Most surgical patients dont know that before their operation begins, a laborious process called an instrument count is down. This procedure includes counting each piece of sterile equipment that will be used during the procedure. The count must be done by a registered nurse and the sterile nurse or scrub nurse. In some jurisdictions, a scrub nurse can be unlicensed personnel called a scrub technician.

As each tray of instruments is opened unto the sterile field, the two nurses will compare the contents with a paper sheet which comes with the tray. Each and every piece within the tray will be counted.

All sterile supplies are counted. This includes sponges, which are usually wrapped together in groups of five or ten. Sponges can be large gauze bundles, or 4X 8 rectangles of gauze. Also, small gauze pieces which are bound together into a peanut shape and called peanuts are counted. Larger balls of cotton stuffed gauze pillows are counted. Sutures are counted and divided by types. Needles without sutures, or free needles, are counted separately. All of these supplies are possible foreign objects that can be left behind in a body cavity.

There is a debate about which surgeries are at risk for lost objects. In most states, the standard is to count instruments, sponges and sutures when a body cavity is opened. A cavity would be the head, abdomen or chest. There is also a risk for left behind sponges in some gynecological surgery where instruments are inserted into the uterus. So sponges and needles are counted for those surgeries.

Major, but minimally invasive surgeries, such as laparoscopic gastric bypass, laparoscopic nissen fundalpication, laparoscopic nephrectomy, or laparoscopic assisted vaginal hysterectomy are surgeries in which multiple, small puncture wounds are made in which specially designed sheaths are inserted and then the scope and instruments access the cavity through the sheaths. Except for thoracic endoscopic surgeries, utilizing a scope requires the body cavity to be expanded in some way. Laparoscopic surgeries use carbon dioxide gas, arthroscopic, genitourinary and gynecological surgeries use fluid. The sheaths prevent the
gases or fluids from escaping from the cavity.

Technically, it is hard to imagine how anything could be left behind in a surgery done with a scope. However, small screws, jaws to graspers, and parts of staple guns have all been left behind in patients, require additional surgeries and time and money lost. Ultimately it is the responsibility of the surgeon to know if the instrument he pulls out of a patient is complete, but part of the team mentality is that the nurses must also know the construction of an instrument so that if something is missing, it can be accounted for.

An example of this is something that I experienced; I was scrubbed on a back surgery and one of the bone instruments I gave the doctor was missing a screw. It didnt affect its operation, but I didnt know if it was missing before I gave it to the doctor or not. It required an xray during the surgery to see if the screw was somewhere within the patients back incision. It was not.

The web sites below, have much more information on these subjects…

According to WebMD, 80 of all Americans suffer from back pain at some time in their lives. Pain is subjective. It is suffered at whatever level the sufferer perceives it. What may be intense, debilitating pain to one patient is tolerable to another. What is unbearable to one may be low level to another. It is up to the patient to find a medical practioner who will listen and help the patient find a solution to their suffering.

Usually the first line of defense is the patients family doctor, who may be a general practioner or a internal medicine doctor. The GP is more likely to offer an exercise regimen, non steroidals, muscle relaxants and the ice, heat routine. This is often a satisfactory treatment for patients with back strain from heavy lifting, or other mechanical injury. Internal medicine doctors are more apt to refer their back pain patients immediately to an othropedic specialist who may also determine after their physical exam that the source of pain is a mechanical injury and prescribe a similar treatment with or without physical therapy.

Those patients who dont respond to conservative therapies may be candidates for the next level of therapy; epidural injections.

First of all, the physician will send the patient for radiographs of the spine, and then if the xray shows any abnormality, he may prescribe an MRI, which will give a detailed image of the spine and its components. It will show problems with alignment, arthritis, disc degeneration and other conditions.

Then the patient will make an appointment with a pain management physician who is a specialist in treating patients with back pain among other pains and also may be an anesthesiologist. The pain management specialist will take a detailed medical history which will include information about lifestyle, exercise, diet, etc. A physical will be done, including reflexes, sensation, and strength. If the pain management specialist feels the patient will benefit from the steroid epidural injection, it will be scheduled at that time.

The day of the steroid epidural injection will come with the patient having fasted after midnight and nothing by mouth in the morning. All jewelry should be left at home, along with any valuables in the female patients handbag. Comfortable, easy to remove clothing should be worn.

The patient will arrive at the facility and speak briefly to the registration person. Then she will be lead to a small room where she will undress and put a hospital gown on, and her temp, blood pressure and pulse will be taken. Then an intravenous line will be started. All the drugs the patient will get during the procedure will be given through this line.

The patient will walk to the room where the injection will be given. In many facilities, the patient will sit on the end of the bed or on their side for the procedure. But state of the art injections are given under fluoroscopy with the patient laying on their stomach. In this way, the physician can guild the injection to the exact space where the patients pain originates.

After the injection is given, the patient will go to the recovery room for one half to one hour, then back to their room to dress and go home. With two days to two weeks, evidence of the effectiveness of the injection should be apparent. Up to three injections may be necessary to obtain relief.

With the increased use of laparoscopic, endoscopic, arthroscopic and thoroscopic surgery, it was just a matter of time before the use of a video monitor would be introduced into the surgical suite. Prior to that time, the eye piece of the lens was literally held up to the surgeons eye. Not only did this promote unsterile conditions, it made it impossible for the assistants around the table to anticipate the needs of the surgeon or to see what was going on. The surgeon used one hand to hold the scope and the other to hold instruments or perform procedures.

The introduction of video monitors not only increased the efficiency of the surgeon by making both hands available for surgery and giving the scope with a camera attached to it to an assistant to hold, it made it possible for the assistants to help grasp tissue with special laparoscopic instruments because they could now see the surgical field.

Use of video monitors made it possible for a large audience of students to learn specific maneuvers without being scrubbed at the field. A record of the entire surgery was available if the recording device was utilized. If networking is employed, several monitors are connected and placed strategically around the operating room, giving a birds eye view to the entire OR staff.

State of the art video equipment now includes computer operated robotic arms employed to hold the scope with the camera attached. One brand is Aesop. The arm is attached to the operating table and draped with a sterile drape. Voice activated, the arm moves up and down telescoping in and out, and side to side by obeying the commands of the surgeons voice which is programmed into the computer prior to the surgery. Making use of robotic arms to hold the scope insures consistent motion in a dynamic situation.