Engidaw Ambelu

1. Introduction to Surgery for
Anaesthesia students
Abebaw M (MD)
Tahsas 2010

2. Objectives
• Understand the evolution of modern surgery
• Recognize key persons in the advance of
surgery
• Remember key milestones in modern surgery

3. “To perform surgery is to eliminate that which is
superfluous, restore that which has been
dislocated, separate that which has been
united, join that which has been divided and
repair the defects of nature.”
Ambroise Pare

4. • The term “Surgery” derived from two Greek
terms-’cheir’-”hand” ‘ergon’-”work”

5. • Antiquity
-Mesopotamia
-Egypt
-India
-Greek
-China
• Middle Ages
• Early Modern surgery
• Modern surgery

6. four fundamental clinical prerequisites :
1. Knowledge of human anatomy
2. Controlling hemorrhage and intraophemostasis
3. Anesthesia: pain-free procedure
4. Explanation of the nature of infection and
elaboration antiseptic and aseptic OR environment

7. EARLY MODERN ERA
• Important advances to the art of surgery

8. Understanding Human Anatomy
Andreas Vesalius(1514-1564)

9. – Renaissance transition to an empirical approach of
'hands-on' dissection
– Advocated that all surgeons should train by
engaging in practical dissections

10. Controlling Hemorrhage
Ambroise Pare (1510-1590)

11. – father of modern military surgery
– employed a less irritating emollient, for
cauterizing gunshot wounds on battlefield
– described more efficient techniques for the
effective ligation of the blood
– major role in updating renaissance surgery

12. Pathologic basis of
surgical diseases
John Hunter (1728-1793)

13. • Scientific surgery*:
– sound, scientific footing
– empirical and experimental approach
– quality of research and written works
– reconstructed surgical knowledge from scratch
– built up a collection of over 13,000 specimens
“the father of modern scientific surgery”

14. latter decades of the 19th century
– surgeon truly emerged as a specialist
– recognized and respected clinical practitioner
– bona fide profession = 1st decades of 20th C

15. Scope of surgery
remained quite limited
• sepsis remained mostly
unmanageable
• abdominal and other
intra body surgery was
virtually unknown
• an ignorance of
anesthesia and
antisepsis

16. Anesthesia
William T.G. Morton (1819-1868)

17. Antisepsis, Asepsis
And Understanding the
Nature of Infection
Joseph Lister (1827-1912)

18. ANTISEPSIS and ASEPSIS
• a more important event in the evolution of surgical
history
• wound and on dressings
• spray it in the atmosphere around the operative field
and table
• proved to be of greater singular impact

19. • German-speaking surgeons:
– among the earliest to expand on Lister's message
– boiling and use of the autoclave
• heat sterilization :
– sterile aprons, drapes, instruments, and sutures
– use of facemasks, gloves, hats, and operating gowns
also naturally evolved
• By the mid-1890s :
– total acceptance by Europe and American surgeons

20. Radiology
Wilhelm Roentgen (1845-1923)
elucidation of x-rays in 1895

21. ASCENT OF SCIENTIFIC SURGERY
• more concern to patients and public
• reliance on experimental surgery: scientific basis
“ensuring the social acceptability

22. • widespread impact
• scientific tone in
surgical history
• from the 19th century
operating theater to the
sterility of modern OR
• sterile rubber gloves
• commingled with
privacy and research
laboratory
William Stewart Halsted
(1852-1922)

23. • Introduced a new surgery based on*
– research
– anatomic, pathologic, and physiologic principles
– animal experimentation to develop sophisticated
operative procedures
• Renaissance in medical education
– developed and disseminated a different system of
surgery referred to as a “school of surgery”
– residency system of training surgeons with unique
primary purpose

24. MODERN ERA
• Surgical techniques more sophisticated
• All organs and areas of the body fully explored
• Few technical surgical mysteries left
• The last decades of the 20th C
– development of new instrumentation and imaging
– Endoscopic instruments and procedures

25. MODERN ERA
• Surgical techniques more sophisticated
• All organs and areas of the body fully explored
• Few technical surgical mysteries left
• The last decades of the 20th C
– development of new instrumentation and imaging
– Endoscopic instruments and procedures

26. 20thcentury surgery land marks
• Improved understanding of shock, hypothermia
• Knowledge of blood group & transfusion
• Understanding of blood clotting
• Development of antibiotics & analgesics

27. • Electrically powered surgical instruments
• Surgical stapling instruments, glues, tapes etc.
• Xrays and scans
• Cryogenic super cooled probes
• Ultrasonic devices, medical Lasers
• Heart lung machines

28. • Orthopaedics:
– cementing substances, bone & joint
replacements
• Microsurgery
• Minimally invasive surgery
• Vascular imaging, Angioplasty
• Transplantation of organs
– 1950 : First successful organ transplant - The kidney

29. • sophisticated surgical operations with better results
• automation may robotize the surgeon's hand
“The surgical sciences will always retain their historical
roots as fundamentally a manually based art and craft “

30. ETHIOPIA:
• Late 19thC = Introduction of modern modern
medical practice
• Poor health coverage, low proportion of Doctors
• Expatriate and Ethiopian Surgeons

32. …today, astonishing surgical breakthroughs are making
limb transplants, face transplants, and a host of
other previously un dreamed of operations possible.
But getting here has not been a simple story of
medical progress…

33. •THANK YOU !!!

