Before the patient is brought to the operating room, everything must be prepared for the surgical operation. For even a minor operation there is much to be made ready, and for a major procedure it becomes a formidable task. All members of the surgical team must perform their duties efficiently and in co-ordination with all others.
Operating Room Personnel
The personnel required varies with each operation. For major operations, besides the surgeon there will be needed his assistant and a surgical nurse at the operating table. For some cases a second assistant or even a third will be required, and often two or more surgical nurses (often called “scrub nurses”) will be needed. The surgeon’s assistant is another physician, often the patient’s family doctor, another surgeon, or a hospital resident surgeon or intern. The surgical nurses are registered graduate nurses with special training and experience in this nursing specialty. The anesthetist is always present, even when local anesthesia is employed. A constant watch over the patient’s general condition must be maintained. Often the anesthetist will have an assistant.
Besides those personnel who actually are at the table, there are those who must assist by operating all the accessory equipment, bringing in any additional instruments and supplies, and waiting on those at the table. These are called the circulating personnel and may number from one to four. Just as the scrub nurse waits on the surgeon, so the circulators wait on the scrub nurse. Everything is very formal, with the surgeon in complete charge. The only exception is when a physician-anesthetist relieves the surgeon of the anesthesia responsibilities, but even then close co-ordination of the performance of both is paramount.
It is the surgical nurse’s duty to see that all equipment necessary has been prepared, with the aid of her assistants. The surgeon tells her well in advance the general outline of the operation and of any special instruments or equipment needed. In this respect the surgical nurse is a specialist in her own field, and by training and experience has learned to prepare any instrument that the surgeon would possibly want. Similarly, the anesthetist assembles and makes ready all the anesthesia equipment and supplies. The anesthetist also sees that all drugs which may be used through the course of the operation are in the operating room ready for use.
No persons other than those who have a specific role to play in the operation are allowed in the operating room. In some training hospitals students and trainees are required to observe operative techniques of the experienced personnel, but a special section is provided for this, such as an amphitheater or a glassed-in observation chamber. Under no circumstances can relatives, friends, or curiosity-seekers be allowed in the operating suites. The psychological inference and serious breaches of techniques, if such were allowed, can well be imagined.
Surgery as practiced until the latter half of the nineteenth century was a distressing art and necessarily limited to a very few desperate operations. Complicatons from infection were common, and prolonged illnesses and crippling disabilities often resulted. Too often death ensued. But in 1857 a chemist named Louis Pasteur demonstrated the presence of bacteria, or germs, and showed them to be the cause of infection. He found that these organisms could be killed by heat and certain chemicals, and that preventing the organisms from entering wounds eliminated this undesirable tissue putrefaction. Soon other scientists directed attention to Pasteur’s work. Joseph Lister prevented surgical wound infections by using chemicals on the surgeon’s hands, the patient’s skin and incision, and all material used at the operation. He also used chemical sprays over the operative area. These were the first steps in the evolution of our modern concepts of prophylaxis in surgery. This was antiseptic (against infection) surgery.
Rather than attempting to kill the bacteria at the operative site, attention is directed at preventing their initial entrance into the area. This is called aseptic (without infection) surgery.
Chemical sterilization (killing all germ life) has been largely replaced by heat sterilization, insofar as is possible. Chemical means of sterilizing are still used on the patient’s skin and on all equipment which would be damaged by heat.
It has been found that when pressure is also used, a lower temperature is necessary to kill bacteria. In present-day surgery this method of sterilization is most practical. In the surgical preparation rooms large “ovens” called autoclaves furnish controlled heat, steam, and pressure to their contents. Instruments, linens, and all types of supplies are sterilized in these large pressure vats. Treating by chemicals and boiling is still necessary for many items, but most pass through the autoclaves. The technique and control of these operations is very exact, yet very complicated. Volumes have been written on this subject for operating room personnel. The handling of the materials after they have been sterilized is also highly technical.
Everything that is to come in contact with the operative area or that is to be handled by the surgeon or his aides must be rendered sterile and must be kept sterile. Nothing that is to come in contact with the incision or tissues can have any germs on it or touch anything that has not been sterilized. This includes all instruments, sutures, dressings, gloves, needles, drapes, and sponges.
