toxemia. Hypertension can constrict blood flow to the placenta and
the fetus.

64. (A) The goal of endometrial ablation is the destruction and scarification of the endometrium to render it
nonfunctional.

65. (A) A laparoscopic-assisted vaginal hysterectomy is removal of the uterus by using a combined
laparoscopic and vaginal approach.

66. (B) En bloc is a term meaning “in one piece.” In surgery, it describes the technique of removing tissue
usually performed in a radical hysterectomy.

67. (D) The umbilical cord is wrapped one or more times around the fetus’ neck. This usually occurs with an
active fetus seldom diagnosed before labor.

68. (D) The uterine ligaments are the broad, the cardinal, uterosacral, and round.

69. (A) In an ectopic pregnancy, the fertilized egg implants itself outside the uterus. The fallopian tube is a

412
 common site of an ectopic pregnancy.

70. (A) A laparoscopic or an open approach can be used depending on the patient’s condition and the
surgeon’s choice.

71. (C) The patient is placed in supine position, prepped and drapped for a laparotomy.

72. (C) A salpingostomy is an incision into the tube to remove the embryo while preserving the tube for
future pregnancy.

73. (A) The tube is grasped with a Babcock which is an atraumatic.

74. (C) Risk factors of an ectopic include a previous history of a PID, smoking, previous tubal surgery
history of STDs.

75. (C) To test tubal patency, methylene blue or Indigo carmine in a saline solution is introduced into the
uterine cavity. The tubes are viewed through a laparoscope. Dye seen coming from one or both tubes
indicates patency.

76. (C) To test for tubal patency during laparoscopy, diluted methylene blue or indigo carmine solution is
injected through the intrauterine cannula in the cervical canal. If the fallopian tubes are patent, dye can
be seen at fimbriated ends.

77. (A) After the cervix is dissected and amputated from the vagina, the uterus is then removed. Potentially
contaminated instruments used on the cervix and vagina are placed in a discard basin and removed from
the field (sponge sticks and suction as well).

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 ___________________ CHAPTER 20 ___________________

Ophthalmology

• Conjunctiva—a thin transparent membrane that lines the surface of the eyelids and covers the sclera
• Globe—eyeball
• Cornea—it is a transparent window which light passes through to the retina, this is where images are
focused
• Bony orbit—the two orbital cavities, they contain the globe (eyeball)
• Sclera—it is the white part of the external globe
• Lens–the lens changes shape and allows the eye to focus
• Retina—this is the photoreceptive layer of the eye
• Color blindness is caused by a defect in the retina
• There are six muscles that function to move the eye
• Block—retrobulbar (this block is performed directly into the base of the eyelids or into the back of the
globe of the eye)
• Miotic drugs—this drug constricts the pupil. Examples include:
Miochol—you must reconstitute immediately before using and must be used within 15 minutes
Pilocarpine
Miostat
• Mydriatics—this drug dilates the pupil but allows the pupil to focus. Examples include:
Neo-Synephrine
Atropine
• Cycloplegics—this drug dilates the pupil but inhibits focusing. Examples include:
Atropine (anticholinergic—nerve blocking agent)
Epinephrine
• Topical anesthetics—a topical anesthetic is used to numb the surface of the eye. Examples include:
Tetracaine hydrochloride—Pontocaine
• Injectable anesthetics—an anesthetic that can be injected under/into the eye. Examples include:
Lidocaine
• Additives to local anesthesia—these medications combined with anesthetics can help to prolong the effects
of the anesthesia, help to reduce bleeding, and increase diffusion. Examples include:
Epinephrine—prolongs the effect and reduces bleeding
Hyaluronidase—Wydase

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 Increases diffusion (the movement of particles from high concentration to low concentration (it
spreads the medication quicker and more evenly)
Also used as a lubricant to help separate tissues before removal of the lens
• Viscoelastics—these drugs lubricate, and maintain a separation between tissues examples include:
Healon
Provisc
Viscoat—used to coat the lens before implantation
• Irrigants—used to keep the cornea moist during surgery. Examples include
BSS—balanced salt solution
• Anti-inflammatory agents—used to treat inflammatory and allergic conditions. Examples include:
Betamethasone—Celestone
Decadron
Depo-medrol
• Antibiotics—infection treatment or prevention. Can be administered as ointments
Neomycin
Gentamicin
Tobramycin
• Anti-inflammatory—prevents swelling. Can be a steroid or an NSAID, controls postoperative
inflammation
• Prednisone
• Decadron
• Celestone
• Evisceration—removal of the eye contents, leaving the sclera and attached muscles intact
• Enucleation—removal of the entire eyeball, with its muscle attachments and optic nerve
• Prosthetic implants are made of glass, silicone, and coralline
• Exteneration—this is removal of the entire orbital contents
• The lacrimal duct system helps to maintain moisture in the eye
• Lacrimal duct dilation—this is performed for excessive tearing caused by blockage of the duct
• Bowman lacrimal duct probes are used for dilatation, they come in graduated sizes
• Dacryocystorhinostomy—a procedure to relieve blockage of the nasolacrimal duct which drains tears into
the nose. This is performed for chronic dacryocystitis
• Chalazion—an obstruction of the meibomian gland
• Meibomian gland is a sebaceous gland that helps to lubricate the eyelids
• Blepharoplasty—this is a procedure to correct drooping skin and fat of the upper and lower eyelids
(dermatochalasis)
• Pterygium—this is a benign growth on the nasal side of the conjunctiva
• Strabismus—a condition when eyes are not straight and do not focus on the same object because the
muscles are either too long or too short

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• Esotropia—cross eyes
• Exotropia—wall eyes
• Recession—this procedure is performed for esotropia (cross eyes)—it weakens the eye muscle by
reattaching it further back on the eye
• Resection—this procedure is performed for exotropia (wall eyes)—it strengthens the muscle. A portion of
the muscle (lateral rectus muscle) is made shorter
• Keratoplasty—corneal transplant
• Trephine is an instrument used to make the cylindrical cut in the cornea for the transplant
• The corneal tissue is taken from a human cadaver
• Radical keratotomy—this is performed for myopia (nearsightedness)
• Lasik surgery—an excimer laser is used to reshape the cornea. This allows the patient to see well at a
distance
• Argon/Nd:YAG lasers are commonly used in eye surgery because it is able to pass through clear tissue
without heating it up

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 Questions

1. In cataract surgery, a viscoelastic drug sometimes used to occupy space in the posterior cavity of the eye
is:

(A) alpha-chymotrypsin
(B) mannitol
(C) Healon
(D) Wydase

2. An example of a miotic drug is:

(A) pilocarpine
(B) homatropine
(C) atropine
(D) scopolamine

3. What topical anesthetic is used most frequently for preoperative ocular instillation?

(A) Lidocaine
(B) Tetracaine
(C) Cocaine
(D) Dorsacaine

4. The drug added to a local ophthalmic anesthetic to increase diffusion is:

(A) alpha-chymotrypsin
(B) hyaluronidase
(C) epinephrine
(D) Varidase

5. A solution used for eye irrigation is:

(A) phenylephrine HCl

(B) normal saline
(C) alpha-chymotrypsin
(D) balanced salt solution

6. A synthetic local anesthetic that is effective on the mucous membrane and is used as a surface agent in

417
 ophthalmology is:

(A) Miochol
(B) Zolyse
(C) Dibucaine
(D) tetracaine

7. Dilating eye drops are called:

(A) mydriatics
(B) miotics
(C) myopics
(D) oxytocics

8. Which of the following uses ultrasonic energy to fragment the lens in extracapsular cataract extraction?

(A) Keratome
(B) Ocutome
(C) Cystotome
(D) Phacoemulsifier

9. A chalazion is a chronic inflammation of the:

(A) lacrimal gland

(B) meibomian gland
(C) eyelid
(D) conjunctiva

10. What procedure is done for chronic dacryocystitis?

(A) Extirpation
(B) Lacrimal duct probing
(C) Myomectomy
(D) Dacryocystorhinostomy

11. A procedure to treat retinal detachment is:

(A) scleral buckle

(B) trabeculectomy
(C) goniotomy
(D) vitrectomy

12. Sagging and eversion of the lower lid is:

(A) entropion
(B) blepharitis

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 (C) ectropion
(D) ptosis

13. Removal of the entire eyeball is:

(A) keratoplasty
(B) exenteration
(C) enucleation
(D) evisceration

14. Which piece of equipment is used to treat glaucoma in addition to the slit lamp?

(A) Argon or Nd:YAG laser

(B) Cavitron
(C) Phacoemulsifier
(D) Cryoprobe

15. Removal of a portion of an ocular muscle with reattachment is called:

(A) recession
(B) resection
(C) strabismus
(D) myomectomy

16. Opacity of the vitreous humor is treated by performing a:

(A) cataract removal

(B) scleral buckling procedure
(C) vitrectomy
(D) goniotomy

17. Miochol solution is prepared for a cataract procedure no more than ______ minutes before the actual
instillation.

(A) 5
(B) 15
(C) 30
(D) 60

18. A drug used as a lubricant and as viscoelastic support to maintain separation of tissues before removal of
lens during cataract surgery is:

(A) 5-fluorouracil
(B) Healon
(C) Mitomycin

419
 (D) Miostat

19. A drug used to contract the sphincter of the iris during an intracapsular cataract extraction is:

(A) Zolyse
(B) Healon
(C) Miochol
(D) Mitomycin

20. What procedure accomplishes correction of myopia?

(A) Keratoplasty
(B) Keratophakia
(C) Radical keratotomy
(D) Both B and C

21. An enzymatic drug commonly used with anesthetic solutions to increase tissue diffusion is:

(A) Viscoat
(B) epinephrine
(C) Ophthaine
(D) Wydase

22. Injection of anesthetic solution into the base of the eyelids or behind the eyeball to block the ciliary
ganglion and nerves is known as:

(A) retrobulbar
(B) van Lint block
(C) O’Brien akinesia
(D) Bier block

23. A fleshy, triangular encroachment onto the cornea is surgically termed a/an:

(A) pterygium
(B) chalazion
(C) ectropion
(D) entropion

24. A procedure performed when the cornea is thickened or opacified is called a:

(A) keratomileusis
(B) keratotomy
(C) corneal trephining
(D) keratoplasty

25. What is the procedure used to correct accidental vitreous loss during a cataract extraction?

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 (A) Posterior vitrectomy
(B) Anterior vitrectomy
(C) Pars plana vitrectomy
(D) All of the above

26. A surgical treatment for chronic wide angle closure glaucoma that reestablishes communication between
the posterior and anterior chamber of the eye is:

(A) iridectomy
(B) Elliot trephination
(C) cyclodialysis
(D) posterior lid sclerectomies

27. What eye disease uses the argon slit lamp with a noninvasive procedure, which if successful, prevents the
need for more invasive surgery?

(A) Cataract
(B) Retinal detachment
(C) Glaucoma
(D) Pterygium

28. Removal of the entire contents of the orbit is:

(A) exenteration
(B) enucleation
(C) evisceration
(D) orbitectomy

29. A technique used for retinal detachment which involves a cold probe is:

(A) nitro therapy

(B) diathermy
(C) cryothermy
(D) cryodermy

30. Keratoplasty involves surgery of the:

(A) eyelid
(B) cornea
(C) iris
(D) retina

31. The photo receptive layer of the eye is:

(A) choroid

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 (B) cornea
(C) iris
(D) retina

32. The gel-like substance that fills the posterior chamber and nourishes the tissue layers is:

(A) vitreous humor

(B) aqueous humor
(C) conjunctiva
(D) Healon

33. A condition caused by inadequate drainage of aqueous humor is:

(A) retinal detachment

(B) glaucoma
(C) entropion
(D) cataract

34. Inflammation or infection of the lacrimal sac is:

(A) occularitis
(B) uveitis
(C) iritis
(D) dacryocystorhinitis

35. When using an anticholinergic, such as atropine, during eye surgery, the pupils will:

(A) dilate
(B) constrict
(C) have no effect on the pupil
(D) None of the above

36. Drugs that dilate the pupil but permit focusing are:

(A) cycloplegics
(B) mydriatics
(C) anesthetics
(D) viscoelastics

37. A transparent structure that permits the eye to focus rays to form an image on the retina is the:

(A) sclera
(B) retina
(C) cornea
(D) lens

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38. The purpose of the iris is to:

(A) regulate the amount of light entering the eye

(B) protect the iris
(C) supply the choroid with nourishment
(D) receive images

39. The structure that is seen from the outside as the colored portion of the eye is the:

(A) cornea
(B) pupil
(C) retina
(D) iris

40. The nerve that carries visual impulses to the brain is the:

(A) ophthalmic nerve

(B) optic nerve
(C) oculomotor nerve
(D) trochlear nerve

41. The white outer layer of the eyeball is the:

(A) conjunctiva
(B) sclera
(C) choroid
(D) retina

42. A jelly-like substance in the eye’s posterior cavity is called:

(A) choroid
(B) palpebra
(C) vitreous humor
(D) aqueous humor

43. The conjunctiva is the:

(A) colored membrane of the eye

(B) covering of the anterior globe except the cornea
(C) gland that secretes tears
(D) membrane lining the socket

44. Color blindness is caused by a defect in the:

(A) cones in the retina

(B) sclera

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 (C) iris
(D) lens

45. The function of the lacrimal duct system:

(A) provides drainage of the meibomian gland

(B) prevents pterygium
(C) helps the eyes to focus
(D) helps to maintain moisture in the eye

46. Bauman lacrimal duct probes are used for:

(A) dilatation
(B) to make a cylindrical cut on a keratoplasty
(C) used to measure intraocular pressure
(D) none of the above

47. When the eyes do not focus on the same object, this condition is called:

(A) extropia
(B) recession
(C) strabismus
(D) astigmatism

48. Recession is performed for:

(A) esotropia
(B) extropia
(C) obstruction of meibomian gland
(D) obstruction of the nasolacrimal duct

49. During a resection, the muscle that is shortened to treat wall eyes is:

(A) inferior oblique

(B) lateral rectus muscle
(C) levator
(D) superior oblique

50. All apply to a trephine EXCEPT:

(A) used to measure intraocular pressure

(B) instrument used to make the cylindrical cut in the corner
(C) used on a cadaver
(D) used on a keratoplasty

51. A radical keratotomy is:

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 (A) performed for myopia
(B) performed for nearsightedness
(C) Both A and B
(D) performed for farsightedness

52. What laser is commonly used for Lasik surgery?

(A) Excimer
(B) Argon
(C) Nd:YAG
(D) CO2

53. Removal of the eye contents leaving the sclera and muscle intact is:

(A) enucleation
(B) evisceration
(C) exenteration
(D) corneal transplant

54. Removal of the entire eyeball including muscles and nerves is called:

(A) enucleation
(B) exenteration
(C) evisceration
(D) corneal transplant

55. All are true for exenteration EXCEPT:

(A) Removal of entire orbital contents

(B) Removal of External structures of the eye
(C) Removal of the globe only
(D) Performed for malignancy

56. The fluid that fills the anterior and posterior chamber of the eye is:

(A) aqueous humor

(B) vitreous humor
(C) Both A and B
(D) None of the above

57. All are true of the canal of Schlemm EXCEPT:

(A) drains aqueous humor from the anterior chamber

(B) if blocked can cause glaucoma
(C) it is located between the lens and the retina

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 (D) it is located in the anterior chamber

58. All are procedures to treat glaucoma EXCEPT:

(A) goniotomy
(B) cyclodialysis
(C) iridectomy
(D) scleral buckle

59. Following a vitrectomy, the vitreous humor is removed and replaced with:

(A) saline
(B) gas
(C) Both A and B
(D) water

60. A mydriatic drug, Neo-Synephrine, is used to:

(A) constrict the pupil

(B) dilate the pupil
(C) anesthetize the eye
(D) lower intraocular pressure

61. Immobility of the eye, along with lowered intraocular pressure is facilitated by the use of:

(A) Diprivan block

(B) Versed block
(C) xylocaine block
(D) retrobulbar block

62. Miochol is a/an:

(A) antihistamine
(B) blood thinner
(C) miotic
(D) anti-inflammatory

63. An agent that keeps the cornea moist during surgery and is used for irrigation as well is:

(A) mannitol
(B) Miochol
(C) Chymar
(D) BSS

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427
 Answers and Explanations

1. (C) Sodium hyaluronate (Healon) is a viscous jelly sometimes used to occupy space and prevent damage
when opening the anterior capsule.

2. (A) Pilocarpine is a miotic. A miotic causes the pupil to contract.

3. (B) Tetracaine provides rapid, brief, and superficial anesthesia. It is widely used as a local ocular
anesthetic. It is the generic name for Pontocaine.

4. (B) Hyaluronidase is commonly added to an anesthetic solution. This enzyme increases diffusion of the
anesthetic through the tissue, thereby improving the effectiveness of the block.

5. (D) Balanced salt solution is an eye irrigant. It is used to keep the eye moist during surgery. It is supplied
in a sterile solution.

6. (D) Tetracaine produces surface anesthesia in eye surgery and is available in a 0.5% concentration for
this use. Pontocaine is the trade name for this topical solution.

7. (A) Mydriatics dilate the pupil while allowing the patient to focus. A cycloplegic drug also can dilate the
pupil, but it disturbs focusing ability.

8. (D) In extracapsular extraction, the phacoemulsifier is used in a microsurgical technique to remove the
lens. Ultrasonic energy fragments the hard lens, which can then be aspirated from the eye.

9. (B) Removal of a chalazion is the incision and curettage of a chronic granulomatous inflammation of one
or more of the meibomian glands of the eyelid.

10. (D) Chronic dacryocystitis in adults requires dacryocystorhinostomy to establish a new tear passageway
for drainage directly into the nasal cavity to correct deficient drainage with overflow of tears.

11. (A) A scleral buckling is the operative treatment for retinal detachment. The procedure is aimed at
preventing permanent vision loss by sealing off the area in which a hole or tear is located.

12. (C) Ectropion is the sagging and eversion of the lower lid. It is common in older patients and is
corrected by a plastic procedure that shortens the lower lid in a horizontal direction.

13. (C) Enucleation is removal of the entire eyeball. Evisceration is removal of the contents of the eye,
leaving the sclera intact.

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14. (A) Argon or Nd:YAG laser therapy is used to treat acute (angle-closure) glaucoma and open-angle
glaucoma. It is uncomplicated and utilizes a slit lamp for laser beam delivery. It is noninvasive and a
fairly uncomplicated out-patient procedure.

15. (B) Resection of part of the ocular muscle rotates the eye toward the functional muscle, and is
reattached. This strengthens it.

16. (C) In its normal state, the vitreous gel of the eye is transparent. In certain disease states, it becomes
opaque and must be removed.

17. (B) Miochol solution is used to constrict the pupil to prevent vitreous loss during a cataract extraction.
The Miochol solution must be used within 15 minutes after preparation. If complications arise, new
solution should be prepared.

18. (B) Healon functions as a lubricant and as a viscoelastic support maintaining a separation of tissues. It is
used in intraocular procedures to protect the corneal epithelium and as a tamponade.

19. (C) After the lens is removed slowly from the eye, the pupil is constricted with Miochol or Miostat if an
intraocular lens (IOL) is to be inserted.

20. (C) Radial keratotomy is the procedure used to correct myopia. A keroplasty and keratophakia are
procedures used to reshape the cornea with the use of donor corneal tissue.

21. (D) Wydase, also referred to as hyaluronidase, is an enzyme that increases tissue diffusion and
effectiveness of nerve blocks during ophthalmology procedures.

22. (A) Retrobulbar anesthesia is an injection of anesthetic solution into the base of the orbital margins or
behind the eyeball to block the ciliary ganglion and nerves.

23. (A) Pterygium is a fleshy, triangular encroachment onto the cornea and tend to be bilateral. When a
pterygium encroaches on the visual axis, it is removed surgically.

24. (D) A corneal transplant is grafting of corneal tissue from one human eye to another. This is known as
keratoplasty and is performed when one’s cornea is thickened or opaque because of disease or injury.

25. (B) Vitreous humor may accidentally enter the anterior cavity of the eye if a miotic drug is not used
during surgery. A vitreous catheter is placed through the cataract wound to remove vitreous humor and
not allow it to fill the anterior chamber. It is then constricted with acetylcholine.

26. (A) All of the procedures treat glaucoma. Iridectomy provides a communication between the anterior
and posterior chambers to relieve intraocular pressure.

27. (C) Argon or Nd:YAG laser therapy is being used to treat acute and open angle glaucoma. It is a
noninvasive procedure and may, if successful, prevent more invasive procedures.

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28. (A) Exenteration is the removal of the entire contents of the orbit.

29. (C) Cryothermy is a technique in which a cold probe is used to freeze tissue such as sclera, ciliary body,
or retinal detachment.

30. (B) Keratoplasty is surgery of the cornea. The term penetrating keratoplasty refers to corneal
transplantation.

31. (D) The innermost layer of the posterior globe is called the retina. The retina is the posterior receptive
layer of the eye. It records and transmits images to the brain via the optic nerve.

32. (B) Aqueous humor fills the anterior and posterior chambers of the eye.

33. (B) Glaucoma is a disease characterized by optic nerve and visual field damage usually caused by
inadequate drainage of aqueous humor.

34. (D) Dacryocystorhinitis is inflammation of the lacrimal sac and usually arises from an obstruction of the
lacrimal canal.

35. (A) Anticholinergic dilates the pupil and inhibits focusing.

36. (B) Mydriatics are drugs that dilate the pupil and permit focusing.

37. (D) The lens is a transparent, colorless structure in the eye that is biconvex in shape. It is enclosed in a
capsule. It is capable of focusing rays so that they form a perfect image on the retina.

38. (A) The purpose of the iris is to regulate the amount of light entering the eye. The pupil is the
contractile opening in the center of the eye.

39. (D) The iris is a thin, muscular diaphragm that is seen from the outside as the colored portion of the eye.

40. (B) The optic nerve carries visual impulses received by the rods and cones in the retina to the brain. This
is the second cranial nerve.

41. (B) The eyeball has three separate coats or tunics. The outermost layer is called the sclera and is made of
firm, tough connective tissue. It is known as the white of the eye.

42. (C) Vitreous humor helps maintain the eye’s conical shape and assists in focusing light rays. The
posterior cavity lies between the lens and the retina and contains a jelly-like substance called vitreous
humor, which helps prevent the eyeball from collapsing.

43. (B) Conjunctiva is the mucous membrane that lines the eyelids and covers the anterior surface of the
globe, except for the cornea. It is reflected onto the eyeball.

44. (A) Color blindness is caused by a defect with the cones in the retina. Sclera is the white part of the eye.
The iris contains the color of the eye. The lens allows the eye to focus.

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45. (D) The lacrimal duct system moistens the eye. The meibomian gland is a sebaceous gland at the rim of
the eyelids. The lens helps the eye to focus.

46. (A) These probes are used for dilatation. The instrument used to make the cylindrical cut in the
keratoplasty is a trephine. The instrument used to measure intraocular pressure is a tonometer.

47. (C) Strabismus is when the eyes are not straight and cannot focus on the same object because the
muscles are either too long or too short. Extropia is wall eyes. Recession is when the muscle is detached
from the surface of the eye and reattached further back. Astigmatism is an irregularly shaped cornea and
causes blurred and distorted vision.

48. (A) Esotropia requires a recession to fix crossed eyes. Extropia is wall eyes and requires a resection.
Obstruction of meibomian gland is a chalazion. Obstruction of the nasolacrimal duct is a blockage of
the duct.

49. (B) The lateral rectus muscle is shortened to treat wall eyes. The inferior oblique muscle pulls the eye
upward and laterally. The levator is the muscle of the upper eyelid. The superior oblique muscle
internally rotates the eye.

50. (A) A tonometer is used to measure intraocular pressure. A trephine is used to make a cylindrical cut on
a cadaver for a keratoplasty.

51. (C) A radical keratotomy is performed for myopia which is nearsightedness. There is no procedure to
correct farsightedness.

52. (A) The excimer laser is used for lasik surgery. The argon laser is used for glaucoma. The Nd:YAG is
commonly used in cataract surgery and acute angles glaucoma. The CO2 laser is used in other
specialties.

53. (B) Evisceration is removal of the eye content leaving the sclera and muscles intact.

54. (A) Enucleation is the removal of the entire eyeball.

55. (C) Exenteration includes removing the entire orbital contents, removal of external structures of the eye
and performed for malignancy.

56. (A) Aqueous humor fills the anterior and posterior chamber of the eye. Vitreous humor is in the vitreous
body.

57. (C) The canal of Schlemm is a circular channel and is located at the base of the cornea. It drains aqueous
humor from the anterior chamber of the eye and can cause glaucoma when blocked. The vitreous body
is located between the lens and the retina.

58. (D) A scleral buckle is performed to treat a detached retina.

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59. (C) The vitreous body can be filled only with saline solution and/or gas to help retain the shape of the
eyeball.

60. (B) Neo-Synephrine dilates the pupil.

61. (D) A retrobulbar block results in a quiet eye and also immobility of the eye and lowered intraocular
pressure.

62. (C) Miochol is a miotic used to constrict the pupil. It reduces intraocular pressure or in cataract surgery
helps prevent the loss of the vitreous.

63. (D) Balanced salt solution is used to keep the cornea moist during surgery and also is an irrigant for the
anterior or posterior segment.

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 ___________________ CHAPTER 21 ___________________

Otorhinolaryngology

Upper Facial Fractures

• The frontal bone is formed by the forehead and the upper part of the orbits and also contains the frontal
sinus. A fracture in this area is called displaced frontal fracture—dent in the forehead
Orbital floor fracture is also called a blowout fracture. A Le Fort III procedure is performed to correct
this type of fracture
Corneal eye protectors are used as a covering on the eye
Two incisions performed for this procedure include:
Subciliary—under the eye lashes
Transconjunctival—in the conjunctiva of the inferior eye lid
Instruments used for this procedure include:
Maxillofacial instruments
Small malleable retractors—brain spatula retractors
Periosteal elevators
#15 blades
• Zygomatic bone is also called the malar bone and cheek bone
A zygomatic fracture is commonly repaired with plates and screws and k-wires

Midface Fractures

• LE FORT l—this fracture includes the nasal floor, septum, and teeth. It is also called a mustache fracture
• This fracture is repaired with ARCH BARS—MAXILLOMANDIBULAR FIXATION—MMF:
Arch bars are used to realign the teeth, mandible, and maxilla
The arch bars can be left for a few weeks, or removed immediately after the procedure as long as the face
is stabilized with plates and screws
A thin metal strip is wired to the teeth and then to each other to with stainless steel
The wire gauge used is 24–26
The hooks on the arch bars are placed upward on the upper jaw and downward on the lower jaw
The steel wires are passed and threaded with heavy needle holders
Standard protocol is to insert the wires clockwise and remove them counterclockwise. In the event of an
emergency, where they need to be removed immediately, protocol can be followed
Wire cutters are kept with the patient at all times in the hospital and when they go home in the case of

433
 an emergency
The STSR should remain sterile and be prepared to perform an emergency tracheostomy if the patient
experiences respiratory difficulty
• Instruments used:
Arch bars
Maxillofacial instruments
Small malleable retractors—brain spatula retractors
Periosteal elevators
#15 blades
• The orbital floor defect is repaired with:
Bone grafts (autogenous or synthetic)
Nylon sheeting
Silastic sheeting
Molded metal implants
• LE FORT II—PYRAMID MAXILLARY FRACTURE—(frontal sinus fracture), involves the nasal
cavity, hard palate, and orbital rim
This fracture can be associated with cerebrospinal fluid leakage and herniation of brain tissue into the
nasal sinus
Neurosurgeon must be present
• Instruments include:
ENT
Maxillofacial power equipment
Neuro instruments
Raney clips are special neuro clips almost like a barrette while providing a form of retraction and
hemostasis
The frontal sinuses are checked to see if there is damage to them. Shattered pieces of bone are removed
with mosquito clamps. Bone may be gently shaved with a power burr
The surgeon will try to enter through existing wounds instead of creating a new incision
• LE FORT lll—ORBITAL FLOOR FRACTURE—BLOWOUT FRACTURE—CRANIOFACIAL
FRACTURE—discussed above
• MANDIBULAR FRACTURES—repair of facial fractures of the lower jaw
Plates, screws, K-wires, power equipment, maxillofacial instruments, and ENT/plastic instruments
MMF fixation—arch bars
Incision for the ORIF can include:
Gingival-buccal mucosa
Skin over fracture site
Periosteal elevators are used to repair the depressed fracture
• MAXILLOMANDIBULAR ADVANCEMENT (MMA)—this is performed to correct deformities of

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 the upper jaw (maxilla) and the lower jaw (mandible) by moving them forward. It is also used to correct:
Malocclusion—the upper jaw and lower jaw do not line up properly and cause the teeth to be misaligned
It is also used for sleep apnea
• ODONTECTOMY—tooth extraction
LABIAL—his is the side of the mouth/teeth closest to the lips
LINGUAL—the tongue
BUCCAL—refers to the cheek
THROAT PACKING—is used during an extraction to prevent aspiration and any debris from being
swallowed. This packing is part of the surgical count
• TEMPOROMANDIBULAR JOINT (TMJ)—this procedure is performed to reduce pain and increase
mobility of the joint which can cause:
Muscle tension
Grinding of the teeth
Malocclusion
Trauma

ENT

• The ear is divided into three parts. The external ear, middle ear, and inner ear
• Hearing is the last sense to disappear when you fall asleep and the first to return when you awaken
• INNER EAR—the inner ear is made up of a series of tunnels called LABYRINTHS. These are
responsible for the body’s equilibrium. The bony labyrinth consists of the:
Cochlea—snail-shaped structure which contains the organ of Corti
• THE MIDDLE EAR—extends from the tympanic membrane to the middle ear. It includes the
OSSICLES:
Malleus—hammer bone
Stapes—stirrup
Incus—anvil
These bones extend across the middle ear and conduct vibrations from the tympanic membrane through
oval window
• EXTERNAL EAR—the external ear includes:
The outer surface of the tympanic membrane
AURICLE OR PINNA—outer cartilage of the ear covered by skin
The external auditory canal is lined with glands that produce a waxy substance called CERUMEN. It
terminates at the tympanic membrane
• The Eustachian tube connects the nasopharynx to the middle ear
• Diagnostic testing for the ear includes:
Tuning fork
Audiometry

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 Otoscope—lighted instrument used to view the ear canal
CT scan
MRI
• NASAL ANATOMY—the nose is covered by skin and is made up of bone and cartilage
The external nares are the opening into the nose for the passage of air
The nostrils and the tip of the nose are made up of ALAR CARTILAGE
The SEPTUM separates the two nostrils.
The roof of the nose is formed by the NASAL BONE.
The floor is formed by the maxilla and palatine bones
The nasal cavity is lined with mucous membranes that aid in warming and humidifying air. The cavity
also contains small hairs that help filter out large particles
The nasal cavity is connected to the ear by the EUSTACHIAN TUBES
• CHOANAL ATRESIA—is a congenital disorder where the passageway between the nose and pharynx is
blocked by an abnormal bony tissue that closed during fetal development
The procedure performed to repair this defect is CHOANAL ATRESIA REPAIR
Instruments include:
SMR instrumentation
Power drills
Microdebrider
30-degree scope
• PARANASAL SINUSES—include:
MAXILLARY—paired sinuses below the orbits where the roots of teeth are located
FRONTAL—lie behind the lower forehead
ETHMOID—are in the roof of the nasal cavity between the lateral wall and the turbinates (on the side
of the nose by the eyes)
SPHENOID—lie above the ethmoid sinus and below the frontal sinuses
• ANTRUM—opening or a cavity
• ANTROSTOMY—surgical opening into the maxillary sinus performed to drain the sinus due to chronic
infection (SINUSITIS)
• ORAL CAVITY—is composed of the mouth and the salivary glands
The mouth is formed by the cheeks, hard palate, mandible, and tongue
The HARD PALATE forms the top of the mouth. It is formed by the maxilla and palatine bones
The MANDIBLE AND FLOOR OF THE MOUTH form the lower boundary of the oral cavity
• SALIVARY GLANDS—include:
SUBLINGUAL—these glands lie underneath the tongue beneath the mucous membrane on the floor
of the mouth and the side of the tongue
SUBMANDIBULAR—these glands lie slightly above and slightly below the posterior half of the
mandible

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 The submandibular duct is known as WHARTON’S DUCT
• PAROTID—is the largest of the salivary glands. It lies below the cheek bone in front of the mastoid
process and behind the ramus of the mandible
The PAROTID DUCT is known as STENSEN’S DUCT
During parotid surgery it is important to preserve the seventh cranial nerve (facial nerve) and its
branches
• PAROTIDECTOMY—this procedure is performed to remove a tumor, treat recurrent parotiditis and/or
obstruction of saliva from the parotid gland
The incision is made in the upper neck in front of the earlobe
You must be careful not to damage the seventh cranial nerve—facial nerve.
• PHARYNX—is a tubular structure that extends from the nose to the esophagus and is separated into
three areas:
NASOPHARYNX
OROPHARYNX—tonsils are situated on each side of the oropharynx
HYPOPHARYNX—LARYNGOPHARYNX
• LARYNX—the larynx has three main functions that include:
Passageway for respiration
Prevents aspiration
Vibratory source for vocalization
• It is divided into three portions that include:
SUPRAGLOTTIS—upper portion above the true vocal cords
GLOTTIS—level of the true vocal cords
SUBGLOTTIS—below the true vocal cords
• The larynx consists of nine separate cartilages. Three are stand alone and six are arranged in pairs they
include:
CRICOID
THYROID—ADAM’S APPLE
EPIGLOTTIS
TWO ARYTENOID
TWO CORNICULATE
TWO CUNEIFORM
• LARYNGEAL SURGERY—this surgery is performed for diagnostic purposes and/or treatment for
malignant/benign tumors
It can be performed endoscopically or open
The larynx is also called the ADAM’S APPLE
Laryngitis is an inflammation of the vocal cords
• LARYNGOSCOPY—this procedure is performed for direct visual examination of the larynx
A rigid lighted scope is used (laryngoscope)

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• LARYNGECTOMY—is performed for partial/total removal of the larynx caused by malignant tumors
and trauma to the larynx
Once the larynx is removed the person will breathe out of a permanent opening called a STOMA
TOTAL LARYNGECTOMY includes:
Complete removal of the larynx
Hyoid
Strap muscle
PARTIAL LARYNGECTOMY includes:
Partial removal of the larynx
• LASER SURGERY OF THE LARYNX—CO2 LASERS, HELIUM, and NITROGEN are used to
treat lesions of the larynx and vocal cords
The combination of these lasers is used to destroy target tissue at the precise point without damaging
surrounding tissue
STAINLESS STEEL and COPPER ENDOTRACHEAL TUBES are wrapped with adhesive tape
to prevent a fire
Wet gauze is placed above the cuff
Cloth towels are placed around the surrounding tissue to prevent damaging healthy tissue
• NASOPHARYNGOSCOPE—this is performed with a fiber optic scope used for visualization of the
vocal cords for nodules, polyps, removal of a foreign body or for a diagnosis
• TRACHEA—is composed of incomplete c-shaped rings of hyaline cartilage
• TRACHEOSTOMY—is the opening into the trachea through a midline incision at a point below the
cricoid cartilage. A cannula is inserted and used to treat upper respiratory obstruction
This includes:
Chronic lung disease
It can be temporary/permanent
Radical neck procedures
Severe edema
Vocal cord paralysis
Trauma
Allergic reactions
• Procedure:
Supine position with the neck hyperextended
Local—Lidocaine with epinephrine
#15 blade, blunt dissection with a clamp through the platysma, and strap muscle
The trachea is lifted with the trach hook
Once the trachea is identified, an #11 blade is used to make a puncture through the second and third
tracheal rings
1% Lidocaine is injected into the trachea to reduce the coughing reflex as the tube is being inserted. A

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 trach spreader is used to open the incision for visualization
The tracheostomy tube is placed
The obturator/cannula is removed and the balloon is inflated
The tracheostomy tube is immediately suctioned with a catheter
The mouth is suctioned with a Yankauer suction
The trach is suctioned with a thin flexible catheter
Patient is connected to ventilator
• BRONCHOSCOPY—is performed to visualize the trachea, bronchi, and lungs. It is also performed for
removal of a foreign body, and diagnosis. This procedure can be performed with:
FLEXIBLE BRONCHOSCOPE—the patient is given topical anesthesia and is placed in a sitting
position
RIGID BRONCHOSCOPE—the patient is given general anesthesia and is placed in supine position
• ESOPHAGOSCOPY—direct visualization of the esophagus and stomach
This is performed to remove tissue, secretions, tumors, and foreign bodies
A RIGID ESOPHAGOSCOPE or GASTROSCOPE is used
• TONSILLECTOMY AND ADENOIDECTOMY —this procedure is performed for enlarged infected
tonsils. They are made up of lymphoid tissue
PHARYNGEAL TONSILS—are also known as the ADENOIDS
PALATINE TONSILS—are known as the TONSILS
TONSILITIS and be acute or chronic
They become infected by the STREPTOCCAL MICROORGANISM
• Procedural instrumentation includes:
Davis Mouth Gag or Jennings Mouth Gag—used to hold the mouth open
Wieder tongue depressor
Robinson catheter—used to retract the uvula. It is inserted through the nose to the throat
Tonsils are grasped with a long curved Allis and extracted with a scalpel, tonsil snare, cautery, scissors,
or the COBLATOR
COBLATOR—this is an instrument that uses radio frequency energy combined with saline to remove
the target tissue
Adenoids are removed with an adenotome, curettes, and Hurd dissector
Yankauer suction tip
Hurd dissector
Pilar retractor
• The position of the patient following a T&A is lateral with the head of the bed slightly raised
• FACIAL NERVE MONITORING—this is used during head and neck surgery to identify nerves and
prevent damage to them. Important nerves of the head and neck include:
FIFTH CRANIAL NERVE—TRIGEMINAL—supplies sensory to the face, oral cavity, nose, nasal
cavity, and maxillary sinus

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 SEVENTH CRANIAL NERVE—RIGHT/LEFT FACIAL NERVE—responsible for all the
movements of the facial muscles
EIGHTH CRANIAL NERVE—VESTIBULOCOCHLEAR—connects the inner ear to the brain
TENTH CRANIAL NERVE—VAGUS—important motor nerve of the pharynx and larynx
• MYRINGOTOMY—this procedure is performed for EFFUSION
EFFUSION—is an abnormal accumulation of fluid between membranes causing ACUTE OTITIS
MEDIA
OTITIS MEDIA—inflammation of the middle ear with fluid and infection
This can also be caused by congenital anomalies that include enlarged adenoids
• An incision is made in the pars tensa of the tympanic membrane with a myringotomy knife
• Fluid is suctioned with a Frazier suction tip and small hollow tubes are placed
• These tubes are called:
PETs—PRESSURE EQUALIZATION TUBES
MYRINGOTOMY TUBES
TYMPANOSTOMY TUBE
• If left untreated it can cause hearing loss, delayed language development, and MASTOIDITIS
• MASTOIDITIS—inflammation of the mastoid process of the temporal bone
• PROCEDURE:
Microscope/surgeons loops are used
Supine position, head turned and placed in a donut headrest
No prep/drape
Farrier speculum is inserted into the ear
Wax is removed with a cerumen curette
Incision with myringotomy blade/knife
Tube is placed with an alligator forceps
Rosen needle facilitates placement of the tube
Antibiotics/steroid drops placed into the ear
External ear is packed with cotton
• TYMPANOPLASTY—this procedure is performed to repair the tympanic membrane
Commonly caused by trauma
Graft is usually taken from the temporalis fascia
Drills/microcurettes are used
Drills are irrigated with sterile water to prevent heat from the burrs that can cause damage to
surrounding tissues
The graft is inserted with alligator forceps
Gelfoam packing is used to secure the graft
The external ear is packed with gelatin sponge pledgets which are soaked in epinephrine and antibiotic
ointment

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• MASTOIDECTOMY—this is performed to remove a diseased portion of the mastoid bone
This procedure is performed for the treatment of CHOLESTEATOMA
CHOLESTEATOMA—is a crystal encrusted accumulation of squamous epithelium that forms a mass
in the cells of the mastoid process
• STAPEDECTOMY—it is performed to restore the ossicular chain
The stapes bone becomes fused and prevents it from vibrating and carrying impulse. One of the main
causes of this is OTOSCLEROSIS
OTOSCLEROSIS—is an abnormal bone growth/hardening of bone that holds the stapes in place
After a stapedectomy, the patient is instructed to avoid blowing the nose, coughing, sneezing,
swimming, and air travel
Various materials used as prostheses for the stapes include:
Stainless steel
Platinum
Teflon
Fine hooks in different angles are used to dissect during a stapedectomy
• MENIERE’S DISEASE—a disease of the inner ear with dizziness and TINNITIS
• TINNITUS—buzzing or ringing in one or both ears with progressive hearing loss
• Procedures performed for Meniere’s disease include:
LABYRINTHECTOMY
ENDOLYMPHATIC SAC PROCEDURE
VESTIBULAR NEURECTOMY
• LABYRINTH—this is made up of three compartments they include:
Vestibule
Semicircular canals
Cochlea
• The principal organs that control equilibrium are the vestibule and semicircular canal
• BELL’S PALSY—is an unknown virus that affects the seventh cranial nerve. The seventh cranial nerve
controls facial muscles where one side becomes swollen or inflamed. The face feels stiff and can droop
causing your smile to be one sided and can prevent your eye from closing properly
The procedure performed for the treatment of severe cases of Bell’s palsy is FACIAL NERVE
DECOMPRESSION—this procedure is performed to relieve compression of the facial nerve (seventh
cranial nerve)
Trauma
Infection
Tumors
Bell’s palsy
• MICROVASCULAR DECOMPRESSION SURGERY—this is performed to prevent a blood vessel
from compressing the trigeminal nerve

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• ACOUSTIC NEUROMA—VESTIBULAR SCHWANNOMA—are slow growing nonmalignant
tumors of the eighth cranial nerve. Treatment includes:
Radiation therapy
Surgery—there are three approaches used:
Translabyrinthine approach
Suboccipital approach
Middle fossa approach
• TRIGEMINAL NEURALGIA—is a condition with episodes of facial pain that last from a few seconds
to several minutes or hours
• Pain runs along the trigeminal nerve
• This is controlled with medication. Severe cases may require surgery
• COCHLEAR IMPLANTS—this procedure is performed for sensory neural deafness to restore sound
perception and to treat deafness
Deafness can be either congenital or acquired
The primary reason for placing a cochlear implant in a child is to treat congenital deafness
The device is implanted in the cochlea with the receiver placed in the mastoid process
As the device receives sound through the receiver, it gives off electrical impulses into the cochlea and
along the acoustic nerve
These impulses are interpreted as sound in the brain. The patient must be taught to interpret these
sounds which require training
• SUBMUCOUS RESECTION (SMR)—NASOSEPTOPLASTY
This procedure is performed when the nasal septum is damaged, deformed, or fractured causing an
obstruction of the sinus opening
COCAINE is a topical medication commonly used before nasal surgery and most commonly used in
ENT surgery
• A MOUSTACHE DRESSING—is used following nasal surgery
The nose is packed using bayonet forceps and packing. Tape is placed on the nose and under the nose to
block the nasal opening like a moustache
Instruments include:
BAYONET FORCEPS
FREER ELEVATOR
COTTLE SPECULUM
RASP
CHISELS and MALLOT
JENSEN–MIDDLETON FORCEPS
• TURBINECTOMY—this procedure is performed to improve nasal air flow. Enlargement of the
turbinate causes congestion and rhinorrhea
• RHINORRHEA—persistent discharge of the nose

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• CLOSED REDUCTION OF A NASAL FRACTURE—caused by trauma to the midface usually both
nasal bones are fractured
Simple nasal fractures are repaired with local and topical anesthesia
A Joseph elevator and the surgeon’s hands are used to repair the fracture
Nasal packing and a splint are used to stabilize the reduction
• EPISTAXIS—(nose bleed) treatment includes:
Direct pressure by squeezing the nasal openings for about 15 minutes
For more severe nose bleeds where the patient needs to go to the emergency room, the nose is packed
using packing soaked in epinephrine
A balloon catheter can also be used to apply pressure to the bleeder
In serious cases, the patient may require endoscopic surgery to cauterize and control the bleeding and
perhaps to have artery ligation surgery
• FUNCTIONAL ENDOSCOPIC SINUS SURGERY—FESS
This procedure is performed to treat diseases of the paranasal sinuses, nasal cavity, skull base and to
improve nasal air flow
Lidocaine with epinephrine is injected
Packing with decongestant is inserted in the nose for a few minutes then removed.
Scopes used are : 0, 30, 70, 90, and 120 degrees
Most commonly used scope is the 0 degree
Nasal drills
Cautery
• FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)—this procedure becomes more difficult if
it needs to be repeated a second time because the surgical landmarks have been altered with the first
surgery
• ENDOSCOPIC POLYPECTOMY—polyps are benign tumors that grow on a stalk and can be found on
mucous membranes
The surgeon uses a nasal polyp snare or microdebriders. A morcellator breaks up the polyps into tiny
pieces and suctions at the same time
• FRONTAL SINUS TREPHINATION—a small opening is made in the frontal sinus to drain pus and
fluid. A drain may be placed for additional drainage
The word TREPHINATION is a surgical procedure where a hole is drilled, or scraped into the skull
bone
Symptoms are severe headache and fever
• CALDWELL–LUC—WITH RADICAL ANTROSTOMY—this procedure is performed to create an
opening into the maxillary sinus for gravity drainage due to infection, polyps or disease of the maxillary
sinus
The CALDWELL–LUC is the approach used. The incision is in the CANINE FOSSA
CANINE FOSSA—under the upper lip into the gum

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• RADICAL NECK DISSECTION—this is performed for squamous cell carcinoma and/or metastatic
lesions of the mouth and jaw
The structures removed include:
Cervical lymph nodes
Jugular vein
Sternocleidomastoid muscle
A trifurcate neck incision is performed
This procedure is performed en bloc
A Hemovac drain is placed in the wound
To repair the mandible a bone graft can be taken from the fibula
Pectoralis major and other muscles are also used for reconstruction

THYROID AND PARATHYROID

• THYROID GLAND—is a highly vascular butterfly/H-shaped GLAND that lies in the anterior portion
of the neck at the midline of the trachea
It consists of a right and left lobe connected which are connected by a middle portion called the
ISTHMUS
The thyroid produces two hormones which are:
Thyroxine—T4
Triiodothyronine—T3
Thyroid function is controlled by the PITUITARY gland located beneath the brain
The PITUITARY GLAND produces a hormone called TSH (THYROID STIMULATING
HORMONE) which stimulates the thyroid to produce T3 and T4
• THYROID ASSESSMENT includes:
Palpation of the thyroid
CT, MRI, US
Thyroid scan
Fine-needle aspiration
• THYROID SCAN—determines the size/shape/position of the gland
This procedure is performed in nuclear medicine
They use radioactive material called RADIOTRACERS which include:
RADIOACTIVE IODINE
TECHNETIUM 99M
The radiotracers are injected into a vein or ingested and go directly to the thyroid cells
The radioactive iodine is given and a butterfly image appears on the screen showing the outline of the
thyroid gland and can determine whether a nodule is considered hot or cold
• NODULES—are an abnormal growth of thyroid cells that form a mass. They can be hot or cold
Hot nodule—show up darker (absorb more iodine)

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 Cold nodule—show up lighter (do not absorb as much iodine)
• HOT NODULES—these nodules absorb the radiotracer and will show up darker on the screen. These
are considered to be HOT nodules and function independently. They overproduce the TSH hormone
which can lead to hyperthyroidism
• COLD NODULES—they are hypofunctional or nonfunctional. These nodules appear lighter because
they do not absorb the iodine
• GOITER—refers to an enlarged thyroid gland. These can contain nodules both benign and malignant. It
looks like a large lump in the front of the neck
• ULTRASONIC SCAN—this test determines the size, shape, and number of nodules. This procedure
also helps when needle placement is required for the FINE-NEEDLE ASPIRATION procedure
• FINE-NEEDLE ASPIRATION—this is the only true diagnostic test currently available to determine
thyroid cancer. The procedure is performed under ultrasound guidance. Several samples are taken from the
nodule
• HEMITHYROIDECTOMY/UNILATERAL THYROIDECTOMY—removal of one thyroid lobe
with excision of the isthmus
• TOTAL THYROIDECTOMY—removal of both lobes of the thyroid and all thyroid tissue. This is
performed for thyroid cancer. It is extremely important during thyroid surgery NOT to remove the
parathyroid glands
If there are lymph nodes present they are also excised
• GRAVES DISEASE—this is the most common form of HYPERTHYROIDISM. This is an
autoimmune disease that causes the thyroid to secrete excessive amounts of the thyroid hormones. This
can result in:
A goiter
Protruding eyes
Palpations
Excessive sweating
Diarrhea
Weight loss
Muscle weakness
Sensitivity to heat
• HASHIMOTO’S DISEASE—this is a disease caused by HYPOTHYROIDISM causing obstruction of
the trachea. Symptoms include:
Fatigue and sluggishness
Increased sensitivity to cold
Constipation
Unexplained weight gain
Muscle aches
• PARATHYROID GLAND—consists of four small endocrine glands located on the rear surface of the

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 thyroid gland
The parathyroid gland produces a hormone called the PARATHYROID HORMONE. This hormone
controls the amount of CALCIUM in the blood and the bones
Because the parathyroid controls calcium production and absorption, the surgeon must be very careful
during thyroid surgery not to accidentally remove any of the parathyroid
• PARATHYROID ASSESSMENT—one of the biggest concerns with parathyroid malfunction is
HYPOCALCEMIA
HYPOCALCEMIA—lower than normal calcium levels in the blood causing a number of symptoms
which include:
Muscle weakness/atrophy
Back/joint pain
Nausea/vomiting/constipation
Ulcers
Cardiac issues
• TETANY—a disease caused by hypocalcemia
• Laryngeal spasms—a complication the patient having neck procedures may experience. Laryngeal spasms
cause respiratory problems. A TRACH SET should always be available and accompany the patient to the
PACU in the event of an emergency
• THYROID STORM—refers to an acute hyperthyroid period. The thyroid levels have changed drastically
for the worst and can be life threatening
• Positioning for thyroid/parathyroid surgery includes:
Patient is in supine position
Neck is hyperextended
Arms are tucked at the side and a shoulder roll is placed
Transverse incision/COLLAR INCISION is used
• INSTRUMENTATION/PROCEDURE:
The skin flaps are retracted with stay sutures which are usually silk
THE STRAP AND PLATYSMA MUSCLES ARE INCISED WITH A KNIFE
THE STERNOCLEIDOMASTOID MUSCLES ARE RETRACTED with a loop retractor or a
self-retaining retractor
Allis/Lahey clamps are used to grasp the thyroid
Moist peanuts are used for blunt dissection
Dressings include: Queen Anne’s Collar, thyroid dressing and a Jackson–Pratt drain
• It is extremely important to preserve the RECURRENT LARYNGEAL NERVE during thyroid surgery
• NERVE STIMULATOR—this device delivers mild shocks to a part of tissue identifying the nerves
before cutting. The recurrent laryngeal nerve is identified using the nerve stimulator
RECURRENT LARYNGEAL NERVE—this is a branch of the vagus nerve which is the 10th cranial
nerve

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 If there is UNILATERAL damage the patient will be hoarse
If there is BILATERAL damage the patient may not be able to speak and have difficulty breathing
• THYROGLOSSAL DUCT CYST—congenital cyst found in the neck. The thyroglossal duct is an
embryonic structure arising from the thyroid gland into the anterior portion of the neck and forming a
cystic pouch
• NECK DISSECTION—this is performed for lymph node metastasis, head and neck cancers, malignant
melanoma, or metastasis of the cervical lymph nodes
• Procedure includes:
Trifurcate neck incision is used
Patient in supine position
• The classical radical neck dissection encompasses removal of these structures on one side of the neck that
include:
The lymph nodes
Carotid artery
Vagus nerve.
Phrenic nerve
Brachial plexus
Internal jugular vein
Anterior scalene muscle
External jugular vein, inferior aspect cut and ligated
Hypoglossal nerve
Sternocleidomastoid muscle
• GLOSSECTOMY—performed to treat cancer of the tongue which can be a partial or hemi removal

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 Questions

1. Which dressing is used after nasal surgery?

(A) Collodion
(B) Moustache
(C) Pressure
(D) Telfa

2. What combination of lasers is particularly useful in surgery of the larynx and vocal cords?

(A) CO2 and argon

(B) CO2 and helium–neon
(C) CO2 and Nd:YAG
(D) Argon and helium–neon

3. The most common topical anesthetic agent used in ENT surgery is:

(A) Xylocaine
(B) Procaine
(C) Cocaine
(D) Surfacaine

4. Irrigation is used with the ear drill:

(A) to remove bone fragments

(B) to minimize transfer of heat from burr to surrounding structures
(C) to add moisture
(D) to control bleeding

5. A surgical schedule would describe the procedure to treat acute otitis media as a:

(A) myringotomy
(B) stapes mobilization
(C) fenestration operation
(D) Wullstein procedure

6. In myringotomy, the tube to facilitate drainage is placed into the tympanic membrane with a/an:

(A) alligator forceps

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 (B) Castroviejo
(C) wire loop curette
(D) Tobey forceps

7. A perforated eardrum is corrected by:

(A) myringotomy
(B) stapedectomy
(C) stapedotomy
(D) tympanoplasty

8. Severe vertigo may be relieved by:

(A) stapedectomy
(B) myringotomy
(C) labyrinthectomy
(D) mastoidectomy

9. Middle ear ventilation is facilitated by:

(A) antrostomy
(B) myringotomy
(C) stapedectomy
(D) turbinectomy

10. Cholesteatoma is treated by doing a:

(A) tympanoplasty
(B) myringotomy
(C) stapedectomy
(D) mastoidectomy

11. A benign tumor arising from the eighth cranial nerve, which may grow to a size that produces
neurological symptoms, is a/an:

(A) myoma
(B) acoustic neuroma
(C) teratoma
(D) fibroma

12. Facial nerve trauma can be decreased by use of:

(A) computerized nerve monitor

(B) fluoroscopy
(C) Berman locator

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 (D) Doppler

13. Another name for submucous resection is:

(A) septoplasty
(B) rhinoplasty
(C) antrostomy
(D) trephination

14. Surgical correction of a deviated septum is known as a/an:

(A) antrostomy
(B) submucous resection
(C) rhinoplasty
(D) turbinectomy

15. A forceps used in nasal surgery is a/an:

(A) bayonet
(B) Russian
(C) rat-tooth
(D) alligator

16. Which sinus is entered during an intranasal antrostomy (antral window)?

(A) Ethmoid
(B) Sphenoid
(C) Maxillary
(D) Frontal

17. Nasal polyps are removed with either a polyp forceps or a/an:

(A) Antrum rasp

(B) Coakley curette
(C) Freer elevator
(D) nasal snare

18. Which of the following medications would be used as a topical anesthetic before nasal surgery?

(A) Numorphan
(B) Codeine
(C) Cocaine
(D) Marcaine

19. Which surgery requires an incision under the upper lip above the teeth?

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 (A) Caldwell–Luc
(B) Submucous resection
(C) Frontal sinus operation
(D) Frontal sinus trephination

20. To establish a tracheostomy, a midline incision is created in the neck, below the:

(A) suprasternal notch

(B) hyoid bone
(C) cricoid cartilage
(D) corniculate cartilage

21. Which medication is found on a tracheostomy setup to reduce the coughing reflex at tube insertion?

(A) Cocaine 4%
(B) Lidocaine 1%
(C) Cocaine 10%
(D) Lidocaine 10%

22. When a tracheostomy tube is inserted, the obturator is quickly removed and the trachea is suctioned
with a:

(A) catheter
(B) Frazier
(C) Poole
(D) Yankauer

23. The majority of benign salivary gland tumors occur in which gland?

(A) Sublingual
(B) Submaxillary
(C) Parotid
(D) Submandibular

24. Which position is used following a tonsillectomy?

(A) Dorsal recumbent

(B) On side, horizontally
(C) Reverse Trendelenburg
(D) Supine

25. Total laryngectomy includes all of the following EXCEPT:

(A) soft palate

(B) strap muscles

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 (C) hyoid bone
(D) larynx

26. What mode would be utilized to maintain drainage postoperatively in radical neck surgery?

(A) Penrose drain

(B) Hemovac
(C) Sump drain
(D) T-tube

27. A trifurcate neck incision is done for a/an:

(A) parotidectomy
(B) submaxillary gland excision
(C) uvulopalatopharyngoplasty
(D) radical neck dissection

28. During ear surgery, pledgets generally used to control bleeding are soaked in:

(A) saline
(B) heparin
(C) thrombin
(D) epinephrine

29. In cochlear implantation, the receiver is placed into which bone of the skull to gather impulses and send
it along to the cerebral cortex?

(A) Parietal
(B) Mastoid
(C) Occipital
(D) Frontal

30. Which of the following endotracheal tubes can prevent a fire?

(A) Stainless steel

(B) Silicone
(C) Latex
(D) Red rubber

31. Lesion of the larynx and vocal cords can be addressed surgically using which laser?

(A) Nd:YAG
(B) Holmium
(C) CO2
(D) Argon

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32. Which degree endoscope is used ONLY in maxillary sinus surgery?

(A) 30 degrees
(B) 70 degrees
(C) 90 degrees
(D) 120 degrees

33. What is the instrument used to effect removal of the septal cartilage in a rhinoplasty?

(A) Knight nasal scissor

(B) Joseph nasal scissor
(C) Jansen–Middleton forceps
(D) Freer septum knife

34. After the anterior pillar of a tonsil is incised with a #12 blade, the tonsil is freed from its attachments
with a:

(A) Sluder guillotine

(B) La Force guillotine
(C) Hurd dissector
(D) Boettcher scissors

35. What is the most effective barrier to stop laser energy from penetrating healthy tissue?

(A) Proper use of goggles

(B) Covering reflective windows
(C) Checking laser equipment after each use
(D) Moist padding of surrounding tissue

36. A safer alternative laser retardant endotracheal tube used for CO2 laser surgery of the larynx is made of:

(A) copper
(B) stainless steel
(C) silicone
(D) Both A and B

37. Plates and screws are the primary means of repairing facial fractures. What is the order of
instrumentation used for this procedure?

(1) Power drill with drill bit, (2) placement of plate, (3) placement of screws, (4) depth gauge
(A) 1, 2, 3, 4
(B) 2, 3, 4, 1
(C) 3, 4, 1, 2
(D) 2, 1, 4, 3

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38. Maxillomandibular fixation (MMF) is a procedure used to realign the teeth or to maintain the patients
normal bite position. Which of the following is used during MMF?

(A) Arch bars

(B) Bicoronal plate
(C) Bicortical screw
(D) Plates and screws

39. If arch bars remain in the patient postoperatively, what must be kept with the patient at all times to
access the airway in case of emergency?

