1. M K Alam FRCS Ed ALMAAREFA COLLEGE
Operation theatre
M K Alam FRCS Ed
ALMAAREFA COLLEGE

2. ILOs
Describe the principles of sterilization, disinfection, antisepsis and different methods of sterilization, haemostasis
Explain principles of commonly used equipments in operating room such as electro-surgery, drains, sutures and surgical instruments used in open & minimally access surgery.

3. OR/ OT
Unfamiliar environment
Specific regimented procedures
New terms
Unfamiliar techniques
Unfamiliar instruments

4. Operation room Designed around accepted principles One way traffic
Speedy access to ITU/ICU, ER, X-ray
Spaces for preoperative / postop. patients
TSSU (theatre sterile supply unit) / CSSD (central sterile supply department)

5. Patient flow Central reception Transferred to theatre trolley
Anaesthetic room
Operating table
Recovery area
From recovery to inpatient.

6. OR layout
Transfer zone- reception, staff changing area
Clean zone- theatre storage area
Sterile zone- main theatre area
Disposal zone- least clean area

7. Infection control
High standard of cleanliness
Sterilization: Process of complete destruction of all micro-organisms including bacterial spores.
Disinfection: Reduces the number of viable organisms. Does not inactivates viruses and bacterial spores.
Antisepsis: Destroys organisms between wound and external environment.
Asepsis: Process to have as few organisms in the immediate vicinity of the operating field

8. Sterilization
Two types: Heat & cold
HEAT:
Steam under pressure: Increasing the atmospheric pressure raises water boiling point Autoclaves: Instruments and drapes(pre-packed) °C & 30 lb./in² for 3 min. or 121°C & 15 lb./in² for 15 min.
Dry heat: 160°C for 2 hrs Suitable for airtight containers & instruments for risk of corrosion.

9. Autoclave sterilizer

10. Cold Sterilization
Irradiation by gamma rays- disposable items syringes, catheters, gauze, sutures.
Ethylene oxide: Highly penetrative gas used for delicate items- endoscopes, electrical equipments, single use plastic items.
Glutaraldehyde (CIDEX): Liquid chemical to clean lensed instruments

11. Patients skin preparation
Shower
Shaving vs clipping
Wide area of skin cleaned with povidone-iodine and alcohol
Surgical field isolated with sterile drapes

12. Surgical team Scrubbing: Hand & fore-arm cleaning process
All jewelry removed
Fingers, hand & fore-arm cleaned with chlorhexidine (Hibiscrub) 3-5 min.
Drying of hands and forearm with sterile towel
Gowns & gloves
High- risk patients (HIV, hepatitis B & C)

13. Patient positions
Supine
Trendelenburg: Supine with 30° head down
Reverse Trendelenburg: Head up
Lithotomy: Supine with knee & hip fully flexed & foot in stirrups
Lloyd-Davies: as Trendelenburg with legs abducted, hips & knee slightly flexed and legs in rests
Lateral: With upper arm raised above & in front of the head.

14. Trendelenburg Reverse Trendelenburg

15. Lithotomy position

16. Lloyd-Davies position

17. Temperature control
Unconscious patient- lose ability to control body temperature
Risk of hypothermia if ambient temp. < 21°C for 1-2 hours
Prevention:
1. Minimize time patient left uncovered
2.Limiting exposure time of large area (chest, abdomen)
3.Use of heating mattress, warm-air heated blankets
4.Humidification of inspired anaesthic gas
5.Warming devices for fluid & blood

18. Surgical technique
Gentle handling of tissues, careful hemostasis and appropriate irrigation.
Incisions: along normal skin line, adequate exposure
Atraumatic handling: minimize necrosis of skin margin.
Dissection: least trauma, dissect in natural tissue planes
Debridement: management of contaminated wounds

19. Surgical technique
Hemostasis: to minimize blood loss and prevent hematoma formation
Wound closure: Primary closure for clean wounds. Delayed primary closure- contaminated wound left open for dressing, closure after 3-4 days
Suturing: simple interrupted suture, mattress suture, subcuticular suture.

20. Common suture techniques for wound closure

21. Surgical technique
Dressing: Protects from mechanical trauma & bacterial invasion Sterile dressing applied before removal of drapes Infected wounds needs dressing that absorb exudates.
Immobilization: Reduce lymphatic flow and minimizing the spread of wound flora, elevation reduces interstitial edema.
Suture removal: Proper timing for suture removal
Prophylactic antibiotics: before skin incision

22. Surgical techniques: Haemostasis
Dry wound (minimal oozing): a pre-requisite of surgical wound closure.
Compression or packing at least for 5 min.
Ligation: Absorbable or non-absorbable sutures, clips
Thermal coagulation: High frequency electric current Bipolar or Unipolar instruments
Cutting diathermy
Ultrasound: coagulation/ cutting (Harmonic scalpel)

24. Bipolar diathermy

25. Unipolar diathermy

26. Ultrasonic coagulation & cutting (Harmonic scalpel)

27. Laser
Argon beam coagulator (ABC): For parenchymatous organs Unipolar coagulation, non touch technique Less depth of penetration 2-3 mm.
Surgical lasers:
Argon Laser: Ophthalmology, vascular anastomosis.
CO2 Laser: To cut tissue
Nd:YAG Laser: Used for paranasal sinus and tracheobronchial tree
Er:YAG Laser: Strongly absorbed by the water of tissue, Can vaporize cartilage, fibrous tissue and bone

28. Surgical needles
Open French eye needle
Swaged on needle- eyeless
Straight or curved
Cross section: Round, triangular or flattened
Needle point: Cutting, tapered or blunt

30. Absorbable sutures
Absorption & disappearance of the suture from the tissue implantation site
Catgut: made from the intestine of cattle or sheep. Absorption-plain catgut is about 10 days Chromic catgut- (treated by chromium salt) up to 20 days.
Polyglycolic acid (Dexon): synthetic suture, absorbable braided, higher tensile strength, reabsorption by hydrolysis at 60 to 90 days.
Polyglyconate ( Maxon): synthetic monofilament.
Polyglactic acid (Vicryl): braided synthetic suture, very high tensile strength, absorbed in 60 days
Polydioxanone (PDS): monofilament absorbable

32. Non absorbable sutures
Silk: Protein filament from the silkworm larva Dyed, treated by polybutylene & braided Good tensile strength
Polyester (Dacron): superior strength & durability
Nylon: synthetic polyamide polymer, monofilament and multifilament.
Polypropylene (Prolene): monofilament, minimal tissue reaction
Stainless Steel: low carbon iron alloy, monofilament or multifilament Used for bone suturing

33. Staplers
TA Instruments: linear everting double line, length 30, 55, 90 mm. staple size 3.5 and 4.8 mm. 3.2 mm for vessel closure.
GIA Instruments: two double rows of staples and divide the tissues in between.
EEA Instruments: end to end or end to side circular staplers
Skin staples: speed of skin closure and efficacy.

35. Drains Historical aspects Dates back to Hippocrates
Metal tubes, glass tubes, bone, gauze , combination of gauze & rubber
Tapered lead and bronze tubes to drain abdominal cavity by Celsius in 1st century
Penrose drain 1890, cigarette drain 1897
Air vent suction by Heaton 1889

36. Principles of wound drainage
Drain cavity / soft tissue to prevent collection of serum or blood
Not a substitute for meticulous hemostasis.
Either passive or active, prophylactic or therapeutic.
Drains- soft, nonirritating, firm, smooth & resistant to decomposition.

37. Penrose drain (obsolete)
Types of drains
Penrose drain (obsolete)
Efficient but significant risk of secondary infection.
Soft, flexible latex rubber wick.
Drain purulent material, blood or serum from body cavity
Brought out through a separate stab at dependent area.
Anchored to the skin with a non absorbable suture

39. Closed suction drain
Lower infection rate, might clog and cease function
Firm multi-holed catheters made of polyvinyl chloride or silicone.
Effective to drain soft tissue under large skin flaps

40. Sump drain Large and bulky
Double or triple lumen allow irrigation and aspiration
Rely on continuous flow of air from outside predisposes to secondary infection.
Less likely tissue occlusion
For high volume enteric fistula

41. Percutaneous drainage catheters
Inserted by radiologists.
CT or US guided to drain accessible localized collection

42. Minimal access surgery
Laparoscopic surgery- Diagnosis & therapy
CO₂ for pneumoperitoneum
Telescope & instruments- introduced through small trocars
Common procedures: cholecystectomy, GORD, bariatric, colon, splenectomy, adrenalectomy, pancreatic tumour, hernia repair
Thoracoscopic surgery
NOTS: “Natural Orifice Transluminal Surgery
Single port laparoscopic surgery

43. Minimal access surgery
Advantages:
Less tissue trauma, less response to trauma.
Reduced pain
Fast post operative recovery, shorter hospital stay
Reduced wound complications (infection, dehiscence)
Reduced risk of (disease transmission) contact with patient blood
Disadvantages:
Procedure generally slower
Special expertise necessary
Tactile feed back lost
Control of bleeding more difficult
Organ extraction some time difficult

44. Thank you!