Operating theatre
Regular maintenance will ensure correct air
ventilation with 20—40 changes per hour in a general surgical theatre.
Ultra-clean air will be used in orthopaedic theatres. The temperature should
range between 19 and 220C with a humidity of 45—5 5 per cent. The lights should be of appropriate design and
will therefore differ in orthopaedic and general surgical theatres.
Anaesthetic
gases and suction should be piped with different colour coding. Cables on the
floor should be kept to a minimum. Trolleys should be steel with no sharp
corners.
The
operating table should have a smooth action for raising and lowering the table,
the appropriate handle and gears to alter the tilt giving Trendelenberg or
reverse Trendelenberg positions, lateral roll and a bridging system for use in
procedures such as nephrectomy. The function of electrically operated tables
must be understood before starting the operation.
The
mattresses must be well maintained, cleaned and sealed. The table should be
checked to see that it is correctly orientated, particularly when an
intraoperative X-ray is anticipated.
Diathermy
In surgical diathermy a high frequency
alternating current is passed through body tissue and the concentration of
current producing an area of high current density liberates heat —temperatures
may rise to 10000C or above. Current frequencies in the range of 400
kHz—10 mHz are used, and in this range there is minimal muscular response.
Mono polar
diathermy
A high-frequency current is generated from the
diathermy machine and is delivered to the active electrode held by the surgeon.
There is high current density where the electrode touches body tissue, producing
local heating, and the current then spreads through the body and returns to the
diathermy machine or generator via the patient electrode.
Bipolar
diathermy
The surgeon holds a pair of forceps connected
to the diathermy generator, the current passes down one limb of the forceps,
through a small piece of tissue and then back through the other limb
of the forceps to the generator. There is no requirement for a plate and the
system uses considerably less power, but it cannot be used for cutting and
tissue must not be squeezed between the diathermy forceps. As the bipolar
current will only pass directly from one diathermy arm to the other it is very
safe.
Safety measures. Certain safety measures are
essential.
• The diathermy generator and accessories require a regular service
with a full record being kept.
• Plugs, leads and sockets need to be checked to ensure that all are
sound.
• The foot pedals should be checked to ensure that they are completely
sealed and sensitive to light pressure.
• The alarm systems should all be in order.
• The appropriate mode of diathermy, whether it be monopolar or
bipolar, should be selected prior to use and the correct setting to be used is
checked. When monopolar diathermy is used care must be taken to ensure that the
coagulation and cutting levels are correctly set (cutting and fulguration
involve higher power current than coagulation; these are not applicable to
bipolar).
• Make sure that the indifferent
electrode in the mono polar system uses a flat surface which is dry and there is
no thick hair present, as this may interfere with conduction.
• Ensure that the patient is
protected from metal, and that the skin is checked after removal of the plate.
• Ensure that the live electrode
is always placed in the quiver and never on the drapes or on the tray.
Insulation of the instruments should be checked regularly.
• faulty connection;
• faulty active electrode;
• poor contact of plate;
• a disconnected or faulty cable.
Precautions. The following precautions should
be taken:
• staff should understand the clear rules of operation of diathermy;
• the alarm system, generator and equipment should be checked
regularly;
• the power should not be turned up if the diathermy appears to be
ineffective without first carrying out a number of checks;
• diathermy should never be
used in the presence of ether and should be kept at least 50 cm from the
anaesthetic machine;
• alcoholic disinfectants must be dried before diathermy is used.
• incorrect application of the patient plate;
• the patient touching earth, metal objects such as parts of the table;
• careless technique, e.g. the electrode not being put back into the
cover.
Positioning the
patient
When the patient is transferred from the
anaesthetic room to the operating theatre, the trolley should be positioned
close to the operating table and the height of the latter should be adjusted.
The optimal way of transfer is using the ‘patient slide’ as this avoids
lifting at awkward angles which may cause back problems to the staff. It also
avoids the use of a canvas which may be worn or defective or where the lifting
poles have been inserted incorrectly. The patient should be positioned correctly
in respect of the cushions, particularly if either the lithotomy or Lloyd-Davies
position is used. The patient’s legs should be supported so that undue
pressure on the calf does not occur. Both surgeon and anaesthetist should be
fully aware of the optimal position required during movement; the airway and
intravenous drip lines should be protected and particular care taken to ensure
that the patient’s head is on the canvas, so that in the paralysed patient the
head does not become unsupported with hyperextension of the neck. Lithotomy
poles and Lloyd-Davies stirrups must be securely anchored to the table.
Protection of
nerves
This is particularly important in thin
patients.
•
In the Lloyd-Davies stirrups, care must be taken to protect the lateral
peroneal nerve. It is important to ensure that the stirrups are well padded so
that there is no direct contact with metal.
•
If the arms are by the patient’s side or placed on an arm board, care
must be taken to protect the ulnar nerve at the elbow.
•
If the arm is placed above the head, as it may be in some breast biopsy
procedures, then care should be taken to ensure that the shoulder is supported
posteriorly, as failure to do this will result in a brachial plexus traction
injury.
•
In patients with rheumatoid arthritis the team should always be aware of
the possibility of a fracture dislocation of the odontoid peg with subluxation.
Endotracheal intubation in such patients is a risky procedure and patients
should wear a protective cervical collar.
•
Patients who have lumbar disc problems should be positioned
particularly carefully if lithotomy is to be considered.
