Operating Room Technic
by Robert K. Felter, M.D.
Frances West, R.N.
Copyright 1937, 1940, 1942 Printed 1945
Manual Loaned by Becky Sawyer
Most nurses are familiar with the weird and gruesome scenes surrounding operative procedures of the past, when asepsis was a thing unheard of and the physical and mental comfort of the patient was entirely neglected. Within the last few years the science of surgery has made great strides and bright, spotless operating rooms have taken surgery out of the family kitchen and local barber shop. Today the words "asepsis" and "sterilization" have become so closely associated with operative technic that it is to this department the nurse is sent early in her course to obtain the practical application of principles learned in Microbiology and General Surgery.
The words "Operating Room" have a formidable sound to most people. To the average layman, it is the one place in the world to which he hopes he will never have to go. The student nurse faces assignment to the operating room with dread and apprehension and the surgeon, knowing that so much depends upon his skill, is working under strain and tension. Well planned and skillfully conducted teaching programs do much to help the nurse adjust to this type of work, but a large portion of the nurse's success is due to the possession of certain traits. She must be a person who can think quickly and logically, plan work well, be alert at all times, have almost perfect self control, be scrupulous, conscientious, and able to work harmoniously with the group. Teamwork, cooperation, and conscientiousness are essential qualities in any ward situation, but never more so than in an operating room where a minute's delay, a weakened ligature, a torn glove, unnecessary questioning of orders, or a break in technic may mean the life of the patient.
Upon assignment to the Operating Room the nurse should become familiar with the physical layout of the suite, the location of the rooms, the arrangement of equipment, the general nature of all supplies and where they are kept. Early acquaintance with the personnel and a knowledge of each person's duties will aid adjustment and lead to well organized teamwork. Each person should know exactly what duties she is to perform and to whom she is directly responsible. It is the purpose of this chapter to present to the student nurse some of the duties connected with operating room work and to discuss in a general fashion some of the skills she should acquire while there. Be- cause of the dissimilarities in hospital procedures, little attempt is made to deal with specific technics, but whatever procedure is adopted, the underlying principles remain the same.
II. Basic Principles
All operating room technic is based upon principles already learned in the course of Microbiology. Before proceeding further, the nurse should review this course with special emphasis on organisms and pathways by which they enter the body; types of infection, their cause and prevention ; methods of sterilization, and principles of aseptic technic.
It will be recalled that one route by which pathogenic organisms enter the body is through a break in the skin or mucous membrane. Since almost every operation involves an incision through the protective coverings of the body, it is obvious that every measure must be taken to prevent organisms from entering through this opening. The keyword, then, to operating room technic is Asepsis, which is an attempt to free from organisms all objects that come in direct or indirect contact with the wound. The process by which these organisms are destroyed is known as sterilization. The methods of sterilization most commonly used in the operating room are boiling, steam under pressure, or autoclaving, and chemical agents.
When assisting the doctor with surgical dressings on the ward, the nurse carried out aseptic technic. All instruments, gauze, and other materials which came in contact with the wound were sterile. The patient was draped with a sterile towel and the doctor wore sterile gloves. A small sterile field was set up on a tray, on which instruments and dressings were placed. Operating room technic is merely an elaboration of these very same skills. Here large sterile fields are prepared. Many more instruments are sterilized for use, the patient is draped more extensively and sterile masks and gowns are used in addition to gloves, but the principle is exactly the sameto prevent organisms from entering the wound and thereby causing infection.
III. Preparation of Supplies Used in an Operation
A large part of a nurse's work in the operating room is the selection and preparation of various supplies. Many of these supplies are similar to those used on the surgical wards and are prepared in like fashion. The nurse has learned to care for and sterilize rubber gloves, towels, gauze sponges, dressings, packing, glassware, instruments, scissors, knives, trays, and basins. These supplies are cared for and sterilized in the same manner as on the wards except that large quantities are made ready at one time. Some supplies differ and these we shall discuss more in detail.
