general surdery asepsis

1. General surgery
Lecture N1
1. Introduction to the study of general surgery.
2. Asepsis and antisepsis.

2. - The main operation principles.
The surgeon carried out the operation must aim at patient’s
life preservation and be influenced by following main points:
* Anatomical accession
* Technical possibility
* Physiological permission
Surgery (from the Greek: χείρ, "hand", and ἔργον, "work"), via Latin: chirurgiae,
meaning "hand work") is an ancient medical specialty that uses operative manual and instrumental
techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to
help improve bodily function or appearance or to repair unwanted ruptured areas (for example, a
perforated ear drum). An act of performing surgery may be called a "surgical procedure",
"operation", or simply "surgery". In this context, the verb "operate" means to perform surgery. The
adjective "surgical" means pertaining to surgery; e.g. surgical instruments or surgical nurse
Surgery

3. Anatomical accession. Non each organ or formation can be easy accessible for carrying out of operation.
Anatomical accession may be different. There are easy accessible organs (stomach, liver, bowel) and difficult
accessible organs (esophagus, posterior mediastinum). Sometimes the operation may be non carried out due to
impossibility for penetrating to the organ (base of the skull).
Technical possibility. The many operations become possible there, where earlier were impossible. Due to
developing of the science the hard operations of the heart and magisterial vessels excluding of the heart from
blood circulation become possible. Using of the different equipment (heart-lung apparatus, US-generators,
monitors, ect.) enlarges the diapason of the surgical interventions.
Physiological permission. So that the first aim of the operation is the preservation of patient’s life, in some cases
the organ function must be kept. For example, the operations on the pancreas are anatomically accessible,
technically easy, but it must be solely carried out spared, in order to preservation its functional ability. This rule
may be taken to other organs, from which patient’s health and life depend. Technically carrying out total
pancreatectomy is not difficult, but patient’s surviving in this case is impossible. The main principle of these
cases is radical removing of the pathologic hearth and maximally to keep of organ function.
Stages of operation:
- Operative access (start of operation)
- Operative way (operative technique)
- Going out from operation
The main operation principles.

4. General surgery
General surgery, it is the part of surgical
science, which studies the care of surgical patients, the
principles of prevention and treatment of surgical
infection /aseptic and antiseptic/, main principles of
anesthesia and traumatology, principles of arresting of
bleeding and blood transfusion, principles and methods
of purulent surgical diseases treatments, examination of
a surgical patient and the principles of emergency
medical care.
Without such a basical knolige, the study of
all subsequent surgical disciplines (surgical diseases,
urology, oncology, obstetrics and gynecology, etc.) is
simply impossible.

5. A surgical hospital contains the main functional blocks which are as follows: a
surgical block, surgery departments, plaster and treatment rooms and dressing-rooms.
An operating unit houses special rooms for operating on patients. It has to be
isolated from surgery departments on a separate floor or detachment of the building and be
connected with the them by a corridor.
To provide the regimen of sterility, there are the four special functional zones in the
surgical block:
1. The sterile zone, i.e. the operating theatre (to operate on patients), scrub-up room (for
preoperative cleansing surgeons' hands and forearms) and the room for sterilisation (to
sterilise the instruments to be used during the operation).
2. The clean zone, i.e. the rooms for personal hygiene and changing clothes of the staff.
3. The technical zone, i.e. the rooms where apparatus for air-conditioning or oxygen
supplying and vacuum devices are stored.
4. The dirty zone, i.e. the sister's room, the room of the head of surgery and the one for dirty
clothes etc.
Surgical hospital

