Ensure the temperature and flow of the water is to your liking (Fig. 9.1). Open the nailbrush package and place the nailbrush (still contained in the packaging) at the back of the scrub sink
Fig. 9.1
Wet your hands and arms with the prescrub wash. Create a heavy lather and wash from your hands all the way to your elbows (Fig. 9.2)
Fig. 9.2
Hands and arms should be rinsed thoroughly allowing water to run from the hands to the elbows. Do not retrace or shake your arms, rather let the water drip from the elbows (Fig. 9.3)
Fig. 9.3
Open the sterile brush and pick’s package and remove them. Use the pick to clean underneath fingernails and then discard it.
(Fig. 9.4)
Fig. 9.4
Use the sponge side of the brush to lather the fingertips. Then use the bristle side of the brush to scrub the spaces under the fingernails on both hands (Fig. 9.5). When scrubbing it is essential that the hands remain above the level of the elbows and distant to the theatre wear to avoid splashing and contamination
Fig. 9.5
Using the sponge side of the brush, lather and wash the all sides of the finger (Fig. 9.6)
Fig. 9.6
Ensure the hands are scrubbed in the following order:
(1)Palm to palm
(2)Right palm over left dorsum and left palm over right dorsum
(3)Palms together with the fingers interlaced
(4)Palms to the dorsum of the opposing fingers interlocked
(5)Rotational washing of right thumb in left palm and vice versa
(6)Clasp fingers of right hand in left palm and rub. Repeat on opposite side
Wash the arms up until the two thirds of the forearm to avoid compromising the cleanliness of the hands
Rinse the hands and arms thoroughly from the fingertip to the elbow without retracing (Fig. 9.7). Ensure water drips from the elbow before moving on to the gown pack
Fig. 9.7
The gown pack should be opened for you. Pick up a single hand towel from the gown pack and step away from the table (Fig. 9.8) Open the towel fully ensuring the towel does not contact anything unsterile – including unsterile parts of your body. Keep your hands and arms above elbow level whilst simultaneously keeping your arms away from your body (Fig. 9. 9)
Fig. 9.8
Fig. 9.9
Grasp the towel in one hand and use it to dry the fingers of the opposite hand using a blotting motion (Fig. 9.10)
Continue this down the arm from forearm to elbow using the dry areas of the towel. Do not retrace any areas. Once completed discard the towel (Fig. 9. 11)
Repeat the previous steps with the second towel using the other hand (Fig. 9.12)
Fig. 9.10
Fig. 9.11
Fig. 9.12
Figs. 9.13–9.17
Guide to gowning
Using one hand pick up the entire pre-folded gown from the packaging by grasping the gown through all of its layers. Ensure that only the inside top layer – which is exposed- is touched. Move away from the trolley or shelf (Fig. 9.13) |  Fig. 9.13 |
Hold the gown as shown in the corresponding image – near the gowns neck and allow it enable it to unfold whilst ensuring it does not touch any unsterile object or the body (Fig. 9.14) |  Fig. 9.14 |
Slip arms partially into the sleeves of the gown whilst keeping hands at the level of the shoulders and away from the body (Fig. 9.15) |  Fig. 9.15 |
Slide arms in the gown sleeves up until the fingertips touch to proximal boundary of the cuff. Using the thumb and index finger grasp the interior of the seam at the cuff hem ensuring that no part of the hand protrudes out of the cuff (Fig. 9. 16) |  Fig. 9.16 |
A circulating individual should now assist to help position the gown over the gowning individual’s shoulders by grasping the interior surface of the gown at the seams of the shoulder. The circulating person can now adjust the gown comfortably over the persons shoulder The circulating individual’s hands should only be in contact with the interior surface of the gown (Fig. 9.17) The circulating individual now prepares to secure the gown. The neck and back are secured using Velcro tabs or ties. They tie the gown at waist level at the back This method prevents contaminated surfaces at the posterior of the gown contacting anterior portions of the gown |  Fig. 9.17 |
Figs. 9.18–9.25
Guide to gloving
Using the index finger and thumb contained still contained in the proximal cuff edge, open the inner package of the gloves and pick up one glove (Fig. 9.18) |  Fig. 9.18 |
Put the glove palm down on the opposite gown’s sleeve. The glove fingers should be pointing in the direction of the shoulder. The palm inside the sleeve should be facing upwards (Fig. 9.19) |  Fig. 9.19 |
The gloves rolled cuff edge should overlay the seam between the gown sleeve and cuff. Pinch the bottom of the rolled cuff edge of the glove using the thumb and index finger (Fig. 9.20) |  Fig. 9.20 |
While still pinching the gloves cuff edge with the ipsilateral hand, grasp the uppermost edge of the glove cuff with the opposite hand. Do not let the fingers protrude from either gown cuff (Fig. 9.21) |  Fig. 9.21 |
