GENERAL SURGERY Scrub Circ. EQUIPMENT Scrub Circ. Hernias Breast Biopsies Perineal Resection Anal Fissurectomy Mastectomy Radical Mastectomy Bowel Resection Colostomy / Ileostomy Adreanalectomy Appendectomy Gastroectomy Clectomy Hepatic Resection Whipple Hydrocelectomy Laparoscopy Diagnostic Lap Cole Lap AP Lap Hernia Leveen Peritonela Shunt Pilonidal Cystectomy Lumbar Sympathectomy Nissesn Fundoplication Portal Caval Shunt Saphenous Vein Ligation and Stripping Pancreatectomy Splenectomy Staging Laporotomy Thyroglossal Duct Cyst Excision Blood warmer Cardiac Monitor & Pacemaker Types: Arthroscopy Cameras Laser Water Sterilizer Bovie Electrosurgical Kit Aquamatic K Thermia Unit Cell Saver Eye Magnet Kiddie Pneumatic Tourniquet Flash autoclave Disposable Bovie Plates Fiber Optic Luminators Ultra Sonic Cleaner Types; Vac-Pac Positioner Steri-Vac Aeration Cabinet Fluid Pumps Ethylene Oxide Sterilzer Nerve Stimulator Operating Microscope Dermatomes Drills Vacuum Curettage Other: (Please List): Pg. 1
EAR, NOSE and THROAT Scrub Circ. GYNECOLOGY Scrub Circ. Acoustic Neuroma Tonsillectomy Adenoidectomy Laryngectomy Tracheostomy Vocal Cord Stripping Ethymoidectomy Fenestration Procedure Mastoidectomy Myringotomy Stapedectomy Tympanoplasty Nasal polypectomy Glossectomy Frontal Flap Sinus Procedure Pharyngeal Flap Procedure Parotidectomy Sinusotomy Maxillary Advancement with Hip Graft Open Reduction Facial Fractures Open Reduction Tripod Fractures Ranulectomy PE Tube Insertion Radical Neck Dissection Selective Osteotomy of Maxilla / Mandible Submucous Resection Other: (Please list): Pg. 2 D & C (Dilation & Curettage) Cone Biopsy Operative Hysterectomy Operative Laparoscopy Diagnostic Hysterectomy Vaginal Hysterectomy Endometrial Ablation Pubo Vaginal Sling LAVH Colpotomy Salpingoplast Vaginal Reconstruction Shirodkar Operation C-Sections Radium Insertion NEUROLOGY Carpal Tunnel Burr Holes Lumbar and Cervical Laminectomy Cartoid Endarterectomy Cartoid Ligation Craniotomy for Subdural Hematoma Craniotomy for Tumor excision Clipping for Intracranial Aneurysm Meningocele Repair VA & VP Shunt Shunts Transphenoid Hypothypectomy
NEUROLOGY CON TD. Scrub Circ. ORTHOPEDICS CONT D. Scrub Circ. Ventricular Procedures Laminectomy Vinke Tong Insertion Capsularrhaphy Anterior Crucidate Ligament Repair Harrington Rod Insertion I.M. Rodding Open Reduction Fracture OPHTHALMOLOGY Closed Reduction Fracture Chelazion Fracture Table Use Cataract Dwyer Anterior Fusion Lacrimal Probing Hand Surgery with Implants IOL Glaucoma Filtering Procedures Insertion of Swanson Finger Prosthesis Retinal Surgery Tendon Implants Corneal Transplant Heel Cord Lengthening Insertion of Tibial Plateau Prostheses Patellectomy ACL / PCL Instrumented Spines ORTHOPEDICS Zimmer Hip Compression Dupuytrens Nailing Procedures I & D Excision of Olecranon Bursa Amputation Arm / Leg Arthroscopy Achilles Tendon Repair Application of Halo Traction ORIF with Plates and Screws OPEN HEART / THORACIC Anterior Crucidtae ligament repair CABG Hemiarthropsy Cervical Rib Excision Cup Arthroplasty Closed Thoracotomy Total Joint Replacement Esopagectomy Pg. 3
OPEN HEART / THORACIC CONT D. Scrub Circ. VASCULAR Scrub Circ. Chamberlain Procedure Heller Procedure Valve replacement Pacemaker Implantation Myocardial Pacemaker Implantation Endocardial Port A Cath Insertion Patent Ductus Arteiosus ASD (Atrial Septal defect) VSD ( Ventricular / Ventral Septal defect) Pneumonectomy (Lobectomy) Tracheal Resection Resection of Coarctation Aorta First Rib Resection Insertion of Vascular Access Devices A-V Fistula Shunt Pacemaker Insertion Arterial Bypass Grafts Aortic Aneurysm AAA Mohin-Uddin Umbrella Resection of Carotid Aneurysm with Graft Tenkhoff Catheter Placement Embolectomy / Thrombectomy Leaking Ruptured Aneurysm Vena Cava Ligatio TRANSPLANT Kidney Heart Liver Lung TRAUMA Gun Shot Wounds: Chest Abdomen Burns Automobile Accidents Traumatic Amputations PLASTICS Skin Grafts Abdominal Lipectomy Liposuction Breast Augmentation Breast Reduction Scar Revisions Myelomeningocele Repair Mentoplasty Blepheroplasty Rhinoplasty Otoplasty Pg. 4
UROLOGY Scrub Circ. Ages of Patients Cared For Scrub Circ. Circumcision Infants and Toddlers (to age 3) Diagnostic Cystoscopy Children (aged 4 12 years ) Hydrocele / Variocele Adolescents (aged 13-20 years ) Cystectomy Young Adults (aged 21 39 years ) Nephrectomy Older Adults (aged 41 64 years ) Perineal Prostatectomy Seniors ( over 64 years) Suprapubic prostatectomy Pyleoplasty Pyelolithotomy Penile Prosthesis Radical Node Dissection Ureteroscopy TUR Prostate Brachytherapy Holmium Laser Lithotripsy Indigo Laser Lithotripsy Vasectomy Vasovasotomy Ileo conduit I hereby certify the above to be true and accurate. Signature: Date: