Staplers, Implants, Drains and Catheters

This is Unit Twenty-One of Tech in Surgery Prep. Unit Twenty ended with a wrong size caught before the package was opened. This unit turns to the devices of surgery: staplers, implants, drains and catheters, and the small items that are easiest to lose. Carry one idea through this lecture. Anything that enters the patient, or might stay behind, must be accounted for, and a fixed habit works even when the case gets busy, which is exactly when memory fails. A worked example near the end shows a lost implant label caught, and a habit built so it cannot happen again. By the end you will be able to describe staplers and clip appliers. To handle and record implants. To explain drains, tubes and catheters. And to account for packing, small items and fragments.

Four entries on surgical staplers, their reloads, clip appliers, and why devices are tracked.

Rows of staples.

TSC 501 Surgical Staplers

Surgical staplers place rows of staples to join, close or divide tissue, often faster than hand suturing. They rejoin bowel and other hollow organs, tie off vessels and remove specimens, and may be single-use or reloadable, manual or powered. Staples come in several sizes, so the reload matches the surgeon's request.

Three types.

TSC 502 Linear, Cutting and Circular

A surgical student guide describes three main types. A linear stapler places a straight line of staples without cutting. A linear cutter staples and cuts between the rows in one action, sealing both edges as it divides. A circular stapler makes a circular cut and staple line to rejoin hollow organs such as the large bowel. Endoscopic staplers do the same through laparoscopic ports, some with articulating heads, and clip appliers place single clips on vessels. Each stapler has its own reloads, so keep them together and confirm the size before passing one.

Devices are accounted for.

TSC 503 Staplers Are Tracked Devices

Staplers and other devices are accounted for even when they are not in the traditional count. Devices such as staplers, drains and catheter sets are tracked by the facility's methods, because devices and their fragments can be left behind. Know your facility's method and follow it every time.

Clips on vessels.

TSC 504 Clip Appliers

Clip appliers place small metal or absorbable clips around vessels or ducts to close them. They come in open and laparoscopic versions, loaded in the applier or preloaded in cartridges. Ask which clip size the surgeon wants, and keep spare loaded appliers ready during dissection.

Three entries on implants, their records, and the items left in the patient on purpose.

Devices meant to stay.

TSC 505 Handling Implants

Implants are meant to stay in the patient, so their sterility, identity and records get extra care. The implant's type and size are confirmed with the surgeon, and critical implants are reviewed at the time out. The package is inspected for damage, moisture and expiration. Implants are opened only when the surgeon confirms them, to avoid waste. Facility-processed implants come from monitored loads, ideally held until results are negative. The implant's identity is recorded and linked to the patient. Immediate-use sterilization is not recommended for implants.

A record for every implant.

TSC 506 Implant Records

Every implant is recorded with information that identifies it and links it to the patient. Records let the facility trace it if a sterilization problem or recall is found later. An implant without its record cannot be traced, so the record is completed before the case ends.

Left on purpose.

TSC 507 Items Intentionally Left in the Patient

Some items are left in the patient on purpose, such as implants, drains or packing, and they are documented. The count record notes instruments, sponges or packing intentionally left, so the next team knows. An item left on purpose but not documented looks exactly like a retained item.

Six entries on drains, chest tubes and urinary catheters, and the infection risk catheters carry.

Removing fluid after surgery.

TSC 508 Surgical Drains

A surgical drain removes blood or serous fluid from a wound or body space after surgery. The surgeon decides whether one is needed and places it through the skin near the wound. It is usually sutured to the skin so it cannot be pulled out, the site is dressed, and its location is recorded for the recovery team. Afterwards, staff check its output and watch for leaks and bleeding. A drain stays after the case, so the scrub person prepares it and its suture and tracks it under the device process.

An early warning.

TSC 509 Drains Show Bleeding Early

Drain output gives an early signal of bleeding after surgery. A moderate amount of fresh, bright red blood in a drain or on a dressing is one of the textbook's cues of postoperative bleeding. Unusual output is reported promptly so the surgeon can evaluate it.

Keeping a drain in.

TSC 510 Securing a Drain

Drains are usually sutured to the skin so they cannot be pulled out. The scrub person prepares the securing suture and dressing, and the drain is connected to its collection device off the sterile field. A drain pulled out during transfer may mean another procedure, so it is protected when the patient moves.

Draining the chest.