(A) Endotracheal tube

(B) Nasoendotracheal tube
(C) Wire cutter
(D) Tracheostomy tray

40. What type of facial fracture is associated with the leakage of cerebrospinal fluid into the nasal sinus?

(A) Le Fort I
(B) Le Fort II
(C) Le Fort III
(D) Le Fort IV

41. What is the facial bone that makes up the chin?

(A) Frontal
(B) Zygomatic
(C) Maxilla
(D) Mandible

42. Temporal mandibular joint (TMJ) arthroplasty is performed for all of these disorders EXCEPT:

(A) grinding of the teeth

(B) trauma
(C) wisdom teeth
(D) arthritis

43. During a thyroidectomy, the surgeon identifies and preserves which of the following structure(s):

(A) recurrent laryngeal

(B) parathyroid glands
(C) superior laryngeal
(D) All of the above

44. What is the primary reason for performing a thyroplasty?

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 (A) Facial nerve paralysis
(B) Unilateral vocal cord paralysis
(C) Goiter
(D) Tumor in the lymph nodes

45. During a parotidectomy, what cranial nerve is carefully elevated and retracted in order to preserve it?

(A) Vagus
(B) Optic
(C) Oculomotor
(D) Facial

46. Epistaxis can be defined as:

(A) gene interaction

(B) bleeding from the nose
(C) congenital urethral defect
(D) extrachromosomal replication

47. The vocal cords are located in the:

(A) larynx
(B) pharynx
(C) windpipe
(D) trachea

48. The function of the trachea is to:

(A) conduct air into the larynx

(B) serve as a pathway for food into the esophagus
(C) serve as a resonating chamber for speech
(D) conduct air to and from the lungs

49. The nasal cavity is divided into two portions by the:

(A) concha
(B) septum
(C) ethmoid
(D) vomer

50. The lower jawbone is the:

(A) maxilla
(B) mandible
(C) mastoid

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 (D) zygoma

51. The bone located in the neck between the mandible and the larynx, which supports the tongue and
provides attachment for some of its muscles, is the:

(A) palatine bone

(B) vomer
(C) pterygoid hamulus
(D) hyoid bone

52. The structure that connects the middle ear and the throat, allowing the eardrum to vibrate freely is the:

(A) membranous canal

(B) external auditory canal
(C) Eustachian tube
(D) semicircular canal

53. The great sensory nerve of the face and head is the:

(A) trochlear
(B) oculomotor
(C) hypoglossal
(D) trigeminal

54. Which of the following structures transmits sound vibrations to the inner ear?

(A) external auditory canal

(B) tympanic membrane
(C) semicircular canal
(D) stapes

55. The winding, cone-shaped tube of the inner ear is the:

(A) vestibule
(B) semicircular canal
(C) labyrinth
(D) cochlea

56. Which of the following is not an auditory ossicle?

(A) cochlea
(B) stapes
(C) incus
(D) malleus

57. Why would an aspirated foreign body be more likely to enter the right bronchus rather than the left

456
 bronchus?

(A) The right bronchus is more vertical, shorter, and wider than the left
(B) The division of the right bronchus is wider
(C) The right bronchus is longer
(D) The left bronchus is not in line with the trachea

58. Adenoids are also called:

(A) palatine tonsils

(B) pharyngeal tonsils
(C) lingual tonsils
(D) uvula

59. The function of the molar teeth is to:

(A) tear and crush food

(B) crush and grind food
(C) cut food
(D) manipulate food

60. Mumps occur in the:

(A) sublingual glands

(B) submandibular glands
(C) parotid glands
(D) thyroid gland

61. The salivary glands located under the tongue are the:

(A) subungal
(B) sublingual
(C) submaxillary
(D) parotid

62. An orbital floor fracture is also called a:

(A) blowout fracture

(B) Le Fort III
(C) Le Fort II
(D) Both A and B

63. The zygomatic bone is also called the:

(A) orbit bone

(B) cheek bone

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 (C) chin bone
(D) jawbone

64. All are true facts regarding MMF except:

(A) the wire gauge commonly used is 24–26

(B) the steel wires are threaded and twisted with a heavy needle holder
(C) standard protocol is to insert the wires counter clock wise and remove them clockwise
(D) the hooks on the arch bars are placed upward on the upper jaw and downward on the lower jaw

65. Maxillomandibular Advancement is performed for:

(A) to correct deformities of the upper and lower jaw

(B) malocclusion
(C) sleep Apnea
(D) All of the above

66. The _____ is the side of the mouth/teeth closest to the lips, the _____ side of the mouth contains the
tongue, and the _____ side of the mouth refers to the cheek side of the mouth:

(1) Buccal, (2) labial, and (3) lingual

(A) 2, 3, 1
(B) 1, 2, 3
(C) 3, 1, 2
(D) 2, 1, 3

67. The bony labyrinths in the inner ear are responsible for:

(A) equilibrium
(B) vibration
(C) TMJ
(D) the production of cerumen

68. The external ear terminates at the:

(A) pars tensa

(B) ossicles
(C) tympanic membrane
(D) cochlea

69. The congenital disorder where the passage between the nose and pharynx is blocked by an abnormal
bony tissue that failed to rupture during fetal development is termed:

(A) dacryocystorhinostomy
(B) choanal atresia

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 (C) SMR
(D) septoplasty

70. All are paranasal sinuses EXCEPT:

(A) Maxillary
(B) Ethmoid
(C) Nasopharynx
(D) Sphenoid

71. The submandibular duct is also known as:

(A) Stensen’s duct

(B) Parotid duct
(C) Wharton’s duct
(D) duct of Wirsung

72. The tubular structure that extends from the nose to the esophagus and is separated into three divisions is
termed:

(A) Larynx
(B) Pharynx
(C) Esophagus
(D) Epiglottis

73. The part of the larynx where the true vocal cords are located is the:

(A) supraglottis
(B) glottis
(C) subglottis
(D) cricoid

74. The adenoids are also known as the:

(A) Pharyngeal tonsils

(B) True tonsils
(C) Palatine tonsils
(D) Both A and B

75. During a T&A the uvula is retracted with:

(A) Davis
(B) Jennings
(C) Robinson
(D) coblator

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76. The graft used for a tympanoplasty procedure is taken from the:

(A) middle ear

(B) pina
(C) temporalis fascia
(D) pars tensa

77. All apply to the stapedectomy procedure except:

(A) the stapes bone becomes fused and prevents it from vibrating and carrying an impulse
(B) otosclerosis is the cause for a stapedectomy
(C) prosthesis used for a stapedectomy include Silicone and plastic, stainless steel is contraindicated for
use
(D) fine hooks in various angles

78. All are true regarding Meniere’s disease except:

(A) it is a disease of the inner ear

(B) it is a disease of the middle ear
(C) symptoms include dizziness
(D) symptoms include tinnitus

79. The virus that affects the seventh cranial nerve and causes stiffness and drooping of one side of the face
is termed:

(A) Bell’s Palsy

(B) Meniere’s
(C) vestibulitis
(D) ptosis

80. Slow growing tumors of the eighth cranial nerve are:

(A) acoustic neuromas

(B) vestibular schwannomas
(C) Both A and B
(D) glioblastoma

81. The procedure performed for sensory neural deafness is:

(A) trigeminal neuralgia

(B) cochlear implants
(C) microvascular decompression
(D) Both A and C

82. The procedure performed to improve nasal airflow caused by congestion and rhinorrhea is:

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 (A) rhinoplasty
(B) SMR
(C) closed reduction of a nasal fracture
(D) turbinectomy

83. When performing a FESS (functional endoscopic sinus surgery) it becomes more difficult if a second
surgery is needed because:

(A) you cannot pass the scope through the nose

(B) hemorrhage is a major consideration
(C) the surgical landmarks have been altered by performing the first procedure
(D) the nose can be easily broken by the endoscope the second time

84. The right and left lobes of the Thyroid gland is connected by the:

(A) isthmus
(B) septum
(C) parathyroids
(D) goiter

85. The Thyroid gland produces:

(A) Thyroxine
(B) T3
(C) TSH
(D) Both A and B

86. When performing a Thyroid scan they use radiotracers to determine the size, shape, and position of the
gland, these include:

(A) methylene blue

(B) Technetium 99
(C) radioactive iodine
(D) Both A and B

87. The condition associated with hyperthyroidism is:

(A) thyroid storm

(B) Graves’ disease
(C) hypocalcemia
(D) tetany

88. One of the most common complications of head and neck surgery is:

(A) back pain from positioning

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 (B) laryngeal spasms
(C) hemorrhage
(D) malignant hyperthermia

89. During a thyroid procedure the _______ and _______ muscles are incised, and the _______ muscle is
retracted.

(A) platysma and strap/sternocleidomastoid

(B) platysma and sternocleidomastoid/strap
(C) pectoralis and strap/platysma
(D) pectoralis and platysma/strap

90. A congenital cyst found in the neck formed from an embryonic structure arising from the thyroid gland
is termed:

(A) goiter
(B) thyroglossal cyst
(C) cervical lymph node
(D) scalene node

91. An instrument used to elevate the thyroid lobe during surgical excision is a:

(A) Babcock
(B) Lahey
(C) Green
(D) Jackson

92. In a thyroidectomy, a loop retractor retracts the:

(A) platysma muscle

(B) cervical fascia
(C) thyroid veins
(D) sternocleidomastoid muscle

93. Which structure(s) are identified and preserved in thyroid surgery?

(A) Parathyroid glands

(B) Hyoid bone
(C) Thyroglossal duct
(D) Thyroid lobe

94. Which muscles are incised in the midline of the neck once the skin flaps are completed during a
thyroidectomy?

(A) Sternocleidomastoid

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 (B) Strap
(C) Sternothyroid
(D) Sternoclavicular

95. Which bone is transected with bone-cutting forceps before removal of a thyroglossal cyst?

(A) Ethmoid
(B) Hyoid
(C) Pterygoid
(D) Zygomatic process

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 Answers and Explanations

1. (B) A moustache dressing may be applied under the nose (nares) to absorb any bleeding.

2. (B) The CO2 laser is efficient and has a high-power output. It uses a combination of CO2, nitrogen, and
helium. As energy levels subside, light beams are produced that form a single beam of light in the
ultraviolet range that is invisible. For this reason, a red beam from a helium–neon laser is added so that
it may be properly aimed at the affected tissue.

3. (C) Cocaine is unrivaled in its power to penetrate the mucous membrane to produce surface anesthesia.
Onset is immediate. It also causes vasoconstriction to reduce bleeding. Administration is only topical
because of its high toxicity.

4. (B) The scrub cleans the burrs during the procedure. Continuous irrigation is necessary to minimize the
transfer of heat from the burr to surrounding bone and structures. A suction irrigation may be used.

5. (A) Incision of the tympanic membrane, known as myringotomy, is done to treat otitis media. By
releasing the fluid behind the membrane, hearing is restored and infection controlled. Frequently, tubes
are inserted through the tympanic membrane.

6. (A) An alligator forceps is used to insert the tube into the incision.

7. (D) Perforation of the eardrum (tympanic membrane) is the most common serious ear injury.
Tympanoplasty using grafted tissue improves hearing and prevents recurrent infection.

8. (C) Labyrinthectomy is a procedure that destroys the membranous labyrinth to relieve the patient of
severe vertigo when other means have been tried. The operation leaves the ear deaf.

9. (B) Myringotomy is incision into the tympanic membrane to ventilate the middle ear.

10. (D) Mastoidectomy is the removal of the diseased bone of the mastoid, along with cholesteatoma that
results from an accumulation of squamous epithelium and its products. This putty-like mass destroys
the middle ear and mastoid, so diseased bone must be removed.

11. (B) An acoustic neuroma arises in the eighth cranial nerve (acoustic). These tumors are benign but may
grow to a size that produces neurological symptoms. The main patient complaint is hearing loss.

12. (A) Computerized facial nerve monitoring is used intraoperatively to decrease trauma during tumor
dissection and to assess facial nerve status.

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13. (A) Submucous resection is also known as septoplasty—removal of either cartilage or bone portions of
the septum that obstruct the sinus opening and prevent a clear airway.

14. (B) A submucous resection is done for nasal septum deformity, fracture, or injury that has impaired
normal respiratory function and has impaired drainage.

15. (A) A bayonet forceps is used to introduce sponges into the nose.

16. (C) This surgery is done to relieve edema or infection of the membrane lining the sinuses and resultant
headaches. An opening is made into the maxillary sinus.

17. (D) Polyps are removed with a snare, polyp forceps, and suction.

18. (C) Frequently, a topical anesthetic is used before nasal surgery. The drug of choice is cocaine, 10% or
4%, and would be administered by means of soaked applicators introduced into the nasal cavity and
absorbed by the mucous membrane.

19. (A) A Caldwell–Luc (radical antrostomy) entails an incision under the upper lip above the teeth. It is
done to ensure drainage and aeration and permit, under direct vision, removal of diseased sinus tissue.

20. (C) Tracheostomy is the opening of the trachea and establishment of a new airway through a midline
incision in the neck, below the cricoid cartilage. A cannula is put in place to maintain the airway. This is
an emergency procedure.

21. (B) Lidocaine 1% (1 or 2 mL) may be instilled into the trachea to reduce the coughing reflex when the
tube is inserted.

22. (A) A catheter is used to suction the trachea at tube insertion.

23. (C) Most neoplasms of the salivary glands are benign mixed tumors; most of these affect the parotid
gland.

24. (B) The patient is placed in the semi recumbent (Fowler’s) position or on one side, horizontally, to
prevent aspiration of blood and venous engorgement postoperatively.

25. (A) Total laryngectomy is complete removal of the larynx, hyoid bone, and the strap muscles.

26. (B) To maintain hemostasis postoperatively in radical neck surgery, a Hemovac is generally employed.
Continuous pressure from the gauze pressure dressings reduces the accumulation of serosanguineous
fluid, which is removed by the Hemovac.

27. (D) For radical neck, a Y-shaped or trifurcate incision is used in the affected side of the neck. A parotid
incision is also a Y incision but on both sides of the ear and below the angle of the mandible.

28. (D) During ear surgery, a local anesthetic with epinephrine is often the surgeon’s choice because the
epinephrine acts as a vasoconstrictor and prevents oozing in the wound. Epinephrine-soaked pledgets

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 are also used to control bleeding.

29. (B) The device is implanted in the cochlea, with the receiver resting in the mastoid bone. As the device
receives sound through the receiver, it emits electrical impulses through the transmitter into the cochlea
and along the acoustic nerve. These impulses are interpreted as a sound in the temporal cortex of the
cerebrum.

30. (A) All choices except for A (stainless steel) can cause fires if hit by a laser beam. To protect the patient,
the endotracheal tube must be protected by wrapping it with adhesive sensitive tape. In addition, wet
gauze is placed just above the cuff. Stainless steel, copper, and commercially prepared noncombustible
are better choices.

31. (C) The advent of the CO2 laser added a new dimension to the laryngologist’s treatment of lesions of
the larynx and vocal cords. The laser is efficient and has a high-power output. It uses a combination of
CO2, nitrogen, and helium gas.

32. (D) The 120-degree endoscope is used only during maxillary sinus endoscopy. The 70-degree endoscope
may occasionally be used in special maxillary procedure, but is a diagnostic scope generally.

33. (C) During a rhinoplasty, the dorsal hump can be taken down with an osteotome. A cartilaginous hump
can be removed by means of a cutting forceps, such as a Jansen–Middleton forceps.

34. (C) During a tonsillectomy, the tonsil is grasped with a tonsil-grasping forceps, the mucous membrane
of the anterior pillar is incised with a knife, and the tonsil lobe is freed from its attachments to the pillar
with a tonsil dissector.

35. (D) It is imperative that all gauze pads or patties be kept moistened during the surgery to prevent
damage to healthy tissue from stray or reflected beams of light. Moisture is the most effective barrier to
stop the laser energy from penetrating healthy tissue or igniting materials in the area.

36. (D) Because regulation endotracheal tubes are combustible, they must be carefully wrapped with
adhesive sensing tape. A safer alternative is the use of copper (Carden), stainless steel (Porch), or
commercially prepared laser retardant endotracheal tubes on a jet ventilation system.

37. (D) The surgeon chooses the size and the type of plate, the appropriate drill bit is loaded onto the power
drill, screw holes are drilled, depth gauge is used to determine the depth of the screw holes, correct
screw is loaded onto a screw driver and screwed into place.

38. (A) Arch bars are a thin metal strap. It is wired to each row of teeth. The bars are then wired together
with stainless steel suture performed to occlude the jaw.

39. (C) Wire cutters are kept with the patient at all times in case of airway emergency.

40. (B) Le Fort II is associated with leakage of CSF into the nasal sinuses.

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41. (D) The lower face is composed of the mandible (chin).

42. (C) TMJ is characterized by persistent pain due to stress related muscle tension, grinding of teeth,
malocclusion, trauma, and arthritis.

43. (D) As the surgeon dissects the thyroid gland from the surrounding tissues, the parathyroid glands, the
superior laryngeal nerve, and the recurrent laryngeal nerves are identified and preserved.

44. (B) A thyroplasty is performed for a unilateral vocal cord paralysis due to surgical trauma of the laryngeal
nerve or prolonged intubation.

45. (D) If the deep lobe of the parotid must be excised, the facial nerve is elevated and retracted with vessel
loops during a parotidectomy.

46. (B) Epistaxis is bleeding from the nose caused by local irritation of mucous membranes, violent sneezing,
and a variety of other reasons. Also known as nosebleed.

47. (A) The vocal cords lie in the upper end of the larynx. They are responsible for voice production.

48. (D) The windpipe or trachea, conducts air to and from the lungs. It is a tubular passageway located
anterior to the esophagus. It further divides into the right and left bronchi.

49. (B) The nasal cavity is a hollow area behind the nose. It is divided into right and left portions by the
nasal septum. The anterior septum is made of cartilage.

50. (B) The mandible is the lower jawbone. It is the only movable bone in the skull. It is horseshoe shaped.

51. (D) The hyoid bone is located in the neck between the mandible and the larynx. It supports the tongue
and provides an attachment for its muscles. It does not articulate with any other bone.

52. (C) Normally the air pressure on the two sides of the eardrum is equalized by means of the Eustachian
tube. This connects the middle ear cavity and the throat. This allows the eardrum to vibrate freely with
the incoming sound waves.

53. (D) The trigeminal nerve is the great sensory nerve of the face and head. It has three branches that carry
general sense impulses. The third branch is joined by motor fibers to the muscles of chewing
(mastication).

54. (B) The tympanic membrane (eardrum) transmits sound vibrations to the internal ear by means of the
auditory ossicles.

55. (D) The cochlea looks like a small spiral shaped shell. It is a tube coiled for about two and a half turns
into a spiral, around a central axis of the bone.

56. (A) Expanding across the middle ear area are three exceedingly small bones called the auditory ossicles:
the malleus, the incus, and the stapes.

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57. (A) The right primary bronchus is more vertical, shorter, and wider than the left. As a result, foreign
objects in the air passageways are more likely to enter it than the left and frequently lodge in it.

58. (B) Adenoids are also known as pharyngeal tonsils. They have a glandular appearance particularly
lymphoid like.

59. (B) The molar’s job is to crush and grind food.

60. (C) Mumps typically attacks the parotid glands. It is an inflammation and enlargement (swelling).

61. (B) The sublingual glands are located under the tongue. They open into the floor of the mouth in the
oral cavity.

62. (D) An orbital floor fracture is also called a blowout fracture and a Le Fort III.

63. (B) The zygomatic bone is also referred to as the cheek bone and the malar bone.

64. (C) Standard protocol is to insert the wires clockwise and remove them counter clockwise.

65. (D) MMA is performed for deformities of the upper and lower jaw, malocclusion, and sleep apnea.

66. (A) The labial side of the mouth/teeth closest to the lips, the lingual side of the mouth contains the
tongue, and the buccal side of the mouth refers to the cheek side of the mouth.

67. (A) The bony labyrinths in the inner ear are responsible for equilibrium, the ossicles in the middle ear
are responsible for conduct vibrations, TMJ stands for temporal mandibular joint, and cerumen is the
wax in the external ear.

68. (C) The external ear terminates at the tympanic membrane.

69. (B) Choanal atresia is the congenital disorder where the passage between the nose and pharynx is
blocked by an abnormal bony tissue that failed to rupture during fetal development.
Dacryocystorhinostomy is performed to restore the flow of tears into the nose from the lacrimal sac.
SMR is a submucous resection/septoplasty procedure to repair a deviated septum.

70. (C) The nasopharynx is a division of the pharynx.

71. (C) The submandibular duct is also known as Wharton’s duct and the parotid duct is known as Stensen’s
duct.

72. (B) The pharynx is a tubular structure that extends from the nose to the esophagus and is separated into
three divisions the nasopharynx, oropharynx, and hypopharynx (laryngopharynx).

73. (B) The part of the larynx where the true vocal cords are located is the glottis.

74. (A) The adenoids are also known as the pharyngeal tonsils and the palatine tonsils are known as the
tonsils.

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75. (C) The Robinson catheter is used to retract the uvula during a tonsillectomy, the Davis and Jennings
are types of mouth gags, and the coblator uses radiofrequency energy combined with saline to remove
the tonsils.

76. (C) The graft used for a Tympanoplasty procedure is taken from the temporalis fascia on the side of the
head, the pinna is the outer cartilage of the ear covered by skin, the pars tensa is part of the tympanic
membrane.

77. (C) The prostheses used on a stapedectomy include stainless steel, platinum, and Teflon.

78. (B) Meniere’s disease is not a disease of the middle ear, it effects the inner ear with symptoms of
dizziness and ringing in the ears.

79. (A) Bell’s Palsy is a virus that affects the seventh cranial nerve and causes stiffness and drooping of one
side of the face.

80. (C) Slow growing tumors of the eighth cranial nerve are acoustic neuromas also known as vestibular
schwannomas. Glioblastomas are an aggressive malignant brain tumor.

81. (B) The procedure performed for sensory neural deafness is cochlear implants, trigeminal neuralgia is a
condition of the trigeminal nerve causing facial pain, and microvascular decompression is performed to
prevent a vessel from compressing the trigeminal nerve.

82. (D) Turbinectomy is the procedure performed to improve nasal airflow caused by congestion and
rhinorrhea. A rhinoplasty is performed for cosmetic surgery, closed reduction of a nasal fracture is
performed for fractured nasal bones, and an SMR is performed for a deviated septum.

83. (C) When performing an FESS (functional endoscopic sinus surgery) it becomes more difficult if a
second surgery is needed because the surgical landmarks have been altered by performing the first
procedure.

84. (A) The right and left lobes of the thyroid gland are connected by the isthmus.

85. (D) The thyroid gland produces thyroxine (T4) and triiodothyronine (T3) the pituitary produces thyroid
stimulating hormone (TSH).

86. (D) When performing a thyroid scan they use radiotracers to determine the size, shape, and position of
the gland, these include Technetium 99 and radioactive iodine, this is performed in nuclear medicine.

87. (B) The disease associated with hyperthyroidism is Graves’ disease, hypocalcemia is a lower than normal
calcium level, Tetany is a disease caused by hypocalcemia, and a thyroid storm is an acute hyperthyroid
episode.

88. (B) Laryngeal surgery is one of the most common complications of head and neck surgery.

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89. (A) During a thyroid procedure the platysma and strap muscles are incised, and the sternocleidomastoid
muscle is retracted.

90. (B) A congenital cyst found in the neck formed from an embryonic structure arising from the thyroid
gland is a thyroglossal duct cyst.

91. (B) A Lahey vulsellum forceps is used to grasp and elevate the thyroid lobe so that sharp dissection of
the lobe away from the trachea can be accomplished.

92. (D) The sternocleidomastoid muscle is retracted with loop retractors.

93. (A) Care is taken throughout thyroid surgery to identify and preserve parathyroid glands. Removal of all
parathyroid tissue results in severe tetany or death.

94. (B) After the upper and lower skin flaps are undermined at the level of the cricoid cartilage, the fascia in
the midline is incised between the strap (sternohyoid) muscles with a knife. The sternocleidomastoid
muscles are then retracted with loop retractors.

95. (B) After the head is extended, the incision is made between the hyoid bone and the thyroid cartilage
through the subcutaneous tissue. Sharp and blunt dissection is used to mobilize the cyst and duct, and
the hyoid bone is transected twice with bone-cutting forceps, and the cyst is freed from adjacent
structures.

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 ___________________ CHAPTER 22 ___________________

Plastic and Reconstructive Surgery

Plastic and Reconstructive Surgery

• Treats abnormal structures of the body caused by birth defects, developmental problems, disease, tumors,
infections, or injury
• Intact skin is the most effective barrier to protect the body from harmful microorganisms
• Epidermis—this is the outermost protective nonvascular layer of the skin
• Dermis—this is the layer of skin below the epidermis. It consists of vascular connective tissue, nerve
endings, hair roots, and sebaceous glands
• Langer’s lines—these are natural lines in the skin. The plastic surgeon follows these lines for the surgical
procedure to provide a better cosmetic appearance postoperatively

Tissue Layers Under the Skin

• Subcutaneous layer/sub-q—is a fatty layer of tissue below the dermis

• Fascia—is a fibrous tissue that adds support the superficial skin layers and muscle
• Peritoneum—this is a thin two-layered membrane that lines the interior abdominal cavity and viscera
• From most superficial layer to deep layer:
Skin
Subcutaneous fat
Muscle
Fascia
• Cicatrix—is a scar
• Keloid—a type of a scar that is raised, reddish, and can be nodular they develop at the site of an injury
• Hypertrophic scar—similar to a keloid but not as pronounced
• Burns
Rule of nines—the body surface is divided into equal parts by using multiples of 9% of total body
surface. The breakdown includes:
This is used for adults
4.5% front of head
4.5% back of head
18% front of body
18% back of body

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 4.5% each arm front and back
9% each leg front and back
Lund–Bowder chart
The percentage of the burn is estimated on the basis of age in addition to the anatomic location of the
burn. Most accurate for use with children
• Classification of burns
First-degree burn—superficial—only the outer layer of the epidermis is involved. The skin is red. A sun
burn is considered a first-degree burn
Second-degree burn—partial thickness—all of the epidermis and some of the dermis are effected. The
skin is blistered, painful, moist, and red
Third-degree burn—full thickness–all of the epidermis/dermis and subcutaneous tissue. The skin is dry,
pearly white or charred in appearance. No grafts are required
Fourth-degree burn—these burns damage down to the bone, muscle, tendons, blood vessels, and nerves
• Dressings—goal of dressings:
Immobilize
Apply even pressure over the wound
Collect drainage
Provide comfort for the patient
Protect the wound

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• Pressure dressings
Prevents edema
Absorbs extensive drainage
Distributes pressure evenly
Eliminates dead space
• Stent dressing—type of pressure dressing, uses Xeroform, fluffs, 4 × 4’s and silk suture to crisscross and tie
• Negative wound pressure dressing—type of dressing technique that provides negative pressure to the
wound with a vacuum and special dressing. This dressing helps to pull the wound edges together and
remove bacteria
• Skin grafts
STSG (split-thickness skin graft)
Contains epidermis and only a portion of dermis
Grafts may be meshed; this allows the skin graft to become stretched larger than its original size
FTSG (full-thickness skin graft)
Contains epidermis and dermis

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 • Types of grafts
Auto graft—tissue taken from a patient’s own body and transferred to a different part of their body
Heterograft/xenograft—tissue transplanted from a donor of a different species (pig to human/heart
valve)
Allograft—transplantation of tissue from one person to another (of same species/human to human)
• When prepping the donor site it should be done with a colorless solution.
The proper technique when prepping for the graft is donor site first
There should be two different set ups
One donor and one recipient table
• Dermatome—this is a surgical instrument used to cut thin slices of skin from a donor area to use them as
skin grafts
Dermatomes can be operated either manually or electrically
Brown dermatome—uses an oscillating blade and is electrically operated. This is commonly used
today
Padgett dermatome and Reese dermatome—manual dermatome—hand controlled
Ferris-Smith/Watson/Weck—hand-held knife dermatomes
Mesh device—derma-carrier—this is used to stretch/expand the donor skin and provide skin that
covers a larger surface area. Split-thickness skin graft is commonly used with this device
Procedure:
Mineral oil is used to lubricate the donor graft, and a tongue depressor is used to provide smooth
traction
• Pedicle flap/graft—a full-thickness skin graft that remains attached at some point on the body, this is
where it continues to receive its blood supply
• Basal cell skin cancer—grows on the skin surface, the cancer is in the basal cells. It is the least risky skin
cancer
• Squamous cell skin cancer—squamous cells make up the main part of the epidermis layer of the skin. This
cancer is a major form of skin cancer and can be considered aggressive
• Melanoma skin cancer—the most serious type of skin cancer, very aggressive and can spread to other
organs
• Mohs surgery—technique used to remove a skin lesion, it is performed by removing thin layers of skin for
examination under the microscope
• Pressure ulcers—a pressure ulcer usually occurs over a bony prominence. It begins with a reddened area
which spreads to deeper tissue causing a severe breakdown of tissue until it becomes an ulcer. Common
sites include:
Sacrum
Ischium
Heel

Breast surgery

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 • Reconstructive breast surgery following a mastectomy—surgery using tissue expanders—when a
mastectomy is performed it leaves a shortage of skin and tissue expanders are introduced into a sub
muscular pocket of the breast and are used to stretch the skin by filling the expander with NACL.
Repeated office visits are made and they are gradually filled with NaCl until the expander is the desired
size
Implants are handled as little as possible
They are soaked in antibiotic solution prior to insertion
Drain is placed to prevent hematoma and seroma formation
Fiberoptic-lighted breast retractors are used to facilitate insertion
• Second stage tissue expander breast reconstruction—the tissue expander is deflated, removed, and replaced
with the permanent prosthesis

Breast reconstruction using a myocutaneous flap

• Tram flap—transverse rectus abdominis muscle—this procedure is performed to reconstruct a breast from
the muscle in your lower abdomen between your waist and your pubic bone “rectus abdominis.” A flap of
this skin, fat, and muscle are used. The muscle is severed distally and tunneled subcutaneously to form the
breast
This is a type of pedicle flap
Blood supply to maintain this flap is:
Superior epigastric artery and vein
A Doppler is used to preserve the artery
An abdominoplasty is performed to close the defect in the abdomen
• Nipple reconstruction—a skin graft is taken to reconstruct the nipple after this reconstruction of the breast
has healed. The technique of tattooing is used to recreate the areola
• Augmentation mammoplasty—this procedure is performed to increase the size of the breasts with
implants
Breast implants are filled with silicone or saline
Incisions used for an augmentation include:
Inframammary
Periareolar
Transaxillary
Transumbilical
• Four different placement options for breast implants include:
Subglandular placement of the implant is below the mammary glands and above the muscle
Subfascial—above the muscle under the facia
Subpectoral—placement of the implant is below the pectoralis major muscle
Submuscular—placement is actually under the pectoralis major muscle
• When handling implants the STSR should know:

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 Powder should be wiped off gloves before handling
There should be no oil on gloves
Be placed on lint-free surface
Prosthetics usually are wet prior to insertion (soaked in an antibiotic solution)
• Capsulotomy/capsulectomy—this procedure is performed to remove scar tissue that has formed around the
breast implant. This scar tissue can distort the symmetry of the implant and harden the area
The tissue can be removed and or released
• Reduction mammoplasty—this procedure is performed to reduce the size of extremely large breasts.
Extremely large breasts can cause:
Back and shoulder pain
Neck pain
Impaired breathing
Skin irritation and other health problems
Performed on men who suffer from gynecomastia
• Mastopexy—this is performed for breast ptosis (drooping of the breasts). It is a breast lift. This is caused
by:
Gravity/aging skin
Breast feeding
Hormonal changes
• When performing microsurgery, a microscope and/or loupes are needed
• Reimplantation of amputated finger
Needs to be performed within 4–6 hours after injury. Steps of the procedure include:
Debridement
Bone to bone fixation
Tendon repair
Nerve repair
Arteries and vein repair
Skin
• Scar revision—this is performed to reshape a scar for cosmetic results
Subcuticular suture technique is used
• Z-plasty—this is performed for a scar revision or closure of wound to get the best cosmetic results. Most
common techniques used:
One or more z-shaped incisions are made within the skin lines
It elongates the scar and gives a smaller appearance
Other techniques include:
W-plasty
M-plasty
Y–V–plasty

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• Mentoplasty—performed for reconstruction of a deformity of the chin
• Otoplasty—this is performed to reconstruct and/or repair the ear. It can change the shape, size and
position of the ear
• Microtia—this is a congenital deformity of the pinna (outer portion of the ear).These babies are born with
small deformed ears
• Rhytidectomy (facelift)—is performed to improve sagging and aging in the middle face and neck
• Mini face lift—this is performed for severe drooping of the upper neck and jowl
Jowl—skin of the lower cheeks and jaw
• SMAS (superficial muscular aponeurotic system)—this muscular system is continuous with the platysma
muscle in the neck. This muscle is tightened to provide a cosmetic effect of the jowl and midface
• Brow lift—this is also called a forehead lift-this is performed to reduce the wrinkle lines across the
forehead, raises the sagging eye brows and the bridge of the nose
• Endoscopic brow lift—this is a minimally invasive procedure performed to reduce the wrinkle lines across
the forehead and raise sagging eye brows
Three tiny incisions are made in the hairline
• Blepharoplasty—this procedure is performed to remove fat deposits and excess skin from the eyelids to
improve the cosmetic appearance of the eyes. In some cases severe sagging could impair vision
Dermatochalasis—excessive sagging of the upper and lower eyelids. A blepharoplasty is performed for
this
Incisions include:
Subciliary incision
Transconjunctival incision
• Laser surgery
CO2 laser—most popular for skin resurfacing
• Laser resurfacing is a treatment to reduce facial wrinkles and acne scars
• Tattoo removal
Candela dye laser and Q-switched laser are used
• Liposuction—the surgical removal of fat from parts of the body. The abdomen, buttocks, hips, thighs, and
knees. The fat is sucked out through a cannula that is inserted under the skin and attached to a high-
pressure vacuum
A tumescent solution of lidocaine and epinephrine diluted mixture helps to swell and break up the fat
while producing an anesthetic affect
Cannulas of various sizes are used to suck out the fat
Hemostasis is achieved and a compression dressing is applied
• Gynecomastia/macromastia—this is the term used for large breasts in the male
This procedure can be performed by liposuction techniques or by an open procedure. With an open
procedure, the incision is made under the armpit or around the areola
• Malar implants—this is a cosmetic procedure performed to emphasize a person’s cheek bones. The

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 implants are placed over the cheek bones, they can also inject the patient’s own fat to add contour
The incision is in the canine fossa (gum line)
Sizers are used to determine the correct size and symmetry, they are removed and the implants are
placed
• Submalar implants—this procedure is performed for soft tissue reconstruction
• Rhinoplasty—this procedure is also called a “nose job”, it is performed for cosmetic correction of the nose
and to put it in proportion with the face
Straightening the internal septum
Corrects sinuses/breathing
Bone
Skin
Reduces the size of the nose
• Plastic instruments:
Iris scissors
Stevens tenotomy scissors
Skin hooks
Adson tissue forceps
Bishop–Harmon forceps
Webster needle holder
Frazier suctions
Blepharoplasty calipers
Castroviejo needle holder

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 Questions

1. A dressing that is held in place by long suture ends crisscrossed and tied is called a:

(A) passive
(B) strip closure
(C) Proxi-Strip
(D) stent

2. All of the following statements regarding the preparation for a skin graft are true EXCEPT:

(A) the dermatome is placed on the recipient table

(B) the donor site is prepared with a colorless antiseptic agent
(C) separate setups are necessary for skin preparation of recipient and donor sites
(D) items used in preparation of the recipient site must not be permitted to contaminate the donor site

3. When using a sterile syringe, the scrub nurse should:

(A) always let the surgeon attach the needle

(B) always use a Luer–Lok tip
(C) never use a Luer–Slip (plain) tip
(D) never touch the plunger except at the end

4. Colorless prep solution may be indicated for:

(A) orthopedic surgery

(B) vascular surgery
(C) plastic surgery
(D) urological surgery

5. A graft containing epidermis and only a portion of the dermis is called a:

(A) split-thickness graft

(B) full-thickness Wolfe graft
(C) composite graft
(D) full-thickness pinch graft

6. A progressive disease of the palmar fascia is termed:

(A) Dupuytren’s contracture

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 (B) tendinitis
(C) carpal tunnel syndrome
(D) synovitis

7. Microtia refers to:

(A) protrusion of the external ear

(B) absence of the external ear
(C) abnormally small ear
(D) imperforate ear

8. Good contact between a skin graft and the recipient site is facilitated by use of a/an:

(A) stent dressing

(B) Elastoplast
(C) splint-ace bandage dressing
(D) biological dressing

9. Syndactyly refers to:

(A) an extra digit

(B) an absent digit
(C) webbing of the digits
(D) an ear protrusion

10. A face lift is termed a:

(A) blepharoplasty
(B) mentoplasty
(C) rhytidectomy
(D) lipectomy

11. The intraoperative use of bone allografts requires all of the following responses from the scrub team
EXCEPT:

(A) culture before implant

(B) wash with an antibiotic solution
(C) completely thaw
(D) Both A and B

12. Bulky dressings added to the intermediate layer of a three-layer dressing are used to:

(A) eliminate dead space

(B) concentrate pressure in one area
(C) immobilize a body part

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 (D) Both A and C

13. All of the following rules cover handling of prosthetic devices during plastic surgery procedures
EXCEPT:

(A) powder must be wiped from gloves before handling

(B) prosthesis must be dried completely before implanting it
(C) gloves must be used to prevent skin oils from causing inflammatory response
(D) prosthesis must be placed on lint-free surface to sterilize

14. Free jejunal tissue transfers are frequently successful as adjunct surgical revisions following:

(A) laryngectomy
(B) esophagectomy
(C) ileectomy
(D) Both A and B

15. What bandage affects the process of exsanguination of a limb prior to the use of a tourniquet?

(A) Kling
(B) Elastoplast
(C) Esmarch
(D) Ace

16. Which muscle is utilized to effect a TRAM flap in breast reconstruction?

(A) Latissimus dorsi

(B) Transrectus abdominis
(C) Pectoralis major
(D) Pectoralis minor

17. The most widely used method of scar revision next to scar removal is:

(A) chemical peel

(B) sanding
(C) Z-plasty
(D) planing

18. A scar that is hypertrophic and bulbous and usually does not reduce over time is:

(A) papilloma
(B) keloid
(C) eschar
(D) nevis

19. Burned tissue that is nonelastic and may constrict underlying structures is:

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 (A) eschar
(B) split-thickness skin graft
(C) keloid
(D) None of the above

20. A graft derived from pig tissue.

(A) Feline
(B) Bovine
(C) Porcine
(D) Allograft

21. The skin provides which of the following vital functions:

(A) protects underlying tissues and organs

(B) excretes organic waste and stores nutrients
(C) excretes water and dissipates heat as a means of thermoregulation
(D) All of the above

22. The most common type of skin cancer is:

(A) basal cell

(B) melanoma
(C) squamous cell
(D) nevi

23. A graft transferred from one individual to another is:

(A) hemograft
(B) porcine
(C) autograft
(D) allograft

24. A graft made up of tissue taken from one species and grafted to another species is:

(A) homograft
(B) autograft
(C) xenograft
(D) allograft

25. Removal of nonviable tissue from a nonhealing or traumatic wound is known as:

(A) debridement
(B) undermining
(C) grafting

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 (D) Mohs surgery

26. A mentoplasty involves augmentation of:

(A) chin
(B) lips
(C) ears
(D) nose

27. Macromastia in males is referred to as:

(A) accessory
(B) gynecomastia
(C) small breasts
(D) None of the above

28. A panniculectomy is also known as:

(A) abdominoplasty
(B) Z-plasty
(C) mammoplasty
(D) otoplasty

29. In order to reduce friction between the skin and the blade of the dermatome, the site is prepped with:

(A) methylene blue

(B) Betadine
(C) Chloraprep
(D) mineral oil

30. What are natural lines in the skin that are used as landmark for plastic surgeons to provide optimum
cosmetic results?

(A) keloids
(B) Langer’s
(C) Lund
(D) Bowder

31. Place in the correct order from most superficial to deepest layer:

(1) subcutaneous, (2) muscle, (3) fascia, (4) skin

(A) 4, 1, 3, 2
(B) 1, 2, 3, 4
(C) 3, 1, 2, 4
(D) 2, 3, 1, 4

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32. The large scar with a raised, nodular, and reddish appearance is termed:

(A) cicatrix
(B) keloid
(C) hypertrophic
(D) eschar

33. When using the rule of nines burn assessment chart, what percentage is given to both legs together front
and back:

(A) 9%
(B) 18%
(C) 27%
(D) 36%

34. What burn is characterized by a white pearly skin appearance and includes all of the epidermis, dermis
and subcutaneous tissue?

(A) First
(B) Second
(C) Third
(D) Fourth

35. What burn is characterized by destruction of skin, muscles, tendons, vessels, and bone?

(A) First
(B) Second
(C) Third
(D) Fourth

36. What is the manual instrument used to harvest thin slices of skin from a donor area for use in skin
grafting?

(A) brown
(B) Padgett
(C) Weck
(D) Watson

37. Which dermatome is commonly used to retrieve skin for a graft that contains an oscillating blade?

(A) Ferris–Smith
(B) Brown
(C) Reese
(D) Padgett

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38. Which of the following is a hand held knife dermatome?

(A) Ferris–Smith
(B) Watson
(C) Weck
(D) All of the above

39. A pedicle flap is:

(A) a graft that includes the epidermis and part of the dermis
(B) a full-thickness graft that does not remain attached for the blood supply
(C) a full-thickness skin graft that remains attached to an area where it continues to receive blood
supply
(D) a graft that only removes the epidermis

40. The most aggressive skin cancer that can spread to other organs is:

(A) basal cell

(B) melanoma
(C) squamous cell
(D) nevus

41. Sites of pressure ulcers include:

(A) sacrum
(B) ischium
(C) heel
(D) All of the above

42. The blood supply that maintains the TRAM flap is:

(A) iliac artery

(B) subclavian artery
(C) femoral artery
(D) superior epigastric artery and vein

43. What muscle is used for the TRAM flap?

(A) Rectus abdominis muscle

(B) Oblique
(C) Transversalis
(D) Pectoralis major

44. What procedure is performed to increase the size of the breasts?

(A) Augmentation mammoplasty

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 (B) Mastopexy
(C) Transverse rectus abdominis myocutaneous flap
(D) Both A and B

45. The procedure performed to reduce the size of extremely large breasts is termed:

(A) mastopexy
(B) simple mastectomy
(C) reduction mammoplasty
(D) modified radical mastectomy

46. When performing the procedure for reimplantation of a finger, the order of repair is:

(1) nerve repair, (2) bone to bone fixation, (3) debridement, (4) artery and vein repair, (5) skin, (6)
tendon.
(A) 3, 2, 1, 4, 5, 6
(B) 3, 2, 6, 1, 4, 5
(C) 2, 3, 1, 4, 6, 5
(D) 6, 5, 4, 3, 2, 1

47. A congenital deformity of the pinna is termed:

(A) otitis media

(B) mentoplasty
(C) microtia
(D) cheiloplasty

48. What procedure is performed to reduce the wrinkle lines across the forehead and raise the sagging
eyebrows and the bridge of the nose?

(A) brow lift

(B) forehead lift
(C) endoscopic brow lift
(D) All of the above

49. The blepharoplasty is performed to remove fat deposits and excess skin from the eyelids. Incisions used
include:

(A) subciliary
(B) transconjunctival
(C) Both A and B
(D) limbus

50. Dermatochalasis is the diagnosis for what procedure?

486
 (A) rhytidectomy
(B) microtia repair
(C) blepharoplasty
(D) mastopexy

51. Tattoo removal is performed with which laser?

(A) Candela dye laser

(B) Q-switched laser
(C) YAG
(D) Both A and B

52. Which of the following pertain to liposuction?

(A) tumescent solution is used

(B) can be performed on the abdomen, buttocks, hips and thighs
(C) compression dressings are applied
(D) All of the above

53. The term used for large breasts is:

(A) gynecomastia
(B) macromastia
(C) ptosis
(D) microtia

54. Malar implants are inserted into:

(A) chin
(B) cheeks
(C) eyelids
(D) forehead

55. A rhinoplasty is:

(A) nose job

(B) facelift
(C) cheek implants
(D) brow lift

56. The burn classification that is characterized by a dry, pearly white, or charred-appearing surface is:

(A) first
(B) second
(C) third

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 (D) fourth

57. Occupational Safety and Health Administration (OSHA) is a governmental regulating agency whose
aim is to:

(A) provide guidelines to prevent transmission of blood-borne infections

(B) execute requirements designed to prevent transmission of blood-borne pathogens in the work
environment
(C) require that communicable diseases be reported to a public health agency
(D) train employees how to recognize and execute safe practices

58. Inflammation is characterized by pain, redness, heat, swelling, and loss of function. The redness can be
attributed to:

(A) serum brought into the area

(B) constriction of capillaries
(C) vasodilation bringing more blood to the area
(D) heat from metabolic reaction

59. Removal of contaminated debris from a wound is called:

(A) decontamination
(B) debridement
(C) dehiscence
(D) desiccation

60. If tissue is approximated too tightly it can cause:

(A) ischemia
(B) excessive scar tissue
(C) keloids
(D) adhesions

61. Tensile strength of a wound refers to:

(A) the suture strength

(B) ability of tissue to resist rupture
(C) wound contraction
(D) tissue approximation

62. The substance that unites with thrombin to form fibrin, the basic structural material of blood clots is:

(A) fibrinogen
(B) prothrombin
(C) fibrin

488
 (D) thrombin

63. A cicatrix is:

(A) an abscess
(B) a scar
(C) pus
(D) a wound

64. Keloids are:

(A) a form of abscess

(B) an adhered serous membrane
(C) a raised, thickened scar
(D) a benign tumor

65. A wound that is infected or one in which there is excessive loss of tissue heals by:

(A) primary intention

(B) secondary intention
(C) third intention
(D) fourth intention

66. The type of wound healing that requires debridement is:

(A) first
(B) second
(C) third
(D) fourth

67. To promote healing, a surgical wound must have all of the following requisites EXCEPT:

(A) suture closure of dead space

(B) drains to remove fluid or air
(C) a moderately tight dressing
(D) loose sutures

68. Wound healing that employs a technique allowing the wound to heal from the INSIDE OUT is called:

(A) interrupted intention

(B) first intention
(C) second intention
(D) third intention

69. A band of scar tissue that binds together two anatomical surfaces that are normally separate from each
other is called:

489
 (A) keloid
(B) adhesion
(C) cicatrix
(D) dehiscence

70. What is the classification of a wound that is indicated by a delayed closure?

(A) Primary intention

(B) Secondary intention
(C) Third intention
(D) Fourth intention

71. Complications of wound closure when the organs protrude through the edges of the wound is:

(A) adhesions
(B) dehiscence
(C) evisceration
(D) hemorrhage

72. Arrange the three phases of wound healing in the correct order: (1) proliferation, (2) inflammatory, (3)
remodeling.

(A) 1, 2, 3
(B) 3, 2, 1
(C) 2, 3, 1
(D) 2, 1, 3

73. Tissue breakdown at the wound margin is:

(A) adhesion
(B) hematoma
(C) debridement
(D) dehiscence

74. Wound complications include:

(A) hematoma
(B) seroma
(C) evisceration
(D) All of the above

75. A wound is described as ____ when there is a collection of pus around the incision.

(A) hematoma
(B) suppurative

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(C) granulation
(D) dehiscence

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 Answers and Explanations

1. (D) A stent dressing or fixation is a method of applying pressure and stabilizing tissues when it is
impossible to dress an area. In the case of the nose, for example, long suture ends are crisscrossed over a
small dressing and tied.

2. (A) Separate setups are used in skin preparation of the recipient and donor sites. Items used in
preparation of the recipient site must not be permitted to contaminate the donor site. The donor site
should be scrubbed with a colorless antiseptic agent so the surgeon can evaluate the vascularity of the
graft postoperatively. Always place dermatome separately, never on recipient table.

3. (D) The scrub nurse should not touch the plunger except at the end because glove powder can act as a
contaminant. Contamination of the plunger can contaminate the inner wall of the barrel and the
solution that is drawn into it.

4. (C) A colorless prep solution may be used in plastic surgery to facilitate observation of the true color of
the skin.

5. (A) A split-thickness graft, or partial-thickness graft, contains epidermis and only a portion of the
dermis.

6. (A) Dupuytren’s contracture is a progressive disease involving the palmar fascia and the digital
extensions of the palmar fascia. The surgery required is a palmar fasciectomy.

7. (B) Microtia refers to congenital total or subtotal absence of the external ear.

8. (A) A stent or tie-over dressing exerts even pressure, ensuring good contact between graft and recipient
site.

9. (C) Syndactyly refers to webbing of the digits of the hand or foot.

10. (C) A rhytidectomy is a face lift designed to improve appearance by removing excess skin and sometimes
excess fat of the neck.

11. (C) Frozen allografts are stored in plastic or cloth wraps to ensure sterility and prevent grafts from drying
out. When requested for a procedure, the allograft is delivered to the field slightly thawed. It is then
cultured and washed with an antibiotic solution.

12. (D) Pressure dressings are used mainly in general surgery or plastic procedures to eliminate dead space,

492
 absorb extensive drainage, distribute pressure evenly, and immobilize a body part when muscles are
moved.

13. (B) Breast prostheses and tissue expanders should be placed in a container with sterile saline or antibiotic
solution on the sterile field.

14. (D) Reconstructive problems in patients undergoing laryngectomy and upper cervical esophagectomy
can be adequately solved by a free jejunal transfer. Modern microscopic techniques greatly improve the
success rate.

15. (C) An Esmarch bandage is used to exsanguinate the extremity before institution of a pneumatic
tourniquet.

16. (B) The TRAM flap is a single-stage reconstruction of a post mastectomy breast with the transverse
rectus abdominis muscle of the lower abdomen.

17. (C) The simplest form of scar revision is excision of an existing scar and simple resuturing of the wound.
The Z-plasty is the most widely used method of scar revision. It breaks up linear scars, rearranging
them so that all tissue lies in the same direction.

18. (B) A keloid is a hypertrophic scar usually occurring in dark-skinned individuals and does not reduce
over time.

19. (A) Eschar consists of tissue that has been burned but remains adherent to the wound. Eschar is
nonelastic and may constrict underlying structures and impair vital functions.

20. (C) Porcine is derived from pig tissue.

21. (D) The skin or the integumentary system performs a number of vital functions as well as its sensory
organs transmit touch, pressure, pain, and temperature which alert the body to personal injury.

22. (A) Basal cell carcinoma is the most common cancer and arises from the basal layer of the epidermis.

23. (D) A graft that is transferred from one individual to another is known as an allograft or a homograft.
They are harvested from donors and preserved by the tissue bank until needed.

24. (C) A graft made up of tissue taken from one species and grafted to another species is a xenograft.

25. (A) Removal of tissue and burn wounds require repeated debridement to remove dying and dead tissue
so that healing can continue.

26. (A) Another name for a mentoplasty is a chin augmentation.

27. (B) Macromastia in males is referred to as gynecomastia.

28. (A) Abdominoplasty or a panniculectomy is removal of excess skin and adipose tissue from the

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 abdominal wall.

29. (D) Mineral oil is applied to the donor graft site to reduce friction prior to using the dermatome.

30. (B) Langer’s lines are the natural lines in the skin used for a landmark. Keloids are a type of scar. Lund–
Bowder is the chart used for burn assessment.

31. (A) The correct order is skin, subcutaneous, fascia, muscle.

32. (B) A keloid is a raised, nodular scar. Cicatrix is a flattened scar. Hypertrophic is similar to a keloid but
not as pronounced. An eschar is the debrided tissue from a burn.

33. (B) Both legs front and back is equal to 18%.

34. (C) A third-degree burn is white pearly white skin that includes the epidermis, dermis, and
subcutaneous tissue. First degree is only the epidermis. Second degree is blistered, painful, moist, and
red. Fourth-degree burns are deep into the muscles.

35. (D) Fourth-degree burn includes destruction of skin, muscles, tendons, vessels, and bone

36. (B) The Padgett dermatome is manual. The brown is electric with an oscillating saw. The Weck and
Watson are dermatome knives.

37. (B) The Brown dermatome uses an oscillating blade. The Ferris–Smith is a dermatome knife. Reese and
Padgett are manually used.

38. (D) Ferris–Smith, Watson, and Weck are all hand held knife dermatomes.

39. (C) A pedicle flap is a full-thickness skin graft that remains attached to a blood supply. STSG includes
epidermis and dermis. A full-thickness skin graft does not remain attached to a blood supply.

40. (B) Melanoma is the most aggressive skin cancer that can metastasize to other organs. Basal and
squamous are less aggressive.

41. (D) Pressure ulcers can form the sacrum, ischium, and heel as those tissue remains touching the sheets
for long periods of time without being rotated.

42. (D) The blood supply that feeds the TRAM flap comes from the superior epigastric artery and vein.

43. (A) The muscle used to perform a TRAM flap is the rectus abdominis muscle.

44. (A) Augmentation mammoplasty increases the size of the breast. A mastopexy is performed for breast
ptosis. A transverse rectus abdominis myocutaneous flap is performed for breast reconstruction.

45. (C) A reduction mammoplasty reduces the size of extremely large breasts. A mastopexy is done for a
breast ptosis. A simple mastectomy removes breast tissue.

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46. (B) The order of repairs done for reimplantation of a finger are debridement, bone to bone fixation,
tendon repair, nerve repair, artery and vein repair, and skin.

47. (C) Microtia is a congenital deformity of the pinna. Otitis media is inflammation of fluid in the inner
ear. Mentoplasty is for fixation of the chin. Cheiloplasty is repair of the lip.

48. (D) A brow lift, forehead lift, and endoscopic brow lift are all procedures that reduce wrinkles across the
forehead, to raise the sagging eyebrows and bridge of nose.

49. (C) A blepharoplasty can be performed through a subciliary or transconjunctival incision. A limbus
incision is used for a cataract removal.

50. (C) A blepharoplasty is done for dermatochalasis. Rhytidectomy is a facelift. Microtia repair is done for
small ears and a mastopexy is performed for ptosis of breast.

51. (B) The candela dye laser and the Q-switched laser are used to remove tattoos.

52. (D) Liposuction is a surgical procedure done to remove fat from the abdomen, buttocks, hips, thighs,
and knees. A tumescent solution of diluted lidocaine and epinephrine is injected into that area prior to
the procedure to produce an anesthetic effect.
Compression dressings are applied.

53. (B) Macromastia is the term used for large breasts. Gynecomastia is enlarged breast tissue in males due
to hormones. Ptosis is a drooping of the breast and microtia is small ears.

54. (B) Malar implants are inserted into the cheeks.

55. (A) A rhinoplasty is a nose job. A rhytidectomy is a facelift. Cheek implants are called malar.

56. (C) A third-degree burn includes the skin with all its epithelial structures and subcutaneous tissue
destroyed. It is characterized by a dry, pearly white, or charred-appearing surface void of sensation. The
destroyed skin forms a parchment-like eschar over the burned area.

57. (B) In 1991, OSHA adopted requirements designed to prevent transmission of blood-borne pathogens
in the work environment. It can fine health care facilities for noncompliance with regulations.

58. (C) The inflammatory response is the body’s attempt to neutralize and destroy toxic agents at the site of
injury and prevent their spread. After injury, the metabolic rate increases, quickening heartbeat. More
blood circulates to the area, causing dilation of vessels. The large amount of blood in the area is
responsible for redness.

59. (B) After debris and infected or contaminated tissue is removed by debridement, the wound is irrigated
thoroughly. Devitalized tissue is removed because it acts as a culture medium. The third intention of
healing requires debridement.

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60. (A) Closure that is too tight or under tension causes ischemia, a decrease in blood supply to the tissues,
and eventually tissue necrosis.

61. (B) When the collagen in the tissue remains constant, the fiber pattern reforms crosslinks to increase
tensile strength in the tissue. Tensile strength is the ability of the tissues to resist rupture.

62. (A) Fibrinogen unites with thrombin (a product of prothrombin and thromboplastin) to form fibrin,
which is the basic structural material of blood clots. It is essential for the clotting of blood.

63. (B) A cicatrix or scar is formed by the intertwining of cells surrounding the capillaries and binding
together in final closure of a wound. It is a scar left by a healing wound.

64. (C) A keloid is a scar formation of the skin following trauma or surgical incision. The result is a raised,
firm, thickened red scar. Black people are especially prone to keloids.

65. (B) Healing by granulation (second intention) involves a wound that is either infected or one in which
there is excessive loss of tissue. The skin edges cannot be adequately approximated. Generally, there is
suppuration (pus formation), abscess, or necrosis.

66. (C) Healing by third intention implies that suturing is delayed for the purpose of walling off an area of
gross infection involving much tissue removal, as in debridement of a burn when suturing is done later.
Third intention of healing means that two opposing granulation surfaces are brought together.
Granulation usually forms a wide, fibrous scar.

67. (D) Loose sutures prevent the wound edges from meeting and create dead spaces, which discourage
healing. Tight sutures or closure under tension causes ischemia.

68. (C) Second-intention healing is commonly referred to as granulation healing. This form of wound
healing takes longer than first intention, but is equally as strong once healed. It heals from the inside to
the outside surface.

69. (B) A band of scar tissue that binds together two anatomical surfaces that are normally separate from
each other is an adhesion. They are not commonly found in the abdomen, where they form after
abdominal surgery, inflammation, or injury.

70. (C) Third intention is employed when the wound is infected or contaminated. There is a delayed
primary closure.

71. (C) Evisceration is the protrusion of viscera through the edges of a totally separated wound.

72. (D) The three phases of wound healing are inflammatory, proliferation, and remodeling.

73. (D) Dehiscence is the tissue breakdown at the wound margin.

74. (D) All are wound complications.

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75. (B) When a wound exudates a collection such as pus, serum, or dead cells around the incision the wound
is described as suppurative.

