In order of importance, the most serious sources of infection in a theatre are bacteria from: (1) The pus and excreta left behind by previous patients, especially on its equipment or towels, etc. (3) The clothes, hands, skin, mouths, or perineums of the staff; the bacteria on them may have been derived from other patients. (4) The patient himself.
Minimize the risk of infection by: (1) Following the design rules in the previous section as far as you can. (2) Keeping the theatre as clean as possible, so that the pus and excreta of previous patients are removed. (3) Making sure that the autoclaving is done conscientiously. (4) Following the rules about the indications for operating, the timing of operations, wound closure (54.2), and careful tissue handling. (5) Creating and maintaining the sterile zone in Fig. 2-1.
This sterile zone has to be created anew for each patient in a theatre in which the risk of infection has been reduced as much as possible. Its creation starts when a nurse swabs the top of a trolley with antiseptic, puts two sterile towels on it and lays out sterile gowns and gloves. The sterile zone grows as the surgeon, his assistant and the scrub nurse put on their gowns. The operation site joins the sterile zone as it is prepared with an antiseptic solution and draped. Thereafter, nothing which is contaminated must touch anything in this zone until the end of the operation. If the technique of the team is poor, the sterile zone becomes smaller and smaller as the operation proceeds.
WOUND SEPSIS AND THE ART OF SURGERY Professor IJP Loefler speaks in the reference given below: ''In summary, I believe that regard for tissue is the foremost of our priorities. Let us strive to become first class surgeons, and let us train considerate disciplined theatre staff. Let us have plenty of soap and water, or some not too corrosive detergent. We do need sterilizers and autoclaves. We need well ventilated rooms which are light and easy to clean, and where the number of additional items is kept low. We should don theatre attire, should indeed change frequently, and should certainly change our masks. Gloves are important though not indispensable. Use sharp knives, few instruments and keep things neat and clean. Do not bury undue amounts of biologically irritating material in the tissues. Beware of haematomas and lymph collections. Use suction drains frequently. Use delayed primary closure where this is indicated (54.4). In the wounds you make yourself bring the skin edges together carefully so that the wound is sealed in a few hours. Hydrate your patient, and do not oversedate him. Avoid stasis by elevation and movement. Use dressings sparingly, and observe the wound. If you find a haematoma and evacuate it speedily you will prevent sepsis''. Loefler IJP, ''Wound sepsis and the art of surgery', Proceedings of the Association of Surgeons of East Africa 1979;2:172-180 SUITS, theatre, cotton, with short sleeved shirt, and long trousers, assorted sizes, local manufacture, 30 only. The purpose of these is to make sure that nobody enters the theatre in his ordinary clothes, or in clothes which he has worn elsewhere in the hospital. Everyone entering a theatre should put on a theatre suit in the changing room. These suits should be laundered, and if possible ironed, but need not normally be sterilized each time they are used, unless they have been used for septic cases.
CLOGS, assorted sizes, ten pairs only. Rubber boots are outmoded; sandals are less easy to keep clean and less comfortable than clogs. Change into them at the barrier between the theatre and the rest of the hospital.
APRONS, macintosh, assorted sizes, local manufacture, eight only. These protect the suits and are worn under a theatre gown. If they are merely hung up in the changing room after use, they become progressively more contaminated and more dangerous. So make sure that they are at least washed and regularly swabbed down with an antiseptic solution, and are always swabbed after septic cases. Keep two for special clean cases only.
CAPS, cotton, 30 only. Put on a cap before you enter the theatre, and make sure it completely covers your hair.
MASKS, theatre, 100 only. Make these from 4 layers of muslin. A mask must cover your nose; if it fogs your glasses, arrange its top edge, so that your breath does not drift upwards, or, rub your glasses with ordinary soap and polish them. Use a new mask for each major case.
GOWNS, cotton, 50 only. These should go right round the wearer and cover his back. Before sterilisation they must always be folded so that the inner surface on the wearer is exposed to the outside in the drum.