6. Hygienic requirements for operation unit (OU):
1. it may not be places on the ground floor;
2. area of operation theatre (ОТ) should not be less 36 m2 per 1 operation
table & 54 m2 per 2 operation tables;
3. height of ОТ - not less 3,5 m, width - not less 5m;
4. walls should be smooth, covered by oil paint or tile;
5. all types of electric conductors & heating apparatus (radiators) should be
walled up;
6. Light coefficient 1:3-1:4 (the best 2:3);
7. Lighting of the wound - 3000-10000 lx;
8. Lighting of ОТ 300-500 lx (not less 200 Jx);
9. Increase of air temperature 0,5 m above operation table not more 2-3°;
10. Air temperature 20-22°C (in winter 19-20°C), humidity 50-55%, air
velocity 0,1 m/sec
11. Validity of sterile surgeon's coat is 3-4 hours
12. Contamination of air before the operation - 500-600 per m3, by the end
of operation - not more than 1500-2000 per m
13. Power of UVI lamps - 3 Wt/m2
14. Ratio of ventilation is 5-6, in conditioning - 8-10.
Surgical hospital

7. The main paths of infection
dissemination are: exogenous and endogenous.
1. The main sources of exogenous infections
include patients with purulent inflammation or «healthy»
carriers of the microbes, and occasionally animals.
The modes of transmission from exogenous
sources are usually as follows: airborne, direct contact
(instruments, surgeon’s hands, dressing material) and
implantation (prosthesis).
Surgical infection

8. Surgical infection
2. The major sources of endogenous
infections incorporate chronic infections
outside the area of the operation (e.g. skin
diseases, dental or tonsillar conditions) or
of the organs operated on as is (e.g.
appendicitis, cholecystitis, osteomyelitis),
as well as the oral, intestinal and
respiratory saprophytes.
Among the modes of
transmission of endogenous infections are
direct contact, lymphoand haematogenous
spread.
The prophylaxis of this kind of
infection includes timely revealing centers
of chronic & acute infection in patient's
organism and their sanitation.

9. ASEPSIS AND ANTISEPSIS
Asepsis is a totality of
measures directed on the prevention of
microbe contamination of wounds, the
formation of sterile conditions for the
whole surgical work.
An antisepsis is a totality of
measures directed on the extermination
of microbes in wounds & the whole
organism.
All the methods of antisepsis
can be divided into 4 kinds: mechanical,
physical, chemical, biological.
There are two main organizational principles of modern asepsis:
1. Everything touching the wound should be sterile (use of sterile instruments and use the
gloved no touch technique).
2. All surgical patients must be divided into 2 streams: "clear" and "suppurative" (accordingly
there are "clear" operating theatre and "suppurative").

10.  1847 - Semmelweis identifies surgeons hands as route of
spread of puerperal infection
 1865 - Lister introduces hand and wound asepsis with the
use of carbolic acid ( C6H5OH).
 1880 - von Bergmann invents the autoclave
 1882 - Trendelenburg constructed an apparatus for
sterilization of surgical material and instruments with dry
steam.
 1886 Bloodgood invented rubber gloves for protection of
a surgeon's hands from infections.
History of problem

11. Asepsis
Everything touching the wound should be sterile (use of sterile instruments and use
the gloved no touch technique).
1. All objects used in a sterile field must be sterile;
2. Sterile objects become un-sterile when touched by un-sterile objects;
3. Sterile items that are out of vision or below the waist level of the nurse are considered
unsterile;
4. Sterile objects can become unsterile by prolonged exposure to airborne microorganisms;
5. Fluids flow in the direction of gravity; moisture that passes through a sterile object draws
microorganisms from un-sterile surfaces above or below to the sterile surface by capillary
action;
7. The edges of a sterile field are considered un-sterile;
8. The skin cannot be sterilized and is un-sterile.
Precautions:
* Sterile can touch only sterile * Do not turn back on field
* Do not spill on a sterile field * Outer 1 inch is considered sterile
* Hold objects above waist * If in doubt, treat as contaminated
The basic principles of surgical asepsis:

12. Asepsis
The paths of prophylaxis of contac tinfection: the sterilization
of everything that touches the wound. Sterilization is the total
desctruction of all forms of life, including bacterial spores.
All methods of the sterilization are divided into 2 kinds:
physical and chemical.
1. The physical methods:
A. Firing & boiling in 2% solution of sodium hydrocarbonate
B. Autoclaving (the sterilization with steam under pressure).
2 regimens of the sterilization of surgical instruments exist:
- in pressure 1,1 atmosphere - 45 min (temperature 120°C)
- in pressure 2 atmospheres - 20 min, (temperature 132°C)
Surgical instrument, dressing material, suturing apparatus are
sterilized in metal boxes - drums. A closed sterile drum keeps its sterility
during 72 hours, if surgical cloth is kept in cotton sacs, & 48 hours, if it’s
preserved without cotton sacs.
C. The sterilization with heat air in special closets (the regime of
sterilization is 60'in 180° C).
D. Radiation sterilization with y-rays, infrared rays (regimen of
sterilization - 30' in 300°C), US (ultrasound). The most use was gotten by
y-sterilization but only in industrial conditions (average sterilizing dose is
2,5 Mrad).

13. Asepsis
2. The chemical methods:
A. by gas (vapour of formalin - 24 hours – or ethylene oxide) in
special cameras. The method is used for the sterilization of
optical parts of instruments & apparatus. Ethylene oxide in
mixture with air is in concentration 3-80% is explosive, that's
why they use it with addition of flegmatizers (carbon dioxide,
chladon, methyl bromide). Optimum conditions of sterilization
in usage of ethylene oxide is dose 0,75-1,0 g per 11 of
sterilizing chamber, t 55-60°C, relative humidity 80-100%,
exposition 4-6 hours. Formaldehyde may be used for
generating its vapors mixed with vapors of water in special
sterilizators with perliminary providence of vacuum. They
provide vaporizing 1,2 ml of 16% water solution of
formaldehyde per 11 of sterilizing chamber in 70° & exposure
not less 5 hours.
B. By solutions of antiseptic drugs (6% hydrogen peroxide
solution during 6 hours in I8°C & 3 hours in 50°C, ethyl spirit,
0,5% spirit solution of chlorhexidine).
.

14. Asepsis
Preparation of the hands for operation:
Scrubbing of the hands is a very important way of preventing
infection. Surgeons, operating theatre and dressing nurses should always
see to it that their hands are clean, take care of their skin and nails. Taking
care of the hands prevents from their cracking and callosity of the skin are
prevented. The nails should always be trimmed and short. Whenever very
dirty work is to be done manually, gloves should be it is better to worn.
Taking good care of the hands should be regarded as a step in the
preparation for operation. Whatever method of scrubbing the hands is used,
this should start with mechanical cleansing.
Washing of surgeon's hands is carries out with pervomur (the
mixture of formic acid, hydrogen peroxide and water, as a result epiformic
acid forms which has strong sterilizing properties, 2,4% solution is
prepared ex tempore) during 60 seconds, after it the hands are dried with
sterile napkin. In emergent cases the hands may be washed with 96% spirit
during 10 min. (Broon's method), spirit solution of chlorhexidine during
3min. After washing hands with soap, 5% tannin solution in 96% alcohol
(Zabludovsky’s method), 5% iodine solution in benzene (Hyesner’s
method), solution "Manopronto" (twice during 5 min. after washing hands
with soap and drying with sterile napkin or towel).
Despite the mechanical action and the chemical
antimicrobial component of the scrub process, skin is never sterile - we
must wear gloves

15. Asepsis
Preparation of the place of the expected
incision (operative field or site) starts on the day preceding
the operation, which includes hygienic baths and a change
of underwear. On the day of operation, the skin of the
expected place of incision is dry-shaved and cleaned with
alcohol.
One must get the following rules:
- wide washing (much wider then the place of cutting);
- from center to outlying area;
- repeated washing during the operation (rule by Grossikh-
Filontchikov);
- contaminated parts of body are processed lastly.
Immediately before the operation, on the
operating table, the operative field is abundantly smeared
with 5% alcohol solution of iodine. The operation site itself
is isolated with sterile towels and again smeared with 5%
alcohol solution of iodine.
Before suturing, the skin is smeared with 5% alcohol solution of iodine and repeated after the suturing. This
is known as Grossich-Filonchikov's method.
In a patient allergic to iodine the skin can be prepared with brilliant green (Bakkal's method). On the
operating table, the operation site can be can be prepared with derivatives of iodine such as iodonate, povidon-iodine,
betadin.
In urgent operations, the preparation of the operation site involves shaving of the hair, cleaning the skin with
0,5% ammonium, using one of the methods (Grossich-Filonchikov's or Bakkal's one or application of iodine derivatives).

