This document discusses principles related to operating room procedures and patient care. It covers topics such as patient positioning, antiseptic skin preparation, surgical drapes, universal precautions like gloves and gowns, sharps management, preoperative preparation including setting up materials and the operating room, intraoperative care, postoperative care, and the decontamination process. Biocompatibility of implant materials like stainless steel and titanium alloys is also discussed.

1. Operating Room Principles

2. Patient

3. Patient’s
Position

4. Antiseptic Skin Preparation
• Antiseptics that are used to prepare the skin immediately before
surgery act against the resident and transient microorganisms found
on the skin.
• They work quickly to reduce microbial levels and inhibit regrowth for
a period to lower the risk of wound contamination by the patient’s
own skin flora.
• The choice of antiseptic solution should not just be infl uenced by
surgeon preference but should also be guided by the patient’s skin
condition, any known hypersensitivities to the solution, and the area
to be prepared.

5. Surgical Drapes
• The patient’s skin should be dry before drapes are applied
• Drapes should be handled as little as possible and held high over the
patient to avoid contamination from nonsterile areas
• Sterile gloves are protected from contamination by cuffing the
draping material over the hands
• Drapes should be placed at the incision site first and then carefully
opened out to the periphery

6. Universal Precautions
• Gloves
• Sterile Gloving
• Surgical Gown
• Donning a sterile gown
• Masks
• Protective Glasses
• Personnel Protection
• Sharps management

7. Gloves & Sterile Gloving

8. Gloves & Sterile Gloving

9. Surgical Gown & Donning a Sterile Gown
• The gown is lifted upward and away from the table. The
gown is grasped firmly at the neckline and allowed to
unfold completely with the inner side facing the wearer.
• Slip both hands into the open armholes keeping the hands
at shoulder level and away from the body. Push both hands
and forearms into the sleeves of the gown, advancing the
hands only to the proximal edge of the cuff in order to use
the closed gloving technique (Fig 1.2-4).
• The ungloved hand should never touch the front of the
gown.
• The circulating nurse should secure the neck and waist ties,
touching only the inner aspect of the gown while doing so.
• Following the donning of sterile gloves, the wrap-around
gown can be closed and tied.

10. Masks and Protective Glasses
• The mask is a filter which forms a
protective barrier between user and
patient and prevents transmission of
microorganisms. They must cover both
nose and mouth
• These are solely designed to protect the
user against conjunctival contamination
and subsequent infection by infected
body fluids. This is an uncommon but
recognized risk.

11. Sharps Management
• During a surgical procedure the following precautions should be taken
with all sharp instruments:
• Do not bend or recap needles.
• Do not touch sharp instruments, such as needles or scalpel blades,
with the hands if they have been in contact with blood, or other body
fluids.
• Open medicine ampoules using an ampoule opener or gauze swab.

12. Sharps Management
• During a surgical procedure the following precautions should be taken
with all sharp instruments:
• Do not bend or recap needles.
• Do not touch sharp instruments, such as needles or scalpel blades,
with the hands if they have been in contact with blood, or other body
fluids.
• Open medicine ampoules using an ampoule opener or gauze swab.

13. Sharps Management
Checklist for safe assisting during sterile procedures:
• Avoid handling needles manually.
• Never hold a scalped-loaded holder or any sharp item in the same hand at the same time
as other instruments.
• Use verbal warning to announce transfer of a sharp instrument.
• Use detachable sutures or safety devices to facilitate needle removal.
• Avoid finger contact with tissue being sutured or cut.
• Keep eyes on all sharp items in use until they are returned to the neutral zone.
• Replace the shield to the tip of a drain, or trocar using an instrument, and not the
fingers.
• When a syringe needs to be refi lled while injecting incrementally, the needle can be left
in the tissue, the syringe removed and refilled, and then the syringe reattached to the
needle.
• When removing the needle from a suture, park the needle safely or protect the needle
tip with the needle holder.

14. Preoperative Preparation
• Information for an operation must be acquired before the procedure.
• Surgeons give the team details of the operation to be performed.
• They must provide clear and adequate information including the
name, gender, age and general condition of the patient, the nature of
the injuries, and the type of operation.
• Surgeons must also inform the operating room personnel (ORP) of the
patients’ wishes.

15. Setting Up Material
• Operating room time is the most expensive resource in a hospital.
• Having adequate, proper functioning instruments, and equipment
ready at hand enhances patient safety, prevents delay, saves money,
and increases staff and surgeon satisfaction and is therefore
important.
• All devices for sterilization must be packed using materials that are
resistant to liquids and bacteria and maintain the sterility of the
contents

16. Setting up the OR
• Number of trolleys, equipment, containers, instruments, and implants
necessary for the particular operation are organized within the OR so
that work can be performed efficiently.
• Sterile equipment is kept separate from nonsterile equipment and
liquids necessary for rinsing and disinfecting the surgical-site.
• The circulating ORP finalizes room set up and is responsible for
presenting all material as it is required in a sterile and logical manner
to his/her colleague. The circulating ORP is also responsible for the
continuous supervision of aseptic technique and needs of the patient.

