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Hi. Hi, guys. Thanks everyone for joining us. We are just going to give it a few more minutes to let everyone else trickle through. You just sit tight for a sec, okay? I think Let's get started. So, firstly, thank you all for coming today. My name's Prisca. I'm part of the education team for STDs, and we are running a three part series on the theater experience. So you've already heard from Zarah earlier this week on pre op optimization. I'm going to talk you through the intraoperative experience. And then on Monday, seven PM again, uh, there'll be a talk on postop optimization to hopefully see you over there as well. So why do we talk on the interpretive experience? I think theater is quite a daunting place for people who haven't been before. There's some do's and don'ts and theater adequate that it would be really helpful to know if whether you're starting your surgical job as an f y or whether you're going to a surgical placement as a med student. So we're going to run through some tips. I wish I knew before. So just a shoutout to ask easy who we are running this series in collaboration with. They have a series of events finals, easy surges, et cetera that you can see here and you can also find them on Spotify and YouTube. And here are a couple of the social media handles just to check. Can everyone hear me? Okay, Yeah, we can hear. Okay, let's get that started properly, then. Thank you. So how we're going to run today? It's only going to be a fairly speedy talk, but we're going to go back ground some preop tips preop ward round theater etiquette Some knowledge that I think will make life a lot easier when you're preparing to be questioned by the consultant. We just want to keep up with what's going on and then a couple of top tips to round off so background. People in general have limited exposure to theatre during med school, and that was before Covina, so I'm sure the situation is much worse now. But theater is proven actually in the literature to be a really invaluable tool for learning, and it also your experience in theater help shape your career goals if you can go there, understand what's going on and and impress the surgeon. You're far more likely to want to pursue a career in surgery, and so it's important to get the most from your time there. So also you're more likely to have to scrub in if you are enthusiastic and confident. First thing I would do if I was planning to go to theater, and this is how the day will work. I'll talk you through. If I was planning to go to theater, I'd focus on this and I focus on this than this. So first thing is you want to turn up to the Preop Ward round does mean waking up a little bit earlier, but it is a chance to see the whole process, understand the surgical job, and also you get to know a bit more about the operation and the patient journey. So you want to turn up early and join the surgeon. While you're doing this, they are going to mark the site of the operation, and this mark will remain visible during the time in theater to make sure you're in the right place and avoid wrong site surgery. And they're also going to go through the consenting process. And so the consenting, and this is a typical starting. Your F Y jobs is meant to be done by someone who understands the surgical procedure. So that's not the F. Y. So this is not something you should be doing, but it is something you can be observing. And consent involves an explanation of the reasons for the procedure what exactly is going to happen, and then the complications, both the common ones and the rarer, but more serious ones. And then this is written in the documentation. Um, and this is a good time for you to recap the knowledge of the procedure in case this is something that the surgeon ask you during the operation. So in theater a couple of tips when you're in there. So what to wear is the first one. I'm sure you'll probably all be going around hospital in scrubs, but in theater, you want to change into specific theater scrub. So even if you're wearing some mountain about hospital, try and get changed into one day supply in theater, you want the clothes on and you want a hat Everywhere I've worked, the medical staff have worn the blue hats, but that is probably trust specific, and you want to mask something to remember for later. Your mask is not sterile, so once you've scrubbed in, don't touch it. How to enter theater. So a theater block tends to have the operating room, the scrubbing room, the anesthetics room and maybe a store room. And it's important that during the operations whilst the operation is going on, you never enter theater directly from the corridor to the theater room, as this disrupts airflow and can increase the risk of infection. So when entering theater, you don't want to go to the anesthetics room because the patient may be there and I don't want to disturb the process. You don't want to go directly into the operating theater, so instead, try and enter directly into the scrub room and from the scrub room, move into the operating theater. When you get there, make sure you introduce yourself. It can be quite daunting when everyone's busy and running around. But try and say hello to introduce yourself and your status and ask if you're able to scrub in the people, you can expect to see when you're there. The scrub nurse, the operating department practitioner, the anesthetist and the surgeon. So the scrub nurse is in charge of preparing the equipment preop and will also work with in the sterile field. Passing tools to the surgeon and at the end is responsible for all equipments will be counting things like sutures and swabs, the difference between a scrub nurse and an O. D. P, which is something that's quite helpful to know what they can both work within the sterile field. The operating department practitioner has also been trained to assist the anesthetist with the airway, and the ODP is only able to work with in the theater department, whereas nurses are trained to work throughout the hospital. As I'm sure you guys will know, the anesthetist obviously conducts the anesthesia, controls the airway and