16. ANTISEPSIS
There are for types of antisepsis: mechanical, physical, chemical and biological.
1. Mechanical antisepsis is based on surgical debridement of
wounds. This is performed in the surgical theatre and involves
excision of the edges, walls and the floor of wounds to remove
the non-viable tissue and microorganisms within the wound. It is
the major method to treat accidental, infected wounds.
2. Physical antisepsis are an important part of modern methods of
treatment of wounds and inflammatory processes. The agents of
this type of antiseptics are light, heat, sound waves, different
irradiation, and phenomenon of hygroscopicity. Physical
antiseptics includes the following methods: the use of hygroscopic
dressing material, hypertonic solutions (5-10% solutions of NaCl),
draining, the use of sorbents, the use of laser, UV and X-rays, US
etc.
Draining may be in 2 forms:
• passive (with rubber strips or plastic tubes),
• active (with any pump which removes the effusions from the
wound).

17. ANTISEPSIS
3. Chemical antisepsis is the elimination of microbes in the pathological center or the whole organism
with any chemical substances. All the chemical drugs may be divided into 3 kinds according to their
purposes:
1. disinfecting drugs (1-4)
2. antiseptic drugs (5-9)
3. chemotherapeutic drugs (10-13).
According to the chemical structure antiseptic drugs are divided into the following groups:
1. including haloids :
a) iodine tincture (5-10%), iodonat, iodopiron are used for washing of operative
field; Lugol's solution - for the sterilization of catgut and like a
chemotherapeutic drug in the treatment of goiter
b) chloramine В - 1-3% solution - for the disinfecting of objects of care,
rubber instruments, chambers.
2. Salts of heavy metals - dichloride of mercury, silver nitrate - strong poisons and that's why their use is
restricted
3. Ethyl alcohol
4. Formalin
5. Dye-stuffs - brilliant green, methylene blue, fuchsin
6. Acids - boric acid, carbolic acid
7.0xidizers - hydrogen peroxide, potassium permanganate - active agent is
atomic oxygen - antiseptic, hemostatic, forms a foam improving cleaning of
the wound.

18. 8. Detergents - chlorhexidine bigluconate (hebitan), miramistin;
9. Antiseptics of plant origin – chlorophylliptum;
10. Derivatives of nitrofuran - furacilin, nitrofurantoin (furadonin), furazidin (furagin, furamag), furazolidone;
11. Derivatives of chinoxalin – dioxydin;
12. Derivatives of nitroimidazole (bactericidal) - metronidazol (clion, metragil;
trichopol), tinidazol (fazigin), tiberal, naxogin, atrican;
13. Sulfonamides (SA):
a) short-term - aethazol (globucid, sethadil), sulfacyl sodium (acetopt, octsetan), streptocid (dipron,
deseptyl), sulfadimesin (diazol, superseptyl), urosulphan (euvemil, urenil), sulgin, phthallazol
(talidine, thalistatyl);
b) middle-term - sulfadimetoxin (madribon), combined drugs (biseptol, grosseptol, triseptol,
sumentrolim, bactrim, oriprim, sulfaton due to presence of trimetoprim), sulfamoxol;
c) long-term - sulfalen (kelfizin), diameton, kinex, sulfadoxin.
ANTISEPSIS
3. Chemical antisepsis
4. Biological antiseptics - the substances are divided into 2 groups:
- with direct action (antibiotics, proteolytic enzymes, means of specific passive immunization - sera,
antitoxins, ϒ-globulins, bacteriophages, hyperimmune plasma);
- with indirect action (stimulators of non-specific resistance – UVI of blood, Laser irradiation of blood, the
use of spleen cells, blood and its components transfusion; stimulators of non-specific immunity - vitamins,
preparations of thymic gland (thymalin, T-activin), Prodigiosan, Levamisol (decaris), Methyluracil, Penthoxil;
means of specific active immunization - vaccines, anatoxins).