Chapter 21: Surgical Radiography

Detailed Chapter Overview

Chapter 21 provides an essential guide to surgical radiography, a highly specialized field that requires radiographers to function as integral members of the surgical team within the unique and demanding environment of the operating room (OR). This chapter emphasizes that success in the OR is built upon a foundation of adaptability, anticipation, and impeccable communication. A central theme is the absolute necessity of understanding and maintaining the sterile field. The chapter meticulously details the principles of surgical asepsis, the components of the sterile team, and the radiographer's specific responsibilities in preventing contamination. It provides a comprehensive overview of the specialized equipment used in surgical imaging, with a deep dive into the mobile C-arm fluoroscopy unit—the workhorse of the OR. The text thoroughly explains the operational modes of the C-arm, including pulse mode and magnification, and the critical importance of orienting the x-ray tube and image intensifier to minimize radiation dose to both the patient and staff. The chapter systematically covers the most common surgical procedures that require imaging guidance, from orthopedic cases like open reduction internal fixation (ORIF) to cholangiography and laparoscopic interventions. For every procedure, the text outlines the specific role of the radiographer, the anticipated sequence of images, and the anatomical landmarks the surgeon will need to visualize, ensuring the radiographer can provide confident and proactive support.

In-Depth Study Guide

The Surgical Environment and Team

Principles of Surgical Asepsis

The primary goal in the OR is to prevent infection. Surgical asepsis is the practice and procedures used to create and maintain a sterile, microbe-free field.

• The Sterile Field: This is a microorganism-free area that includes the patient, surgical drapes, the instrument table, and the scrubbed, gowned, and gloved surgical team.
• Radiographer's Responsibility: The radiographer is considered "non-sterile" and must never touch or cross over the sterile field. All equipment brought into the sterile field (such as the C-arm or an IR in a sterile cover) must be handled in a way that preserves sterility. Constant awareness and communication are key.

The Surgical Team

• Sterile Team Members:
  • Surgeon: The primary physician who performs the surgical procedure.
  • Surgical Assistant: Another physician, physician's assistant (PA), or senior surgical tech who assists the surgeon.
  • Scrub Nurse/Technologist: Prepares the sterile instrument table, passes instruments to the surgeon, and maintains the integrity of the sterile field.
• Non-Sterile Team Members:
  • Anesthesiologist/CRNA: Responsible for administering anesthetic agents and monitoring the patient's vital signs.
  • Circulating Nurse/Technologist: Assists the sterile team from the periphery of the room, obtaining supplies, positioning the patient, and managing documentation.
  • Radiographer: Responsible for providing intraoperative imaging as requested by the surgeon. The radiographer must communicate clearly with the entire team.

Mobile C-arm Fluoroscopy: The Workhorse of the OR

The mobile C-arm is a fluoroscopic x-ray unit with a C-shaped arm that allows for versatile positioning around the patient and surgical table.

Key Components and Operation:

• X-ray Tube and Image Intensifier: The x-ray tube is located at one end of the C, and the image intensifier (or flat-panel detector) is at the other. The image intensifier is the component that should be positioned as close to the patient as possible to reduce magnification and patient dose.
• Positioning Controls: The C-arm has a wide range of motion, including vertical and horizontal movement, pivoting, and angulation (tilting), allowing for AP, PA, lateral, and oblique projections without moving the patient.
• Monitor Cart: Displays the live and stored fluoroscopic images for the surgeon to view.

Radiation Safety with the C-arm: A Critical Concern

The OR presents significant radiation safety challenges. The source of radiation exposure to staff is scatter from the patient.

• Tube Orientation: The single most important factor in reducing staff dose is the orientation of the C-arm. The x-ray tube should **always be positioned under the patient**, with the image intensifier above. This configuration significantly reduces scatter radiation to the head, neck, and torso of the surgeon and staff standing near the table. Reversing this (tube on top) dramatically increases staff dose.
• Distance: The radiographer should maximize their distance from the patient and tube during exposures.
• Time: Use of the "pulse" mode on the C-arm delivers radiation in short bursts instead of continuously, significantly reducing dose. Last-image-hold features should also be used to reduce "beam-on" time.
• Shielding: All personnel remaining in the OR during fluoroscopy must wear lead aprons. The radiographer is responsible for ensuring this.

Common Surgical Procedures Requiring Radiography

Operative Cholangiography

• Purpose: Performed during a cholecystectomy (gallbladder removal) to visualize the biliary ducts and check for any residual gallstones after the gallbladder has been removed.
• Procedure: The surgeon places a small catheter directly into the common bile duct. A small amount of water-soluble iodinated contrast is injected by the surgeon.
• Radiographer's Role: The radiographer positions a C-arm or a mobile x-ray unit to take an AP or slight RPO projection of the right upper quadrant to visualize the opacified ductal system.

Orthopedic Procedures: Open Reduction Internal Fixation (ORIF)

• Purpose: ORIF is a surgical procedure to fix a severe bone fracture. "Open reduction" means the surgeon makes an incision to re-align the bone manually. "Internal fixation" means the bone fragments are held together with hardware like plates, screws, rods, or pins.
• Radiographer's Role: The C-arm is used extensively throughout the procedure. The radiographer provides real-time AP and lateral images to guide the surgeon in:
  • Confirming the initial fracture alignment.
  • Guiding the placement of hardware (e.g., ensuring screws are the correct length and do not enter a joint space).
  • Verifying the final reduction and hardware placement before the incision is closed.

Retrograde Pyelography

• Purpose: A non-functional study of the urinary system, typically performed to visualize the pelvicaliceal system and ureters to locate an obstruction (like a stone).
• Procedure: A urologist uses a cystoscope to look inside the bladder and passes a small catheter up a ureter. Contrast is injected directly into the renal pelvis.
• Radiographer's Role: To provide AP images (KUBs) as the contrast is injected, demonstrating the outline of the collecting system.

Spinal Surgery

• Purpose: C-arm guidance is essential for procedures like spinal fusion, laminectomy, and kyphoplasty.
• Radiographer's Role: The radiographer provides frequent AP and lateral images to help the surgeon identify the correct vertebral level, guide the placement of pedicle screws and other hardware, and confirm the final alignment. Precision and clear communication are paramount in these cases.