Gowns, Drapes, Masks, Gauze Dressings, Sponges, and Pads: The types of gowns, dressings, etc., vary somewhat, although within recent years they have become more standardized. The method of caring for them is very much the same. Gowns, drapes, sponges, and dressings are packed in drums or wrapped in cloth or paper and sterilized by autoclaving. Masks are wrapped either in individual packages or in groups of two and three. When drums are used they should be care fully inspected before being packed, being sure that they are dry, well lined and that the holes on the sides are open. Instead of packing several types of articles in one drum as is generally done on the ward, one drum is used for gowns, another for towels, another for larger drapes, one for gauze, etc. All articles are examined for imperfections before being packed and are folded so that they may be removed from the drum and unfolded for use with speed and without danger of contamination. Gowns are folded so that the outside of the gown is turned inside and are placed in the drum in such a fashion that they may be removed from the container without touching the outside of the gown. The method of folding articles and packing drums varies greatly but a standard system used throughout a hospital aids efficiency. The articles should be packed loosely to allow complete penetration of the contents by steam. A sterilometer may be placed in the center of the drum so the nurse may check to see whether the contents of the drums are sterile. Each drum should be labeled.
When articles are sterilized in packages, each package should be wrapped loosely, but securely in paper or in two thicknesses of cloth, tied, and labeled.
Suture material is classified into two large groups: Absorbable sutures which are absorbed by the tissues during the healing process of wounds and, therefore, do not have to be removed, and nonabsorbable sutures which are not absorbed and have to be removed.
Absorbable Materials: Plain Catgut: A light tan colored suture made from the intestines of sheep. It is purchased, ready sterilized, in tubes. Catgut is absorbed in from two to eight days, depending upon the size, which varies from 00-5. Number 00 absorbs in two days and number 0 in four days, so they are used for tissues which heal quickly, e.g., superficial ligatures. Number I absorbs in six days and is used to tie off muscle bleeders and for sewing muscle.
Chromicized or Tanned Catgut: Catgut treated with a salt of either chromic or tannic acid and prepared in sterile tubes. This material resists absorption longer than plain catgut and is used where approximation is required to last from 10 to 20 days Numbers 00 and 0 are used on mucous membrane and small tendons, numbers I and 2 for sewing fascia, peritoneum, and tying off small organs, and numbers 3-5 for tying off larger organs such as lungs and kidneys. Chromic catgut comes in small sizes welded on a straight or curved needle. These are called atraumatic sutures and are used for work where diminished trauma is desired, e.g., intestinal work.
Kangaroo Tendon: Used for orthopedic work, for recurrent hernias, and cases where absorption is not desired before 30 to 60 days. All absorbable materials, unless otherwise stated on the tube, are sterilized by chemical action or by tying the tubes in gauze and boiling.
Nonabsorbable Materials: Pagenstecher: Linen thread which has been treated with a celluloid and rendered nonabsorbable. It comes in varying sizes and is used chiefly for gastrointestinal work. Although nonabsorbable, it is not removed from the tissue. It is sterilized by autoclaving or boiling.
Deknatel: A waxed, treated, nonabsorbable suture used in such operations as herniotomy and thyroidectomy and is not removed. It is sterilized by autoclaving or boiling.
Silk, Either Black or White: Comes in various sizes according to number and is used mostly for suturing the skin. Silk also comes welded to a small round, curved needle used for suturing nerves and arteries, and a small cutting needle for plastic work. Silk may be autoclaved or boiled. If boiled, it should be wrapped around a spool made from rubber tubing. It should not be resterilized as the process weakens the material.
Horsehair: Used mainly for suturing the skin and is sterilized by boiling. It should first be washed thoroughly in soap and water and then boiled in a soda solution for ten minutes to render it free of tetanous spores.
Silkworm Gut: Unspun silk from the silkworm used for superficial retention sutures. Strands of the gut are placed through a piece of Dakin's tube and boiled. Reboiling weakens the material.
Dermal: A fine, plain catgut used for suturing the skin. It comes inclosed in a tube and is sterilized by boiling or autoclaving.
Fascia Lata (in tubes): Derived from the ox and is used for recurrent hernias when it is impossible to use human fascia. The tubes are sterilized by placing in a chemical solution for 20 minutes.