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 ___________________ CHAPTER 23 ___________________

Genitourinary

Genitourinary

• Surgical anatomy includes—two kidneys/two ureters/bladder/urethra/prostate gland/two adrenal

glands/male reproductive organs/female urinary system
• Kidneys—are located in the retroperitoneal space, one on each side of the vertebral column at the level of
the 12th thoracic rib to the 3rd lumbar vertebra
Gerota’s fascia—tissue and fat surrounding the fascia of the kidney also called Gerota’s capsule, helps
keep the kidney in its normal position
Hilum—located on the medial side of the kidney, the renal vein/artery enters and exits the kidney
Renal pelvis—a funnel-shaped structure within the kidney, it divides into branches called the renal
calyces
The major blood supply to the kidneys is from the renal artery
Glomerulus—this is a capillary network of blood vessels within the renal cortex that functions as a filter.
It is surrounded by Bowman’s capsule
Glomerular filtration—is the first step of urine production where fluids are dissolved and forced through
the membrane
The Loop of Henle—helps to reabsorb filtered water and sodium, calcium, chlorine and potassium in a
normal kidney. The loop of Henle is found in the medulla of the kidney
• Nephron—the functional unit of the kidney responsible for removing waste and regulating fluid
Adrenal glands—each adrenal gland has a medulla that secretes epinephrine/adrenaline
• Adrenal cortex—makes steroid hormones, adrenaline, and noradrenaline. These hormones are influenced
by the pituitary gland
• ACTH—adrenocorticotropic hormone—is the hormone secreted by the pituitary to the adrenals
• Ureters—each ureter is a continuation of the renal pelvis. It extends from the renal pelvis to the bladder
Peristaltic contractions in the ureters help transport urine from the kidney to the bladder
• Urinary bladder—the bladder acts as a reservoir for urine until micturition/voiding
Trigone area includes:
two ureter openings
one urethral opening
• Urethra
The urethra in the male extends from the bladder to the penis

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 The urethra in the female lies beneath and behind the symphysis pubis anterior to the vagina
Because the female urethra is short and close to the anus and vagina, microorganisms have easy access
to the bladder and can cause UTIs
• The prostate gland—a donut-shaped gland located at the base of the bladder neck and completely
surrounds the urethra
It is responsible for providing fluid for sperm
• Benign prostatic hyperplasia—(BPH) this is a noncancerous overgrowth of prostatic tissue which pushes
against the bladder/urethra causing a blockage of urine flow
• KUB—this is an ultrasound examination of the kidneys, ureters, and bladder. It shows the size, shape, and
location of the organs
• IVU—intravenous urogram/pyelogram—x-ray with contrast media that shows the entire urological system

Male Reproductive Organs

• Scrotum—located behind and below the base of the penis and in front of the anus
The scrotum has two sacs lined with smooth glistening tissue called the tunica vaginalis
The tunica vaginalis has clear fluid within the sacs that also contain the testicles, epididymis, and some
of the spermatic cord
The scrotum is separated by a septum called the median raphe
• Epididymis—this is where sperm are stored and mature. It secretes a seminal fluid which helps sperm to
migrate
• Vas deferens—it carries sperm from the testes to the urethra
• Ejaculatory duct—is formed by the vas deferens and seminal vesicle duct. Semen passes through the
prostate gland, enters the urethra and exits the body via the tip of the penis through ejaculation
• Spermatic cord—contains veins, arteries, lymphatics, and nerves
The spermatic cord begins in inguinal ring and passes through the inguinal canal and ends at the
superficial inguinal ring in the scrotum
• Cowper’s glands/bulbourethral glands located on both sides of the bulbar urethras
Each gland secretes mucous into the urethra to aid in the ejaculation process
• Penis—contains a sponge like body surrounding the urethra. It contains erectile tissue and an exit route for
urine
Right corpus cavernosum and left corpus cavernosum- are the two outer bodies
Corpus spongiosum urethra—the inner body, surrounds the urethra
These tissues are vascular channels that fill the penis with blood during an erection
• Prepuce/foreskin—is located at the distal end of the penis, covers the glans penis
• Glans penis—head of the penis that contains the urethral orifice
• Special care must be taken when prepping for a GU procedure, you must be careful of the perineal area to
avoid contamination from the rectum to the urethra. The prep should be done in a downward motion and
the sponge discarded once it has contacted the vagina or anal area

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• Irrigation fluids are used to:
Distend the bladder for visualization
They should be warmed to meet the patient’s body temperature to prevent hypothermia
They come in collapsible bags and provide continuous irrigation
You must know sterile technique because the sterile parts of the tubing and IV bag need to be kept
sterile to prevent infection
• Distilled water—used for a simple cysto, retrograde pyelogram, and bladder tumor fulguration
• Nonelectrolytic and nonhemolytic solution—these solutions do not conduct electricity
When using the ESU you cannot use saline solution because it can conduct electricity
They are used for a TURP—transurethral resection of the prostate. They include:
Glycine
Mannitol
Sorbitol
• These solutions prevent:
Extravasation—entry of too much fluid into the blood
Hemolysis—rupturing of RBC’s and releasing their contents into the surrounding blood stream due to
extravasation
It is the STSR/circulators responsibility to keep track of the amount of irrigating solutions to be used to
prevent extravasation from occurring
• Ureteral catheters
Used to identify the ureters during pelvic or intestinal surgery
To perform a retrograde pyelogram
Retrograde pyelogram—an x-ray of the kidney and ureter
• Contrast media is injected into the ureters to visualize the ureter and the kidney to see if there is a blockage
in the urinary tract
• Used to bypass an obstruction in the ureter such as a tumor, stone, or stricture
• The most commonly used ureteral catheters are:
Whistle tip
Cone tip
Olive tip
Garceau tip
• Stent are a specially designed hollow tube, made of a flexible plastic material that is placed in the ureter.
They are used to:
Bypass an obstruction—commonly placed in the ureter, between the kidney and the bladder. They
remain in the ureter following surgery or an obstruction—hence the name indwelling
Indwelling urethral stents include:
Double pigtail
Double j

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• Urethral catheters function as: stents and drainage tubes, they include:
Plain—temporarily inserted to:
Drain urine from the bladder
Decompress the bladder
Obtain a urine specimen, example is a red Robinson and a Coude. These catheters do not require a
drainage bag
Commonly used to evacuate the bladder before a D&C
Indwelling—they are used to measure urinary output and provide bladder decompression
Examples include Foley catheters
Most Foley catheters use gravity drainage bags (urimeter—measures the urine output). These gravity
drainage bags must be kept below the level of the bladder to promote drainage and prevent reflux
To fill the balloon on the Foley catheter you use water not saline because it can erode the balloon
To fill a 5–cc balloon, approximately 8–10 cc of water is used
A two-way Foley has two ports, one to fill the balloon, and the second for urine drainage. This catheter
is used on most operative procedures
The three-way Foley has three ports, one to fill the balloon, one for drainage, and the third for irrigation
Suprapubic—this catheter is placed in the bladder through a surgical opening in the abdomen.
Examples of these catheters include:
Foley
Pezzer (mushroom)
Malecot
The Pezzer and Malecot rely on their tip to hold the catheter in place unlike the Foley that use a balloon
• Foley Goalie is a traction device used to prevent a Foley catheter from being pulled out of the male penis,
if there is too much traction being forced on the catheter the traction device tightens and prevents the
catheter from coming out
• Nephrostomy tubes are inserted percutaneously into the kidneys to remove urine. The nephrostomy tube
drains urine from your kidney into a collecting bag outside your body
• Interventional radiology—is a separate department from the operating room and radiology where
procedures are performed. Many OR procedures are now being done in interventional radiology. They
place catheters and/or stents to introduce contrast media for fluoroscopy procedures
• Cystoscopy—is an examination of the lower urinary tract including the urethra, bladder and ureteral
orifices. Indications for a cystoscopy include:
Hematuria—blood in the urine
Urinary retention
UTI
Cystitis
Tumors
Fistulas

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 Stones
Urinary incontinence
• Cysto table—stationary table that allows the patient to be positioned in supine, lithotomy, and various
positions. It provides x-rays and fluoroscopy during the procedures. It has a mesh attachment for catching
specimens and a drainage attachment built into the floor
• The most common stirrups used are Allen and yellofin—they relieve pressure on the popliteal space
• Prep includes the entire pubic area, scrotum, and perineum
• Special cysto drape used, it has a sterile screen portion to allow irrigation/fluids to drain, and catch
specimens
• Basic cysto set-up includes:
Light source
Cystoscope
Cystourethroscope
Bridge
Telescopes
Stopcock
Irrigation fluid and tubing
Rubber catheter nipples/adaptor
• Extra equipment sometimes needed on a cysto procedure include:
Randall Stone forceps
Bladder biopsy forceps
Instruments for crushing stones
instruments—general surgery/vascular/thoracic, rib/long instruments
Herrick Pedicle clamp
• Flexible Cystoscope—used on patients that have a rigid prostatic urethra, and those who cannot be placed
lithotomy position. This procedure can be performed at the patient’s bedside
• Litho-La-Paxy/Litholapaxy—is a procedure where large bladder stones are crushed in the bladder with a
lithotrite (a special instrument used to crush stones) and removed through irrigation
• Endoscopy of the genitourinary tract is considered a class II clean contaminated case
• This requires high level disinfection cleaning
• Glutaraldehyde is the choice of disinfectant, it is also called Cidex
The level of disinfection is based on the time, temperature, and concentration of the disinfectant
Once activated the shelf life is 14 days
Rinse with sterile water, and make sure all surfaces are rinsed including all ports and channels
It is effective for- (10 minutes/68–86°F/2.0–2.4%)
Bacteria
Fungi
Viruses—HIV/HBV

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 TB (45–90 minutes/77–86°F/2.0%
Spores (10 hours/room temp)
• Laser ablation of condylomata and penile carcinoma—these procedures are being performed with the laser
more often than the ESU because the heat from the laser is distributed more evenly and can also target the
underlying tissue
Smoke evacuator must be used to prevent inhaling the plume because it is a carcinogen. The lasers used
include:
Argon
CO2
KTP—potassium
Nd—Neodymium
Yag
• Circumcision—procedure to excise the foreskin (prepuce) of the glans penis
In males it is performed for the relief of phimosis
Phimosis—the foreskin becomes stenosed over the tip of the penis and is difficult to retract. This can
cause infection because it is difficult to clean
Basic instruments, ESU, and have available straight hemostats
Dressings used are nonadherent allowing for urination such as Xeroform and a 4 × 4
• Urethral meatotomy—is an incisional enlargement of the urethral meatus performed for
congenital/acquired stenosis or a stricture at the external urethral meatus
This procedure is done to provide relief of a urethral stricture
Van Buren sounds—they are urethral dilators
Phillips filiforms and followers—they are plastic/woven dilators that can pass through a stricture. The
followers are then passed over the filiform to dilate the stricture. They come in graduated sizes
Filiforms are used to get past difficult strictures and followers are used for dilation and drainage
• Urethroplasty—this is reconstructive surgery of the urethra caused by:
Strictures
Infection
Trauma and a congenital anomaly
• Penectomy—this is the partial or total removal of a cancerous penis
• Penile implant—this is performed for organic sexual impotence. Sexual impotence may be caused by:
Diabetes
Priapism (persistent and painful erection)
Peyronie’s disease (distorted/bent penis)
Penile trauma
Neurological/vascular problems
• The cylinders are implanted into the penis, the pump is implanted into the scrotum, and the reservoir is
implanted in the abdomen

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• Bacitracin antibiotic irrigation is used during the procedure and to soak the implants prior to implanting in
the body
• Hydrocelectomy—a hydrocele is an abnormal accumulation of fluid in the tunica vaginalis layer of the
scrotum. It is usually the result of trauma or infection
Procedure includes a scrotal incision where the fluid is suctioned out and the sac is inverted and sutured
• Vasectomy—this procedure is performed to sterilize males
Allis clamp is used to grasp the vas deferens
The vas deferens are separated and then tied/cauterized to prevent sperm from entering the seminal
stream
• Vasovasostomy—this procedure is performed to correct obstructions of the vas deferens caused by:
Congenital anomalies
Inflammation
Trauma
It is also performed for reversal of a vasectomy
Microscope is used
• Epididymectomy—this procedure is performed to remove an inflamed portion of the epididymis. Fluid
and sperm are prevented from passing through the epididymis
• Spermatocelectomy—an abnormal cyst/sac filled with fluid that may contain sperm
• Varicocelectomy—is an abnormal dilatation of the spermatic veins in the spermatic cord that drain the
testicles. This causes a painful swelling of the scrotum
This is a ligation of the spermatic vein performed to prevent a rise in temperature in the scrotum to
preserve the sperm and increase sperm count
• Prostatectomy—the surgical removal of part or all of the prostate gland. The procedure can be performed:
Transurethral—through the urethra (TURP)
Suprapubic—through the bladder
Retropubic—around the bladder
• Symptoms of BPH are similar to that of prostate cancer. There are two screening tests to determine
prostate disease they include:
PSA—prostate-specific antigen
DRE—digital rectal examination
• The PSA is used to screen for prostate cancer
It measures the amount of prostate-specific antigen in your blood
• Another test used for screening of the prostate is the DRE—digital rectal examination. The prostate lies in
the front of the rectum and the physician can feel the gland by using a gloved/lubricated finger inserted
into the rectum
• Gleason score—this is a system used to grade prostate cancer. Two cell types are tested and combined to
give you a score
• Needle biopsy—once prostate cancer is clinically suspected a needle biopsy of the prostate is indicated

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 Tru-Cut biopsy needle is used to obtain a prostate specimen
This procedure is performed in the urologists office, a 22-g needle is used transrectally or transperineally
• TURP—transurethral resection of the prostate—this is the endoscopic surgical removal of the prostate,
you can remove part of or all of the prostate
This can be done transurethrally or open
TURP for BPH is done by direct visualization of the prostate with the cystoscope through the urethra
The tissue is removed with electrocautery/resectoscope—these are used for performing a resection with
electrical current
The surgeon passes a resectoscope into the bladder through the urethra, and resects pieces of tissue from
around the bladder neck and lobes of the prostate leaving the capsule intact
Ellik evacuator/Toomey syringe—used to evacuate prostatic chips and clots following a TURP
A triple lumen catheter is inserted at the end of the case for drainage and irrigation it is a Foley triple
lumen catheter 30-cc balloon
One lumen is to fill the balloon
The second is for irrigation
The third is for drainage and aspiration
• Laser—light amplification by the simulated emission of radiation/laser procedures of the prostate
KPT laser—Potassium-titanyl phosphate—also known as the GREEN LIGHT LASER—used for
vaporization of benign prostatic disease
• Laser safety includes:
Eyewear
Fiberoptic beam must not be directly placed on the drapes
Proper suction equipment must be used for smoke plume
Laser signs should be posted on all doors/windows in the room to alert outside personnel
• Retropubic prostatectomy—this is the removal of the hypertrophic prostate tissue with a extravesicle
approach (around the bladder)
• Suprapubic prostatectomy—this is removal of the prostate through a transvesicle approach (through the
bladder)
• Simple perineal prostatectomy—this is removal of a prostate through a perineal approach. This is done
when there is suspicion of cancer
• Radical retropubic prostatectomy with pelvic lymphadenectomy—a radical prostatectomy is performed to
remove the cancerous prostate gland
The entire gland, capsule, and the seminal vesicles are removed
The posterolateral neurovascular bundles are spared to preserve erectile function
The second part of the procedure is to remove the lymph nodes en bloc to prevent seeding
• Laparoscopic radical prostatectomy—this is a minimally invasive procedure
• Robot-assisted laparoscopic radical prostatectomy—robotic equipment is used to perform this procedure,
allowing the robot to imitate the surgeon’s movement. Same advantages as a laparoscopic radical

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 prostatectomy
The robotic system consists of:
Surgeons console
Cart with interactive robotic arms and jointed instruments that simulate the human hand and wrist
A high-resolution three-dimensional image
• Transrectal seed implantation—this is performed for cancer that is contained within the prostate
For this procedure there are many different physicians involved in a collaborative effort to treat the
patient, they include:
Radiation oncologist
Medical physicist
GU surgeon
Oncologist
• Surgery of the bladder—surgeries of the bladder can be performed with an open abdominal incision or
transurethral
For most open bladder procedures supine position/Trendelenburg (this position is used to displace
abdominal organs for better visualization of the bladder)
• Suprapubic cystostomy—a cystostomy catheter is placed into the urinary bladder through a low abdominal
incision
When a drainage tube is inserted into the bladder through an abdominal incision the procedure is called
a cystostomy
• Transurethral resection of bladder tumors—TURB—bladder tumors are removed with:
Resectoscope working element, loop electrode and biopsy forceps
The scope is inserted transurethrally into the bladder
• As with the TURP procedure you must be aware of the irrigating solution you use and the amount used.
With bladder tumors sterile water is recommended
• Transurethral laser ablation—the Yag laser is used to destroy small recurrent bladder tumors and large
bladder tumors
• Suprapubic cystolithotomy—this is removal of bladder stones with special instruments. Electrohydraulic
lithotripter is used to crush the stones with an electric current
Yag laser can also be used to zap the stones

Vesico-fistulas

• They are an abnormal hollow or tubular connection between two organs

Vesicointestinal fistula—Enterovesical fistula—fistula between the bladder and intestines
Vesicovaginal—fistula between the bladder and vagina
• Vesicourethral suspension—Marshall–Marchetti–Krantz—this procedure is performed to treat urinary
stress incontinence in women
The objective is to bring the bladder and the urethra back up into the pelvis, they use sutures to correct

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 this
Everyone must be double gloved and change every time they go into the vagina they should change their
gloves because the vagina is considered dirty
Pereyra needle—this is a surgical technique for the correction of stress incontinence
• TVT sling—tension-free vaginal tape—this is performed on women who have urinary stress incontinence,
sphincter deficiency
The tape used is made of polypropylene mesh encased in plastic and is attached to two large trocar
needles at each end of the tape
The mesh is passed through the pelvic tissue and positioned under the urethra, creating a supportive
sling
A cystoscopy is performed at the beginning of the case to confirm the integrity of the bladder. This is
performed after the first needle is inserted and again at the end to make sure they didn’t perforate the
bladder
• Radical cystectomy—this is total removal of the bladder and adjacent structures along with pelvic lymph
node dissection
This procedure is done en bloc to prevent any further seeding
• Ileal conduit—this is an exterior urinary diversion where the bladder is removed with a radical cystectomy,
and the ureters are rerouted to a loop in the bowel and it is brought out to the skin (ileostomy) and drains
into a urinary drainage bag
• Bladder augmentation/neobladder—this is surgically performed to create a new bladder. Interior urinary
diversion within the intestines and a new bladder is created with the intestine
Names of the urinary diversion procedures include:
Knock pouch
Indiana pouch
Le bag
• Cutaneous ureterostomy— this is another type of urinary diversion where the ureters are brought out to
the skin when bowel cannot be used
• Surgery of the ureters and kidneys—surgery is performed to prevent urine obstruction and subsequent
renal failure
The most common cause of urinary tract obstructions include:
Stones
Infections
Tumors
Congenital malformations
Previous surgery
When surgery of these stones is performed they are sent to pathology for chemical analysis and should
always be sent dry
Staghorn calculus—is a stone that lodges itself in the renal calyx and continues to grow large. Surgical

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 intervention is required
Stones are sent to pathology in a dry container
The incision used for ureter and/or kidney surgery may require removal of the 11th and 12th ribs
• Urethrectomy—Nephroureterectomy—this is complete removal of the ureter, usually involves removing
the kidney due to tumors involving the kidney and ureter
• Ureteroenterostomy—is diversion of the ureter into a portion of the colon (ileum)
Ureteroenterostomy—rerouting the ureters into the colon. This is one part of the ileal conduit
Ileal conduit—the entire procedure of removing the bladder and re-routing the ureters into a portion of
the colon
• Ureteroureterostomy—this is removal of the diseased portion of the ureter and then reconnecting it to
another portion of the same ureter
• Ureterocystostomy—is the re-routing of the ureters into another part of the bladder. Even though we are
not removing the bladder on this procedure, we are still creating a urinary diversion
• Ureteropyeloscopy—removal of a stone or stricture in the ureter or kidney by way of transurethral
approach—through the urethra to the bladder and into the ureter
• Nephrostomy—creating an opening into the kidney for temporary or permanent drainage of urine when
there is an obstruction in the urinary tract to preserve the renal tissue. If urine doesn’t flow out of the
kidney you will get infection, renal failure, and destruction of the renal tissue
• Nephrotomy—incision into the kidney usually due to a blockage from a calculus
• Percutaneous nephrolithotomy—this procedure is performed to remove stones from the patients urinary
tract by means of a flexible nephroscope passed into the kidney percutaneously (through the skin)
• ESWL—extracorporeal shock wave lithotripsy—uses shock waves to break a kidney stone into small
pieces that can more easily travel through the ureter
The machine is the lithotripter and the part of the bed you lie in submerged in the water is the
lithotripter tub
High-energy sound waves pass through your body without injuring it and break the stone into small
pieces
• Pyelolithotomy—removal of a calculus from the renal pelvis (part of the kidney that connects to the ureter)
• Pyleostomy—making an opening into the renal pelvis for temporary/permanent diversion of urine flow
• Pyelotomy—incision into the renal pelvis as an access to stones in the renal pelvis
• Laser lithotripsy—the laser is used to destroy stones and there is no damage to the surrounding tissue. The
Yag laser is used
• Nephroureterectomy—open approach—this is removal of the kidney and its entire ureter
This is performed for hydroureteronephrosis (distension and dilation of the renal pelvis and ureter)
causing atrophy
This is caused by an obstruction in the renal pelvis and ureter
• Nephrectomy—open approach—this is the surgical removal of the kidney. It is performed for:
Congenital hydronephrosis (distension/dilation of the kidney. Kidney becomes very large and becomes

508
 atrophied)
Renal tumor
Renal trauma
Stones causing severe infection
• The 11th and 12th ribs may be removed for a nephrectomy
• Heminephrectomy—this is removal of a portion of the kidney.
• Lateral kidney position:
The patient position is lateral with the operative kidney up and the dependent side placed on the kidney
rest
Left lateral kidney—right side up
Right lateral kidney—left side up
The upper arm is supported on padded mayo stand and the lower arm is on a padded arm board
The patients legs are positioned with a pillow between the legs, the lower leg is bent and the upper leg is
straight
The kidney rest is then raised and heavy 2-in tape or a bean bag is used to stabilize the patient.
The purpose of the kidney rest is to increase the space between the lower ribs and iliac crest
Before closing on a kidney case, the kidney rest is lowered and the table is straightened to help create
better approximation of tissues
• Laparoscopic nephrectomy—the most common approach used for a laparoscopic nephrectomy is the
transabdominal
You must always be prepared to open
• Radical nephrectomy—this is removal of the kidney, fatty tissue, adrenal gland, Gerota’s capsule, and the
lymph nodes
• Kidney transplant—a kidney transplant is the transplantation of a living related, or a cadaver donor kidney
into the recipient’s iliac fossa. Common diagnosis for a kidney transplant is polycystic kidneys
The ideal donor is a twin or an immediate family member usually a parent or sibling
Different IV solutions are used before, during, and after the procedure. Mannitol is given on the
morning prior to surgery to the living donor to insure diuresis before, during, and after the procedure
Mannitol—is the drug of choice given to the donor patient to reduce swelling and increase urine
output
Osmosis—when molecules of water go from where there are plenty of them to where there are
little of them (high concentration to lower concentration)
Ringer’s lactate IV solution—is used to perfuse the harvested kidney (this solution is chilled)
• Collins or Sachs solution—is used to perfuse the harvested kidney from a cadaver donor but should never
be used to perfuse a kidney from a living donor. This solution is chilled
Two adjacent OR rooms are prepared for the surgery because the procedure is performed simultaneously
The right kidney is usually taken because it is the smaller one. The larger kidney is left in the donor
Gibson incision—commonly used for a transplant

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 The position for the recipient is left lateral decubitus
The cadaver donor is placed in supine position
• Adrenalectomy—the adrenal glands lie above each kidney, they produce hormones such as epinephrine,
norepinephrine, androgens, estrogens, aldosterone, and cortisol. This procedure is performed to excise
partial/total of one or both adrenal glands
• This is performed for hypersecretion of the adrenal hormones
• Wilms tumor/nephroblastoma—congenital malignant tumor of the kidney found in children

510
 Questions

1. The Pereyra needle is used in which specialty area of surgery?

(A) Neurology
(B) Urology
(C) Orthopedics
(D) Ophthalmology

2. The use of distilled water during a highly invasive genitourinary procedure such as a transurethral
resection of the prostate (TURP) is prohibited for irrigation because of the potential for:

(A) hemolysis of RBC

(B) electrolytic dissipation of current
(C) increase of blood pressure
(D) body fluid shift

3. Why is a 30-cc bag Foley used after a TURP?

(A) Hemostasis
(B) Decompression
(C) Creation of negative pressure
(D) Aspiration

4. The three lumens of a Foley are used for inflation, drainage, and:

(A) prevention of urine reflux

(B) access for sterile urine specimens
(C) continuous irrigation
(D) additional hemostasis

5. The purpose of the kidney bar or kidney lift is to:

(A) increase the space between the lower ribs and iliac crest
(B) increase the space between the ribs
(C) stabilize the patient
(D) support the body in the flexed position

6. Why is the table straightened before closing a kidney incision?

511
 (A) To facilitate easier respirations
(B) To create better approximation of tissues
(C) To facilitate better circulation
(D) To prevent nerve damage

7. Nonmalignant enlargement of the prostate is termed:

(A) prostatitis
(B) benign prostatic hypertrophy (BPH)
(C) balanitis
(D) prostatism

8. Urethral strictures can be dilated by use of each of the following EXCEPT:

(A) Philips filiform and followers

(B) Van Buren sounds
(C) Braasch bulb
(D) McCarthy dilators

9. A staghorn stone is one that lodges and continues to grow in the:

(A) renal calyx

(B) space of Retzius
(C) ureter
(D) hilum

10. In cystoscopy, the irrigating solution is:

(A) distilled water

(B) glycine
(C) mannitol
(D) sorbitol

11. Rib removal for surgical exposure of the kidney requires all of the following EXCEPT a/an:

(A) Alexander periosteotome

(B) Doyen raspatory
(C) Heaney clamp
(D) Stille shears

12. Penile condylomata are most successfully removed by:

(A) dermabrasion
(B) laser
(C) cautery

512
 (D) ultrasound

13. Removal of a testis or the testes is called:

(A) orchiopexy
(B) orchiectomy
(C) epididymectomy
(D) vasectomy

14. Which solution is NOT used during a transurethral prostatectomy?

(A) Normal saline

(B) Sorbitol
(C) Mannitol
(D) Glycine

15. Temporary diversion of urinary drainage by means of an external catheter that drains the renal pelvis is
called:

(A) vesicostomy
(B) nephrostomy
(C) pyelostomy
(D) cystostomy

16. The procedure to treat organic sexual impotence is:

(A) spermatocelectomy
(B) varicocelectomy
(C) testicular implant
(D) penile implant

17. Microscopic reversal of the male sterilization procedure is termed:

(A) spermatogenesis
(B) orchiopexy
(C) vasovasostomy
(D) vasectomy

18. A needle biopsy of the prostate may be accomplished with a/an:

(A) butterfly needle

(B) angiocatheter
(C) Tru-Cut needle
(D) taper needle

19. When the male penis is curved ventrally with the meatus and the glans in close proximity to each other

513
 it is called:

(A) paraphimosis
(B) phimosis
(C) epispadias
(D) chordee

20. Continuous irrigation following TURP is accomplished by use of a:

(A) suprapubic cystotomy tube

(B) 30-cc three-way Foley catheter
(C) 5-cc three-way Foley catheter
(D) 30-cc two-way Foley catheter

21. When the prostate gland is removed through an abdominal incision into the anterior prostatic capsule, it
is called a ____ prostatectomy.

(A) perineal
(B) suprapubic
(C) retropubic
(D) transurethral

22. Kidney stones are sent to the laboratory in:

(A) saline
(B) water
(C) dry state
(D) formalin

23. A Pereyra procedure is done for:

(A) stress incontinence

(B) chronic bladder infection
(C) drainage of the bladder
(D) impotence

24. A percutaneous nephrolithotomy utilizes all of the following EXCEPT:

(A) ultrasound wand

(B) flexible nephroscope
(C) lithotripter
(D) lithotripter tub

25. Orchiopexy can be defined as:

(A) fixation of an ovary

514
 (B) uterine suspension
(C) testicle removal
(D) fixation of a testicle

26. Abdominal resection of the prostate gland through an incision into the bladder is known surgically as a:

(A) retropubic prostatectomy

(B) suprapubic prostatectomy
(C) transurethral prostatectomy
(D) suprapubic cystostomy

27. A lumbar or simple flank incision for ureter or kidney surgery may include removal of which ribs?

(A) 5 and 6
(B) 7 and 8
(C) 9 and 10
(D) 11 and 12

28. An abnormal accumulation of fluid in the scrotum is a/an:

(A) hydrocele
(B) enterocele
(C) varicocele
(D) hydronephrosis

29. Bladder stones are crushed with a:

(A) basket catheter

(B) lithotrite
(C) cautery
(D) resectoscope

30. Urethral meatal stenosis is corrected by a/an:

(A) frenulotomy
(B) meatotomy
(C) urethral dilation
(D) extirpation of the penis

31. In a penile implant, the inflation pump is located in the:

(A) distal penis

(B) proximal penis
(C) scrotum
(D) groin

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32. Excision of the tunica vaginalis is a:

(A) vagotomy
(B) vasectomy
(C) varicocelectomy
(D) hydrocelectomy

33. Circumcision refers to:

(A) removal of the foreskin

(B) removal of the glans
(C) widening of the urethral opening
(D) lengthening of the foreskin

34. An alternative approach to surgical TURP utilizing a cystoscopic setup as its base is:

(A) suprapubic prostatectomy

(B) transcystoscopic urethroplasty
(C) perineal prostatectomy
(D) retropubic prostatectomy

35. The laser used to destroy small recurrent bladder tumors is the:

(A) CO2
(B) argon
(C) Nd:YAG
(D) Both A and B

36. Following anastomosis of a ureter during a ureteral reimplantation procedure, a ____ is left in place to
ensure free drainage of the kidney postoperatively.

(A) Foley catheter

(B) ureteral catheter
(C) T-tube
(D) soft stent

37. A reverse sterilization procedure in the male is called a/an:

(A) vasostomy
(B) vasovasostomy
(C) epididymovasostomy
(D) Both B and C

38. Before insertion of a penile implant, the insertion site, as well as the implant itself, is irrigated with:

(A) normal saline

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 (B) Betadine
(C) sterile water
(D) kanamycin and bacitracin

39. To prevent thrombi from forming in the walls of the renal vein during transfer from the donor to the
recipient, _______ is given just before clamping of the renal vessels.

(A) furosemide
(B) protamine sulfate
(C) heparin
(D) mannitol

40. The drug of choice for adequate diuresis of a living donor before, during, and postremoval of the kidney
is:

(A) urea
(B) protamine sulfate
(C) Ringer’s lactate solution
(D) mannitol

41. All of the following are ideal requirements of cadaver donors EXCEPT:

(A) any age

(B) free of infection or malignancy
(C) normotensive up until death
(D) under hospital observation before death

42. Cooling and flushing of pancreas, liver, and kidneys of cadaver donors is accomplished by cannulation of
the organ and infusion of large amounts of cold

(A) saline solution

(B) Ringer’s lactate solution
(C) sterile water
(D) Sack’s solution

43. Nonconducting, isosmotic glycine irrigating solution must be used in the surgical presence of a:

(A) cystoscope
(B) ureteroscope
(C) resectoscope
(D) nephroscope

44. All of the following procedures may be completed through a cystoscope EXCEPT:

(A) biopsy of bladder tumor

517
 (B) removal of foreign body in bladder
(C) total removal of bladder tumor
(D) cystogram for diagnostic studies

45. After incision is made into the scrotum during a vasectomy, the forceps used to grasp the vas and bring
it to the surface for surgery is the:

(A) Allis
(B) Babcock
(C) Kelly
(D) mosquito

46. Extracorporeal shock wave lithotripsy (ESWL) disintegrates stones by introducing shock waves into the
body through the medium of:

(A) water
(B) air
(C) gas
(D) saline

47. Laser lithotripsy utilizes the tunable pulse-dyed laser known as:

(A) diode
(B) Nd:YAG
(C) Candela
(D) argon

48. The inability to control urination is:

(A) reflux
(B) urinary incontinence
(C) hydrocele
(D) chronic bladder infection

49. The radiographic diagnostic test used to outline the structures of the kidney ureters and bladder is
known as:

(A) MRI
(B) retrograde pylogram
(C) GU radiograph
(D) KUB

50. Overabsorbtion of irrigation fluid that may result in vascular overload is known as:

(A) extravasation

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 (B) intravasation
(C) hemolysis
(D) hydronephrosis

51. All are urethral catheters EXCEPT:

(A) whistle tip

(B) spiral tip
(C) Braasch bulb
(D) three-way Foley

52. When performing an ileal conduit for urinary diversion, the ureters are implanted into:

(A) bladder
(B) ileum
(C) trigone
(D) large intestine

53. If a patient is undergoing a right nephrectomy for a right renal tumor, the position is:

(A) a right lateral kidney

(B) a left lateral kidney
(C) supine
(D) prone

54. What syringe is used to evacuate bladder, prostate or Stone fragments?

(A) Cystoscope
(B) Ellik
(C) Toomey
(D) Both B and C

55. Which of the following dilators are used to dilate the urethra?

(A) Hanks
(B) Hagar
(C) Cysto
(D) Van Buren

56. Which incision is used when doing a TURP?

(A) Suprapubic
(B) Retropubic
(C) Pfannenstiel
(D) None of the above

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57. Insertion of a suprapubic catheter into the bladder for drainage away from the vaginal and urethral area
is:

(A) Foley catheter

(B) ileal conduit
(C) cystostomy
(D) Stamey procedure

58. Discharge of urine from the urinary bladder is called:

(A) plasma flow

(B) albumen urea
(C) renal clearance
(D) micturition

59. The condition in which the urethral meatus is located on the top side of the penis?

(A) Penile implant

(B) Hypospadias
(C) Epispadias
(D) Meatotomy

60. This procedure is performed on a patient with chronic and end-stage renal disease to aid in filtering the
blood and removing ingested toxins.

(A) AV fistula
(B) AV shunt
(C) Peritoneal dialysis
(D) All of the above

61. The tissue covering of the kidney that keeps it in its normal position is:

(A) glomerulus
(B) renal pelvis
(C) Gerota’s
(D) loop of Henley

62. Which of the following instruments are used to dilate the urethra?

(A) Hank
(B) Hagar
(C) Bakes
(D) Van Buren

63. The first step of urine production where fluids are dissolved and forced through the membrane is:

520
 (A) glomerular filtration
(B) peritoneal dialysis
(C) hemolysis
(D) osmosis

64. The functional unit of the kidney responsible for removing waste and regulating fluid is:

(A) renal pelvis

(B) nephron
(C) renal calyx
(D) Gerota’s capsule

65. Procedure to remove urinary calculus include:

(A) ileal conduit

(B) laparoscopic nephrectomy
(C) ESWL
(D) TURP

66. The trigone includes:

(A) openings of both ureters

(B) urethral opening in the bladder
(C) Both A and B
(D) connection of the kidney to ureter, ureter to bladder, bladder to urethral meatus

67. Rupturing of RBCs and releasing their contents into the surrounding blood stream is caused by:

(A) hemolysis
(B) extravasation
(C) hydronephrosis
(D) distribution

68. The catheter placed in the bladder through a surgical opening in the abdomen for urinary diversion is:

(A) Coude
(B) Robinson
(C) supra pubic
(D) None of the above

69. How many cc’s of sterile water is used to fill a 16-F 5-cc Foley catheter?

(A) 1–5
(B) 5–6
(C) 8–10

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 (D) 10–12

70. When performing a penile implant, the reservoir is placed in the _____, the cylinders in the _____, and
the pump in the _____.

(A) scrotum, penis, abdomen

(B) penis, scrotum, abdomen
(C) abdomen, penis, scrotum
(D) abdomen, scrotum, penis

71. Transrectal seed implantation is performed for cancer within the prostate. The physicians involved with
the treatment include all except:

(A) radiation oncologist

(B) OB/GYN
(C) GU
(D) medical physicist

72. A vesicovaginal fistula is a fistula between the:

(A) vagina and intestines

(B) vagina and anus
(C) vagina and bladder
(D) vagina and the rectum

73. A TVT sling is used for:

(A) urinary stress incontinence

(B) kidney stones
(C) kidney tumor
(D) Both b and C

74. All are true regarding a kidney transplant EXCEPT:

(A) the right kidney is usually taken because it is the smaller one and the larger kidney is left for the
donor patient.
(B) Gibson incision is used
(C) Mannitol is used
(D) a kidney transplant is the transplantation of only a cadaver donor kidney into the recipient’s iliac
fossa

75. The most common tumor of the kidney in children is:

(A) Wilms tumor

(B) neuroblastoma

522
(C) nephrosarcoma
(D) glioblastoma

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 Answers and Explanations

1. (B) A Pereyra needle suspension is used to treat stress incontinence, a urinary condition.

2. (A) When water is used for irrigation on an invasive surgical procedure, the pressure of the water against
the exposed vessels creates a hemolytic reaction and therefore destroys red blood cells.

3. (A) Pressure from a 30-cc catheter balloon inserted after closure of the urethra helps obtain hemostasis
by controlling venous bleeding.

4. (C) The third lumen provides a means for continuous irrigation of the bladder for a time postoperatively
to prevent formation of clots in the bladder.

5. (A) The OR table is flexed so that the kidney elevator can be raised the desired amount to increase the
space between lower ribs and iliac crest.

6. (B) When the kidney position is being used, the table is straightened before closure to afford better
approximation of tissues. It is used for procedures on kidneys and ureters. This is done by the
anesthesiologist.

7. (B) As the male ages, the prostate gland may enlarge and gradually obstruct the urethra. This condition
is known as benign prostatic hypertrophy (BPH).

8. (C) A Braasch bulb is a ureteral catheter used to occlude the ureteral orifice during x-ray study. Urethral
dilatation is accomplished using McCarthy dilators, Philips filiform and followers, and Van Buren
sounds.

9. (A) A stone may lodge in a renal calyx and continue to enlarge, eventually filling the entire renal
collecting system. It is known as a staghorn stone.

10. (A) For simple observation cystoscopy or retrograde pyelogram, sterile distilled water may be used.

11. (C) The Alexander periosteotome, Doyen raspatory, and Stille shears are all instruments required to
remove a rib. A Heaney clamp is a hemostatic clamp used in gynecological surgery.

12. (B) Laser ablation of condylomata is the eradication of diseased tissue by means of a laser beam. The
recurrence rate with this technique is low.

13. (B) Removal of the testes (orchiectomy) renders the patient both sterile and hormone deficient. Bilateral

524
 orchiectomy usually denotes carcinoma. Unilateral orchiectomy may be indicated for cancer, infection,
or trauma.

14. (A) Sorbitol, mannitol, and glycine do not produce hemolysis. They are nonelectrolytic and do not cause
dispersion of high-frequency current with loss of cutting power as occurs with normal saline.

15. (C) Pyleostomy is entering the pelvis of the kidney with a small blade. A catheter is placed through the
incision into the renal pelvis to create a short-term urinary diversion.

16. (D) A penile prosthesis is implanted for treatment of organic sexual impotence.

17. (C) Vasovasostomy is the surgical reanastomosis of the vas deferens, utilizing the operative microscope.

18. (C) The Tru-Cut or Vim–Silverman biopsy needle is used to retrieve a prostate biopsy.

19. (D) Chordee is when the male penis is curved ventrally with the meatus and the glans within close
proximity to each other. Epispadias is when the urethral opening is on the dorsum of the penis.
Phimosis is a congenital narrowing of the foreskin on the head of the penis. Paraphimosis is when the
foreskin cannot be retracted from an uncircumcised penis which can result in gangrene and amputation
of the penis.

20. (B) Following a TURP, the urologist may insert a 30-cc three-way Foley catheter. The third lumen
provides a means of continuous irrigation of the bladder for a period after surgery to prevent the
formation of clots. The large balloon aids in hemostasis.

21. (C) Retropubic prostatectomy is the enucleation of hypertrophied prostate tissue through an incision
into the anterior prostatic capsule. Good exposure and excellent hemostasis are obtained.

22. (C) Stones removed during surgery are subjected to chemical analysis and thus are submitted in a dry
state. Fixative agents invalidate the results of the analysis.

23. (A) A Pereyra procedure is a bladder neck suspension involving ureterovesical suspension with
vaginourethroplasty.

24. (D) A percutaneous nephrolithotomy facilitates the removal of stones using a rigid or flexible
nephroscope. Accessory instrumentation includes an ultrasonic wand (sonotrode), lithotripter probe,
stone basket, and stone grasper. A lithotripter tub is used in extracorporeal shock wave lithotripsy.

25. (D) Orchiopexy is regarded as the transfer or fixation of an imperfectly descended testicle into the
scrotum and suturing it in place.

26. (B) After a suprapubic incision is made abdominally, an opening is made into the bladder, and the
prostate is removed from above.

27. (D) The lumbar or simple flank incision may include removal of the 11th or 12th rib, thus a rib set

525
 should be available.

28. (A) A hydrocele is an abnormal accumulation of fluid within the scrotum, contained in the tunica
vaginalis.

29. (B) A lithotrite is used to crush large bladder calculi.

30. (B) Urethral meatotomy is an incisional enlargement of the external urethral meatus to relieve stenosis or
stricture either congenital or acquired.

31. (C) The pump is placed in the most dependent portion of the scrotum.

32. (D) A hydrocelectomy is the excision of the tunica vaginalis of the testis to remove the enlarged fluid-
filled sac.

33. (A) Surgical removal of the foreskin of the penis is frequently performed immediately after birth. At
times, the condition known as phimosis (stricture of the foreskin) that causes a circumcision to be done
on an adult male who was not circumcised at birth.

34. (B) Balloon dilatation of the prosthetic urethra, also known as transcystoscopic urethroplasty, is an
advanced alternative to transurethral prostatectomy. It is nonsurgical, and with a cystoscopic setup and
balloon dilatation catheters, the urethra is stretched for a better urinary flow.

35. (C) The advantages of the Nd:YAG laser in the eradication of bladder tumors are that bleeding is
minimized, only sedation is required, operating time is short, and there is minimal damage to healthy
tissue.

36. (D) The proximal stoma is transferred to the site of the anastomosis for reimplantation. Following
anastomosis with fine atraumatic sutures, a stent is left in place until healing occurs.

37. (D) Both vasovasostomy and epididymovasostomy are microscopic reanastomosis options for
sterilization reversal in the male. Success rates vary from 40% to 70%.

38. (D) A serious complication to a penile implant is infection. Meticulous aseptic technique and careful
draping are essential. Intraoperatively, and before insertion of the implant components, a prophylactic
antibiotic irrigant of bacitracin is used on the implants and in the insertion sites.

39. (C) Heparin is given IV to the donor just before clamping the renal vessels before removal of the kidney.
Immediately after the kidney is removed (and only in a live donor), 50 mg of Protamine sulfate is given
to reverse the action of the heparin in the donor.

40. (D) Forty-five minutes before surgery, 12.5 g of mannitol is given to the kidney donor to ensure diuresis
during anesthesia induction. The dose is repeated 5 minutes before the renal vessel is clamped to
maximize diuresis and once again at the end of the procedure.

526
41. (A) The ideal cadaver donor should be young, free of infection or cancer, and normotensive until just
before death. There must also be family permission, and the medical examiner must unequivocally
establish brain death.

42. (B) Just before completion of full dissection of the donor liver, the donor is heparinized and systemically
cooled. Further cooling and flushing of the pancreas, liver, and kidneys is achieved by cannulation and
infusion of cold Ringer’s lactate solution via the inferior vena cava until properly cooled.

43. (C) The use of the resectoscope requires that irrigation be accomplished with a nonconducting,
isosmotic solution to prevent conduction of current into the bladder, as well as to prevent hemolysis
attributable to electroresection of tissue.

44. (C) All of the following procedures can be accomplished through a cystoscope: bladder biopsy, removal
of a foreign body, insertion of radionuclide seeds, coagulation of a hemangioma with argon laser, and
cystographic studies. Excision of a bladder tumor requires the use of a resectoscope.

45. (A) The vas is located by digital palpation of the upper part of the scrotum. A small incision is made
over the vas. An Allis forceps is inserted into the scrotal incision to grasp the vas.

46. (A) A noninvasive approach to urolithiasis management is the use of ESWL. This device disintegrates
stones by introducing shock waves into the body, utilizing a specially treated water as a medium.

47. (C) The Candela laser, a tunable dye laser, allows the operator to dial the desired wavelength within a
limited range. It has the ability to disintegrate stones without damaging surrounding tissue. The
technique may be used during an ureteropyeloscopy or nephroscopy.

48. (B) Urinary incontinence is the inability to control urination most commonly caused by loss of sphincter
control at the bladder neck.

49. (D) KUB is a radiograph of the kidneys, ureters, and bladder.

50. (A) Extravasation is the absorption of irrigation fluids into the vascular system which results in fluid
overload and can result in cardiac arrest.

51. (D) A three-way Foley is used for irrigation and hemostasis.

52. (B) An ileal conduit is urinary diversion away from the bladder before or after a radical cystectomy, in
which the bladder and surrounding tissue have been removed as a treatment for cancer.

53. (B) The patient is placed in a right lateral position with the flank over the table break with the operative
side up.

54. (D) Small pieces of tissue or stones are released into the irrigation fluid in the bladder and evacuated
with the Ellik evacuator or Toomey syringe.

527
55. (D) The Van Buren are the dilators commonly used to dilate the urethra.

56. (D) A TURP is done transurethrally with a resectoscope and therefore, no incision is required.

57. (C) Cystostomy is an opening made into the urinary bladder through a low abdominal incision with
insertion of a suprapubic catheter.

58. (D) Micturition refers to urination.

59. (C) Epispadias is a rare condition in which the urethral meatus is located on the top side of the penis.

60. (D) AV shunt and AV fistula are used to access the vascular system for hemodialysis. During peritoneal
dialysis, a silastic tube is implanted in the supra pubic peritoneal space.

61. (C) Gerota’s capsule is the tissue covering of the kidney. The glomerulus is a network of capillaries that
help filter the kidney. The renal pelvis is the funnel-shaped structure within the kidney and the loop of
Henley helps to reabsorb filtered water, sodium, calcium, chlorine, and potassium in a normal kidney.

62. (D) Van Buren dilators are used to dilate the urethra. Hank and Hagar dilators are used on a D&C.
Bakes dilators are used for common duct exploration.

63. (A) glomerular filtration is the first step of urine production. Peritoneal dialysis is used for renal failure.
Hemolysis is rupturing of RBC’s and osmosis is the movement of fluid from a higher concentration to a
lower concentration.

64. (B) The nephron is the functional unit of the kidney. the renal pelvis is the funnel-shaped structure
within the kidney. the renal calyx are the champers of the kidney where urine passes and Gerota’s
capsule covers the kidney.

65. (C) ESWL is used to remove kidney stones. An ileal conduit follows a total cystectomy. A laparoscopic
nephrectomy removes the kidney and a TURP is a transurethral resection of the prostate.

66. (C) The trigone includes the openings of both ureters and the urethral opening in the bladder.

67. (A) Hemolysis is the rupturing of RBCs which release their contents into the blood stream.
Extravasation is too much fluid entering the blood stream. Hydronephrosis is enlargement of the kidney
due to failure. Distribution involves dividing and spreading.

68. (C) A supra pubic catheter is placed in the bladder through an opening in the abdomen. A Coude is an
indwelling catheter with a curved tip. A Robinson is a straight catheter.

69. (C) 8–10 cc sterile water is used to fill a 5-cc Foley.

70. (C) The reservoir of the penile implant is placed in the abdomen. The cylinders are placed in the penis
and the pump in the scrotum.

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71. (B) An OB/GYN surgeon is not needed during a transrectal seed implantation.

72. (C) A vesicovaginal fistula is a fistula between the vagina and the bladder.

73. (A) A TVT sling is used for urinary stress incontinence.

74. (D) A live donor’s kidney can also be transplanted. It is not only a cadaver donor.

75. (A) Wilms tumor is the most common tumor of the kidney in children.

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 ___________________ CHAPTER 24 ___________________

Thoracic

THORACIC

• The thoracic cavity is enclosed by the ribs, spine, and sternum, and diaphragm
• Ribs—12
1–12—ALL connected to the vertebrae
1–7—connected anteriorly to the sternum directly or indirectly by costal cartilage
True ribs—they are attached directly to the sternum
8–10–connected to the rib cage by the costal cartilage
False ribs—not directly attached to the sternum but attached by the costal cartilage to the sternum
11–12—floating ribs are attached posteriorly only
• Sternum consists of the:
Manubrium
Body
Xiphoid process
• The thoracic cavity contains :
The heart
Lungs
Great vessels
• The great vessels include:
Superior and inferior vena cava
Pulmonary artery
Pulmonary vein
Aorta
• The lungs are a pair of air-filled organs located in the chest
Right lung—three lobes/left lung—two lobes
Air is inhaled through the mouth > to the trachea > into the lungs > into the bronchi > they divide into
smaller branches called bronchioles > and then into clusters of air sacs called alveoli
Alveoli—air and CO2 exchange takes place here
Visceral pleura—covering of the lung
Parietal pleura—covers the thoracic cavity
Lungs work on negative pressure for proper pulmonary function

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• Mediastinum—area between the two lungs, this includes:
Thymus
Thoracic aorta
Heart and great vessels
Esophagus and trachea
• Diaphragm—separation between the peritoneal cavity and thoracic cavity
• A double endotracheal tube is commonly used in thoracic surgery
This provides expansion for the good lung and collapse of the lung on the surgical side
• Thoracotomy instruments include:
Bronchus clamp—Sarot clamp
Lebsche rib shears
Davidson scapula retractor
Allison lung retractor
Bailey rib approximator
Duval lung clamp
Tuffier rib retractor
Finochietto rib retractor
• Anytime the pleural space is entered you must use a Pleur-evac/closed water seal drainage system
Closed water seal drainage is hooked up to suction at the end of the surgical procedure. When moving
the patient it is removed from the suction and kept below the patient’s chest level to prevent drainage
from going back into the lung and causing an infection. Once the patient is in the PACU they are
immediately hooked up to suction again.
Chest tube is placed and hooked up to the drainage system to reestablish negative pressure
When two chest tubes are used, the superior chest tube is used to evacuate air, the inferior chest tube is
used to drain fluid and/or blood
• Bronchoscopy—a bronchoscope is inserted through the nose or mouth to provide a view of the
tracheobronchial tree. It is also used to collect bronchial and lung secretions. Tissue biopsies can also be
done
There are two types of scopes, they include:
Rigid—this scope is commonly used for foreign body retrieval
Flexible—this is used on patients who cannot hyperextend their neck
• Mediastinoscopy—this procedure is performed to view areas of the mediastinum. This is the cavity
between the lungs, it contains:
Thymus
Thoracic aorta
Heart and great vessels
Esophagus and trachea
• The incision is made in the notch of the neck

531
• Biopsy of the lymph nodes is performed for the staging of lung cancer
• Thymus gland—it is located in the space between the lungs called the mediastinum
Thymomas are slow-growing tumors. The prognosis is excellent when they are discovered in the early
stages
The most commonly associated condition with thymoma is myasthenia gravis
Myasthenia gravis—this is an autoimmune disease that effects neuromuscular tissue causing weakness
of the muscles
Thymectomy—removal of the thymus gland. The incision is a median sternotomy
• Mediastinal shift—this is caused by a loss of negative pressure on one side of the pleural cavity which
causes the other side to shift the mediastinum in order to equalize the pressure
• Thoracoscopy—insertion of a chest tube hooked up to a closed drainage system to provide negative
pressure to the thoracic cavity
• Thoracoscopy—performed for direct visualization of the pleural cavity, mediastinum, and pericardium.
This is performed to diagnose fluid buildup, pus, blood and to biopsy lung tumors and biopsy specimens
• VATS procedure/video-assisted thoracic surgery—this is a minimally invasive surgical procedure used to
diagnose and treat diseases of the thoracic cavity. They include:
Biopsy for tissue diagnosis
Surgery of the esophagus
Surgery on the lung
• Video equipment is needed, endoscopic instruments
• Anesthesia requires a double endotracheal tube
• Endoscopic linear staplers
• Have available thoracic and vascular instruments
• Position is posterolateral, lateral, anterolateral, or supine
• Thoracoabdominal
• Rib resection—is performed for reconstructive procedures of the face, ear, etc.
• Pneumothorax—collapsed lung
• Blebs—are thin-walled air sacs located on the apex (top) of the lung, if ruptured they can cause a
pneumothorax
• Pectus deformities—these are congenital deformities of the chest wall. This deformity can cause pressure
on the heart and respiratory distress, dyspnea, and/or chest pain
Pectus carinatum—chest bows outward
Pectus excavatum—funnel chest
• Thoracotomy—incision into the chest wall
• Lung resection—this is performed for diseased lung. All or part of the lung can be resected
Pneumonectomy—removal of the entire lung. This is usually performed for a malignancy
Hemoptysis—a condition where the patient is coughing up blood. This can be caused by an irritation of
the bronchial tree or something more serious as a lung malignancy

532
 Lobectomy—removal of one lobe of the lung
The nerves that are preserved during a pneumonectomy include:
Vagus
Left recurrent laryngeal
Phrenic
Wedge resection—a small wedge portion is removed from one lobe of a lung
Segmental resection—same as above except the portion removed is a little larger resection than the
wedge
Scalene nodes/supraclavicular nodes are used to detect metastatic cancer from the lung
Pulmonary function tests are a group of tests that measure how well the lungs take in and out and
oxygenate the body
The total lung capacity—the total amount of air that you can inhale into your lungs. Forced
expiratory volume—this test determines how much air is forced out (exhaled)
Tidal volume—the amount of air that enters the lungs during normal inhalation
Vital capacity—is the highest amount of air that can be expelled from the lungs after taking a deep
breath
Spirometer—this is an instrument used to measure the air capacity inhaled and exhaled from the
lungs
• Lung volume reduction surgery (LVRS) is a surgical procedure performed to remove diseased lung tissue
caused by emphysema
Emphysema—the alveoli at the end of the bronchiole tree become enlarged and cause destruction of the
air sacs. This causes the lung to over inflate
• Decortication of the lung—this procedure is performed to remove the surface layer of the lung. It is the
fibrous layer. The layer becomes thick and restricts the lung from expanding
Dissection can be performed with a metzenbaum scissor and blunt dissection with the surgeon’s fingers
and/or peanuts
• Thoracic outlet syndrome—the thoracic outlet is between the collarbone and first rib. This is caused by
trauma, and an extra rib
The nerves and blood vessels in the thoracic outlet become compressed and irritated and cause pain in
the arms, shoulder, and neck. You can also have tingling, numbness along your arm and fingers
This can also be a result of an extra first rib or a problem with the clavicle that causes the space to
become too small for the vessels and nerves
• Thoracentesis—this procedure is performed to remove blood or air in the pleural cavity by introducing a
needle and syringe for aspiration
Pleural effusion is a buildup of excess fluids which includes blood, infection, and tumors A thoracentesis
is performed for a diagnosis of the pleural effusion
Once the fluid is removed they insert a talcum powder or antibiotic solution to dry out the space and aid
in eliminating the space from preventing further fluid buildup

533
 This helps the patient to breathe easier
• Hiatal hernia—the stomach protrudes through the diaphragm into the pleural cavity
This procedure can be performed with an abdominal approach or through the thoracic cavity
• Lung transplant—this is performed for patients with severe lung disease
They can be donated by cadaver lung donors and live donors
One lung, both lungs, or a lobe of a lung from multiple donors may be taken for the transplant
Collin’s solution is one solution that can be used to preserve the donor kidney prior to transplantation
The heart lung machine is used
Chest tube and closed chest drainage are used
Single-lung transplant—unilateral
Incision is made on the side of the chest that is being transplanted
Lung is removed and replaced with the donor lung
Donor—supine position
Recipient—supine or lateral position
Double lung transplant—bilateral
The incision is made across the entire chest from below the breast “clamshell incision”
The procedure is performed on one side then the other side
Donor—supine
Recipient—supine
The side chosen is based upon the lung requiring the lesser perfusion
• There are three anastomoses in order to provide an effective lung transplant, they include:
From the most posterior:
Bronchus
Pulmonary artery
Atrial cuff

534
 Questions

1. The tube that collects bronchial washings is:

(A) Broyles
(B) Lukens
(C) Ellik
(D) Toomey

2. What instrument is used to view lymph nodes or masses in the space that medially separates the pleural
cavities?

(A) Bronchoscope
(B) Mediastinoscope
(C) Endoscope
(D) Colonoscope

3. The procedure of choice for removal of a foreign body in a child’s tracheobronchial tree is:

(A) bronchoscopy
(B) mediastinoscopy
(C) fluoroscopy
(D) telemetry

4. A cytological specimen collector used in bronchoscopy is:

(A) Ellik
(B) Toomey
(C) Jackson
(D) Lukens

5. All of the following are true regarding disposable chest drainage units EXCEPT:

(A) provides drainage collection from intrapleural space

(B) maintains a seal to prevent air from entering the pleural cavity
(C) provides suction control determined by water level
(D) aids in reestablishing positive pressure in the intrapleural space

6. Compression of the subclavian vessels and the brachial plexus usually caused by the first rib is surgically

535
 known as:

(A) cervical sympathectomy

(B) thoracic outlet syndrome
(C) thoracic sympathectomy
(D) decortication

7. A reduction of negative pressure on one side of the thoracic cavity that causes the negative pressure on
the normal side to pull in an effort to equalize pressure is called:

(A) vital capacity

(B) mediastinal shift
(C) subatmospheric pressure
(D) pneumothorax

8. Surgical removal of fibrinous deposits on the visceral and parietal pleura is called:

(A) posterolateral thoracoplasty

(B) talc poudrage
(C) decortication of the lung
(D) anterior thoracoplasty

9. What substance is introduced through a thoracoscope to deal with recurrent pleural effusion attributable
to advanced cancer?

(A) Chemotherapeutics
(B) Talc
(C) Tetracycline
(D) Hemostatic agents

10. What instrument is used to reapproximate the ribs following an open thoracotomy?

(A) Doyen
(B) Bailey
(C) Alexander
(D) Bethune

11. What cold solution is used to preserve a donor lung before transplant into a recipient?

(A) Ringer’s lactate

(B) Saline
(C) Collin’s
(D) Physiosol

12. How many anastomoses must be completed to effect a single-lung transplant?

536
 (A) One
(B) Two
(C) Three
(D) Four

13. What is the preferred solution used for bronchial washings?

(A) Sterile water

(B) Sterile saline
(C) Heparinized saline
(D) Ringer’s lactate

14. During the mechanical process of breathing the diaphragm contracts _____ and relaxes during _______.

(A) inhalation, exhalation

(B) exhalation, inhalation
(C) compression, expansion
(D) normal respiration, maximum respiration

15. Biopsy of this node is performed before a thoracotomy to stage cancer staging or to confirm a diagnosis:

(A) axillary
(B) mediastinal
(C) iliac
(D) scalene

16. The most important laboratory test done to measure pulmonary function is:

(A) CBC (complete blood count)

(B) ABGs (arterial blood gases)
(C) hemoglobin and hematocrit
(D) WBC (white blood count)

17. Which of the pulmonary function tests measures the amount of air exhaled during normal respiration?

(A) Forced vital capacity

(B) Total lung capacity
(C) Vital capacity
(D) Tidal volume

18. All of the following are TRUE regarding the rigid bronchoscope EXCEPT:

(A) used for procedures which require a large bore endoscope

(B) used for removal of a tissue mass and foreign bodies
(C) patients who have difficulty hyperextending the neck and difficult jaw manipulation

537
 (D) complications include injury to the tracheal bronchial structures if patient moves

19. A thymectomy is commonly performed for malignant tumors and:

(A) myasthenia gravis

(B) Graves disease
(C) muscular dystrophy
(D) pneumothorax

20. What nerves are carefully preserved during a pneumonectomy?

(A) Vagus, left recurrent laryngeal, and phrenic

(B) Vagus, pneumatic, and phrenic
(C) Vagus, pneumatic, and epigastric
(D) Phrenic, right recurrent laryngeal, and vagus

21. When performing a thoracotomy, the wound edges are covered to protect them from bruising with
what?

(A) Nothing is used, to prevent loosing something

(B) Moist lap pads or towels
(C) To and fros
(D) 4 × 4 s

22. The lung is divided into anatomical regions. The right lung has _____ lobes and the left lung has _____
lobes.

(A) two and two

(B) three and two
(C) three and three
(D) two and three

23. In which surgery would a closed drainage system be used?

(A) Thoracoscopic lung biopsy

(B) Open thoracotomy
(C) Lung volume reduction surgery
(D) All of the above

24. Bleeding arising from the respiratory tract is called:

(A) empyema
(B) pleural effusion
(C) hemoptysis
(D) blebs

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25. Positioning for a single-lung transplant, the donor patient is ______ and the recipient patient is
_______.

(A) supine, lateral

(B) supine, supine
(C) lateral, lateral
(D) lateral, supine

26. Place the three anastomoses that provide an effective lung transplant in order:

(A) atrial cuff, pulmonary artery, bronchus

(B) pulmonary artery, atrial cuff, bronchus
(C) bronchus, pulmonary artery, atrial cuff
(D) bronchus, atrial cuff, pulmonary artery

27. When performing a bilateral lung transplant, the first lung to be transplanted is determined by:

(A) the amount of blebs present

(B) whether the donor was a live or cadaver donor
(C) based on the lung requiring lesser perfusion
(D) All of the above

28. The incision performed for a bilateral lung transplant is:

(A) Median sternotomy

(B) Clamshell
(C) Right subcostal
(D) Midline

29. When two chest tubes are placed in the chest, the superior chest tube is used to:

(A) drain air

(B) drain blood
(C) prevent a mediastinal shift
(D) All of the above

30. The approach to repairing a hiatal hernia includes:

(A) abdominal approach

(B) thoracic approach
(C) Both A and B
(D) mediastinal approach

31. The procedure performed for pleural effusion is termed:

(A) nissen fundoplication

539
 (B) decortication of the lung
(C) thoracentesis
(D) vagotomy

32. When performing a decortication of the lung, the fibrous lining can be planed with:

(A) peanuts
(B) surgeon’s fingers
(C) metzenbaum scissors
(D) All of the above

33. Lung volume reduction surgery can be performed for:

(A) chronic bronchitis

(B) emphysema
(C) clots
(D) thoracic outlet syndrome

34. The disease caused when the alveoli at the end of the bronchiole tree become enlarged and destroy the
air sacs and cause the lung to over inflate is termed:

(A) hemothorax
(B) pneumothorax
(C) emphysema
(D) pleural effusion

35. Pulmonary function tests include all except:

(A) total lung capacity

(B) tidal volume
(C) ABGs
(D) vital capacity

36. A spirometer is an instrument used to:

(A) measure the amount of fluid in the lung

(B) measure the amount of fluid in the mediastinum
(C) used to measure the air capacity inhaled and exhaled from the lungs
(D) assists in breathing

37. A ___________ is removal of the entire lung. A ________ is removal of a lobe of the lung and a
____________ is removal of a portion of the lobe of the lung.

