SURGICAL RADIOGRAPHY

SURGICAL RADIOGRAPHY

KARI J. WETTERLIN

Surgical radiology is a dynamic experience. The challenges a radiographer encounters in the surgical suite are unique. Knowing the machinery and its capabilities and limitations is most important; in that regard, the radiographer can enter any operating room (OR) case, whether routine or extraordinary, and, with good communication, be able to perform all tasks well. An understanding of common procedures and familiarity with equipment enables the radiographer to perform most mobile examinations ordered by the physician. Surgical radiography can be a challenging and exciting environment for the radiographer but can also be intimidating and stressful. Surgical radiology requires educated personnel familiar with specific equipment routinely used during common surgical procedures. It requires expertise in teamwork. Preparedness and familiarity with equipment are key. Standard health and safety protocols must be followed to avoid contamination and to ensure patient safety. These are the basics, and the pieces come together in surgical radiology in distinctive ways.

This chapter focuses on the most common procedures performed in the surgical area. The basic principles of mobile imaging are detailed, and helpful suggestions are provided for successful completion of the examinations. This chapter is not intended to cover every possible combination of examinations or situations that a radiographer may encounter, but rather provides an overview of the surgical setting and a summary of common examinations. The scope of radiologic examinations in a surgical setting is vast and may differ greatly among health care facilities (Box 29-1). The goals of this chapter are to (1) provide an overview of the surgical setting and explain the role of the radiographer as a vital member of the surgical team, (2) assist the radiographer in developing an understanding of the imaging equipment used in surgical situations, and (3) present common radiographic procedures performed in the OR. The radiographer should review the surgery department protocols because they vary from institution to institution.

BOX 29-1 Scope of surgical radiography

Surgical fluoroscopic procedures

• Abdomen: cholangiogram

• Chest-line placement: bronchoscopy

• Cervical spine: anterior cervical discectomy and fusion

• Lumbar spine

• Hip: cannulated hip screws or hip pinning, decompression hip screw

• Femoral and tibial nailing

• Extremity fluoroscopy

• Humerus: shoulder in beach chair position

• Transsphenoidal resection of pituitary tumor

• Femoral/tibial arteriogram

Mobile surgical radiography procedures

• Localization examinations of cervical, thoracic, and lumbar spine

• Mobile extremity examinations in OR

Surgical Team

At no other time is a patient so well attended as during a surgical procedure. A surgeon, one or two assistants, a surgical technologist, an anesthesia provider, a circulating nurse, and various support staff surround the patient. These individuals, each with specific functions to perform, form the OR team. This team literally has the patient’s life in its hands. The OR team has been described as a symphony orchestra, with each person an integral entity in unison and harmony with his or her colleagues for the successful accomplishment of the expected outcomes. The OR team is subdivided, according to the functions of its members, into sterile and nonsterile teams.

STERILE TEAM MEMBERS

Sterile team members scrub their hands and arms, don a sterile gown and gloves over proper surgical attire, and enter the sterile field. The sterile field is the area of the OR that immediately surrounds and is specially prepared for the patient. To establish a sterile field, all items necessary for the surgical procedure are sterilized. After this process, the scrubbed and sterile team members function within this limited area and handle only sterile items (Fig. 29-1). The sterile team consists of the following members:

Fig. 29-1 OR staff showing sterile (left) and nonsterile (right) team members.

• Surgeon: The surgeon is a licensed physician who is specially trained and qualified by knowledge and experience to perform surgical procedures. The surgeon’s responsibilities include preoperative diagnosis and care, selection and performance of the surgical procedure, and postoperative management of care. The surgeon assumes full responsibility for all medical acts of judgment and for the management of the surgical patient.

• Surgical assistant: The first assistant is a qualified surgeon or resident in an accredited surgical educational program. The assistant should be capable of assuming responsibility for performing the procedure for the primary surgeon. Assistants help to maintain visibility of the surgical site, control bleeding, close wounds, and apply dressings. The assistant’s role varies depending on the institution and with the type of procedure or surgical specialty.

• Physician assistant: The physician assistant is a nonphysician allied health practitioner who is qualified by academic and clinical training to perform designated procedures in the OR and in other areas of surgical patient care.

• Scrub nurse: The scrub nurse is a registered nurse (RN) who is specially trained to work with surgeons and the medical team in the OR.

• Certified surgical technologist (CST): The CST is responsible for maintaining the integrity, safety, and efficiency of the sterile field throughout the surgical procedure. The CST prepares and arranges instruments and supplies and assists the surgical procedure by providing the required sterile instruments and supplies. In some institutions, a licensed practical nurse (LPN) or RN may assume this role.

NONSTERILE TEAM MEMBERS

Nonsterile team members do not enter the sterile field; they function outside and around it. They assume responsibility for maintaining sterile techniques during the surgical procedure, but they handle supplies and equipment that are not considered sterile. Following the principles of aseptic technique, they keep the sterile team supplied, provide direct patient care, and respond to any requests that may arise during the surgical procedure.