then monitors the OBS and is responsible for resuscitation and stabilization. Should anything go wrong and the surgeon will be carrying out the procedure, that's just a bit of background to how the theater staff work. So when you go there, you'll know what to expect. So this is a question for you guys when you go to theater, When is the signing done? As part of the W. H. O checklist, and I will give you a minute to work through that. Uh huh. Your answers are anonymous, by the way, so don't be afraid to give it a go. Okay? Only a couple of people left. I'll give you one more second. Okay, So the okay, changing percentages. Um, the majority of people have gone for before, bringing the patient down from the ward. Actually, it's the second most common answer we've gone so before. Anesthesia is when you do the sign in as part of the W A checklist. And this is just a picture of the checklist. If I talk you through it, the signing is done. As I was saying before anesthesia. And it's when the anesthetist confirms the patients. I d make sure the sight has been marked which was done during the preop ward around and check things like allergies and whether the patient is likely to have a difficult airway. So that is preparation. That's the first step in the checklist. The next step is called the Time Out step, and that's done before the first incision is made, and that's again you confirm the patient side. You confirm the procedure that's being done. The site is being done at and you discuss any predicted issues, and that's things like blood loss or complications. You can assure you're adequately prepared before you make an incision. Then the third part of the checklist is called the Sign out, and that's done before the patient leaves theater. And that's when the scrub nurse checks. They've got a full equipment count to make sure there's no swabs or anything missing and and discuss any concerns with the surgery anesthetist. So are they likely to have any difficult complications or any problems with the airway? And that's this checklist once completed, then recorded in the patient's notes. So it's an important piece of documentation, and it's something you can expect to see every procedure you go to. But it's next one for you guys. Let me get that. Running is about understanding which positions are used in which different operations, because then you'll know what to expect when you go to different types of theater. So how would you position a patient who is having a guinea operation? Okay, don't be afraid to give it a go. Guys will go through the answers in a minute anyway. just a minute. For those of you who still thinking about it. Okay, so you do one sec. I have my nurse to share the wrong question, haven't I? Never mind. I'm going to put the correct pull ups. Sorry, guys. That's, uh, that one. Not great with check. This is the one you were meant to be having. So if you can work through that one Yeah. Okay. So most of you have gotten the right answer here. So this is the lithotomy position. That is a position is commonly used for gynecological, urological and some colorectal procedures. So in terms of patient patient positioning pardon, the most common position that you'll see used in theater is the supine position lying supine on the back with their arms tucked in. And that's good for a variety of different types of operation, including abdominal, intracranial and lower limb operations. But there are several other positions for patients that you can expect to see. So we've already discussed lithotomy. That's one that you're seeing Jaynie in urology. There's also the jackknife position which is used in some colorectal procedures. Fowler's position, which is when the patient is seated up right and that's good for shoulder and some neuro conditions and prone, which is lying on their front and that's used for spinal and neck operations. So it's nice to know before going into theater, I think how you can expect to set up the patient. And you can always impress the surgeon with knowing that in advance positioning is very important, not just obviously for the access, but also because poor positioning can harm the patient through things like pressure sores, nerve compression and DVT. Don't forget they're going to be staying like this for potentially several hours, so it's important to get this done properly. Next, I'm going to talk you through the procedure for scrubbing in because this is something I found hard work when I first started going to theater. And if you just started a surgical rotation in med school or a job, something you will hopefully get to do in order to get involved so we'll talk through it. Scrubbing in is important because it sterilizes your hands and upper arms and then once your ground and gloved um, makes you a septic so you're able to join the sterile field. Uh, it's important to sterilize obviously, to improve patient outcomes by reducing the risk of infection. When you're scrubbing in before you start washing, you want to open your gown and gloves first. You have those ready on the side with in the sterile field created by their packaging. When you're picking gloves, you want to pick two pairs. One's going directly into your hands, so that wants to be your size, and one is going on top of this other path that wants to be half a size bigger. Some places use two gloves of the same color. Some will use a clear out of gloves that you can see if it's been pierced and know when you need to change gloves before you start washing. You also want to get a nail brush and a sponge, and the antimicrobial should already be supplied that is, normally iodine or chlorhexidine. I have a video which doesn't look like it's going to play, Never mind. So this video was going to talk you through the procedure for, uh, scrubbing in, but instead I'll just talk you through it and and this link can always be available later. If you'd like to watch it yourself. Procedure for scrubbing in, so you're going to have your nail brush and your sponge ready, and in the scrub room, the soap will be supplies next to the sink. You want to do a pre scrub wash, which is just with the soap on your hands, cleaning