•
In patients in whom hyperextension of the cervical spine is required,
such as thyroidectomy, the surgeon should ensure that the weight of the head is
not being taken on the unsupported hyperextended cervical spine.
Deep venous thrombosis prophylaxis must be considered. The calves should be protected against pressure by whatever means is chosen: graduated support stockings or intermittent flow compression. Subcutaneous low-dose heparin is widely used additionally (see Chapter 15 on ‘Arterial disorders’).
The patient
On entry to theatre the patient should be
clean, the gown should be appropriately applied and, before anaesthesia is
started, the ties at the back should have been loosened (the patient’s modesty
should be protected), fingernails should be clean and free from coloured
varnish.
In
theatre the appropriate area of skin should be disinfected with care taken to
avoid splash (particularly adjacent to the diathermy plate) or pooling of
alcoholic disinfectant, which must not be allowed to run under a tourniquet. The
appropriate drapes should be used with attention to the possibility of allergy.
Tourniquets must be applied correctly with the appropriate time of starting noted.
Theatre staff
Although the number of persons in the theatre
should be kept to a minimum from the point of view of infection, it is obviously
important to have a clear policy whereby nurses of adequate seniority act as
the scrub nurses. The circulating nurses must be aware of the importance of
meticulous counting of swabs, needles and instruments, and also the handling of
samples and specimens. Appropriate training with the possibility of advancement
and promotion is considered important in the maintenance of morale and
standards.
•
Of particular importance are the counts at the beginning and the end of
the procedure. It is essential to have an instrument, swab and needle count
prior to closure after laparotomy, and a final count prior to removal of any
equipment from the theatre. In this respect, swabs, packs, disposable equipment,
instruments, needles and such items as tapes are to be recorded. The creation of
swabs in bundles of five with a radio marker and red string bundles is
helpful. Dirty swabs should be placed singly in the swab holders. It is
important to stress that all swabs should be removed from the previous surgery
before any current count is taken.
•
It is important to have a count before body cavities, incised organs or
joint spaces are closed.
•
Rubber tubes and tapes should never be cut.
• Nothing should be removed from the operating theatre until the incision is
closed and the scrub nurse indicates that all is correct.
•
Particular care should be taken when there is a change over of staff,
which may occur during prolonged surgery, such as a oesophagectomy,
pancreatectomy, spinal or neurosurgical procedures. At such a time:
— the surgeons should
stop;
— the first scrub
nurse only descrubs when the second scrub nurse and the surgeon have indicated.
The time and the names of those who change should be noted in the theatre
record.
•
Nonradio-opaque swabs should not be used during surgery and radiopaque
swabs should not be cut.
•
Needles should be checked, both for number and the fact that they are
complete.
•
With regard to power tools, the nurse should check that all detachable
parts are neither faulty nor loose.
The surgeon
The surgeon should be thoroughly familiar with
the procedure and should have received appropriate training. If he or she is a
doctor in training then appropriate senior cover must be present.
•
He or she should be in good health with no upper respiratory chest
infection and no septic lesions, and should not have a positive carrier state
for Staphylococcus aureus.
•
The scrub up procedure should be carried out thoroughly, with brushes
restricted to cleaning nails. Gowning, masking and gloving should proceed with
aseptic precautions, and the amount of talking and movement should be cut to the
minimum.
•
Assistants should not lean on patients, as this may cause damage,
bruising or neuropraxia.
Specimens
Great care should be taken with the handling
of specimens.
•
The specimens must be identified and, if multiple, should be placed into
separate labelled specimen pots which should be appropriate for the study
required, namely histology, cytology, microbiology or biochemistry.
•
For histology and cytology the appropriate method of fixation should be
selected and checked (all too often samples for microbiology are placed in
formalin and vice versa).
•
All specimens and all request forms should be labelled fully and clearly,
and clinical details must be given.
•
The circulating nurse should check with either the scrub nurse or the
surgeon that the correct fixative or microbiological storage agent has been
selected.
The
samples should be checked for a good seal prior to transport.
•
Specimens at high risk of infectivity should be identified and treated
securely according to the policy.
•
Formalin splashing when placing a large specimen in a container must be
avoided.
•
The record book must be signed with the full description of the specimen
and the time that it left theatre.
Disposables
Those disposables such as drains should be
secured to the patient and checked for patency. Those disposables to be
discarded such as soiled linen, drapes and other waste should be disposed of
appropriately, and material of high infectivity needs to be sealed and marked
accordingly.
The record book
This should be kept in each theatre; if a
surgical procedure is different from the one that was planned it is the responsibility of the surgeon to inform both the
patient subsequently and the relatives.
Radiation and
image intensification
All surgeons using X-ray equipment should be
in possession of a certificate, to the effect that they have attended a course
on Protection Against Ionizing Radiation. Staff should reduce exposure to the
minimum and good-quality aprons must be available.
•
Random dose recording should be a part of quality control.
•
Pregnant staff must not be in the vicinity of radiation.
•
Sterility must not be compromised.
Lasers
Lasers should be used in a designated
operating theatre by fully trained medical staff. In addition to this,
further precautions are appropriate:
•
warning signs must be present on the operation doors;
•
no reflective or inflammable fixtures or furnishings must be present in
that operating theatre;
•
care with the direction of the laser beam is critical in safe usage;
•
protective eye wear must be worn at all times;
•
the surgeon should warn the staff before firing the laser.