Antiseptic surgery

This used to be standard practice before aseptic methods made it obsolete. But it may still be useful when power supplies have failed or your autoclave breaks, or an important operation has to be done in some remote place.

Aim to sterilize everything coming into contact with the wound by soaking it for a sufficient time in an antiseptic solution. Unfortunately: (1) An antiseptic solution leaves everything wet. (2) Sterilization is slow so that you may only be able to do one operation at a time. (3) Wide areas of the body are exposed to the antiseptic, which causes much exudation from the wound. Even so, antiseptic surgery is simple, and makes many kinds of operation possible. If necessary, you can combine antiseptic and aseptic methods, and sterilize smaller instruments in a pressure cooker. Chlorhexidine is the most practical antiseptic, but is far from perfect. The methods below are mostly those used by JF Dick working on the slopes of Mount Everest. Here is his account.

ANTISEPTIC SURGERY UNDER ADVERSE CONDITIONS. ''The only means of access to our hospital at present is by walking over the mountains for a week. All supplies have to be carried in by porters who take two weeks for the journey. For the first two and a half years, we worked in a traditional Nepali house with a thatched roof and a floor made of mud and cow dung. In it we did over 100 operations by the antiseptic method, without serious mishap. Later, limited space became available, so that although we enjoyed the advantages of tap water, a concrete floor, a clean ceiling, and adequate window ventilation, we still had to operate on a light outpatient type of table and in the same room in which the outpatients received all their medicines, injections, dressings, incisions, and dental extractions. We almost always used epidural or local anaesthesia''. Dick JF, ''Antiseptic surgery', Lancet 1966;ii:900.

ANTISEPTIC SURGERY ANTISEPTIC SOLUTIONS. Use chlorhexidine 5% concentrate to make two solutions: (1) A weak solution of 1/2000 of the active agent in water. Use this for soaking towels, etc. (2) A strong solution for instruments, as described above (2.5). Make up small quantities of solutions frequently, make them up hot, and clean out the containers well between batches.

''STERILIZING' EQUIPMENT AND DRAPES. Soak everything which will come into contact with the wound in one of these solutions for at least 30 minutes. Soak sutures and gloves in this solution overnight. Use monofilament (4.6) for ligatures and sutures, and the minimum number of simple instruments.

The most appropriate drape, for a tubal ligation, for example, may be a single solution soaked plastic sheet long enough, and wide enough, to cover the whole patient, with a hole in the middle through which to operate. If you have two such drapes, one can be in use while the the other is being soaked in a flat container of solution.

CAUTION ! Don't use syringes and needles soaked in antiseptic to give a subarachnoid or epidural anaesthetic.

PERIOPERATIVE ANTIBIOTICS for routine use in antiseptic surgery. Some operators have given their patients 1 g of chloramphenicol intravenously immediately before the operation. This is questionable practice, but if you are going to try to use antibiotics prophylactically, this is the logical way to use them (2.7).

WHILE OPERATING, Treat the patient's skin with the solution for at least five minutes before the operation.

Wash your hands as usual and put on the wet gloves. If you are not using gloves, soak your hands in solution for five minutes.

Wring out the soaked drapes as dry as you can, and apply them as near as possible to the operation site. Clean the patient's skin with the same solution. If there is a danger that he might get cold, cover him with a dry blanket in a plastic sheet, and put this between his skin and the wet towels above and below the operation site, where it will not get in the way.

Swab the trolley with the solution, or put the instruments on a solution-soaked towel. Keep two bowls near the operating table, one containing water and the other antiseptic solution. When instruments have been used, wash them in water and keep them in the solution until you use them again. Shake off the excess solution before you use them.

Handle the patient's tissues as little as you can, and try to keep the solution out of his wound as much as possible. Don't let it get into his body cavities.

If his wound is well sutured and is not expected to discharge, leave it open to the air. This is better than covering it with a questionably sterile dressing.

AFTER OPERATING rinse everything free of blood. Rinse the instruments, and put them away. If possible, carry nothing over to the next operation.