Tech in Surgery Prep / Unit 26 TSC 646 review, 2 to 3 minutes
Closing a Laparotomy, Layer by Layer
The idea
A worked example, constructed for this course, follows the scrub person through the closure of an open abdomen from the first closing count to the dressing.
In practice
The main part of the operation is finished. Morgan, the scrub person, has set out the closing sutures in order of the layers. Before the first layer is closed, Morgan and the circulating nurse count sponges, sharps, small items and instruments, while the surgeon examines the abdomen, looking between the bowel loops and under the edges of the wound. The count is correct, and the circulating nurse announces it. The surgeon closes the deep layer of the abdominal wall, including the midline, with the strong suture Morgan has loaded on a long needle holder; Morgan passes straight Mayo scissors to cut each tie and keeps the next suture ready. The surgeon closes the fatty layer with a finer suture. At skin closure, Morgan and the circulator count sponges and sharps again, and the surgeon closes the skin with staples. Morgan has the dressing open and ready, sized to the incision. The surgeon applies it, and Morgan passes tape. Then the drapes are removed, and the patient is covered again promptly. The circulating nurse records the counts, the dressing and the closure.
Where people slip
Every layer had its suture ready before it was needed, and the counts came at the right moments, before the abdomen was closed and before the skin was sealed. A smooth closure is mostly preparation and timing. The surgeon's examination of the abdomen and the count were done together, each covering the other's limits, and only when both were complete did the deep layers close over the space where a forgotten item could hide.
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