C5-thoracic1 anterior cervical discectomy and fusion with iliac bone grafting

Here is another spine case scrub by me awhile ago. I have to write and post it now or else i might forget it later.
Anterior cervical discectomy and fusion (ACDF) with iliac bone grafting is a surgical procedure to treat nerve root os spinal cord compression by decompressing the spinal cord and nerve root of the cervical spine in order to stabilize the corresponding vertebrae.
To prevent the vertebrae from collapsing and to increase stability the open space is often filled with bone graft, taken from the pelvis or cardiac bone.

picture of vertebrae and disc: normal and herniated situation

The surgeon will completely remove the disc as well as the arthritic bone spurs. The disc material, pressing on the spinal nerve or spinal cord, is then completely removed.

overview of acdf

PROCEDURE	ANTERIOR CERVICAL DISCECTOMY AND FUSION WITH ILIAC BONE GRAFTING
POSITION	Supine
EQUIPMENT / ACCESSORIES	Gel Pad Elastoplast- to secure patient shoulder position Image Intensifier (II) Lead Screen Diathermy Machine Suction Machine Medtronic console (SB) Microscope (SB)
SKIN PREPARATION	CETRIMIDE 1% POVIDONE IODINE Tincture
PHARMACEUTICALS	Infiltration for Bone Grafting: Marcaine 0.5% 10mls Xylocaine 1% 10 mls Adrenaline 1:1000 10 units
DRAPE	Universal Drape Ioban 6640 x 2 ABD sheet for X-ray lateral view ABD sheet to cover the lead screen
INSTRUMENTS / SUPPLEMENTARY SET	Laminectomy Set Spine Supplementary Set Casper Cervical Distractor ACDF Trimline(colorful one) Colibri Spinal Nerve Root Retractor Set Korros Punch Ortholegend attachement and cables (SB)
LOOSE INSTRUMENTS	Small Mallet Small Curved Osteotome Small Homman X 2
VENDOR SET (JandJ)	1. CSLP Set 2. Vectra Set 3. Bengal Set
CONSUMABLES	Raytex Gauze Penny Towel Peanut Harrington Patties (SB) Gelfoam Large Blade 10 X 2 Blade 15 X 1 Spinal Needle G.22 (black) 50mls Syringe 20mls Syringe Insulin Syringe Green Needle Lantern Drain Burr (SB)
SUTURES	Vicryl 1 Vicryl 2-0 Monocryl 3-0
DRESSING	Steristrips Aquagel Ag Small (for the neck) Primapore (Pelvis) Tegaderm to secure the drain
REMARKS	1 suction only

Proper draping for anterior cervical spine surgery with iliac bone graft:

1. Mayo cover to use on mayo stand.

2. Top first (head part, check drawing)

3.  Bottom Drape (check drawing) – to paste drape on patient just below iliac crest

4. Back Table Drape (blue drape) – from patient below the neck to just above patient iliac crest

6. Sides X 2 (check drawing)

7. Ioban 6640 X 2

8.  ABD Sheet + 2 Blunt Towel Clips for X-ray Lateral 

9. Dressing Towel to cover the cautery and sucker tubings

steps in draping

Procedure (again this steps varies on which doctor your assisting)

Harvesting of bone graft:

1. Infiltration of local anestesia

2. Blade 10 to skin

3. Gillies toothed and monopolar to dissect the muscle to bone

---once the iliac bone is exposed

4. penny becker to separate some tissue or muscle to the bone

5. Small homman to help to retract the muscle to the bone

6. Small Oscillating saw

7. Curved Osteotome

8. Mallet

---secure/keep the harvested bone in a gollipot

9. Wash with saline (op-site)

10. Pack with Large gelfoam- to close the incision site after the acdf procedure using Vicryl 1-0 to suture the muscle, vicryl 2-0 for fascia or subcutaneous and monocryl 3-0 to close the skin. The incision site then will cover with steri-strips and primapore it might or not needed for the pressure dressing.

ACDF Procedure:

1. New Blade 10 to skin

2. Monopolar and Gillies toothed forceps

3. Hand held retractor (coddman retractor - on spine supplementary set).

---Dissect and expose the cervical disc.

4. Trimline Retractor - ask the surgeon if what size or color that they are going to use. You may give the whole set so as to surgeon will choose which color he want. Load the blade into trimline handle and give the surgeon X 2 with same blade size. Once the surgeon already place the blade on the operative site he will ask for the trimline retractor frame to secure the blades on place.

metronic trimline acdf instrument set

handle, blades (purple color) and retractor frame

when surgeon ask for the trimline retractor attached
the blades from the handle by pressing downward
the button at the handle and slide in the blade

5. Give bended spinal needle gauge 22 (black) surgeon may need 2 of this.

6. Blade 15 - inside knife to cut the disc or soft tissues

6. Pituitary Rongeur to remove the disc and arthritic bone

7. Casper Pins X 2 load it on the Casper pins screw driver.

green handle (casper pin screw driver) Purple pin (casper pin) 2 knots (casper pins cover) and pin distractor holder

8. give the distractor pin retractor

9. load the knot to the casper pin screw driver and give to the surgeon X 2

10. Pituitary Rongeur

11. Kerrison Punch 1 or 2

---clean the kerrison punch and pituitary rongeur once every use of the surgeon. to remove the bone, disc and tissues that the surgeon removing from the cervical bone.