34. Aseptic & Antiseptic
Techniques
Abebaw M(MD)
Tehasas 2010

35. outline
 Definition
• Introduction
• Asepsis
– Classification
– Techniques
• Antiseptics
• Patient preparation
• Surgical Hand Scrub-Technique
• Gowning and Gloving Techniques

36. Definitions
• Antisepsis - is the use of antimicrobials in
human body.
• Cleaning -removes all debris and the material
on which microorganisms exist.
• Disinfection —process that eliminates many
pathogenic microorganisms from inanimate
objects, except for bacterial spores.
• Sterilization —is the complete elimination of
all forms of microbial life.
36

37. Sterilization
• Sterilization — Sterilization is the complete
elimination of all forms of microbial life.
• Accomplished by either physical or chemical
processes.
• Steam under pressure, dry heat, low
temperature sterilization processes and liquid
chemicals are the main sterilizing agents used.
• Steam sterilization remains the most widely
used technique.
37

38. Introduction
o Surgical procedures
• interfere with the normal protective skin barrier
• expose the patient to microorganisms from both
endogenous and exogenous sources
• Infections may be limited to the surgical site or
widespread with systemic effects
o Prevention of surgical site infections (SSIs)
• primary concern to surgeons
• must be addressed in the planning of any
operation

39. …Cont’d
• Most disease transmissions occur due to actions of
health care personnel that ignore basic concepts of
aseptic techniques.
• Reuse of syringes/ needles
• Touching of a sterile device on to a non-sterile surface

40. Asepsis
• Def:
– Reducing the number of microbes to an irreducible
number
• The purposeful prevention of the transfer of microbes
from one person to another.

41. …Cont’d
• Aseptic techniques
– is a general term involving practices that minimize the
introduction of microorganisms to pts during pt care
– used to reduce the risk of post-procedure infections and
to minimize the exposure of health care providers to
potentially infectious microorganisms
– include practices performed just before, during or
after any invasive procedures

42. Antiseptics
• Antisepsis
– prevention of sepsis by inhibition or destruction of causative
agents
• Antiseptic agents
• Chemicals applied to the skin or other living tissue to
inhibit or kill microorganisms ( both transient &
resident) thereby reducing the total bacterial counts

43. Classification
• Two categories of asepsis
 General asepsis
• w/h applies to pt care procedures outside the OR*
• general aseptic procedures as insertion of IV catheters or urinary
catheters and examples of “no-touch” technique
Surgical asepsis
• Relating to procedures /processes designed to prevent surgical
site infection

44. Principles of medical asepsis
• Even though intact skin is a good barrier against
microbial contamination, a pt can become colonized
with microbes if appropriate precautions are not taken
• All body fluids from any pt. is considered contaminated.

45. …Cont’d
• Hands of health workers are the most common
source of cross-infection
• Although the use of gloves reduces the
transmission of bacteria, hand washing is still
essential after the gloves have been taken off in
order to remove any contamination that might
have occurred via small punctures, and the
multiplication of organisms that occurred in
warm , moist env’t caused by glove wearing.

46. Hand washing
- is the single most important procedure for preventing
nosocomial infection.
- On the ward, even minimal contact with colonized
patients has been demonstrated to transfer
microorganisms. As many as 1,000 organisms were
transferred by simply touching the patient's hand,
taking a pulse, or lifting the patient.
- Hands can be washed with soap and water or antiseptic
hand rub can be used

48. 48
Surgical Asepsis
Keep the surgical
environment completely free
of all microorganisms
Sterile technique used for
even minor operation or
injections
Object is either sterile or not
sterile; if unsure then it is not
sterile.

49. Surgical Principles Of Asepsis
• The pt should not be a source of contamination
• The OR team should not be a source of contamination*
• Recognize potential env’tal contamination
– proper room cleaning, doors kept closed, limited traffic
• Technique of the surgeon of utmost importance

50. Key Processes Of Surgical Asepsis
• Operation theater
• Should Meet standards of asepsis at all times.
• Even the best OR design will not compensate for improper
surgical technique or failure to pay attention to infection
prevention,
• Instruments and equipment
• Disinfected , Sterilized
• Surgical team
• Use of Personal protective equipments (hat, mask, goggle)
• Surgical hand scrub
• sterile gloves
• sterile guans
• Safe handling of instruments
• Post-procedure hand washing

51. …Cont’d
• Patient
• preoperative hospital stay (as short as possible)
• Preparation of operative site ( hygiene, hair removal……
• Remote infections ( treated)
• Prophylactic antibiotics, bowel preparation in colon surgery
• Skin preparation
• Surgeon
• Technique ( dissection, hemostasis, …
• Use of drains, electrocautery,….
• Duration of operation, wound (close/ left open)….

