When we last left our OR call team during the lap appy, surgery had just begun.
To recap, it has been 45 minutes since the page. In that time the RN and the scrub tech drove to the hospital, got dressed in scrubs, picked the case. The scrub tech opened and set up the case. The RN grabbed a unit phone, went and picked up the patient from ED, and started the pre-op work. Anesthesia came and did their part. The surgeon came and explained the risks and benefits of surgery to the patient. The RN witnessed the patient signing the consent for surgery, and anesthesia. The first time, the pre-procedure time out was done, the H&P had been put in by the surgeon, the patient and his wife said see you later, and anesthesia took the patient to the room. The RN walked the wife to the waiting room, explaining what was going to happen next, and stressing the importance of answering the waiting room phone call, and returned to the room. The scrub tech and RN put the sequential stockings on the patient, made sure his seatbelt was secure. And anesthesia put the patient to sleep. The scrub tech used Avagard to cleanse her hands and put on the sterile gown and gloves. The RN clipped the hair on the abdomen, prepared the skin of the abdomen with chloraprep, and while that was drying, put am electronic grounding pad on the patient. The surgeon used Avagard to cleanse his hands and the scrub tech put on his sterile gown and gloves. The RN moved the tower into position after spinning the surgeon. While the surgeon waited with blue towels to square off the incision, the scrub tech and RN counted soft goods such as sponges, blade, needles, fog reduction liquid, and instruments. By now the 3 minute wait time has expired and the RN gives the surgeon the okay to drape. The scrub tech hands off the camera, light cord, CO2 tubing, bovie, and Enseal to the corresponding sides of the table where the RN plugs them in. The RN puts the consents on the prep table where she can see them during the pre-incision pause, the pre-incision pause is done and the fire risk pause is done. All is in agreement. The scrub tech hands off the blade and the surgeon makes incision.
Are you tired yet? This is a lot of accomplish in 45 minutes. And the case has just started!
I turn on the radio after incision to whatever I know the MD listens to, or what is listed on his preference card if I don’t know it.
The cut down incision is made at the umbilicus (belly button) and the initial trocar is introduced. This is usually the largest one.
The surgeon calls for the CO2 to be turned on. On full. This means 30 liters per minute, to an abdominal pressure of 15 mm Hg.
The surgeon scans the abdomen with the scope, looking for adhesions, looking at the liver, looking into the pelvis. He then asks for the blade and the next trocars, which are placed.
The lap appy can not begin in earnest.
The surgeon trains his scope at the site that the appendix is anatomically; the junction of the small bowel and the colon. With luck the appendix is sitting there on top of the bowel coils, ready for its closeup. Sometimes the appendix is buried under the coils of bowel, sometimes it is retroperitoneal, or behind the colon. It just depends on the patients anatomy. And whether or not there is purulent material or pus, depends on how bad the appendix is. As a surgeon put it this week, sometimes the patient can have appendicitis for a week with no rupture, or 6 hours with rupture. It depends on how mad it is. Sometimes the appendix has ruptured and begun to wall itself off in an abscess construct. This is not good because after 3 weeks or so this walling off will break down and the patient will be even sicker. Sometimes the appendix has ruptured so badly that the appendix is not evident because it has burst like a balloon. I’ve only seen a few of these in my 21 years of OR.
While the surgeon is searching for the appendix my job as the circulator is just beginning. There are many things that I, as the circulator, need to be doing. The next thing that the field will be asking for is the stapler, with a load. I do a quick scan to make sure they are in the room and the retrieval bag is on the sterile field. I also do a check that there are more than 1 reload, in case the appendix is larger than the usual stapler and a reload is required. I do a quick glance at the bag of LR that the CRNA is using, to make sure that they have enough fluid still in the bag for the rest of the case. All the while, I am listening to the beeps that the monitors make.
Much of this is not done on instinct, but done on experience. If the patient were to go bad, and the CRNA to begin noticing trouble with the patient, these monitor beep changes are often the first things. Or there is a lot of movement, behind the drapes, of the CRNA. A flurry of movement can indicate the CRNA is pulling meds to counteract a vital sign reading. If that is the case, I move to where I can see the monitors and pull out my phone to contact the anesthesiologist if required.
If I am fairly certain that I have everything they need, I begin to chart. Charting is always the least of my worries. What is happening in real time is more important. And I have a secret weapon, a macro that I created for the surgeon, for the case. This will fill in a lot of the holes that I need to chart. But that will be part 7.