12. nerve retractor

13. Peanut loaded in a allies X 2

14. Give the bone graft in a gollipot together with the long tissue forceps non-toothed.

15. Bone Punch followed by Mallet to secure the bone in place.

---standby the mc donald
---once the bone is secure in place the surgeon then will choose plates to place on patient cervical spine to more secure the bone.
16. The surge on may or may not ask for the awl at this time. (creating a landmark for drilling)

awl

17. 2.5 Drill bit
18. drill sleeve (in this instrument you ask first the surgeon if what screw are their going to use, if it is variables or fixed screws)

Difference between Fixed Drill Sleeve and Variables Sleeve

variables sleeve notice the color coded and the name of the instrument on its handle

fixed angle drill sleeve

19. Depth Gauge- to measure the exact screw size.

spine depth gauge

20. Screw Driver/ Screws confirm with the type of screws. wo types of screws variables and fixed screws.

check the color of the screws

---once all screws are put up, wash the excision site, they will do final x-ray to make sure the proper placement of the bone screws and plates.

21. Lantern drain

22. Close with Vicryl 1-0 for the muscle 

22. Vicrly 2-0 fascia or subQ

24. Monocryl 3-0 skin

25. Steristrip

26. Aquacel AG (do not cut)

27. Scure the lantern drain with Tegaderm.

Total knee replacement

Total Knee Replacement or TKR is a surgical procedure whereby the diseased knee joint is replaced with artificial material. During a total knee replacement, the end of the femur bone is removed and replaced with a metal shell. The end of the lower leg bone (tibia) is also removed and replaced with a channeled plastic piece with a metal stem.

When surgery is recommended for TKR:

1. Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
2. Moderate or severe knee pain while resting, either day or night
3. Knee deformity — a bowing in or out of your knee
4. Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries. 

Assisting in TKR on my previous hospital is totally different from the hospital where im working now, totally different in a sense that mostly in my previous hospital vendors are allowed to scrub in to help us scrub nurses in assisting surgeon. Mostly they are the one who handed the right instruments to the surgeon and us just the basic instrument. Now in my new working place the whole process of surgery you alone assisting the surgeon and the vendors was just there on a scrub suit acting as somewhat your circulating nurse guiding you.
Before when I'm a nurse incharge (well at that time i have the power to teach) I always tell my students, nurse trainees, junior staff and senior staff that in every procedure you must know the anatomy of all the cases so as to know what part are they(surgeon) going to do and what are the instruments are they going to use on that part 
of the body. Im blogging about TKR so here is the normal anatomy of the knee. 

normal anatomy of the knee

Mostly during TKR surgeon preferred to do first the femoral bone and then the tibial bone, knowing these you will picture it to your mind or set to your mind to prepare all the instruments that are needing for removal of femur bone then the tibia then finished it with cementing placing of implant then suturing.

Things that ill be writing here, the commonly use instruments, consignments, supplies table settings and step by step procedure etc etc... are the one we usually do on our operating theater where im working.

PROCEDURE	TOTAL KNEE REPLACEMENT
POSITION	Supine with TKR foot support
EQUIPMENTS/ACCESSORIES	Torniquet Machine Suction Machine X 2 Diathermy Machine
SKIN PREPARATION / PHARMACEUTICALS	Cetrimide 1% 10% Povidone with 10% Alcohol 3L Normal Saline for washing using surgilav
INFILTRATION	Refer To Doctors Cocktail Dilution
DRAPES	Disposable Extremity Drape ABD Pack – placed under the knee during suturing and washing
STEPS IN DRAPING	Mayo Cover (to be used as orthomac) U-Drape from the set Dressing Towel to hold the leg Stockinette (loose) Elastic bandage + Scissors Extremity Drape Loose Mayo Cover (Bridge from OT table to main working table)
INSTRUMENTS SETS / SUPPLEMENTARY SETS / LOOSE INSTRUMENTS	Tibial and Femoral Retractor TKR Supplementary Set Large Ortho Basic set A-Set Basin X 3 Lambotte Osteotomes Straight Bone Nibbler SS Tray Medium wooden curette H/C Diathermy Light Holders Quiver X 2 Double Prong Retractor (SB) Bone Punch ZIMMER Sets (Vendor Sets)
SUPPLIES / CONSUMMABLES	Surgical Marker Raytec Gauze Penny Towel Plain Gauze Suction Tubing X 2 Hand Control Diathermy 50mls Syringe Diathermy Scrapper Disposable Suction Tip X 2 Ioban 6650 X 1 Blade 10 X 5 Crepe Bandage X 3 Surgilav with Handpiece Trauma tip softcone Palacos Bone Cement R+G; high viscosity Cement bowl Redivac drain 400mls X 1 Specimen Container Tegaderm X 2 (to seal the hole from disposable suction tip)
SUTURES	Vicryl 1 cutting X 2 (muscle) Vicryl 2-0 cutting X 2 (fascia) Monocryl 3-0 X 1 (skin)
DRESSING	Steri-Strip ½ X 2 Large Primapore X 1 (cut one end) Medium Primapore X 1 Small Primapore (do not cut use to anchor drain) Plain Gauze 6inches elastic bandage

