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.

  If diathermy is ineffective, before increasing the current, look for:

  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. The commonest causes of diathermy injury are:

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.