1. Surgeon Name: HYPOSPADIAS OR Protocols Template for: HYPOSPADIAS There are explanations of each template - how it will look when finished and how to correctly complete each template. Please fill each section out and return to max.maizels@gmail.com 1.OR Checklists 2.Procedure Sequence Guide 3. Room Arrangement 4. Instrument Labels Margarett Shnorhavorian, MD, MPH

2. Surgeon Name: Glove Size: OR Protocols - General Checklist Please use the line shape below to cross out items on the example checklist that you do not wish to have included on your personal checklist. If you wish to add additional items not listed here, please use the following slides to add them to the appropriate section. Copy, paste and move this line as many times as required. Margarett Shnorhavorian, MD, MPH 6 Sensicare

3. DoneN/A 1. Pre-Flight (Preparations) Checklist Please add any items you wish to include on your list. General: For All Cases Anesthetic plan established Preoperative antibiotics established Resident/Fellow participating in case established Patient examined after administration of anesthesia to confirm diagnosis Surgical time out performed

4. DoneN/A Please add any items you wish to include on your list. 2. In-Flight (Procedure) Checklist General: For All Cases

5. DoneN/A Please add any items you wish to include on your list. DoneN/A DoneN/A NEXT Case Preparations: THIS Case Preparations: 3. Landing (Post-Procedure) Checklist General: For All Cases Determine location of next patient Need for H/P or consent of next patient Parents notified PACU orders written Postoperative antibiotics and pain medication plan established Postoperative orders written Disposition established Equipment issues Improvements

6. Surgeon Name: Procedure: Glove Size: OR Protocols – Procedure Checklist Please use the line shape below to cross out items on the example checklist that you do not wish to have included on your personal checklist. If you wish to add additional items not listed here, please use the following slides to add them to the appropriate section. Copy, paste and move this line as many times as required. Hypospadias Margarett Shnorhavorian, MD, MPH 6 Sensicare

7. DoneN/A 1. Pre-Flight (Preparations) Checklist Please add any items you wish to include on your list. Hypospadias-Specific If under age 2: sutures: 4-0 PDS on RB-1, 5-0 monocryl on P3, 6-0 monocryl on P3 Needle tip on bovie electrocautery If over age 2: sutures: 3-0 PDS on RB-1, 4-0 monocryl on P3, 5-0 monocryl on P3

8. DoneN/A Please add any items you wish to include on your list. 2. In-Flight (Procedure) Checklist Hypospadias-Specific

9. DoneN/A Please add any items you wish to include on your list. DoneN/A DoneN/A NEXT Case Preparations: THIS Case Preparations: 3. Landing (Post-Procedure) Checklist Hypospadias-Specific

10. OR Protocols – Procedure Sequence Guide Here is an example of the procedure sequence guide. It contains components and steps for each part of the surgery. The 3 rd column lets the nurse or scrub tech know what instrument to have ready. Please use the following slides to create your procedure sequence guide with the specifics of how you perform the surgery.

11. Components StepsInstruments / Scrub Tech Surgical Procedure: HYPOSPADIAS Mark Incision 1.Mark 1-2 cm incision along Langerhans lines 1/3 of the distance between ASIS and pubic tubercle 1.Marking pen 2.Raytec Incision and Dissection 1.Make incision at skin 2.Spread fat and expose Scarpa’s fascia 3.Open Scarpa’s fascia and spread 4.Develop external oblique fascia 5.Define shelving edge and superficial inguinal ring 1.15 blade scalpel 2.Adson forceps x 2 3.Metzenbaum 4.Electrocautery with needle tip 5.S retractors x 2 Open Fascia and Expose Cord 1.Cut fascia with 15 blade 2.Spread with metzenbaum 3.Sweep fibers off underside of fascia 4.Sweep off nerve 1.15 blade 2.Metzenbaums 3.Debakey forceps x 2 Mobilize Cord and Repair Hernia 1.Deliver testicle and cauterize gubernaculum 2.Clean cremasteric fibers off spermatic cord 3.Open distal tunica vaginalis and expose testicle 4.Cauterize appendix testicle 5.Identify sac and mobilize from vas and vessels 6.Place clamp over sac and divide sac 7.Dissect hernia sac off cord proximally 8.Ligate and tie hernia sac 1.Debakey forceps 2.Electrocautery 3.Metzenbaum’s 4.Adson forceps 5.Mosquito 6.Straight snap 7.4-0 PDS (if over age 2, use 3-0 pds) Deliver and Anchor Testicle 1.Develop inguinal canal with finger 2.Incise mid scrotum 3.Create subdartos pouch 4.Deliver testicle through scrotum 5.Check for twisting of cord 6.Close dartos neck 7.Close dartos and catch tunica albuginea 1.Marking pen 2.Electrocautery 3.Adson 4.Mosquito 5.Tonsil clamp 6.S retractor 7.4-0 PDS (if over age 2, use 3-0 pds) 8.Debakey 9.5-0 monocryl (if over age 2, use 4-0 monocryl) Close Fascia and Skin 1.Irrigate 2.Close external oblique fascia 3.Close Scarpa’s fascia 4.Deep dermal approximating stitch 5.Close skin (inguinal) running subcuticular 6.Dermabond 1.Debakey and S retractor 2.Irrigation 3.4-0 PDS (if over age 2, use 3-0 pds) 4.5-0 monocryl (if over age 2, use 4-0 monocryl) 5.6-0 monocryl (if over age 2, use 5-0 monocryl) 6.Adson forceps x 2 7.Dermabond

12. Components StepsInstruments / Scrub Tech

13. Components StepsInstruments / Scrub Tech

14. OR Protocols – Room Arrangement This section shows how the room should be arranged for each procedure and where each staff member generally stands. On the following slide, move the objects around to position them correctly for your hypospadias procedure. If you need more objects, simply copy and paste one, then double click the text to change the name of the item. IV Pole Foot Pedal

15. Room Arrangement: Hypospadias Please use the shapes below as shortcuts for any new items. OR Table Surgeon Assistant Scrub Video Bovie Back table IV Pole Anesth Door to OR Circulator’s Computer Mayo Circulator Foot Pedal Patient’s head Text Extra Text

16. OR Protocols – Instrument Labels This section shows how to correctly set up the mayo stand or back table. It also shows the names of each instrument so that mistakes are avoided. On the following slide, please insert your own photo of your mayo stand or back table. Then use the blank labels to type in the correct names and position the labels appropriately.

17. Mayo Stand | Hypospadias Copy/Paste to re-use. The shape will change to fit the amount of text. Text Label Mosquito (2) Straight Snap (2) Schnidt S Retractor (2) Light Handles (3) Tenotomy Metzenbaum Adson (2) Debakey (4) Marking Pen Raytec Electrocautery with Needle Tip