Settings of the Main Table and Working table for the the vendors set

main trolley set up for TKR

Blades, pins (headed, headless, bullet and golden) and drills use in TKR

instruments use for TKR

Here is the procedure itself in which the surgeon "MIGHT" ask during the procedure. Nurses who are reading this blog should also need to look what are the surgeon doing listen on what are the surgeon asking be attentive and assertive at the same time. This is I know when I'am the scrub nurse this is the way I handed or assist the surgeon in TKR. We might have different way in assisting, and also sometimes surgeon kept changing their plan during the procedure.

TOTAL KNEE REPLACEMENT PROCEDURE 

1. First Knife to cut the skin
2. Second knife or the inside knife
3. Rake Retractor (3rd assist surgeon will help suctioning the op site while the surgeon is cutting)
4. Surgeon might use Diathermy and Lanes Forceps for hemostasis or use for cutting
5. Inside Knife (3rd knife) followed by Curve Mayo Scissors to cut the muscles
6. Inside Knife (4th knife) and Lanes Forceps surgeon will start to collect specimen for histo and culture.

*once the femoral bone and tibial bone are exposed*

(to note all pins needed in femoral bone are headed pins)

Surgeon will start to Femoral Bone

1. Surgeon might ask Bristol to separate some of the muscles to the bones
2. Sharp Homman Reractor X 2 to retract the skin and muscle for more exposure of the femoral and tibial bone.
3. Straight Bone Nibbler to remove the osteomized fragments
4. Starter Punch followed by mallet to make a small hole into femoral bone and act as a marker for the insertion of first jig. 

   

   starter punch

5. Long Drill (create a hole into femoral bone

   

   first drill

6. Blunt Homman To expose the femoral bone
7. Handed the first jig followed by the 3rd degree rotation they will insert this to the hole that they made, surgeon might re drill again (first drill) or he might use mallet. 

   

   first jig and 3rd degree rotation

8. Small Drill 

   

   second drill to drill the hole into 3rd degree rotation

9. T-Handle to remove the First Jig 

   

   T-Handle

10. Second Jig then give 2 headed pin plus mallet handed the stylus followed by ochsner just to tighten or lock the screws. surgeon will check if it is correct measurement and placement give the sea guide. 

    

    second jig, stylus, sea guide

11. Surgeon might ask nibbler and sharp homman
12. Third Jig check if you handed the right position of the jig. So you must know if the operative site is left or right. 

    

    3rd jig check the correct placement

13. Ochsners to remove the stylus
14. 3 Headed Pin followed by mallet each pin

    

    headed pin

15. Extractor - surgeon might removed some other pin. 

    

    extractor

16. Standby staight osteotome size 20 surgeon might ask for it
17. Big Saw
18. Extractor - to remove the third Jig
19. Femoral Sizer - surgeon will now determine on what size he will be using on his femoral implant.  

    

    sizer

20. MIS Femoral finishing comes in different sizes usually from B to E you need to screw in the triangular template. 

    

    you will need screw driver on this stuff

21. Headed Pin X 2 followed by mallet
22. Hexagonal Screw driver to removed the triangular template
23. Drill (rounded shape) 

    

    drill

24. starter punch with bullet X 2 surgeon might use mallet. 

    

    load the bullet to starter punch

25. Small Saw then Big Saw after. 

    

    small saw

26. Extractor To removed the headed pins
27. T-Handle to removed the MIS Femoral Finishing
28. Surgeon might ask for the Straight Osteotome size 20 to remove the cut bones.

