OR Setup for an Open Incisional Hernia Repair with Mesh (South College, Knoxville, TN)
Shannon Morris, AS-ST, CST
South College, Knoxville, TN
Successful surgical treatment of incisional hernias after abdominal surgery depends in part on the creation and maintenance of the sterile field. Optimal arrangement of surgical instrumentation and organization of the sterile field are important elements that can impact surgical outcomes and patient safety. This educational video covers sterile field preparation, including back table and Mayo stand arrangement, preparation for the initial surgical count with a circulator, and mesh management. This setup shown here presents how to arrange forceps by type/usages, and establish specific zones for sharps. The initial surgical count includes all sponges, sharps, and instruments according to current surgical safety guidelines. The goal of this educational video is to demonstrate how surgical technologists create and maintain the sterile field and prepare for the initial surgical count to support efficient surgical operations and patient safety.
Percutaneous Nephrostolithotomy for Treatment of Impacted Ureteropelvic Junction Calculus
Max S. Yudovich, MD; Joseph Y. Clark, MD
Penn State Health Milton S. Hershey Medical Center
Percutaneous nephrostolithotomy (PCNL) is a minimally invasive urologic procedure used to treat large kidney stones or stones which are not accessible from a retrograde approach. When untreated, these stones can cause chronic pain, infections, and over time, decreased renal function. The indications for PCNL include total renal stone burden greater than 20 mm, lower pole stone burden greater than 10 mm, or any stone burden which cannot be treated with ureteroscopy or extracorporeal shockwave lithotripsy, such as in the setting of a ureteral stricture or ureteropelvic junction obstruction.
During the procedure, the patient is typically positioned prone, and a needle is used to puncture the kidney through the flank. As in the case of our procedure, a pre-existing nephrostomy tube can also be used. After wire access to the kidney is obtained, the tract is dilated and an access sheath is placed to facilitate irrigation and insertion of instruments. Large stones can be removed through ultrasonic lithotripsy, pneumatic (ballistic) lithotripsy, laser lithotripsy (typically holmium:YAG or thulium lasers), and combination devices that integrate ultrasonic and pneumatic mechanisms. Smaller stones, such as in our case, can be extracted using graspers. In this video, we present a left-sided PCNL in which we remove a total of 2.1 cm of renal stone burden. Following stone removal, a ureteral stent and nephrostomy tube were placed to enable maximal drainage of the kidney. Postoperative CT showed complete clearance of stone burden.
OR Setup for a Laparoscopic Cholecystectomy (South College, Knoxville, TN)
Madison Campbell, AS-Ed, AS-ST, CST
South College, Knoxville, TN
The laparoscopic approach is widely regarded as the preferred surgical method for gallbladder removal procedures. The operating room setup for laparoscopic cholecystectomy follows established protocols that provide patient safety through the use of aseptic technique and AORN guidelines for surgical counts. These procedures form the foundation for successful surgery and are covered in this article.
Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy
Swetha Jayavelu, MD; Marc Mankarious, MD; Bryanna M. Emr, MD
Penn State Milton S. Hershey Medical Center
Ovarian cysts are a common gynecologic finding in adolescent females and are typically benign, often resolving without requiring intervention. However, larger cysts can cause significant symptoms and pose a risk for complications such as torsion. These cysts were traditionally removed with a full midline laparotomy. Surgery as a field has moved towards minimally invasive approaches to promote healing and aesthetics. With large benign cysts, this is achieved with controlled intentional decompression, allowing for extraction with a smaller incision. In this case, we present a 14-year-old female who presented with abdominal discomfort and was found to have a 24x20x9-cm left ovarian cyst. She underwent controlled cyst decompression into a specimen bag, minimizing peritoneal contamination prior to removal of the cyst. This was achieved in a 5-cm Pfannenstiel incision. The patient was discharged the same day without complications and demonstrated full recovery with no cyst recurrence at the 12-week follow up. This case highlights the safe, effective management of large benign ovarian cysts using controlled decompression and innovative containment strategies to enable minimally invasive surgical access.
Hepatic Artery Infusion (HAI) Pump Placement For Unresectable Intrahepatic Cholangiocarcinoma with Vessel Abutment and Intrahepatic Metastasis
Rushin D. Brahmbhatt, MD
Penn State Health Milton S. Hershey Medical Center
The management of unresectable intrahepatic cholangiocarcinoma (ICC) faces major difficulties due to limited therapeutic options for liver-confined disease. A 72-year-old woman with a centrally-located ICC that involved both portal vein branches received robotic HAI pump placement. The procedure started with diagnostic laparoscopy before moving to robotic arterial dissection for catheter placement in the gastroduodenal artery (GDA) and ending with comprehensive perfusion testing using indocyanine green and methylene blue.
Preoperative imaging results showed less disease presence than the intraoperative ultrasound results that displayed multiple hepatic metastases, which led to a change in treatment approach from neoadjuvant to definitive palliative care. The surgeons confirmed proper hepatic perfusion and no abnormal extrahepatic blood flow after they placed the catheter successfully. The robotic HAI pump placement system provides a minimally invasive solution for delivering regional chemotherapy in cases of unresectable ICC through improved visualization and precision compared to open surgical approaches.
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