Handbook of

Operation Theatre Techniques

Handbook of

Operation Theatre Techniques

Arun B Kilpadi Consultant Surgeon Professor of Surgery St. John’s Medical College Hospital Addl. Vice Dean, St. John’s Medical College Bangalore

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd EMCA House, 23/23B Ansari Road, Daryaganj New Delhi 110 002, India Phones: 23272143, 23272703, 23282021, 23245672, 23245683 Fax: +91-011-23276490 e-mail: [email protected] Visit our website: http://www.jpbros.20m.com Branches • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East, Bangalore 560 001, Phones: 22285971, 22382956 Tele Fax: 22281761 e-mail: [email protected] • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza Pantheon Road, Chennai 600 008, Phone: 28262665 Fax: 28262331 e-mail: [email protected] • 4-2-1067/1-3, Ist Floor, Balaji Building, Ramkote Cross Road, Hyderabad 500095, Phones: 55610020, 24758498 Fax: 24758499 e-mail: [email protected] • 1A Indian Mirror Street, Wellington Square Kolkata 700 013, Phone: 22451926 Fax: 22456075 e-mail: [email protected] • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital Parel, Mumbai 400 012 , Phones: 24124863, 24104532 Fax: 24160828 e-mail: [email protected] Handbook of Operation Theatre Techniques © 2004, Arun B Kilpadi All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published on good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only. First Edition: 2004 ISBN 81-8061-320-8 Typeset at

JPBMP typesetting unit

Printed at Repro India Limited

Preface This brief manual is a collection of material that I used for my own enlightenment and thereby the enlightenment (hopefully) of the staff nurses, nursing students and operation theatre technicians of St. John’s Medical College Hospital where I work. These lectures were the result of a request from one of our senior Operation Theatre staff nurses. I enjoyed preparing this material as much as I enjoyed talking to my co-workers. At the end of the lecture course I was gratified to be requested by the same senior staff nurse to give her this material to aid her in her work abroad. In order to give the same benefit to those who work in any operation theatre, these notes have been compiled into this little handbook for nurses and operation theatre technicians. Note: This is intended to be a handbook and not an exhaustive and extensive textbook. The purpose of this book being to give the aspiring theatre nurse/technician a glimpse into some aspects of operation theatre work, many procedures in the general surgical repertoire and most procedures in specialized areas have been dealt with only briefly. This has been done intentionally with an eye to brevity, conciseness and ease of reading. Arun B Kilpadi

Acknowledgements I wish to place on record my gratitude to the following people who helped or inspired me to prepare this book for publication. • Ms. Molly Simon, formerly Senior OT Staff Nurse, St. John’s Medical College Hospital, Bangalore • Mr. K. Krishnamohan, for photographic assistance • Mr. James, Photographer, St. John’s Medical College, Bangalore The staff of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi and Bangalore Branch for their willing assistance and co-operation at all times.

Contents 1. Instructional Course Lectures for Operation Theatre Nurses and Technicians .................................................. 1 2. Some Common General Surgical Operations: Regionwise ............................. 59 (with a short note on the definition and indication of each procedure) Index ................................................................... 87

Chapter 1

Instructional Course Lectures for Operation Theatre Nurses and Technicians

A TYPICAL OPERATION THEATRE SCENE

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HANDBOOK OF OPERATION THEATRE TECHNIQUES

CLEANING, DISINFECTION AND STERILIZATION These terms do not mean the same thing. The first implies the removal of visible debris and dirt; the second means the reduction of the number of pathogenic organisms except spores. It does not remove all pathogens and certainly does not eliminate spores. Sterilization, however, destroys all pathogens including spores. A. Cleaning is done by (a) washing with detergent (soap) and water or by using (b) the ultrasonic cleaning device which removes dirt even from within tubes and catheters and from the grooves, teeth and serrations of instruments, which cannot be satisfactorily cleaned or may be damaged by (c) the use of a plastic or wire brush. B. Disinfection/sterilization can be done by the methods which are listed below: 1. Antiseptic solutions—e.g. a. 70% alcohol (surgical or methylated spirit) b. 0.5% chlorhexidine requiring only 2 minutes of immersion for disinfection, c. Aldehydes (2% Glutaraldehyde—Cidex)— disinfection occurs with 10 minutes of immersion and sterilization takes 10 hours. This solution needs to be freshly prepared and tends to stain the skin. The addition of 1 gm of Sodium Nitrite tablets will prevent rusting of metallic instruments, which are cleaned with water. 2. Boiling: This is a cheap, quick and widely used method of disinfection but it does not destroy spores (e.g. clostridia). Instruments are first washed and

