''It is one thing to operate with the chief at your elbow on a patient whose vital functions are being monitored by an expert anaesthetist at the head of the table. It is quite another to be almost alone at midnight, struggling with a patient in shock from a ruptured ectopic pregnancy, as the light fades in and out while a superannuated generator tries to function on adulterated diesel oil. Then is the moment of truth when you realize that an excellent theoretical foundation is not the only thing you need[...]'' Gerald Hankins, The Shanta Bahwan Hospital, Kathmandu, Nepal
Although aseptic surgery has been done in a tent, under a tree, or on a kitchen table, it is safer if it is done in a room which has been designed to preserve the sterility of the surgical field, to make surgical routines easier, and to prevent mistakes. The difficulty with aseptic methods is that they require an autoclave. If you don't have one, we describe an antiseptic method that you can use instead (2.6). You will need two theatres, a major one and a minor septic one (2.2). We are concerned here with the major one.
When you start work in a theatre, look at it carefully. How many of the desirable features that we are about to describe does it have? Is there anything which you could do to make it safer or more efficient?
The operating team should be as small as possible. It consists of: (1) Yourself the surgeon. (2) Your assistant, when you need one. (3) The scrub nurse responsible for the instruments. (4) The circulating nurse to fetch and carry. (5) The anaesthetist. (6) His assistant, if he has one. Two other people are important: (a) The theatre charge nurse responsible for organizing the theatre, and who in a smaller hospital will take a turn at being on call. And (b) the ''theatre dresser' who is less educated, but, unlike the nurses who come and go, has spent his whole career in the theatre, and so knows its routines and where things are.
In an emergency roles (2) and (3) can be combined in an efficient nurse or medical assistant, and so can roles (4) and (6). The first three members of the team are ''sterile', the last three are not. An important part of the drill is to prevent the last three from compromising the sterility of the first three, and the surgical field.
Two zones in the theatre ensure this. There is : (1) A sterile zone which includes the operation site, the first three members of the team, and that part of the theatre immediately around them. (2) An unsterile zone which usually includes the head end of the patient, and the rest of the theatre. The last three members of the team can move freely in this zone. The patient's entrance and the access to the sluice room are continuous with it. A separate room for scrubbing up is not essential, and it can be done in the theatre in two domestic pattern sinks with draining boards. They should be fitted with elbow taps which are very highly desirable, although you can scrub up from a bucket.
Fig. 2-1 STERILE AND UNSTERILE ZONES IN A THEATRE. A, the sterile zone in a vertical dimension. B, the sterile zone in a horizontal dimension. The sterile zone contains the operation site, the instrument trolley and the three scrubbed up members of the surgical team. The unsterile zone comprises everything else in the theatre. The great danger, when technique is poor, is for the sterile zone to become smaller and smaller as the operation progresses. Adequate space is essential, so that staff can move freely within their zones, and without touching one another. Space is needed for manoeuvering and parking the patient's stretcher next the operating table, and for parking trolleys without congestion. Twenty-five square metres is the absolute minimum, a room 5[mu]6.5 m (32 m['2]) is better, and 42 m['2] is ideal. The more equipment you have in the theatre the more space you need, and in the developed world or in a central hospital 64 m['2] is normal. If the case load is heavy, a second theatre is usually considered more useful than making the first one unduly large.
Straightforward physical cleanliness is important. Sophisticated methods are unnecessary. Sluicing the floor between cases, washing the walls weekly and mobile equipment daily will ensure a high enough standard without using antiseptics on the theatre itself. The floor is important. The most dangerous sources of infection are pus and excreta from the patients, which must be cleared away between every operation, and must not be allowed to contaminate the theatre. To make this easier, it should have a terrazzo floor, but a smooth concrete finish is almost as good and much cheaper. To make it easier to wash down, it should have a 1:1000 slope towards an open channel along the foot of the wall at the unsterile end of the theatre. This channel should have a plugged outlet leading directly outside to an open gulley. Fit a sparge pipe to the wall at the sterile end 150 mm above the floor, so that the whole floor can be flooded by turning a tap. A little dust on trolley wheels or shoes, or from open windows, is less dangerous than is generally believed.