Germs are on everything that has not been sterilized, so every surface must be protected against dissemination of its germs. This includes the operating room personnel. The persons at the operating table wear rubber gloves which have been processed in the autoclave to render them sterile. But as an added protection against the tearing of a glove or a minute imperceptible hole in a glove, the hands are scrubbed with soap and water and treated with chemicals beforehand. The precise technique of this hand scrubbing and preparation takes a full 10 minutes. A surgical cap is worn by all persons in the operating room to enclose the head and hair. A mask is worn by all over the nose and mouth to filter and deflect the germ-laden expired air. A long-sleeved sterile gown is worn over the clothing of all at the operating table. Freshly laundered and ironed operating room garments are worn by everyone who enters, to prevent relaying germs from the street and the rest of the hospital. Special ventilating units equip the operating room which do not communicate with the rest of the hospital, to keep the bacteria content of the air as low as possible.
The sterile supplies are brought into the operating room from the sterilizing rooms in large packages or bundles, which have been processed through the autoclaves. After a final check has been made of all the larger pieces of equipment which need not be sterile, such as suction machines, aspirators, electric cautery, and lights, the bundles are placed on the large surgical table and unwrapped. The outer coverings unfold in such manner as to provide the table cover, the top of which is thereby sterile with the supplies on it. After preparation of her hands, the surgical nurse then puts on her sterile gown and gloves. (Cap and mask are in place before she enters the room.) She then makes final check of all the sterile instruments and supplies, and places them in their correct position on the table for ready use.
Literally hundreds of instruments are at hand for a major operation. The surgical nurse covers a smaller instrument stand, which will adjust over the operating table, with a sterile sheet and then places on it the instruments to be used first. Throughout the course of the operation the larger surgical table will supply the smaller instrument stand as needed. Sterile tubing is connected to the suction machine, and similarly the leads for the electric cautery are connected.
The surgeon and his assistants then enter from the scrub room, where hands have been prepared, and don their gowns and gloves. If general anesthesia is employed, the anesthetist indicates when the proper level of anesthesia has been attained.
The patient by this time has been placed in the specified operative position. The position on the operating table depends on the operation and the physical condition of the patient. The final position may be assumed before or after the anesthetic is rendered, but usually before. When spinal or other regional anesthesia is used, a preliminary position is needed for this, and then the operating position adopted. The most frequent position is with the patient flat on the back with the arms at the side. This position is used for most abdominal and chest operations, as well as for most operations on the arms and legs. For pelvic operations the legs may be placed up in “stirrups” to expose the area. For operations about the head and neck the patient may be in a sitting or semi-sitting position. For kidney and some chest operations the patient is placed on the side with the hips and knees slightly flexed, and for operations on the back the patient lies on the abdomen with head turned to one side. Frequently the veins of the arms are used for drug administration through the course of the operation, so either or both arms may be extended out from the side on arm boards. Sometimes the position is changed during an operation, and operating tables are designed to tilt and bend for this, as well as to vary the height. Specific positions are used for each operative approach, but they may have to be adapted to the individual patient, such as an obese person. The patient’s arms are anchored to prevent his inadvertently touching the operative area or any sterile equipment. This may be done before or after the anesthesia.
The patient remains covered with sheet and blankets on the operating table. When all is in readiness and the anesthetist signifies that anesthesia is complete, the operative area is exposed and the skin preparation may begin. The preparation of the patient’s skin is an important part of the aseptic technique. The highest possible degree of cleanliness and disinfection is sought over an area considerably larger than that area of skin requiring exposure during the operation. Several agents and chemicals are used, but care is taken not to injure the skin in any way. They are applied by sterile sponges held with instruments. It may be done by the surgeon or one of the circulators. If the surgeon prepares the skin, he changes gloves before the next step, as a precautionary measure.
The patient’s body is then covered with sterile drapes, leaving a small uncovered area at the operative site. These drapes are often changed or others added during the course of the operation. If local anesthesia is to be used, this is then injected by the surgeon. If the patient is already asleep from general anesthesia, this is not necessary of course. The stage is now all set for the surgeon to make his incision.
The incision the surgeon makes has been carefully calculated. Not only is it devised to provide adequate exposure to accomplish the purpose of the operation, but it is also planned so as to damage the least amount of normal tissue and minimize disfigurement. The site of the incision is usually over the organ or tissues mainly involved in the surgical disease. But often the main incision will be somewhat removed from these tissues in order to avoid certain interposed vital structures or to gain approach from a different angle. The surgeon knows the normal anatomical position of each organ by its relationship to the bony parts (skeleton) and other surface landmarks. Any changes in size, shape, or position of an organ by a disease process have been determined by palpation (feeling) during the preoperative examinations and by special studies such as x-rays. Any gross changes in the tissues of course alter the surgeon’s choice of incision. Occasionally the site of the incision is changed to a location where less surface disfigurement will result; for example, tumors within the cheek may be removed through the mouth rather than from the outside to avoid a scar on the face.