INSTRUCTIONAL COURSE LECTURES

3

cleaned before boiling for 5 minutes at 100-212°F. However, the temperature reached is dependent on atmospheric pressure and is much less effective at higher altitudes. This method is not suitable for linen. 3. Hot Air Oven: This is a thermostatically controlled oven in which instruments are sterilized at 160°C (320°F) for an hour. Obviously this method is unsuitable for perishable items such as rubber, latex and plastic articles. 4. Autoclaves: This is the most efficient method of sterilizing instruments, packs and dressings. It is suitable for most materials. The autoclave is basically a pressure cooker (Figs 1.1A and B, Plates 1 and 2). In this apparatus higher temperatures (up to 134°C or 273°F) can be reached in a short time by increasing the pressure (up to 30 psi) in the chamber. The air in the sterilizing chamber is removed and replaced with steam, which enters the spaces surrounding the load. As the steam comes into contact with the cooler layers of the load, it leaves a minute quantity of water of condensation. The steam is displaced downwards and the layers of cloth covering the load absorb the latent heat that is given off. The next film of steam that enters then penetrates the outer layer and heats the inner parts of the load. This process continues till the core of the load reaches the same temperature as the outer layer. The Quick Cycle (flash) in the autoclave heats the water to 134°C for 3.5 minutes under a pressure of 30 psi.

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HANDBOOK OF OPERATION THEATRE TECHNIQUES

The Slow Cycle is more suitable for plastics and heats water to 120°C under pressure of 15 psi. To sterilize effectively, a vacuum should be created first before letting in steam at the appropriate temperature and pressure. The chamber must be saturated with steam, which should not mix with but displace all the air. The steam must reach the core and every part of the load. When the desired temperature and pressure are reached, they must be “held” for a critical time called the ‘holding time’. The standard holding time is 15 minutes at 121°C, but may need to be varied according to the nature of the load. The cycles of operation can be summarized as follows. Stage I—Pre-vacuum removal: Here the air is removed completely from the chamber by a pump and controlled steam is introduced in a pulsatile fashion. The vacuum achieved should be in the order of 0.5 mm Hg. Stage II—Sterilization: When all parts of the load have reached the desired temperature (134°C it is maintained for 3.5 minutes. Stage III—Drying: This is achieved by adequate postvacuum which is checked periodically by a test pack of towels which when removed from the sterilizer, unfolded and allowed to cool are not damp. Stage IV—Breaking the vacuum-air replacement: This should be completed within 3 minutes through a fiberglass or ceramic filter.

INSTRUCTIONAL COURSE LECTURES

5

The chamber is then unloaded and the packs marked with the batch number to that particular load. Double-walled autoclaves are preferred because they can reach a higher pressure and maintain this for a longer time. Also, a horizontal chamber is better because in a vertical chamber the lower parts of the load may not reach the desired temperature so their sterility is doubtful. Single-walled chambers cannot take the desired pressure. Also, moisture may not be completely eliminated which is a dangerous situation as far as bacterial growth is concerned. In a doublewalled autoclave steam is let into the space between the two walls so that moisture does not come directly into contact with the load. Also, sterile air can be let into this space to break the vacuum and for cooling and drying at the end of the process. Surgical Instruments Like all equipment, surgical instruments too need to be cleaned and maintained in good condition by means of regular care and attention. Dirt and rust can make instruments less efficient, more dangerous and infective and more difficult to sterilize. Most surgical instruments are made of stainless steel. They have smooth surfaces, which however can become pitted and scarred if not handled properly during washing, cleaning, polishing and lubrication (which is necessary particularly in instruments which have joints). The use of corrosive and abrasive cleaning agents can cause permanent damage on the surface.