Metal Clips, Silver Wire, and Bone Wax: Various sizes of metal clips are used for skin sutures. Silver wire and bone wax (sterilized beeswax) are used in orthopedic work, the silver to wire bone together and the bone wax to control bleeding from bone. The metal clips and wire are sterilized by boiling and the bone wax by a chemical agent.
Needles: There are many kinds of needles on the market and each surgeon has his preference. Some surgeons change the type of the needle to fit the tissues being sewed. while others use one kind of needle for practically all their work. The nurse needs to find out the preference of each surgeon and prepare the type he uses. Needles come in all sizes and shapes, t t they may be generally classified into straight and curved needles, those with a cutting edge, and those with a round edge. As a rule, straight, cutting edge needles are used for surface work, while curved needles with a round edge are used for the deeper layers. Unless special type needles are requested, a suggested list for a laparotomy is as follows:
2 straight skin needles for suturing the skin.
2 medium curved skin needles for superficial tension sutures.
2 large curved skin needles for deep tension sutures.
2 large Mayo needles for suturing muscle tissue.
2 medium Mayo needles for suturing the peritoneum.
2 small Mayo needles for suturing fascia.
2 straight intestinal needles.
2 small curved intestinal needles.
Needles are sterilized by boiling, autoclaving, or a chemical solution.
Drains and Packing: A drain is some material inserted into a wound to provide an exit for toxic materials, blood, and serum. Practically all drains are made from rubber tubing, rubber sheaths, gutta percha, and gauze. Because gauze readily adheres to the wound and causes pain when removed, it is usually covered with some other substance, rubber being most commonly employed. A common type of drain is the cigarette drain, made of a rubber sheath with gauze packing running through the lumen in the form of a wick. A small Penrose drain, composed of rubber with no packing, is used to drain off serum in such cases as thyroidectomy. Some other types of drains employed are plain rubber dams, catheters, mushroom catheters, Dakin's tubes, and perineal tubes. Mayo tubes and T-tubes are frequently used to drain gall ducts and the gallbladder. Whenever a drain is needed, a sterile safety pin is prepared to insert through the outer end of the drain and prevent it slipping into the wound. Drains are sterilized by boiling.
Gauze packing is used in sizes from 1/4 inch to 3 inches in width. The packing is placed in the wound and only a small amount is removed at one time. This process keeps the wound open, allowing the lower layers to heal first, meanwhile leaving an opening for drainage.
Medicated gauze, particularly iodoform gauze, is sometimes used for packing. This cannot be sterilized and so the gauze drain is medicated under sterile conditions. Vaselined gauze is placed around wounds where there is considerable drainage in order to prevent irritation of the adjacent skin areas.
Instruments: A dissecting tray, which contains instruments necessary to open and close an area, is the fundamental tray used in all operations. Other instruments are added, depending upon the type of operation performed and the surgeon's preference. Dissecting trays vary somewhat in different hospitals, but a suggested list of instruments is as follows:
1 knife to make the skin incision. This knife is discarded after the incision is made.
1 knife for cutting tissues under the skin.
1 straight scissors.
1 curved scissors.
1 suture scissors.
2 mousetooth forcepsto pick up tissues for suturing, etc.
2 anatomical forceps (smooth) to pick up delicate tissues, such as the peritoneum.
6 small curved Kelly clampsto clamp off superficial arteries.
6 small straight Kelly clampsto clamp off superficial arteries.
6 medium curved Kelly clampsto clamp off vessels in the muscle layers.
6 Allis clamps.
6 Kocher clamps.
1 grooved director.
1 set of aneurysm needles for ligature carriers.
2 rake or prong retractors.
2 smooth retractors.
1 needle holder.
2 sponge sticks
4 towel clips
Electrical and Mechanical Appliances: Various appliances such as a Cameron light, suction machine, and cautery, are ,used frequently. The nurse needs to become familiar with the type of appliance employed in her institution. She should know the use of the machine, how to test it before using, the method of handling during an operation, the care of the machine after it has been used and should understand the mechanical principles involved. They should be available for use at a moment's notice.