The incision must be of sufficient length to provide adequate exposure of all parts involved in the operation. The surgeon cannot economize on the length of the incision at the expense of inadequate viewing and care of the tissues. A short incision is not always the mark of brilliant surgery. As each layer of tissue is incised it has to be retracted (pulled open) to expose the next layer. A short incision will necessitate so much retraction that the tissues are damaged by the forceful pulling on them. Actually more tissue damage will result from the stretching and tearing than from dividing them by cutting. Healing is prolonged and more surface and deep scarring results. Also the opportunity to inspect all tissues in the vicinity of the diseased parts may be obviated if exposure is not adequate. The surgeon may lengthen the incision at any time during the operation. Incisions heal from side to side, and the length of the incision has little bearing on the healing time. Long incisions heal just as rapidly as shorter ones. Moreover, two or more incisions require no more time to heal than one.
Whenever the incision is likely to become infected, such as those for the approach of an abscess deep within other tissues, the incision may be purposely short. Surface abscesses which will be left open, however, must have an incision of sufficient size for adequate drainage. For the most part, it may be said, long incisions are better than short.
The direction of the incision will depend on its location. The strain placed on the incision with body movements during convalescence is dependent on the direction the tissues were severed. The skin is incised in the direction of its cleavage lines (or “with the grain” as compared with wood). Muscles and fibrous layers are cut or split in the line of their fibers. Less strain, less tissue damage and scar, and hastened convalescence are the results of adhering to such principles whenever possible. In a few cases, however, it may be necessary to forego these in order to gain adequate exposure, which is of greater import. In some cases the skin and deeper layers are all cut in different directions. Abdominal incisions may be vertical or horizontal (transverse), or may be at any angle.
The incision is not the main part of the operation, of course. But in many cases the surgeon feels justified to give it the greatest consideration. In operations about the face, neck, hands, or other exposed areas, particular efforts are made to keep the skin scar and disfigurement at a minimum. The incision will be kept as short as possible. Greater damage to deeper structures and a much more difficult operation may ensue as the principle of adequate exposure is ignored. But the sacrifice usually pays great dividends by limiting disfigurement. Special attention is also attended the incision in its repair and after-care.
Control of Bleeding
Bleeding control throughout the course of the operation is of great concern. Every tissue of the body must have oxygen or it cannot live. The oxygen is brought to the tissues by the blood which circulates in the blood vessels between the tissues and the lungs. The pumping action of the heart propels oxygenated blood from the lungs to the tissues and then back to the lungs again for more oxygen. The blood vessels carrying the blood to the tissues are called arteries. These branch into many smaller tributaries like the branches of a tree until they are microscopic in size. The smallest of these are called capillaries. These connect to the smallest of the vessels which carry the blood back to the lungs for more oxygen. These are veins. The veins join onto larger and larger veins until they reach the main trunk leading back to the oxygen source.
The capillaries are minute and numerous. They are in the immediate vicinity of every cell in the body. The oxygen (and other nutrients) pass through the capillary wall by an osmotic process to bathe each cell with the vital substances it needs. The waste products of the cell also pass into the blood in the capillary. Similarly, the capillaries in the lungs make the necessary gaseous interchanges.
Whenever any tissue in the body is cut, the blood from the severed arteries, veins, and capillaries will exude. This is true, of course, in the surgical incision as well as the accidental one. This must be controlled through the course of an operation to avoid too great a blood loss, to avoid large blood clots from forming in the wound, and so that tissues can be visualized; yet, care must be taken to avoid impairment of the circulation to any tissue at the operative site or any tissue contingent upon the same blood vessels. It can be seen how cutting a large artery would stop the flow of blood to all its branches, and all tissues supplied by it would die. Likewise, injury to a vein would prevent the flow of unoxygenated blood away from the area so that oxygenated blood could enter.