• Anesthesia provider: The anesthesia provider is physician (anesthesiologist) or certified RN anesthetist who specializes in administering anesthetics. Choosing and applying appropriate agents and suitable techniques of administration, monitoring physiologic functions, maintaining fluid and electrolyte balance, and performing blood replacements are essential responsibilities of the anesthesia provider during the surgical procedure.

• Circulator: The circulator is preferably an RN. The circulator monitors and coordinates all activities within the OR, provides supplies to the CST during the surgical procedure, and manages the care of the patient.

• Radiographers: The radiographer’s role in the OR is to provide intraoperative imaging in a variety of examinations and with various types of equipment.

• Others: The OR team may also include biomedical technicians, monitoring technologists, and individuals specialized in equipment or monitoring devices necessary during the surgical procedure.

Proper Surgical Attire

Surgical attire protocols may change from institution to institution but should be available for review, understood, and followed by all staff members. Although some small variances in protocol exist among institutions, there are common standards.

Large amounts of bacteria are present in the nose and mouth, on the skin, and on the attire of personnel who enter the restricted areas of the surgical setting. Proper facility design and surgical attire regulations are important ways of preventing transportation of microorganisms into surgical settings, where they may infect patients’ open wounds. Infection control practices also involve personal measures, including personal fitness for work, skin disinfection (patient and personnel), preparation of personnel hands, surgical attire, and personal technique (surgical conscience). Daily body cleanliness and clean, dandruff-free hair help prevent superficial wound infections.

Operating Room Attire

The OR should have specific written policies and procedures for proper attire to be worn within the semirestricted and restricted areas of the OR suite. The dress code should include aspects of personal hygiene important to environmental control. Protocol is strictly monitored so that everyone conforms to established policy.

Street clothes should never be worn within semirestricted or restricted areas of the surgical suite (Fig. 29-2). Clean, fresh attire should be donned at the beginning of each shift in the OR suite and as needed if the attire becomes wet or grossly soiled. Soiled surgical attire should be changed to reduce the potential of cross-infection. Blood-stained or soiled attire including shoe covers is unattractive and can also be a source of cross-infection or contamination. Soiled attire is not worn outside of the OR suite, and steps should be taken to remove soiled clothing immediately on exiting. OR attire should not be hung in a locker for wearing a second time. Underclothing should be clean and totally covered by the scrub suit (Fig. 29-3). Other aspects of proper attire include the following:

Fig. 29-2 OR suite layout showing restricted, nonrestricted, and semirestricted areas. ORs are “restricted.”

Fig. 29-3 Properly attired radiographers with protective eyewear.

• Protective eyewear: Occupational Safety and Health Administration (OSHA) regulations require eyewear to be worn when contamination from blood or body fluids is possible.

• Masks: Masks should be worn at all times in the OR but are not necessary in all semirestricted areas.

• Shoe covers: Shoe covers should be worn when contamination from blood or body fluids can be reasonably anticipated. Shoe covers should be changed whenever they become torn, soiled, or wet and should be removed before leaving the surgical area.

• Caps: Caps should be worn to cover and contain hair at all times in the restricted and semirestricted areas of the OR suite. Hoods are also available to cover hair, such as facial hair, that cannot be contained by a cap and mask.

• Gloves: Gloves should be worn when contact with blood or body substances is anticipated.

• Radiation badge and identification: Radiation badge and proper identification should be worn at all times.

PERSONAL HYGIENE

A person with an acute infection, such as a cold, open cold sore, or sore throat, is known to be a carrier of transmittable conditions and should not be permitted within the OR suite. Daily body cleanliness and clean hair are also important because good personal hygiene helps to prevent transportation of microbial fallout that can cause open wound infections.

Dance of the Operating Room

The concepts of sterile and aseptic technique date back to Hippocrates, who boiled wine and water to pour into open wounds in an attempt to prevent infection. Galen changed the technique a bit and began boiling the instruments instead, and shortly thereafter Semmelweis noted a dramatic decline in postoperative infection by having the staff wash their hands and change gowns between surgical procedures.

Maintaining the sterile field in an OR suite can be like a well-choreographed dance when the team works well together. Certain moves and rules must be followed. Proper adherence to aseptic technique eliminates or minimizes modes and sources of contamination. Basic principles must be observed during the surgical procedure to provide the patient with a well-defined margin of safety. Everyone who cares for patients must carry out effective hospital and OR infection control programs. Infection control involves a wide variety of concepts including methods of environmental sanitation and maintenance of facilities; cleanliness of the air and equipment in the OR suite; cleanliness of the skin and apparel of patients, surgeons, and personnel; sterility of surgical equipment; strict aseptic technique; and careful observance of procedural rules and regulations.

