1. By: Dr. Yasser El Basatiny Prof. of Laparoscopic Surgery
Sterilization
By:
Dr. Yasser El Basatiny
Prof. of Laparoscopic Surgery

2. Antisepsis Definitions: Antisepsis = against putrefaction
To eliminate or reduce the germs
Antisepsis: use of antimicrobial chemicals on human tissue
Disinfection: use of antimicrobial chemicals on inanimate objects

3. Historical background
In 18th and 19th century , serious infections among hospitalized patients, morbidity and mortality was very high nearly all trauma and surgical wound got infected and suppuration
Hand wash and clothing change policy reduced maternal mortality from 11.4% in 1846 to 1.3% in 1848
Pasteur’s discovered bacterium and it’s role in wound infection.
Lister published 1st antiseptic principle in 1867
Kocher reported 2.3% infection rate in clean wound by 1899.

4. Aseptic technique Hygienic hand wash
Preoperative preparation of patient’s skin
Gloving
Sterile draping
Isolation precaution
Autoclaving of instruments
Proper waste disposal

6. Principles of sterilization
Operating room:
Minimum size is 5x5 meter
Appropriate ventilation, changing room air 20 to 25 times per hour.
Passing inflow air through “high efficiency particulate air” HEPA filter
All doors of OR. should be closed
Air pressure should be positive
The primary source of perioperative infection is the patient and the secondary source are the OR team

7. A CFD simulation of a Cleansuite installation in an operating room shows laminar air flowing from diffusers in the ceiling, down and away from the patient, and out vents near the floor

8. Patient as a source of infection
Wounds:
Clean wounds
Clean contaminated
Contaminated
Dirty
Intrinsic resistance to contamination
Age, obesity, diabetes, cirrhosis, uremia and immunodeficiency.

9. Methods of sterilization
Iodophors (Betadine) broad spectrum antimicrobial against fungi, viruses, gram positive and gram negative.

10. Operative team
Scrub the hands and arms with antiseptic solution like iodophors and chlorhexidine
Face mask over the mouth and nose, head cover and shoe covers
Disposable sterile gloves
Sterile gown: impermeability to moisture.
Sterile drapes impermeable to bacteria

11. Methods of sterilization
Steam heat (Autoclave)
Chemical solution: used for instruments tolerate moisture but not heat. 2% glutaraldehyde
Dry heat: for items can tolerate heat and not penetrated well by steam
Gas sterilization: for delicate instruments

12. Autoclave sterilizer

13. Surgical technique
Gentle handling of tissues, careful hemostasis and appropriate irrigation.
Incisions: along normal skin line, adequate exposure, same incision in reoperation
Atraumatic handling: minimize necrosis of skin margin
Dissection: least amount of trauma in dissecting in natural tissue planes
Debridement: the most important single factor in management of contaminated wounds

14. Surgical technique
Hemostasis: to minimize blood loss and prevent hematoma formation
Wound closure: primary closure for clean wounds, delayed primary closure should be considered on or after 4th day in contaminated wound
Suturing: simple interrupted sutures, mattress suture, subcuticular suture

15. Surgical technique
Dressing: protect the wound from mechanical trauma and bacterial invasion, sterile dressing applied before removal of drapes, moist dressing speed up epithelization 10 folds, infected wounds needs dressing that absorb exudates.
Immobilization: it reduce lymphatic flow and minimizing the spread of wound flora, more resistance to bacterial growth, elevation reduces interstitial edema.
Suture removal: proper timing for suture removal
Prophylactic antibiotics: before skin incision

16. Operative equipments Electrocautery:
High frequency alternating current
For hemostasis and incise tissue
Unipolar, rapid dehydration of the cell and the blood vessels within the tissue coagulate
Bipolar, more precise and confines the damage to the tissue between the tips of forceps

17. Operative equipments Argon beam coagulator (ABC):
For parenchymatous organs, unipolar coagulation non touch technique. Less depth of penetration 2-3 mm
Surgical lasers:
Argon Laser, ophtalmogic tratment and vascular anastomosis.
CO2 Laser, to cut tissue
Nd:YAG Laser, flexible quartz fiber can be used for paranasal sinus and tracheobronchial tree
Er:YAG Laser, very strongly absorbed by the water of tissue can vaporize cartilage, fibrous tissue and bone
Harmonic scalpel
Use of ultrasonic power for cutting and coagulation

18. Sutures and needles Needles Open French eye needle
Swaged on needle (eye less)
Straight or curved
Cross section: can be round triangular or flattened
Needle point: cutting, tapered or blunt

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

22. Sutures and needles Non absorbable sutures
Silk: protein filament from the silkworm larva, dyed, treated by polybutilate and braided. Good tensile strength
polyester (Dacron): superior strength and durability
Nylon: synthetic polyamide polymer, monofilament and multifilament.
Polyprolene (Prolene): monofilament, minimal tissue reaction
Stainless Steel: low carbon iron alloy, monofilament or multifilament. Used for bone suturing

23. Sutures and needles 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.

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

25. Principles of wound drainage
To drain cavity or soft tissue to prevent collection of serum or blood
It is not a substitute for hemostasis or meticulous technique
Either passive or active, prophylactic or therapeutic.
It should be soft, nonirritating, firm, smooth and resistant to decomposition.

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

28. Types of drains 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

29. Types of drains 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

30. Types of drains Closed suction Penrose drain Percutaneous catheters
Combination of closed suction drain and Penrose drain which uses capillary action
Low secondary infection, effective in abdominal cavity
Ideal drainage system
Percutaneous catheters
Inserted by radiologists CT or US guided to drain accessible localized collection

31. Minimal invasive surgery
Laparoscopic surgery
Thoracoscopic surgery
NOTS “natural orifice transluminal surgery
Single port laparoscopic surgery

32. Minimal invasive surgery
To reduce tissue injury, fast post operative recovery, short hospital stay
Pneumo-peritonium to create room to work

33. Thank you