IV. Immediate Preparation for Operation
- Preparation of the operating room
- Selection and preparation of equipment
- Technic of "scrubbing"
- Preparation of aseptic fields
At least four nurses are needed to prepare and assist with any major operation. For convenience we will give these nurses titles, although the terms used are colloquial. Both the "instrument nurse" and "suture nurse" are dressed in sterile gown, gloves, etc., and directly assist the surgeon during the operation. The "utility nurse" is unscrubbed and remains in the operating room during the entire procedure to wait upon those who are scrubbed. The "ether nurse" receives the patient, cares for him in the anesthetizing room and places him on the operating table. She also has charge of all duties which take one from the immediate operating vicinity.
Before preparing for an operation, all nurses involved should become familiar with the operating schedule, noting the type and order of operations, the kind of anesthesia to be used and the surgeons operating. Dressing rooms and lockers should be equipped and ready for use.
Preparation of the Operating Room: The entire operating room should be spotlessly clean. Walls and furniture are dusted with a damp cloth or washed. Sinks and floors are cleaned. The furniture and equipment should be arranged to permit the greatest amount of efficiency. The details of arrangement will differ depending upon the environment, equipment, and type of operation. The operating table should be placed where the maximum amount of light can be obtained. The room should be well ventilated but in such a fashion that there is no draught on the patient.
Selection and Preparation of Equipment: Usually each nurse has definite preparatory duties for which she is responsible but in general the following preparation is necessary : All materials needed for the schedule should be selected and brought to the operating room before the nurse begins to "set up." Materials kept in the room should be checked to make sure there is an adequate supply. The anesthetizing room is prepared for the patient. Scrubbing materials are placed by the "scrub-up" sinks. Mechanical appliances are tested. Specimen jars are made ready. Water tanks are checked to see that there is plenty of sterile hot and cold water. Basins are selected, placed in the basin sterilizer and boiled for at least 20 minutes. A chemical solution is made and knives, needles, scissors, and other articles which need to be sterilized in this manner are placed in it and left for 20 minutes. Instruments are selected, tested to see that they work properly and easily, and placed in the instrument sterilizer to boil. Sutures are chosen and sterilized.
Technic of "Scrubbing": Although the technic of scrubbing varies in different hospitals, the purpose is always the sameto make the hands and arms as clean as possible. The method consists of two processes, a thorough scrubbing with soap under running hot water and the use of some kind of disinfectant. A suggested procedure is as follows:
- PREPARATION FOR SCRUBBING:
- Either a short sleeved operating room dress is worn or else sleeves are rolled up three inches above the elbow.
- Fingernails should be short, evenly filed and free from polish.
- A cap is worn which completely covers the hair.
- A sterile mask is placed over the nose and mouth to prevent bacteria from being expelled on the sterile field and wound.
- All articles used for scrubbing, brushes, orangewood sticks, etc., are sterile.
- THE SCRUB-UP PROCEDURE:
- Clean the fingernails.
- Dip the fingertips in 3 1/2 per cent iodine and allow it to dry.
- Rinse both hands and arms completely under running hot water, holding the fingertips up and allowing the water to drain off the elbow.
- Wet the brush with green soap solution and beginning on the outside of the thumb, with a circular motion, scrub each finger as though it had four sides.
- Rinse completely.
- Start at the fingertips and scrub the palm of the hand with a circular motion to the wrist. Scrub the back of the hand in the same fashion. Rinse again.
- Start at the wrist, scrub the arm with a circular motion, advancing toward and including the elbow. Rinse.
- Scrub the other hand and arm in the same manner.
- Clean underneath the nails with an orangewood stick.
- Repeat the procedure from step "c," this time omitting the elbow.
- Scrub the fingertips of each hand for one minute.
- Rinse completely under running water.
- Rinse completely with alcohol
The entire scrub should take ten minutes.
- Dry the hands and arms on a sterile towel.
- Put on sterile gown and gloves.
A three-minute scrub is all that is necessary between cases providing technic has not been broken, or the previous case was not septic.
Preparation of Aseptic Fields: The various pieces of furniture, such as gown table, supply table, Mayo stand, saline table, and basin racks, are draped with sterile sheets and pads to create and maintain an aseptic field. The method of draping will vary, depending somewhat upon the type of drapes and furniture used.