GLOVES, operating, reusable, (a) Size 6, 20 pairs. (b) Size 6[1/2], 40 pairs. (c) Size 7, 40 pairs. (d) Size 7[1/2], 40 pairs. (e) Size 8, 20 pairs only. Remember that gloves are designed to protect the surgeon as much as the patient. The type of gloves you buy is critically important, and so is the relative number of the various sizes. They must be capable of being resterilized many times. Most nurses wear size 6[1/2] and most doctors size 7 or 7[1/2]. Pack each pair in a cloth or paper envelope, one glove on each side with its cuff turned outwards. Gloves are more useful to protect you and the next patient, than the patient you are actually operating on. If necessary, you can operate without gloves, so don't let the absence of gloves prevent you doing a life-saving operation.
GLOVES industrial, three pairs only. These are useful for picking up hot objects, and used on the correct indications will save many pairs of surgical gloves.
GLOVE POWDER, absorbable, 3 kg only. Don't use starch or talc because it causes granulomas. Put the powder into little gauze bags which can be used as shakers, or use small pieces of paper.
SOAP, hexachlorophene, carbolic, 50 tablets only. If necessary, the cheapest soap that does not irritate the skin will do.
BRUSHES, nylon, nesting, autoclavable, 50 only. Autoclave several of these each operating day and store them between cases in a bowl of antiseptic solution. They will last longer if you merely keep them clean and immerse them in an antiseptic solution.
TOWELS, cotton, green, theatre. (a) Hand towels 25 cm square, 100 only. (b) Theatre drapes 100[mu]75 cm, 100 only. (c) Abdominal sheets, ten only. An abdominal sheet covers a patient completely from head to foot and has a slit in it through which the operation is done. The upper end acts as a guard which keeps the patient's head and the anaesthetist out of the operative field.
OTHER SUPPLIES, (1) Pyjamas and pyjama trousers, 20 only. (2) Dresses, 20 only. (3) Macintosh drapes, 75[mu]100 cm, 20 only. (4) Squeegees, two only. (5) Bucket and mop, three only.
Fig. 2-5 SCRUBBING AND GOWNING. A, make sure your cap covers your nose. B, scrub your hands in a systematic manner. C, scrub your nails. D, turn off the taps with your elbow. E, while your hands are wet, hold them higher than your elbows. F, blot your hands on one corner of the towel, then dry your forearms. G, hold the gown away from your body, high enough not to touch the floor. H, ask the circulating nurse to grasp the inner sides of the gown at each shoulder and pull it over your shoulders (I).
ASEPTIC TECHNIQUE ENTERING THE THEATRE. Anyone entering the theatre must change, in the changing room, into clogs or sandals and into a suit. Decide which operations need gowns, gloves or masks.
SCRUBBING UP. Adjust the elbow taps to deliver water at a comfortable temperature. In most tropical countries only a cold water tap is necessary. Wet your hands, apply a little soap or detergent, and work up a good lather. Rub your hands and forearms to 5 cm above your elbows for one complete minute. Wash your forearms.
Then take a sterile brush and put soap on it. Scrub the lateral side of your left thumb, then its medial side, then the lateral and medial aspects of each successive finger. Scrub your nails, and then the back and front of your left hand. Do the same with your right hand. Scrub for 5 minutes in all.
Alternatively, some surgeons merely scrub their nails, unless they have got ingrained dirt from some other dirty task, and then thoroughly wash their hands and arms to their elbows.
Rinse the suds from your hands while holding them higher than your elbows. Turn off the taps with your elbows.
Dry your hands with a sterile towel before you put on a sterile gown. Dry your hands first, then your forearms. Grasp the folded towel with the fingers of both hands, then step clear, so that you don't touch anything with the open towel. Blot your hands on one corner, then dry your forearms. Try not to bring a wet (unsterile) part of the towel back to a dry area.
GOWNING. Hold the gown away from your body, high enough to be well above the floor. Allow it to drop open, put your arms into the arm holes while keeping your arms extended. Then flex your elbows and abduct your arms. Wait for the circulating nurse to help you. She will grasp the inner sides of the gown at each shoulder and pull them over your shoulders.