(A) segmental resection, wedge resection, pneumonectomy

(B) lobectomy, segmental resection, pneumonectomy

540
 (C) lobectomy, pneumonectomy, segmental resection
(D) pneumonectomy, lobectomy, segmental resection

38. The congenital pectus deformity of the chest also known as funnel chest is:

(A) excavatum
(B) carinatum
(C) mediastinal shift
(D) scoliosis

39. Blebs are:

(A) fluid buildup in the lungs

(B) thin-walled air sacs on the apex of the lung
(C) enlarged alveoli at the end of the bronchial tree
(D) fluid-filled sacs within a lobe of the lungs

40. Pressure in the thoracic cavity is:

(A) positive
(B) left lung positive
(C) right lung negative
(D) negative

41. The thymus gland is located in the:

(A) mediastinal cavity

(B) pericardial cavity
(C) clavicular notch of the neck
(D) endocardial space

42. The retractor commonly used to retract the lung is:

(A) Bailey
(B) Finochietto
(C) Tuffier
(D) Allison

43. All are parts of the sternum except:

(A) manubrium
(B) xyphoid
(C) apex
(D) body

44. There are 12 pairs of ribs. The ribs known as the floating ribs are attached:

541
(A) anteriorly to the sternum
(B) posteriorly to the vertebrae
(C) anteriorly to the costal cartilage
(D) both anteriorly and posteriorly to the sternum and vertebrae

542
 Answers and Explanations

1. (B) Suction tubing with a Lukens tube collects washing specimens during a bronchoscopy.

2. (B) The mediastinoscope is used to view the lymph nodes or masses in the superior mediastinum.

3. (A) A rigid bronchoscope is the instrument of choice for removal of foreign bodies in infants and
children.

4. (D) A Lukens or a Clerf is used to hold secretions as they are sucked through the aspirating tube. They
collect bronchial washings and sent to cytology.

5. (D) Disposable chest drainage collects drainage, maintains a water seal, and provides suction control. It
is aimed at providing a conduit for air, blood, and other fluids as well as the reestablishment of negative
pressure in the intrapleural space.

6. (B) Decompression for thoracic outlet syndrome is done to correct either a congenital deformity or
traumatic injury resulting in anatomical changes in the skeletal structure of the first rib.

7. (B) A reduction of negative pressure on one side causes the negative pressure on the normal side to pull
on the mediastinum in an effort to equalize the pressure. This is referred to as mediastinal shift; it tends
to compress the lung, causing dyspnea.

8. (C) Removal of the fibrinous deposit or restrictive membrane on the visceral and parietal pleurae that
interfere with pulmonary function is called decortication of the lung.

9. (B) Pleural effusions are a significant cause of morbidity, particularly in patients with advanced cancer.
Instillation of talc is done to dry up excessive fluid that accumulates in the pleural cavity. Excessive fluid
impairs breathing and causes limited expansion which leads to a pneumothorax.

10. (B) All instruments are used to effect an open thoracotomy. A Doyen is a rib elevator, an Alexander is a
rib raspatory, a Bethune is a rib shear, and a Bailey is a rib approximator.

11. (C) After harvesting of the lung is complete, the trachea is stapled shut, and the donor lung is placed in
cold Collin’s solution.

12. (C) Three anastomoses are completed for a single-lung transplant: bronchus to bronchus, pulmonary
artery to pulmonary artery, and recipient pulmonary veins to donor atrial cuff.

543
13. (B) Sterile saline is the solution used for bronchial washings.

14. (A) Breathing is a complex physiological and mechanical process controlled by the autonomic nervous
system also under voluntary control. During inhalation, the diaphragm contracts and relaxes during
exhalation.

15. (D) Lung cancer spreads through the intrathoracic and mediastinal lymphatics to the supraclavicular
nodes, which are the last nodes in the drainage chain. The scalene fat pad is biopsied in conjunction
with a thoracotomy to diagnose and stage malignant and nonmalignant thoracic disease.

16. (B) With ABGs the blood is assessed for oxygen, carbon dioxide, and pH acid–base balance. This is the
most important laboratory test done to measure pulmonary function.

17. (D) PFTs are a group of procedures performed with a complex breathing machine that measures lung
function. Tidal volume test measures the amount of air exhaled during normal respiration.

18. (C) The flexible bronchoscope is preferred over the rigid bronchoscope for patients who have difficulty
hyperextending their neck or jaw manipulation is difficult or impossible.

19. (A) Myasthenia gravis is a neuromuscular disease that involes the muscles and nerves that control them.
Removal of the thymus gland may result in permanent remission, and lessens the need for medication.

20. (A) The vagus, left recurrent laryngeal, and phrenic nerves are retracted with vessel loops or moist
umbilical tape to protect them.

21. (B) When performing a thoracotomy, the edges of the wound are covered with lap pads or towels to
prevent bruising.

22. (B) The right lung has three lobes and the left lung has two lobes.

23. (D) After spontaneous or traumatic air leak or surgery is performed in which the pleural cavities are
opened, negative air pressure must be restored in order for the lungs to expand. Chest tubes and a
closed chest drainage system are used.

24. (C) Hemoptysis is one of many pathological indications for a bronchoscopy. It is bleeding arising from
the respiratory tract.

25. (A) The donor patient is placed in supine because this allows the best exposure of organs to be excised
and the recipient patient is placed laterally with the operative side up.

26. (C) The correct order the anastomoses must be done is bronchus, pulmonary artery, and then atrial cuff.

27. (C) The lung requiring less perfusion is the first lung to be transplanted.

28. (B) The clamshell incision is used for a bilateral lung transplant. This incision is placed under bilateral
submammary areas that are connected in the middle.

544
29. (A) When two chest tubes are placed into the chest, the superior chest tube is used to drain air. The
inferior tube is used to drain the blood.

30. (C) Approaches used to repair a hiatal hernia are an abdominal approach and a thoracic approach.

31. (C) Thoracentesis is performed to drain fluid surrounding the lungs. A nissen is used for a hiatal hernia.
Decortication of the lung includes scraping the fibrous connective tissue off of the lung and a vagotomy
is done to reduce gastric secretions.

32. (D) When a decortication of the lung is needed, the surgeon can use peanuts, his/her fingers, or a
metzenbaum scissor.

33. (B) Lung volume reduction is performed for emphysema.

34. (C) Emphysema is the disease caused by alveoli becoming enlarged which destroy the air sacs and cause
the lung to over inflate. Hemothorax is blood in the lungs. Pneumothorax is a collapsed lung and
pleural effusion is a fluid buildup in the lungs.

35. (C) Pulmonary function tests include checking total lung capacity, tidal volume, and vital capacity.
ABGs check arterial blood to see how well the patient’s lungs move O2 to the blood and remove CO2.

36. (C) A spirometer is used to measure the air capacity inhaled and exhaled from the lungs.

37. (C) Lobectomy is removal of the entire lung. Pneumonectomy is removal of a lobe of the lung, and a
segmental resection is the removal of a portion of the lobe of the lung.

38. (A) Pectus excavatum is a deformity of the chest also known as funnel chest. Pectus carinatum is a
condition where the chest bows outward. Mediastinal shift is a movement of one side to the other and
scoliosis is a condition of a curved spine.

39. (B) Blebs are thin-walled air sacs on the apex of the lung.

40. (D) The pressure in the thoracic cavity is negative.

41. (A) The thymus gland is located in the mediastinal cavity.

42. (D) The Allison is the retractor commonly used for exposure of the lung. Baley is a rib approximator, a
Finochietto and Tuffier are rib retractors.

43. (C) The apex is not a part of the sternum. It is the area in the superior portion of the lungs.

44. (B) The floating ribs are attached posteriorly to the vertebrae.

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 ___________________ CHAPTER 25 ___________________

Cardiac

• The heart is located in the mediastinum

• Pericardium—covering of the heart. It has two layers:
Outer layer—fibrous pericardium
Inner layer—serous pericardium
• The wall of the heart consists of three layers:
External layer—epicardium
Middle layer—myocardium
Inner layer—endocardium
• Blood flow through the heart:
Blood enters the heart through the veins (deoxygenated blood) > into the superior and inferior vena cava
> into the right atrium > through the tricuspid valve > into the right ventricle > through the pulmonary
valve (semilunar valve) > into the pulmonary artery > flows out through the lungs (becomes oxygenated)
> oxygenated blood flows back through the pulmonary vein > into the left atrium > through the bicuspid
valve > into the left ventricle > through the aortic valve into the aorta > to the body through the arteries
• SA (sinoatrial) node of the heart—“Pacemaker of the heart”
• AV node (atrioventricular node)—major element in the cardiac conduction system, controls heart rate
• Cardiac conduction system—the main components include:
SA node—“Pacemaker of the heart”
AV node
Bundle of His
Purkinje fibers
• Tachycardia—rapid heart rate over 100 beats/min
• Bradycardia—slow heart rate less than 60 beats/min
• Coronary artery disease—narrowing of the arteries caused by plaque formation
• Arrhythmia—an abnormal heart rhythm
• Endocarditis—inflammation of the inner lining of the heart
• Pericarditis—inflammation of the pericardial lining of the heart
• Pericardial effusion—fluid buildup of the pericardial cavity
• Fibrillation—irregular muscle contractions
• Atrial fibrillation—abnormal rhythm of the heart. The electrical impulse does not travel properly through

546
 the atrium
• Ventricular arrhythmia—rapid heart rate occurring in the ventricles
• Ventricular fibrillation—this is erratic rapid impulses. It is caused when the ventricle quivers instead of
pumping blood.
• Cardiac arrhythmias can be treated with defibrillation
• Electrocardiogram—traces the electrical activity of the heart
• Echocardiogram—shows the heart muscle using ultrasound
• Arteriogram—x-ray of the arteries using contrast media
• Angiogram—x-ray of veins using contrast media
• AED—automated external defibrillator—portable electronic device that evaluates the heart for
arrhythmias and delivers a shock to the heart to bring it back to a normal rhythm
• Pacemaker—implanted device to regulate the heart beat when you have irregular heart beats
Cardiac catheterization—procedure performed to visualize your arteries, and how your heart is
functioning to diagnose heart disease
• Catheter is introduced through the femoral or brachial artery to your heart and injected with contrast
media
• Angioplasty—this procedure is performed during cardiac catheterization. A balloon catheter is inserted
and the vessel is dilated and a stent is placed to keep the artery open
• Aneurysm—enlargement of an artery wall caused by weakening of the wall
• Ventricular aneurysm—bulge and weakening in the wall of the ventricle. These occur in patients who have
had a heart attack
• Angina—chest pain caused by lack of blood flow to the heart
• Cardiac transplantation—this is performed for end-stage heart disease. A cadaver heart is transplanted into
the recipient. The recipient’s heart is either removed or left to support the transplanted heart
• Cardiopulmonary bypass:
During cardiac surgery the CPB takes over the function of the heart and lungs for the patient
Also called the heart lung machine
Used in cardiac surgery to stop the heart from beating and create a bloodless surgical field so the surgery
can be performed. It is difficult to operate on a moving target. It provides blood to the body organs while
also providing a bloodless surgical field.
It filters and oxygenates the blood
This is a form of extracorporeal circulation (circulation outside the body)
The machine is operated by a perfusionist
It is also used for induction of hypothermia (lowering the body temperature) requiring less oxygen
intake
Cooling the heart allows the surgeon to stop the heart for long periods of time without damaging it
The bypass machine cools the blood flowing back into the body
They can use cool saline solution

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 Cardioplegia—this solution (potassium solution) stops the heart and prevents cell death during cross-
clamping of the aorta
• Cardiac cannulation—this is needed for cardiopulmonary bypass
A cannula is placed to retrieve, filter, oxygenate, and warm or cool the blood and return it to the body
through a second cannula
Purse string suture is used to secure the cannulas
To retrieve the blood, a cannula can be placed in the:
Right atrium
Vena cava
Femoral vein
To return the blood the cannula is placed in the:
Ascending aorta
Femoral artery
• Important parts to the heart lung machine:
Oxygenator—removes CO2 and adds oxygen to the blood
Heat exchanger—controls blood temperature, can heat or cool the blood
Pump—acts as the heart muscles and pushes the blood through the tubes on the machine
• The position used for heart procedures is supine/dorsal recumbent
• The prep extends from the chin to the toes of both feet, abdomen laterally both sides and both legs
circumferentially.
• Incision: extends from the sternal notch to the xyphoid process
• Specialty cardiac instrumentation:
Vascular instruments
Thoracic instruments
General surgery
Sternal saw
Sternal retractor
Lebsche knife
Herrick kidney clamps
Satinsky clamps
• Coronary artery bypass graft surgery (CABG)—the surgery is performed to replace diseased or blocked
arteries. The bypass forms a new route for the blood to flow through the heart.
Autograft vessels are taken from another part of the patient’s body and used to replace the diseased
vessels.
The vessels used to bypass the diseased ones include:
Internal mammary arteries
Greater saphenous veins
• CABG—coronary artery bypass graft—requires the heart lung machine

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• MIS—minimally invasive surgery/MID-CABG —minimally invasive direct coronary artery bypass graft—
this procedure does not require the heart lung machine. Surgery is performed on a beating heart
• OPCAB—off-pump coronary artery bypass graft. This procedure does not require the heart lung machine
and the procedure is performed on a beating heart
• IABP—intra-aortic balloon pump—it is a polyethylene balloon catheter inserted through the femoral
artery to the aorta to increase cardiac output. The balloon inflates during diastole and deflates during
systole with the change in the patient’s condition, it is controlled by a machine
• VAD—ventricular assist device—the pump is surgically placed inside the chest and connected to your
heart. The pump controller is attached and secured to the abdomen. This takes control of the heart’s
pumping action and is also used for the patient who has difficulty coming off the heart lung machine
• Cardiac valve replacement—the mitral/bicuspid, tricuspid, and aortic valve can be replaced
• Aortic valve replacement—when the aortic valve does not function properly caused by a leaky valve or
stenosis. The valve is replaced with an artificial valve
• Mitral valve replacement—the mitral valve connects the left atrium to the left ventricle. With this disease
the valve does not open properly. It is commonly caused by rheumatic fever. The valve can be replaced or
repaired
• Patent ductus arteriosus—the ductus arteriosus (blood vessel) does not close at birth. Treatment includes
medication, if it doesn’t work, surgery is required to close the ductus
• Tetralogy of Fallot—this is a combination of four cardiac defects. There are variations including VSD,
infundibular or pulmonary valve stenosis, an aorta that overrides the VSD, and right ventricular
hypertrophy. Of the four above, the first three are congenital and the right ventricular hypertrophy is
acquired resulting from pressure within the right ventricle. This is the most common cyanotic heart defect
in children
• Atrial septal defect—a defect in the septum of the heart’s upper chambers that separate the atria that
remain open after birth
• Ventricular septal defect—the septum separating the left and right ventricles fails to close
• Coarctation of the aorta—this is a narrowing of the aorta where the vessel should be normal
• Cardiac medications:
Warfarin/Coumadin—anticoagulants, which lower the risk of blood clots. People who have atrial
fibrillation (A-fib or AF) are at risk for blood clots because their heart does not beat normally. These are
medications taken by mouth
Heparin—is an anticoagulant (blood thinner) that prevents the formation of blood clots. These are
administered via IV
Protamine sulfate—reverses the anticoagulant effects of heparin
Papaverine—relaxes the blood vessels, prevents vasospasms
Lidocaine hydrochloride/Xylocaine—used to treat ventricular fibrillation
Streptokinase—is used to dissolve blood clots that have formed in the coronary artery vessels and lungs.
Tissue plasminogen activator—is a protein used in the breakdown of blood clots.
Cardioplegia—is used to cause temporary cessation of the heart during cardiac surgery. The main

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component is potassium

550
 Questions

1. The action to be followed if a patient is experiencing a cardiac arrhythmia, specifically a ventricular

fibrillation, would be to:

(A) start an IV
(B) defibrillate
(C) order blood to replace blood volume
(D) administer intravenous lidocaine

2. Dextran is used parenterally to:

(A) expand blood plasma volume

(B) renourish vital tissue
(C) carry oxygen through the system
(D) decrease blood viscosity

3. Which drug can be added to saline for irrigation during a vascular procedure?

(A) Protamine
(B) Epinephrine
(C) Sublimaze
(D) Heparin

4. The intraoperative diagnostic test that measures tissue perfusion is:

(A) blood volume

(B) respiratory tidal volume
(C) arterial blood gases
(D) hematocrit

5. Passage of a sterile catheter into the heart via the brachial or femoral artery for the purpose of image
intensification is called:

(A) angiography
(B) arteriography
(C) cardiac catheterization
(D) cardioscopy

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 6. Hypothermia is employed in cardiac surgery:

(A) to reduce oxygen consumption

(B) to reduce elevated temperature
(C) to slow metabolism
(D) to induce ventricular fibrillation

7. Which vessels are harvested for a coronary artery bypass?

(A) Pulmonary vein and external mammary vein

(B) Portal vein and hepatic artery
(C) Saphenous vein and internal mammary artery
(D) Pulmonary artery and pulmonary vein

8. The term used to denote the function accomplished by the cardiopulmonary bypass machine is:

(A) diversion
(B) dialysis
(C) perfusion
(D) profusion

9. In balloon angioplasty, the dilating balloon is inflated with:

(A) diluted heparin

(B) diluted solution of contrast media
(C) saline
(D) Ringer’s lactate solution

10. Decompression of the portal circulation can be achieved by all of the following EXCEPT:

(A) splenorenal shunt

(B) portacaval anastomosis
(C) arteriovenous shunt
(D) mesocaval shunt

11. A drug used intraoperatively for its antispasmodic effect on the smooth muscle of the vessel wall is:

(A) Ringer’s lactate

(B) papaverine hydrochloride
(C) Physiosol
(D) protamine sulfate

12. The technique applied to the patient who is unable to be weaned from cardiopulmonary bypass is:

(A) IAPB
(B) VADs

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 (C) Pacemaker
(D) Both A and B

13. What is the most commonly acquired valvular lesion?

(A) Mitral regurgitation

(B) Mitral stenosis
(C) Tricuspid valve regurgitation
(D) Aortic insufficiency

14. What drug is used to effect coronary thrombolysis in the cardiac catheterization laboratory?

(A) Tissue plasminogen activator

(B) Heparin
(C) Streptokinase
(D) Both A and C

15. Electrical impulses that stimulate the heart muscle are achieved with:

(A) pacemaker
(B) arterial defibrillation
(C) ESU
(D) alligator clamp

16. Fibrillation is described as:

(A) fast heart rate

(B) involuntary muscle contraction
(C) slow heart rate
(D) coronary artery occlusion

17. The cardiac phase when the ventricles contract is:

(A) systole
(B) diastole
(C) fibrillation
(D) relaxation

18. Bradycardia is defined as _______ beats/min.

(A) 40–60
(B) 80–100
(C) Higher than 110
(D) 100–110

19. The most commonly used incision for surgical procedures of the heart is:

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 (A) right lateral
(B) left lateral
(C) anterior thoracotomy
(D) median sternotomy

20. The aortic valve maintains one way blood flow to the aorta from the:

(A) right atrium

(B) left atrium
(C) left ventricle
(D) right ventricle

21. The only arteries in the body that carry deoxygenated blood to the lungs are:

(A) carotid
(B) subclavian
(C) coronary
(D) pulmonary

22. During dialysis the patient’s blood is shunted to the outside of the body. The term referring to outside
the body is:

(A) in situ
(B) angiogram
(C) extracorporeal
(D) intracorporeal

23. The relaxation phase of the cardiac cycle is:

(A) systole
(B) infarction
(C) diastole
(D) intraoperative vasospasm

24. A precipitous drop in the patient’s blood or fluid volume is:

(A) hypovolemia
(B) hypervolemia
(C) hypertension
(D) ischemia

25. The surgical incision used for cardiac surgery is:

(A) lateral
(B) supraclavicular

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 (C) thoracoabdominal
(D) median sternotomy

26. Which surgery requires the use of a heart lung machine?

(A) CABG
(B) AAA
(C) IVC filter umbrella
(D) VATS

27. The heart is located in which cavity?

(A) mediastinal cavity

(B) endocardial cavity
(C) myocardial cavity
(D) Both B and C

28. The inner layer of the heart is the:

(A) endocardium
(B) myocardium
(C) epicardium
(D) pericardium

29. The semilunar valve is also known as:

(A) tricuspid
(B) bicuspid
(C) pulmonary
(D) SA

30. All are components of the cardiac conduction system except:

(A) AV node
(B) SA node
(C) purkinje fibers
(D) pericardium

31. Arrhythmia:

(A) rapid heart rate

(B) slow heart rate
(C) abnormal heart rhythm
(D) None of the above

32. What medication is used for ventricular arrhythmias?

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 (A) Xylocaine
(B) Carcaine
(C) Heparin
(D) Both A and B

33. Pericardial effusion:

(A) inflammation of the inner lining of the heart

(B) irregular muscle contractions
(C) fluid buildup surrounding the heart
(D) inflammation of the pericardial lining of the heart

34. Which of the following shows the heart using ultrasound?

(A) Echocardiogram
(B) Arteriogram
(C) Angiogram
(D) None of the above

35. What arteries are used during a cardiac catheterization?

(A) Femoral
(B) Brachial
(C) Carotid
(D) Both A and B

36. What vessel increases cardiac blood flow to the heart following a CABG:

(A) Carotid
(B) Brachial
(C) Internal mammary
(D) Saphenous vein

37. What diagnostic procedure visualizes the cavity between the lungs, aorta, and vena cava?

(A) Angiogram
(B) Mediastinoscopy
(C) VATS
(D) Echocardiogram

38. Levophed:

(A) increases cardiac output

(B) decreases venous return to the heart
(C) increases urine secretion

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 (D) restores and maintains blood pressure

39. A drug used to treat metabolic acidosis is:

(A) Inderal
(B) Pronestyl
(C) sodium bicarbonate
(D) Isuprel

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 Answers and Explanations

1. (B) Ventricular fibrillation requires prompt defibrillation and cardiopulmonary resuscitation. It is rapidly
fatal because respiratory and cardiac arrests follow quickly unless successful defibrillation is effected.

2. (A) Dextran is used to expand plasma volume in emergency situations resulting from shock or
hemorrhage. It acts by drawing fluid from the tissues. It remains in the circulatory system for several
hours.

3. (D) Heparin may be used locally or systemically to prevent thrombosis during vascular operative
procedures. When a vessel is completely occluded during surgery, heparin is often injected directly.
Heparinized saline irrigation may also be used. The dosage and concentration may vary according to the
surgeon’s preference. The saline used must be injectable saline.

4. (C) Serial monitoring of blood gases is indispensable in evaluating pulmonary gas exchange and acid–
base balance. Either or both arterial or venous blood gas determination can be monitored. It is a
chemical analysis of the blood for concentrations of oxygen and carbon dioxide.

5. (C) Cardiac catheterization is used to diagnose coronary artery disease. It involves a sterile setup and
fluoroscopy to diagnose ischemic heart disease. The brachial or femoral artery is used to effect this
procedure.

6. (A) Hypothermia deliberately reduces body temperature to permit reduction of oxygen consumption by
about 50%.

7. (C) Coronary artery bypass grafting (CABG)involves harvesting of the saphenous vein and internal
mammary artery (IMA).

8. (C) Perfusion is the technique of oxygenating and perfusing the blood by means of a mechanical pump-
oxygenator.

9. (B) The goal is to restore internal patency of a vessel by creating a channel through the diseased artery
and then introducing a balloon catheter. The dilating balloon is inflated with fluid consisting of a dilute
solution of the contrast media.

10. (C) Shunt operations for portal hypertension are splenorenal shunt, portacaval anastomosis, and
mesocaval shunt. An arteriovenous shunt is used for dialysis.

11. (B) Vasospasm may be of particular concern in working with small vessels during a procedure.

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 Papaverine HCl may be added to saline solution for its direct antispasmodic effect on the smooth
muscle of the vessel wall.

12. (D) The IAPB is a technique that employs the principle of counterpulsation. It increases the cardiac
output and may permit separation of the patient from CPB. VADs are designed to augment cardiac
output if patients cannot be weaned from CPB with IAPB.

13. (B) Mitral stenosis, the most commonly acquired valvular lesion, is usually caused by rheumatic fever. It
causes a rise in pressure and dilatation of the left atrium.

14. (D) The cardiac catheterization laboratory has also become the site for more aggressive interventional
therapies related to evolving and acute myocardial infarctions. Coronary thrombolysis with
streptokinase and tissue plasminogen activator can dissolve fresh blood clots and reopen the artery.

15. (A) An artificial pacemaker is implanted in the body to correct cardiac arrhythmia caused by disease in
the conduction system.

16. (B) Fibrillation is a small local involuntary muscle contraction due to spontaneous activation of single
muscle cells or muscle fibers.

17. (A) Contraction of the ventricles during which blood is forced into the aorta and the pulmonary artery.

18. (A) Bradycardia is a heart rate from 40–60.

19. (D) A median sternotomy is the most common incision used in heart surgery.

20. (C) The aortic valve maintains one way blood flow to the aorta from the left ventricle.

21. (D) Arteries are vessels that carry oxygenated blood away from the heart to the rest of the body except
the pulmonary arteries. They carry deoxygenated blood.

22. (C) The term extracorporeal refers to outside the body.

23. (C) Diastole is the phase where there is maximum cardiac relaxation.

24. (A) With hypotension there is a drop in blood pressure. There is a fluid shift between spaces in the body
also caused by shock and infection.

25. (D) The surgical incision used for cardiac surgery is a median sternotomy. Lateral is for the kidney,
thoracoabdominal is for surgery on the esophagus, stomach, and lung.

26. (A) CABG, coronary artery bypass graft patients must be put on the heart lung machine. This machine
is not necessary for AAA, IVC, or VATS.

27. (A) The heart is located in the mediastinal cavity. The endocardium is the inner layer of the heart. The
myocardium is the middle layer.

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28. (A) The inner layer of the heart is the endocardium. The myocardium is the middle, epicardium is the
outermost, and the pericardium encases the heart.

29. (C) The pulmonary valve is also known as the semilunar valve.

30. (D) The pericardium is the membrane that covers the heart. It has nothing to do with conduction.

31. (C) An arrhythmia is an abnormal heart rhythm. A rapid heart rate is tachycardia and a slow heart rate is
bradycardia.

32. (A) Xylocaine is used to treat ventricular arrhythmias.

33. (C) Pericardial effusion is fluid buildup between the lining of the heart. Endocarditis is the
inflammation of the inner lining of the heart. Irregular muscle contractions are called fibrillation and
pericarditis is inflammation of the pericardium of the heart.

34. (A) An echocardiogram examines the heart using ultrasound. Arteriogram is an x-ray of the arteries
using contrast media and an angiogram is an x-ray of veins using contrast media.

35. (D) The femoral and brachial arteries can both be accessed during a cardiac catheterization.

36. (C) The internal mammary increases cardiac blood flow to the heart following a CABG.

37. (B) A mediastinoscopy visualizes the cavity between the lungs, aorta, and vena cava. An angiogram is the
x-ray of veins using contrast media and a VATS procedure visualizes the thoracic cavity with a scope.
Echocardiogram examines the heart using ultrasound.

38. (D) Levophed (norepinephrine) restores and maintains blood pressure following peripheral vascular
collapse or as a result of severe hypotensive or cardiogenic shock.

39. (C) Sodium bicarbonate treats acidosis. It should not be mixed in an IV line.

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 ___________________ CHAPTER 26 ___________________

Vascular

• Peripheral vascular surgery includes surgeries of the veins and arteries outside of the brain and heart
• Arteriosclerosis—hardening/stenosis of the arterial wall
• Atherosclerosis—is the most common form of arteriosclerosis. It is a thick yellowish plaque that causes a
blockage in the artery and lack of blood flow to a particular part of the body
• Thromboembolic disease
Embolus—this is a clot of blood, air, or organic material that moves freely in the vascular system
Thrombus—stationary clot
• Three layers of blood vessels include:
Tunica intima—innermost
Tunica media—muscular middle layer
Tunica externa/adventitia—composed of fibrous tissue
• Arteries—carry oxygenated blood from the heart to body
Pulmonary artery—the only artery that carries deoxygenated blood
Blood is moved by the pumping action of the heart
Blood loss is rapid and severe
• Veins—carry deoxygenated blood to the lungs
Pulmonary vein—the only vein that carries oxygenated blood
Blood is moved by contractions of the skeletal muscles
Veins have valves
• Venous stasis—pooling of blood
• Varicosity—abnormally dilated veins caused by venous stasis
When the valve in the vein malfunctions it causes venous stasis, which then causes the vein to dilate, and
causes a varicosity. This can also cause a thrombus
• Arteries branch into → arterioles → capillaries →venules → veins
• Aorta—it is the largest artery in the body, begins from the arch of the heart
Thoracic descending aorta → abdominal aorta → iliac arteries → femoral arteries → popliteal → tibial
artery
• Three major arteries that arise from the aorta and supply blood to the upper extremities include
Brachiocephalic
Common carotid

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 Left subclavian
• Angiography—contrast medium is used to get a radiographic image of the vessel
• Angioscope—is performed with a fiberoptic angioscope to visualize the inside of a vessel and diagnose
what is causing the blockage
• Doppler scanning—can be used intraoperative and postoperatively. Probe is used to hear the blood flowing
through the vessel
• Ultrasonography
• Arterial plethysmography—performed for small arterial disease. It is used to find a stricture at a particular
point on the leg. Three pressure cuffs are placed at different points on the leg, they are inflated and the
pressure reading should be the same, the one that varies is where the stricture is
• Arterial catheter—used to measure blood pressure on extremely ill patients and also to instill dyes and
chemo agents
• Central venous catheters—used to administer IV fluids, drugs, nutritional solutions, and to withdraw
blood
• Angioplasty—this procedure involves opening up a clogged artery by inserting a balloon catheter to help
widen the artery. A stent is placed following the procedure to maintain patency of the vessel.
Groshong catheter—is used for more long-term IV therapy chemo. The catheter is introduced into the
subclavian vein to the vena cava
Hickman catheter—used for chemo, blood withdrawal, medications, and/or dialysis. The catheter is
introduced into the jugular vein to the superior vena cava
Broviac catheter—similar to a Hickman catheter, it has a very small lumen, can be used for children.
Introduced same as above
• Blood pressure
Systolic pressure—occurs during contraction of the ventricles (top number)
Diastolic pressure—occurs during relaxation phase of the cardiac cycle. (bottom number)
• Hypotension—low blood pressure
• Hypovolemia—low blood volume (loss of blood)
• Shock-this condition is caused when the tissues of the body do not receive enough oxygen and can lead to
cellular death—organ failure—death
clinical symptoms of shock are:
Hypovolemia
Hypotension
Tachycardia
• Hypertension—high blood pressure
• Medications:
Heparin—prevents blood from coagulating/thins the blood
Mixed with saline for irrigation
Is given by the anesthesiologist 3–4 minutes before cross-clamping an artery

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 Protamine sulfate—antagonist for heparin
Papaverine hydrochloride—prevents vessels from spasm
Thrombin—topical hemostatic agent. Never inject topical thrombin directly into a vessel
Gel foam/Gelfilm/Avitene—absorbable hemostatic agent helps control bleeding
• Vascular grafts
Synthetic—knitted Dacron grafts: preclotted. This is performed to cut down on bleeding
Polyester
Gore-Tex
Natural materials include:
Autografts (e.g., saphenous)
Banked human umbilical
Bovine
• Sutures
Polypropylene—most common
Polytetrafluoroethylene—PTFE
Ethibond
Silk
• Suture gauges for vascular surgery:
Aorta 3-0/4-0
Iliac 4-0/5-0
Femoral 5-0/6-0
Popliteal 5-0/6-0
Tibia 6-0/7-0
Carotid 6-0/7-0
Brachial 6-0/7-0
Radial ulnar 6-0/7-0
• Suture boots—they are placed on mosquitos and used to hold one end of a double armed suture. They
prevent kinks in the suture that a normal clamps would cause, when pulling through a vessel the kink
could increase the size of the hole and increase bleeding
• Vessel loops—are used to identify structures, retract vessels, and occlude vessels
• Pledgets—small teflon-coated cottonoids attached with sutures. They are used to reinforce the
anastomosis, and are commonly used on an AAA
• Rummel tourniquet—used to occlude a vessel. Dacron tape is wrapped around a vessel and threaded
through a small silastic bolster and tightened
• Arterial embolectomy—performed to remove clots. A Fogarty embolectomy catheter is used with a
tuberculin syringe
• Hemodialysis—this procedure is performed on the patient in renal failure because their blood is no longer
being properly filtered by the kidney. They need extracorporeal hemodialysis (blood removed from the

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 body and filtered outside the body in a machine and infused back to the patient)
• Arteriovenous fistula—direct anastomosis between an artery and vein
When performing this procedure, the vein and artery used are:
Forearm—radial artery to cephalic vein
Upper arm—brachial artery to basilic vein
• Brachial artery to cephalic vein
The large cannulation bore hole needles are injected into the vein three times a week for dialysis
The arterial pressure enlarges the vein for dialysis access
A Doppler is used intraoperatively (sterile) and postoperatively
Bruit/Brui—the pulse in the fistula/graft is called signal/thrill/buzzing (swishing sound)
• Arteriovenous shunt—the graft is used to connect the artery and vein instead of a direct (no graft)
connection between the artery and vein
They can use synthetic grafts or the patient’s own vein or bovine, carotid artery or human umbilical vein
Gore-Tex grafts are commonly used. Gore-Tex—PTFE
• Vascular anastomosis include:
Side to side
End to end
End of vein to side of the artery
End of artery to side of vein
• Tenckhoff catheter insertion—performed for renal dialysis—it filters the patient’s blood. This is used for
peritoneal dialysis
A silicone catheter is inserted into the abdominal cavity
A special fluid (dialysate) is infused into the abdominal cavity and remains for 3–6 hours then drained
The intestines and peritoneal membrane act as a filter between the fluid and the blood stream
Waste products and excess water are removed from the body
• Venus catheter—this is used for quick short-term dialysis—this type of central venus catheter can be
inserted into the:
Internal jugular
Subclavian vein
Femoral vein
• Vena cava filter placement—this is performed to prevent clots from traveling to the lungs (pulmonary
embolism)
• This is caused by DVT (deep vein thrombosis) clots in the deep veins of the body
Fluoroscopy is used
The vena cava filter can be inserted through:
Femoral vein
Jugular vein
The filter is placed in the inferior vena cava

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• Vein stripping and ligation—varicose veins are large dilated veins caused by venous stasis (pooling of
blood)
The most common vein effected is the saphenous vein and its branches in the leg
A vein stripper is used to remove the saphenous vein
Smaller veins are clamped and tied with clamps
• Sclerotherapy—a procedure used to eliminate varicose veins. It is an injection of a salt solution directly into
the vein. The solution destroys the lining of the blood vessel and causes the vessel to swell and become
stenosed
• Endarterectomy—performed to remove plaque from an artery
Freer elevator is used to dissect/plaque from the arterial wall
• Carotid endarterectomy—the procedure is performed to remove plaque from the carotid artery. The three
carotid vessels include:
Internal/external/common
The order in which the carotids must be clamped off:
First internal carotid
Second external carotid
Third common
The order in which the clamps must be removed is the opposite:
First common
Second external
Third internal
Primary indication for surgery is cerebral ischemia (small pieces of plaque break off from the vessel and
travel to the brain causing stroke)
Remove plaque from the carotid artery to increase blood flow to the brain
Javid and argyle shunts are the most common carotid shunts
• Claudication—disabling pain during rest. A condition in which cramping pain in the leg is caused by
ischemia
• Cross clamping—two vascular clamps are placed on a vessel to occlude the vessel so they can work in a
bloodless field
• Abdominal aortic aneurysm/AAA
• Aneurysms—are weakened areas on an arterial wall, atherosclerotic plaque builds up and can cause the wall
to dissect or rupture. There are two types they include:
Saccular—ballooning of one area on the arterial wall
Fusiform—involves the entire circumference of the artery wall
• Dissecting aneurysm—blood seeps through the walls of the aneurysm
• Grafts for the AAA include:
Bifurcated if the iliacs are involved (low aneurysm)
Tubular Dacron knitted—needs to be preclotted

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• Cell-saver—intraoperative cell salvage machine- a salvage device that suctions, washes, and saves the blood
cells so they can be transfused directly back into the patient. It is used on patients with religious objections
to receiving blood transfusions and patients who do not want to use banked blood
Commonly used on AAA
The cell-saver should not be used on patients with metastatic cancer. If any hemostatic agent (Avitene)
is in use or when there is the presence of amniotic fluid
• Hemolysis—buildup of fluid in a vessel causing the RBC’s (erythrocytes) to rupture. They must be careful
with the heparin when using the cell-saver
• Disseminated intravascular coagulation—DIC is a disorder in the blood. There is an over stimulation of
blood clotting in the blood vessels and causes bleeding within the body. Activation of the clotting cascade
occurs and normal clotting is disrupted and causes widespread bleeding and organ death
• Endotoxins—bacterial toxins located within the blood that can cause sepsis. Sepsis can cause the
stimulation of blood clotting and DIC
• Endovascular AAA—minimally invasive procedure performed in interventional radiology under
fluoroscopy
The incision is in the femoral artery
A metal stent covered with fabric and has holes that allow the blood to flow freely is inserted through
the femoral artery. The endograft is fitted inside the aneurysm not sewn
Can be bifurcated or tubular
• Femoral–popliteal bypass—performed for blockage in femoral artery. It restores blood flow to the leg
Can use a synthetic or the saphenous vein (from the patient’s own leg)
Incisions are in the femoral area and popliteal area
A tunneler is used to pass the graft from one incision to the other (actually looks like a tube/tunnel)
• Saphenous vein in situ—contained- in its original position
All tributaries are tied off with 4-0 silk free ties
Once the vein is out both ends are occluded and heparinized saline is injected to check for leaks
The saphenous vein is placed in situ (original position)
• Fem/tibial bypass—this is performed for blockage in the femoral artery/popliteal artery
Incisions in the femoral artery and the tibial artery
• Fem/fem bypass—performed for blockage in the iliac artery
Incisions in both femoral arteries
• Aortofemoral bypass—performed for blockage in the iliacs
Incisions are in each of the femoral arteries and the aorta
• Axillofemoral bypass—blockage can be in the aorta/iliacs where blood flow to the lower extremities is
compromised
Incisions in the axilla and the femoral artery
• Collateral circulation/blood flow—it is the rerouting of blood circulation around a blocked artery or vein.
This is often a result of anastomoses of branches between adjacent blood vessels

566
• Amputation—performed for vascular insufficiency caused by plaque/clots, the limb becomes ischemic and
necrotic and must be removed
It can be below the knee or above the knee
Above the knee is performed when there is not good vascular flow below the knee and the wound will
not heal
Soft tissue instruments and orthopedic instruments needed:
Power saw/gigli saw/rasps/rongeurs
Limbs are wrapped and sent to morgue and refrigerated
• Phantom pain—this is described as a sharp burning pain in the amputated limb. As time goes by the pain
diminishes
• Stripping and ligation—this is performed for varicose veins. The saphenous vein is the most common vein
involved
Vein stripper with various sizes of acorn tips for stripping the vein.
Inner layer—endocardium

567
 Questions

1. In which procedure could a Fogarty catheter be utilized?

(A) Embolectomy
(B) Gastrectomy
(C) Craniotomy
(D) Thoracotomy

2. Amputated extremities are:

(A) sent to the pathology laboratory as are other specimens

(B) preserved in formaldehyde
(C) wrapped and refrigerated in the morgue
(D) placed in a dry container

3. If a knitted graph is preclotted, it:

(A) minimizes bleeding

(B) makes a graft more pliable
(C) facilitates attachment
(D) prevents rejection

4. The antagonist to heparin sodium is:

(A) epinephrine
(B) mannitol
(C) sodium bicarbonate
(D) protamine sulfate

5. Pedal pulses are assessed with a:

(A) Berman locator

(B) Doppler
(C) Mobin–Uddin device
(D) polytetrafluoroethylene prosthetic (PTFE)

6. Heparin is utilized during vascular surgery:

(A) to coagulate blood

568
 (B) to correct acidosis
(C) to constrict arteries
(D) to prevent thrombosis

7. The prime consideration in a ruptured abdominal aortic aneurysmectomy is:

(A) shunting blood flow

(B) hemorrhage control
(C) bypassing occlusion
(D) removal of thromboembolic material

8. In which surgery would a tunneler be used?

(A) Abdominal aortic aneurysm (AAA)

(B) Angioplasty
(C) Embolectomy
(D) Femoral–popliteal bypass

9. Which piece of equipment would be placed on an embolectomy setup for the purpose of removing clots
through an arteriotomy?

(A) Wishard
(B) Swan–Ganz
(C) Fogarty
(D) Garceau

10. The goal of a carotid endarterectomy is to:

(A) remove a thrombus

(B) provide a shunt for blood flow
(C) bypass the affected area
(D) remove plaque

11. Plaque removal from a vessel is termed:

(A) embolectomy
(B) thrombectomy
(C) shunt
(D) endarterectomy

12. Placement of a vascular graft proximal to and inclusive of the common iliac vessels will necessitate the
use of a/an:

(A) autogenous graft

(B) straight Teflon graft

569
 (C) bifurcated graft
(D) polytetrafluorethylene graft

13. The most common vessels used for access procedures to facilitate hemodialysis are:

(A) radial artery and cephalic vein

(B) radial artery and cephalic artery
(C) brachial artery and cephalic vein
(D) cephalic artery and brachial vein

14. Migrating clots that have formed in the lower extremities can be intercepted on the way to the heart or
lungs by a:

(A) Greenfield Filter

(B) Pudenz shunt
(C) Scribner shunt
(D) LeVeen shunt

15. Retraction of fine structures and blood vessels during vascular surgery is accomplished by use of:

(A) Senn retractor

(B) Penrose drain
(C) malleable ribbon retractor
(D) vessel loops

16. Fluoroscopy is required for all of the following vascular procedures EXCEPT:

(A) Greenfield filter

(B) endocardial pacing electrode
(C) myocardial pacing electrode
(D) AV arteriovenous fistula creation

17. Compression of subclavian vessels and brachial plexus at the superior aperture of the thorax is known as:

(A) thymoma
(B) pectus excavatum
(C) thoracic outlet syndrome
(D) pectus carinatum

18. In vascular surgery, the term in situ graft references the use of a/an:

(A) autogenous graft

(B) heterogeneous graft
(C) allograft
(D) synthetic graft

570
19. The surgery scheduled as “Greenfield filter insertion” indicates a diagnosis of:

(A) emboli formation

(B) venous stasis
(C) arteriovascular occlusion
(D) kidney failure

20. During a vascular procedure, monitoring the activated clotting time intraoperatively provides useful data
for judging the need for reversal or addition of:

(A) Angiovist
(B) papaverine
(C) heparin
(D) protamine sulfate

21. A low–molecular-weight protein that, when combined with heparin, causes a loss of anticoagulant
activity postoperatively is:

(A) papaverine
(B) protamine sulfate
(C) tromethamine
(D) Angiovist

22. What is the purpose for the surgical creation of an arteriovenous fistula?

(A) Hemodialysis
(B) Insertion of Greenfield filter
(C) Peritoneal dialysis
(D) Placement of Javid shunt

23. Conservative treatment of occlusive disease involving recanalization to restore the lumen of a vessel is
called:

(A) PTFE
(B) percutaneous transluminal angioplasty (PTA)
(C) Greenfield filter
(D) endarterectomy

24. What procedure is used intraoperatively and postoperatively to determine blood flow in a vessel?

(A) Arteriogram
(B) Swan–Ganz
(C) Doppler ultrasound
(D) Angioscopy

571
25. Removal of atherosclerotic plaque from a major artery is termed:

(A) embolectomy
(B) aneurysmectomy
(C) endarterectomy
(D) thrombectomy

26. An abnormal localized dilatation of an artery resulting from mechanical pressure of blood on a weakened
wall is called:

(A) atherosclerosis
(B) arteriosclerosis
(C) collateral circulation
(D) aneurysm

27. What is the treatment of choice for capturing emboli that arise from the pelvis or lower extremities?

(A) Permacath
(B) Greenfield filter
(C) Vas-cath
(D) Porto-cath

28. What intraoperative test determines the needed reversal or addition of heparin?

(A) Arterial blood gases (ABGs)

(B) Activated clotting time (ACT)
(C) Activated partial thromboplastin time (APPT)
(D) None of the above

29. What drug is used intraoperatively in a topical manner for its direct effect on the muscle of the vessel
wall?

(A) Papaverine hydrochloride

(B) Heparin
(C) Topical thrombin
(D) Protamine sulfate

30. The term in situ graft represents the use of a/an:

(A) autograft
(B) biograft
(C) Dacron graft
(D) filamentous velour

31. The buildup of fat residue on a vessel wall is:

572
 (A) atherosclerosis
(B) lipidosis
(C) vasodilation
(D) vasoconstriction

32. The self-retaining retractor used when performing a femoral–popliteal bypass is:

(A) Debakey
(B) Finochietto
(C) Weitlaner
(D) Alm

33. Chronic cerebral ischemia most often leads to:

(A) femoral endarterectomy

(B) carotid endarterectomy
(C) electroencephalogram
(D) electrocardiogram

34. AAAs commonly occur:

(A) above the renal arteries

(B) below the renal arteries
(C) above the iliac arteries
(D) below the iliac arteries

35. Occluding peripheral vessels is achieved with the use of:

(A) Glassman
(B) Leland–Jones
(C) Bulldog
(D) Myergils

36. When performing an arteriotomy, the surgeon will require a #11 blade and:

(A) Potts–Smith scissor

(B) Metzenbaum
(C) Lahey
(D) Stevens

37. Removal of plaque during a carotid endarterectomy requires:

(A) Cobb elevator

(B) Hurd dissector
(C) Freer elevator

573
 (D) None of the above

38. Which of the following is the correct order from outermost to innermost layers of blood vessels:

(1) tunica adventitia, (2) tunica media, (3) tunica intima

(A) 1, 2, 3
(B) 3, 2, 1
(C) 3, 1, 2
(D) 1, 3, 2

39. A Javid shunt is used during a:

(A) AV fistula
(B) carotid endarterectomy
(C) femoral–femoral bypass
(D) abdominal aortic aneurysm

40. The procedure that is performed for dialysis that produces a direct anastomosis between an artery and a
vein is:

(A) Gore-Tex graft insertion

(B) AV shunt
(C) endarterectomy
(D) AV fistula

41. When performing a femoral–femoral bypass, the atherosclerotic disease is in the:

(A) femoral artery

(B) aorta
(C) femoral vein
(D) iliac artery

42. Thick plaque that causes blockage in the arteries is:

(A) atherosclerosis
(B) arteriosclerosis
(C) thrombus
(D) emboli

43. All are true regarding venous stasis EXCEPT:

(A) the valves in the vein malfunction

(B) the vein becomes dilated
(C) blood pools
(D) requires a vena cava filter

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44. The major arteries that arise from the aorta and supply blood to the upper body are:

(A) brachiocephalic
(B) common carotid
(C) left subclavian
(D) All of the above

45. All apply to central venous catheters EXCEPT:

(A) they are introduced into an artery

(B) medications can be instilled directly into the catheter
(C) can be accessed to infuse chemotherapy
(D) can be accessed to draw blood

46. Symptoms of shock include:

(A) hypovolemia
(B) hypotension
(C) bradycardia
(D) Both A and B

47. A common suture gauge used on a carotid endarterectomy procedure is:

(A) 3-0 and 4-0

(B) 4-0 and 5-0
(C) 6-0 and 7-0
(D) 10-0

48. All of the following pertain to a Rummel tourniquet EXCEPT:

(A) to occlude a vessel

(B) used with Dacron tie threaded through a silastic bolster
(C) used on cardio and vascular surgery
(D) used to identify a vascular structure

49. Hemodialysis is:

(A) necessary for patients with end stage renal failure

(B) extracorporeal filtration of blood
(C) may require AV shunt or AV fistula
(D) All of the above

50. A Tenckhoff catheter is:

(A) used for peritoneal dialysis

(B) inserted into the thoracic cavity

575
 (C) used for filtering blood extracorporeally
(D) inserted through the fistula

51. The procedure used to destroy varicose by introducing a saline solution directly into the vein is:

(A) vein stripping

(B) ligation of saphenous vein
(C) sclerotherapy
(D) endarterectomy

52. Following a carotid endarterectomy, clamps must be removed in which order?

(A) internal, external, common

(B) common, external, internal
(C) external, common, internal
(D) external, internal, common

53. The type of aneurysm that forms circumferentially is called:

(A) saccular
(B) dissecting
(C) leaking
(D) fusiform

54. A cell salvage machine can be used on patients:

(A) diagnosed with metastatic cancer

(B) in the presence of all medications
(C) in the presence of anticoagulants
(D) is also known as autologous

55. The following statements are true regarding disseminated intravascular coagulation EXCEPT:

(A) is caused by exotoxins

(B) caused by endotoxins
(C) causes widespread bleeding
(D) can cause organ death

576
 Answers and Explanations

1. (A) In an embolectomy, a Fogarty catheter is inserted beyond the point of clot attachment. The balloon
is inflated, and the catheter is withdrawn along with the detached clot.

2. (C) Amputated extremities are wrapped before sending them to a refrigerator. The morgue is the usual
place that receives them, unless hospital policy dictates otherwise. They must be tagged and labeled
properly.

3. (A) A knitted graft is prepared before inserting to minimize blood loss from seepage through graft
interstices. The patient’s own blood may be used, immersing the graft in a small quantity.

4. (D) Protamine sulfate reverses heparin.

5. (B) Pedal pulse can be assessed manually or with an ultrasonic instrument (Doppler). It assesses
movement of blood through a vessel.

6. (D) Heparin can be used locally or systemically to prevent thrombosis during an operative procedure. It
can be directly into the IV or used as heparinized saline irrigation. (e.g., 5,000 units in 500 mL of
saline)

7. (B) The prime surgical consideration when a dissection or rupture occurs, there is control of the
hemorrhage by occluding the aorta proximal to the point of rupture.

8. (D) A femoral–popliteal bypass is the restoration of blood flow to the leg with a graft bypassing the
occluded section of the femoral artery with either a saphenous vein or a graft. The tunneler is passed
from the popliteal fossa to the groin, and the graft is pulled through.

9. (C) A Fogarty biliary catheter is used on an embolectomy to remove the clot.

10. (D) Carotid endarterectomy is the removal of an atheroma (plaque) at the carotid artery bifurcation. A
temporary shunt or bypass can be used.

11. (D) Endarterectomy is the removal of arteriosclerotic plaque from an obstructed artery. It occurs
frequently at the bifurcation of the vessel.

12. (C) A graft placed proximal to and inclusive of the common iliac vessels will necessitate the use of a
bifurcation into the common iliac branches.

577
13. (A) Either a shunting device or an arteriovenous fistula using the radial artery and cephalic vein are used
to facilitate hemodialysis.

14. (A) A filter device may be inserted (in its collapsed form) through a cut-down in a large vein, usually the
right internal jugular. The Greenfield filter is shaped like an umbrella. It is designed to allow blood to
pass through the vena cava while filtering clots.

15. (D) To prevent undue trauma, umbilical tapes or vessel loops are used for retraction and vascular control.

16. (D) AV fistulas do not require fluoroscopy.

17. (C) The cause of this compression of the subclavian vessels, known as thoracic outlet syndrome, is
usually congenital deformity or traumatic injury to the first rib.

18. (A) In situ femoral popliteal bypass is the restoration of blood flow to the leg bypassing an occluded
portion of the femoral artery with a patient’s own saphenous vein. The advantages of a vein bypass
procedure include graft availability and improved patency.

19. (A) Greenfield vena cava filter insertion entails the partial occlusion of the inferior vena cava (IVC) with
an intravascular filter that maintains a patent vena cava but prevents pulmonary embolism by trapping
emboli at the apex of the device.

20. (C) Heparin is the most common drug used in vascular surgery. It may be given as an intravenous bolus
to systemically anticoagulate the patient. It is given just before the placement of the vascular clamp and
is monitored regularly during surgery to determine its level in the body.

21. (B) A low–molecular-weight protein that, when combined with heparin, causes a loss of anticoagulant
activity is called protamine sulfate. It is administered by the anesthesiologist IV after bypass is complete.

22. (A) A direct anatomic arteriovenous fistula provides a dilated vein valuable for direct cannulation with
large-bore needles for hemodialysis.

23. (B) PTA is a conservative treatment for localized or segmental stenosis or occlusive vascular disease.
PTA recanalizes the vessel to allow for better flow. PTFE is a microporous graft for bypass. Greenfield
filters are placed to catch venous thrombi, and endarterectomy requires the opening and scraping of a
vessel to remove plaque.

24. (C) After vascular closure is completed, a Doppler pulse detector (ultrasound) is used to check patency of
a vessel and ultimate blood flow.

25. (C) Endarterectomy is the excision of diseased endothelial lining of an artery and removal of plaque that
has built up.

26. (D) An aneurysm is the wall of the vessel becomes weakened. This localized abnormal dilatation results
from mechanical pressure of blood on a vessel wall.

578
27. (B) Vena cava filter insertion entails the partial occlusion of the IVC with an intravascular filter, inserted
under fluoroscopy. The Greenfield device offers the option of jugular or femoral vein insertion. It is the
most widely successful device available.

28. (B) Monitoring the ACT intraoperatively provides useful data for judging the need for reversal or
addition of heparin.

29. (A) Papaverine hydrochloride may be added to a heparinized saline for its direct antispasmodic effect on
the smooth muscle of the vessel wall and its vasodilating properties.

30. (A) An in situ graft is used from an autograft. The patient’s own vessel.

31. (A) Atherosclerosis is the buildup of fat residue on a vessel wall.

32. (C) A Weitlaner is a retractor used to retract during a femoral–popliteal bypass.

33. (B) Chronic cerebral ischemia can lead to a carotid endarterectomy.

34. (B) AAA commonly occurs below the renal arteries.

35. (C) Bulldogs are used to occlude peripheral vessels.

36. (A) An arteriotomy is performed using an #11 blade and a Potts–Smith scissor.

37. (C) A Freer elevator is used to peel plaque off of the carotid artery during endarterectomy.

38. (A) Tunica aventia is outermost, tunica is the middle, and tunica intima is the innermost.

39. (B) During a carotid endarterectomy a Javid shunt is used to provide continuous blood flow to the brain.
The shunt is inserted into the internal and common carotid arteries.

40. (D) The two techniques used for hemoaccess is an AV fistula which is a direct connection between an
artery and a vein and an AV shunt which is a Gore-Tex graft that is used to connect the cephalic vein
and the brachial artery.

41. (D) A femoral–fem bypass is performed for atherosclerotic disease in the iliac arteries. For a femoral–
popliteal bypass, the disease is in the femoral artery.

42. (A) Arteriosclerosis is the disease caused by atherosclerosis. A thrombus is a stationary clot in a vessel
and an emboli is a clot that can travel.

43. (D) A vena cava filter is inserted to stop blood clots from entering the lungs. With venous stasis, the
valves are incompetent, the veins become dilated and the blood pools.

44. (D) All mentioned arteries supply blood to the upper body.

45. (A) CVP catheters are introduced into veins not arteries. Medication can be instilled into the catheter

579
 including chemotherapy and blood can be drawn from the CVP.

46. (D) Patients in shock experience both hypovolemia and hypotension.

47. (C) 6-0 and 7-0 sutures are used on carotid endarterectomy surgery.

48. (D) Rummel tourniquets are not used to identify vascular structures.

49. (D) Hemodialysis is necessary for end stage renal failure. The filtration of blood takes place
extracorporeally accessing an AV shunt or AV fistula.

50. (A) A Tenckhoff catheter is used for peritoneal dialysis. It is inserted through the abdomen and not a
fistula. This does not filter blood extracorporeally.

51. (C) During sclerotherapy, a saline solution is injected directly into the vein.

52. (B) Clamps must be removed in the following order following a carotid endarterectomy; common,
external then internal carotids.

53. (D) A fusiform aneurysm forms circumferentially. A saccular aneurysm balloons in one area. A
dissecting aneurysm is one that is slowly tearing through the arterial walls and a leaking aneurysm is a
slow leak of blood from the artery.

54. (D) Cell salvage machine is the patients own blood or autologous blood. Cell-saver cannot be used if the
patient has metastatic cancer. It cannot be used with all medications nor in the presence of
anticoagulants.

55. (A) Disseminated intravascular coagulation DIC is not caused by exotoxins.