52. Operation Theatre
• Filtered air
• limited human trafficking (surgeon, assistant, scrub nurse,
anaesthesit with his assistant and circulating nurse)
• Clean it thoroughly after each day’s and completely every week.

53. Patient Preparation
• Preoperative hospital stay
- should be as short as possible to reduce likelihood of being
colonized by nosocomial pathogens or acquire nosocomial
infections.
• Remote infections
• Presence of untreated remote infection is associated with an increased
incidence of wound infection.
• Should be appropriately treated.
• In patients with urinary tract infections, wounds frequently become
infected with the same organism.

54. Preparation Of Skin
• The sole reason for preparing the pt's skin before an operation is
to reduce the risk of wound infection
• A preoperative antiseptic bath
• not necessary for most surgical pts ( but assess their
personal hygiene)
• Chlorhexidine gluconate is the recommended agent for
such baths(if needed)
• Multiple preoperative baths may prevent postoperative infection
in selected pt. groups,
( who carry S.aureus on their skin or who have infectious lesions)

55. Hair Removal
• should not be removed from the operative site unless it
physically interferes with accurate anatomic approximation of the
wound edges
• If hair must be removed, it should be clipped in the OR
• Shaving hair from the operative site, particularly on the evening
before operation or immediately before wound incision in the OR,
increases the risk of wound infection secondary to the trauma of
the shave and the inevitable small areas of inflammation and
infection.

56. skin preparation
• Necessary reduction in microorganisms can be
achieved by using
- 70% iodine
- 0.5% chlorhexidine gluconate
- 70% alcohol
• both for mechanical cleansing of the umbilicus and for
painting the operative site
For iodine-sensitive pts, one can use 70% ethyl
alcohol. Apply to the skin with a gauze swab for 3
minutes and allow to dry before draping

57. Prophylactic Antibiotics
• Depending on the class of wound, use of implants, pt status
• Immediately before incision

58. Surgical Wound
• Q: What are the risk factors other than the
microbiology for wound infection?
Decreased host resistance:
Systemic factors
Local wound characteristics
Operative characteristics

59. Surgical wound classification
Clean(Class 1)
 Uninfected operative wound
 No acute inflammation
 Closed primarily
 Respiratory, GI,biliary, and UT not entered
 No break in aseptic technique
 Closed drainage used if necessary
 Risk of infection < 2%

60. Clean contaminated (class ll):
 Elective entry into respiratory,GI,biliary and UT
and with minimal spillage
 No evidence of infection or major break in aseptic
technique
 Risk of infection < 10%

61. Contaminated (Class iii):
 Nonpurulent inflammation present
 Gross spillage from GI tract
 Penetrating wounds < 4 hrs
 Major break in aseptic technique
 Risk of infection about 20%

62. Dirty-infected (Class iv):
 Purulent inflammation present
 Preoperative perforation of vicera
 Penetrating traumatic wounds > 4 hrs
 Risk of infection about 40%

63. Draping
• Sterile drapes helps to create sterile surgical
field(s) by delineating the field around the pt
• Sterile drape packs should be opened aseptically
• Contents do not touch non-sterile items
• Drapes should be sterile, dry

64. Surgical Team
• The surgical scrub
• Definition
– is the process of removing as many microorganisms as
possible from the hands and forearms by mechanical
washing and chemical antisepsis before participating in a
surgical procedure
• Despite the mechanical action and the chemical
antimicrobial component of the scrub process, skin is never
sterile
• Duration
• Not universally defined
• 5 min scrub before the 1st case
• 2 - 3 min scrub in between cases

65. Surgical Hand Scrub-Technique
1. Wet the hands and forearms
2. Apply antiseptic agent from the
dispenser to the hands
3. Wash the hands and arm thoroughly
to 2 inches above the elbows,
several times
4.Rinse thoroughly under running water
with the hand upward, allowing
water to drip from the flexed
elbows

66. 5. Take a sterile brush or
sponge (from a package or
dispenser) and apply an
antiseptic agent ( if it is
not impregnated in the
brush)
6. Scrub each individual
finger, including the nails,
and the hands, a half
minute for each hand.

