Preparing for surgery – the surgical team

When undertaking aseptic surgery, it is much easier (and more comfortable) to change into a “scrub suit” and then wear a sterile gown.

Clothing worn beneath the surgical gown should consist of:

• A clean scrub suit, the shirt tucked into the trousers.
• Footwear, which is only worn in the surgical suite and is cleaned frequently.
• A cap, which should cover all the hair.
• A facemask, which fits snugly.

Prior to “scrubbing”:

• Take off all rings and jewellery and ensure that nails are short and all nail polish is removed.
• The gowning pack consisting of the surgical gown and sterile hand towels is opened. In opening the pack only the outside surfaces of the paper are grasped leaving the inner surfaces free from contamination. Personnel should take care not to pass their hands over the opened pack.
• A pair of sterile, disposable gloves of the appropriate size should be opened, without touching the contents, and placed beside the gowning pack.

The objectives of the surgical scrub are to:

• Remove gross dirt and oil from the hands,
• Reduce the micro-organism count as close to zero as possible, and
• Have a prolonged depressant effect on the microflora of the hands and fore-arms.

Scrub up procedure

Note that although the process is described as “scrubbing” the only use of the brush is to clean the fingernails – all of the rest of the procedure only involves repeated washing of the hands and arms. If a scrubbing brush was used on the skin this would remove outer layers of skin and increase the bacterial contamination:

• First, turn on the taps over the scrub sink and adjust the temperature of the water to as hot as is comfortable.
• Thoroughly wash the hands and arms up to the elbow with an antiseptic solution such as povidone iodine (Betadine) or chlorhexidine gluconate (Hibiscrub). Start by briefly lathering the soap on the hands and forearms and then perform a systematic wash of the hands, during this time return to the forearms intermittently and re-lather the soap. Take care to include each surface of each finger as well as the surfaces of the hands and forearms.
• The hands are held higher than the elbow throughout the entire procedure to ensure that water cannot run off the non-sterile upper arm and contaminate the scrubbed forearm and hands.
• Rinse to remove soap and lather.
• Take a scrubbing brush and scrub the fingernails of one hand for at least one minute. Repeat on the other hand.
• Discard the brush and rinse the hands and arms, still taking care to keep the hands above the level of the elbows.
• Repeat the first stage i.e. the thorough wash with antiseptic soap, this time concentrate on the hands, the forearms should only be briefly lathered at the start of this final wash.
• Scrubbing and washing should take at least five minutes.
• The hands and arms are then dried with the sterile towel from the gowning kit. If two towels are provided one is used for each hand and arm, otherwise a different corner of the towel should be used for the left and right. Care is taken to ensure that drying is performed systematically from hand to elbow.

The gowning procedure:

• All gowns are placed in the container inside-out, so that the right side is not contaminated when the gown is lifted up. A gown is lifted from the opened pack and grasped by the shoulders, holding it away from the body and other surfaces, it is allowed to unroll.
• The surgeon places one hand in each sleeve to the level of the cuff.
• An assistant then ties the tapes at the back.

The gloving procedure:

The merit of closed gloving over open gloving is that the potential for the operator to contaminate the sterile surface of their gown is substantially reduced. This is because the hands do not exit from the cuffs of the gown until such time as they are entering the inside of the gloves.

Closed gloving:

• The right glove is taken from the open glove pack with the covered left hand. It is placed on the surgeon’s right arm with the cuff of the glove touching the cuff of the gown, the thumb of the glove face down and the fingers pointing towards the surgeon’s elbow.
• The cuff of the glove is grasped through the sleeve with the covered right fingers.
• The cuff is then grasped on the opposite side with the covered fingers of the left hand and folded out and over the cuff of the right sleeve.
• The right hand can then be extended onto the glove by pulling on the cuff of the gown and glove with the covered left hand.
• The procedure is then repeated for the other hand.
• The gloves are adjusted as necessary ensuring the fingertips fit snugly.

Once the surgeon has gloved and gowned, the gown should be considered a sterile field only from the level of the shoulders to the waist, including the sleeves. The hands are held clasped together away from the gown in front of the chest, to minimise the risk of contamination until surgery commences.

All of these procedures are illustrated on www.procedureswithcare.org.uk

Rodent surgery

Some research facilities adopt lower standards of asepsis for rodent surgery in comparison to those required when working with larger specie. Differences between these two types of surgery arise for a number of reasons. One reason that can be justified is that in large animal surgery, a large proportion of a surgeon’s body will enter the surgical field whereas in rodent surgery often only the surgeon’s hands will significantly encroach on the surgical field. Other reasons that personnel give for approaching these two types of surgery differently are often not valid and if they are critically assessed amount to economic reasons or an ingrained belief that rodents don’t get infection due to bacterial contamination of the wound during surgery (see Examining the myth that rodents do not get post-operative infection).

An assistant

It is not possible for a person to undertake aseptic surgical procedures and also assume the role of the anaesthetist and theatre nurse / technician. Nevertheless, a sizeable proportion of people that undertake rodent surgery seek to do this and thus compromise their aseptic technique in the process. The value of an assistant cannot be over-estimated, enabling the surgeon to practice aseptic technique and also speeding up procedures, especially in the case of batch surgery.

How to dress

A sterile gown should be worn. It is not acceptable to wear outer clothing that has been worn whilst undertaking other tasks. A lab coat that has been worn in the laboratory before entering the operating room or clothes that have been worn whilst performing animal husbandry tasks will be contaminated and will introduce a significant source of infective material into the surgical field. A hat, mask and either theatre footwear or overshoes should be worn. Sterile gloves should be worn, after following the “scrub-up” procedure described above.