Specialized procedures and preoperative preparation

Endoscopic procedures

An endoscope is a medical device consisting of a miniature camera mounted on a flexible tube with an optical system and a light source used to examine the area inside an organ or a cavity. Many types of endoscopes are used, and they are named according to the organs or areas they are used to explore, such as the urinary bladder, bronchus, larynx, colon, stomach, uterus, abdomen, and various joints. Small instruments can be used to take samples of suspicious tissues through the endoscope.

Direct visualization with an endoscope is used for diagnostic purposes or to perform surgical procedures. Endoscopes may be rigid (e.g., laparoscope or hysteroscope), semirigid, or flexible (e.g., colonoscopes, bronchoscopes, gastroscopes). All are delicate and expensive, and they require extreme care in handling to protect them from damage.

Accessory equipment used with endoscopes includes fiberoptic light cables and light source, irrigators for solution instillation and suction, and a camera, monitor, printer, and video recorder. The fiberoptic light cable consists of hundreds of glass fibers. It is important to protect it from being bent, dropped, kinked, squashed, or smashed. The light source can become very hot and must be kept out of contact with the patient, the provider, the staff, and any flammable material, such as surgical draping. All equipment must be checked before and after use. Always follow the manufacturer’s recommendations for the use, care, and maintenance of equipment.

Endoscopic instruments would be damaged by the high temperature and steam under pressure in autoclaves. Special care must be taken in sanitizing and using high-level disinfectants after each procedure to destroy pathogenic organisms and prevent cross-contamination to subsequent patients.

Cryosurgery

Cryosurgery involves the use of a very low-temperature probe to destroy tissue by freezing it on contact. The probe’s temperature is usually below 4°F (−20°C). This cold temperature is achieved by circulating liquid nitrogen through the tip of the probe. A local anesthetic is usually administered before cryosurgery. Cryosurgery is used to treat cancers of the skin and warts. In many situations, cryosurgery is less invasive than traditional surgery and, therefore, generally has fewer associated complications. Cryosurgery is often performed in an ambulatory setting or an outpatient surgery center.

Joint aspiration and therapeutic injections

A joint aspiration, also known as an arthrocentesis, can easily be done in the provider’s office. This procedure involves the removal of fluid from a joint, most commonly from the knee. This may be done to reduce swelling from an injury or infection. It may also be done to help diagnose arthritis or other conditions of the joint. A therapeutic injection involves injecting medication, such as corticosteroids, into the joint to relieve pain. For both a joint aspiration and therapeutic injection, sterile technique is used, and ultrasound is usually used to help guide the needle within the joint. If an aspiration is done, a sample of the fluid removed will be examined under the microscope to help determine the cause of the accumulation of fluid in the joint. After either of these procedures, the patient should remain sitting for several minutes to make sure that they are not dizzy.

Preparation for surgical procedures

For a procedure to go smoothly, things must be prepared well. If patients do not understand what they are required to do before the procedure, the procedure may have to be postponed. If the room is not properly prepared, the procedure may be delayed, upsetting the provider and patient. The following sections discuss the proper preparation of the patient and the procedure room.

Preparation of the patient

Whether minor surgery is performed because of an unforeseen accident or is a planned, elective procedure, the patient needs both psychological and physical support. A patient facing a surgical procedure may be concerned about pain, disfigurement, and the possible diagnosis. An injured patient may feel anxious about medical bills or possible loss of employment. Because surgery is a frightening experience, the medical assistant must take the time, both preoperatively and at the time of surgery, to help the patient deal with fears and anxieties. The best way to help is to make sure that the patient understands the details of the procedure, all questions are answered by the provider, and the patient has the opportunity to talk about the procedure and voice any concerns.

Questions should be answered directly, but you should answer only the questions that are within your scope of knowledge and the policies of the office. If you cannot answer a question, assure the patient that you will relay it to the provider before the procedure and then be sure to do so. What may seem like a minor or unimportant question to you may be a frightening concern to the patient. The minor surgery room can be intimidating, so unless the patient is sedated, try to make conversation with him or her while you prepare for the provider’s arrival.