580
 ___________________CHAPTER 27___________________

Neurosurgery

• The nervous system is divided into two systems, they include:

CNS—central nervous system—the spinal cord and the brain
PNS—peripheral nervous system—this includes the nerves from the brain, and the spinal nerves that
originate from the spinal cord
• The peripheral nervous system is further divided into:
Somatic (voluntary system)
Autonomic (involuntary system)
• Somatic nervous system—voluntary
Skeletal muscles control body movement
Contain afferent/efferent nerve impulses
Afferent—carry impulses to the brain (e.g., a burn from your hand to your brain)
Efferent—they provide instructions from the brain to the rest of the body in order to react
• Mnemonic—afferent arrives/efferent exits
• Autonomic nervous system-involuntary—this is the subconscious it includes:
Breathing, heartbeat, digestion
It is broken down even further into:
Sympathetic—“fight or flight”
Associated with the adrenal secretion of epinephrine
Increased heart rate
Increased blood flow to the brain and muscles
Raised sugar levels
Sweaty palms
Dilated pupils
Parasympathetic—calms you down when the emergency is over so you can get back to healing the
immune system

581
• Skull—provides protection for the brain. The bones of the skull are flat bones
• Cranial bones/bones of the face—these bones are irregular
• Galea—a tough fibrous layer of tissue, that covers the pericranium (outer layer of the skull)
• The bones of the skull are connected by seams called sutures, they include:
Sagittal suture—joins the two parietal bones
Squamous suture—joins temporal and parietal
Coronal suture—joins the frontal and parietal bones
Lambdoid suture—joins the occipital bone and the parietal bones
• These bones connected by sutures have nonmoveable joints called synarthrotic joints
• Craniosynostosis—this is the most common pediatric skull deformity. This results from a premature
closure of the cranial suture lines
This procedure is performed between 6 weeks to 6 months of age. At this time the infant’s skull bones
are still malleable and easier to work with
• Cranioplasty—this is the surgical procedure used to repair a cranial defect. It is used to treat
craniosynostosis
• Meninges—this is the covering of the brain and spinal cord. It has three layers, they include:
Dura mater—this is in direct contact with the skull
Arachnoid mater—web-like membrane
Pia mater—the inner most layer it is closest to the brain
• Subdural space—this is the space between the dura mater and the arachnoid space
• Subarachnoid space—space between the arachnoid space and the pia mater

Brain—encephalon—is made up of grey and white matter

• The brain is divided into three basic parts:

Forebrain
Midbrain
Hindbrain
• The Hindbrain—this part of the brain that controls respiration and heart rate, it includes:
The upper part of the spinal cord
Brain stem

582
 Cerebellum
• Midbrain—the uppermost part of the brainstem that controls some reflex actions and eye movements and
other voluntary movements
• Forebrain—it is the largest part of the brain it consists of the cerebrum
• Diencephalon—the thalamus and hypothalamus are located here
The hypothalamus—controls body temperature
The thalamus—controls hunger, thirst, emotions.
• Cerebral hemisphere—it is divided into right and left sides
The right cerebral hemisphere—controls the left side of the body
The left hemisphere—controls the right side of the body
They are connected by the corpus callosum
• Each cerebral hemisphere can be divided into lobes, they include:
Frontal lobes—directly behind the forehead
Parietal lobes—side of the head
Occipital lobes—back of the head
Temporal lobes—side of the forehead
• Blood supply to the brain is provided by:
Carotids
Vertebral arteries
Basilar arteries
• Circle of Willis—it is the circular connection of arteries that supplies blood to the brain
• Brainstem—extends from the cerebral hemisphere to the spinal cord
• Pons—it is responsible for horizontal eye movement and facial movement
• Cerebrum—largest part of the brain
• Cerebellum—it is responsible for balance and coordination
Sub occipital approach is used for procedures on the cerebellum
• Medulla oblongata—is responsible for cardiac and respiratory functions
• Ventricles—they are cavities within the brain are filled with CSF
The first two ventricles are the lateral ventricles
The third ventricle
The fourth ventricle
• Aqueduct of Sylvius—this connects the third and fourth ventricle
• Cerebral spinal fluid—clear fluid that cushions, nourishes, and bathes the brain
CSF is produced in the choroid plexus
• Intracranial tumors—brain tumors
Astrocytoma—most common of all brain tumors
Glioblastoma—cancerous and fast growing
Medulloblastoma—common in children

583
• Vestibular schwannomas/acoustic neuroma—tumors of the eighth cranial nerve. These tumors effect
balance and hearing
As the tumor grows it causes pressure on the eighth cranial nerve ( acoustic nerve, vestibular nerve)
causing one-sided hearing, dizziness, and problems with balance
The tumor can also cause pressure on the seventh cranial nerve (facial nerve) causing facial numbness
and pain
• Meningiomas—tumors of the meninges begin in the covering of the brain
• Encephalocele—cranial defect causing a sac-like protrusion through the skull that contains CSF,
meninges, and brain tissue
This defect results from failure of the neural tube to close
• Anencephaly— these infants are born without formed brains or all parts of their skull
• Spina Bifida—this is an incomplete closure of the vertebral arches in the spine causing damage to the spine
and nerves
• Cerebrospinal fluid—clear colorless fluid that nourishes, bathes, and protects the brain and spinal cord
It is formed in the choroid plexus of the third and fourth ventricle
It is aspirated by performing a lumbar puncture
• Hydrocephalus—is a condition where there is an excessive amount of CSF in the brain
Causes pressure in the brain
Hydrocephalus can be congenital or acquired. The congenital condition found in infants and children
causes an enlargement of the child’s head
Hydrocephalus can also present itself as a blockage of CSF in one of the ventricles of the brain and can
cause stroke
• Ventriculoperitoneal shunt—is a shunt is placed in the lateral ventricle of the brain to the peritoneal cavity
to shunt the excess CSF away from the lateral ventricles of the brain to another location in the body in this
procedure it is the peritoneum
These shunt procedures are performed to reduce intracranial pressure
• Ventriculoatrial shunt—performed for the same principle as the VP shunt except the CSF is shunted into
the right atrium
• Manometer—this is an instrument used to measure CSF fluid pressure in the brain
• Ventriculoscopy—this is performed for an enlarged ventricle in the brain to drain excess CSF
A hole is created within the ventricle for drainage
Usually from the third
• Aneurysms—weakening in the arterial wall of a cerebral vessel
May be congenital or acquired as a result of high blood pressure, infection or trauma
The vessels most often involved include the:
Vertebral arteries
Basilar arteries
Most common approach for aneurysm repair in the brain is frontotemporal area

584
 Types of aneurysm repair equipment are:
Coils
Stents
Aneurysm clips
• Hematomas—abnormal collection of clotted blood in an area of the brain. It can be caused by:
Leakage of vessels
Head injury
People with bleeding disorders
• Epidural hematoma—hematoma between the skull and the dura
Commonly caused by a blow to the head
The procedure to correct this is burr holes to drain excess fluid
• Subdural hematoma—this type of hematoma is bleeding in the space between the dura (covering of the
brain) and the brain itself
Causes intracranial pressure
The procedure performed is burr holes
• Burr holes—are performed to drain blood from the cranial cavity to reduce intracranial pressure
They can be enlarged with a double action rongeur, or Kerrison rongeur
Bleeding is controlled with bone wax
• Cranial nerves
I—Olfactory—sense of smell (nose to brain)
II—Optic—visual information to the brain (retina to brain)
III—Oculomotor—controls muscles around the eye, constricts the pupil
IV—trochlear—supplies only the superior oblique muscle
V—Trigeminal—sensory nerve that controls the sensation of the face, forehead, mouth, nose, top of the
head and chewing
VI—Abducens—controls lateral movement of the eye
VII—Facial—motor nerve that controls the muscles in the face and scalp, as well as tears and salivation
VIII—Vestibulocochlear—acoustic—controls hearing and equilibrium
IX—Glossopharyngeal—controls the sense of taste and pharyngeal movement, as well as the parotid
gland and salivation
X—Vagus—stimulates the pharyngeal and laryngeal muscles, heart, pancreas, lungs, and digestive
systems
XI—accessory—has two parts:
The cranial portion helps control the pharyngeal and laryngeal muscles
The spinal portion controls the trapezius and the sternocleidomastoid muscle
XII—Hypoglossal—stimulates the muscles of the tongue
• Computed tomography (CT) scan—is the standard used for brain and spinal cord injury. Studies can be
done with or without contrast media

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 • Magnetic resonance imaging (MRI)—performed to diagnose tumors, abscesses, ligament damage and
herniated disks
• Angiography—injection of contrast medium into the blood vessels to diagnose vascular abnormalities
• Myelography—contrast medium is injected into the subarachnoid space in the spine and fluoroscopy is
used to view the spinal cord, nerve roots, and spinal column
• Lumbar puncture—a spinal needle is placed in the subarachnoid space to get CSF, they can measure the
pressure to determine if there is increased pressure surrounding the brain and spinal cord
• Electroencephalogram (EEG)—electrodes are placed on the scalp or on the brain itself that measures
electrical brain activity

Operating room bed and attachments

• Jackson table/Andrews table—used for posterior spine surgery.

• Headrests: used to stabilize the head during surgery. (separate sterile set-up is used to insert the headrest)
Mayfield headrest
Three-pin suspension skull clamps
Gardner-Wells tongs
• Ultrasonic aspirator—Cavitron ultrasonic surgical aspirator (CUSA)—this is used for precise dissection,
irrigation, and aspiration of brain tumors without affecting surrounding tissue
• Craniotome—has a perforator drill for creating burr holes with a dura guard attachment to protect the
dura. Bleeding is controlled with bone wax
• Gigli saw—hand-held saw used to remove bone flap on a craniotomy
• Midas Rex—high-speed pneumatic (compressed air powered drill) power drills contain a variety of
instrument attachments

Neurology instruments

• Titanium plates and wires (used to reattach bone flap)

• Bipolar cautery
• Metal Frazier suction tips
• Leyla–Yasargil—self-retaining retractor for brain tissue
• Penfield dissector—used to separate the dura from the cranium (5 with different tips)
• Raney scalp clips—they are applied to the scalp and galea using a clamp or gun to provide hemostasis
• Dandy clamps—hemostatic clamp with a sideways curve
• Adson–Beckman retractor—self-retaining retractor
• Cerebellar retractor—self-retaining retractor
• Meyerding hand-held retractor
• Padded brain spatulas
• When marking the skin for a craniotomy you should never use methylene blue on a cotton tip applicator
because it is damaging to neuro tissue. Skin markers are the ink of choice

Hemostatic agents

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 • Bone wax (formed into a little ball and placed on the tip of a freer elevator or a Penfield dissector)
• Cottonoid strips/patties
• Gelfoam—can be used dry or soaked in topical thrombin. Gelfoam is followed by a patty to add extra
compression to the bleeder
• Surgicel/fibrillar—absorbable hemostatic agent that contains bacterial properties
• Bone instruments

Sutures

• The dura mater can be closed with silk, polypropylene and nylon
• Never use a chromic because of the alcohol solution it is preserved in, as this could damage neuro tissue
• Wires, plates, screws, and methylmethacrylate bone cement are used to suture cranial bones back in place
Small holes are drilled into the bone flap and skull wire is passed through them and twisted together
with a wire tightener
• Skin staples are used for skin
• When performing micro neurosurgery microscopes and/or loops are used, it is important for the STSR to
carefully place the instruments in the surgeon’s hands as they are to be used, his field of vision is restricted
• Craniotomy—surgical opening into the cranium, they are performed for:
Tumor
Aneurysm
Hemorrhage
Insert Electrodes can also be placed
• Supratentorial craniotomy
Includes the temporal, parietal, frontal, and occipital lobes
Position—supine-dorsal recumbent
• Infratentorial craniotomy
• Includes the areas of the brain stem (mid-brain, pons, medulla, cerebellum)
• Position for the infratentorial craniotomy varies from prone to Fowler position
• Craniectomy—removal of a section of the cranium. The bone flap is not replaced
Burr holes are made and the flap is extended with a craniotome (it cuts from burr hole to burr hole)
When the bone flap is removed it is safely placed in antibiotic solution
The bone flap is sutured back in place with wires or plates and screws
• Cranioplasty—this is performed to repair a skull defect, the skull bone is replaced with a bone graft and/or
synthetic graft
This is performed to improve the patient’s cosmetic appearance
Method 1—mesh is used to make a mold and methylmethacrylate is molded over the mesh and
hardens
Holes are drilled into the cement and skull bone and the bone flap is sutured in place with wire
• Method 2—the defect is measured prior to surgery with a CT scan and a synthetic flap is made and

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 attached with micro-plates and screws
• Arteriovenous malformation—this is an abnormal connection between veins and arteries in the brain
causing hemorrhage. This is caused by a congenital defect or trauma
Cerebral aneurysms are commonly found by the Circle of Willis
Embolization—this is the procedure performed to treat this deformity, they repair it with:
Coils
Glue
Microscopic plastic particles
Bipolar cautery
Laser
• Decompression of the trigeminal nerve—this procedure is performed to treat trigeminal neuralgia This is
severe pain in the face caused by compression of the trigeminal nerve (fifth cranial nerve)
• Transsphenoidal hypophysectomy—is performed to remove all or a part of the pituitary gland and the
tumor. These tumors are endocrine dependent malignant tumors. This procedure helps control the
hormones and therefore helps to slow the cancer cells
Transsphenoidal approach—this is the approach used for a transsphenoidal hypophysectomy. Incision is
made through the nose or through the upper gum line
They can also perform this procedure endoscopically
Performed for tumors of the pituitary gland that rests on the sellica turcica
To perform this procedure a neurosurgeon and otorhinolaryngologist work together
• Stereotactic procedures/stealth craniotomy—this procedure uses the technique of MRI and a CT-scan
with geometric coordinates (magnetic markers) to provide a three-dimensional picture of the brain;
specifically the target the tissue of concern
This procedure allows a small probe, needle, laser beam to be guided to the target tissue without
damaging other tissue
• Carpel tunnel syndrome—this is caused by compression of the median nerve by the carpel ligament in the
wrist. This causes pain, tingling, and numbness in the hand
The incision in on the palmer surface of the hand
The ligament is cut and the tendons are released
• Ulnar nerve transposition—this procedure is performed to move the ulnar nerve from behind the medial
epicondyle (inner side of the elbow) to a better position to prevent irritation and impingement on the
nerve
• Spinal nerves—the spinal nerves come in pairs and branch off to both sides of the body. They include:
7 pairs of cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal

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• Meninges—the vertebrae and the meninges protect the spinal cord
The dura mater, arachnoid mater and pia mater of the spinal cord are continuous with those of the brain
Cerebrospinal fluid is in the subarachnoid space
• Brain—consists of the:
Central nervous system
The rest of the body is the peripheral nervous system
• Vertebral disk
Atlas—first cervical vertebrae
Axis—second cervical vertebrae
Intervertebral disks—are a fibrocartilage joint that act as cushions in between the vertebrae. Examples
include: C3, T5, L4
Annulus fibrosis—this is the tough outer part of the disc
Nucleus pulpous—this is the soft gel-like substance in the center of the disk
Ligamentum flavum—elastic tissue that runs between the lamina
• Spina bifida—a birth defect caused by failure of the neural tube in the spine to close during embryonic
development.
• Meningocele—is a type of Spina bifida. A fluid-filled sac protrudes through an opening in the spine.
There is usually little or no nerve damage. This type of Spina Bifida can cause minor disabilities
• Myelomeningocele—a fluid-filled sac that contains the spinal cord and nerves protrude through the part of
the spinal cord these nerves and cord are damaged and causes disabilities from loss of feeling in the legs
and feet to not being paralyzed
• This is the most serious form of Spina bifida
• Benign spinal tumors—benign spine tumors include:
• Meningiomas
• Schwannomas
• Osteoblastomas
• Malignant tumor—include:
• Chondrosarcomas
• Ewing sarcomas
• Osteosarcomas
• Diagnostic tests include:
• MRI
Myelography/myelogram—x-ray of the spine with contrast media
• Disc disease—The central canal of the spine can become narrow and cause compression on the spinal cord.
If the pressure begins to cause symptoms, a decompression is performed by removing segments of bone at
the affected site. Prolonged pressure on the cord can cause permanent nerve damage
• Lumbar laminectomy and fusion
Lumbar laminectomy is a surgical procedure to relieve pressure on the spinal nerve. The back part of the

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 vertebra called the lamina is removed to relieve the spinal stenosis and take pressure off the spinal nerves
• Anterior cervical decompression and fusion—this procedure is performed to treat cervical disk herniation
or cervical spondylosis (degeneration of the spine)
The incision is made in the front of the neck where the herniated disk is removed
Following removal of the disc, a fusion is performed. Bone is taken from the iliac crest and placed above
and below the diseased disc for support
There are two preps one for the iliac crest and the other for the anterior cervical incision
• Artificial disk replacement—performed for degenerative disk disease/and spinal stenosis
The mechanical implant replaces the disk and restores movement to the spine
• Rhizotomy—surgical procedure where the spinal nerve roots are cut to relieve intractable pain providing
relief from chronic back pain and muscle spasms
• Cordotomy—this surgical procedure is performed for relief of spinal nerve pain due to terminal cancer or
other debilitating diseases. The nerve fibers on one or both sides of the spinal cord are cut to prevent nerve
impulses to travel to the brain
• Kyphoplasty—this is performed to repair an injured or collapsed vertebra this procedure restores the
original shape and position of the vertebra and relieves pain and restores height
A balloon instrument is inserted in between the injured vertebra to create a space and bone cement is
put in to repair the vertebra and restore height
• Scoliosis: is a deformity of the spine in which a person’s spine is curved from side to side
• Lordosis: the deformity is in the lower back, the spine curves inward
• Kyphosis: this deformity of the spine is in the upper back, hunch back
• Instrumentation includes:
Weitlaner
Osteotomes/oscillating saw used to remove the bone graft.
Cobb periosteal elevators
Penfield dissectors
Bipolar cautery
Kerrisons
Pituitary rongeur
Curettes
Nerve root retractors
• Thoracic outlet syndrome
Brachial plexus—is composed of nerves and arteries that pass between the clavicle and first rib. When
these structures become impinged it causes muscle tightness, irritation, and poor alignment—this is
termed thoracic outlet syndrome

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591
 Questions

1. Raney clips are:

(A) skin clips

(B) hemostatic clips
(C) aneurysm clips
(D) hemostatic scalp clips

2. Which of the following are tongs providing skeletal traction for cervical fracture/dislocation?

(A) Yasargil
(B) Cushing
(C) Gigli
(D) Crutchfield

3. A surgical procedure used most frequently to control intractable pain of terminal cancer is called a:

(A) sympathectomy
(B) neurectomy
(C) cordotomy
(D) thermocoagulation

4. Which operative procedure facilitates the draining of a subdural hematoma?

(A) Cranioplasty
(B) Hypophysectomy
(C) Craniosyntosis
(D) Burr holes

5. Hemostasis in neurosurgery is achieved by using Gelfoam saturated with saline solution or:

(A) heparin
(B) topical thrombin
(C) mannitol
(D) epinephrine

6. A tumor arising from the covering of the brain is a/an:

(A) hemangioblastoma

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 (B) angioma
(C) meningioma
(D) glioma

7. Which of the following is used to control bleeding beneath the skull and around the spinal cord?

(A) Webril
(B) Gauze sponges
(C) Cottonoid
(D) Kitners

8. A large, encapsulated collection of blood over one or both cerebral hemispheres that produces
intracranial pressure is known as a/an:

(A) epidural hematoma

(B) intracerebral hematoma
(C) subdural hematoma
(D) subarachnoid hematoma

9. A surgical procedure in which a nerve is freed from binding adhesion for relief of pain and restoration of
function is termed a:

(A) neurexeresis
(B) neurorrhaphy
(C) neurotomy
(D) neurolysis

10. Surgical creation of a lesion in the treatment of a disease such as Parkinson is called:

(A) cryosurgery
(B) diathermy
(C) rhizotomy
(D) pallidotomy

11. During neurosurgical procedures, venous stasis in the lower extremities and maintenance of blood
pressure may be aided by all of the following EXCEPT:

(A) Esmarch bandage wrapped groin to toe

(B) elastic bandages wrapped toe to groin
(C) sequential compression devices
(D) special tensor stockings (TED) stockings

12. Which of the following diseases CANNOT be treated by a sympathectomy?

(A) Intractable nerve pain

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 (B) Vascular extremity disorders
(C) Hyperhidrosis
(D) Neuroma

13. All of the following are used for hemostasis in a neurosurgical procedure EXCEPT:

(A) bone wax

(B) compressed cotton strips
(C) bipolar coagulation
(D) monopolar coagulation

14. Upon craniotomy closure, the bone flap is sutured on with:

(A) stainless steel suture

(B) silk
(C) absorbable suture
(D) nonabsorbable suture

15. Removal of an anterior cervical disc with accompanying spinal fusion is termed a:

(A) Schwartz procedure

(B) Cloward procedure
(C) Torkildsen operation
(D) stereotactic procedure

16. In laminectomy, herniated disc fragments are removed with a:

(A) bayonet
(B) Cloward punch
(C) Scoville
(D) pituitary rongeur

17. When using the perforator to create burr holes, heat is counteracted by:

(A) irrigating drill site as hole is drilled

(B) surrounding the area with cool lap pads
(C) dipping perforator in water
(D) working quickly, stopping often

18. A ventriculoperitoneal shunt treats:

(A) Parkinson disease

(B) hydrocephalus
(C) Meniere disease
(D) trigeminal neuralgia

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19. The advantage of using a Javid Shunt during a carotid endarterectomy is:

(A) continuous cerebral blood flow

(B) prevention of dislodging debris
(C) ease in securing patch to artery
(D) clearer view of surgical site

20. Neurosurgical sponges soaked in solution are placed within the reach of the surgeon and displayed on
a/an:

(A) inverted emesis basin

(B) dry sterile towel
(C) plastic drape
(D) Both A and C

21. All of the following statements are true about knee–chest positioning for laminectomy EXCEPT:

(A) decreased bleeding

(B) better exposure of laminae
(C) increased operating time
(D) increased ease of ventilation

22. What is the most common congenital lesion encountered, requiring neurosurgical intervention?

(A) Meningomyelocele
(B) AV malformation
(C) Aneurysm
(D) Neurofibromas

23. To effect hemostasis during a neurosurgical procedure, small pieces of Gelfoam are cut into several
different sizes and soaked in:

(A) saline
(B) Avitene
(C) topical thrombin
(D) hydrogen peroxide

24. What instrument is used to excise the laminae overlying the herniated disc during its removal in a
laminectomy procedure?

(A) Cloward
(B) Leksell
(C) Kerrison
(D) Beckman–Adson

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25. Malabsorption of cerebrospinal fluid (CSF) and resultant hydrocephalus are corrected by a
neurosurgical:

(A) VP shunt
(B) AV shunt
(C) VA shunt
(D) Both A and C

26. Neurosurgical procedures done for the purpose of locating and destroying target structures in the brain
are called:

(A) stereotactic
(B) cranioplasties
(C) craniosynostosis
(D) trigeminal rhizotomies

27. What is the incisional approach used to effect a transsphenoidal hypophysectomy?

(A) Middle of the upper gum

(B) Bifrontal approach
(C) Frontal approach
(D) Frontotemporal approach

28. Dorsal sympathectomy entails removal of which of the following chains of the sympathetic division of
the autonomic nervous system?

(A) Thoracolumbar
(B) Cervicothoracic
(C) Lumbar
(D) Cervical

29. Which of the following is used to control bleeding around the spinal cord?

(A) 4 × 4 s
(B) Thrombin
(C) Cottonoid
(D) Peanut

30. Which of the following meninges lies closest to the brain?

(A) Dura mater

(B) Pia mater
(C) Arachnoid
(D) Subarachnoid

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31. What cranial nerve is responsible for the sense of smell?

(A) I
(B) II
(C) III
(D) IV

32. Diagnostic test used to measure electrical activity of the brain is:

(A) electrocardiogram
(B) myelogram
(C) electromyography
(D) electroencephalogram

33. Imaging studies used to visualize the spinal cord are an MRI and _________.

(A) myelography
(B) electromyelography
(C) ultrasound
(D) discography

34. A fatal disease of the nervous system that is caused by a prion (infectious protein) which cannot be
destroyed by normal disinfection and sterilization is:

(A) Parkinson disease

(B) Creutzfeldt–Jakob disease
(C) Meniere disease
(D) hydrocephalus

35. Incomplete closure of the spine is:

(A) scoliosis
(B) intervertebral disc disease
(C) subdural hematoma
(D) spina bifida

36. A slow growing tumor of the vestibular branch of the eighth cranial nerve is:

(A) acoustic neuroma

(B) glioma
(C) seizure disorder
(D) meningioma

37. A type of malignant brain tumor is:

(A) meningioma

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 (B) glioma
(C) sacrococcygeal tumor
(D) teratoma

38. What medication is used to prevent increased intracranial pressure and reduce cerebral or spinal edema?

(A) Papaverine
(B) Lidocaine
(C) Mannitol
(D) Topical thrombin

39. There are _______ cervical vertebrae.

(A) 6
(B) 7
(C) 12
(D) 4

40. The system controlling the “fight or flight” response of the body is:

(A) sympathetic
(B) parasympathetic
(C) autonomic
(D) Both A and B

41. The most common site for a bone graft is:

(A) iliac crest

(B) femur
(C) vertebral spine
(D) acetabulum

42. When performing a ventriculoperitoneal shunt, the catheter is placed in the _______ and ________.

(A) lateral ventricle, peritoneal cavity

(B) epidural space, peritoneal cavity
(C) third ventricle, subcutaneous space
(D) third ventricle, peritoneal cavity

43. What self-retaining retractor is used to maintain traction of brain tissue?

(A) Craniotome
(B) Raney
(C) Gelpi
(D) Yasargil

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44. A gigli saw is used during a:

(A) laminectomy
(B) Cloward
(C) cordotomy
(D) craniotomy

45. The following are types of brain tumors EXCEPT:

(A) meningioma
(B) glioma
(C) ependymoma
(D) hematoma

46. During a craniotomy, a Penfield dissector or a Woodson dissector are used to release the _______ from
cranial bone.

(A) dura mater

(B) galia
(C) rami
(D) gyri

47. What type of bone is the cranium?

(A) Irregular
(B) Round
(C) Sesamoid
(D) Flat

48. During cranial surgery, the patient’s hair is:

(A) discarded
(B) sent to pathology
(C) saved with the patient’s chart
(D) there is no standard procedure

49. What is the congenital cranial deformity where the suture lines of the infant’s cranium fail to close?

(A) myelomeningocele
(B) craniosynostosis
(C) scoliosis
(D) anencephaly

50. What suture could be used for closure of the dura?

(A) Chromic

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 (B) Steel
(C) Nylon
(D) Silk

51. A brain tumor causing decreased muscle coordination and balance would be found in the:

(A) cerebellum
(B) Circle of Willis
(C) medulla oblongata
(D) fourth ventricle

52. What surgeon works alongside the neurosurgeon on a pituitary tumor using the transsphenoidal
approach?

(A) Ophthalmologist
(B) Cardiovascular
(C) Otorhinolaryngologist
(D) Endodontist

53. What is the area of the brain that controls respirations?

(A) Pituitary
(B) Cerebrum
(C) Circle of Willis
(D) Medulla oblongata

54. Cerebral aneurysms are commonly found in:

(A) choroid plexus

(B) Circle of Willis
(C) hypothalamus
(D) None of the above

55. The bones of the skull are connected by nonmoveable joints called:

(A) synarthrotic
(B) amphiarthrotic
(C) diarthrotic
(D) subarachnoid

56. The autonomic nervous system controls:

(A) breathing
(B) heartbeat
(C) fight or flight

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 (D) All of the above

57. The tough fibrous tissue that covers the pericranium is termed:

(A) dura mater

(B) pia mater
(C) galea
(D) arachnoid mater

58. The corpus callosum:

(A) divides the right and left half of the brain

(B) controls the right side of the body-left hemisphere
(C) controls the left side of the body-right hemisphere
(D) located in the medulla oblongata

59. Blood supply to the brain is provided by all EXCEPT:

(A) carotids
(B) vertebral arteries
(C) basilar arteries
(D) ventricles

60. Aqueduct of Sylvius connects:

(A) the third and fourth ventricle

(B) lateral ventricles
(C) choroid plexus
(D) cerebrum to the pons

61. Equipment for neurological procedures include all EXCEPT:

(A) Mayfield headrest

(B) CUSA
(C) Midas Rex
(D) Alvarado

62. The pituitary gland rests on the:

(A) third ventricle

(B) aqueduct of sylvis
(C) sellica turcica
(D) forebrain

63. The technique that uses geometric coordinates to provide a three-dimensional picture of the brain for
surgery is:

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 (A) stereotactic
(B) embolization
(C) myelography
(D) fusion

64. The first cervical vertebra is:

(A) atlas
(B) axis
(C) C1
(D) Both A and B

65. The surgical procedure where the spinal nerve roots are cut to relieve intractable pain is called:

(A) kyphoplasty
(B) cordotomy
(C) rhizotomy
(D) anterior cervical fusion

66. The procedure that uses a balloon instrument inserted in between injured vertebra to and infuses bone
cement to repair the vertebra and restore height is termed:

(A) rhizotomy
(B) laminectomy
(C) kyphoplasty
(D) None of the above

67. The instrument used for precise dissection, irrigation and aspiration of brain tumors is:

(A) Midas Rex

(B) craniotome
(C) perforator
(D) CUSA

68. A sponge used in brain surgery is a/an:

(A) Cottonoid patty

(B) Kitner
(C) impregnated gauze
(D) porcine

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 Answers and Explanations

1. (D) Hemostatic scalp clips include Michel, Raney, Adson, and LeRoy clips.

2. (D) Head and neck stabilization in a patient with a cervical fracture and/or dislocation is effected by use
of Vinke or Crutchfield tongs for skeletal traction.

3. (C) Cordotomy is division of the spinothalamic tract for the treatment of intractable pain.

4. (D) Burr holes are placed to remove a localized fluid collection beneath the dura mater in a subdural
hematoma.

5. (B) Gelfoam is supplied in powder and also a compressed sponge. The sponge form can be applied to an
oozing surface, dry or saturated, with saline solution or topical thrombin.

6. (C) Meningioma arises from the arachnoid space tissue, the middle covering of the brain. It is slow
growing and very vascular. Removal may be difficult.

7. (C) Cottonoid pledgets or strips or “patties” are used because they are gentler on the fragile tissue located
here. They are counted items.

8. (C) A subdural hematoma, one that occurs between the dura and the arachnoid, is usually caused by a
laceration of the veins that cross the subdural space.

9. (D) Neurolysis is the freeing of an adhered nerve to restore function and relieve pain. Carpal tunnel
syndrome is an example in which the median nerve is entrapped in the carpal tunnel of the wrist.

10. (A) Cryosurgery utilizes subfreezing temperatures to create a lesion in the treatment of disease, such as
Parkinson disease. This brain lesion destroys diseased cells of the brain and reduces the tremors
associated with the disease.

11. (A) Preoperatively, elastic bandages (toe to groin), TED, or sequential compression stockings may be
applied to help prevent venous stasis in lower extremities and also to help maintain blood pressure.

12. (D) Neuromas are frequently caused by retraction of nerve ends after trauma. The inability of
regenerating axons to bridge the gap between both divided ends because of scar tissue requires that part
of scar to be removed. This would not be accomplished by eliminating a neuropathway.

13. (D) Bipolar units are commonly used in neurosurgery. They provide a completely isolated output with

603
 negligible leakage of current between the tips of the forceps, permitting use of coagulation current in
proximity to structures where ordinary unipolar coagulation would be hazardous.

14. (A) In craniotomy the bone flap may be anchored with stainless steel suture.

15. (B) A Cloward procedure is done to relieve pain in the neck, shoulder, or arm caused by cervical
spondylosis or herniated disc. It involves removal of the disc with fusion of the vertebral bodies.

16. (D) Herniated disc fragments are removed in laminectomy with a pituitary rongeur.

17. (A) A great deal of heat is generated by the friction of the perforator against the bone. For this,
irrigation of the drilling site counteracts the heat and removes bone dust.

18. (B) In hydrocephalus, there is an increase in CSF in the cranial cavity caused by excessive production,
inadequate absorption, or obstruction of flow. The shunt procedures divert CSF from ventricles to other
body cavities from which it is absorbed.

19. (A) The Javid or Argyle shunt, commonly used in carotid endarterectomy has as its main advantage
continuous blood flow to the cerebrum during the surgery. It inhibits the surgeon’s view during the
surgery and during the repair.

20. (D) Neurosurgical sponges, thoroughly soaked with saline or Ringer’s lactate solution may be displayed
near the surgeon’s hand on an inverted basin, plastic drape, Vi-drape, or a small bowl. A dry towel
absorbs the solution before its use.

21. (C) All are advantages of the knee–chest position except the increase in operating room time. Knee–
chest actually reduces operating time.

22. (A) The most common congenital lesion encountered is a lumbar meningocele or meningomyelocele.
The fluid-filled, thin-walled sac often contains neural elements. Surgical correction is necessary when
the sac wall is so thin that there is a potential or actual CSF leak.

23. (C) Gelfoam will be cut into assorted sizes and soaked in topical thrombin for placement on the brain.

24. (C) The edges of the laminae overlapping the interspace with a herniated disc are defined with a curette.
A partial hemilaminectomy of these laminal edges extending out into the lateral gutter of the spinal
canal is performed with a Kerrison rongeur.

25. (D) Hydrocephalus is a pathologic condition in which there is an increase in the amount of CSF in the
cranial cavity because of inadequate absorption or obstruction through the ventricular system.
Ventriculoatrial (VA) shunts and ventriculoperitoneal (VP) shunts are used for absorption of excess
cerebrospinal fluid.

26. (A) The use of complex mechanisms to locate and destroy target structures in the brain is known as
stereotactics. Common target areas include obliterating tumors, aneurysms, abolishing movement

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 disorders, and alleviating pain.

27. (A) Bifrontal, frontal, and frontotemporal approaches are frequently used for removal or
craniopharyngiomas, optic gliomas, and other suprasellar and parasellar tumors. A transsphenoidal
hypophysectomy approaches the pituitary gland through the upper gum margin into the floor of the
sella tunica.

28. (B) Sympathetic denervation of the upper extremities and heart may be accomplished by cervicothoracic
sympathectomy (dorsal). The vasospastic phenomenon of Raynaud disease is relieved by this procedure.

29. (C) Cottonoids are small square felted sponges made of cotton or rayon. They are used to control
bleeding on neuro and vascular tissues.

30. (B) The meninges has three protective coverings. The outermost is the dura mater, the middle the
arachnoid mater, and the pia mater is closest to the brain.

31. (A) Cranial nerve I is the olfactory nerve and is responsible for the sense of smell.

32. (D) Electroencephalogram (EEG) is the diagnostic test used to measure the electrical activity of the
brain.

33. (A) Myelography uses contrast medium injected into the subarachnoid space of the cervical or lumbar
spine and plane x-rays are taken to produce images.

34. (B) Creutzfeldt–Jakob disease is a disease of the nervous system that is caused by a prion, which cannot
be destroyed by normal disinfection and sterilization. Recommendations include using disposable
instruments, which are isolated and incinerated upon disposal.

35. (D) An incomplete closure of the spine is spina bifida.

36. (A) A slow growing tumor of the vestibular branch of the eighth cranial nerve is an acoustic neuroma. It
is composed of Schwann cells. It is also known as a vestibular schwannoma.

37. (B) A glioma is a malignant tumor of the brain composed of glia cells.

38. (C) Mannitol acts on the kidneys to remove fluid from the tissues.

39. (B) There are seven cervical vertebrae.

40. (A) The sympathetic system controls thermoregulation, heart rate, peristalsis, and vascular constriction
or dilation.

41. (A) The iliac crest is the most common bone grafting donor site.

42. (A) The ventriculoperitoneal is placed through a burr hole into the lateral ventricle and the peritoneal
cavity.

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43. (D) A self-retaining retractor used to maintain traction of brain tissue is a Yasargil.

44. (D) During a craniotomy, burr holes are connected with a craniotome or a gigli saw.

45. (D) A hematoma is a collection of blood in the tissue.

46. (A) A Penfield dissector or a Woodson dissector are used to release the dura mater from the cranial
bone.

47. (D) The ribs, cranial bones, scapula and sternum are examples of flat bones.

48. (C) The patient’s hair is personal property and should be shaved and sent with the patient’s chart.

49. (C) Craniosynostosis is the congenital deformity where the suture lines of the infants’ cranium fail to
close. A myelomeningocele is a defect in the spine where the spinal cord and meninges protrude
through the spine. Scoliosis is a side to side curvature of the spine. Anencephaly is when a baby is born
without fully formed brains or the entire skull.

50. (D) Silk is used to close the dura. The salt solution in the chromic could damage brain tissue. Steel is
used to close the skull bones. Silk could cause a reaction in the dura so is not used.

51. (A) The cerebellum is responsible for balance and coordination. The Circle of Willis is the circular
connection of arteries that supply blood to the brain. The medulla oblongata is responsible for cardiac
and respiratory functions. The fourth ventricle is the cavity within the brain filled with CSF.

52. (C) When removing a pituitary tumor, an otorhinolaryngologist works with the neurosurgeon because a
transsphenoidal approach is used.

53. (D) The medulla oblongata is responsible for cardiac and respiratory function. The pituitary is an
endocrine gland that influences growth and development. The cerebrum is the largest part of the brain.
The Circle of Willis is the circular connection of arteries that supply blood to the brain.

54. (B) Cerebral aneurysms are commonly found at the Circle of Willis. Choroid plexus is where CSF is
produced. The hypothalamus is responsible for body temperature.

55. (A) The nonmoveable joints in the skull are connected by synarthrotic joints. Amphiarthrotic joints join
vertebra. Diarthrotic joints have free movement.

56. (D) The autonomic nervous system involves breathing, heartbeat and the fight-or-flight response.

57. (C) The tough fibrous tissue that covers the pericranium is termed galea. The dura mater is the layer of
the meninges which has direct contact with the skull. The pia mater is the closest layer of the meninges
to the brain. Arachnoid mater is the middle layer.

58. (A) The corpus callosum divides the right and left half of the brain. The left hemisphere controls the
right side of the body. The right hemisphere controls the left side of the body. The medulla oblongata

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 controls respiration and cardiac functions.

59. (D) The carotids, vertebral and basilar arteries all supply blood to the brain.

60. (A) The aqueduct of Sylvius connects the third and fourth ventricle. The lateral ventricles are the first
two ventricles. The choroid plexus produces CSF. The pons is responsible for horizontal eye movement
and face movement and the cerebrum is the largest part of the brain.

61. (D) The Alvarado is a knee holder. The others are equipment used during neurological procedures.

62. (C) The pituitary gland rests on the sellica turcica. The third ventricle is one of four chambers in the
brain containing CSF. The aqueduct of sylvis connects the third and fourth ventricle. The forebrain is
the largest part of the brain and contains the cerebrum.

63. (A) The stereotactic technique uses geometric coordinates that provide three-dimensional pictures of the
brain prior to treatment.

64. (A) The first cervical vertebra is the atlas. The axis is the second cervical vertebra.

65. (C) A rhizotomy is the surgical procedure where the roots of the spinal nerves are cut to relieve
intractable pain. A kyphoplasty is performed for a collapsed vertebra. A cordotomy is the procedure
performed for spinal pain from terminal cancer.

66. (C) A kyphoplasty is the procedure that uses a balloon instrument in between injured vertebra to infuse
bone cement to repair the vertebra and restore height. A rhizotomy is the procedure where the spinal
nerve roots are cut to relieve intractable pain. A laminectomy is a procedure to relieve pressure from a
nerve in the spine that is affected.

67. (D) The cavitron ultrasonic surgical aspirator (CUSA) is the instrument used for precise dissection,
irrigation and aspiration of brain tumors. The Midas Rex is a high-speed pneumatic drill. A craniotome
is a perforating drill used to drill the skull during a craniotomy. The perforator is the drill attachment
that is used to create burr holes.

68. (A) Cottonoid patties are compressed rayon or cotton sponges that are used moist on delicate such
structures as nerves, brain, and spinal cord.

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 ___________________CHAPTER 28___________________

Orthopedics

• The skeleton is divided into:

Axial skeleton—skull/ribcage/vertebrae
Appendicular skeleton—bones that make up the limbs
• Axial skeleton—the skull or cranium is connected by connective tissue called sutures
Skull bones—are the bones on the top of the head—flat bones
Cranial, facial bones—bones of the face—irregular bones, they include:
Facial bones include: nasal sinus, orbit of the eye, and jaw (mandible, zygoma)
• Spinal nerves—the spinal nerves come in pairs and branch off to both sides of the body. They include:
7 pairs of Cervical—true ribs—connected by costal cartilage anteriorly to the sternum and directly to the
vertebra posteriorly
8,9,10—false ribs—these ribs are connected to the sternum by the lowest true ribs, and directly to the
vertebra posteriorly
12 Thoracic—floating ribs—11, 12 ribs are not connected anteriorly, and to the vertebra posteriorly
5 Lumbar
5 Sacral
4 Coccygeal
• Sternum—forms anterior chest:
Manubrium
Body
Xiphoid
• Long bones
Humerus
Radius
Ulna
Femur
Tibia
Fibula
Giant cell tumor—this is a tumor of the epiphysis of long bones and commonly occurs between the age
of 20 and 40
Osteogenic sarcoma—this is a malignant tumor that occurs in long bones, it also metastasizes to the

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 lungs
• Epiphysis—the end of the long bone
• Diaphysis—the shaft of the long bone
• Short bones
Bones in the hand—carpels
Foot—tarsals
• Flat bones
Scalpel
Patella
Pelvic girdle
Sternum
• Irregular
Vertebrae
Cranial bones/facial
• Bone marrow—it is the innermost substance of bone and it is classified either red or yellow Bone marrow
is responsible for the formation of red blood cells and certain white cells
Plasma cell myeloma—this is a malignant bone tumor found in the plasma cells of bone marrow
• Ewing sarcoma tumor—bone tumor common to children, it can occur in the bone and soft tissue
• Cortical/compact bone—outer layer of bone, it is hard connective tissue
• Cancellous bone—middle layer is soft spongy bone
• Periosteum—a strong fibrous membrane that covers bone
• Bone healing—bone healing takes place in four steps, they include:
Hematoma formation
Blood collects at the break site
Phagocytosis (white blood cells destroy necrotic tissue)
• Callus formation
Fibrin and collagen form
• Calcification process
Calcification begins
• Remodeling phase
Bone begins to gain its normal structure
• Cartilage—it is a fibrous connective tissue at the articulating surface of joints and a smooth gliding surface
for joint movement
It does not have a direct blood supply, lymphatic supply, or vascular supply
Chondroma—this is a benign tumor of cartilage
• Muscles—cover bones and provide movement to the skeletal system. They are classified as:
Smooth—involuntary
Cardiac

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 Striated—voluntary
• Ligaments—attach bone to bone
Tendons—they attach muscle to bone
• Joints—joint articulation is where two bones come together
Joints have a membranous lining called the synovial membrane it secretes synovial fluid to lubricate the
joint
There are many different types of joints and they are classified according to structure and their ability to
move, they include:
Synarthrotic—immovable—examples include suture lines in the cranium
Amphiarthrotic—slightly moveable and are connected by cartilage—examples include pubis
symphysis, intervertebral joints
Diarthrotic—they have one or more range of motion and are lined with a synovial membrane. They
include:
Ball and socket joint—provides the widest range of motion
Example is the hip and shoulder joint
Condyloid joint—movement is in one plane with some lateral movement
Example is the temporomandibular joint
Gliding joint—they provide a side-to-side movement and a twisting movement
An example is the carpals of the wrist
Hinge joint—this joint has movement in one plane, like the hinge on a door
An example is the elbow
Pivot joint—the movement is rotational around an axis
The proximal end of the radius is an example of a pivot joint
Saddle joint—movement is in a variety of planes
• Arthralgia—joint pain
• Arthritis—joint inflammation
• Rheumatoid arthritis
Autoimmune disease—the body produces antibodies that fight against the body’s own natural antibodies
This disease mainly affects the synovium in the joint causing inflammation and joint stiffness and pain
An example is the thumb
• Abduction—moving a body part away from the midline
• Adduction—moving a body part toward the midline of the body
• Circumduction—moving a particular body part without moving the entire body part
• Rotation—moving a body part around a central axis
• Dorsiflexion—bending the foot upward at the ankle joint
• Plantar flexion—bending the foot downward at the ankle joint
• Eversion—turning the foot outward
• Inversion—turning the foot inward at the ankle joint so the sole of the foot is pointing inward

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• Flexion—bending a joint
• Extension—straightening a joint
• Pronation—pointing a body part downward, the palm of the hand downward
• Supination—pointing a body part upward
• Diagnostic testing includes:
Arthrogram—an x-ray of a joint after an injection of contrast medium
Electromyography—a recording of the electrical activity of muscle by using electrodes attached to the
skin or inserted into the muscle
MRI
CT scan
X-rays/fluoroscopy
Bone scans—a visual image of bone following an injection of contrast medium
• Fractures—a fracture is the medical term for a broken bone
Displaced fracture—the bone breaks into two or more parts and moves so that the two ends are not
lined up straight
Nondisplaced fracture—the bone brakes either part of the way or all of the way through, but maintains
its proper alignment
Closed fracture/simple fracture—this is when the bone breaks but it does not puncture through the skin
Open fracture/compound fracture—bone breaks and protrudes through the skin
Greenstick fracture—with this fracture one side of the bone is broken and the other side is bent. This
type of fracture occurs most often in children
Transverse fracture—a fracture at a right angle to the bone’s axis
Oblique fracture—a fracture in which the break has a curve, it breaks diagonally
Comminuted fracture—a fracture in which the bone breaks into several pieces
Impacted fracture/buckle fracture—at the point of the break the bones are one whose ends are jammed
into each other
Colles’ fracture—fracture of the distal radius
Pathologic fracture—this type of fracture caused by a disease that weakens the bones and causes them to
break
Avulsion fracture—avulsion fracture occurs when a tendon or ligament comes away from the bone and
can pull a small piece of bone with
Stellate fracture—the fracture occur at a central point on the bone and radiates outward from the
fracture site
• Subluxation—partial dislocation
• Dislocation—displacement of one particular surface from another
• Equipment includes:
Fracture table—are used to stabilize the patient and provide traction
Andrews table—used for spine surgery

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 Jackson table—provides skeletal traction
Alvarado foot holder for total joints
Shoulder attachments used for open procedures or arthroscopic procedures
Arthroscopic holder knee attachments
Pneumatic tourniquet—they provide a bloodless surgical field
• Traction can be used: preoperatively/intraoperatively/postoperatively
Various traction techniques include:
Skin—strips of tape
Straps
Elastic bandages—all are attached directly to skin
Manual—this is done by hand to pull on the bone being realigned
Skeletal—traction is applied directly to the bone using pins
Skeletal traction is often used with the fracture table using pins to reduce long bone fracture
• Casting is the most common for bone immobilization of a fractured bone. Casting material includes:
Plaster
Synthetic
Fiberglass
To apply a cast:
The limb is covered with Webril padding
Fill a bucket with room temperature water
Vertically hold the cast material until all the bubbles rise to the top
Examples of various casts include:
Walking cast
Hip Spica
Minerva jacket
Abduction pillows are used on hip cases to prevent the hip from dislocating, and rotating inward
• Complications of bone healing include:
Delayed union—delay in healing
Malunion—the fracture does not heal in its original position
Nonunion—the fracture does not heal and come together
• Osteoma—bone tumor
• Osteoarthritis—disease of the joint, the cartilage wears away causing bone friction
• Osteomyelitis—bone infection, staphylococci is the bacteria commonly associated with this disease
• Osteonecrosis/avascular necrosis—lack of blood supply to bone caused by infection or trauma
• Osteomalacia—metabolic bone disease that causes softening of bones
• Osteogenesis imperfect—genetic congenital condition of the connective tissue causing brittle bones that
easily fracture
• Osteoporosis—a disease caused by a lack of calcium it causes a loss of bone density, the bone becomes hard

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 and porous and easily fractures
• Compartment syndrome—after an injury, blood or edema accumulate in the area of the break and cause
increased pressure. The fascia cannot expand and pressure builds preventing blood flow to tissues in the
area. Severe tissue damage and tissue death can occur
• Positions
Lateral position
Prone position
Prone position is a challenge for anesthesia it is very important that positioning is performed properly
and the chest has room to expand with respirations, and to protect the endotracheal tube
Supine position—when the patient is positioned in supine it is important not to use the draw sheet and
tuck their arms under the mattress but under the patient’s body
• Bone cement—PMMA—polymethylmethacrylate
Used to secure an implant
Used on pathological fractures to fill in bone tumors, the cement is made into beads and they are placed
with bone graft material into the fracture
When mixing the cement it is attached to suction to remove the fumes because they are toxic to
mucous membranes and the liver
Bone cement is extremely toxic to pregnant women
• Problems with bone cement include:
Hypotension
Pulmonary embolus
Thrombophlebitis
Allergic reaction
• Lasers—CO36/Nd:YAG—used on arthroscopies/total joints/lumbar laminectomies
• Sutures
Surgical steel—bone to bone/sternum
Ethibond (polyester)—tendon to bone
Prolene (polypropylene)—tendon to bone
Nylon (neurolon)—tendon to bone
Chromic—periosteum
Vicryl (polyglactin)—periosteum
• Antibiotics are used for irrigation include:
Polymycin
Bacitracin
These antibiotics and irrigations can be administered by asepto syringe or a pulse lavage irrigation
system (pulsating irrigation)
• Steroids—dexamethasone (injected into the joint)
• Hemostatic agents include:

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 Bone wax
Gelfoam/Thrombin
Microfibullar
• Bone grafts are used to:
Fill cavities after removal of bone that will help to improve the stability of the bone
To fill bony defects
To promote healing of a bone fracture
• Bone grafts include:
Autograft—patient’s own bone commonly taken from the iliac crest
Allograft—bone from a tissue bank
Allograft bone is used when there is insufficient bone from the patient

Surgical Procedures

• Closed reduction—the surgeon manipulates the bone manually with his hands
Closed reduction may be attempted before an open reduction
Reduction may be performed under fluoroscopy
• Skeletal traction—this technique uses a pulling force directly applied to bone via a pin in the bone using
weights and pulleys
• Manual—this is done by the surgeons hand pulling on the bone being realigned
• External fixation includes:
Bone-anchoring devices
Threaded Steinmann pins
K-wires
Smooth rods/stabilizing bars

Internal Fixation Devices

• Treatment of choice for long bones and hip region include:

Compression plate and screw
Pins
Intramedullary rods, nails
Wiring
• Types of screws include:
Cortical—the threads run the entire length of the screw and cuts a path into the bone, they are also
blunt ended
Cancellous—threads run further apart, bone collects in threads to form a union, cancellous screws are
self-tapping
• Closed reduction—the fracture is reduced by manual manipulation and traction is applied with
percutaneous insertion of pins, nails, and or rods
• Open reduction and internal fixation (ORIF)—this is performed by open method at the fracture site and

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 repairing it with fixation devices
The fracture is reduced
Bone holder and fixation device placed
Screws inserted, the procedural steps include:
Drill
Measure
Tap
Place screw
• Acromioclavicular joint separation—this joint begins at the end of the collar bone (clavicle) and connects
to the acromion process of the shoulder blade (scapula)
The fracture is repaired with Steinmann pins and or screws
• Correction of a sternoclavicular dislocation—this joint is between the clavicle and sternum. This
dislocation is treated by manipulation, and manual traction
• Rotator cuff tear—this is a large tendon that is made up of four muscles that form a cuff over the head of
the humerus. The muscles include:
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Repair of this procedure includes:
Supine position/semi-sitting position
Minor tear repair can be performed with heavy nonabsorbable suture
Major tears are repaired with bone-anchoring devices and power equipment
• Recurrent anterior dislocation shoulder—the shoulder joint is a ball and socket joint that connects humeral
head with the shallow socket in the scapula called the glenoid cavity
A dislocation occurs when the humeral head comes completely out of the socket and stays out
A subluxation occurs when the humeral head comes partly out of the socket and then slips back in
The two common procedures performed on the shoulder include:
Bankart procedure
Putti-Platt
The anterior capsule is reattached to the rim of the glenoid fossa with heavy suture
Glenoid fossa rim is scrapped with curette or rasp to provide raw surface to attach capsule
Capsule may be attached by anchors
The shoulder is immobilized and padding is placed between the skin fractures of humeral shaft
• Fractures of the humeral head can be repaired with an intramedullary rod/compression plate/lag screw or
locking nail with distal screws. A bone graft may be needed
• Olecranon fracture—elbow fracture.
The elbow joint consists of the humerus in the upper arm and the radius and ulna in the forearm, it is a

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 hinge joint
The olecranon process is the bony prominence on the upper end of the ulna in the elbow
• Transposition of the ulna nerve—ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes
compressed or irritated
The most common place where the nerve gets compressed is behind the elbow
• Excision of the head of the radius—this is a severe comminuted fracture of the radial head. The radial
head is important for rotation of the forearm and elbow loss of motion is a complication of this surgery
• Ganglion cyst—a ganglion cyst is a swollen, closed fluid-filled sac under the skin. The sac may arise from
the sheath of a tendon or joint
The ganglion can be on your hand, wrist, foot, or other part of your body
• Fracture of the carpel bones—they are the small bones that make up the wrist, they connect the hand to
the forearm
Scaphoid bone is the most commonly fractured bone of the carpels
Fixation is performed with k-wires, and small compression screws, mini-fragment plates and screws
When performing surgery on the hand a tourniquet is used and Webril is placed below the tourniquet to
protect the skin
An Esmarch is used to exsanguinate the limb prior to surgery to create a bloodless field, the Esmarch is
wrapped distal to proximal
• Acetabulum—the acetabulum is the socket of the hipbone in which the head of the femur fits
• Pelvis—the pelvis is made up of:
The ilium
Ischium
Pubis,
Acetabulum

Hip Fractures

• Intertrochanteric fracture—this fracture occurs near the hip joint in the femur
Free-lock compression plate and lag screw are used for the repair
• Hemiarthroplasty is an operation that is used most commonly to treat a fractured femoral head. Also called
an Austin Moore prosthesis
The operation is similar to a total hip replacement, but it involves only half of the hip
The hemiarthroplasty replaces only the ball portion of the hip joint, not the socket portion. In a total
hip replacement, the socket is also replaced
The prosthesis is composed of a metal stem that fits into the hollow marrow space of the femur, it also
has a metal ball that fits into the acetabular socket
• Two types of prosthesis are used:
Unipolar
Unipolar—solid metal ball that replaces the femoral head along with the stem is one component
Bipolar

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 Bipolar—the bipolar implant has a femoral head that swivels and attaches to the stem.
• Instrumentation includes:
Rasp/Femoral Broach—used to ream the femoral canal
Acetabula Reamer
Hibbs retractor
Townley caliper—used to measure the femoral head
Acetabular trials/femoral trials
Acetabular powered reamers
Powered reamer driver/saws
Sagittal—side to side on the sagital plane
Reciprocating—front back motion/push, pull
Oscillating—the blade runs along the same axis as the handle and the motion is back and forth
When working with power equipment the STSR should irrigate the tip of the power equipment
being used to prevent heat damage from surrounding tissue throughout the procedure
Femoral neck elevator—used during femoral broaching
Bone hook—used to dislocate the hip
Cement Mixer
Cement Restrictor—this is inserted prior to placing the cement in the femoral canal for the implant
• Coxa valga—outward turning of the hip
• Coxa vara—inward turning of the hip joint
• Tibial plateau fracture—a tibial plateau fracture is a bone fracture in the proximal part of the tibia or
shinbone. A fracture here affects stability and motion of the knee
Repair of this fracture includes:
Intramedullary nails
Plates and screws
Buttress plate—this is a curved plate, fits over curved bones
Commonly used on tibial plateau fractures
• Patella—a broken kneecap occurs when the small round bone (patella) that sits over the front of your knee
joint breaks
The patella is a sesamoid bone
Repair of the patella consists of:
Wires and screws
• Ligaments—are tough bands of tissue that connect the ends of bones together
Stability of knee depends all four ligaments
There are two collateral ligaments—they provide side-to-side motion of the knee
Medial collateral ligament (MCL) is found on the side of the knee closest to the other knee
The lateral collateral ligament (LCL) is found on the opposite side of the knee
The anterior cruciate ligament (ACL) keeps the tibia from sliding too far forward

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 ACL tears are caused by pivoting or sidestepping movements and landing off-kilter
The posterior cruciate ligament (PCL) sits in front of the ACL. It prevents the tibia from sliding too far
back
PCL tears are caused by a direct hit to the front of the knee while the knee is bent
MCL/medial cruciate ligament—this is caused to a hit from the outside of the knee
LCL/lateral cruciate ligament—the tear is caused by a twisting
• Repairs are performed by replacing the torn ligament
The common ligament used for the repair is the patient’s own patellar tendon (autograft)
CPM/continuous passive motion machine—this provides continuous motion it straps to the post-
operative leg and electronically bends and straightens the leg to prevent joint stiffness
• Baker’s cyst—a baker’s cyst is a swelling caused by fluid from the knee-joint bulging to the back of the
knee in the popliteal fossa. They are caused by degenerative changes
Treatment includes:
Rest/ice-packs
Drainage
Cortisone injection
Ice packs
• Pott’s fracture/bimalleolar ankle fracture—the fracture occurs in the fibia near the ankle and in the medial
malleolus in the tibia
• Trimalleolar fracture—this is a fracture of the ankle that involves the lateral malleolus, medial malleolus,
and the distal posterior aspect of the tibia. This is a fracture of all three bones
This can be repaired with plates and screws
• Triple arthrodesis—arthrodesis is the medical term for fusion, and with this procedure it applies to fusing
of three joints:
Talocalcaneal
Talonavicular
Calcaneocuboid
The goal of a triple arthrodesis is to relieve pain from arthritic, congenital deformities, and unstable
joints
Congenital deformities include:
Clubfoot
Polio
• Bunionectomy—hallux valgus—this refers to the bump at the base of the big toe and the lateral deviation
of the big toe
Bunions are caused by a combination of uncomfortable shoes and heredity
Procedures performed to repair the bunion are called:
Keller
McBride

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 Exotosis (over growth of bone)—the surgeon removes the overgrowth of bone and realigns the big toe
K-wires/power wire driver/and microsaggital saw
• Hallux varus—big turns towards the midline
• Hammer toe—when a person has hammer toe, the end of their toe bends downward and the middle joint
curls up. Eventually, the toe gets stuck in a stiff, claw-like position
Hammer toe usually affects the second toe (the toe next to the big toe), but it can affect other toes too
• Talipes valgus—congenital deformity where the foot is turned inward and the person walks on the inside
of the foot
• Talipes varus—congenital deformity where the heel is turned inward, it is a type of clubfoot
• Metatarsal fracture—these bones are the long bones in the foot above the toes
Repair with K-wires, screws or plates
• Metatarsal resection—this is performed to replace head due to arthritis or injury
• Knee arthroscopy—minimally invasive procedure performed for:
Diagnostic
Removal of foreign bodies that can cause pain and obstruct movement
To perform a meniscal repair
• Meniscus—this is a fibrous cartilage between the joint of the knee
A meniscal tear is one of the most common knee injuries
Bucket handle tear—common meniscal tear
Joint mice—loose particles of bone and cartilage within the knee joint. These particles become
trapped and cause pain, irritation and limit movement
Instrumentation includes:
Ringer’s lactate or sterile normal saline is the medium used to inflate the knee
Arthroscope
Tubing
Trocar and cannula
Shaving/cutting instruments
Biopsy punch
Probes, hooks, scissors, knives
Patient position is supine with the knee positioned at a 90-degree angle
• Total knee replacement—this procedure is performed for a diseased knee joint. There are three
components to a total knee, they include:
Tricompartmental (most common) total knee replacement
Femoral component
Tibial component
Patellar component
• Partial knee replacement—this procedure resurfaces one or two bones of the knee
Unicompartmental includes one of the following components:

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 Medial unicondylar component
Lateral unicondylar component
Femoral-patellar component.
Bicompartmental knee replacement includes:

Replaces both medial and lateral surfaces of femur and tibia

• Genu valgum—the knees are closed in and the space at the ankles is further apart. Knock kneed
• Genu varum—bowlegged—the space between the knees is further apart and bows closer at the ankles.
Bow-legged
• Total shoulder—this is performed for severe pain and stiffness caused by arthritis or degenerative joint
disease
Position is beach chair
Implants include a ball and stem for the humeral component and a plastic socket
• Shoulder arthroscopy—this is performed for diagnosis, frozen shoulder, rotator cuff repair
Position—beach chair
Beach chair position is used
Glenohumeral joint is distended with saline
• Above the knee amputation/below the knee amputation is performed for:
Trauma
Diabetic patients
Vascular disease
Tumors
The goal of the procedure is to preserve as much movement to the limb as possible so they can use a
prosthesis
Amputated limbs are sent to the morgue

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 Questions

1. Seamless tubular cotton that stretches to fit a contour and is used for padding is called:

(A) Ace bandage

(B) Webril
(C) Sheet wadding
(D) stockinette

2. What is the proper wrapping procedure utilizing an Esmarch bandage?

(A) Start at the distal end of the extremity

(B) Start at the proximal end of the extremity
(C) Start after the cuff is inflated
(D) Start at the incision site

3. Baker’s cysts are found in the:

(A) popliteal fossa

(B) interdigital fossa
(C) intercarpal joints
(D) olecranon fossa

4. Benign outpouchings of synovium from intercarpal joints are called:

(A) ganglia
(B) exostosis
(C) polyps
(D) synovitis

5. Compression of the median nerve at the volar surface of the wrist is known as:

(A) Dupuytren’s contracture

(B) carpal tunnel syndrome
(C) ganglia
(D) Volkmann’s contracture

6. A fixation device that provides maximum holding and rigid fixation of a fracture by tightening bone
fragments together is called a/an:

621
 (A) compression plate and screws
(B) intramedullary nailing
(C) Ilizarov technique
(D) interlocking nail fixation

7. In a total hip replacement, which structure is reamed?

(A) Acetabulum
(B) Greater trochanter
(C) Lesser trochanter
(D) Femoral head

8. The ideal candidate for a noncemented total hip arthroplasty is:

(A) young and healthy person

(B) young with arthritis
(C) old and healthy
(D) old with osteoporotic bone disease

9. A total hip replacement would be indicated when the patient has:

(A) degenerative hip joint disease

(B) hip fracture
(C) congenital hip dislocation
(D) hip cancer

10. Joint reconstruction is known as:

(A) arthrodesis
(B) arthroplasty
(C) arthrotomy
(D) arthropexy

11. Osteogenesis or bone growth can be induced by:

(A) bone grafting, autogenous

(B) bone grafting, homogeneous
(C) hormone installation
(D) electrical stimulation

12. An infection in bone is termed:

(A) osteomalacia
(B) osteomyelitis
(C) osteitis

622
 (D) osteoporosis

13. A surgical procedure designed to stiffen or fuse a joint is called:

(A) arthropexy
(B) arthroplasty
(C) joint fixation
(D) arthrodesis

14. A lateral curvature of the spine is:

(A) kyphosis
(B) scoliosis
(C) lordosis
(D) orthosis

15. Harrington rods are used to treat:

(A) femoral fracture

(B) scoliosis
(C) talipes deformity
(D) congenital hip dislocation

16. The congenital deformity known as clubfoot is surgically referred to as:

(A) talipes valgus

(B) talipes varus
(C) hallux valgus
(D) exostosis

17. The most frequent site of cartilage tears in the knee joint are at the:

(A) collateral ligament

(B) cruciate ligament
(C) lateral meniscus
(D) medial meniscus

18. An abduction pillow would be used to:

(A) immobilize hip joints after hip surgery

(B) stabilize a femoral fracture
(C) immobilize the tibia post-surgery
(D) rotate the hips outward after hip reconstruction

19. A Free-Lock compression screw system is indicated for correction of a/an _______ fracture.

623
 (A) hip
(B) wrist
(C) elbow
(D) cervical

20. Decreased bone mass results in a condition called:

(A) osteoporosis
(B) osteomyelitis
(C) ossification
(D) ecchymosis

21. Place the stages of fracture healing in order: (1) hematoma formation, (2) remodeling, (3) fibrin network
formation, (4) callus formation, (5) invasion of osteoblasts.