Whilst still grasping the glove, stretch and unroll the glove cuff over the hand contained in the gown (Fig. 9.22) |  Fig. 9.22 |
The opposite sleeve covered hand should grasp both the glove cuff and sleeve cuff seam and pull the glove over the hand (Fig. 9.23) |  Fig. 9.23 |
Use the hand that is now gloved to repeat the process on the other hand (Fig. 9.24) |  Fig. 9.24 |
When gloving is completed correctly, no part of the skin should have touched the exterior surface of the glove. Check that the cuff of the gown is covered completely by the glove. Adjust fingers of the glove as necessary to ensure a snug fit (Fig. 9.25) |  Fig. 9.25 |
Figs. 9.26–9.30
Guide to the final gown tie
The scrubbed person will hold the belt tab proximal to any boundary line – here indicated in blue – in the right hand. The left hand will hold onto the left tie. Pull the tab with the right hand and give it to the circulating assisting person (Fig. 9.26) |  Fig. 9.26 |
The circulating person will take hold of the tab distal to any indicating line (Fig. 9.27) |  Fig. 9.27 |
The circulating person will walk clockwise around the scrubbing person (Fig. 9.28) |  Fig. 9.28 |
The scrubbing person will turn if necessary to receive the tie that is being carried by the circulating person When the scrubbing person is properly positioned to receive the circulating tie, they can take hold of it without touching the tab. The scrubbing person now pulls the tie free from the tab leaving the tab in the hands of the circulating person (Fig. 9.29) |  Fig. 9.29 |
The scrubbing person can now secure the ties on the left side (Fig. 9.30) |  Fig. 9.30 |
Figs. 9.31–9.39
Guide to disposing of the gown and gloves
The circulating person unties the neck (Fig. 9.31) and back ties (Fig. 9.32) |  Fig. 9.31  Fig. 9.32 |
The scrubbing person now grasps the gown at the shoulders (Fig. 9.33) and pulls the gown forward and down over the arms and gloved hands (Fig. 9.34) |  Fig. 9.33  Fig. 9.34 |
Keeping the arms away from the body, the scrubbing person now folds the gown ensuring the outside is folded inwards. The gown is then discarded in the appropriate bag/container (Fig. 9.35) |  Fig. 9.35 |
Using a gloved hand, grasp the outer surface of one hand (Fig. 9.36) and peel off (Fig. 9.37). This is a ‘rubber to rubber’ peel. The glove is then discarded in the appropriate container |  Fig. 9.36  Fig. 9.37 |
The second glove is removed by placing the fingers of the ungloved hand inside the cuff of the gloved hand (Fig. 9.38). This is a ‘skin to skin’ peel. The glove is then pulled up off the hand and then discarded into the appropriate container (Fig. 9.39) |  Fig. 9.38  Fig. 9.39 |
Gowning and Gloving
The sterile surgical gown and gloves are donned in a rather complex manoeuvre to avoid contaminating their outer surfaces. Both procedures require the aid of a circulating person, to open the unsterile packages and tie the gown at the back. The only parts of the surgical gown that are considered sterile are the sleeves (except the axillae), and the front between the neck and waist [5].
We have included step-by-step guides on gowning and gloving, but don’t worry if you can’t remember it all precisely! If you need to scrub up, theatre staff in the scrub room will be happy to help you (Figs. 9.13–9.39).
Incisions and Closures
Surgical Incisions
The surgical incision is a cut made through the skin (typically using a scalpel) by the surgeon in order to access internal viscera. The placement and length of incisions depend on the surgical procedure taking place, and in some cases multiple incisions may be necessary. Any surgical incision is traumatic and will impinge on the post-surgical stress response, the risk of surgical site infection (SSI), and the final cosmetic outcome. As such, it is important to minimise the size of an incision by placing it appropriately while at the same time allowing sufficient access to carry out the operation. Incisions may sometimes have to be extended, for example in order to remove a larger than expected mass or organ. The rationale behind reducing incision size has played a part in the development of minimally invasive surgical techniques, such as laparoscopy.
There are a number of common incisions, particularly in the thorax and the abdomen, which it will be useful to know as a medical student. While some incisions, such as the midline, are utilised in many surgical procedures, others are commonly associated with one operation in particular. It is therefore possible to deduce a little of a patient’s medical history just by observing their surgical scars.
Horizontal Versus Vertical Incisions
Horizontal (transverse) incisions follow Langer’s lines (the general direction that collagen fibres are organised in the dermis) and typically yield better cosmetic results with less pain. Vertical incisions are faster, may afford better exposure of internal structures, and are more easily extensible, but are more likely to become infected or dehisce (fall apart) [8].