67. 7. Hold the brush in one hand and
both hands under running
water, and clean under the
fingernails with a disposable
plastic nail cleaner. Discard the
cleaner after use
8. Again scrub each individual
finger, including the nails and
the hands with the brush, half a
minute for each hand

68. The Final Rinse
1. Be sure to keep both
arms in the upright
position (careful not to
touch the faucet!) so
that all water flows off
the elbows and not back
down to the freshly
scrubbed hands.
2. Bring arm through the
water once, starting with
the fingers, then pull the
arm straight out. Do not
let water run down to
hands, must drip off
elbows

69. Drying the Hands and forearms
1. Reach down to the
opened sterile package
containing the gown, and
pick up the towel. Be
careful not to drip water
onto the pack. Be sure no
one is within arm’s reach
2. Open the towel full-length,
holding one end away
from the nonsterile scrub
attire. Bend slightly
forward

70. 3. Dry both hands thoroughly
but independently. To dry
one forearm, hold the towel
in the opposite hand and,
using the oscillating motion
of the forearm, draw the
towel up to the elbow
4. Carefully reverse the towel,
still holding it away from the
body. Dry the opposite
forearm on the unused end
of the towel

71. Gowning and Gloving Techniques
1. Reach down to the sterile
package and lift the folded
gown directly upward
2. Step back away from the table
into an unobstructed area to
provide a wide margin of
safety while gowning
3. Holding the folded gown,
carefully locate the
neckline

72. 4. Holding the inside front of the
gown just below the neckline
with both hands, let the gown
unfold, keeping the inside of
the gown toward the body.
Do not touch the outside of the
gown with bare hands
5. Holding the hands at shoulder
level, slip both forearms into
the armholes simultaneously

73. 6. The circulator nurse brings
the gown over the shoulders
by reaching inside to the
shoulder and arm seams.
The gown is pulled on,
leaving the cuffs of the
sleeves extended over the
hands.
The back of the gown is
securely tied or fastened at
the neck and waist, touch the
outside of the gown at the
line of ties or fasteners in the
back only.

74. Scrubbing, Gowning, and Gloving Complete

75. Sterile Technique
• Sterile object remains sterile only when touched by another
sterile object
• Only sterile objects may be placed on a sterile field
• A sterile object (field) out of range of vision or an object held
below a person’s waist is contaminated
• Unsterile personnel stay beyond one foot of the sterile field

76. Define Sterility
• Gowns are considered sterile in front from chest high to
the operative level
• Sterile persons should keep hands in sight and keep
them at or above waist level
• Tables are sterile only at the operative level.

77. Remedy contamination immediately!!!
• When contamination occurs , take care of it
immediately
• Break in technique is pointed out and action is
taken to change situation …..change gloves

78. Surgeon
• Most of the local factors that make a surgical site favorable to
bacteria are under the control of the surgeon
– Careful attention to cleanliness and technique
• Hemostasis
• fine sutures
• anatomic dissection
• gentle handling of tissues
• obliterate dead space
• Speed and poor technique are not suitable
approaches(contamination certainly increases with time,
Wound edges can dry out, become macerated, or in other
ways be made more susceptible to infection)
• Appropriate use of electrocautery…

79. • Drains
• Operative site should not be drained through
the wound(can also function as an access route
for pathogens)
• Closed suction drain… preferable

80. Surgical site infections(SSI)
Def: (CDC)
– an incisional SSI is an infection that occurs at the incision site
within 30 days after surgery or within 1 year if a prosthetic
implant is in place.(mesh, vascular graft, prosthetic joint, and
so on)
– SSIs are divided into incisional superficial (skin, subcutaneous
tissue), incisional deep (fascial plane and muscles), and
organ/space related (anatomic location of the procedure
itself). Examples of organ/space SSIs include intra-abdominal
abscesses, empyema, and mediastinitis.
– SSIs are the most common nosocomial infection in our
population and constitute 38% of all infections in surgical
patients.

81. • Incisional infections are the most common; they
account for 60% to 80% of all SSIs and have a better
prognosis than organ/space-related SSIs do, with the
latter accounting for 93% of SSI-related mortalities.
• Staphylococcus aureus remains the most common
pathogen in SSIs, followed by coagulase-negative
staphylococci, enterococci, and Escherichia coli.

82. Surgical site infection

83. Risk Factors for Surgical Site Infection According to the three
Main Determinants of Such Infection
Microorganism : like remote site infection, recent
hospitalization, duration of the procedure, wound
class , preoperative shaving , Bacterial number and
virulence.
Surgical technique : Hematoma, necrosis, sutures
and foreign body.
Patient factor : Age, Immunosuppression, Steroids,
Malignancy, Obesity, Diabetes, Malnutrition,
Multiple comorbid conditions, Cigarette smoking .

84. “To which may be added:
The patient is the centre of the medical
universe around
which all our works revolve and towards
which all our
efforts trend.”
J.B. Murphy, 1857–1916, Professor of
Surgery,
Northwestern University, Chicago, IL, US

85. THANK YOU!!!