(A) 1, 3, 5, 4, 2
(B) 1, 2, 5, 4, 3
(C) 1, 3, 2, 4, 5
(D) 5, 3, 4, 1, 2

22. An olecranon fracture occurs in the:

(A) wrist
(B) knee
(C) elbow
(D) finger

23. All of the following are considered good methods of maintaining strict asepsis within an orthopedic
surgical suite EXCEPT:

(A) ultraviolet light

(B) laminar flow rooms
(C) charcoal masks
(D) space suits

24. Water temperature for plaster cast application is:

(A) 50–55°F
(B) 70–75°F
(C) 85–90°F
(D) 95–100°F

25. Orthopedic surgery prepping:

(A) is done under sterile conditions

624
 (B) is done the day before surgery
(C) is eliminated
(D) is increased in time only

26. Limb exsanguination is accomplished by using:

(A) limb elevation

(B) tourniquet application
(C) Kling bandage
(D) Esmarch bandage

27. In orthopedic surgery, the viewing of the progression of a procedure on a television screen is known as:

(A) image intensification

(B) radiography
(C) portable filming
(D) x-ray

28. Surgery on the medial malleolus would be of the:

(A) fibula
(B) jaw
(C) tibia
(D) radius

29. Plaster is ready for application:

(A) when air bubbles cease to rise

(B) when air bubbles begin to rise
(C) after 2 minutes of submersion
(D) after 10 minutes of submersion

30. Which fracture most commonly occurs in childhood?

(A) Spiral
(B) Compound
(C) Greenstick
(D) Comminuted

31. Which orthopedic hip procedure is indicated for patients with degenerative joint disease or rheumatoid
arthritis?

(A) AO external fixation

(B) Total hip arthroplasty
(C) Femoral endoprosthesis

625
 (D) Modular endoprosthesis

32. What skeletal traction requires the use of sterile supplies for application of a traction appliance?

(A) Thomas splint

(B) Russell
(C) Crutchfield
(D) Buck’s extension

33. An infectious musculoskeletal condition affecting the bone and marrow is:

(A) osteomalacia
(B) osteoporosis
(C) osteomyelitis
(D) Paget’s disease

34. An immobilization device used after total hip arthroplasty is:

(A) adduction pillow

(B) abduction pillow
(C) sling
(D) splint

35. Electrical stimulation is artificially-applied postoperative electrical current that influences:

(A) osteomalacia
(B) osteogenesis
(C) osteoporosis
(D) osteoarthritis

36. All of the following are indications for external fixation EXCEPT:

(A) infected joints

(B) clean long-bone fractures
(C) highly comminuted closed fractures
(D) major alignment and length deficits

37. A procedure done to correct recurrent anterior dislocation of the shoulder that involves reattachment of
the rim of the glenoid fossa is called a:

(A) Bankart
(B) Putti–Platt
(C) Bristow
(D) Monteggia

38. The most commonly fractured carpal bone is the:

626
 (A) scaphoid
(B) lunate
(C) trapezium
(D) capitate

39. Compression force of the distal femur upon the tibia produces varying types of fractures of the:

(A) patella
(B) tibial plateau
(C) femoral condyle
(D) head of the femur

40. Surgery that requires incision of the long extensor tendon of the interphalangeal joint of the four lateral
toes and subsequent fusion is called:

(A) exostectomy
(B) Keller procedure
(C) hammer toe correction
(D) McBride procedure

41. The rare use of laser during orthopedic surgery may be seen in the use of the CO2 laser during a revision
arthroplasty to:

(A) remove a cemented implant

(B) vaporize protein
(C) weld tissue for collagen bonding
(D) create hemostasis

42. After surgery on a shoulder, the arm may be bound against the side of the arm for:

(A) comfort
(B) abduction
(C) immobilization
(D) mobilization

43. The most commonly used implants in hand surgery are made of flexible:

(A) polypropylene
(B) Silastic
(C) tantellum
(D) polyethylene

44. Before the insertion of cement into the femoral medullary canal during a total hip arthroplasty, which of
the following is placed with an inserter to occlude the femoral medullary canal?

627
 (A) Polyethylene insert
(B) Cement restrictor
(C) Broach
(D) Distal centralizer

45. Femoral prostheses such as Austin Moore and Thompson are used to correct all of the following
diagnoses EXCEPT:

(A) avascular necrosis

(B) nonunion fractures
(C) displaced femoral neck fractures
(D) rheumatoid arthritis

46. Orthopedic implants are covered by all of the following rules EXCEPT:

(A) different metals should not be mixed because they may react chemically
(B) If the implant is driven by force, a driver with a metal head must be used
(C) a template must be used for sizing purposes
(D) handle as little as possible before insertion

47. Galvanic corrosion is a process that occurs postoperatively because of:

(A) poor handling of device during implant

(B) mixed use of metals for implant
(C) misplacement of implant
(D) damage of an implanted device

48. Bunionectomy is also known as:

(A) metacarpal arthroplasty

(B) hallux valgus
(C) triple arthrodesis
(D) hammer toe

49. A Colles’ fracture is a fracture of:

(A) distal radius

(B) femur
(C) patella
(D) fibula

50. The Keller and McBride procedures are types of:

(A) bunionectomy procedures

(B) shoulder repairs

628
 (C) ankle repairs
(D) patellectomy procedure

51. The three phases of bone healing in order are:

(1) remodeling
(2) inflammatory phase
(3) reparative phase

(A) 1, 2, 3
(B) 2, 1, 3
(C) 2, 3, 1
(D) 3, 1, 2

52. The patella is what type of bone?

(A) Flat
(B) Short
(C) Sesamoid
(D) Round

53. Polymethylmethacrylate (PMMA) is a type of bone cement most commonly used in what procedure?

(A) Arthroplasty procedures

(B) Kellar procedures
(C) ACL repair
(D) Triple arthrodesis

54. The proper position for the patient undergoing arthroscopic knee surgery is:

(A) skeletal traction on fracture table

(B) lateral position, foot of table flexed at 45 degrees
(C) the Alvarado knee holder
(D) supine position, foot of table flexed at 90 degrees

55. Orthopedic saws are identified by the movement of the blade. Which saw blade is mounted along the
same axis as the handle and moves back and forth?

(A) Sagittal
(B) Reciprocating
(C) Oscillating
(D) Rotating

56. An orthopedic screw is the most commonly used type of orthopedic implant. All are orthopedic screws
EXCEPT:

629
 (A) cancellous
(B) lag
(C) self-tapping
(D) depth screw

57. The three main components of a knee arthroplasty are:

(1) femoral
(2) acetabular
(3) tibial base plate
(4) patella component

(A) 1, 3, 4
(B) 1, 2, 3
(C) 2, 3, 4
(D) 4, 2, 1

58. Which graft / grafts are used to replace the anterior cruciate ligament during an ACL repair?

(A) Patella tendon

(B) Cadaver
(C) Hamstring or quadriceps
(D) All of the above

59. A Putti–Platt is used to correct:

(A) ankle
(B) wrist
(C) patella
(D) shoulder

60. What connects bone to bone?

(A) Ligament
(B) Tendon
(C) Muscle
(D) Bursa

61. The shaft of the long bone is _______ and the end of the long bone is _______.

(A) diaphysis/epiphysis
(B) epiphysis/diaphysis
(C) symphysis/diaphysis
(D) symphysis/epiphysis

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62. A fracture that consists of multiple bone fragments is:

(A) comminuted
(B) greenstick
(C) spiral
(D) impacted

63. Bone healing is termed:

(A) osteoporosis
(B) osteoplasty
(C) osteogenesis
(D) osteomalacia

64. A hemostatic agent used on bone is:

(A) heparin
(B) bone wax
(C) lidocaine
(D) Cottonoid

65. A pneumatic tourniquet is placed:

(A) as soon as the patient enters the OR

(B) directly after the patient is prepped and draped
(C) before the patient is prepped and draped
(D) as soon as anesthesia says it is okay

66. Equipment needed to repair a femoral neck fracture using a compression screw and sliding plate includes
all of the following EXCEPT:

(A) fracture table

(B) C-arm (fluro)
(C) K wires
(D) pneumatic tourniquet

67. A pressurized solution of antibiotics or saline, commonly used for wound debridement and irrigation is
called:

(A) pulse lavage system

(B) ancillary system
(C) inactive irrigation system
(D) topical irrigation system

68. A traction that requires surgical insertion of metal rods or pins through bone, and are attached to a

631
 traction device that applies force or is attached to a weighted pulley is known as:

(A) skin traction

(B) applied traction
(C) manual traction
(D) skeletal traction

69. During a procedure involving a power saw in use, the surgical technician in the scrub role should:

(A) clean the blade

(B) lightly apply irrigation to the blade in use
(C) suction bone debris
(D) do nothing

70. The condition where fibrous bands cause contractures in the fingers, commonly the ring finger and the
little finger is:

(A) compartment syndrome

(B) Dupuytrens
(C) exostosis
(D) ganglion

71. The condition that involves the proximal interphalangeal (PIP) joint of the foot is called:

(A) bunion
(B) Dupuytrens
(C) hammer toe
(D) hallux valgus

72. The surgical repair of a torn tendon is:

(A) triple arthrodesis

(B) percutaneous tendonectomy
(C) tendonitis
(D) tenorrhaphy

73. The tendon involved causing the inability to plantar flex the foot is:

(A) Achilles
(B) lateral metatarsal
(C) capsular tendon
(D) digitorum tendon

74. The position of Mrs. Smedley on the OR table is:

(A) lateral

632
 (B) supine
(C) prone
(D) semi-Fowlers

75. The responsibility of the STSR when applying the case is to keep the foot in a plantar flexed position
(toes downward) in order to:

(A) keep good blood supply to the foot

(B) keep the muscle hyperextended
(C) keep stress off the new suture line
(D) this allows the local to penetrate the surgical site

76. A stellate fracture is:

(A) bone breaks in a central pint and radiates outward, like a cracked mirror
(B) the fracture curves around the bone due to twisting motion
(C) a bone fracture where the bone remains attached by a ligament
(D) the bone is driven inward

77. Dorsal flexion is where the foot is _______and plantar flexion is where the foot is turned ________.

(A) upward/downward
(B) downward/upward
(C) inward/outward
(D) outward, inward

78. When the joint is freely movable and is lined with a synovial membrane, it is termed:

(A) amphiarthrosis
(B) diarthrosis
(C) synarthrosis
(D) none of the above

79. All apply to compartment syndrome except:

(A) the wound is closed following an I&D with a pulse lavage system
(B) an incision is made and the wound is left open until swelling is reduced
(C) commonly occurs in the arm or leg
(D) the tough walls of fascia cannot easily expand and compartment pressure, preventing adequate
blood flow to tissues inside the compartment

80. When the calcaneocuboid, talonavicular, and talocalcaneal bones are fused together, the procedure to
correct this is:

(A) McBride

633
 (B) arthroscopy
(C) triple arthrosis
(D) arthroplasty

81. Subluxation is:

(A) complete fracture

(B) incomplete dislocation
(C) malunion fracture
(D) nonunion fracture

82. The procedure performed for rotator cuff tear is:

(A) Keller
(B) acromioplasty
(C) arthroscopy
(D) ORIF

83. All pertain to intertrochanteric fracture EXCEPT:

(A) occurs on the femur

(B) occurs at the lesser trochanter
(C) repaired with a dynamic hip screw
(D) occurs at the acetabular head

84. The bones of the palm of the hand are referred to as:

(A) phalanges
(B) carpals
(C) metacarpals
(D) calcaneus

85. The gastrocnemius is the chief muscle of the:

(A) calf of the leg

(B) stomach
(C) stomach’s greater curvature
(D) thigh

86. A connective tissue band that holds bones together is called:

(A) cartilage
(B) tendon
(C) joint
(D) ligament

634
87. The medial bone of the forearm, which is located on the small-finger side of the hand, is called the:

(A) ulna
(B) radius
(C) humerus
(D) fibula

88. The bone located in the neck between the mandible and the larynx, which supports the tongue and
provides attachment for some of its muscles, is the:

(A) palatine bone

(B) vomer
(C) pterygoid hamulus
(D) hyoid bone

89. The adult vertebral column has:

(A) 33 bones
(B) 28 bones
(C) 26 bones
(D) 32 bones

90. How many cervical vertebrae are there?

(A) 7
(B) 12
(C) 5
(D) 4

91. The bone in the axial skeleton that does not articulate with any other bone is the:

(A) sternum
(B) trochlea
(C) talus
(D) hyoid

92. A slender, rod-like bone that is located at the base of the neck and runs horizontally is the:

(A) scapula
(B) shoulder blade
(C) clavicle
(D) sternum

93. The upper, flaring portion of hipbone is the:

(A) ischium

635
 (B) pubis
(C) ilium
(D) femoral head

94. The larger, weight-bearing bone of the lower leg is the:

(A) humerus
(B) talus
(C) fibula
(D) tibia

95. The bone that fits into the acetabulum, forming a joint, is the:

(A) tibia
(B) femur
(C) fibula
(D) patella

96. Another name for the kneecap is:

(A) patella
(B) tibia
(C) fibula
(D) phalange

97. The longest bone in the body is the:

(A) femur
(B) fibula
(C) tibia
(D) humerus

98. A rounded protuberance found at a point of articulation with another bone is called a:

(A) trochanter
(B) trochlea
(C) tubercle
(D) condyle

99. An infection of the bone is:

(A) osteoarthritis
(B) osteomyelitis
(C) osteoporosis
(D) osteomalacia

636
100. Oil glands of the skin are called:

(A) sudoriferous
(B) ceruminous
(C) sebaceous
(D) hypochlorous

101. What is the most commonly used donor tendon for a free flexor tendon graft?

(A) Palmaris longus

(B) Plantaris tendon
(C) Abductor pollicis longus
(D) Both A and B

637
 Answers and Explanations

1. (D) Stockinette is a knitted, seamless tubing of cotton 1–12 in wide. It stretches to fit any contour
snugly.

2. (A) Wrapping of an extremity begins at the distal end.

3. (A) Baker’s cysts are found in the popliteal fossa. They are frequently painful and can become large.
Excision requires prone position.

4. (A) Ganglia are benign outpouchings of synovium from the intercarpal joints that become filled with
synovial fluid. They often resolve spontaneously but occasionally must be excised.

5. (B) In carpal tunnel syndrome, the median nerve becomes compressed at the volar surface of the wrist
because of thickened synovium, fractures, or aberrant muscles.

6. (A) Rigid fixation by compression plate and screws uses heavy and strong compression plates to give
maximum hold and rigid fixation. Tightening the nut on compression instruments brings bone
fragments together.

7. (A) The femoral head is removed and replaced with a prosthesis. The acetabulum is reamed to the
configuration of the acetabulum component, which is then fixed in the socket.

8. (A) Young active individuals with strong healthy bones are ideal candidates for noncemented total hip
replacement. Elderly patients with osteoporotic and those patients with poor quality bone are usually
candidates for cement because their bones may lack the compressive strength to support weight-bearing
forces.

9. (A) Total hip replacement is indicated for patients with hip pain caused by degenerative joint diseases or
rheumatoid arthritis.

10. (B) Reconstruction of a joint (arthroplasty) may be necessary to restore or improve range of motion and
stability or to relieve pain.

11. (D) Electrical stimulation is artificially-applied electrical current that induces or influences osteogenesis.
This accelerates fracture healing. Bone growth stimulations also are used in treating infected nonunions
because the electrical stimulation retards bacterial growth.

12. (B) Osteomyelitis or an infection in bone occurs after bone is injured in an accident or is involved in

638
 surgical repair. It may cause nonunion of fractures. Microorganisms reach the bone via the bloodstream.
Staphylococcus aureus is commonly the causative agent.

13. (D) Arthrodesis is most commonly employed to relieve pain by eliminating motion, to provide stability
where normal ligament stability has been destroyed, or to correct deformity by realignment at the level
of fusion.

14. (B) Scoliosis is a lateral curve and rotation of the spine.

15. (B) Harrington rods are used with spinal fusion to treat scoliosis.

16. (B) Talipes varus, the condition known as clubfoot, refers to the inversion of the forefoot.

17. (D) Tears in the menisci (semilunar cartilage) are the most common knee injuries occurring most
frequently in the medial meniscus.

18. (A) An abduction pillow aids in immobilizing hip joints after surgery.

19. (A) Internal fixation of a hip can be accomplished with a free-lock compression hip screw fixation
system allowing earlier ambulation and thus fewer complications.

20. (A) Osteoporosis is an age-related disorder characterized by increased susceptibility to fractures as a

result of decreased levels of estrogen.

21. (A) The bone healing process begins with hematoma formation, fibrin network formation, invasion of
osteoblasts, callous formation, and remodeling.

22. (C) An olecranon fracture occurs in the elbow.

23. (C) Charcoal masks when used in the OR restrict inhaling vaporized particles of viruses such as venereal
warts. All of the others are varying degrees of specialized units that address the principle of “strict
surgical asepsis” for orthopedic surgery.

24. (B) Water cast application is at room temperature: 70–75°F.

25. (A) A primary concern in orthopedic surgery is the prevention of infection, thus calling for meticulous
technique with the operative scrub, carried out under sterile conditions.

26. (D) An Esmarch rubber bandage is used to exsanguinate the limb; the tourniquet is then inflated.

27. (A) During orthopedic surgery, the mobile image intensification, also referred to as fluoroscopy or x-ray
image, allows viewing of the case progression.

28. (C) Ankle fractures include fracture of the medial malleolus (tibia), lateral malleolus (fibula), and
posterior malleolus (posterior distal fibia).

29. (A) When preparing plaster rolls or splints, they are submerged in room temperature water (70–75°F).

639
 Water above this temperature will speed up the process and make the cast application ineffective. When
bubbles cease to rise to the surface, the rolls are removed, lightly compressed, and used.

30. (C) An incomplete fracture, only partly through the bone, is commonly found in children whose bones
have not yet calcified. This is a greenstick fracture.

31. (B) The hip procedure indicated for degenerative joint disease or rheumatoid arthritis is total hip
arthroplasty, cemented, or noncemented. All of the others are femoral head components used to treat
fractures that have not achieved union in a conventional manner.

32. (C) Some cervical spine fractures or injuries may require Crutchfield or Gardner–Wells tongs inserted
into the skull to stabilize the vertebrae and reduce spinal cord damage. Application of traction requires
the use of sterile supplies, including a bow, pins, and drill.

33. (C) An infectious musculoskeletal condition affecting the bone and the marrow is osteomyelitis. This
infection may develop from bloodborne pathogens deposited at the site. The infection develops as
pathogenic organisms become trapped in small arteries in the metaphyseal area.

34. (B) Splints and slings are both immobilization devices used in orthopedics. The device used after total
joint replacement is the abduction pillow. This prevents adduction, internal rotation, and hip flexion,
which could dislocate the hip.

35. (B) Three types of stimulators that induce osteogenesis are implantable, percutaneous, and capacitance
coupling.

36. (A) This method of fracture management provides rigid fixation and reduction with the ability to
manage severe soft tissue wounds.

37. (A) A Bankart procedure involves reattachment of the anterior capsule to the rim of the glenoid fossa. A
Putti–Platt is similar; in addition, it requires the lateral advancement of the subscapularis and produces
a barrier against dislocation of the shoulder.

38. (A) The scaphoid is the most commonly fractured carpal bone. Internal fixation is generally
accomplished with Kirschner wires, small compression screws, or minifragment compression plates and
screws.

39. (B) Tibial plateau fractures have historically been attributed to bumper or fender injuries. Compression
force of the distal femur upon the tibia produces varying types of plateau fractures.

40. (C) A hammer toe flexion deformity develops at the proximal interphalangeal joint of the four lateral
toes. It is treated by incising the long extensor tendon and fusing the middle joint.

41. (A) Although not used as commonly as in other surgical specialties, lasers are used in some orthopedic
procedures. Methylmethacrylate can be vaporized with a carbon dioxide laser to remove a cemented
implant. Nd:YAG laser can be used in arthroscopy to vaporize protein as well as to weld tissue by

640
 bonding collagen.

42. (C) After a shoulder procedure, the arm may be bound against the side for immobilization. An
absorbent pad or a large piece of cotton or sheet wadding is placed under the arm to keep skin surfaces
from touching because they may macerate.

43. (B) The most commonly used implants in hand surgery are flexible implants made of Silastic. They are
available for arthroplasty within the scope of hand surgery, such as finger joints, wrist joints, carpal
trapezium, lunate, and navicular.

44. (B) After reaming of the femoral canal has been accomplished, a trial component is fitted. After removal
of the trial, the canal is lavaged and brushed to accommodate the femoral component. A cement
restrictor is inserted into the femoral canal. The cement is injected, and the femoral component with
proximal and distal centralizers is inserted.

45. (D) These implants are a single unit including stem and head, which require limited rasping and canal
preparation. Currently, this is the accepted treatment for nonunion fractures, avascular necrosis,
rheumatoid arthritis, and osteoarthritis. Total hip replacement is generally indicated for patients with
degenerative joint disease or rheumatoid arthritis.

46. (B) Metal implants are extremely expensive. Once an implant has been scratched, it cannot be used. All
personnel should follow these rules: store separately, handle as little as possible, use a driver with a
Teflon head to drive the implant, do not bend, and use a template for sizing purposes.

47. (B) Many different alloys are used in the manufacture of implants. However, the implantation of devices
with different metallic composition must be avoided to prevent galvanic corrosion; internal fixation
devices used during an orthopedic procedure should be of the same metal.

48. (B) A bunionectomy is an enlarged metatarsal head, hallux valgus. It is reduced or removed. The goal of
this surgery is to alleviate pain and increase mobility.

49. (A) A Colles’ fracture is an angulated fracture of the distal radius.

50. (A) Keller and McBride are variations of bunionectomy procedures.

51. (C) The three phases of bone healing in order are inflammatory, reparative, and remodeling.

52. (C) Patella is a type of sesamoid bone. They are irregularly shaped bones.

53. (A) Implants used in arthroplasties (joint replacement) may be cemented in place with PMMA.

54. (D) The patient is placed in supine position and the foot of the table may be flexed at 90 degrees.

55. (C) The oscillating blade is mounted along the same axis as the handle and moves back and forth.

56. (D) Orthopedic screws come in different sizes, shapes, and designs. They are made of titanium, stainless

641
 steel or bio absorbable material. They include cancellous, cortical, lag, Herbert, locking, cannulated, and
self-tapping.

57. (A) The three components are the metal femoral component inserted over the distal femur, tibial base
plate placed over the proximal tibia, and a polyethylene patellar component.

58. (D) A graft can be taken from the central portion of the patellar tendon, hamstring or quad, or using a
cadaver graft.

59. (D) The Putti–Platt procedure is used to correct a recurrent anterior dislocation of the shoulder.

60. (A) A ligament is a band of fibrous connective tissue connecting to the articular ends of bones and
serving to bind bones together.

61. (A) Each long bone has a geographic landmark. The shaft of the long bone is the diaphysis and the end
of the long bone is the epiphysis.

62. (A) This type of fracture consists of multiple bone fragments and fractured bone. It also may require
repair of both soft tissue and bone

63. (C) Osteogenesis is bone healing.

64. (B) During surgery, a waxy preparation called bone wax is pressed into the bleeding area of bone to
control bleeding.

65. (C) The tourniquet cuff is placed proximal to the surgical site before the patient is prepped and draped.

66. (D) A pneumatic tourniquet is used on extremity surgery. A fracture table is used to reduce the fracture.
Fluro is used to view the fracture and K wires are used to stabilize a fracture.

67. (A) The pulse lavage system uses antibiotic solution or saline solution to apply a pulsed stream of
pressurized solution to the wound for debridement and irrigation.

68. (D) Metal rods or pins through the bone is skeletal traction.

69. (B) Power instruments generate heat due to friction of saw on bone. To prevent surrounding tissue
injury, the STSR should irrigate the tip of the blade with an asepto syringe and sterile saline (with
surgeon’s approval).

70. (B) Dupuytrens contracture is when fibrous bands cause contractions in the fingers usually the ring
finger and little finger. They are seldom painful; however, they cause restriction of extension but not
flexion because it does not involve the flexor tendon.

71. (C) A hammer toe is when the toe has contracted at the proximal interphalangeal joint caused by severe
pressure and pain. Ligaments and tendons tighten and cause the toes joint to curl down.

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72. (D) Tenorrhaphy is the surgical repair of a tendon.

73. (A) Achilles tendon rupture presents with the inability to plantar flex the foot.

74. (B) The patient is placed in supine position with the affected leg supported by a soft support or sandbag.

75. (C) The responsibility of the STSR is to keep the foot plantar flexed and keep stress off the new suture
line.

76. (A) A stellate fracture is a bone that breaks in a central point and radiates outward like a shattered
mirror. Fractures caused by a twisting motion is a spiral fracture. A bone fracture where the bone
remains attached by a ligament is an avulsion. A cranial fracture is when the bone is driven inward.

77. (A) Dorsal flexion is an upward motion of the foot and plantar flexion is where the foot is turned
downward.

78. (B) Joints that are freely movable and have one or more range of motion positions and lined with a
synovial membrane are diarthrosis. Amphiarthrosis is a slightly movable joint and synarthrosis is an
immovable joint.

79. (A) Compartment syndrome incisions are never closed. All others pertain to compartment syndrome.

80. (C) A triple arthrodesis is done when the calcaneocuboid, talonavicular and talocalcaneal bones are fused
together. McBride procedure relates to podiatry. Arthroscopy is a scoping of an area. Arthroplasty is a
total joint repair. . All others pertain to the shoulder.

81. (B) Subluxation is an incomplete dislocation.

82. (B) Acromioplasty is performed for a rotator cuff repair.

83. (D) The acetabular head does not pertain to the intertrochanteric fracture. This involves only the femur,
lesser trochanter and can be repaired with a dynamic screw.

84. (C) The metacarpal bones form the palm of the hand. There are five on each side. The heads of the
metacarpal are commonly called the knuckles.

85. (A) The gastrocnemius is the chief muscle of the calf of the leg. It is a large muscle on the posterior part
of the leg. It extends the foot and helps to flex the knee upon the thigh.

86. (D) A ligament is a band or sheet of strong fibrous tissue connecting the articular ends of bones. It
serves to bind them together and facilitate or limit motion. It is a cord-like structure.

87. (A) The forearm is the ulna. It is on the same side as the little finger. On the proximal end is the
olecranon process, which forms the prominence of the elbow.

88. (D) The hyoid bone is located in the neck between the mandible and the larynx. It supports the tongue

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 and provides an attachment for its muscles. It does not articulate with any other bone.

89. (C) In an infant there are 33 separate bones in the vertebral column. Five of these bones eventually fuse
to form the sacrum, and four others join to become the coccyx. As a result, an adult vertebral column
has 26 parts.

90. (A) There are seven cervical vertebrae in the neck, twelve thoracic vertebrae, and five lumbar vertebrae
(lower back).

91. (D) The single hyoid bone does not articulate with any other bone. It supports the tongue providing
attachment sites for muscles of the tongue, neck and pharynx.

92. (C) The clavicles are slender, rod-like bones with elongated “S” shapes. They are located at the base of
the neck and run horizontally between the sternum and the shoulders. Another name is collarbone.

93. (C) The upper, flaring portion or prominence of the hipbone is the ilium. Its superior border is the iliac
crest. The internal surface is the iliac fossa.

94. (D) The tibia is the larger medial bone of the lower leg. It bears the major portion of the weight on the
leg. Another name is shinbone.

95. (B) The head of the femur fits into a lateral depression in the os coxae (the acetabulum), forming a joint.
It is held in place by a ligament and by a tough fibrous capsule surrounding the joint.

96. (A) The patella, or kneecap, is a small, triangular bone anterior to the knee joint. It is a lens-shaped
sesamoid bone situated in front of the knee in the tendon of the quadriceps femoris muscle.

97. (A) Long bones consist of a rod-like shaft with knob-like ends. The longest bone in the body is the
femur. Another name is the thighbone.

98. (D) A condyle is a rounded protuberance found at the point of articulation with another bone. The
distal end of the femur has large condyles. These condyles articulate with the tibia at the knee joint.

99. (B) Osteomyelitis is an infection of bone caused by bacteria that may reach the bone from outside the
body, from other sites of infection, and from adjacent structures.

100. (C) Several kinds of exocrine glands are associated with the skin: sebaceous (oil) glands, sudoriferous
(sweat) glands, ceruminous glands, and mammary glands.

101. (D) The most commonly used donor tendon for a free graft is the palmaris longus tendon of the wrist
and forearm. The plantaris tendon in the leg is also frequently used.

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 ___________________CHAPTER 29___________________

Pediatrics

• Pediatric patients are between the age of birth and 18 years old
• Neonate—the first 28 days outside the mother
• Infant—1–18 months
• Preschool—30 months–5 years
• School age—6–12 years
• Adolescent—13–18 years
• Fears of the pediatric patient include anesthesia and separation from their parents. In order to reduce their
anxiety we can:
Let them bring a toy or stuffed animal to the operating room with them
Introduce them to the surgical team
Let the parents accompany them to the operating room
Allow the parents to come into the PACU at the appropriate time
• Radiation

The transfer of heat between the body and objects that are not in direct contact with each other. Example:
linens, walls of the room and windows. If the infant is placed too close to the cool object they will loose heat

• Evaporation—this is when wet surfaces are exposed to air, heat loss occurs. When the solutions used on
the infants begins to dry, heat loss also occurs. It is important to warm solutions, bath water, and dry the
infant immediately.
• Conduction—when the infant’s skin comes in contact with cold surfaces
• Convection—when the air surrounding the infant is cool, heat is lost. Examples include an air
conditioning as well as people simply walking around the infant
• Airway obstruction is a major complication of extubation
• Hypothermia—when the infants body temperature drops below 36.5°C/97.7°F
• Infants lack the ability to shiver. In order to reduce the risk of hypothermia in infants you can:
Increase the operating room temperature prior to the surgical procedure
Heat lamps
Warm blankets
Wrap the infants limbs
Warm solutions
• The umbilical artery is used for an intra-arterial monitor on a neonate during surgery

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• Central venous catheters are placed in the external jugular vein
• Pyloromyotomy—performed for pyloric stenosis
• Laparoscopic Nissen fundoplication—is performed on infants and children who experience severe
gastroesophageal reflux
• Pectus excavatum—is a genetic defect. Funnel chest is a defect of the sternum and the ribs
• Erythroblastosis fetalis—is a fatal blood disorder in infants where the mother’s blood is incompatible with
the infant
• Esophageal atresia—a serious birth defect in which the esophagus is closed off at some point between the
mouth and the stomach
• Tracheoesophageal fistula—a birth defect where the trachea is connected to the esophagus
• Intussusception—the intestines telescope into one another
• Volvulus—twisting of the intestines causing obstruction
• Hirschsprung’s disease—a congenital defect caused by the absence of ganglion cells in the intestines. This
effects the peristaltic contractions of the intestines
• Imperforate anus—is a congenital defect where there is no anus but a fistula between the anus and vulva or
bladder
• A common hernia in infants and children is an umbilical hernia
• Omphalocele—is a congenital defect where the organs of the body are covered in an amniotic sac and
protrude through a defect in the umbilical ring
• Spina bifida—congenital defect in the spine where part of the spinal cord and the meninges are exposed
through an opening in the backbone
• Myelomeningocele—failure of the neural tube to close. Causes the meninges and spinal cord to protrude
through the skin within a sac
• Bariatric surgery can be performed on children who are diagnosed as obese with a BMI of 40 combined
with life-threating medical conditions
• The bariatric patient should be placed in reverse Trendelenburg position immediately following the
surgical procedure
• A hernia is a complication of gastric bypass surgery
• Complications of bariatric surgery are diagnosed with a laparoscopy
• Cleft lip—the upper lip does not totally form properly and leaves an opening in the skin between the nose
and lip
• The cleft lip repair is performed in stages, and a Z-plasty repair is performed
• Cleft palate—the roof of the mouth does not completely close. This deformity causes complications with
eating and speech
• Wilms tumor—also known as a nephroblastoma —intra-abdominal tumor
• Neuroblastoma—cancerous tumor commonly found in the retroperitoneum, and adrenal medulla
• Sacrococcygeal teratoma—this tumor is located near the sacrum and coccyx. It is made up of different cells
during early development. They can be solid or cystic

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• Epispadias repair—the urethral meatus is on the dorsum of the penis
• Hypospadias repair—the urethral meatus is on the ventral surface of the penis
• Circumcision—this procedure is performed to remove the prepuce / foreskin from the glans penis
• Hydrocele—an abnormal accumulation of fluid in the scrotum. It can cause an infection. A scrotal incision
is made and the fluid is suctioned out
• Orchiopexy—this procedure is performed to bring the testicle to its normal position in the scrotum after
the testicle has traveled up into the inguinal canal
• Cryptorchidism—an undescended testicle
• Ventriculoatrial and ventriculoperitoneal shunts—these procedures are performed for hydrocephalus
Ventriculoatrial shunt—fluid is shunted from the lateral ventricle of the brain to the atrium
Ventriculoperitoneal shunt—fluid is shunted from the lateral ventricle to the peritoneal space
• Two types of shock common to children are:
Septic—commonly caused by a bacterial infection
Hypovolemic—dehydration is the cause of hypovolemic shock in children
• Gastrostomy feeding tubes are commonly used on the pediatic patient following GI procedures
• Percutaneous endoscopic gastrostomy—the peg tube is the most common gastrostomy tube used. It is used
for gastric decompression and external feedings
• Child abuse includes:
Shaken baby syndrome
Neglect
Sexual abuse
Unexplained falls and / or skin, facial, or thermal injuries and fractures
• Head trauma is the leading cause of injury of the pediatric patient. Causes include—car accidents, falls,
bicycle accidents, drowning, burns, and poisonings
• Atrial septal defect—this is a congenital defect where there is a hole in the atrial septum causing blood to
flow from the left atrium to the right atrium
• Ventricular septal defect—this is incomplete closure of the septum between the right and left ventricle
• Tetralogy of Fallot—this is a combination of a few congenital defects. These babies are cyanotic-blue in
skin color. The congenital defects include:
Pulmonary stenosis
Ventricular septal defect
Right ventricular hypertrophy
Dextroposition of the aorta
• Patent ductus arteriosus—a heart defect that happens when the ductus arteriosus does not close at birth.
The ductus arteriosus is the temporary fetal blood vessel that connects the aorta and the pulmonary artery
• Pediatric medications are prescribed according to the child’s weight in kilograms
• Fetal surgery—surgical intervention to repair a birth defect while the fetus is still in the uterus. These
surgical procedures can be repaired percutaneously with a fetoscope or as an open procedure

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 • Craniosynostosis—premature closure of the cranial suture lines. It can occur along one or more suture
lines. The procedure performed is a craniectomy
• Crouzon’s disease—includes premature closure of cranial suture lines causing skull and facial deformities
• Apert syndrome—congenital disorder that causes cranial facial deformities and can also include syndactyly
• Club foot—a congenital deformity of one or both feet. The affected foot rotates inward. Treatment varies
from braces and tapes to surgical intervention
• Tendon lengthening—this is one type of surgical procedure performed for club foot. It is also used for
patients with cerebral palsy. It helps to release contractures
• Otoplasty—performed to correct protruding ears from traumatic injury or a congenital deformity

Microtia—small ears—this is a congenital defect in which all or part of the external ears are missing. The rib
is used as a graft for the patient’s ear

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 Questions

1. The telescoping of the proximal intestine into the lumen of the distal intestine is called:

(A) volvulus
(B) intussusception
(C) pyloric stenosis
(D) ileal atresia

2. An imperforation or closure of a normal opening is called a/an:

(A) hypertrophy
(B) atresia
(C) stenosis
(D) atrophy

3. Failure of the intestines to encapsulate within the peritoneal cavity of a newborn is called:

(A) umbilical hernia

(B) omphalocele
(C) hydrocele
(D) intestinal exstrophy

4. A congenital malformation of the chest wall with a pronounced funnel-shaped depression is called:

(A) truncus arteriosus

(B) pectus excavatum
(C) pectus carinatum
(D) costochondral separation

5. Newborn vomiting, free of bile and projectile in nature, is indicative of:

(A) atresia of the esophagus

(B) pyloric stenosis
(C) volvulus
(D) intussusception

6. The surgical pediatric patient with an increased metabolic rate requires all of the following EXCEPT:

(A) oxygen

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 (B) caloric intake
(C) blood transfusions
(D) fluids

7. Hirschsprung’s disease is synonymous with:

(A) bowel obstruction

(B) malrotation
(C) ileal stenosis
(D) Meckel diverticulum

8. The condition evidenced by incomplete closure of the vertebral arches in newborns is:

(A) hydrocephalus
(B) encephalocele
(C) spina bifida
(D) myelomeningocele

9. The condition involving premature closure of infant cranial suture lines is referred to as:

(A) cranioplasty
(B) stereotactic surgery
(C) craniosynostosis
(D) transsphenoidal hypophysectomy

10. An imperforate anus means:

(A) anal opening is absent

(B) anus is closed
(C) anal sphincter is too tight
(D) anal sphincter is too loose

11. A Wilms tumor, the most common intra-abdominal childhood tumor is known as a / an:

(A) nephroblastoma
(B) neuroblastoma
(C) aganglionic colon
(D) intussusception

12. Nonclosure at birth of the duct that carries blood from the pulmonary artery directly to the aorta is
termed:

(A) tetralogy of Fallot

(B) coarctation of the aorta
(C) patent ductus arteriosus

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 (D) anomalous venous return

13. The most common congenital cardiac anomaly in the cyanotic group is:

(A) tricuspid atresia

(B) tetralogy of Fallot
(C) patent ductus arteriosus
(D) truncus arteriosus

14. The mechanical strength of a weak eye muscle due to strabismus in a pediatric patient can be corrected
by all of the following EXCEPT:

(A) tucking
(B) advancement
(C) recession
(D) resection

15. What surgery is performed to treat otitis media?

(A) Myringotomy
(B) Adenoidectomy
(C) Tympanoplasty
(D) Tonsillectomy

16. What problem is most commonly seen in the pediatric postoperative patient?

(A) Hypotension
(B) Airway impairment
(C) Hypothermia
(D) Metabolic depression

17. During surgery on the pediatric patient, interventions to maintain the patient’s temperature are:

(A) the OR is prewarmed prior to the patient arriving

(B) a warm air blanket is used during procedure
(C) heating lamps are used preoperatively or at anytime needed
(D) All of the above

18. Pediatric medications are prescribed according to the patient’s weight in:

(A) kilograms
(B) pounds
(C) grams
(D) neograms

19. What procedure is performed to reconstruct the external ear?

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 (A) Rotation flap
(B) Lobularplasty
(C) External auditory fixation
(D) Otoplasty

20. The procedure performed to open a stricture at the gastric outlet on an infant is:

(A) gastrectomy
(B) pyloral myotomy
(C) pyloric stenting
(D) Ramstedt

21. Intestinal obstruction by twisting of the intestines is:

(A) pyloric stenosis

(B) volvulus
(C) neuroblastoma
(D) encephalocele

22. Orchiopexy is performed to treat:

(A) testicular cancer

(B) torsion of the testicle
(C) congenital undescended testicle
(D) Both B and C

23. The most common defects that occur when the embryonic development of the central nervous system
(spinal cord and brain) fail to close completely is spina bifida, anencephaly, and encephalocele. This
condition is called:

(A) tetralogy of Fallot

(B) ventricular septal defect
(C) vertebral recession
(D) neural defect

24. A medical term used for the condition characterized by fusion of the fingers and toes is:

(A) club hand and foot

(B) syndactyly
(C) mermaid syndrome
(D) trigger finger

25. An untreated condition in infants that causes the skull to enlarge is called

(A) hydrocephalus

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 (B) cerebral defect
(C) cerebral aneurysm
(D) meningioma

26. A ventricular atrial shunt, a ventricular peritoneal shunt, and an in vitro shunt are performed for the
condition called:

(A) decompression of the cranial nerves

(B) hydrocephalus
(C) cranial neuroma
(D) intracranial aneurysm

27. The transfer of heat between the body and objects without direct contact with each other is:

(A) evaporation
(B) conduction
(C) radiation
(D) convection

28. A major complication in the pediatric patient upon extubation is:

(A) hyperthermia
(B) airway obstruction
(C) hypothermia
(D) aspiration

29. The artery used for intra-arterial monitoring on a neonate during surgery is the:

(A) carotid artery

(B) brachial artery
(C) umbilical artery
(D) femoral artery

30. The CVP catheter is placed in which vein in the neonate?

(A) External jugular

(B) Internal jugular
(C) Subclavian
(D) Brachiocephalic

31. The following procedure is performed on infants and children for severe gastro esophageal reflux:

(A) pyloromyotomy
(B) Billroth 1
(C) gastrojejunostomy

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 (D) Nissen fundoplication

32. Erythroblastosis fetalis is a disorder:

(A) where mother’s blood is incompatible to their infants

(B) too many red blood cells
(C) too few red blood cells
(D) too few platelets

33. The most common hernia in a child is:

(A) umbilical hernia

(B) inguinal
(C) femoral
(D) hiatal

34. Failure of the neural tube to close causing the meninges and spinal cord to protrude through the skin in
a sac.

(A) omphalocele
(B) spina bifida
(C) imperforate anus
(D) myelomeningocele

35. Bariatric surgery can be performed on children who are so obese that their BMI is greater than:

(A) 60
(B) 40
(C) 20
(D) 10

36. What position should the postoperative pediatric / bariatric patient be placed in?

(A) Trendelenburg
(B) Dorsal recumbent
(C) Reverse Trendelenburg
(D) Left lateral

37. The Z-plasty procedure is used to correct:

(A) cleft palate

(B) protruding ears
(C) cleft lip
(D) microtia

38. The cancerous tumor commonly found in the retroperitoneal adrenal medulla?

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 (A) Neuroblastoma
(B) Nephroblastoma
(C) Glioma
(D) Astrocytoma

39. The tumor located near the sacrum and made up of different cells during early development is:

(A) leiomyoma
(B) sacrococcygeal teratoma
(C) nephroblastoma
(D) None of the above

40. The condition where the urethral meatus is on the ventral side of the penis is called?

(A) Epispadias
(B) Cryptorchidism
(C) Phimosis
(D) Hypospadias

41. The procedure performed to remove an abnormal accumulation of fluid in the scrotum is called:

(A) hydrocelectomy
(B) orchidopexy
(C) circumcision
(D) meatotomy

42. Septic shock in children is caused by:

(A) viral infection

(B) bacterial infection
(C) dehydration
(D) both A and C

43. A PEG tube is used for:

(A) gastric decompression

(B) external feeding
(C) internal feeding
(D) A and B

44. Child abuse injuries include:

(A) shaken baby syndrome

(B) malnutrition
(C) thermal injuries

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 (D) All of the above

45. When the fetus is born with their blood flowing from the left atrium to the right atrium is called:

(A) atrial septal defect

(B) ventricular septal defect
(C) coarctation of the aorta
(D) patent ductus arteriosus

46. Which disease includes premature closure of the cranial suture lines with skull and facial deformities?

(A) Craniosynostosis
(B) Crouzon’s
(C) Apert syndrome
(D) Microcephaly

47. The congenital deformity that causes the effected foot or feet to rotate inward is:

(A) ruptured Achilles

(B) hallux valgus
(C) drop foot
(D) club foot

48. The procedure to correct protruding ears is:

(A) z plasty
(B) cheiloplasty
(C) mentoplasty
(D) otoplasty

49. The position of the pediatric patient following a T&A is:

(A) dorsal recumbent

(B) lateral
(C) lateral with head slightly elevated
(D) simms

50. A congenital defect where the abdominal contents are outside the body at birth is:

(A) hiatal hernia

(B) diverticular disease
(C) Crohn’s disease
(D) omphalocele

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657
 Answers and Explanations

1. (B) Intussusception is the telescopic invagination of a portion of intestine into an adjacent part with
mechanical and vascular impairment frequently at ileocecal junction.

2. (B) Atresia is an imperforation or closure of an opening. Atresia and stenosis (a narrowing of an

opening) are the most common causes of obstruction in a newborn.

3. (B) Failure of the intestines to become encapsulated within the peritoneal cavity during fetal
development results in herniation through a midline defect in the abdominal wall at the umbilicus. This
is termed omphalocele.

4. (B) A congenital malformation of the chest wall, pectus excavatum, is characterized by a pronounced
funnel-shaped depression over the lower end of the sternum.

5. (B) The first sign of pyloric stenosis is projectile vomiting free of bile. The surgical procedure for repair
is a pyloromyotomy. The muscles of the pylorus are incised to relieve the stenosis.

6. (C) Oxygen, calories, and fluids must be increased because of the increased demands of surgical stress.
Blood is not given unless there is a need.

7. (A) The goal for Hirschsprung’s is resection and reconstruction of the distal colon to restore functional
peristalsis and to prevent a further bowel obstruction. The diagnosis is confirmed with a rectal biopsy.

8. (C) A newborn anomaly that is evidenced by incomplete closure of the vertebral arches, with or without
herniation of the meninges, is called spina bifida.

9. (C) In craniosynostosis, the suture line of an infant has closed prematurely. A synthetic material (such as
silicone) is used to keep the edges of the cranial sutures from reuniting and preventing brain growth.

10. (B) In imperforate anus, the anus remains closed during fetal development and must be opened soon
after birth.

11. (A) A Wilms tumor, also known as nephroblastoma, is the most common intra-abdominal childhood
tumor. It presents as a painless mass whose enlargement may laterally distend the abdomen.

12. (C) During fetal life, the ductus arteriosus carries blood from the pulmonary artery to the aorta,
bypassing the lungs. After birth, this duct closes in the first hours. Nonclosure is termed patent ductus
arteriosus and requires surgical closure.

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13. (B) Tetralogy of Fallot is the most common congenital cardiac anomaly in the cyanotic group. It is the
result of shunting unoxygenated blood into the systemic circulation.

14. (C) Recession is a procedure done for strabismus where the muscle is overactive. All other procedures
listed deal with the underactive (weak) eye muscle.

15. (A) Secretory otitis media is the most common chronic condition of childhood. Fluid accumulates in the
middle ear from Eustachian tube obstruction. This condition is corrected by myringotomy, an incision
in the tympanic membrane.

16. (B) Airway problems are the most common concern on emergence from surgery and immediately
postoperative. At the conclusion of the operation, the oropharynx and stomach are suctioned. All
monitors are left in place until the patient is fully awake and extubated.

17. (D) The methods used to maintain a pediatric temperature include prewarming the OR, a warm water
filled blanket, heat lamps, a solution warmer, warm IV solution, and prewarmed surgical sponges.

18. (A) The patient’s weight is measured in kilograms.

19. (D) Otoplasty is performed to reconstruct the external ear after trauma or to correct protruding ears.

20. (B) Pyloral myotomy is surgery to correct an infantile hypertrophic pyloric stenosis.

21. (B) A volvulus is a rotation of the intestine around itself or the attached mesentery.

22. (C) The goal of surgery for the undescended testicle is to restore the testicle to its normal position in the
scrotum.

23. (D) The neural tube is an embryonic structure that gives rise to the nervous system. Defects in this
neural tube occur when this tube fails to close completely.

24. (B) Syndactyly is a congenital condition in which the digits of the hand and or feet are joined from birth.

25. (A) Hydrocephalus occurs when the flow of cerebrospinal fluid (CSF) is blocked or obstructed. There
becomes an increased amount of fluid in the ventricles of the brain.

26. (B) All three shunts are performed for hydrocephalus. Ventricular atrial is from the ventricle to the
atrium, ventricular peritoneal is ventricle to the peritoneal cavity, and the in vitro shunt is done while
the fetus is in vitro.

27. (C) The transfer of heat between the body and objects that are not in direct contact with each other is
radiation. Example is linens. Evaporation occurs when wet surfaces are exposed to air. Heat loss occurs.
Conduction is when the infant’s skin comes in direct contact with cold surfaces. Convection is when the
air surrounding the infant is cool, heat is lost. Example is air conditioning.

28. (B) Airway obstruction is a major complication during extubation of pediatric patients. Hyperthermia is

659
 an increase in body temperature. Hypothermia is a decrease in body temperature below 36.5°C / 97.7°F
and aspiration is when the infant swallows fluid directly into the trachea.

29. (C) The umbilical artery is used for intra-arterial monitoring on a neonate during surgery.

30. (A) A CVP is placed in the external jugular vein.

31. (D) A laparoscopic Nissen fundoplication is performed on infants and children who have severe gastro
esophageal reflux.

32. (A) Erythroblastosis fetalis is when the mother’s blood is incompatible with the blood of the fetus.

33. (A) Umbilical hernias are a common hernia in infants and children.

34. (D) Myelomeningocele is failure of the neural tube to close which causes the meninges and spinal cord
to protrude through the skin in a sac. An omphalocele is a congenital defect where the organs of the
body are covered in an amniotic sac and exposed through a defect in the umbilical ring. Spina bifida is a
congenital defect of the spine where part of the spinal cord and the meninges are exposed through an
opening in the backbone. Imperforate anus is the absence of an opening into the anus.

35. (B) BMI > 40 constitutes bariatric surgery.

36. (C) The pediatric / bariatric patient should be placed in reverse Trendelenburg position immediately
following surgery.

37. (C) A cleft lip is a condition where the upper lip does not totally form leaving an opening in the skin
between the nose and the lip. Protruding ears are large ears. A cleft palate is when the roof of the
mouth does not completely close and microtia is the term for small ears.

38. (A) Neuroblastoma is a cancerous tumor commonly found in the retroperitoneal space in the adrenal
medulla. The nephroblastoma is also a Wilms tumor on the kidney. Glioma and astrocytoma are both
cancerous brain tumor.

39. (B) Sacrococcygeal teratoma is a tumor located near the sacrum and coccyx. It is made up of different
cells during early development.

40. (D) Hypospadias is when the urethral meatus is on the ventral side of the penis. Epispadias is when the
urethral meatus is on the dorsal side of the penis. Phimosis is a congenital narrowing of the opening of
the foreskin. Cryptorchidism is a condition when one or both testes fail to descend from the abdomen
to the scrotum.

41. (A) Hydrocelectomy is the procedure performed to drain an abnormal accumulation of fluid in the
scrotum. Orchiopexy is performed to affix the testicle in to its normal position. Circumcision is removal
of the prepuce or foreskin. Meatotomy is a dilation of the narrowed meatus.

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42. (B) Septic shock is commonly caused by a bacterial infection.

43. (D) PEG tubes are used for gastric decompression and external feedings.

44. (D) Shaken baby syndrome, malnutrition and thermal injuries are all examples of child abuse and
neglect.

45. (A) Atrial septal defect is a congenital disorder where there is a hole in the atrial septum causing the
blood to flow from the left atrium to the right atrium. Normal blood flows from the left atrium to the
left ventricle. Ventricular septal defect is an incomplete closure of the septum between the right and left
ventricle. Coarctation of the aorta is a congenital condition where the aorta is narrow. Patent ductus
arteriosus is a heart defect that occurs when the ductus arteriosus does not close at birth.

46. (B) Crouzon’s disease is a premature closure of cranial sutures with skull and facial deformities.
Craniosynostosis is premature closing of cranial sutures. Apert syndrome is a congenital disorder that
causes cranial and facial deformities and also includes syndactyly. Microcephaly is an abnormally small
head and incomplete brain formation.

47. (D) A club foot is a congenital deformity of one or both feet causing the foot to rotate inward.

48. (D) Otoplasty is a surgical correction of protruding ears. A Z-plasty is a type of plastic closure.
Cheiloplasty is surgery of the lip and mentoplasty is plastic surgery on the chin.

49. (C) The position for the postoperative tonsillectomy patient is lateral with the head of the bed slightly
elevated.

50. (D) Omphalocele is a congenital defect where the abdominal contents are outside of the body at birth.

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 ___________________CHAPTER 30___________________

Biomedical Science (Electricity, Hemostasis, Lasers,

and Computers)

• ELECTRONS—negatively charged particles

• NEUTRONS—neutral particles
• PROTONS—positively charged particles
• NUCLEUS—center of an atom. Protons and neutrons are found in the nucleus of an atom and electrons
travel in an orbit around the nucleus
• FREE ELECTRON—an electron that is not attached to an atom and is free to move to another atom
• MASS—any matter that occupies space
• POWER—rate at which work is done. It is measured in watts
• SPEED—how fast an object moves
• VELOCITY—how fast something is moving without concentration or direction
• FREQUENCY—the rate at which something occurs or is repeated over a particular period of time. The
number of cycles or completed alternations per unit time of a wave. Frequency is measured in Hertz
• CURRENT—the movement / flow of electricity. Current is measured in amps
• ACCELERATION—change in velocity over a period of time
• WORK—the force that causes an object to change direction
• VOLTAGE—the pressure that pushes electricity. Voltage is controlled by a power source
• MATTER—is anything that has mass and occupies space
• POWER—this is the rate at which work is done (energy is used). Power is measured in watts
• CONDUCTORS—allow electrical current to flow freely, examples include: metals such as copper and
aluminum
• NONCONDUCTIVE—means that it will not accept electrical current
• INSULATORS—materials that do not conduct electricity. An example of this is the covering on some
laparoscopic instruments. When the current reaches the insulator it does not completely stop but finds an
alternative route to take, when there is no alternative route the current will stop and cause heat
• NEWTON’S LAW OF MOTION
Newton’s first law states that a body at rest will remain at rest, and a body in motion will remain in
motion with a constant velocity, unless acted upon by a force. This law is also called the law of inertia
Newton’s second law—acceleration is produced when a force acts on a mass. The greater the mass (of
the object being accelerated) the greater the amount of force needed to accelerate the object

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 Newton’s third law states that for every action there is an equal and opposite reaction. Thus, if one body
exerts a force on a second body, the first body also undergoes a force of the same strength but in the
opposite direction.
• There are two types of electrical currents, Direct Current and Alternating Current
DIRECT CURRENT—the current flows in one direction. An example is a battery
ALTERNATING CURRENT—the current moves in one direction and can reverse its direction
The voltage used in hospitals is 110 or 120 V

METHODS OF HEMOSTASIS

• BIPOLAR ELECTROCAUTERY / BIPOLAR CAUTERY—the current is delivered to the surgical

site and returned to the generator by forceps. The current passes between the tips of the forceps. One tip is
active and the other is inactive
• MONOPOLAR ELECTROSURGERY—current flows from the generator to the active electrode (bovie
hand piece) to the patient to the inactive dispersive electrode back to the generator
• COAGULATING CURRENT—a current that passes through the active electrode (bovie hand piece)
with intense heat to burn and control bleeding vessels
• CUTTING CURRENT—the current used to cut tissue
• BLENDED CURRENT—a current that can be used to provide hemostasis to tissue and cut tissue
• GENERATOR—the power source, the machine that produces the current by using high-frequency radio
• INACTIVE DISPERSIVE ELECTRODE—the pad used to return the current back to the generator.
Also referred to as the grounding pad / inactive electrode / return electrode
• ACTIVE ELECTRODE—the hand piece or active electrode directs the current to the target tissue
• CRYOSURGERY—liquid nitrogen and CO2 are used to provide extreme cold / freezing to remove tissue
and control bleeding
• ULTRASONIC SCALPEL—the scalpel blade uses ultrasonic motion to cut and coagulate diseased or
abnormal tissue without damage to other tissue
• LIGASURE—bipolar device that seals vessels and tissue
• HARMONIC SCALPEL—uses ultrasonic wave energy to seal and cut tissues and vessels
• MORCELLATOR—a device that cuts and fragments tissue into strips, and is suctioned through the
instrument. This instrument is contraindicated in the presence of cancer

LASERS

• LASER—LIGHT AMPLIFICATION BY STIMULATED EMISSION RADIATION

• The laser light beam is monochromatic (one color or one wave length)
• All the wave lengths are coherent ( they wave together and are lined up)
• Laser light waves travel in the same direction and are parallel to each other
• Lasers can emit their light beam in brief spurts (pulsate), or they can produce continuous light beams
• An active medium is needed to produce a laser beam, they can be gases, solids, crystals, liquid, dyes, and
free electrons

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• You need an energy source; it may be electrical or radiofrequency
• It contains an amplification system so the beam can change direction
• It contains a wave guide to aim and control the beam (pulsing or continuous)
It has back stops to prevent the beam from going beyond its target. They include: wet towels, sponges,
titanium, or quartz rods.
It emits a beam from invisible to infrared

TYPES OF LASERS

• ARGON LASER
The medium used is argon gas
Blue-green beam
Argon lasers are used to treat retinal tears and also in urology for bladder tumors
• CO2 LASER
The medium used is carbon dioxide gas
The laser beam is invisible so a helium–neon laser beam is lined up with the CO2 beam so the surgeon
can aim the beam
The beam is delivered through an articulated arm whereby a hand piece can be attached
The CO2 laser cannot be used on tissue with high water content because it absorbs the beam
It can be used like a scalpel or the beam can be defocused to ablate soft tissue
It is commonly used in plastic, GYN, neuro, ortho, cardiovascular, and general surgery
• EXCIMER LASER
The laser beam is an ultraviolet color
The medium used is a mixture of gases
This beam ablates or disintegrates tissue instead of cutting or burning
Used for Lasik surgery to reshape the cornea, also used for angioplasty
• YAG—HOLMIUM: YTTRIUM–ALUMINUM–GARNET LASER
Uses water as the medium and is commonly used in orthopedics for arthroscopic surgery except for the
spine
This laser uses a pulse type of a beam
• KRYPTON LASER
Uses electrical current as the medium
Emits a red-yellow beam
Works from electrical power
Commonly used in eyes
• KTP / GREENLIGHT LASER
Commonly used for BPH (benign prostatic hyperplasia)
• ND:YAG LASER—(YAG—YTTRIUM ALUMINUM GARNET)
Used on an iridectomy for patients with glaucoma, liver tumors, skin cancers, and thyroid nodules

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LASER SAFETY

• The patients eyes should be covered and protected from the laser beam
• The skin prep used must be a nonflammable solution
• The immediate area around the target area should be covered with moistened cloth towels (water not
saline)
• All sponges and laps should be moistened with water when used around the laser
• Drapes should be nonflammable
• Endotracheal tubes should be insulated (wrapped with a special metallic foil) when the target tissue is on
the face and neck
• Eye protection laser glasses must be worn
• Fire resistant gowns should be worn
• Do not wear metal jewelry—it could absorb heat from the laser and cause a burn

COMPUTERS

• All the components of the computer are termed HARDWARE

• BOOTING—when turning on the computer this is termed booting
• Your name and password are required to log onto the computer for security purpose. MODEM—part of
the computer that helps to send e-mail, access the internet AND other programs
• BYTE—this is equal to a letter, a number, or a sign that computers use
• MOUSE—the mouse allows you to scroll across the computer, it moves the cursor on the computer screen
• COMPUTER SOFTWARE—this is the term used for computer programs
• HARD DRIVE—used to store files and computer programs
• 1,000 bytes = 1 kilobyte
• MONITOR—screen of the computer
• KEYBOARD—this is a separate part of the computer where you type to enter characters and commands
into the computer
• SCROLLING—this is the term used to move up and down on the computer screen using the mouse
• RAM—this is the acronym random access memory
• ROM—this is the acronym for read only memory
• MEMORY—this is the location in a computer that can store information
• BULLETS—they are symbols that help define a list

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 Questions

1. Anything that has mass and occupies space is termed:

(A) element
(B) matter
(C) conductor
(D) insulator

2. The center of an atom is called the:

(A) matter
(B) mass
(C) nucleus
(D) charge

3. The movement of electrical charge through a conductor is called:

(A) migration
(B) electrical current
(C) conduct
(D) insulation

4. The sterile component of the the ESU is:

(A) inactive
(B) active
(C) ground
(D) patient plate

5. Current is measured in:

(A) volts
(B) amps
(C) circuits
(D) loads

6. The path which electricity travels from its energy source and back again is called:

(A) resistor

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 (B) circuit
(C) conductor
(D) ampere

7. Restriction of the flow of current to a source is called:

(A) magnetism
(B) resistance
(C) force field
(D) power

8. In a simple electrical circuit, the wire that connects to the switch is:

(A) neutral
(B) ground
(C) hot
(D) None of the above

9. A separate wire that is an essential protection against an electric shock is:

(A) hot
(B) neutral
(C) ground
(D) active

10. Most outlets in the operating room run on:

(A) 220 V
(B) 110 V
(C) 120 V
(D) 60 V

11. When current moves in one direction and then reverses to return to the source, it is known as:

(A) alternating current

(B) electrical current
(C) direct current
(D) optional current

12. One example of DC (direct current) is:

(A) an electrosurgical unit

(B) a flashlight
(C) a surgical room light
(D) an x-ray machine

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13. Alternating current has the ability to:

(A) step-down voltage

(B) step-up voltage
(C) alternate voltage
(D) All of the above

14. A device that transmits an impulse to a wave-transmitting system is:

(A) an optical fiber

(B) a radio transmitter
(C) an isolated circuit
(D) a resistor

15. An ESU used for delicate surgery is a:

(A) monopolar unit

(B) disposable unit
(C) bipolar unit
(D) dispersive electrode unit

16. A plume of vaporized tissue may contain residual ____ and is, therefore, important to protect the staff.

(A) carcinogens
(B) blood-borne pathogens
(C) mutagens
(D) All of the above

17. An AC (alternating current) cycle is termed a:

(A) wave
(B) volt
(C) amp
(D) hertz

18. Radio waves are considered ____ waves.

(A) isolated
(B) direct
(C) simple
(D) magnetic

19. When current passes from the ESU through the active electrode, the energy is converted from electrical
to ____.

(A) mechanical

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 (B) chemical
(C) thermal
(D) magnetic

20. What material forms the best conductor of electricity?

(A) Rubber
(B) Saltwater
(C) Copper
(D) Lead

21. What device is used to control the flow of electricity at the will of the operator?

(A) Load
(B) Resistor
(C) Switch
(D) Conductor

22. When operating a piece of electrical OR equipment, the most vital prong for safety purposes is the:

(A) ground
(B) negative
(C) positive
(D) safety

23. Which theory explains the flow of electricity?

(A) Ohm’s
(B) Electron
(C) Kirchhoff’s
(D) Atomic

24. The standard metric unit of power is:

(A) amp
(B) volt
(C) watt
(D) hertz

25. A medical imaging technique that reveals the body’s dynamic activities is:

(A) CT
(B) PET
(C) tomogram
(D) ultrasound

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26. Electrosurgery can be used to:

(A) incise tissue

(B) coagulate blood vessels
(C) destroy or remove diseased tissue
(D) All of the above

27. The proper placement of the patient return electrode or grounding pad should be:

(A) on the surgical side

(B) farthest from the surgical site
(C) near a bony surface
(D) always on the opposite side

28. Forceps or an instrument that contains two contact points which are used to coagulate tissue are called:

(A) monopolar
(B) Ferris–Smith
(C) bipolar
(D) Potts forceps

29. Which of the following can be used as a cutting electrode?

(A) Needle tip

(B) Spatula
(C) Wire loop
(D) All of the above

30. When using the ESU for coagulation, the energy delivered is:

(A) intermittent waves at a low frequency and high voltage

(B) intermittent waves at a low frequency and low voltage
(C) intermediate frequency and intermediate high voltage
(D) intermediate waves and low voltage

31. Who is ultimately responsible for abiding by all safety protocols during the use of electrosurgery?

(A) Surgeon
(B) Circulator
(C) STSR
(D) All perioperative personnel

32. What is the sterile component used with the electrosurgical unit?

(A) Grounding pad

(B) Patient return electrode

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 (C) Active electrode
(D) Generator

33. The tips of the active electrodes used in minimally invasive surgery (MIS) are coated with insulation to
prevent:

(A) glare coming off the metal instrument

(B) keeping the metal portion of the instrument clean
(C) patient from being burned
(D) None of the above

34. Sealing vessels with electrosurgery requires:

(A) high frequency

(B) bipolar ESU instrument
(C) physical pressure to create a weld in tissue
(D) All of the above

35. What type of energy is used with the harmonic system? (harmonic scalpel, forceps, scissors)

(A) Ultrasonic
(B) Radiofrequency
(C) Fulguration
(D) Monopolar

36. Motion is known as ___ energy.

(A) mechanical
(B) total
(C) potential
(D) kinetic

37. The rate at which work is done is known as:

(A) velocity
(B) energy
(C) power
(D) watt

38. ___ borders the outer perimeter of an atom and is ___ charged.