to remove any visible debris. And this wash only needs to be done the first time you're scrubbing in for that list because you shouldn't have any visible debris on you after you scrubbed in and then scrubbed out again for the next procedure. You want to wash from your hands to all the way down your forearms to your elbows, and it's very important when you're washing to always keep your hands up right in this sort of position so the water running down from your hands, which will reach your upper arms, doesn't run backwards and contaminate the areas you've cleaned, Um, to summarize, scrubbing in. It's also important to wash every aspect of the hand, so that means each of the four sides of your fingers, individual fingers, finger webs, palms and forearms. Um, a little difficult to talk through. But, yes, very thorough procedure. Do you want to do at least three times. You want to use the idea or chlorhexidine wash. You want to make sure in the second wash you're using the sponge and the nail pick because the nails are one of the hot spots of bugs in your hands. This is probably something that scrub nurses will watch you do carefully, so try and be thorough about it. Uh, it will take you about 3 to 5 minutes to do a thorough job once you've scrubbed and then dried your hands in the same way with your arms up right drying from fingertips down the forearm, you're going to be ready to go down and glove. And this is a good illustration taken from teach me surgery. She talks you through how you do this. You want to open up your gown by shaking it open and making sure, obviously, that it doesn't touch any non sterile surfaces, so shake it open into an open space. Slip your arms in, and as you slip your arms in, make sure your hands don't come out beyond the white part of the gown. So you keep your hands within this white cup of the gown, and then use a pincer like motion to put the first glove on to your hand. This can be a bit fiddly, but make sure you do it slowly and carefully to avoid the sterilizing yourself and having to scrub in again. Once you've got one glove on, you can put the second glove on using that clean gloved hand so life becomes a bit easier. Then you're going to have to have an assistant to the back of your gown because only the front part of your gown is considered sterile. The assistant will tie you up at the back, and then we'll hold the tag whilst you rotate around, take both pieces of string and sort of tie yourself in the side. You will then be considered sterile. You want to keep your hands away from any nonsterile services away from anything that isn't within the sterile field. I'll be ready to join the procedure. The next thing that is going to make life easier when you're going to theater for one of the first times is figuring out which of the equipment is appropriate to use for what? So I put some pictures up here. They are in order so in the top left are forceps. I'm sure everyone is familiar with the four. Steps are generally divided into tooth and non tooth forceps, with the most commonly used type of non tooth forcep being called a DeBakey's forcep helps to know what the names are. If you do get the chance to assist, the surgeon asked you to pass various tools. So diabetes, forceps, most common non tooth forceps, the the tooth type are also used. They're better for grasping tougher tissue, something like fascia but must be avoided for delicate structures like bowel as tooth. Forceps could perforate the bowel next. Here on the top, right, you have a needle holder, which obviously is used for so true. Then in the middle left, you have the scissors, so scissors come in various types. In theater, you've got curved, blunt scissors called makindo scissors, which are used for blunt dissection. You've got the sharper scissors called mayo scissors for cutting. These can be curved or straight, and then you've got suture scissors, which are straight because it is important to cut the sutures evenly in the middle. On the right hand side, you've got the scalpel, which I imagine most people are familiar with, and then we have the retractor in the bottom left. So the image you've got there is a handheld retractor called a Langenbeck retractor. That's one that if you're scrubbed in, you might be asked to hold in position while the surgeon operates. There are also other types of retractors, which can lock in place and don't require you to hold them. Superficial lock in place retractors are called Travers retractors, and ones with longer blades, which are used on deeper structures, are called Norfolk Retractors. Final piece of equipment it would be useful to be familiar with is the diet thermy in the bottom right? So Diathermy is used for cutting and cauterizing and tends to come in two forms. So mono, polar and bipolar mono polar is the most commonly used and and it works by the electrical activity oscillating from the diet for me to a grounding plates beneath the patient. But the patient would prefer to the pardon. The surgeon would prefer to use bipolar if working on if operating on digits, if carrying out microsurgery, or if the patient has a pacemaker in place to avoid disrupting the electrical activity of the pacemaker. Fine opportunities for you to assist. Once you've come to theater, you scrubbed in. You're familiar with what tools or what and who's who. So opportunities to assist, maybe handling the tools we've just discussed. Uh, it could also be laproscopic camera control. And if this is the case, your main job is to keep the surgeon's operating instruments in the center of the field of you, and it is something that is harder than it seems. But it's a great way for you to get involved. And there's also some Motrin, which will come to you later. If you are, they're pre op. You may also get the chance to cannulate and catheterize, uh, if any suggest allows. So we've discussed how you turn up the theater and how you prepare before the operation. One thing you can expect is for the surgeon to ask you questions while you're there. So what I find is it really pays to prepare the night before by finding out what sort of operations are going to be carried out and reading