V. Arrangement of Instruments, Basins, and Other Material
After the instruments have been sterilized they are removed from the sterilizer, dried with a piece of sterile gauze and arranged on the trays and tables. All special instruments are placed on the general supply table. Those forming the basic dissecting tray are always arranged in the same manner, so that everyone is familiar with their placement. They should be placed in the order of use, usually beginning with the right side of the tray and working toward the left. Like instruments should be kept together. The handles should point toward the operator. If extra instruments are needed during the operation they may be secured from the reserve table, but do not clutter up the tray with more than is needed. Other materials are arranged on tables and trays where they will be ready and convenient for use.
VI. Preparation of the Patient
- Dorsal position
- Dorsal lithotomy position
- Trendelenburg position
- Jackknife position
- Modified Sims position
General preparation of the patient, his removal to and acceptance in the anesthetizing room has been discussed in Chapter VI.
Placement of the Patient on the Operating Table: The patient may be placed on the table either before or after administering anesthesia. The arrangement of the table varies with different operations. Every nurse in the operating room should know the various positions used and how to manage the table to secure these positions with ease and rapidity. Several important points -should be kept in mind. The patient should be as comfortable as possible. The part to be operated upon must be exposed and easily accessible, but unnecessary exposure should be avoided. There should be no pressure upon nerves or interference with the circulation or respiration. Patients have been known to develop paralysis due to continuous pressure on a nerve while under anesthesia. Many of the backaches during the postoperative period are due to rough handling and uncomfortable positions while on the operating table. More patients complain of pain in the back of the neck after a thyroidectomy than of pain in the incision. Many postoperative discomforts cannot be avoided, but thoughtful consideration will help eliminate unnecessary ones.
A few of the most commonly used positions are as follows:
Dorsal Position: The patient lies on his back in a horizontal recumbent position with the arms extended at the sides and held in place by a drawsheet. A restraining strap is placed over the knees. This position is used for all laparotomies. It may be varied, e.g., an armboard is added when a radical mastectomy is performed, and a small, hard pillow placed under the neck elevates the area for thyroidectomy.
Dorsal Lithotomy Position: This position is used for rectal and vaginal operations. The arms are folded across the chest while the legs are flexed on the abdomen and held in place by stirrups. The buttocks should be even with or slightly overhanging the edge of the table. Shoulder braces help maintain the position. In all perineal cases a Kelly pad is placed on the table before the patient is transferred from the stretcher.
Trendelenburg Position: Practically all pelvic operations require this position, which by gravity keeps the intestines out of the pelvis. The patient is placed first in the dorsal position with the bend of the knees directly over the break of the table. The arms are held in place at the sides. Shoulder braces are used. The table is then tilted, so the pelvis is higher than the head.
Jackknife or Modified Knee Chest Position: Rectal cases are often performed with the patient in a modified knee chest position. The patient lies on his abdomen, with the hip Joint over the break of the table. Shoulder braces and other methods of support should be used, as this position is uncomfortable and difficult to maintain.
While the patient is being placed on the operating table and anesthetized, the surgeon and his assistants are scrubbing and preparing for the operation. After they have been assisted into sterile gown and gloves, the patient receives the final part of the preparation.
VII. The Operation
- Chemical skin disinfection and draping
- The instrument nurse
- The suture nurse
- "Utility" or "circulating" nurse
- "Ether" nurse
Chemical Skin Disinfection and Draping: Some of the most commonly used skin disinfectants are tincture of iodine, mercuro- chrome, and picric acid, although each surgeon has his preference. The disinfectant chosen should be able to penetrate the surface of the skin, kill organisms living on the skin, and dry rapidly. If iodine is used, great care should be taken to prevent burning. Most surgeons paint first with iodine and then with alcohol.
After the area has been disinfected, sterile towels are placed around it. Then the larger drapes are applied, forming a complete sterile field.
The surgeon and assistant step into position, the instrument trays, saline stands, and other necessary equipment are moved into place and the operation begins.
- Place the handle of the instrument in the surgeon's hand in such a manner that the instrument is- in position for use. Movements should be quick, quiet and sure. Unnecessary movements should be avoided.