TSC 511 Chest Tubes

A chest tube drains air or fluid from the space around the lungs and is inserted with sterile technique. Chest tubes are critical items, sterile when used, because they enter a space that must stay free of microbes. Insertion uses a full sterile field, even at the bedside.

Draining the bladder.

TSC 512 Urinary Catheters

A urinary catheter drains the bladder, and placing one is a sterile procedure with sterile gloves and a sterile field, because the bladder is normally sterile. Catheters are a common cause of health care–associated urinary infections, and national guidance prefers intermittent catheterization whenever feasible. In surgery, one may be placed to empty the bladder or measure output, as the surgeon and anesthesia decide, and its placement is documented. Each day a catheter stays raises the risk, so placing and removing it is a team decision, not a convenience.

A common infection.

TSC 513 Catheter Infection Risk

Catheter-associated urinary infections are among the most common health care–associated infections. Sterile insertion and intermittent catheterization where feasible reduce the risk. An indwelling catheter is a portal of entry, like a wound, for as long as it stays.

Five entries on packing, sponges, small items, costly items and fragments, then two worked examples. The opening idea is paid off at the last.

Material placed in a wound.

TSC 514 Packing

Packing is gauze or other material placed in a wound or cavity, to fill dead space, keep a wound bed moist, or control bleeding by pressure. Deep wounds may be packed with moistened gauze. Packing left in a patient is documented, because it must be removed later and is easy to forget.

Many kinds of sponge.

TSC 515 Sponges and Their Types

Surgical sponges come in many sizes and shapes, all with X-ray markers when used inside a wound: laparotomy pads, smaller pads, gauze squares, round tonsil sponges, small dissecting sponges, and patties used in neurosurgery. Small sponges are easy to lose, so they are accounted for at all times.

Small, and often invisible.

TSC 516 Small Miscellaneous Items

Small miscellaneous items are counted items that are often single-use, often invisible on X-ray, and sometimes in several parts. Examples are electrosurgical scratch pads and tips, vessel loops and umbilical tapes, protective tips and suture holders, port parts and instrument inserts, cotton-tipped applicators, and small hardware such as clips or drill bits. Because many will not show on an X-ray, accurate counting is the main protection. Add each one to the count as it is opened, and keep them in one place.

Opening costly items.

TSC 517 Opening Expensive Items

Expensive items, such as implants and specialty devices, are pulled into the room but opened only when the surgeon confirms they are needed. Cards often separate what is opened before the case from what waits. Confirm size and type aloud with the surgeon before opening anything costly.

Broken pieces.

TSC 518 Device Fragments

Device fragments are broken pieces, such as a drill bit, an instrument tip or a guidewire tip. Broken devices and saved parts are set aside for examination, and every part is accounted for. If a device breaks, say so at once, so the surgeon can look for the missing piece.

A case full of devices.

TSC 519 Supplies for a Bowel Resection

A worked example, constructed for this course, follows Toni on an open bowel resection. The laparotomy pads are counted, while the staplers and reloads stay closed until needed. Each vessel loop is added to the count as it is opened. Before the bowel is divided, Toni confirms the stapler and reload size aloud, and each spent reload goes to a fixed place. The circular stapler is passed ready, and the drain's securing suture is loaded before it is asked for. At closing, sponges, sharps, small items and instruments reconcile, and the devices are accounted for under the tracking process. Bookkeeping done in real time made a device-heavy count quick and certain.

A label in the trash.

TSC 520 An Implant Without a Sticker

A worked example, constructed for this course, pays off the opening idea. During a fracture repair, in the rush of passing screws, one screw's package goes into the trash with its identifying label. When the circulator asks for the label, Drew, the scrub person, says the package was discarded by mistake. The circulator retrieves it with gloves, finds the label intact, and records it. The team then sets a habit: every implant package goes to the circulator before anything is discarded. At the end, every implant has a record, and the screws placed match the screws opened. The habit costs seconds, and it works when the case is busy, which is exactly when memory fails.

Look at what you can now do. You can describe linear staplers, cutters and circular staplers, keep each stapler with its reloads, and explain clip appliers and device tracking. You can handle implants, opening them only when confirmed, record each one, and document anything left on purpose. You can explain drains and their securing and output, chest tubes, urinary catheters and their infection risk. And you can account for packing, sponge types, small items that X-ray will not show, costly items and broken fragments. Unit Twenty-Two turns to anticipating the surgeon during the case.