(A) Neutron, positively

(B) Electron, negatively
(C) Electron, positively
(D) Proton, negatively

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39. The gain or loss of electrons in an atom is termed:

(A) hydraulic pressure

(B) Boyle’s law
(C) ionization
(D) consolidation

40. The transfer of thermal energy by contact is called:

(A) greenhouse effect

(B) radiation
(C) convention
(D) conduction

41. A repeated periodic disturbance or variation of energy, carried through a medium from point to point is
called:

(A) transfer energy

(B) wave
(C) oscillations
(D) molecular change

42. The frequency of sound is stated in a measurement of:

(A) amps
(B) hertz
(C) waves
(D) compressions

43. The study of objects in motion is:

(A) mechanics
(B) velocity
(C) speed
(D) acceleration

44. The three laws of motion that are the basics of classical mechanics are the work of:

(A) Hooke
(B) Newton
(C) Bohr
(D) Ohm

45. Any time that an object’s velocity is changing, we say it is:

(A) accelerating

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 (B) projecting
(C) orbiting
(D) static

46. The property of matter that causes a matter to resist change in motion is called:

(A) speed
(B) inertia
(C) momentum
(D) range

47. For every action there is an equal and opposite reaction references:

(A) Newton’s first law

(B) Newton’s second law
(C) Newton’s third law
(D) Hooke’s law

48. If an object returns to its original position after force has been applied and then removed is said to be:

(A) dynamic
(B) static
(C) elastic
(D) periodic

49. The maximum distance that an object moves from its central position (equilibrium) is called:

(A) frequency
(B) amplitude
(C) cycle
(D) momentum

50. The bending of a light ray as it passes from one substance to another is called:

(A) reflection
(B) refraction
(C) vibration
(D) incidence

51. What scientist, expanding Hooke’s wave theory, theorized that light can bend because it is a wave?

(A) Ohm
(B) Einstein
(C) Newton
(D) Young

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52. The longer wavelengths of the color spectrum are seen in what color?

(A) Violet
(B) Green
(C) Blue
(D) Red

53. Who first identified a collection of particles of light as “photons”?

(A) Einstein
(B) Newton
(C) Bohr
(D) Young

54. On the surface of the Earth, what causes objects to accelerate downward?

(A) Energy
(B) Excitation
(C) Gravity
(D) Electrical charges

55. What laser has the most power output?

(A) Liquid
(B) Semiconductor
(C) Gas
(D) Solid state

56. The fourth force found only in nature, and not in the nucleus, is known as:

(A) electromagnetic force

(B) gravitational force
(C) binding energy
(D) kinetic energy

57. Nucleons are composed of subatomic particles known as:

(A) isotopes
(B) quarks
(C) protons
(D) neutrons

58. All of the following are true of lasers EXCEPT:

(A) LASER is an acronym for light amplification by stimulated emission of radiation

(B) electricity does pass through the patient during laser surgery

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 (C) laser surgery uses intensely hot, precisely focused beams of light to cut and coagulate tissue
(D) electricity does not pass through the patient during laser surgery

59. When entering a room while the laser is in use, you must:

(A) wear a lead apron

(B) wear protective eyewear
(C) no special precautions are necessary
(D) wear a special mask

60. Which laser produces a visible blue-green beam?

(A) Excimer (gas laser)

(B) YAG
(C) Argon laser
(D) CO2 laser

61. Surgery using extremely cold instrument to destroy tissue is called:

(A) laser surgery

(B) phacoemulsification surgery
(C) cryosurgery
(D) ultrasonic surgery

62. Cryoablation uses a high-pressure gas called:

(A) argon
(B) CO2
(C) excimer
(D) KTP

63. All waves in the laser are monochromatic. This refers to:

(A) all waves in the laser have the same length and are one color
(B) all waves move in columns
(C) the diameter of the beam is the same
(D) they use the same power settings

64. What is the medium or elements activated to transmit photons in a laser beam?

(A) Gas
(B) Solid
(C) Liquid dye
(D) All of the above

65. All of the following are true of lasers EXCEPT:

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 (A) lasers do not need to be locked up when not in use
(B) laser warning signs should be visible to areas where laser surgery is being performed
(C) a laser safety officer is required to manage laser risks and define safety protocol
(D) only flame retardant drapes are used in laser surgery

66. Endotracheal tubes and other anesthetic equipment can easily ignite in the presence of laser energy and:

(A) silastic endotracheal tubing

(B) O2-rich anesthetic agents
(C) pacemakers
(D) defibrillators

67. The following equipment must be available during a laser laryngoscopy:

(A) water and wet cottonoids

(B) tracheotomy tray, wet towels
(C) bronchoscope, tracheotomy tray
(D) None of the above

68. Located on the back of the CPU are special openings called _______ for plugging in cables for adding
additional computer components.

(A) drives
(B) cords
(C) ports
(D) networks

69. The device that enables a computer to send and receive information by phone line is called a:

(A) modem
(B) scanner
(C) USB port
(D) lateral port

70. Visual display on the desktop of shortcuts to available programs is called:

(A) topics
(B) windows
(C) displays
(D) icons

71. When open to the Internet, what function can be used to return to a recently opened site that you have
not saved on your computer?

(A) Search

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 (B) History
(C) Favorites
(D) Address book

72. Web research is generally conducted with the help of:

(A) cursors
(B) search engines
(C) browser
(D) instant access

73. A product used to buffer the computer hardware against high electrical voltages is called a:

(A) zip drive

(B) surge protector
(C) modem
(D) lateral port

74. A hardware component that converts printed text or picture to digital information for use in documents
is called the:

(A) scanner
(B) printer
(C) modem
(D) ethernet card

75. The arrow or small hand, which appears on the screen to identify the location of currently addressed
information is known as a:

(A) scanner
(B) cursor
(C) icon
(D) taskbar

76. The component part of the computer that controls the cursor is called the:

(A) scroller
(B) mouse
(C) index
(D) scanner

77. The paper form of data in computer technology is the:

(A) file
(B) hard copy

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 (C) disc
(D) database

78. A specially treated form of surgical gauze that has a hemostatic effect when buried in tissue is:

(A) topical thrombin

(B) Gelfoam
(C) human fibrin foam
(D) Oxycel

79. An enzyme extracted from bovine blood used as a topical hemostatic agent is:

(A) oxytocin
(B) tannic acid
(C) thrombin
(D) collagen

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 Answers and Explanations

1. (B) Matter is anything that has mass and occupies space. All matter consists of atoms, and all atoms
contain protons, neutrons, and electrons.

2. (C) The center of an atom contains the nucleus, which contains in its center, protons and neutrons.

3. (B) The electrical current moves through conductors by movement of free electrons.

4. (B) The active electrode carries the energy to the patient, goes through the ground pad on the patient
into the inactive cord and back to the machine.

5. (B) Current is measured in amperes (amps).

6. (B) The path of electricity from energy source to the piece of equipment and back again is called a
circuit.

7. (B) Restriction of the flow of current to a source is called resistance.

8. (C) In a simple electric circuit, the wire that connects to the switch is hot.

9. (C) A separate wire that is essential for protection against electric shock is the ground wire.

10. (B) Most outlets in the operating room run on 110 V current. X-ray units require the use of 220 V lines.

11. (A) Alternating current (AC) describes the flow of current that reverses direction periodically. Direct
current (DC) indicates current that flows in only one direction (e. g., a flashlight).

12. (B) A flashlight is an example of one-way current or direct current.

13. (D) Alternating current has the ability to step-down, step-up, or alternate voltage continuously.
Hospitals use a reduced current.

14. (B) A device called a radio transmitter carries an impulse or signal to a wave-transmitting antennae
system.

15. (C) The unit used to perform electrosurgery in delicate areas, such as ophthalmology, plastic, and
neurosurgery is the bipolar unit. It has reduced power. The circuit is completed within the hand piece.

16. (D) Certain surgical procedures that employ the use of electrocautery, laser, and drills can produce a
plume of vaporized tissue that may include carcinogens, blood-borne pathogens, and mutagens. Smoke

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 evacuators are frequently used to remove the potentially hazardous smoke.

17. (D) An alternating current cycle is a hertz. The number of cycles per second is a frequency.

18. (D) Radio waves are magnetic waves. The number of wave cycles is also called a frequency.

19. (C) When electrical current passes through the active electrode, it converts electrical energy to thermal.

20. (C) The best conductor of electricity is copper. Examples that use copper wire as a conductor in the OR
are surgical lamps, electrosurgical units, and power drills.

21. (C) A simple electrical circuit is composed of a source of power, conductor, load, and switch. The switch
allows the operator to turn the piece of equipment on and off.

22. (A) When operating a piece of equipment in the OR, the most important prong is the ground. It safely
transfers any leaking electrons to the ground and prevents injury.

23. (A) The scientific theory that explains electricity is Ohm’s Law. It is a mathematical equation that shows
the relationship between voltage, current, and resistance.

24. (C) Power is defined as the rate at which work is done. Power is measured in watts.

25. (B) Positron emission tomography (PET) is the medical imaging of dynamic activities in the body such
as blood flow and glucose uptake in tissues.

26. (D) The most common uses of electrosurgery are all of the above including welding tissue together.

27. (A) The PRE should always be placed close to the surgical site over a large muscle mass, never over a
bony surface, scar, tattoo, hair, or implants. These increase impedance and can cause burns.

28. (C) In bipolar electrosurgery, the surgeon uses a forceps or an instrument that has two contact points or
a return point built into a single tip. The current leaves the power unit and travels from one pole to the
other passing only through the tissue between the contact points. Current goes back to the ESU unit
and no grounding pad is required.

29. (D) The needle tip, spatula, and wire loops are all cutting electrodes.

30. (A) When using the coagulation mode of an ESU, the energy delivered is intermittent waves at a low
frequency and a high voltage. High-frequency waves at a low voltage are used for the cutting mode.

31. (D) All perioperative personnel are responsible for preventing accidents involved with electrosurgery.

32. (C) Active electrode or cautery pencil is the sterile component. Grounding pad and the patient return
electrode are the same. They are placed on the patient before surgery begins, and the generator is the
power source.

33. (C) Insulators such as Teflon, silicone, polyethylene, and polyvinyl are used to protect the patient from

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 being burned by stray electricity.

34. (D) Examples of electrosurgical vessel sealing are LigaSure and Enseal. This system is used during
resection procedures that traditionally require sequential clamping, suturing, and a cutting process.

35. (A) The harmonic energy system uses ultrasonic energy. This energy is generated by high-frequency
vibration and friction. It simultaneously cuts and coagulates tissue by transmitting ultrasonic wave
energy through specially designed forceps and scissors.

36. (D) Motion is known as kinetic energy. The mechanical energy of an object can be a result of its motion.

37. (C) The rate at which work is done is called power. It is expressed as the amount of work per unit of
time.

38. (B) Electrons border the outer perimeter of an atom and are negatively charged. These outer electrons
are known as free electrons, and it is the movement of free electrons that produces electric current.

39. (C) The gain or loss of electrons in an atom is termed ionization. A loss converts an atom into a
positively charged ion, whereas a gain converts an atom into a negatively charged ion.

40. (D) The transfer of thermal energy by contact is called conduction. Some energy is transferred to
molecules of a second object when they collide. Certain substances are better used for this transfer, such
as metals, rather than wood or paper.

41. (B) A wave may be described as a disturbance in a medium such as air, water, or a solid substance.

42. (B) The frequency of sound can be measured in hertz. Multiples of sound are measured megahertz.

43. (A) Mechanics is the study of objects in motion, and is normally restricted to a small number of very
large objects.

44. (B) Isaac Newton’s three laws of motion are the basis of classical mechanics, or Newtonian mechanics.

45. (A) Acceleration is defined as a change in velocity over time.

46. (B) Newton’s first of three laws states that “inertia is a property of matter that causes matter to resist
change in motion.”

47. (C) Also known as the “law of conservation of momentum” states that whenever a force is exerted an
equal or opposite force arises in reaction.

48. (C) If an object returns to its original position after a force is applied or removed, then it is said to be
elastic. An example is a coiled spring.

49. (B) Amplitude is the maximum distance that an object moves from its central position (called
equilibrium).

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50. (B) Refraction is the bending of a light ray as it passes from one substance to another. Light travels at
differing speeds as it travels through one medium or another (such as water or glass).

51. (C) Hooke proposed that light was a wave, but it was Sir Isaac Newton who posited that if light were a
wave, it would bend around corners.

52. (D) The red wavelengths of light are the longest, whereas the violet is the shortest. The view along the
color spectrum changes with each color. White is not a color, but is perceived when all colors hit the eye
at the same time.

53. (A) In 1905, Einstein explained details of the photoelectric effect, which requires that light be a
collection of particles called “photons.” Young continued his work and Neils Bohr of the University of
Copenhagen further refined the research to establish the “Complementarity Principle of Light.”

54. (C) In situation near the surface of the Earth, gravity causes objects to accelerate downward.

55. (D) A solid-state laser creates the most powerful output.

56. (B) The gravitational force, found only in nature and one of the four forces affecting matter, does not
affect the nucleus of an atom.

57. (B) Protons and neutrons act as if they are identical articles and differ only in their electrical charge. The
nucleons themselves are made of subatomic particles called “quarks.”

58. (B) During laser surgery, electricity does not pass through the patient. Therefore, a grounding pad is not
necessary.

59. (B) The laser beam can cause permanent eye damage if viewed directly or indirectly by reflection.

60. (C) Argon gas lasers produce a visible blue-green beam that is absorbed by red, brown pigmented tissue
such as hemoglobin. The argon laser is mostly used in dermatological and ophthalmological procedures.

61. (C) Cryosurgery uses liquid nitrogen which freezes almost immediately and eventually will slough
mainly used to treat small skin lesions.

62. (A) A high-pressure argon gas is injected into the cryoablation probe causing the surrounding tissue to
freeze.

63. (A) All waves in the laser have exactly the same length. Their peaks and troughs are in exactly the same
location. This is called coherency.

64. (D) Laser energy is created when light is pumped into a sealed chamber and filled with a medium.
Examples are gas, solids, and liquids.

65. (A) Lasers are required to be locked up when not in use under the laser precautions and guidelines
(Surgical Technology for the Surgical Technologist).

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66. (B) In the presence of laser energy and O2-rich anesthetic agents, anesthesia equipment could easily
ignite. To minimize the risk of endotracheal fires, a special metallic foil is wrapped around the
endotracheal tube before surgery.

67. (A) Sterile water must be available to keep sponges and linens wet in case of fire.

68. (C) Located at the back of the computer are ports that allow us to access a connection to the hard drive
to attach scanners, printer, and other components to the system.

69. (A) A modem is the communication device that sends and receives information over a telephone line,
thereby, connecting us to the Internet.

70. (D) Icons that appear on the desktop screen are shortcuts to programs that also can be accessed through
the start menu.

71. (B) The computer holds the most recently visited sites in a history menu. Clicking on history will return
the site to the screen for viewing.

72. (B) There are several search engines available to reach the web—for example, Google, Alta Vista, and
Yahoo.

73. (B) A surge protector is a buffer against damaging high voltage surges of energy.

74. (A) A scanner resembles a printer, but reproduces the image electronically rather than duplicating the
print.

75. (B) The cursor is a small arrow that appears on the screen to identify the information to be addressed.

76. (B) The mouse moves the cursor to different areas on the screen and selects commands.

77. (B) The hard copy of data is a paper printout of the data and this is another method of protecting work.

78. (D) Oxycel’s hemostatic action is caused by the formation of an artificial clot by cellulose action as it
reacts with blood. It increases in size to form a gel and stops bleeding. It is used to provide hemostasis.

79. (C) Thrombin accelerates coagulation of blood and controls capillary bleeding. It is an enzyme derived
from bovine blood.

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 ___________________CHAPTER 31___________________

Occupational Hazards / Fire Safety

HAZARDS IN THE OPERATING ROOM

• These are classified as:

Physical injury to the body
Chemical injuries from gases, toxic fumes, and / or cleaning agents
Biological injuries from infectious waste, cross microbial contamination from patient to health care
worker, needle sticks, smoke plume, and / or latex allergies

ENVIRONMENTAL HAZARDS

• OR lights—should be nonglaring and prevent eye fatigue

• Noise—caused by:
Loud music
Talking
Banging instruments
Monitors
• Ergonomics—proper body mechanics for the surgical technologist
Stand with legs shoulder length apart, the wider the better. This helps to distribute your weight evenly
Avoid leaning on one foot. Shift your weight back and forth
Stand next to the OR bed straight with arms loose
When sitting, sit up straight and do not lean over the surgical field
Push do not pull heavy equipment
Instruments should not exceed 25 lb
Squat to lift don’t bend at the waist
Lift with your legs and abdomen not your lower back
Lift with a smooth even motion ease your head up first
When turning, turn with your whole body
Keep your back bowed when lowering supplies and equipment
• Radiation
OR staff should wear lead aprons and thyroid collars
When possible, protect the patient with a lead apron
Stand at least 6 ft from the fluoroscopy beam when possible

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 Exposure should be monitored with an x-ray monitoring device
Pregnant staff should avoid participating on cases with x-ray if possible. If you must participate, leave
the room when the radiation is being used
This is discussed more in depth in Chapter 12
• Electricity
ESU
The active electrode should always be placed in its holder when not in use to prevent burning drapes
or the patient
To prevent burns to the patient, the return electrode must be properly placed
Defibrillators
X-ray machines
This is discussed more in depth in Chapter 30
• Static electricity
Humidity in the OR should be between 20% and 60% to prevent sparks
• Fiber optic beam on laparoscopic and endoscopic cases
Prevent the light from resting on the drape sheets to prevent a fire
• Laser plume

STANDARD PRECAUTIONS / UNIVERSAL PRECAUTIONS

• Gloves should be worn at all times when handling blood and bodily fluids. Every patient should be treated
as if they are potentially infectious
• Use PPE
• Neutral zone / hands-free sharps are passed in a basin to the surgeon instead of hand to hand
• Never recap hypodermic needles
• If stuck with a needle or sharp
All personnel at the sterile field should be double gloved to protect against a needle stick
Immediately remove the instrument / needle from the sterile field
Immediately remove the glove and assess the injury
The injury should be washed with soap and water
The injury should be assessed, reported, and treated within 2 hours
If the injury is in the eye, nasal, or oral mucosa, it should be flushed with water or saline
Fill out an incident report

LASER AND ELECTROSURGICAL PLUME

• The concerns with laser plume are the cells in the smoke. A special suction should be used that contains a
HEPA filter with combined charcoal filter to absorb the plume
• The ESU is not as dangerous as laser smoke, however, it has a strong odor and can be irritating to your
eyes and respiratory tract
• It is the job of the STSR to control the suction. The wand should be as close to the area they are working

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 without blocking the surgeon’s view

LATEX ALLERGY

• Latex is made from rubber (trees)

• Halstead was the first surgeon to wear latex gloves during surgery
• Many other items in the operating room contain latex in addition to surgical gloves
• Symptoms of latex allergies include a skin rash to more severe problems like respiratory arrest.
• It is very important to know if your patient has a latex allergy. It should be stated on the patient’s chart and
all staff must be alerted prior to setting up for the surgical procedure to ensure there is no latex in the room
• A patient with a latex allergy should be the first scheduled case of the day. This allows the room to be free
of latex dust from previous cases

CHEMICAL HAZARDS IN THE OR

• The STSR should be aware of the chemicals they work with in the OR. Many of these chemicals are toxic
causing irritation to the mucous membranes, cancer, and genetic changes. Examples include:
Formaldehyde / formalin (used to preserve specimens)
Glutaraldehyde / Cidex (used for sterilization)
ETO (ethylene oxide used for sterilization)
• Anesthetic gases—these gases can escape from the anesthesia machine and can cause cancer, renal, brain,
and nerve damage if overexposed.
Every anesthesia machine should have a gas scavenging system attached to the machine to filter and
remove anesthesia gases. The ventilation systems in the OR help with eliminating the gas
• PMMA—polymethyl methacrylate—bone cement—it is a mixture of liquid and powder used to secure
prostheses in bone
It is very toxic to the mucous membranes, eyes (can damage soft contact lenses), and the respiratory tract
Bone cement implantation syndrome—the cement in the bone causes a reaction where emboli can travel
through the vessels to the lungs
PMMA can also cause hypotension (abnormally low blood pressure)

FIRE SAFETY

Fire safety guidelines:

• Class A fire—water—used for wood, paper, and textiles

• Class B fire—CO2—used for flammable liquids, gas, and oils
• Class C fire—Halon extinguisher—used for lasers and electrical fires
• PASS—acronym used for working the fire extinguisher:
P—pull
A—aim
S—squeeze
S—sweep

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• Most operating rooms use the acronym RACE to prepare employees for a potential fire:
R—rescue / remove anyone from the fire
A—alert / sound the alarm
C—contain the fire
E—extinguish/ evacuate

NATURAL DISASTERS

• Avalanche
• Rockslide landslide
• Winter storm, tropical storms, and hurricanes
• Heat wave—this is a prolonged period of abnormally hot weather that can cause many conditions
including death
Heat cramps—painful muscle cramps caused by exercise or working in a hot environment
Heat exhaustion—a condition caused by exposure to extreme heat. Symptoms include physical
weakness, collapse, nausea, muscle cramps, and dizziness
Heat stroke—this is caused by the body’s failure to regulate its temperature when exposed to excessive
heat along with dehydration. Symptoms include fever and confusion and can be as serious as
unconsciousness and death. This is a life-threatening condition. The body immediately needs to be
hydrated and cooled
• Wildfires
• Earthquakes
Richter scale is used to determine how powerful an earthquake is
Earthquakes can cause tsunamis/tidal waves

MAN-MADE DISASTERS

• These are caused by people, they include:

Explosions where chemicals are released into the environment including chemical weapons and bombs
Nerve agents—causes difficult breathing and death
Vesicants/mustard gas—causes damage to the skin, mucous membranes, and respiratory tract
Choking agents—cause damage to the respiratory tract and can cause pulmonary edema
• Car, plane, train accidents
• Nuclear devices/nuclear power plants
• Radiological devices
Dirty bomb—this type of bomb causing damage to the land, radiation sickness, and physical injury
including:
Sickness/cancer
Lacerations
Retinal burns/flash blindness
Damage to the land

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TERRORISM / BIOTERRORISM
Terrorism—is the use of threats and violence to intimidate a population in order to coerce them to take
certain actions or beliefs commonly relating to religion or politics
Bioterrorism / germ warfare—is a form of terrorism where biological agents are released to cause harm to
humans and the environment. They include:
• Anthrax
• Botulism
• Cholera
• Ebola
• Plague
• Smallpox
• Many more
These agents enter the body through the skin, mucous membranes, eyes, open wounds, and the
respiratory tract

EAP—EMERGENCY ACTION PLAN

HEALTH CARE FACILITY EAP

• All health care workers should know their responsibility in the event of a bioterrorism attack
• EAP—should be in place including a proper chain of command
Safe transfer and evacuation of patients to a safe place “safe zone”
All health care workers should know their responsibility in the event of a bioterrorism attack
PPE
Preserving blood, medications . . .
Backup generators
Laptops/medical records
A way to track the patients
Status of the patients

A HAZARDOUS EVENT WHICH INCLUDES MASS CASUALTY

• PATIENT DECONTAMINATION AREA

This area is important for chemical and radiological decontamination
Radiological decontamination
Clothing is removed and placed in a sealed bag
Wounds are cleaned with saline
Body and hair are cleaned with soap and water
Chemical decontamination
Clothing is removed
The skin and wounds are treated with sodium hypochlorite (one part bleach/nine parts H2O)—rinse
with normal saline

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 Do not use this solution in the eyes
• HOT ZONE—area where the disaster occurred
• WARM ZONE—300 ft or more from the hot zone
• COLD ZONE—near the warm zone where less severe injuries are evaluated
• TRIAGE CATEGORIES—this is a way of sorting patients according to the severity of their injuries

START—SIMPLE TRIAGE AND RAPID TREATMENT

• DIME—DELAYED / IMMEDIATE / MINIMAL / EXPECTANT—these are the four categories to

place patients during triage. A tag is placed on each patient, they include:
MINOR—green tag—minor injuries/ “walking wounded”
DELAYED—yellow tag—bleeding controlled, airway open, patient is stable
INTERMEDIATE—red tag—patient is in serious condition and needs to be treated immediately
within the hour which is the “GOLDEN HOUR” in order for the patient to survive
EXPECTANT—black tag—patient is beyond healing. They are given pain medication for comfort but
supplies are saved for the victims in the other three categories

SURGICAL TECHNOLOGISTS ROLE IN TRIAGE

• Train for triage

• Perform CPR
• Perform basic first aid
• Transport

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 Questions

1. Excessive exposure to radiation can affect the:

(A) integumentary system

(B) brain
(C) reproductive organs
(D) stomach

2. Radiation exposure of the staff is monitored with:

(A) a homing device

(B) a Holter monitor
(C) film badges
(D) a notation on each operative record

3. Ionizing radiation protection is afforded by the use of:

(A) iron
(B) ebonized coating
(C) zinc
(D) lead

4. A potential safety hazard associated with laser surgery is:

(A) eye injury

(B) electrical shock
(C) carcinogenic activity
(D) ionizing radiation exposure

5. An OR hazard that has been linked to increased risk of spontaneous abortion in female OR employees is
exposure to:

(A) x-ray control

(B) radium
(C) sterilization agents
(D) waste anesthetic gas

6. While using this mixture, a scavenging system is used to collect and exhaust or absorb its vapors. It is

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 called:

(A) glutaraldehyde
(B) polypropylene
(C) methyl methacrylate
(D) halon

7. The best measure for staff protection against HIV is:

(A) handling all needles and sharps carefully

(B) using barriers to avoid direct contact with blood and body fluids
(C) immunization of all staff with vaccine
(D) Both A and B

8. Which body organ is most susceptible to laser injury?

(A) Skin
(B) Gonads
(C) Eye
(D) Thyroid

9. How is inhalation of the laser plume best prevented?

(A) Double mask worn by scrub team

(B) Filter on suction
(C) Laser on standby whenever possible
(D) Mechanical smoke evacuator on field

10. What components are required for a fire and are found in an OR setting?

(A) O2
(B) Fuel
(C) Source of ignition
(D) All of the above

11. Fuel sources found at the surgical site include:

(A) dry sponges and drapes

(B) endotracheal tube
(C) prep solvents
(D) All of the above

12. STSR should ___________ to prevent buildup of heat created by friction.

(A) have suction available to remove smoke plume

(B) check all equipment before cases begin

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 (C) irrigate the active tip (high-speed drills)
(D) do not lay the fiber optic cord directly on the drape

13. A hospital fire plan is based on four immediate actions remembered by the acronym:

(A) PASS
(B) CODE
(C) OFSI
(D) RACE

14. To activate a fire extinguisher, what will be the correct order of the following: (1) sweep, (2) aim, (3)
squeeze, (4) pull?

(A) 1, 2, 3, 4
(B) 3, 2, 1, 4
(C) 4, 2, 3, 1
(D) 4, 3, 2, 1

15. The preferred type of fire extinguisher used for operating room fires is:

(A) water based

(B) CO2
(C) dry powder
(D) oil based

16. When an MRI is used, the primary risk to the patient is the presence of:

(A) CO2
(B) O2
(C) metal
(D) None of the above

17. Harmful toxins created during laser surgery and electrosurgery come in the form of:

(A) heat
(B) smoke plume
(C) anesthesia
(D) None of the above

18. Another name for a “no hands” technique is:

(A) retractable scalpel

(B) blunt trocars
(C) Hassan
(D) neutral zone

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19. Sources of latex include:

(A) wound drain

(B) catheters
(C) pneumatic tourniquet
(D) All of the above

20. Chemical hazards include:

(A) formaldehyde
(B) Cidex
(C) ETO
(D) All of the above

21. For a class A fire, the following is used to extinguish:

(A) water
(B) CO2
(C) halon
(D) None of the above

22. Natural disasters include:

(A) avalanche
(B) rockslide
(C) winter storm
(D) All of the above

23. A condition caused by exposure to extreme heat that causes physical weakness, collapse, nausea, and
muscle cramps is termed:

(A) heat stroke

(B) heat exhaustion
(C) heat cramps
(D) sunburn

24. A Richter scale measures:

(A) how powerful an earthquake is

(B) category of hurricane
(C) height of a tidal wave
(D) Both A and B

25. All apply to a dirty bomb EXCEPT:

(A) causes sickness and cancer

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 (B) damages land
(C) radioactive
(D) nuclear fallout

26. Bioterrorism uses biological agents to cause harm to humans and the environment. They include:

(A) anthrax
(B) botulism
(C) Ebola
(D) All of the above

27. Which decontamination process requires the use of sodium hypochlorite?

(A) Chemical decontamination

(B) Radiological decontamination
(C) Atomic decontamination
(D) Thermal decontamination

28. How many feet away from the disaster is the “warm zone”?

(A) 100 ft
(B) 300 ft
(C) 700 ft
(D) 1 mile

29. A triage patient wearing a black tag designates that they are in which category?

(A) Delayed
(B) Minor
(C) Expectant
(D) Intermediate

30. The so-called “golden hour” refers to:

(A) time of death

(B) 1 hour following the disaster
(C) mandatory treatment within 1 hour
(D) 1 hour preceding the disaster

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 Answers and Explanations

1. (C) Exposure to radiation can cause genetic changes, cancer, cataracts, injury to bone marrow, burns,
tissue necrosis, and spontaneous abortion and congenital anomalies.

2. (C) Film badges are the most widely used monitors measuring total REMS of accumulated exposure.
Data are reviewed.

3. (D) Shielding with lead is the most effective protection against gamma rays and x-rays in the form of
lead-lined walls, portable lead screens, lead aprons, lead-impregnated rubber gloves, lead thyroid--
sternal collars, and lead glasses.

4. (A) Eye and skin exposure must be avoided. Fire must be prevented. Avoid inhalation of laser plume.
Ionizing radiation is from x-ray exposure.

5. (D)Waste anesthetic gas is gas and vapor that escape from the anesthesia machine and equipment, as
well as gas released through the patient’s expiration. The hazards to personnel include an increased risk
of spontaneous abortion in females working in the OR, congenital abnormalities in their children as
well as in the offspring of unexposed partners of exposed male personnel, cancer in females
administering anesthesia, and hepatic and renal disease in both males and females. This problem can be
reduced by a scavenging system that removes waste gases.

6. (C)Methyl methacrylate, bone cement, is mixed at the sterile field. Vapors are irritating to eyes and
respiratory tract. It may be a mutagen, a carcinogen, or toxic to the liver. It can cause allergic dermatitis.
A scavenging system is used to collect vapor during mixing and exhaust it to the outside or absorb it
through activated charcoal.

7. (D)A patient may come to the OR infected but may not yet test positive. Careful handling of needles
and sharps and using barriers to avoid direct contact with blood and body fluids are the best measures to
prevent transmission. A vaccine has not been developed for immunization.

8. (C) The eye is the organ most susceptible to laser injury. Safety goggles should be worn at all times when
the laser is in use. The patient’s eyes must also be protected.

9. (D) A mechanical smoke evacuator or suction with a high-efficiency filter removes toxic substances
including carcinogens and viruses from the air. Personnel should not inhale the fumes.

10. (D) Fire requires three components. Oxygen available in the air or as in a pure gas, fuel, combustible

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 material, and a source of ignition usually in the form of heat.

11. (D) Any material capable of burning is a potential fuel for fire.

12. (C) When high-speed instruments are used such as drills and saws, the active tip should be irrigated to
prevent buildup of heat created by friction.

13. (D) RACE means rescue, alert, contain, and evacuate (Fuller).

14. (C) These steps can easily be remembered by the acronym PASS.

15. (B) The preferred type of fire extinguisher used in operating rooms is CO2.

16. (C) Whenever an MRI is used, the primary risk to the patient is the presence of metal. It can be drawn
from its source into the path of the powerful magnetic field.

17. (B) Smoke plume is created during laser and electrosurgery. It contains harmful toxins that must be
removed from the immediate surgical environment.

18. (D)This technique uses a hands-free space (designated receptacle) on the sterile field where sharps can
be placed and retrieved so that the surgical technologist and the surgeon do not hand instruments
directly to each other.

19. (D) All of the above are sources of latex.

20. (D) Formalin, Cidex, and ETO are all potential hazardous chemicals handled in the operating room.

21. (A) A class A fire uses water to extinguish. It is for fires consisting of wood, paper, and textiles. Class B
fire requires CO2 to extinguish and is for fires from liquids, gas, and oils. Class C fire requires a halon
extinguisher for lasers and / or electrical fires.

22. (D) An avalanche, a rock slide, and a winter storm are all examples of natural disasters.

23. (B)Heat exhaustion is caused by exposure to extreme heat. Symptoms include physical weakness,
collapse, nausea, and muscle cramps. Heat cramps are painful muscle cramps caused by exercise or
working in an extremely hot environment. Heat stroke is caused by the body’s failure to regulate its
temperature when exposed to excessive heat and dehydration. Symptoms include fever, confusion, and
can be as serious as unconsciousness and death.

24. (A) A Richter scale is used to determine how powerful an earthquake is.

25. (D) A dirty bomb causes sickness and cancer. It also damages the land and it is a radioactive type of
bomb, not nuclear.

26. (D) Anthrax, botulism, Ebola, plague, and cholera are all types of biological agents used in bioterrorism.

27. (A) Sodium hypochlorite is used for chemical decontamination (one part household bleach / nine parts

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 water and must be rinsed with NaCl). Radiological decontamination requires cleaning wounds with
saline.

28. (B) The “hot zone” is the area where the disaster occurred. The “warm zone” is 300 ft or more from the
hot zone. The “cold zone” is near the warm zone where there are less severely injured people.

29. (C)Expectant category is the triage category where the patient is tagged with a black tag meaning
beyond healing. They are given pain medication for comfort but no supplies will be used as they will be
used on the other patients. Minor category is the triage category marked by green tags. They have
minor injuries. The delayed category patients wear yellow tags meaning the patient is stable.
Intermediate category patients wear red tags and are in serious condition. These patients should be
treated within the hour.

30. (C) The “golden hour” refers to the patient being treated within the hour following their injury.

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 ___________________CHAPTER 32___________________

Endoscopy, Minimally Invasive Surgery, and Robotics

Principles of MIS
MIS—minimally invasive surgery—is performed using a rigid scope and long instruments. The
instruments are introduced through small incisions surrounding the operative site.
Trocar/cannula system—telescopic instruments are introduced through small incisions around the
operative site by a trocar (sharp trocar fits inside the cannula and is advanced beyond the tip of the cannula
and punctures the abdominal wall). The trocar is removed and the cannula is left in place to receive the
laparoscopic instruments.

• Port—is the incision where the cannula is left in place

• Cannulas—they protect the abdominal wall and maintain a seal between the inside of the body and the
outside
• Blunt trocar/Hasson—an infraumbilical incision is made and the open method (cut down) is performed.
The Hasson blunt trocar is inserted through this incision.
• Fiberoptic light source—is used to provide a cool illumination in the body cavity.
The fiberoptic light is designed to remain cool inside the body; however, it should never be placed on
the drapes because it can cause a fire.
The light cord is made up of thousands of glass fibers. It should not be tightly coiled as the cord fibers
can break. The cord should be handled carefully and loosely coiled
• Insufflation—this is the method of expanding the body cavity for visualization during MIS/endoscopic
surgeries. The term is called creating a pneumoperitoneum. Expansion medias include:
Laparoscopy—CO2
Arthroscopy—irrigation
Bladder—irrigation fluid (saline, glycine, sorbitol, etc.)
Inguinal hernia repair—balloon dissector

Multiple-Incision MIS

• One port for the camera

• Up to four other ports are placed for surgical instruments

Single-Incision Laparoscopic Surgery

• Also known as SILS

The incision is at the umbilicus

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 A large flexible port with three subports is placed into the umbilical puncture
Instruments and camera are placed through these ports
The disadvantage is that it is a tight space to work

Advantages to MIS Surgery

• Reduced trauma
• Reduced blood loss
• Reduced pain
• Quick recovery

Disadvantages / Hazards

• High risk of adhesions if the patient has had previous surgery

• Risk of perforation with the trocar
• Bleeding
• Limited vision and range of motion with the instruments
• All staff must be trained in MIS surgery
• Gas embolism
• Preperitoneal insufflation—improper placement of the Veress needle

Maintaining Patient Normothermia

• The use of CO2 lowers the body temperature because it cools as it fills the abdominal space
• Distension fluids used elsewhere (uterus, knee, etc.) have the same effect

Conversion to an Open Case

• Any MIS has the potential to become an emergency open case

• The STSR and circulator must have all sterile supplies ready to go in case of a conversion to an open case

Equipment Used in MIS Surgery

• Monitor
• Fiberoptic light source and light cord
• Rigid telescope. Care of the telescope includes:
Always holding the scope by its head
Be careful not to ding or hit the scope
Only use lint-free soft material to wipe the scope
Always check for damage before use
Prevent lens fogging with defogger
White balance:
Helps to focus the scope
When white balancing you should not use a 4 × 4. It must be a solid white background
Evens out the brightness

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 Prevents dark spots
Provides better picture quality
• Video camera
Pixel—this is the silicone chip located in a camera head or at the tip of the telescope. These pixels
determine the clarity of an image. The more pixels there are, the clearer the image
Focus ring—turns to clarify the image
Endocoupler—connects the camera to the telescope
• Video cables
• Digital output recorder
• Equipment cart
• Specialty scopes

Tissue Expansion Techniques

• Insufflation—CO2 for the abdominal cavity

• Continuous irrigation/fluid distension—uterus, bladder, joints
• Balloon expansion—expansion of tissue planes used in extraperitoneal hernia repair

Specimen Retrieval

• Morcellator—reduces large tissue specimens to small tissue pulp so it is small enough to be suctioned from
the wound. Not used in the presence of cancer
• Tissue shaver—commonly used in endoscopic cases. The shaver sucks tissue into the channel where a burr
shaves it down into small pieces before it is suctioned out
• Retractable tissue bag—large tissue specimens are put in a bag and pulled from a laparoscopic port or
through a small abdominal incision

Instruments

• The handles are at a distance from the working end

• Instruments are reusable and disposable
Retractors—probe, rods, hooks
Scissors—come in straight, hooked, curved, electrosurgery and ultrasonic sheers
Forceps—grasping instruments, examples include Maryland, Mixter, Allis, and claw grasper
Suction and irrigation
Hemostatic clips and staples
Knot pusher

Sutures

• Various instruments are designed to tie knots and suture tissue.

• There are three types:
Extracorporeal—the knot is tied outside of the body and pushed into place with a knot pusher
Intracorporeal—a surgical loop is used inside the body and tied with two grasping instruments

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 Ligation loop—Surgiwip—ligation ties instead of using a suture

Stapling Guns

• GIA is commonly used and inserted through a 12-mm port

• Laparoscopic hemoclip appliers

Endoscopic Surgery

• Endoscopes are used for diagnosis, biopsy, repair, and removal of foreign bodies
• Endoscopic surgery is performed by inserting instruments into the body through small narrow incisions or
a natural body orifice
• Diagnostic endoscopy—this is performed with a flexible, semirigid or rigid endoscope that is inserted into
a natural body orifice

Flexible Endoscopy

• Endoscope control head (connects to the camera)

• Insertion tube—the part of the scope that enters the patient and also contains the fiberoptic light channel
• Instrument channel—provides access for other instruments to retrieve tissue specimens. Examples include
biopsy forceps and brushes

Care for Endoscopes

• Endoscopes must be disassembled before cleaning

• Wash as soon as possible with an enzymatic cleaner
• Make sure all ports and channels are opened and flushed with an enzymatic cleaner
• Use a brush to clean all lumens
• Do not submerge the camera or allow electrical connections to become wet
• Rinse with deionized water or sterile water. All ports must be flushed
• Drain instruments and dry them
• Preclean
• Leak test—determines if there are any leaks in the flexible scope
• Instrument is cleaned, rinsed and all water is removed from the channels
• The scope is sterilized according to manufacturer’s instructions

Sterilization of Endoscopes

• Steam sterilization—this includes some parts of the endoscope. Examples are hollow sheaths and
obturators
• ETO—this is used for scopes and instruments that cannot be exposed to steam sterilization because high
temperatures and moisture will breakdown the cement holding the lens
• Cidex—instruments must be able to be submerged and all ports left open. Following the sterilization
process, the instruments must be thoroughly rinsed with sterile distilled water
Direct coupling—this occurs when the active electrode comes in contact with another instrument causing
the tissue touching the instrument to be burned. Examples include:

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 • When the surgeon asks you to hold a clamp while he touches the cautery to it to coagulate the tissue
• This can also be unintentional and cause a burn
Capacitive coupling—this occurs when there is a stray current that causes an unintentional burn

Lasers used in endoscopic procedures include:

• CO2 laser—laser of choice for bronchoscopies and arthroscopies

• Nd:YAG—GI, bronchoscopies, laparoscopic cholecystectomy, arthroscopies, GU, GYN, colonoscopies,
and neuroprocedures
• Stereotactic laser—brain tissue—neurology
• Argon—laparoscopic cholecystectomy, diabetic retinopathy/ophthalmology, and neurosurgery
• KTP—laparoscopic cholecystectomy and ophthalmology
• Excimer—arteries/vascular

Endoscopic and laparoscopic procedures include:

• Fetoscopy—this is performed for direct visualization of the fetus inside the uterus. It is performed under
sonographic visualization
A fiberoptic type of needle scope is inserted into the amniotic fluid to:
Obtain a biopsy of fetal blood
Direct viewing of the fetus for congenital abnormalities
This procedure can be performed at 16 weeks of gestation
• Angioscopy—this is performed to visualize the inside of vessels
The angioscope is a fiberoptic scope connected to a camera that is visualized on a monitor screen
• ERCP—endoscopic retrograde cholangiopancreatogram—this is performed to take a biopsy, remove
stones in the CBD, or dilate a stenosis of the bile duct by placing a stent
The scope is put through the mouth and gently moved down the esophagus. It extends into the stomach
and duodenum until it reaches the point where the ducts from the pancreas and gallbladder drain into
the duodenum. X-rays can then be taken.
• Hysteroscopy—this is performed to diagnose and treat conditions of the uterus. They include:
Menorrhagia
Fibroids
Polyps
Endometrial ablation
Remove IUDs
The uterus is distended with fluid and a rigid scope is inserted into the uterus
• Sigmoidoscopy/proctoscopy—a rigid or flexible endoscope for visual examination of the rectum and
sigmoid colon
Can be a flexible or rigid scope
This is routinely performed before rectal surgeries
This has helped in the early detection of tumors and polyps

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• Anoscopy—this is performed for an examination of the anus
A small rigid instrument is inserted a few inches into the anus to evaluate problems of the anal canal
• Gastroscopy—this is a flexible fiberoptic scope inserted through the mouth into the stomach
This is performed for:
Visual diagnosis
Bleeding
Biopsy
• Bronchoscopy—this is performed on the tracheobronchial tree
• Esophagoscopy—this procedure is performed to view the inside of the esophagus and the esophageal
orifice of the stomach for:
Biopsies and cytological brush biopsies
Removing foreign bodies
Diagnosis of diseases
Diverticula
Varices
Tumors, lesions
• It can be performed with a rigid or flexible scope
• The STSR’s job is to introduce suction, instruments, and bougies
• Endoscopic brow lift—this is a cosmetic procedure performed to lift the eyebrow. It elevates the drooping
eyebrow and removes deep wrinkle lines in the forehead. Three to five small incisions are inserted at the
hairline
• Endoscopic sinus surgery—this is the surgical treatment of sinusitis and nasal polyps performed to restore
ventilation and drainage
• Cystoscopy—viewing of the GU tract, specifically the bladder
• Ureteroscopy—viewing of the ureters
• TURP—transurethral resection of the prostate
• TURB—transurethral resection of bladder tumors
• Choledochoscopy—this provides images of the biliary system
It is introduced into the CBD and normal saline is used as the medium to provide distention for
visualization
This is commonly performed for removal of stones
The Nd:YAG laser can be introduced onto the scope to crush stones in the distal common hepatic duct
• Laparoscopic cholecystectomy—this is performed with a rigid scope inserted into the abdomen
The pneumoperitoneum is created with CO2
This can be performed with a:
Trocar and cannula system
Hasson blunt trocar
SILS

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• Laparoscopic hernia repair—there are two basic types, they include:
TAPP—transabdominal preperitoneal repair —this is the more conventional approach into the
peritoneal cavity with a trocar and cannula. The mesh is inserted through a peritoneal incision to cover
the hernia
TEP—totally extraperitoneal repair—TEP is different in that the peritoneal cavity is not entered and
mesh is used to seal the hernia from outside the peritoneum
A dissection balloon is inserted into the preperitoneal space to create a cavity.
The trocar and cannula are inserted and the laparoscopic procedure begins
• Laparoscopic Nissen fundoplication—this procedure is performed to restore the function of the lower
esophageal sphincter (the valve between the esophagus and the stomach) by wrapping the stomach around
the esophagus
• Laparoscopic liver biopsy—this utilizes laparoscopic instrumentation along with a needle biopsy
• Laparoscopic bariatric surgery—the most common procedures performed include:
Gastric bypass—a portion of the stomach is removed with laparoscopic instrumentation and guns and
reconnected to the duodenum
Sleeve gastrectomy—this is removal of a portion of the stomach along the greater curvature of the
stomach forming a sleeve or tubular stomach
Adjustable gastric band—this is an inflatable silicone band surgically implanted around the top of the
stomach creating a small pouch that holds a small amount of food.
• Laparoscopic appendectomy—this procedure is performed laparoscopically
• Laparoscopic colon resection—a technique known as minimally invasive laparoscopic colon surgery is
performed through small incisions with the laparoscope and instrumentation to resect a segment of the
colon
• Laparoscopic GYN procedures use a 10/12-mm scope with a 0-degree or 30-degree lens is inserted into
the peritoneal cavity. The pneumoperitoneum is created with CO2
Chromopertubation—this is performed to determine tubal patency
Methylene blue dye mixed with saline is injected into the vagina and observed with the laparoscope
going through the fallopian tubes
LAVH—laparoscopic-assisted vaginal hysterectomy—this procedure is performed using a laparoscope
and laparoscopic instruments into the abdomen to guide the removal of the uterus and/or fallopian tubes
and ovaries through the vagina
Laparoscopic ectopic pregnancy—this procedure is performed laparoscopically to remove the products of
conception from the fallopian tube or anywhere outside the uterus
Laparoscopic myomectomy—this procedure is performed laparoscopically to remove uterine
leiomyomas, also known as fibroids
Laparoscopic oophorectomy—removal of one or both ovaries laparoscopically
Laparoscopic salpingectomy—removal of one or both fallopian tubes laparoscopically
• Laparoscopic nephrectomy—removal of a kidney by percutaneous endoscopic technique through the

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 abdomen
• Endoscopic spinal discectomy—this endoscopic procedure is performed to remove herniated disc material
that is causing pain in the lower back, legs, arms, and neck
Although a scope is not inserted, a trocar system is used under fluoroscopy
A cutting type of instrument called a nucleotome is inserted through the trocar and the herniated
nucleus pulposus disc material is removed
• Ventriloscopy—this procedure is performed through a burr hole in the skull for the treatment of:
Hydrocephalus
Lesions in the sella turcica (this is a depression in the sphenoid bone where the pituitary gland rests)
Cerebral aneurysms
The argon laser can be inserted to remove intravascular lesions
Nd:YAG laser can be used to remove cysts
• Endovascular AAA—this procedure is performed to repair abdominal aortic aneurysms that begin below
the renal arteries through an incision into the femoral artery. The procedure involves the placement of a
stent graft into the aorta without opening the abdomen to reach the aorta. The procedure is performed by
an interventional radiologist or vascular/cardiac surgeon
• Radiofrequency ablation of varicose veins—this procedure uses radiofrequency energy to heat, collapse, and
seal blood vessels
• MIDCAB—minimally invasive coronary artery bypass surgery—it is also known as “beating heart”
surgery, which means that stopping the heart (cardioplegia) and the heart lung machine is not required
• Video-assisted thoracoscopic surgery—also known as VATS
It includes pathology of the thoracic cavity and lumbar spine
This is performed for the same reason as an open thoracotomy except that:
Recovery is quicker
Allows entry into the chest cavity without removing a rib or spreading them, both which are painful

Robotics

• The most commonly used robot is the Da Vinci robot by Intuitive Surgical
• Provides three-dimensional viewing
• Telchir—the name given to remote controlled robots
• Instrumentation with better rotation than a surgeon’s hand (endowrist instruments) and more precise
surgical movements
• They require surgeon control and input by remote control and voice activation
• They can perform procedures from a distance
• Shorter stay in the hospital
• The robot is commonly used on:
Cardiac surgery
Colorectal surgery
General surgery

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 Gynecological surgery
Head and neck surgery
Thoracic surgery
Urological surgery
• Manipulators—the technical term for robotic arms
Can move in three dimensions:
• Articulated—The sections of the robot arms (manipulators)
• Motions of the robot are described in geometric terms
• Degrees of freedom—the number of ways the manipulators move in three dimensions (yaw, roll, pitch)
Yaw—right and left movement
Roll—rotating movement
Pitch—up and down movement
Grip—open and close
Insertion—back and forth
• Degrees of rotation—this relates to the manipulators’ clockwise and counterclockwise movement around
an axis
• Resolute geometry—refers to the robotic arm that can move in three dimensions, it resembles the
movements of a human arm
• Resolution—it is the robot’s ability to differentiate between two objects
• Sensitivity—the ability of the robot to see in dim light or detect weak impulses
• Telesurgery—the term used to perform surgery at a distance
• Binaural hearing—this gives the robot the ability to hear what direction sound is coming from. The robot
has two sound transducers as we have two ears
• Cartesian coordinate geometry—(allows the robot to locate a point in three dimensions). This refers to a
plane that is perpendicular to each other and used to graph mathematical functions. Also called rectangular
coordinate geometry
• Micromanipulators—the computer translates messages from micromanipulators on the remote console
controlled by the surgeon’s hand. This translates the surgeon’s hand movements to the robotic arm and
instrumentation
• Telepresence—refers to the operation of a robot at a distance. The operator is in one location and the
patient and robot are in another

Components of the Robot

• Console—where the surgeon sits to control the manipulators and performs the surgical procedures
• Patient-side cart—this cart system contains the robotic arms that directly contact the patient
• Manipulators—four robotic arms
• High-definition three-dimensional vision system
• Endowrist instruments—instruments placed in the manipulators
Cautery

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 Grasping instruments
Needle holders
Retractors
Hemoclip appliers
Each insertion into the robot with an instrument represents one use of the instrument. The average
amount of uses is 10

Advantages

• Eliminates hand tremors

• Allows the surgeon to perform complex procedures within a small space
• Better visualization through three-dimensional imaging
• 360-degree wrist movement
• Instruments bend and rotate better than the human wrist
• Telepresence—the procedure can be performed from a distance the patient can be at one hospital and the
surgeon at another. This represents virtual reality

Disadvantages

• Very expensive
• Instruments cost thousands of dollars each
• Requires special training

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 Questions

1. All of the following applications can be performed through an endoscope EXCEPT:

(A) cavity washings for diagnosis

(B) video monitoring
(C) biopsy
(D) resection of malignant tumors

2. During minimally invasive surgery (MIS), what is used to achieve a pneumoperitoneum?

(A) Warm saline

(B) Oxygen
(C) Carbon monoxide
(D) Carbon dioxide

3. Not all patients are suitable for MIS. The term is for patients who have scarring of internal organs due
to previous abdominal surgeries is:

(A) abdominal adhesions

(B) wound dehiscence
(C) intestinal polyps
(D) evisceration

4. Which endoscope is used to perform surgical assessment and operative procedures such as a TURP?

(A) Flexible endoscope

(B) Rigid endoscope
(C) Laparoscope
(D) Sigmoidoscope

5. The system used to accommodate insertion of a laparoscope and endoscopic instruments is called:

(A) diagnostic endoscope

(B) trocar and cannula
(C) Veress needle
(D) endocoupler

6. When performing MIS in the upper abdomen or the lower esophagus the patient is positioned in:

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 (A) Trendelenburg
(B) lateral
(C) reverse Trendelenburg
(D) prone

7. For a laparoscopic tubal ligation, the patient is placed in:

(A) lithotomy
(B) semi-Fowler
(C) lateral
(D) reverse Trendelenburg

8. All of the following statements are true of the fiberoptic light cord EXCEPT:

(A) the cable is composed of thousands of glass or plastic fibers

(B) the fibers are aligned in parallel longitudinal bundles
(C) the cord can be overflexed and coiled
(D) fibers are easily broken

9. The clarity of the image depends on the number of signals or silicone units the chip contains. The name
for these silicone units is:

(A) adapter
(B) pixel
(C) endocoupler
(D) Storz

10. All are guidelines for proper handling of a telescope EXCEPT:

(A) take care to prevent scratches or dents in the shaft of the scope
(B) always hold the scope by its shaft
(C) use warm water or a defogger to prevent the lens from fogging during surgery
(D) everyone who handles the scope from processing to end stage is responsible to ensure integrity of
the instrument

11. What part of the endoscopic equipment transmits digital data from the camera head to the camera
control unit and from the monitor to the output recorder?