- Anticipate the surgeon's needs.
- Do not give more than one clamp at a time.
- After an instrument has been used, clean it and place on the tray in its former position. Replace instruments on the tray from the reserve table as necessary.
- Always keep the tray neat and the towel under the instruments dry and clean.
- As soon as the peritoneum is opened remove all loose sponges-from the tray.
- Either the instrument nurse or the suture nurse keeps the surgeon supplied with warm laparotomy pads and sponges. Whoever has charge of this should verify the pad and sponge count before the peritoneum is closed and at the end of the operation.
Preparing Catgut: Catgut comes in a solution which will irritate the eyes and cause gloves to deteriorate, so when breaking the tube, both the eyes and gloves should be protected. This can be done by first shaking the catgut down to one end of the tube, then turning the tube over so the solution runs to the other end. Place a piece of gauze over the tube and break away from you. Discard the gauze and tube. Rinse the catgut in warm saline. Catgut comes in 36-inch strands. These pieces are cut into half lengths (18 inches) for suturing a wound when continuous stitches are taken. If interrupted stitches are used, one quarter lengths are sufficient. After the catgut has been cut it is rinsed again, and threaded in the needle or placed on the suture table.
Threading the Needles: In threading a curved needle, thread away from the point; that is, from the concavity to the convexity. Pull the suture far enough through the eye that it doesn't pull out, then place the needle on the needle holder.
Handing the Suture to the Surgeon: Before handing the suture to the surgeon dip it again in saline (this makes the third rinse). Hand the needle holder to the surgeon so that he grasps it by the handle and,it is in position to use. Do not let the end of the suture drag over the table but hand it to the assistant surgeon at the same time you hand the operator the threaded needle. Always have a duplicate suture prepared for use.
Duties of the "Utility" or "Circulating" Nurse: The "utility" nurse should be within easy access to the instrument and suture nurses throughout the entire operation. She should not leave the room for any reason while the operation is in progress. Some of the duties for which she is responsible are as follows:
- Wait upon the "scrub nurse," furnishing her with additional supplies, hot saline, etc.
- See that all necessary supplies are on hand and prepare as far as possible for the next case.
- Keep the operating room in order the floor mopped, sponges picked up, etc.
- Collect, label, and dispose of specimens.
- Keep the sterilizer filled with boiling water.
- Adjust the suction apparatus, cauery, etc.
- Prepare the scrub sinks, brushes, and dishes for the next case.
- Prepare stretcher, warm blankets, and gown for the removal of the patient from the operating room to the ward.
- Prepare adhesive straps needed to keep the dressings in place.
- Remove all emptied drums, wrappers, glove cases, etc., from the room.
- Send for and prepare the next patient scheduled for operation.
VIII. After the OperationTopic Preview
Care of the Patient: After the dressings have been applied, the patient is removed from the operating table to the stretcher. Great care should be taken to prevent injury to the patient. He should be placed on the stretcher in such a manner as to permit relaxation of the body and prevent strain on the operative area. The head is usually turned on one side so that mucus and vomitus may drain easily from the mouth. An emesis basin and gauze wipes are placed at the head of the stretcher. To prevent chilling, a dry warm gown is placed on the patient and he is covered with warm blankets. The patient should be accompanied to the ward by the anesthetist or doctor (SEE: Chapter VIII).
Preparation for the Next Operation: If another operation is to be performed directly following this one, instruments are washed and resterilized, the surgeon and scrub nurses rescrub for three to five minutes, gowns and gloves are changed and new sterile fields are prepared.
Clean-up at the End of the Operating Schedule: The furniture is undraped and rearranged. All unused sterile supplies are replaced. Empty drums, wrappers, used oxygen tanks, etc., are removed from the room. Refuse is looked over carefully and all instruments, gloves, etc., which may have fallen in the sponge pails are removed. Some institutions save soiled gauze sponges and dressings to be used later as "washed gauze." Gloves are washed and cared for. Instruments are soaked in cold water to remove the blood, then washed in hot, soapy water, scoured, rinsed, dried, and replaced in the instrument cabinets. Those instruments having joints and screws are oiled. The entire room is tidied, cleaned, and placed in order.