17. Intraoperative Care
• A professional scrub ORP makes a major contribution to minimizing the
operation time through efficient team work, the practice of strict asepsis,
and thus improving the patient’s health status and reducing the risk of
complications, such as surgical-site infections. He/she should be able to
think and work at least one step ahead of the surgeon and anticipate the
surgeon’s needs.
• If time allows, it is highly recommended to clean instruments as the
operation proceeds.
• During the whole operation the OR team must behave in a correct manner.
Doors must be kept closed throughout the surgery to guarantee optimal
function of the laminar flow. Unnecessary movement of personnel must be
avoided. Nonsterile personnel approaching the surgical-site or sterile
trolleys and equipment must keep a minimum distance and stay outside
any laminar flow canopy.

18. Postoperative Care

19. Decontamination Proccess
• Decontamination is a strict and standardized procedure. It is a
combination of processes which includes cleaning, disinfection,
and/or sterilization to make a medical device safe for further use
• The aim is to maintain the functionality of the instrument and to
reduce microorganisms, soiling, chemicals, corrosion, and other
potential debris on the surface of a device so that it is hygienically
safe for the patient and the OR team to use.

20. Sorting of Material
• The decontamination process starts with an initial cleaning
immediately after use. All instruments and sets are then sorted for
manual or automated cleaning and disinfecting.
• The instruments must be handled with care so that damage and self-
inflicted injuries are prevented

21. Cleaning – Disinfection Procedure
• Water is necessary to remove major soiling from instruments.
• Mechanical action to remove soiling involves wiping, scrubbing, flushing,
or vibration using ultrasonic waves. Mechanical action during an
automated process is provided by fl ushing and spraying.
• Chemical action is provided by detergent mixed with water to kill
pathogens. Fat and proteins are dissolved by detergent. The detergent may
contain additives to protect the surface of instruments.
• Heat improves the dilution power of water and detergent. The correct
temperature must be chosen to optimize the cleaning disinfection
procedure. If the temperature is higher than 45°C, blood and tissue
residues tend to coagulate. Alkaline detergents, however, need a higher
temperature to hydrolyze the proteins.

22. Choice of Implant Material
• The choice of material depends primarily on the requisite function to be
accomplished and also on the manner in which the implant will be applied.
a. Stainless Steel: Today stainless steel is one of the most frequently used
biomaterials for implants in internal fi xation. Stainless steel is a good
implant material as it has excellent mechanical properties; it is corrosion
resistant and cost-effective compared with other suitable metals
b. Commercially pure titanium (cpTi): Titanium has also been used as an
implant material safely for many years. Because of cpTi’s superior
strength, corrosion resistance, acceptance by bone and soft tissue
c. Titanium alloys: the high strength and low modulus of elasticity of
titanium alloys are ideal for implants demanding high resistance to stress
loading

23. Biocompatibility
• This describes the suitability of a material for exposure to the body
tissues or fluids within the site of application; ie, the way the body
reacts to the implanted material. The body provides a hostile
electrolytic environment that can lead to the corrosion of implants.
Nonbiocompatible materials may cause the foreign body reaction
with fibrous encapsulation and/or inflammation.
• In general, cpTi and titanium alloys are considered to have better
biocompatibility than stainless steel which is again attributable to the
oxide layer of the material, and there is some evidence that titanium
implants may be more resistant to infection than stainless steel ones.

24. Implant-tissue interface
• The implant-tissue interface is the contact between implants to soft
tissue and bone. There are different tissue reactions depending on
what metal implant is used. To date, stainless steel implants are
fabricated for clinics with a smooth, mirrorlike surface; while in
contrast, cpTi and its alloys are produced with a standard microrough
surface
• Due to the smooth surface of stainless steel, micromotion within the
implant-tissue interface may occur. This micromotion can lead to the
formation of a thick and dense fibrous capsule with a liquid-filled
void.

25. Checking and ensuring validity of sterile
implants
To ensure that sterilized implants selected for surgery are in optimal
sterile condition, the following checks must be undertaken:
• Integrity of packaging
• Sterilization and expiry date
• Type of sterilization process
• Serial or lot number corresponding to the company’s checklist
• If implants are sterilized on site the same checks are performed.