The design of the vascular (vessel) system of the body must be well understood by the surgeon. All of the major and vital blood vessels and their tributaries are named for quick reference. It is fortunate that their patterns are as consistent as the organs and tissues they supply. During an operation avoiding injury to all the vital vessels is the primary means of controlling hemorrhage and avoiding death of a part (gangrene). Some tissues and organs have a dual (collateral) blood supply to their capillaries, and many areas in the body have a dual venous system for the return of blood to the lungs. In this instance a vessel can be sacrificed if necessary. But the surgeon must know what vessels can safely be spared.
It would be impossible to avoid all vessels in an area, of course, and many of the small tributary arteries and veins have no uniform anatomical course. Severing these smaller branches is of no consequence, as no damage results. Moreover, the smaller blood vessels in the body regenerate as healing takes place. But there is bleeding from these vessels as they are cut across. To control this a clamp called a hemo- stat, which looks like a small pair of pliers with a fine point and which locks closed, is immediately snapped onto each cut end of the severed vessel. At an opportune time, a ligature (strand or “string” of surgical tying material—see sutures, below) is tied (ligated) securely about the vessel and the hemostat removed. Special knots are used. The excess ligature is then cut off at the knot. This step may be necessitated many times during an operation, depending on its magnitude; for some, it is not uncommon to make more than a hundred ligations.
Another means of stopping the blood flow from the smaller vessels is by electrocoagulation. In this method the hemostat placed on the cut end of the vessel is touched momentarily with a lead connected by wire to an electricity source in the electrocautery machine. With the operating table grounded through the machine, heat forms at the tip of the hemostat which sears the vessel. The hemostat is then removed, and the coagulated end of the vessel inhibits further flow from the vessel.
The blood remaining in the tip of the vessel so ligated or coagulated soon clots. As in the process of healing, the clot and vessel in a few days become scar, and eventually shrivel to a microscopic strand of fibrous tissue. So there need be no further concern about these vessels.
Capillary bleeding stops almost immediately of its own accord. As the capillary is severed, it retracts just as a taut rubber band would when cut. As it pulls itself back into the adjacent tissues, its greater wall thickness and the pressure of its surrounding cells inhibit further flow through its lumen. There may be a small drop ooze from the capillary but usually not a consequential amount. Any undue amount of capillary bleeding is controlled by ligation or coagulation as the larger vessels are; but this is rarely necessary. In the healing process the capillaries form new “buds” which grow out in branches to connect between the smallest arteries and veins in the area. As they form their channels, a whole network of regenerated capillaries is created across the wound. When healing nears completion, any excess capillaries will shrivel away. This, of course, is all a microscopic process.
Throughout the operation the structures are all kept visible by blotting any escaped blood out of the wound, with surgical sponges. These so-called sponges are pieces of soft absorbent gauze. Many of these are used in the course of an operation. Just before closure of the operational wound a final check is made for any bleeding area. The wound must be totally “dry.” This is to assure that there will be no postoperative bleeding and that there will be no free blood or clots in the wound which would delay healing.
All vital structures at the operative site are carefully avoided. A knowledge of anatomy and the anatomical changes caused by the disease process, and careful dissection by the surgeon, assure preservation of all tissue which must not be injured. Of particular concern are the nerves in the area. No organ can function without an impulse from the brain directing it to. The impulse reaches each organ through the nerves leading to it. Nor can any sensation be realized without a nerve pathway to relay a sensory impulse to the brain. Therefore, particular care is attended the nerves so as not to “paralyze” any structures at the operative site or in a distant area. With modern technique and equipment, such nerve injuries as well as damage to other vital structures are extremely rare.
Repair by Suturing
All tissues which are divided throughout the operation are brought back into apposition with each other, and any anatomical changes required are so brought into union, so that they will heal readily and with attachment to the correct structures. This is done by actual sewing, or suturing. As a matter of nomenclature, to suture means simply to sew. The material used for this is called suture. It is threaded onto a needle just as with any ordinary sewing. The needles are of various sizes and shapes, the choice being dependent on the tissues to be united. The needles are usually curved and are handled with instruments. A variety of different stitches are employed; some are simple single loops through each edge to be joined, while others are complex interlacings designed to overlap or invert an edge, or the like. Some tissues will not readily unite with others, and some have to be approximated in a special way. The stitches are tied with secure knots, but care is taken not to strangulate the tissues. The number of stitches taken varies greatly in different operations, some necessitating well over a hundred. No record of the number taken is kept, as it would be of little actual value.