The walls of the theatre should be smooth, but they need not be tiled. A sand and cement backwash application painted with one coat of emulsion and two coats of eggshell gloss is adequate. Gloss paint is satisfactory for the walls, and the fewer the doors, sills, ledges, crevices, mouldings, architraves, and window boards, the better. Every time a door is opened, dust from the floor is whirled into the room. There is no need for a door between the changing rooms and the theatre. A door is only needed between the sluice and sterilizing room, if these rooms will be used when the theatre is not.
The ceiling should be at least 3.5 metres high and the roof timbers solid enough to support an operating light. It should also have a pair of 2 metre fluorescent tubes.
The ambient level of illumination should be high, so make the windows big enough. They may enable most operations to be done by daylight. There should be a window of 5 m['2] at the head and the foot ends, facing north and south shaded by a roof overhang of at least 800 mm. Even better are windows on three sides. Fit ordinary low windows, and frost only the panes below eye level, so that the staff can look out (which improves morale), but that anyone looking in can only see their heads, not the patient. In the tropics avoid windows in the roof.
Fig. 2-2 A SIMPLE THEATRE AND ITS TABLE. This is about the smallest practical theatre. Figure 2-3 shows the various ways in which it can be provided with a sterilizing room, an anteroom and changing rooms. B, the simple pattern operating table described in the text. A, adapted from ''Design for Medical Buildings' with the kind permission of the African Medical and Research Foundation (AMREF). Don't have more shelves than you need, but keep the things you need daily nearby; use trolleys where you can. When shelves are needed, set them 50 mm away from the wall on metal rods, so that they can be lifted away for ease of cleaning. All shelves should be at least a metre high so that trolleys can be pushed under them. The glove shelf should be at least 1.2 m high, so that you can keep your hands higher than your elbows to prevent water running back down over your now dry hands. The anaesthetist needs a small lockable cupboard, a trolley, and also a worktop near the patient's head. Ideally, he also needs a sink. Electric sockets should be 1.5 m above the floor to minimize the danger of igniting explosive gases.
The preparation room should lead off the theatre. A big one is desirable, because it needs to contain two autoclaves, a big and a small sterilizer, sterile packs, instrument cupboards and space to lay out instrument trolleys. Ideally, it should be 64 m['2] and serve two theatres. About 25 m['2] is the absolute minimum, with a terrazzo shelf round most of two walls, a sink, a draining board, a single vertical autoclave (preferably two), a large boiling water sterilizer standing on the floor, and a small one on the bench.
OPERATING TABLE, simple pattern, (NES) each $240, one only. At the time of writing this table has to be made to order. The minimum requirements of an operating table are that: (1) You must be able to tilt the patient's head down rapidly for the Trendelenburg position, and if he vomits (A 3.1, A 16.2). (2) You should be able to adjust its height. This table does these things at a fraction of the cost of the standard hydraulic ones, which need careful maintenance, and are useless when their hydraulic seals perish. However, if a simple general purpose hydraulic table is well maintained, it lasts a long time. A really sophisticated one can cost as much as the entire building of the theatre. A dirty table is a menace, so make sure yours is kept clean.
If the head of your table does not tilt head down, get one that does. Meanwhile, in an emergency, you can put a low stool under the bar at its foot. If it does not tilt from side to side, make a wooden wedge to fit under the mattress. If it does not have a kidney bridge and you want one (most surgeons don't use them now), use folded plastic covered pillows.
Locally made ''Chogoria' supports (15-3) are a useful addition to a standard table. They are made of two suitably bent pieces of pipe which fit into the holes for ordinary stirrups and keep the patient's hips widely abducted, and his hips and knees moderately flexed, so that his lower legs are horizontal. His legs rest on boards attached to these pipes. These supports are more comfortable than stirrups and are particularly useful for such operations as tubal ligation.
ALTERNATIVE OPERATING TABLE, as Seward minor (SEW), or equivalent, one only. This is slightly more versatile and considerably more expensive than the table above.
MATTRESS, for operating table, (a) one only, with (b) three mackintosh covers only. A dirty mattress is a potentially serious source of infection. So swab the cover after each patient, and replace it regularly.
ARM BOARD, for operating table, locally made, one only. This is simply a piece of hardwood about 20[mu]120[mu]1000 mm, which you push under the mattress to rest the patient's arm on, when you want to inject it.