GLOVING. Dust your hands with powder and rub them together to spread it. Be careful to touch only the inner surface of the gloves. Grasp the palmar aspect of the turned down cuff of a glove, and pull it on to your opposite hand. Leave its cuff for the moment.
Put the fingers of your already gloved hand under the inverted cuff of the other glove, and pull it on to your bare hand. It is a good routine to wash your gloved hands in sterile water to remove the powder.
Now help the next person who has gowned on with their gloves.
If you TEAR OR CONTAMINATE A GLOVE during an operation, remove it. Grasp its cuff from the outside, and pull it down over your palm. Ideally, don't remove the glove yourself, because you will contaminate your other hand. Instead, hold out your hand to the circulating nurse, who will grasp the edge of the cuff and pull it off. In practice most circulating nurses are too nervous to do this, so you will have to do it yourself by touching the outer side of the cuff only.
THE OPERATION SITE SHAVING. The operation site should be socially clean before the operation, and you may have to check this. There is usually no need to shave a patient. If you shave him, do so on the morning of the operation, or as part of the operation. If you shave him a day or two before, minute abrasions in his skin will become infected and the risk of wound infection will increase. If hair is going to get in the way, all you need to do is to clip it short immediately before the operation.
PREPARATION. Do this as soon as the patient is anaesthetized. Start with a soapy solution, and follow this with spirit. Or, better, if there is a low sensitivity to iodine in the community (as in most of Africa), use alcoholic iodine (2.5). Take a sterile swab on a holder, start in the middle of the operation site, and work outwards. Discard both swab and holder, and repeat the process with a second swab (some surgeons use a third). The spirit will evaporate to leave the skin dry. Some surgeons consider this is over-elaborate, and merely use a single application of iodine.
Be sure to prepare a wide enough area of skin. In an abdominal operation this should extend from the patient's nipple line to below his groin.
DRAPING. Wait until he is anaesthetized. Place the first towel across the lower end of the operation site. Place another across its nearer edge. Apply a towel clip at their intersection. Place another towel across the opposite edge of the site, and finally one across its upper edge. Clip them at their intersections. If necessary, grip his skin with the clips, or secure the towels with a stitch. Alternatively, drape him with two longitudinal towels clipped at each end, with a towel above and below. Then, in an abdominal operation, cover his whole abdomen with an abdominal sheet with a narrow quadrangular hole in it.
If important areas near the surgeon become contaminated, cover them with fresh sterile towels.
SWABS AND PACKS. Use 10 cm gauze squares on spongeholding forceps (''swabs on sticks'). You will also need abdominal packs.
CLEANING THE THEATRE. Clean it thoroughly after each day's list, and completely every week.
CLEANING INSTRUMENTS. Use an old nail brush. Open hinged instruments fully, scrub them, and take special care to clean their jaws and serrations.
DIFFICULTIES [s7]WITH ASEPTIC METHODS If you have NO GLOVES or very few gloves, scrub up and then rinse your hands and arms in alcoholic chlorhexidine (2.6). The alcohol will dehydrate your skin. You can reduce this by adding 1% glycerol to the solution. Unfortunately, although antiseptics may help to protect the patient, they are less effective in protecting you from AIDS (28a.4).
If you have NO DRAPES OR GOWNS or very few of them, use plastic sheets and aprons and soak them in an antiseptic solution (2.6).
Fig. 2-6 PUTTING ON GLOVES. A, take hold of the inside of the glove with your right hand, and put your left hand into it. B, put the fingers of your left hand under the cuff of the glove. C, pull your right glove on without touching your wrist. D, the first person to glove up (usually the scrub nurse) now gloves the second person (usually the surgeon), by holding out his gloves for him like this. E, How [f10]not [f11]to wear your mask! Don't put your left hand in your axilla[md]it is not a sterile area, even after gowning. E, after Ian Donald, ''Practical Obstetric Problems'. Lloyd-Luke, with kind permission.