up on them a little. So when I'm reading up on an operation, I like to think about the indications, the pathology, the complications and then the process that includes how you can expect to position the patient How, um, the steps in the procedure and the key landmarks. So I'm going to talk you through a laparoscopic cholecystectomy, which is the most common general surgical operation worldwide, as an example of the things I would read up on it if I were to prepare to go and see one the next day. So logically, uh, indications for locally, would anyone like to pop a few in the chat? If you know, I'll give it one second in case anyone's feelings bold. So the complications. Yep, that is correct. Gallstones is one. So Colecystitis colelithiasis, gallbladder masses and polyps and gallstone pancreatitis are some of the reasons you would carry out that coli pathology is obviously dependent on the conditions, and I would read up on that, too, potential complications of a gall bladder operation. So the general surgical operation, um, part of the general complications with any surgery is the need for further intervention. Bleeding and infection specific to a lab collie is also the risk of bile leak, hernias, adhesions, bowel injury and conversion to an open procedure, which would then involve a larger incision into a larger scar and more post operative pain. These are things the surgeon will probably run through during the Preop Ward round as well. But nonetheless, it's something I'd read up on that. I was familiar with the procedure, the pros and the cons. In terms of positioning. This is an abdominal operation, particularly upper GI and not a colorectal operation. So we would use the supine position as we discussed earlier process. So laproscopic operation. So your first going to create a pneumoperitoneum, then you're going to insert your ports. Then comes the dissection of calories triangle. In order to know where you should dissect in a laparoscopic cholecystectomy, you need to achieve the critical view of safety, which is created by clearing the sort of fibrous and fatty tissue that's overlying the gall bladder and exposing the gallows triangle. Uh, for background, the gallows triangle was the superior border of the inferior liver. Immediately common hepatic duct and laterally, the cystic duct, and you want to expose this and separate the lower third of the gall bladder from the liver in order to see that there are only two structures entering the gall bladder and in this way, identify those structures as the cystic duct in the cystic artery. And that's important in this operation to avoid any damage to the common bile duct, which is another of the potential complications. Once you've identified your cystic duct and artery, they would be and be clipped, dissected, and the gallbladder would be dissected out. Actually, that's a bit of a broad overview, but that's as much detail as I would go into before going to the operation if I were hoping to observe and potentially assist. And if you can come with that much information, you want to impress the surgeon and the rest of the surgical staff. So next question for you guys, should you get the opportunity to suture, you may be asked, what type of suture would you like? This is very helpful for you to know, so we'll run through when you use the different types of futures question fuel. Let me pick the right one this time. Very good. So when your future enclosed a facial laceration, which size of suture would you choose? Give it another couple of seconds. I know some of you answered before, but for those of you that are still thinking about it, Okay, so the answer in this case is what the majority of you have gone with, which is a five point oh size suture. So how do you go about deciding which future you're going to choose? So, first of all, you decide. Do you need an absorbable or non absorbable future type? Absorbable sutures are things like Monocril and vicryl. Monocryl is, the name suggests is a monofilament suture. That means it's made up of only one strand and therefore has a lower infection risk because that's a lower surface area. However, the polyp filament vicryl, which is braided whilst having a slightly higher infection risk, is, uh, easier to work with and creates more securitize. So you need to wake up the infection risk versus the ease of tying when choosing between your mono and polyp filaments. When choosing between absorbable and non absorbable, you want to base this on this type of structure and the amount of time you're going to need the to wound edges. To be approximated for so absorbable, as the name suggests offers a shorter period of approximation because then they will dissipate. And they're good for things like skin closure because skin heals in approximately 1 to 2 weeks as long as there are no complications. However, if you're working on a deeper structure such as a tendon, which heels in about six weeks, you're going to need a nonabsorbable suture to maintain the approximation of the edges. And non absorbable sutures are good for another deep structures, like bowel or vessel anastomosis, or for skin approximation, when you're going to need to keep the edges approximated for a longer period of time. Just a note about the silk nonabsorbable futures as well. Those are most commonly used when tying in surgical drains. So if you decided whether you want mono or polyp filament, we decided whether you want absorbable or non absorbable suture, the next thing to think is what size of the future you want. And this is not entirely intuitive. So as you can see on the table here, two point oh is sort of turning point. So two point oh is one of the larger of the 10.0 sutures, but then they actually get bigger than a two point Oh, when you switch to the single numbers of the 012345. So a five size five suture is the largest future there is. And the point is, 11 point suture is the finest future there is. And 11.0 would be used pretty much only an ophthalmological surgeries, whereas something like a 5.0 s were saying is used in facial lacerations. Uh, four point oh, slightly bigger than that is used in the limbs a three point oh!