(A) Endoscopic lock ring

(B) Focus ring
(C) Video cables
(D) Video printer

12. All of following are true of white balancing EXCEPT:

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 (A) the light cable must be connected to the telescope
(B) direct the lens to a solid white object
(C) you can use the back of sterile drape or a surgical sponge
(D) the white balance registers automatically by the light source

13. Technique used in arthroscopic MIS, hysteroscopy, and cystoscopy to expand the body cavity is:

(A) balloon dissection

(B) continuous irrigation
(C) insufflations
(D) infiltration

14. Injury from continuous irrigation where the fluid enters the vascular system is:

(A) embolization
(B) endoscopic distension
(C) extravasation
(D) ablation

15. In MIS, large specimens and dense tissue are reduced to small pieces by a process called:

(A) morcellation
(B) harmonic ultrasonic energy
(C) ablation
(D) fulguration

16. Guidelines for cleaning endoscopic instruments include all of the following EXCEPT:

(A) soak instruments for 2 hours

(B) before cleaning, open all stop cocks, ports, and channels
(C) look for defects in the surface of the instrument before cleaning
(D) drain and dry all instruments

17. What term identifies the arms of a robot in surgery?

(A) Articulations
(B) Ratchets
(C) Graspers
(D) Manipulators

18. An “up and down” movement of a robot’s arm is known as:

(A) roll
(B) yaw
(C) pitch

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 (D) rotation

19. The “right to left” movement of a robotic arm is called:

(A) yaw
(B) roll
(C) pitch
(D) x–y–z-axis rotation

20. What term is used when likening “robotic vision” to “human vision”?

(A) Sensitivity
(B) Binocular vision
(C) Depth perception
(D) Resolution

21. What allows the robotic computer to create and record three-dimensional data of the surgical site?

(A) Magnetic resonance sites

(B) Image planning
(C) Laser scanning
(D) CT scan

22. Which of the following parts for robotic surgery should NOT be sterilized?

(A) Manipulators
(B) The collar that connects the endoscope
(C) The endoscope
(D) Surgical instrumentation

23. Sterilization of component parts for endoscopic robotic surgery is best accomplished by:

(A) STERIS system

(B) steam sterilization
(C) hydrogen peroxide sterilizer
(D) EtO gas sterilization

24. The most popular robotic system used today is:

(A) AESOP
(B) da Vinci system
(C) surgical navigation system
(D) Both A and B

25. All are advantages of robotic surgery EXCEPT:

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 (A) reduction of hand tremors
(B) plays a role in distant surgical interventions
(C) it is expensive and uses valuable resources
(D) robotic images are three dimensional

26. What term is used when the surgeon performs the surgical procedure miles away from the surgeon?

(A) Expert systems

(B) Telesurgery
(C) Coordinate geometry
(D) Degrees of freedom

27. What term is referred as the ability of humans and robots to determine which direction sound is coming
from?

(A) Binaural hearing

(B) Unidirectional hearing
(C) Voice activated
(D) Automated hearing

28. The technical term for the extent that a robotic joint or joints can move clockwise or counterclockwise
around an axis is:

(A) manipulation
(B) degree of freedom
(C) roll
(D) degrees of rotation

29. The ability of a machine, microscope, human, and robot to differentiate between two objects is called:

(A) resolution
(B) binaural vision
(C) cylindrical geometry
(D) degrees of freedom

30. The goal of deformable modeling is:

(A) replace an MRI

(B) translate a surgeon’s hand movements
(C) achieve a three-dimensional model
(D) position the manipulators

31. The ability of the robot to see in dim light is known as:

(A) stereovision

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 (B) binaural vision
(C) sensitivity
(D) depth perception

32. Which term refers to a rotating movement?

(A) Pitch
(B) Rotation
(C) Roll
(D) A 360-degree turn

33. The position used for a robotic-assisted prostatectomy is a:

(A) lateral kidney

(B) low lithotomy
(C) pfannenstiel
(D) prone

34. The STSR’s responsibility when setting up for a robot case includes:

(A) check all instruments prior to using

(B) white balance and calibrate camera
(C) determine where the third arm will be placed
(D) All of the above

35. Where is the robot positioned during a prostatectomy?

(A) Right side

(B) Left side
(C) Between legs
(D) At the head

36. The #3 arm of the robot moves:

(A) up and down

(B) in and out
(C) right and left
(D) left only

37. The #1 arm of the robot holds:

(A) scope and camera

(B) instruments
(C) insufflation tubing
(D) None of the above

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38. STSR’s responsibility when changing instruments on the robotic arm is:

(A) advance the instrument

(B) guide the instrument
(C) choose the next instrument
(D) wash the instrument

39. The robotic system does not engage until the surgeon:

(A) positions the foot switch

(B) robotic arms are engaged
(C) places head in the viewer
(D) surgeon speaks into microphone in console

40. When performing a cholecystectomy using the robot, the robotic arm is placed:

(A) right side, midabdomen

(B) patient’s left side midabdomen
(C) patient’s right thigh level
(D) patient’s left thigh level

41. Which anatomical landmark is used to line up the endoscope for a laparoscopic cholecystectomy using a
robotic arm?

(A) Umbilicus
(B) Chest line
(C) Iliac crest
(D) Xiphoid process

42. A flexible fiberoptic device used to view a fetus in utero is termed:

(A) hysteroscope
(B) laparoscope
(C) fetoscope
(D) Both A and B

43. A Hasson is:

(A) a type of instrument used to grasp the GB

(B) a blunt trocar inserted into the abdomen through an infraumbilical incision
(C) used on a SILS procedure to hold the instrumentation
(D) a type of three-point trocar

44. Disadvantages to MIS surgery include all except:

(A) high risk of adhesions if the patient has had previous surgery

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 (B) bleeding
(C) risk of perforation with the trocar
(D) All of the above

45. The part of the camera that connects the camera to the scope is termed:

(A) pixel
(B) coupler
(C) endocoupler
(D) focus ring

46. Instruments used in MIS surgery include:

(A) suction irrigation

(B) Maryland
(C) probes
(D) All of the above

47. Direct coupling refers to:

(A) the surgeon touching the ESU to an instrument being held by the STSR
(B) this occurs when the ESU is accidently activated while in contact with another instrument causing
the current to travel to the other instrument and cause a burn
(C) stray current caused by improper placement of the grounding pad
(D) None of the above

48. The procedure performed to take a biopsy, remove stones from the CBD, and dilate a bile duct stenosis
with a stent is termed:

(A) ERCP
(B) laparoscopic Nissen fundoplication
(C) TAPP repair
(D) choledochoscopy

49. The laparoscopic bariatric surgery that removes a portion of the stomach and reconnects it to the
duodenum is:

(A) gastric bypass

(B) sleeve gastrectomy
(C) gastrectomy
(D) adjustable gastric band

50. What procedure used methylene blue dye mixed with saline and is injected into the vagina and observed
with the laparoscope going through the fallopian tubes to check for tubal patency?

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 (A) LAVH
(B) Chromopertubation
(C) Laparoscopic tuboplasty
(D) Laparoscopic salpingectomy

51. Ventriloscopy is performed through a burr hole in the skull for the treatment of:

(A) hydrocephalus
(B) lesions in the sella turcica
(C) cerebral aneurysms
(D) All of the above

52. The procedure uses radiofrequency energy to heat, collapse, and seal blood vessels is:

(A) ablation
(B) cautery
(C) cryothermy
(D) None of the above

53. MIDCAB—minimally invasive heart bypass surgery is also known as:

(A) beating heart surgery

(B) bloodless surgery
(C) ½ CB . . . . surgery
(D) All of the above

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 Answers and Explanations

1. (D) Resection of malignant tumors is usually approached through large open incisions because the cavity
must also be explored after removal of the tumor.

2. (D) Carbon dioxide is used to achieve a pneumoperitoneum because it is nontoxic, readily absorbed by
the body and nonflammable.

3. (A) Patients who have had previous abdominal surgery and have developed scarring of their organs or
adhesions are at risk for a perforation of their intestines during insertion of the trocar.

4. (B) A rigid endoscope would be used on a TURP. A laparoscope, although rigid, is only used on the
abdomen whereas a flexible endoscope is used to assess regional anatomy, tissue biopsies, and minor
surgical procedures.

5. (B) A trocar is a solid rod with a tapered or solid end that fits into the hollow tube cannula.

6. (C) Reverse Trendelenburg position is used to displace the abdominal viscera for better visualization.

7. (A) Laparoscopic GYN cases are commonly performed with the patient in lithotomy position. This
allows the surgeon the ability to manipulate the uterus during the procedure.

8. (C) You must handle the fiberoptic cables gently. When storing or transporting the cable, you must coil
it loosely. Do not hang the cable. It must be stored in a flat position.

9. (B) Pixels are located in the head of the camera or the tip of the telescope. The more the pixels, the
clearer the image.

10. (B) Scope should always be held by the head, which is the heavier end, and never by the end or the shaft.
When holding the scope by the lighter end, the weight of the handpiece can bend the shaft and damage
it

11. (C) The video cables are high-quality fiberoptic systems. They transmit data from the camera head to
the camera control unit and from the monitor to the output recorder.

12. (C) You should not use porous or woven materials such as a surgical sponge because this can produce
shadows on the image.

13. (B) Continuous irrigation is used to expand the space for visualization and should be nonconductive and

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 salt free.

14. (C) When an increase in fluid instillation exceeds a safe level, it can cause extravasation when the fluid
enters the vascular system and increases blood pressure.

15. (A) The morcellator reduces the tissue to pulp, which can be suctioned from the wound.

16. (A) Do not soak instruments for longer than 1 hour or as directed by manufacturer. Do not submerge or
allow fluid to enter electrical connections or units.

17. (D) The term used to identify the robotic arms that control the surgical efforts is manipulators.

18. (C) Pitch identifies the up and down movement of the arms jaw, and yaw identifies right and left
movement of the jaw. The rotating movement of the shaft is called a roll.

19. (A) A “right to left” movement of a jaw is called a yaw.

20. (B) Binocular machine vision is analogous to human vision, which is also known as stereovision. This
vision is similar to the robot’s binaural hearing.

21. (C) Once an MRI or CAT scan is performed to retrieve a layout of the person’s anatomy, a laser scan is
then done to achieve a set of three-dimensional coordinates on the patient’s skin.

22. (A) The manipulators that hold the endoscope and the instrumentation are not sterilized, they are
covered with a sterile sleeve.

23. (A) The “STERIS system” (peracetic acid) sterilizer is ideal for sterilization of camera, light cord, and
other delicate components used for the procedure.

24. (B) The primary robotic system used in the operating room today is the da Vinci System.

25. (C) Robotics requires a substantial investment in both time and money, spent learning coordinating and
the imaging system. Instruments cost thousands of dollars and must be discarded after limited use.
They cannot be recycled.

26. (B) Telesurgery refers to the operation of the robot at a distance, the operator is at one location and the
robot is on site with the patient at another location.

27. (A) Binaural hearing is the ability to determine the direction the sound is coming. Humans have two
ears and robots are given two sound transducers that provide the same ability.

28. (D) Degrees of rotation relate to a manipulator’s clockwise and counterclockwise movements around an
axis.

29. (A) Resolution is the extent that a machine, microscope, human, and robot use to differentiate between
two objects.

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30. (C) The goal of a deformable model is to achieve a realistic three-dimensional simulation of soft tissue
behavior under the effect of an external simulator.

31. (C) In some instances, a high level of sensitivity is necessary. An example of this is during an endoscopic
case, OR lights are dimmed or turned off. The robot requires a level of sensitivity to see in such dim
lighting.

32. (C) The rotating movement of a robot is called a roll.

33. (B) The patient is placed in lower lithotomy and the robotic arms are placed between the patients’ knees.

34. (D) The STSR’s duties include checking instruments, while balancing calibrating camera and making
sure the third arm is properly placed.

35. (C) During prostatectomies, the robot is placed between the legs, so the robotic arms come up from the
bottom.

36. (C) The #3 arm on the robotic system swings right and left.

37. (A) The #1 arm on all robots accommodates the scope and camera.

38. (B) The STSR’s responsibility is to only guide the instrument for the surgeon as his/her eyes are on the
screen. They should NEVER advance the instrument for fear of perforating the colon.

39. (C) Before surgery, the surgeon makes adjustments to the seating, optical viewer, and intercom while
his/her head is outside the viewer. The system is engaged when the surgeon places their head in the
viewer.

40. (C) The robotic arm is placed on the patients’ right thigh level.

41. (D)The xiphoid process is used as a landmark prior to starting a laparoscopic cholecystectomy.

42. (C) A fetoscope is a flexible fiberoptic device used to view a fetus in utero. A hysteroscope is a thin,
lighted instrument that is inserted into the vagina to examine the cervix and inside of the uterus for a
diagnosis or treatment of bleeding. A laparoscope is used to perform MIS procedures in the abdomen.

43. (B) The Hasson Is a blunt trocar inserted into the abdomen through an infraumbilical incision. It is an
open method by using a cut-down procedure for laparoscopic surgery instead of using the three-point
trocar and cannula system.

44. (D) Disadvantages to MIS surgery include:

• High risk of adhesions if the patient has had previous surgery

• Risk of perforation with the trocar

• Bleeding
• Limited vision and range of motion with the instruments

719
 • All staff must be trained for MIS surgery
• Gas embolism

• Preperitoneal insufflation—improper placement of the Veress needle

45. (C)Endocoupler connects the camera to the telescope. A pixel is the silicone chip located in a camera
head or at the tip of the telescope. These pixels determine the clarity of an image. The higher the pixels,
the clearer the image. The Focus ring turns to clarify the image.

46. (D) All of the above are instruments used on MIS surgery.

47. (B) This occurs when the ESU is accidently activated while in contact with another instrument causing
the current to travel to the other instrument and cause a burn.

48. (A) ERCP—endoscopic retrograde cholangiopancreatogram—the procedure performed to take a biopsy,

remove stones in the CBD, and dilate a stenosis of the bile duct by placing a stent. A laparoscopic
Nissen fundoplication is performed to restore the function of the lower esophageal sphincter by
wrapping the stomach around the esophagus. The TAPP—transabdominal preperitoneal repair is the
more conventional approach into the peritoneal cavity with a trocar and cannula. The mesh is inserted
through a peritoneal incision over the hernia. Choledochoscopy provides images of the biliary system.

49. (A)Gastric bypass is performed by a portion of the stomach is removed with laparoscopic
instrumentation and guns and reconnected to the duodenum. A Sleeve Gastrectomy is removal of a
portion of the stomach along the greater curvature of the stomach forming a sleeve or tubular stomach.
A Gastrectomy procedure is removal of the stomach for cancer. The adjustable gastric band is an
inflatable silicone band surgically implanted around the top of the stomach creating a small pouch that
hold a small amount of food.

50. (B) Chromopertubation this is performed to determine tubal patency, methylene blue dye is mixed with
saline is injected into the vagina and observed with the laparoscope going through the fallopian tubes.
LAVH—laparoscopic-assisted vaginal hysterectomy—this procedure is performed using a laparoscope
and laparoscopic instruments to guide the removal of the uterus and/or fallopian tubes and ovaries
through the vagina. Laparoscopic tuboplasty is performed to repair patency to the fallopian tube.
Laparoscopic salpingectomy is removal of the one of both fallopian tubes laparoscopically.

51. (D) All of the above procedures can be performed with a ventriloscope.

52. (A) Radiofrequency ablation uses radiofrequency energy to heat, collapse, and seal blood vessels.
Cryotherapy uses a method of localized freezing temperatures.

53. (A) MIDCAB is a minimally invasive heart bypass surgery. It is also known as “beating heart” surgery.
No heart lung machine is necessary.

720
721
 Bibliography

American Heart Association. BLS for the Healthcare Provider. Dallas, TX: American Heart Association; 2010.
Association of Surgical Technologists. Surgical Technology for the Surgical Technologist: A Positive Care
Approach. Littleton, CO: Association of Surgical Technologists; 2004.
Ball KA. Lasers: The Perioperative Challenge. 2nd ed. St. Louis, MO: Mosby-Year Book; 1995.
Bergquist LM, Pogosian B. Microbiology Principles and Health Science Applications. Philadelphia, PA: W.B.
Saunders; 2000.
Burke WM, Gossner G, Goldman NA. Robotic surgery in the obese gynecologic patient. Clin Obstet Gynecol.
54(3):420–430.
Frey K, Price P. Technological Sciences for the Operating Room. 1st ed. Centennial, CO: Association of Surgical
Technologists; 2002.
Fulcher EM, Soto CD, Fulcher RM. Pharmacology: Principles and Applications. A Worktext for Allied Health
Professionals. 1st ed. Philadelphia, PA: Saunders; 2003.
Fuller JK. Surgical Technology: Principles and Practice. 4th, 5th ed. Philadelphia, PA: W.B. Saunders; 2005,
2010.
Lehne RA. Pharmacology for Nursing Care. 4th ed. Philadelphia, PA: WB Saunders Co; 2001.
Meeker M, Rothrock J. Alexander’s Care of the Patient in Surgery. 14th ed. St. Louis, MO: Elsevier; 2011.
Miller BF, Keane CB. Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. 2nd ed.
Philadelphia, PA: W.B. Saunders; 1978.
Mosby’s Medical, Nursing, and Allied Health Dictionary. 8th ed. St. Louis, MO: Mosby-Year Book; 2009.
Nemitz R. Surgical Instrumentation: An Interactive Approach. St. Louis, MO: W.B. Saunders; 2010.
Phillips N. Berry and Kohn’s Operating Room Technique. 10th, 11th ed. St. Louis, MO: Mosby; 2004, 2007.
Price P, Frey K. Microbiology for the Surgical Technologist. Clifton Park, NY: Delmar Learning; 2003.
Rutherford C. Differentiating Surgical Equipment and Supplies. Philadelphia, PA: F.A. Davis; 2010.
Rutherford C. Surgical Equipment and Supplies. 2nd ed. Philadelphia, PA: F.A. Davis; 2016.
Stryker Endoscopy: Video Endoscopy for Perioperative Nurses—A Study Guide. Denver, CO: Stryker.
Tighe SM. Instrumentation for the Operating Room: A Photographic Manual. 8th ed. St. Louis, MO: Elsevier;
2012.
Tortora GJ, Derrickson BH. Principles of Anatomy and Physiology. 12th ed. Wiley; 2009.
Tortora G, Funke B, Case C. Microbiology: An Introduction. 7th ed. Menlo Park, CA: Benjamin Cummings;
2001.
Venes D. Taber’s Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: F.A. Davis; 2009:329.

722
723
 Index

Please note that index links point to page beginnings from the print edition. Locations are approximate in e-readers,
and you may need to page down one or more times after clicking a link to get to the indexed material.

A
Abandonment, 124, 127
Abdominal adhesions, 447, 452
Abdominal aortic aneurysm (AAA), 351–352, 357, 360
endovascular, 352
grafts for, 352
occur in, 357, 360
Abdominal aortic aneurysmectomy, 354, 359
Abdominal midline, 185
Abdominal/thoracic linear staple guns, 188, 192
Abdominal wall, tissue layers of, 221, 234
Abdominoperineal resection (APR), 100, 106
Abdominoplasty, 298, 304
Abduction, 1, 3
pillow, 390, 391, 399
Abortion, complete, 253
Abruptio placentae, 2, 3
Absorption, 29, 36
Acceleration, 423, 429
Acetabulum, 389, 398
Achilles, 395, 401
Acoustic neuroma, 278, 364, 373, 378
Activated clotting time (ACT), 356, 360
Active drains, 187
Active electrode, 420, 421, 422, 427
Active postoperative drains, 189, 193
Adduction, 1, 3, 382, 399

724
Adenoids, 281, 288
Adhesion, 302, 306
Adrenalin, 26, 35
Adult vertebral column, 396, 402
Advanced directive, 124, 127
Adverse reaction, 29, 36
Aeger primo, 125, 127
Aerobic bacteria, 8, 119
AESOP, 449
Agglutination, 42, 43
Airway impairment, 409, 414
Alexander, 335
Alexander periosteotome, 173, 316
Allergic reaction, 9, 14
Alligator forceps, 285
Allis, 318, 324
Allison retractor, 337
Allograft, 304
Alternate voltage, 421, 427
Alternating current (AC), 421, 427
Alvarado, 375, 379
Alveoli, 2, 3
Amnesia, 28
Amperes, 420, 427
Amplitude, 329, 424
Ampulla of Vater, 225, 235
Amputated extremities, 354, 359
Amputated limb, 116, 119
specimen analysis, 116
Amputation, 352–353
Anaerobic bacteria, 119
Anal canal, 225, 235
Anaphylactic shock, 9, 14
Anastomoses, 331, 335
Anastomoses, for single-lung transplant, 331, 335
Andrews table, 366
Anectine, 30, 34, 37
Anencephaly, 365, 378

725
Anesthesia
balanced, 44, 53
general, 46, 54
Anesthesiologist, 98, 105
Aneurysm, 356
Aneurysms, 2, 4, 340, 352, 356, 360, 365
Angina, 340
Angiography, 129, 339, 349, 366
pulmonary, 130
Angioplasty, 340, 350
Angioscope, 349
Anterior, body, 1, 3
Anterior cervical decompression and fusion, 368
Antibiotics, 29
Anticholinergic drug, 23, 33, 264
Anticoagulants, 29, 36
Antiembolic stockings, 253
Antiembolism, 101
Antiemetic, 28, 30, 36
Antigravity suit, 157, 173
Antimuscarinic, 25, 34
Anxiety, 25, 34
Aorta, 349
Aortic valve, 341, 343, 347
Aortofemoral bypass, 352
Apnea, 2, 4
Aqueduct of Sylvius, 364, 375, 379
Arachnoid mater, 364
Arch bars, 287
Argon/Nd:YAG laser therapy, 264
Arrhythmia, 2, 3, 339, 344, 347
Arterial
catheter, 349
embolectomy, 350
needles, 186, 187, 191
plethysmography, 349
Arterial blood gases (ABGs), 27, 35, 40, 42, 43, 331, 333, 335–336, 342, 346
Arteries, 349, 357, 361

726
Arteriogram, 339
Arteriosclerosis, 349
Arteriotomy, 357, 360
Arteriovenous
fistula, 350
malformation, 367
shunt, 351
Arthrography, 130
Artificial disk replacement, 368
Asepsis, 10, 14
Aseptic technique, 8, 13, 51
Aspiration biopsy, 130
Astrocytoma, 364
Atherosclerosis, 349, 356, 357, 360, 361
Atlas, cervical vertebra, 375, 379
Atresia, 2, 3
Atrial fibrillation, 339
Atrial septal defect, 2, 3, 341
Atrioventricular node, of heart, 339
Autogenous graft, 355, 360
Autograft, 356, 360
Autologous, 358, 361
blood, 41, 43
Automated external defibrillator (AED), 339
Autonomic nervous system, 363, 374, 378
Auvard speculum, 175
AV fistula, 357, 361
Avitene, 23, 33, 43, 350
Axillofemoral bypass, 352
Axis, cervical vertebra, 375, 379

B
Babcock forceps, 155, 172
Bacteria cultures, 116, 119
Bacteriostatic, 8, 13
Bailey retractor, 331, 335, 337
Bailey rib approximator, 155, 172
Baker’s cysts, 389, 398

727
Bakes dilators, 160, 174
Balanced salt solution, 257, 263
Balfour retractor, 161, 171
Ballenger swivel knife, 155, 156, 172
Bariatric surgery, 411, 414
Bartholin’s cyst, 247, 253
Bartholin’s glands, 239
Basal cell carcinoma, 297
Basins in autoclave, positioning of, 66
Bayonet forceps, 156, 172, 285
Beaver knife handle, 158, 173
Benign spine tumors, 368
Benzodiazepines, 29
Bethune, 335
Bier block, 26, 34
Bilateral lung transplant, 332, 336
Bioburden, 67, 72
Biological control test, 63, 70
Biopsy, 115, 130
aspiration, 130
brush, 116, 119, 130
excisional, 119
frozen, 132, 134
incisional, 117, 119, 130
lymph nodes, 1, 3, 328
of scalene, 331, 335
Biopsy needle, 187
Bioterrorism, 437, 439
Bladder stones, 317, 323
Blades counting, 110
Blebs, 328, 333, 337
Blepharoplasty, 300, 305
Blood
ABGs, 40
autologous, 41, 43
to brain, 364, 375, 379
carbon dioxide in, 40
collateral circulation flow, 352

728
 count, 39
cross-matching of, 42, 43
donor, 39, 41, 43
flow in heart, 339
HCO3 level, 40
homologous, 41, 43
oxygenation, 42, 44
pH levels, 40
platelets, 42, 44
prothrombin time, 40
transfusion, 39
types, 39
vessels, 349, 357, 360
Blood pressure, 371, 376
diastolic, 350
systolic, 350
Blood clotting mechanism, 23, 33
Blood oxygenation, 26, 35
Blue-green beam, 425, 429
Blunt grasper, 176
Blunt needle, 190
Bone
face, 363
growth, 390, 398
healing, 393, 394, 400, 401
infection, 397, 403
wax, 366
Bookwalter, 159, 161, 174
Bougie dilators, 174
Bougies, 160, 173
Bovine blood, 426, 430
Bowman probes, 154, 172
Bozeman uterine dressing forcep, 175
Brachial artery, 351
Brachial plexus, 369
Brachial plexus injury, 99, 106
Bradycardia, 2, 3, 339, 343, 347

729
Brain, 364, 368
blood to, 375, 379
electrical activity measurement, 372, 377
respirations and, 374, 378
tumors, 373, 374, 378
Brainstem, 364
Breast biopsy, 145
Breathing, 331, 335
Bronchial washings, 331, 335
Bronchoscopy, 328, 330, 331, 335, 336
Broviac catheter, 350
Brush biopsy, 116, 119, 130
Bugbee electrode, 163, 175
Bulb syringe, 245, 251
Bulldogs, 357, 360
Bullet specimen, 117, 119
Bunionectomy, 393, 400
Burn classification, 200
Burr holes, 365, 370, 371, 376, 377

C
CAAHEP accredits programs, 127
Cancerous tumor, 411, 415
Capnometer, 27, 35
Carbon dioxide, 447, 452
Cardiac
arrhythmias, 339
cannulation, 340
conduction system, 339
instrumentation, 340
surgery, 344, 347
transplantation, 340
valve replacement, 341
Cardiac catheterization, 129–130, 132, 134, 339, 342, 346
arteries in, 344, 347
laboratory, 343, 346
Cardioplegia, 341
Cardiopulmonary bypass, 340

730
C-arm, 129
Carotid endarterectomy, 351, 354, 356, 359, 360, 371, 377
Carpal bone, 392, 400
Carpel tunnel syndrome, 367
Case opening, recommendations for, 81
Cassettes, 129
Catheter, 277, 286
Catheters, 340
Cavitron ultrasonic surgical aspirator (CUSA), 366, 375, 379
30-cc syringe, 23, 33
Cell membrane, 8, 13
Cell salvage machine, 358, 361
Cell saver, 40, 42, 43, 352
Central nervous system (CNS), 363
Central venous catheters, 349, 357, 361
Central venous pressure (CVP) catheter insertion, 159, 174
Cerebellum, 364, 374, 378
Cerebral aneurysms, 374, 378
Cerebral hemisphere, 364
Cerebrum, 364
Cervical carcinoma, 244, 251
Cervical conization, 245, 251
Cervical dilatation, 243, 250
Cervical spine, 158
Cervical vertebra, 375, 379
Cervical vertebrae, 373, 378, 397, 402
Cervicothoracic sympathectomy, 372, 377
Cervix, 239
Chalazion, 257, 263
Chemical burns, 151
Chemical hazards, 436, 438
Chemical monitors, 66
Chest drainage units, disposable, 330, 335
Chest tubes, 332, 336
Child abuse injuries, 411, 415
Cholangiography, 130, 132, 134
Chronic cerebral ischemia, 356, 360
Chronic dacryocystitis procedure, 257, 263

731
Circle of Willis, 364, 367, 374, 378
Circulating nurse, 109, 111, 113
Circumcision, 158, 174, 317, 323
Circumferential bandage, 200
Clamps, removal order, 358, 361
Clamshell incision, for bilateral lung transplant, 332, 336
Claudication, 2, 3, 351
Cleaning routines, 81
Closed-wound suction system, 189, 193
Closing count, 109, 111, 112, 113, 114
Clostridium tetani, 9, 13
Cloth towels, 109
Cloward
instrument, 158, 173
procedure, 371, 376
Coarctation of aorta, 341
Cobalt 60 (ionizing radiation), 67, 72
Cocaine, 285, 286
Cochlear implantation, 156, 172
Code of ethics, 125, 128
CO2 laser, 285
Colles’ fracture, 393, 400
Collodion, 200, 202
Colorless prep solution, 296, 303
Color spectrum, 424, 429
Colposcopy, 239
Common bile duct, 156, 172, 174, 175
Common duct dilators, 159, 174
Compartment syndrome, 396, 402
Compazine, 26, 35
Compromised respiration, 100
Computed axial tomography (CAT) scan, 130
Computed tomography (CT) scan, 366
Congenital cardiac anomaly, 409, 413
Congenital defect, 412, 415
Congenital deformity, 412, 415
Congenital pectus deformity, 333, 337

732
Consents
for additional procedure, 137
conditions for signing, 138, 140
in dire emergency, 139
general, 137, 139
implied, 138, 139
informed, 138, 139
obtaining permission for, 139
required for, 138
surgical, 138, 139
withdrawal of, 138
witnessed by, 137, 139
Contaminated area
preparation, 151
scrubbing, 150
Contrast media, 129, 132, 134
Cordotomy, 368, 370, 376
Coronal suture, 363
Coronary artery bypass graft (CABG) surgery, 340, 342, 344, 345, 346, 347
Coronary artery disease, 339
Corpus callosum, 375, 379
Cottonoid patties, 109, 370, 372, 375, 376, 377, 379
Coumadin, 341
Counting, 109
C-section and, 112, 113
initial, 111, 113
instruments, 111, 112, 113, 114
in OR, 111, 113
problems with, 110
sharps, 110
sponge, 112, 114
Cranial bones, 363
Cranial nerves, 365–366
Cranial surgery, 374, 378
Craniectomy, 367
Cranioplasty, 364, 367
Craniosynostosis, 363–364, 378
Craniotome, 366

733
Craniotomy, 367, 373, 378
Cranium, 374, 378
Cricoid pressure, 27, 32, 35
Cross clamping, 351
Crutchfield tongs, 159, 174, 370, 376
Cryoablation, 425, 430
Cryosurgery, 371, 376
Cryothermy, 259
C-section, 112, 113
CTX needle, 187
Culdocentesis, 239
Cultures, 118, 120
Current, 420, 427
restriction of flow, 420
Cutting electrode, 422, 428
Cutting needle, 190
CVP catheter, 410, 414
Cyanosis, 2, 3
Cystic duct, 132, 134
Cystoscopy, 315, 322
Cytologic, 115

D
Davidson scapula retractor, 165, 176
Dead space, 10, 14
Deaverand Richardson retractors, 153
Decontamination of walls, 66
Decontamination process, 437, 439
Decortication of lungs, 329, 330, 333, 335, 336
Deep vein thrombosis, 351
Deoxygenated blood, to lungs, 343, 347
Dermabond, 200, 202
Dermatochalasis, 300, 305
Dextran, 342, 346
Dialysis, 357, 361
Diaphragm, 327
Diastole, 344, 347
Diastolic blood pressure, 350

734
Diencephalon, 364
Dilating balloon, 342, 346
Disc disease, 368
Disposable chest drainage units, 330, 335
Disseminated intravascular coagulation (DIC), 352, 358, 361
Diuretic, 24, 33
Doctrine of Reasonable Man, 124, 127
Donor, blood, 39, 41, 42, 43, 44
plasma donor, 41, 43
Doppler scanning, 131, 349, 354, 359
Doppler ultrasound, 356, 360
Dorsal flexion, 395, 402
Dorsal recumbent, 1, 3, 101, 107
Dosimeter, 132, 134
Double endotracheal tube, 327
Doyen, 335
Doyen raspatory, 157, 173
Draped patient, 50, 55
Drapes
end of case, 47
fenestrated, 148, 151
head, 146, 151
incise, 147, 151
removing procedure, 147, 151
sterile, 47, 50, 55
Draping
break in technique, 146
nonsterile table, 146, 151
table, 146, 150, 151
techniques, 150
Dressings
correct order of, in surgical wound, 200, 202
gauze, 200, 202
stent, 200, 202
Dropped items, 48, 53
Dropped sterile item, use of, 81
Dull hooks and rakes, 171
Dura mater, 364, 374, 378

735
Duval lung forcep, 176
Dysmenorrhea, 240

E
Echocardiogram, 339, 344, 347
Eclampsia, 242
Ectopic pregnancy, 249, 254
Ectropion, 263
Electrical cords, 80, 88
Electrical stimulation, 392, 399
Electrocardiogram (ECG), 130, 133, 134, 339
Electroencephalography (EEG), 131, 366, 372, 377
Electromyography (EMG), 131
Electrosurgery, 422, 428
Electro surgical unit (ESU), 153, 171
Ellik evacuator, 175
Embolectomy, 354, 359
Embolism, 2, 3
Embolization, 367
Embolus, 349
Emphysema, 329, 333, 336
En bloc, 116, 117, 119–120
Encephal/o, 2, 4
Encephalocele, 364–365
Encephalon, brain, 364
Endarterectomy, 351, 355, 356, 359, 360
Endocarditis, 339
Endocardium, heart, 339, 344, 347
Endoclip applier, 176
Endo-fan retractor, 177
Endometrial ablation, 247, 253
Endoscopic instruments, guidelines for, 448
Endoscopic scissors, 176
Endotoxins, 352
Endotracheal tubes, 425, 430
Endovascular AAA, 352
End-to-end stapler, 177
Enterocele, 240

736
Enucleation, 258, 263
Environmental disinfectants, 67, 72
Epicardium, heart, 339
Epidural hematoma, 365
Epinephrine, 278, 286
Episiotomy, 240
Erythroblastosis fetalis, 410, 414
Esmarch bandage, 389, 398
Ethylene oxide, 64, 65, 66, 70
sterilization, 64, 71
function of aerator in, 65
with inert gas, 67, 72
role of moisture in, 65
Event-related sterility, 67, 72
Evidence-based practice (EBP), 50
Excisional biopsy, 119
Exenteration, 264
Exhalation, 331, 335
Extracorporeal, 343, 347
Extracorporeal shock wave lithotripsy (ESWL), 158, 174, 319, 324
Extravasation, 448
Extubation, 28, 35

F
Face lift, 297, 303
Facial nerve monitoring, 285
Falling patient, assisting, 101
Fallopian tube, 244, 251
reconstruction of, 244
Fallot, tetralogy of, 2, 3
Fem/fem bypass, 352
Femoral prostheses, 393, 400
Femoral-femoral bypass, 357, 361
Femoral-popliteal bypass, 352, 354, 359
Fem/tibial bypass, 352
Fenestrated, 148, 151
Fiberoptic light cord, 447
Fibrillation, 339, 343, 347

737
 ventricular, 339, 342, 346
Fibrinogen, 301, 306
Fibroid, 2, 3
Finochietto, 154, 171
Finochietto chest/rib spreader, 174
Finochietto retractor, 334, 337
Fistula, 2, 3
Fixation device, 389, 398
Floating ribs, 334, 337
Floor cleaning, 81
Fluoroscopy, 355, 359
Fogarty biliary catheter, 354, 359
Fogarty catheter, 354, 359
Foley catheter, 244, 250, 251
Forceps, 422, 428
Forebrain, 364
Foreign bodies, 116, 117, 119
Fowler’s position, 102, 106, 107
Fractures, moving patient with, 98, 105
Fracture site, 98, 105
Free-Lock compression screw system, 390, 399
Freer elevator, 357, 360
Frequency of sound, 423, 428
Frozen biopsy, 132, 134
Frozen specimens, 116, 117, 118, 119, 120
Fuel sources, 436, 438
Funnel chest, 333, 337
Furlow inserter, 158, 174
Fusiform aneurysm, 358, 361

G
Galea, 363, 375, 379
Galvanic corrosion process, 393, 400
Garrett dilators, 160, 174
Gas gangrene, 9, 14
Gas sterilization, 64
Gastrointestinal anastamosis stapling device, 177
Gastrointestinal decompression drainage tubes, 187

738
Gastrointestinal endoscopes, 67
Gastrointestinal x-ray, 130
Gauze packing, 200, 202
Gelfilm, 350
Gelfoam, 350, 366, 370, 372, 376, 377
Gigli saw, 366, 373, 378
Glass suction bottle, 80, 88
Glaucoma, 264
Glioblastoma, 364
Glioma, 373, 378
Gloves, changing, 49, 54
Golden hour, 437, 439
Gowning, 48
Gowns
removal of, 49
sterile, 48
Gram-negative specimens, 120
Gram-positive specimens, 117, 120
Gram stains, 131, 132, 134
Graves vaginal speculum, 175
Greenfield filter, 355, 356, 359, 360
Greenfield vena cava filter insertion, 355, 360
Groshong catheter, 350
Gynec/o, 2, 3

H
Halothane, 26, 34
Hanks dilators, 160, 174
Hank uterine dilators, 155, 172
Harrington rods, 157, 171, 173
HCO3 level, Blood, 40
Head drape, 146, 147, 151
Headrests, 366
Heaney clamp, 153, 173
Heart block bradyarrhythmia, 157, 173
Heart lung machine, 340
Hegar dilators, 160, 174
Helium-neon laser, 285

739
Hematocrit, 39, 41, 43
Hematomas, 365, 374, 378
Hemodialysis, 350, 355, 358, 359, 360, 361
Hemoglobin (HGB), 39, 41, 43
Hemolysis, 352
Hemoptysis, 328, 332, 336
Hemostasis, 371, 376
Hemostatic agent, 394, 401
Hemostatic agents, 366
Hemostatic scalp clips, 370, 376
Hemovac, 286
Heparin, 341, 342, 346, 350, 354, 355, 359, 360
Heparin effects, 25, 34
Hernia, 410, 414
Herpes simplex, 9, 13, 14
Herrick, 155, 172
Hiatal hernia, 329, 332, 336
Hickman catheter, 350
Hill, 155, 172
Hindbrain, 364
Hipbone, 397, 402
Hirschsprung’s disease, 408, 413
Histology, 115
Homologous blood, 41, 43
Hooke’s wave theory, 424, 429
Hospital-acquired infections, 10, 14
Hulka forceps, 174
Hulka tenaculum forceps, 243, 250
Humi cannula, 158, 174, 243, 250
Hurd dissector, 278
Hyaluronidase, 263, 264
Hydrocephalus, 365, 371, 377
Hypertension, 2, 4, 248, 254, 350
Hypotension, 2, 4, 350, 358, 361
Hypothalamus, 364
Hypothermia, 342, 346
Hypovolemia, 344, 347, 350, 358, 361
Hysterosalpingogram, 239

740
Hysteroscopy, 239

I
Iliac
artery, 357, 361
crest, 373, 378
Image intensification, 157, 173
Immobilization device, 391, 399
Immune protection, 8, 13
Immunity, 10, 14
Imperforate anus, 408, 413
Implied consent, 138, 139
Incident report, 125, 127
Incise drapes, 147, 151
Incisional biopsy, 117, 119, 130
Induced hypothermia, 32
Infants and children, room temperature for, 80, 88
Inflammation, 301, 305
Inflation pump, 317, 323
Informed consent, 125, 127, 138, 139
Inguinal hernia repair, 169, 177
Inhalation, 331, 335
In situ femoral popliteal bypass, 355, 360
In situ graft, 356, 360
Instrument containers, 110
Instruments counting, 111, 112, 113, 114
Instruments wrapped, sterilization of, 70
Intertrochanteric fracture, 396, 402
Intestinal obstruction, 409, 414
Intestinal tract, 10, 14
Intra-aortic balloon pump, 157, 173, 341, 343, 346
Intracranial tumors, 364
Intraoperative chromotubation, 246, 251
Intrathecal injection, 31
Intravenous (IV) lines and fluids, 101
in vascular surgery, 25, 34
Ionizing radiation protection, 435, 438
Iridectomy, 259, 264

741
Irid/o, 1, 3
Ischemia, 2, 3

J
Jackson table, 366
Jansen-Middleton forceps, 287
Javid shunt, 357, 360–361, 371, 377
Joint reconstruction, 389, 398
Jorgenson dissecting scissor, 175

K
Keith needle, 185, 190
Keller procedures, 393, 400
Keloid 200, 202
Keloids, 301, 306
Kerat/o, 1, 3
Keratophakia, 264
Kerrison rongeur, 154, 176, 372, 377
Kidney bar, 315, 322
Kidney lift, 315, 322
Kidney stones, 316, 322, 323
Kirschner wire, 157, 173
Kittner dissector, 109
Knee arthroplasty, 394, 401
Kneecap, 397, 403
Knee joint, 390, 399
Knitted graph, 354, 359
Kyphoplasty, 368–369, 375, 379
Kyphosis, 369

L
Labor, 243, 250
Labyrinthectomy, 285
Lack of consent, 127
Lacrimal surgery, 154, 172
Lambdoid suture, 363
Laminectomy, 117, 172
Laminectomy, knee-chest positioning for, 371, 377

742
Lapar/o, 2, 3
Laparoscopic instruments, 177
Laparoscopic tubal occlusion, 246, 252
Laparoscopy, 154, 159, 240
Lap pads/towels, thoracotomy and, 332, 336
Large breasts, 300, 305
Laser laryngoscopy, 425, 430
Laser lithotripsy, 319, 324
Lateral, body, 1, 3
Leiomyoma, 241
Leukocytes, blood, 42, 44
Levophed (norepinephrine), 345, 347
Leyla-Yasargil, 158, 174
Liability, 124, 127
Lidocaine, 286
Lidocaine hydrochloride, 341
Limb exsanguination, 391, 399
Linen packs, 70
Liposuction, 300, 305
Lithotomy, 447, 452
Lobectomy, 328, 333, 336
Logan’s bow, 158, 173
Loop electrode, 163, 175
Lordosis, 369
Lukens tubes, 115, 330, 335
Lumbar laminectomy, 368
Lumbar puncture, 366
Lumpectomy, 1, 3
Lungs, 327
anatomical regions of, 332, 336
cancer, 331, 335
capacity, 329
decortication of, 329, 330, 333, 335, 336
deoxygenated blood to, 343, 347
pulmonary function tests for, 329
resection, 328
transplant, 329, 332, 336
Lung volume reduction surgery (LVRS), 329, 332, 333, 336

743
Lymph node biopsy, 1, 3, 328
Lymphocytes, 41, 43

M
Mad cow, 11, 15
Magnetic resonance imaging (MRI), 130, 366
Malar implants, 300, 305
Male sterilization procedure, 316, 322
Malignant hyperthermia, 30
Mammography, 129
Mandible, 279, 287
Mannitol, 373, 378
Manometer, 365
Marcaine, 29
Marsupialization, 239
Maryland dissector, 176
Mask handling, 80, 88
Mason-Judd retractor, 158, 174
Mastoid bone, 286
Mastoidectomy, 276, 285
Maxillary sinus endoscopy, 86
Maxillomandibular fixation (MMF), 279
Mayfield clamp, 173
Mayfield headrest, 100, 106
Mayo stand, 146, 151
McBride procedures, 393, 400
Meconium, 241
Median sternotomy, 343, 344, 347
Mediastinal shift, 328, 330, 335
Mediastinoscopy, 328, 330, 335, 345, 347
Mediastinum, 327
Medulla oblongata, 364, 374, 378
Medulloblastoma, 364
Meninges, 364, 368
Meningiomas, 364, 370, 376
Mening/o, 2, 4
Meningocele, 368
Meningomyelocele, 372, 377

744
Menometrorrhagia, 240
Mentoplasty, 298, 304
Mersilene, 189, 193
Metabolic acidosis, 345, 347
Metacarp/o, 1, 3
Methicillin-resistant S. aureus (MRSA), 10, 14
Microbial death, 8, 13
Microtia, 296, 303
Microvasive evacuator, 161, 175
Midas Rex, 366
Midbrain, 364
Millin, 158, 174
Minimally invasive surgery (MIS), 340–341, 422, 428, 447
Miochol solution, 258, 264
Mitral stenosis, 343, 346
Modified Trendelenburg position, 106
Moist padding, 279
Monocytes, 41, 43
Monofilament suture, 185, 190
Monopolar coagulation, 371, 376
Morcellation, 448
Moustache dressing, 285
Muscle relaxants, 27, 35
Muslin wrappers, 47, 53
storage life for, 48, 53
thickness of, 48, 53
Myasthenia gravis, 328, 331, 336
Mydriatics, 263, 264
Myelogram, 157, 173
Myelography, 129, 132, 133, 134, 366, 373, 377
Myelomeningocele, 368, 378
Myocardium, heart, 339, 344, 347
Myringotomy, 285

N
Naloxone, 23, 33
Nasal polyps, removal of, 277
Nasal setup, 156, 172

745
Natural disasters, 436, 438
Neck (radical) procedure, 147, 151
Needle holder, 154
Needles, 180
Needles counting, 110
Negligence, 124, 127
Nervous system, 363
Neurology instruments, 366
Neurolysis, 370, 376
Neuroma, 371, 376
Neurosurgical sponges, 371, 377
“Neutral zone” technique, 179
Neutrophils, 41, 43
Nitrous oxide, 31
No hands technique, 436, 438
Nonsterile equipment, preparing, 81, 88
Nuchal cord, 242
Nucleons, 424, 429
Nurse, circulating, 109, 111, 113
Nylon, 47, 53

O
Obesity, 199
Occluding peripheral vessels, 357, 360
Occupational Safety and Health Administration (OSHA), 301, 305
Off-pump coronary artery bypass (OPCAB), 341
Olecranon fracture, 390, 399
Omni-Tract, 158, 174
Oophorectomy, 2, 3, 241
Open-glove technique, 54
Open thoracotomy, 331, 335
Operating room
attire, 81
room temperature in, 80, 88
table, 98, 105
Operative paperwork, 125
Orchiopexy, 317, 323, 409, 414
Orthopedic fracture table, 102, 106

746
Orthopedic implants, 393, 400
Orthopedic saws, 393, 401
Orthopedic surgery, 391, 399
Oste/o, 1, 3
Osteogenesis, 390, 398
Otitis media, 409, 413
Otorhinolaryngologist, 374, 378
Ovarian cystectomy, 2, 3
Oxygen-dependent bacteria, 8, 13
Oxytocics, 245, 251

P
Pacemaker, 339, 343, 347
Package wrappers
opening, 48, 53
safety margin on, 48, 53
Palmar fascia, 296, 303
Pandemic, 12, 15
Panniculectomy, 298, 304
Panoramic views, x-ray, 133, 134
Papanicolaou, 245, 251
Papaverine, 341
Papaverine hydrochloride, 343, 346, 350, 356, 360
Parotidectomy, 279, 287
Parotid glands, 286
Patent ductus arteriosus, 2, 3, 341
Patient positioning
aging patient, 101, 106
for anesthetized, 99, 106
changes in, 101, 107
crossing arms across chest, 99
for C-section, 106
on fracture table, 101, 106
history and physical, 133, 134
for laminectomy, 100, 106
lateral, 99
lithotomy, 99, 102
for open bladder surgery, 100, 106

747
 patient safety and surgical site exposure, 101, 107
prone, 100, 106
pudendal nerves injury, 101, 106
risk, 102, 107
supine, 99, 101, 105, 106, 107
for thyroid surgery, 100
unconscious/immobile patient, 102
using armboard, 99, 105
Patient transportation
with fractured femur, 98
from OR table, 98, 105
roller for, 98, 105
safety strap, 105
from transport stretcher to OR table, 98
PCO2 levels, in blood, 40
Peanut sponges, 109
Pectus deformities, 328
Pectus excavatum, 333, 337
Pedal pulses, 354, 359
Pedicle clamp, 154, 171
Pedicle flap, 299, 304
Peel pouches, 72
PEG tube, 411, 415
Pelviscopy, 246, 252
Penfield dissector, 374, 378
Penile condylomata, 316, 322
Peracetic acid, 66, 71
Percutaneous transluminal angioplasty (PTA), 356, 360
Pereyra needle, 315, 322
Pereyra procedure, 317, 323
Pereyra/Stamey, 174
Perfusion, 342, 346
Pericardial effusion, 339, 344, 347
Pericarditis, 339
Pericardium, 339, 344, 347
Peripheral nervous system (PNS), 363
Peripheral vascular surgery, 349

748
Permanent specimens, 117, 119
Personal protective equipment (PPE), 67
Phacoemulsifier, 257, 263
Phantom pain, 353
Pharmacokinetics, 27, 35
Photons, 424, 429
Photo receptive layer, 259
Pia mater, 364, 372, 377
PID—pelvic inflammatory disease, 240
Pig tissue, 297, 304
Pilocarpine, 257, 263
Pinna, 300, 305
Pituitary gland, 375, 379
Pituitary instrument, 167, 176
Pituitary rongeur, 371, 377
Pixels, 452
Placenta previa, 2, 3
Plaster, 391, 399
Platelets, 39, 42, 43
Pledgets, 350
Plethysmography, 131, 133, 134
Pleur-evac/closed water seal drainage system, 327–328
Pneumatic tourniquet, 394, 401
Pneumonectomy, 2, 4, 328, 333, 336
Pneumoperitoneum, 2, 4
Pneumothorax, 2, 4, 328
Poly-, 2, 4
Polyglactin 910, 186, 191
Polymethylmethacrylate (PMMA), 393, 401
Polypropylene, 47, 53
Pons, 364
Pontocaine, 263
Poole’s suction tip, 153, 171
Portable x-ray machine, 129
Portal circulation, decompression of, 342, 346
Positron emission tomography (PET), 130
Potts-Smith scissors, 174
Potts-Smith scissor, 357, 360

749
Pour solution, 48
Povidoneûiodine, 145, 150
Power, 422, 428
Prep solutions, 147, 151
Pressure ulcers, 299, 305
Prolene, 190
Prostate, 315, 322
Protamine sulfate, 341, 350, 354, 355, 359, 360
Protective eyewear, protocol for, 81
Prothrombin time (PT), 40
Protruding ears, 412, 415
Proximal interphalangeal (PIP) joint, 395, 401
Proxim/o, 1, 3
Pulmonary angiography, 130
Pulmonary function tests (PFTs), 329, 331, 333, 336
Pulmonary valve, 344, 347
Pulse oximeter, 42, 44
Purse string suture, 183, 190
Putti–Platt, 394, 401

Q
Quality Assurance (QA) programs, 124, 127

R
Radiation, 435, 438
Radiation exposure, 435, 438
Radical mastectomy, modified, 1, 3
Radiofrequency sponges, 109
Radiographic diagnostic test, 319, 324
Radiography/roentgenography, 129
Radionuclide scan, 130
Radiopaque 4 × 4 sponges, 112, 114
Radio waves, 421
Randall stone forceps, 157, 172, 173, 176
Raney clips, 370, 376
Rapid infusion pump, 42, 44
Raytec sponge and, 117, 119
Rectal surgery prep, 147

750
Rectocele, 2, 3, 240
Rectovaginal fistula, 240
Red blood cell count, 39
Red blood cells (RBCs), 42, 43
Red Robinson catheter, 166
Res ipsa loquitur, 110
Respondeat Superior, 124, 127
Retention sutures, 185, 186, 190
Retina, 264
Retin/o, 1, 3
Retrobulbar anesthesia, 264
Reverse sterilization procedure, 318, 323
Reverse Trendelenburg, 101, 107, 447, 452
Rhinoplasty, 300, 305
Rhizotomy, 368, 375, 379
Rh negative, 41, 43
Rh positive, 41, 43
Ribbon retractor, malleable, 355, 359
Ribs, 327, 334, 337
Richardson retractor, 153, 171
Richter scale measurement, 437, 439
Rickettsia, 11, 14
Rigid endoscope, 447, 452
Rod-like–shaped bacteria, 9, 13, 14
Rongeur, 154, 167, 171–172, 176
Rotator cuff tear, 396, 402
Rubber tubing, 63, 70
Rummel tourniquet, 350, 358, 361

S
Sagittal suture, 363
Salpingectomy, 2, 3, 240
Salpingo-oophorectomy, 241
Saphenous vein in situ, 352
Sarot bronchus clamp, 157, 176
Sauerbruch, 155, 172, 176
Scalene, biopsy of, 331, 335
Scalene nodes/supraclavicular nodes, 328

751
Scalpel blades, 55
Scatter radiation effects, 80
Scleral buckling, 263
Sclerotherapy, 351, 358, 361
Scoliosis, 369, 374, 378
Scoville nerve root retractor, 176
Scoville retractor, 155, 172
Scrub nurse, 296, 303
Scrub tech, 109, 111, 113
Scrub technique, 49
Sealing vessels, 423, 428
Seamless tubular cotton, 389, 398
Sedative/tranquilizer, 25, 34
Segmental resection, 328, 333, 336
Seizure, 248, 254
Sellica turcica, 375, 379
Sentinel lymph node biopsy, 1, 3
Septic shock, 411, 415
Severe vertigo, 276
Sexual impotence, 316, 322
Shave prep, 145
Shock, 358, 361
Shock-this condition, 350
Silk, for closure of dura, 374, 378
Silk suture, 186, 191
Single-lung transplant, 331, 335
Sinoatrial node, of heart, 339
Skeletal traction, 157, 158, 159, 173, 174
Skene’s glands/periurethral glands, 239
Skin, oil glands of, 397, 403
Skin cancer, 298, 304
Skin closure methods, 181
Skin gun, 184
Skin stapler, 188, 192
Skull, 363
Slow exhaust, and solutions, 65, 71
Sodium bicarbonate, 345, 347
Sodium hyaluronate, 263

752
Sodium hypochlorite, 132, 134
Soiled instruments, scrubbing, 153
Soiled sponges, 111, 113
Solu-Medrol, 24, 33
Somatic nervous system, 363
Sources of latex, 436, 438
Specimens, 115
bullet, 117, 119
damage/loss of, 116, 117, 119
femoral implant, 117, 119
frozen, 117, 119
frozen section, 116, 119
gram-negative, 120
gram-positive, 117, 120
permanent, 117, 119
Raytec sponge and, 117, 119
removal, 116, 119
stones, 116, 117, 118, 119, 120
Spina bifida, 365, 368, 373, 378
Spinal nerves, 367–368
Spinal tap, 131, 133, 134
Spine
lateral curvature of, 390, 398
Spirometer, 329, 333, 336
Splenectomy, 156, 171
Sponges, 109
consideration for, 110
counting, 112, 114
Raytec, 117, 119
soiled, 111, 113
Squamous suture, 363
Staghorn stone, 315, 322
Stainless steel suture, 371, 376
Stamey endoscopic procedure, 246, 252
Standard precautions, 35, 40, 50, 54
Stapedectomy, 156
Staphylococcus aureus, 8, 13
Stapling devices, 183

753
Statinsky vena cava clamp, 176
Stealth craniotomy, 367
Steam sterilizer, 63, 70
Steffee plate, 159, 174
Stellate fracture, 395, 402
Stent dressing, 153, 164, 200, 202
Stereotactics, 367, 372, 375, 377, 379
Sterile gowns, 50, 54
Sterile item, flipping, 48, 53
Sterile personnel, 50, 55
Sterile saline, 331, 335
Sterile supplies, 50
Sterile tables, 47, 53
Sterility, 145, 244, 250
Steroids, 24, 33
Stille shears, 157, 173
Stockinette, 146, 150
Stones specimens, 116, 117, 118, 119, 120
Streptokinase, 341, 343, 346
Stripping and ligation, 353
Subarachnoid space, 364
Subdural hematoma, 365, 370, 376
Subdural space, 364
Subluxation, 396, 402
Suction
irrigator, 177
tubing, 145, 150
Super/o, 1, 3
Suprapubic catheter, 241
Surgical
case, 80
hand scrub, 49, 54
technique, 199
Sutures, 350, 363, 366–367
absorbable, 184
boots, 350
classification of, 179
coding, 180

754
 gauges, 350, 358, 361
memory, 185, 190
monofilament, 184
needle, 184
purse string, 184
techniques, 186, 187
types of, 179
Swagged, 185, 190
Sympathectomy, 371, 376
Sympathetic system, 373, 378
Synarthrotic joints, 363, 374, 378
Syndactyly, 296, 303
Synergist agent, 31
Synovial membrane, 395, 402
Systole, 343, 347
Systolic blood pressure, 350

T
Tachycardia, 339
Talc, 331, 335
Tattoo removal, 300, 305
Telescope handling, guidelines, 448
Telfa, 200, 202
Temporal mandibular joint (TMJ), 279
Tenckhoff catheter, 351, 358, 361
Tend/o, 1, 3
Tensile, 190
Terminal sterilization, 67, 72
Testes, 316, 322
Tetracaine, 263
Tetralogy of Fallot, 2, 3, 341
Thalamus, 364
Thoracentesis, 115, 117, 119, 131, 133, 134, 329, 333, 336
Thoracic outlet syndrome, 102, 107, 329, 330, 335, 355, 359, 369
Thoracocentesis, 2, 4
Thoracoscopy, 328
Thoracotomy, 328
instruments, 327

755
 lap pads/towels and, 332, 336
Thorocoabdominal staple gun, 177
Three-way Foley catheter, 175
Thrombin, 350
Thromboembolic disease, 349
Thrombus, 2, 3, 349
Thymectomy, 328, 331, 336
Thymus gland, 328, 333, 337
Thyroidectomy, 279
Thyroplasty, 279, 287
Tidal volume test, 329, 331, 336
Time method, 49, 54
Tissue expanders, 156
Tissue plasminogen activator, 341, 343, 346
Tonsil sponges, 109
Toomey syringe, 175
Topical thrombin, 370, 372, 376, 377
Total laryngectomy, 278, 286
Trachelorrhaphy, 240
Tracheostomy, 277, 286
TRAM flap, 299, 305
Transsphenoidal hypophysectomy, 367, 372, 377
Transurethral resection of the prostate (TURP), 315, 322
Triclosan, 146, 151
Trigeminal nerve, decompression of, 367
Trigone, 320, 325
Trocar, 154, 171, 447, 452
T-tube, 164, 172, 175
Tubal ligation, 240
Tuffier retractor, 334, 337
Tunica vaginalis, 317, 323
Tympanoplasty, 276, 285
Type AB blood, 39, 41, 43
Type O blood, 42, 44

U
Ulnar nerve damage, 99, 106
Ulnar nerve transposition, 367

756
Ulnar neuropathy, 102
Ultrasonic aspirator, 366
Ultrasonic cleaner, 63, 70
Ultrasound, 130, 132, 134
Undermining, 154
Universal blood donor, 39, 41, 42, 43, 44
Universal plasma donor, 41, 43
Universal precautions, 54
Urethral catheters, 319, 324
Urethral meatal stenosis, 317, 323
Urethral meatus, 320, 325
Urethral strictures, 315, 322
Urethrovaginal fistula, 240
Urinary bladder, 320, 325
Uterine ablation, 240
Uterine cavity, 247, 253
Uterine tube, 239

V
Vaginal hysterectomy, 240
Vaginoplasty, 248, 254
Vagotomy, 156, 172
Vagus nerve, 332, 336
Van Buren dilators, 160, 174
Varicosity, 349
Vascular anastomosis, 351
Vascular grafts, 350, 355, 359
Vascular setup, 164, 175
Vascular surgery, 349
Vaseline gauze, 202
Vasoconstrictor, 30
Veins, 349
Vein stripping/ligation, 351
Vena cava filter, placement of, 351
Venous circulation, avoiding, 98, 105
Ventricles, 364
Ventricular aneurysm, 340
Ventricular arrhythmia, 31, 339

757
Ventricular assist devices (VADs), 341, 343, 346
Ventricular fibrillation, 339, 342, 346
Ventricular septal defect, 341
Ventriculoatrial (VA) shunts, 365, 372, 377
Ventriculography, 130, 132, 134
Ventriculoperitoneal (VP) shunts, 365, 371, 372, 373, 377, 378
Ventriculoscopy, 365
Venus catheter, 351
Vertebral disk, 368
Vesicovaginal fistula, 240, 321, 325
Vessel loops, 350
Vessels, 327
Vestibular schwannomas, 364, 373, 378
Video-assisted thoracic surgery (VATS) procedure, 328
Video cables, 448, 452
Vitreous humor, 258
Vulvectomy procedures, 240

W
Warfarin, 341
Web research, 426, 430
Webril, 200, 202
Webster needle holder, 155, 172
Wedge resection, 328
Weitlaner, 155, 172
Weitlaner retractor, 356, 360
Westcott scissors, 154, 171
White blood cell count, 39, 41, 42, 43
in adult male, 41, 43
White blood cells, 41, 43
types of, 41, 43
White balancing, 448
White blood count differential, 39
Wide cuff, 146, 151
Wilms tumor, 409, 413
Wire localization, 1, 3, 155, 172
Woodson dissector, 374, 378
Wound, 301, 306

758
 complications, 302, 306
edges, 10
zipper, 181
Wound healing, 199, 301, 306
factors in, 202
order of, 199, 202
second intention of, 199
third intention of, 202
Wrapped basin sets sterilization, 64, 70
Wrapping materials, 67
Wydase, 258, 264

X
Xylocaine, 29, 341, 344, 347

Y
Yasargil, 373, 378
Y-shaped/trifurcate incision, 286

Z
Zofran, 28, 35
Z-plasty procedure, 297, 411, 415

759