Ligature and Suture Materials. Ligatures and sutures are of several various materials. These may be discussed together, since they actually are the same except for their uses. Ligatures are ties for blood vessels and suture is the “thread” used for sewing. Some of the materials used are absorbable and some are nonabsorbable. The former is dissolved in the body while the latter is not. Absorbable suture is so selected and treated that it begins to disappear in the tissues at a specified time after healing is complete. A common absorbable ligature and suture is catgut. This is animal intestine which has been cut into narrow strips or threads and specially treated. It is so prepared by chemical processes that it will be dissolved and absorbed at a specified time. It is therefore designated as “7-day catgut,” “20-day catgut,” and so forth. There are other absorbable materials, most of which are from animal sources, which are available.
The nonabsorbable ligature and suture materials are those which will remain permanently in the body. They are not absorbed, but their presence in the tissues is of no consequence. They are selected and processed so that there is no tissue irritation and therefore no “foreign- body” reaction. There are numerous nonabsorbable substances used, which are derived from many sources. Some of the commoner ones are silk, cotton, nylon, and stainless steel wire.
Sutures and ligatures are supplied by the surgical supply companies in all the various calibers and strength. A system of nomenclature denotes all features. Some are supplied in sterile packages or tubes, while others are to be sterilized just prior to the operation. The surgeon’s choice of sutures and ligatures will depend on the region of the operation, the layers to be united, the physical state of the tissues, and the required strength.
In a few cases the surgeon may deem it necessary to leave an escape passage for the products of destruction of the disease process. This may be from an infection, an injury, or any case where there is tissue destruction. In the body’s defense against disease millions of white blood cells join in the battle to eliminate germs and particles of dead tissue. As these cells accomplish their mission, they die, to become the greatest component of “pus.” The process of healing is more rapid if these by-products of the disease are allowed to drain out of the region, rather than accumulate and wait for the slower process of absorption and excretion.
Therefore a drain may be placed in the vicinity of the diseased tissues. Not only are the products of inflammation allowed to escape but also any germs and toxins may be drained out. Drains are also left in the vicinity of any abnormal openings in body cavities which contain a fluid, such as the gallbladder, to prevent the accumulation of any substances which might hinder healing. The drain is a piece of soft rubber tubing, one end of which is placed into the area and the other brought out to the surface. This may be done through a small opening left in the operative incision, or through a separate small incision. The drain may be left in place from one day to two or more weeks, usually about two to three days. After it is removed, its tract collapses and heals. Extracting the tube is entirely painless.
Equipment Checks and Counts
Throughout the course of a major operation many pieces of equipment and materials are used. It may seem strange that anything could be “lost” in the patient, but such instances are not entirely unheard of. With the rapid handling of the many small items, keeping close track of all of them is often impossible. Therefore, to guard against such an occurrence, an inventory is made by the surgical nurse and her circulators while the surgeon makes final inspection of the operative area. This is done just before the surgeon begins closure of the layers of the wound. Of particular concern are the sponges used in the procedure, so a “sponge count” is always taken. The surgical nurse assures the surgeon that the count is absolutely correct before he begins closure.
Final Steps of Operation
Each layer of the operative wound is re-united separately, and as this nears completion the anesthetist lightens the anesthesia. When the skin is closed, a sterile dressing is placed over the incision. This is held until the drapes are removed, and then it is secured with adhesive tape. If a cast is required, as after certain operations on bones, it is applied over the dressing. The operation is completed. The patient is transferred onto the hospital cart and transported out of the operating room, in the same manner he was brought in.
Soon after the operation the surgeon dictates or writes a detailed account of the operative procedure. This, along with the anesthesia record, becomes a part of the patient’s chart. Every detail of the operation is included, with a description of all the normal and abnormal anatomy involved in the operation. This operative record may be invaluable to the surgeon or another physician in their care of the patient at a later date. It also provides the nursing staff who are to render postoperative care but were not present for the operation, with a detailed account of the operation and the anesthetic used.
Any tissues or organs removed at the operation are sent to the hospital pathologist for his interpretation of the disease process and microscopic analysis. Abnormal structures such as gallstones, kidney stones, or even foreign bodies, are also sent to the pathologist for analysis and interpretation. The surgical nurse and her staff see to it that such specimens are properly labeled and delivered to the pathology laboratories. The pathologist’s formal report is sent to the nursing station where it is attached to the patient’s chart.