Up to 10,000 microbial particles can be shed from the skin per minute. Nonsterile team members should not reach over a sterile field. When working over the sterile field (e.g., performing a posteroanterior [PA] lumbar spine), the sterile field should be covered with a sterile drape to protect the field (Fig. 29-4). The technologist cannot move the radiographic equipment into position over the sterile field until after the sterile cover is in place. A sterile team member should fold over the sterile drape on itself, and then a nonsterile team member should carefully remove the covering drape, being careful not to compromise the sterile field. If a sterile field is compromised, the OR staff should be notified immediately.

Fig. 29-4 Radiographer leaning over the sterile field while positioning the x-ray tube. The sterile incision site over which the radiographer works is properly covered to maintain a sterile field. Note the sterile instruments in the foreground (arrow). The radiographer should never move radiographic equipment over uncovered sterile instruments or an uncovered surgical site.

Communication is of utmost importance. As a result of the surgical sterile field, the radiographer is unable to help position the image receptor (IR) or the patient. Good, professional communication is essential while using sound, basic knowledge of anatomy and positioning. The radiographer may have to instruct the surgeon or resident on the proper position to visualize the desired portion of the anatomy best. A surgeon or resident may be unaware of the exact rotation and foot flexion required to achieve a proper mortise view of the ankle.

PROPER IMAGE RECEPTOR HANDLING IN THE STERILE FIELD

To maintain proper universal precautions, the radiographer must follow specific steps when handling an IR in the OR.

• Surgical technologist (CST) taking the IR: The CST holds a sterile IR cover open toward the radiographer. The radiographer should hold one end of the IR while placing the other end of the IR into the sterile IR cover. The CST grasps the IR and wraps the protective cover securely (Fig. 29-5).

Fig. 29-5 Radiographer and CST place IR into the sterile drape.

• Radiographer accepting the IR after exposure: After the exposure is made, the radiographer needs to retrieve the IR. The radiographer must be wearing gloves to accept a covered IR that has been in the sterile field or under an open incision. The protective cover is possibly contaminated with blood or body fluids and should be treated accordingly. The radiographer should grasp the IR, open the protective cover carefully away from himself or herself or others so as not to spread blood or body fluids, and then slide the IR out of the cover (Fig. 29-6). The radiographer should dispose of the IR cover in a proper receptacle and remember to remove gloves before handling the IR or any other equipment because the gloves are now considered contaminated. If contamination of the IR occurs, the radiographer should use hospital-approved disinfectant for cleaning before leaving the OR (Box 29-2).

BOX 29-2 Principles of aseptic techniques

• Only sterile items are used within the sterile field.

• Only sterile persons handle sterile items or touch sterile areas.

• Nonsterile persons touch only nonsterile items or areas.

• Movement within or around a sterile field must not contaminate the sterile field.

• Items of doubtful sterility must be considered nonsterile.

• When a sterile barrier is permeated, it must be considered contaminated.

• Sterile gowns are considered sterile in front from the shoulder to the level of the sterile field and at the sleeves from the elbow to the cuff.

• Tables are sterile only at table level.

• Radiographers should not walk between two sterile fields if possible.

• Radiographers should avoid turning their backs toward the sterile field in compromised spaces.

• The radiographer should watch the front of clothing when it is necessary to be next to the patient.

• The radiographer must be aware of machinery close to the sterile field, including lead aprons hanging from the portable machine that may swing toward the sterile field.

• The lead apron needs to be secured if it is being worn next to the sterile field. The apron can easily slip forward when raising one’s arms up to position the tube. A properly worn apron does not compromise the sterile field or jeopardize proper body mechanics.

• When positioning an IR under the OR table, the radiographer should not lift the sterile drapes above table level because this would compromise the sterile field.

Fig. 29-6 A, Radiographer correctly removes IR from now-contaminated bag to a clean table, being careful not to brush contaminants from bag onto self or others. B, Radiographer disposes of bag and removes contaminated gloves before handling IR.

ENEMIES OF THE STERILE FIELD

Lengthy or complex procedures increase the chance of sterile field contamination. Physical limitations, such as crowding, poor lighting, and staffing levels, are also a consideration. The floor is always considered contaminated. The radiographer should avoid placing IRs, lead aprons, and shields on the floor.

Equipment

The radiographer must be well acquainted with the radiologic equipment. Some procedures may seldom occur. The radiographer need not fear a rare procedure if good communication and equipment knowledge are in place. IR holders enable the radiographer to perform cross-table projections on numerous cases and eliminate the unnecessary exposure of personnel who may volunteer to hold the IR. In mobile radiography, exposure times may increase for larger patients, and a holder eliminates the chance of motion from hand-held situations.