26. Further checks to be done are:
• Confirmation of validation of the sterilization process before being
cleared for use
• Batch control (sterilizer number/code)
• Cycle or load and chemical/biological indicators
• Wet items or items that have come into contact with wet surfaces
have to be rejected
• Lack of sterilizing indicator means item is not sterile and requires
reprocessing

27. Operating Table
• General OTs are composed of a platform divided
into major sections: the head, torso, and leg (Fig
1.6-1).
• Each has a corresponding removable mattress
pad.
• The area between each section is called a break;
each section can be angled relatively to its
adjacent section—this is called breaking the
table.
• Each OT is designed with parts and accessory
devices that can accommodate most surgical
positioning needs

28. Operating Table
• Selection criteria for positioning devices and accessories are based on:
• Position needed for surgery
• Availability of appropriate sizes and shapes
• Durability of material and design
• Ability to maintain normal capillary interface pressure
• Resistance to moisture and microorganisms
• Radiolucency
• Fire resistance
• Water resistance
• Nonallergenic to the patient
• Ease of use
• Ease of cleaning/disinfection, if not disposable
• Ease of storage, handling, and replacement
• Cost-effectiveness

29. Image Intensifier

30. Hazards of Radiation Exposure
• Radiation sources are found in a wide range of occupational settings.
If radiation is not properly controlled, it can be potentially hazardous
to the workers’ health and can lead to development of cancer in
sensitive organs, particularly in the thyroid and in bone marrow.
• Although modern x-rays have minimal radiation effects on the
patient, frequent, prolonged, and repetitive use of intraoperative
image intensification have greatly increased the risk of significant
radiation exposure to the surgical teams
• It is the responsibility of every surgeon to be familiar with the image
intensifier and to know how to minimize radiation exposure to
himself/herself, the patient, and other members of the surgical team.

31. Minimizing the Duration of Exposure
• Minimizing the duration of exposure directly reduces the radiation dose:
• Keep beam-on time to a minimum
• Inform the radiographer where the C-arm is positioned
• Perform a trial screening in the planned projections after positioning of patient
• Take only the minimum number of images required
• Rely on stored images without the need for reexposure
• Minimize use of magnification (source close to limb)
• Collimate the image whenever possible
• Use single-pulsed mode image intensification and pulsed screening mode,
instead of continuous image intensification.
• Studies suggest that screening time is controlled predominantly by the surgeon
• Controlling the dose received by the patient will helps in turn control the dose for
the staff

32. Protective Equipment
Protective equipment for staff (Fig 1.6-8) and patients must be provided and used. The following are
recommended:
• Gowns/aprons/skirt/vest with 0.5 mm lead equivalent for
• surgical teams
• Neck shields to protect the thyroid
• Lead glasses decrease exposures of the eyes, 0.15 mm lead equivalent goggles provide 70%
attenuation beam energies
• Gonad shielding of at least 0.25 mm lead equivalence must be used on patients of reproductive
age, if the gonads are in the primary beam and the shielding does not interfere with the
diagnostic procedure
• Lead screens provide additional protection of OR personnel who do not wear lead protection.
Viewing glass materials must have the same lead equivalence as the shield
• Scattered radiation under the table must be attenuated by at least 0.25 mm lead equivalence
shielding
• Walls, ceiling, doors, and fl oor areas of rooms housing diagnostic units must be provided with
suffi cient protective shielding (lead or lead equivalent materials)

33. Protective Equipment

34. Tourniquet
Two types of tourniquets are available:
• Noninflatable (nonpneumatic) tourniquets made of rubber or elastic
cloth. Their surgical use is now limited. For prehospital care of a
patient with trauma to an extremity, a nonpneumatic tourniquet may
be used as a last resort to control hemorrhage.
• Pneumatic tourniquets use a gas-inflated cuff to constrict the blood
flow. This method is no different from the blood pressure-measuring
cuffs. However, pneumatic tourniquets used in operating rooms have
cuffs whose pressure is controlled electronically.

35. Tourniquet
Situations in which tourniquet use is contraindicated include:
• Infection
• Open fractures
• Intramedullary reaming of tibia
• Venous thromboembolism
• Tumor distal to the tourniquet
• Posttraumatic hand reconstruction of long duration
• Severe crushing injuries
• Compromised vascular circulation, eg, peripheral artery disease
• Extremities used for dialysis
• Diabetes mellitus
• Sickle cell anemia
• Skin grafts where all bleeding points must be readily identified

36. Air and Power Supply
• Power tools are complex pieces of machinery and are used extensively. Proper care and
maintenance are a must to avoid expensive breakdowns
Before sterilization all tools should undergo the following:
• After each use and cleansing, the power tool body and all attachments and hoses/cords
must be inspected for wear and damage.
• Hoses/cords should be removed and packed separately or in a separate compartment of
the power tool container as hot metal can damage them. This is why hand pieces,
attachments, accessories, or tools should never lie on hoses or cords during the
sterilization process.
• Lubricate hand piece and attachments after cleansing and before sterilization according
to the manufacturer’s guidelines.
• Do not place hand piece or attachments for sterilization in a “peel pack.” Sterilization in a
sealed pouch traps moisture which can cause damage to the equipment.
• Use manufacturer’s recommended sterilization method.