Common Thoracoabdominal Incisions (Fig. 9.40)
Fig. 9.40
Common thoracoabdominal incisions
Midline laparotomy – A vertical incision is made along the linea alba except where it curves to avoid the umbilicus. It can be longer either above (upper) or below (lower) the umbilicus, or extend from the xyphoid process to the pubic symphysis. This latter variation is typically employed in trauma cases as it offers clear access to the majority of the abdominal cavity.
Paramedian – Any vertical incision placed laterally to the midline. It provides access to lateral abdominal structures, e.g. kidneys, and can be used in simple nephrectomy.
Transverse – Any horizontal abdominal incision. They afford better exposure to the abdominal cavity than vertical incisions in children and obese patients due to their increased transverse abdominal length.
Kocher – A right-sided subcostal incision used to access the gallbladder and biliary tree in open cholecystectomy.
Median sternotomy – A midline thoracic incision made along the sternum, with a division of the sternum itself. It is often used in open cardiac surgeries, such as coronary artery bypass.
Rooftop – Bilateral subcostal incisions, with improved access to upper abdominal structures (e.g. oesophagus, stomach, adrenal glands) compared to the Kocher. Also known as a chevron or gable incision.
Mercedes (−Benz) – A median sternotomy (without the division of sternum) combined with a rooftop incision. It is named after its resemblance to the Mercedes-Benz logo and affords better access to the upper abdominal organs and is used in hepatectomy.
Thoracotomy – An incision made between two ribs to access the thoracic cavity in cardiothoracic surgical procedures. It is typically placed in the sixth intercostal space.
Pfannenstiel – A convex 10–15 cm long incision located 2 cm above the pubic symphysis. It is typically used in abdominal hysterectomy for smaller uteruses (≤20 weeks gestation size). Also known as a bikini-line incision.
McBurney – An oblique incision centred at McBurney’s point (two-thirds along a line from the umbilicus to the right anterior superior iliac spine). It is used in appendectomy. Also known as a grid-iron incision.
Lanz – A transverse incision centred at McBurney’s point. It is also used in appendectomy, and is deemed to give a better cosmetic result than the McBurney [7].
Rutherford Morrison – An oblique, lower quadrant, muscle-cutting incision. It can be used to access the lower abdominal viscera in colectomies, and is also used in acute appendectomy.
Methods of Closure
After the surgical procedure, it is important to correctly approximate and close incisions. Failure to achieve proper closure leads to poor cosmesis, impaired wound healing, increased rates of infection, and dehiscence. There are several methods of incisional closure available:
Sutures – The most common method of surgical closure, where the incision margins are stitched together. Various suture types are available, including monofilament vs. braided and absorbable vs. non-absorbable.
Staples – Both absorbable and non-absorbable surgical staples are available for incisional closure. Non-absorbable staples are made from stainless steel, offering both high tensile strength and low tissue reactivity. Absorbable polymer staples may give a better cosmetic outcome.
Tissue adhesives – These adhesives can be biological or synthetic, and are used to glue incision margins together. Although this closure method has a lower tensile strength than both sutures and staples, it has similar rates of infection and dehiscence while being faster to use.
Adhesive strips – Placing adhesive strips across the incision is a non-traumatic method of closure, but the strips will not stick to moist areas or areas under tension [3].
Surgical Instruments
Instruments in Open Surgery
A wide variety of instruments are available to the surgeon, each designed to perform specific tasks during the course of an operation. While each surgical field makes use of specialised instruments particular to their own fields, there are many surgical instruments that will be found in any operating theatre. It will be useful for a medical student observing in theatre to be able to recognise these commonly used instruments (Fig. 9.41).
Fig. 9.41
Selection of common open surgical instruments. Upper row (L-R): Duval tissue graspers, Crile-Wood needle holders, Robert haemostat, Metzenbaum scissors. Bottom row: Debakey dissecting forceps, scalpel, Watson-Cheyne retractor, Langenbeck retractor
Surgical instruments come in various lengths and come in curved and straight forms (apart from scalpels). Their differences in length (Fig. 9.42) and degree of curvature (Fig. 9.43) best suit them to different tasks. Many of these common instruments have their counterparts in microsurgery, which are smaller, and laparoscopic surgery, where the instrument is at the tip of a long rod in order to pass through a trocar (laparoscopic port). You are not required to know the names of these instruments whilst at medical school, but the most common ones are outlined below to help you orientate yourself.
Fig. 9.42
Length range in surgical instruments
Fig. 9.43
Tip angulation in surgical instruments
Common Surgical Instruments