Tibial Bone

1. Tibial jig. 

   

   this must be assemble to appear like this

2. Man on a boat 
   
3. Golden pin X 2 followed by mallet (golden pin was placed in to hold the 7 degree (right/left) jig.
   
4. Sea guide - to check the level of femur
5. Ochsner X 2 to hold on the golden pins
6. U-Shape thing followed by the allignment rod. - to check the allignment of the bone 

   

   the u shape thing is inserted to 7 degree  by the surgeon

7. Big Saw
8. Surgeon might ask for the broad straight osteotome size 25 or straight nibbler to remove the bone
9. Spacer Block to check the spacing of femoral and tibial implant it comes in different sizes (prepare 9,10 and 12) 

   

   spacer block

10. Sharp Homman 
11. Golden Pin Puller 
    
12. Surgeon might ask for the small saw and osteotome
13. Curette
14. Sea Guide 
15. Small Laminar Spreader
16. Small Curved Osteotome to remove some bones on femur he might use mallet
17. He might going to check again the allignment, so he will be using spacer block and allignment rod.
18. All in one (fifth jig) (Back to femoral bone) 
    
19. Bullet pin on a starter punch X 2 followed by mallet
20. headed pin X 3 followed by mallet each pin
21. Small Saw he might use straight osteotome size 20
22. Oscillating Saw
    
23. Extractor to remove the pins
24. surgeon might use mallet
25. He might use the osteotome again and rongeur to remove the bone. The surgeon then will ask to save the bone the he just remove to use for the later part.
26. Surgeon might use bone file
27. Femoral Temporary Implant (comes in different sizes give the correct size in which he ask before) 

    

    when giving femoral temporary implant give also the femoral punch followed by mallet

28. mickey mouse plate with handle plus the AP sizer (comes in different sizes with correspondent color) (femoral temporary implant and mickey mouse plate with AP sizer was use to check the correct implant that they will be using). 

    

    at first serve the plate with the handle plus the AP sizer (yellow) at a later part just give the plate 

29. Sharp Homman to removed the AP sizer 
30. Femoral Extractor to removed the Femoral Temporary Implant 
    
31. Mickey mouse / tibial plate 

    

    some surgeon doesn't need the handle

32. Headless pins on ochsners X 3 
    
33. Starter Punch followed by mallet to punch in the headless pins
34. Mickey mouse 
    
35. Drill (big)
    
36. Brooch (6th jig)
    
37. Mallet to punch in the brooch
38. T-Handle followed by Mallet to removed the brooch
39. Headless pin remover or pin puller to removed the headless pins
40. Tibial Trial (comes in different sizes) color white followed by tibial punch

    

    tibial trial (white) tibial punch and mallet

41. AP sizer (mostly yellow) 
42. Femoral Temporary Implant 
43. Femoral punch followed by mallet. (placing all the tibial trial femoral temporary implant and the AP sizer surgeon is making sure that he will placed the correct size of the implant if he is certain about that the vendor then can open the necessary implant needed by the patient).
44. T-Handle followed by mallet to removed the tibial plate (white) but sometimes surgeon removed it manually.
45. Femoral Extractor to removed the femoral temporary implant.
46. WASH the operative site before placing the implant. before hand you will ask the surgeon if he needed to give cocktail because sometimes after washing surgeon injected pain reliever and antibiotics on patient knee. But if the patient went to anesthesia block surgeon wont give any cocktail. During washing nurses prepared all the things needed for cementing.

THINGS TO PREPARE FOR CEMENTING AND IMPLANT:
On your SS Tray:

1. Femoral Punch
2. Tibial Punch
3. Mc Donald
4. Articular Surface or spacer or INSERTER
5. Gillies non tooth
6. He might or not need wet gauze.

Mixing of cement, ask the surgeon first if it is okay to mix the cement. The circulating nurse then need a timer to time the mixing of cement. The timing will start once the scrub nurse pour in the solution to the cement powder form. The scrub nurse will mix the cement in one direction up until 1 minute, by then cement is ready. Wet the surgeon gloves with normal saline Serve an ample of amount of cement to surgeon to place on patient tibial bone and tibial implant plate give the tibial punch and mallet. non tooth gillies or mc donald to removed the excess cement. Next serve again cement to surgeon, surgeon then place the cement on patient femoral bone plus the femoral implant. Give the femoral punch followed by mallet, same thing non tooth gillies and mc donald to removed excess cement. Every minute the scrub nurse will announce the timing to the surgeon, it takes for about 10-15 minutes that the cement is fully harden. After implanting surgeon then will placed redivac drain. Close the knee using Vicryl 1 for muscle Vicryl 2-0 for fascia and Monocry 3-0 for skin they will use steristrip close with primapore and plain gauze and wrap with elastic bandage 6 inches. Drain will clamp for 6 hours.

Again this are the things I usually do and prepare when I scrub in TKR. We have a lot of ortho doctors who doesn't follow this, they have their own technique meaning others that are written here are not accordingly to them. For those who have read this especially to all my colleagues feel free to comment, add something if there is something that i have not written here or say something that it should be not written here.

Thank you for reading i hope this will help you and will blog some other op procedures..=)