Some OR suites, such as those used for stereotactic or urologic cases, have dedicated radiologic equipment (Fig. 29-7). Most radiographic examinations in the OR are performed with mobile equipment, however.

Fig. 29-7 In-room urologic radiographic equipment used for retrograde ureterograms.

Mobile image machines are not as sophisticated as larger stationary machines in the radiology department. Mobile fluoroscopic units, often referred to as C-arms because of their shape (Fig. 29-8), are commonplace in the surgical suite. Mobile radiography is also widely used in the OR.

Fig. 29-8 A, C-arm radiographic/fluoroscopic system used in OR. B, Mini-mobile C-arm used for extremity examinations in OR.

Cleaning of Equipment

The x-ray equipment should be cleaned after each surgical case. If possible, the radiographer should clean the mobile image machine, including the base, in the OR suite, especially when the equipment is obviously contaminated with blood or surgical scrub solution. Cleaning within the OR helps reduce the possibility of cross-contamination. The x-ray equipment must be cleaned with a hospitalapproved cleaning solution. Cleaning solutions should not be sprayed in the OR suite during the surgical procedure. If cleaning is necessary during the surgical procedure, opening the cleaning container and pouring the solution on a rag for use prevents possible contamination from scattered spray. Gloves should always be worn during cleaning. The underside of the image machine should be checked to ensure contaminants that might have splashed up from the floor are removed. Cleaning the equipment after an isolation case is necessary to prevent the spread of contaminants. All equipment that is used less frequently should undergo a thorough cleaning at least once a week and just before being taken into the OR.

Radiation Exposure Considerations

Radiation protection for the radiographer, others in the immediate area, and the patient is of paramount importance when mobile fluoroscopic examinations are performed. The radiographer should wear a lead apron and stand as far away from the patient, x-ray tube, and useful beam as the procedure, OR, and exposure cable allow. The most effective means of radiation protection is distance. The recommended minimal distance is 6 ft (2 m). When possible, the radiographer should stand at a right angle (90 degrees) to the primary beam and the object being radiographed. The least amount of scatter radiation occurs at this position. The greatest amount of scatter radiation occurs on the tube side of the fluoroscopic machine. It is recommended that the x-ray tube always be placed under the patient (Fig. 29-9). Because of the significant amount of exposure to the facial and neck region, the x-ray tube should never be placed above the patient unless absolutely necessary.

Fig. 29-9 Radiation safety with C-arm. In the upper image, less radiation reaches the facial and neck region when the x-ray tube is under the patient. This is the recommended position of the C-arm. In the lower image, there is a greater amount of radiation reaching the facial and neck regions. (From Giese RA, Hunter DW: Personnel exposure during fluoroscopy, Postgrad Radiol 8:162, 1988.)

The OR may have signs posted outside the room warning of radiation in use, or “lead aprons required when entering this room.” Lead protection should be provided for individuals who are unable to leave the room.

The patient’s gonads should be shielded with appropriate radiation protection devices during examinations in which shielding would not interfere with imaging of the anatomy that must be shown. When using fluoroscopic equipment with the tube under the table, shielding should be placed under the patient. In addition, the source-to-skin distance (SSD) should not be less than 12 inches (29 cm).

Fluoroscopic Procedures for the Operating Room

OPERATIVE (IMMEDIATE) CHOLANGIOGRAPHY

Operative cholangiography, introduced by Mirizzi in 1932, is performed during biliary tract surgery. After the bile has been drained, and in the absence of obstruction, this technique permits the major intrahepatic ducts and the extrahepatic ducts to be filled with contrast medium.

The value of operative cholangiography is such that it has become an integral part of biliary tract surgery. It is used to investigate the patency of the bile ducts and the functional status of the sphincter of the hepatopancreatic ampulla to reveal the presence of calculi that cannot be detected by palpation and to show such conditions as small intraluminal neoplasms and stricture or dilation of the ducts. When the pancreatic duct shares a common channel with the distal common bile duct before emptying into the duodenum, it is sometimes seen on operative cholangiograms because it has been partially filled by reflux.

After exposing, draining, and exploring the biliary tract, and frequently after excising the gallbladder, the surgeon injects the contrast medium. This solution is usually introduced into the common bile duct through a needle; small catheter; or, after cholecystectomy, through an inlaying T tube. When the latter route is used, the procedure is referred to as delayed operative or operative T-tube cholangiography.

Position of patient: The patient is supine with the abdomen exposed. In laparoscopic cases, such as cholecystectomy, the abdomen is distended because air is injected into the abdominal cavity to allow adequate room for maneuvering of the camera and instruments. The radiographer should ensure no obstacles would impede the movement of the C-arm (Fig. 29-10).

Fig. 29-10 A,

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Tags: Merrills Atlas of Radiographic Positioning and Procedures Volume-2

Mar 4, 2016 | Posted by admin in GENERAL RADIOLOGY | Comments Off

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