Preoperative preparation may include the following:

• Blood and urine tests
• Completion of a consent form
• Gathering of the current history concerning any recent illnesses
• Medications and allergies

Patient preparations before surgery may include a shave prep, cleansing enemas, food intake restrictions, special bathing, and the administration of a sedative medication. On the day of surgery, the patient is instructed to empty the bladder and undress and gown as requested. The vital signs are recorded in preparation for the procedure.

Preoperative instructions

When office surgery is planned, certain procedures are followed before the appointment, such as these:

• Having the necessary consent forms ready to sign
• Giving the patient the necessary preoperative instructions, such as medications to be used and special skin-cleansing instructions
• Telling the patient to bring a relative or friend to drive him or her home after the surgery
• Instructing the patient to leave jewelry and other valuables at home
• Calling the patient the day before the scheduled surgery to confirm any special instructions

Informed consent

The provider must have the patient’s written informed consent before the sedating medication is given and surgery begins. To sign an informed consent form permitting the provider to legally perform the surgery, the patient must understand certain details about the procedure:

• What procedure will be performed
• Why it should be done
• The potential risks and benefits of the surgery
• Alternative treatments (including no treatment)
• Possible risks of any alternative treatment

This legal requirement is not met simply by having the patient sign a consent form; a discussion must occur, during which the provider gives the patient or the patient’s legal representative enough information to enable the person to decide whether to proceed with the proposed surgical treatment. After this discussion, the patient either consents to or refuses the surgery. The patient then signs or refuses to sign the consent form. The discussion must be fully documented in the patient’s health record. A copy of the signed form must also be included in the patient’s record. Sometimes the patient will sign the form directly on the electronic record. Treatment may not exceed the scope of the consent form.

The patient must not be under the influence of any sedative medication at the time he or she signs the consent form. An interpreter must be used if the patient does not understand English. This condition must never be violated.

Positioning

Have the patient disrobe sufficiently to expose the surgical site completely so that accidental contamination does not occur during the procedure. Clothing may also act as a tourniquet or make applying a proper dressing or bandage difficult. In addition, the patient’s clothing may be stained by the skin prep solution or may interfere with adequate site preparation.

The patient needs to be positioned as comfortably as possible for the procedure. An uncomfortable position can be held for only a limited time, and the patient may have to move, perhaps in the middle of a procedure, if you have not ensured his or her comfort from the beginning. When deciding on the correct position, consider where you and the provider will stand or sit, where the instruments will be placed, and where other needed equipment will be located. If the patient has an open wound, wear gloves to assist the patient into position. If there is active and profuse bleeding, wear an impermeable gown and gloves. If there is a danger of blood and body fluid contamination to your face or eyes, wear a face shield.

Skin preparation

The human skin is a reservoir of bacteria, but it cannot be sterilized without the risk of damaging cells and tissues. The goal of adequate skin preparation for a surgical procedure is to reduce the number of transient floras so that any transfer of harmful organisms at the incision site is limited. Cleansing the patient’s skin before surgery with surgical soap and an antiseptic and shaving the area if needed is called a skin prep. Sometimes the patient may be instructed to repeatedly cleanse the surgical area with bacteriostatic or antiseptic soap several days before the surgery. Disposable skin prep trays and electric razors should be available in the ambulatory facility.

Preparation of the room

If you are to assist in a minor surgical procedure, study the provider’s care preferences, review the procedure, and note the materials needed. Next, prepare the room and gather the supplies to be used. Sterile supplies are opened just before the procedure. Opened materials that have been exposed longer than 1 hour, usually because of a delay, are considered nonsterile.

Supplies should not be placed where they can be knocked over or dropped. Wrapped sterile supplies that fall to the floor must not be used. Make sure the patient and family members understand that they should not approach or touch the sterile field.