STOOL, operating, adjustable for height, local manufacture, two only. If you do much operating, a chair with a padded seat, wheels, and a back greatly reduces fatigue.
LIGHT, operating theatre, simple pattern, preferably with sockets to take bayonet or screw fitting domestic pattern light bulbs, in addition to special bulbs, state voltage, one only. Most operating theatre lights take bulbs which are irreplaceable locally, and may cost $70 each, so find out what bulbs your light takes, and try to keep at least three spares. Record their specification and catalogue number somewhere on the lamp casing. When new lights are ordered, they should have fittings that can, if necessary, take ordinary domestic bulbs.
CLOCK, wall, electric, with second hand, one only. This is essential, you must have a proper awareness of time, especially when you apply a tourniquet (3-11), and without a clock you can readily forget it. The instructions given here for controlling bleeding by applying pressure sometimes tell you to wait 5 minutes by the clock.
Fig. 2-3 IMPROVISED LIGHTING. A, if you have to make a light locally, suspend 4 car headlights on a cross, and suspend each end of it on a pulley counterbalanced with a weight. B, better, put the counterweights in a metal casing which will be easier to keep clean. Or, less satisfactorily, hang three fluorescent tubes from the ceiling in the form of a triangle. SPOTLIGHT, free standing on the floor, ''Anglepoise' type, to take ordinary domestic pattern bulbs, state voltage, two only. Also, high efficiency internally reflecting bulb to give a parallel beam, five only. This is necessary, both as a standby to the main theatre lamp, and to illuminate positions that the main threatre light cannot reach. A spotlight can direct an undesirable amount of heat into the wound, so, if possible, it needs one of the new high efficiency bulbs which produce little heat, and yet fit ordinary bulb sockets. These are more expensive initially, but have a longer life. You can improvise a spotlight by removing the headlight of a car, especially the sealed beam type, and attaching it to a drip stand in the theatre. Connect it with a long lead to the battery of a car outside. Or use a slide projector held by an assistant. If the level of illumination is not enough, especially for eye surgery, you can increase the contrast by blacking out the theatre.
SOLAR PANEL, charger, and battery, one only of each. A single solar panel will collect a useful quantity of electricity and enable you to light two wards in the evenings.
BATTERY CHARGER for the common sizes of rechargeable dry batteries, and five rechargeable batteries of each size, one outfit only. This will enable you to recharge batteries for your torches and laryngoscopes etc.
INSTRUMENT CABINET glass door, sides and shelves, 1300[mu]600[mu]400 mm, local manufacture, one only.
X-RAY VIEWING BOX, standard pattern, local manufacture, one only.
TROLLEY, instrument, without guard rail, with two stainless steel shelves, antistatic rubber castors, (a) 600[mu]450 mm, three only. (b) 900[mu]450 mm, one only. Glass shelves ultimately break, so stainless steel ones are better. A larger table will make it easier to lay up for larger cases, especially orthopaedic ones.
STAND, solution, with antistatic rubber tyred castors, complete with two 350 mm stainless steel bowls, side by side, one only. Put water in one bowl, and use the other for spare instruments and the sucker. The bowls can be sterilized in the autoclave or in a boiling water sterilizer.
DRIP stands, telescopic, two only Or, less satisfactorily, use long wire hooks suspended from the ceiling near the head of the table. Hooks for drips sticking out from the wall are useful above some beds in the wards.
Mein P, and Jorgenson T, ''Design for Medical Buildings', AMREF, Box 30125, Nairobi. Fig. 2-4 SOME SURGICAL LAYOUTS. This incorporates the theatre in Fig. 2-2 in progressively more developed settings. A, is the absolute minimum. The changing is done in the sterilizing room. B, is similar but has an anteroom and staff changing room. C, is the arrangement recommended, but is 2 or 3 times the cost of A. The sterilizing room is large enough to prepare sterile items for the rest of the hospital. There is also a changing room with shower and toilet. D, shows the further addition of a minor theatre. Th, main theatre. Mth, minor theatre. An, anteroom. Sl, sluice. Ste, sterilizing. Adapted from ''Design from Medical Buildings' with the kind permission of the African Medical and Research Foundation (AMREF).