O.T.

MANUAL

Operation theatre is sterilized by fumigation of formalin (running formalin machine) for 30

minutes with 200 ml of formalin solution.

O.T. is sterilized weekly twice, day before surgery by O.T. assistant.

O.T walls are cleaned with carbolic acid. Needles, scalpel, scissors are dipped in the Carbolic
Acid or Lysol, before using they are thoroughly rinsed in sterile water.

In Sterilization by steam in an autoclave (pressure sterilizer) air is evacuated and steam is

introduced under pressure and temperature is maintained at 120 Celsius for 30 minutes and
15 lb per sq inch pressure. 45 minutes boiling is used for sterilizing all blunt instruments and
rubber gloves.

Sharp instruments like knives, scissors, chisels, razors etc. are kept in antiseptic solution and
whenever required for use, rinsed properly in sterile water. These instruments are carefully
wrapped and autoclaved.

Used instruments are washed with warm water, dettol and savlon. Instrument trays are
prepared according to type of operation and these trays are placed in auto clave for
sterilization.

Different size bins are also prepared for sterilization of gowns, aprons, drapes, towels, sheets,
gauze piece, cotton, packs and mops. These bins are placed in autoclave for sterilization.

Drain, sutures, thread and needles may be placed in formalin chamber for sterilization.

A proper routine well planned preoperative procedure is applied in all patients.

Patient is admitted 2 days prior to operation. Internee/RMO takes proper history of the case
and carries out thorough examination.

Vitals are being checked and routine blood investigation (Hb%, TLC, DLC, ESR, B.T/C.T,
blood grouping and cross matching (if required), urine routine, Blood Sugar, HbsAg, HIV
I&II) are done.

The field of operation is always examined carefully to exclude any septic spot if present it is
treated first. The patient already dressed is received at the O.T reception.

The patient is brought to reception by ward boy, and then the patient is taken by O.T. staff
and directed towards the O.T. table under observation. Before entering Operation Theatre I.
V. line (if required) is established and premedication if any recommended is given and pre-
operative vitals are recorded.

Surgeon and his assistant adopt full aseptic precautions before starting the surgical procedure.
Surgeon puts on the vest, the trouser and the shoes particularly kept for him in the O.T. He
also wears the cap and mask.

Surgeon and his assistant do scrubbing or washing in running water with liquid soap and
chlorhexidine up to well above the elbow with particular care to the nail, creases and webs of
the hands. It takes 10-15 minutes.

Gown is worn only after hands are dried in the sterile towels. He puts on the gloves of exact
size. Now the hand is not hanged down. The hands are held in front of the chest with folded
elbow. The skin is prepared in the evening before operation well beyond the field of
operation.

The skin is first scrubbed thoroughly with soap and water taking special care for the fold and
crevices, the skin is then shaved. After the patient arrives at the operation table, the operation
site with good surrounding area is painted with 30% savlon or 1% iodine with the help of
sponge holding forceps and gauze piece.

The patient is operated as per standard operative technique recommended for that particular
disease by the qualified surgeon. The patient is then taken out from O.T. and is kept under
observation for about 2 hours, immediately the vitals are recorded and when the patient is
stable he is shifted to post-operative ward.

PREPERATION OF THE PATIENT FOR THE ABDOMINAL INCISION

Before going for scrubbing the surgeon should quickly go through the history sheet and
investigations of the patient.

Position of the patient

After being anaesthetized, it is of utmost importance to position the patient properly. This
will not help the surgeon to operate on the patient, but also access to the pathological organ
will be easier.

For operation on the urinary bladder and prostate, the patient is placed in trendelenburg
position, therefore leaving the urinary bladder free for operation.

Shoulder rests are generally used to prevent the patient from sliding downwards.

For operation on kidney, patient lies on his sound side with his back brought well over
towards the edge of the table. The loin over lies the bridge of the table can be screwed up to
increase the space between the costal margin and the iliac crest.

To maintain the stability of this position, the lower hip and the knee are kept fixed and the
upper leg is extended over them. Sandbags are kept in position with a wide strapping to
prevent from rolling over. The lower arm is pulled forward so that the patient does not lie in
it. The upper arm is supported on an arm rest to prevent the shoulder from sagging forwards
and to relieve the chest of compression by the weight of the arm.

For haemorrhoidectomy patient is placed in lithotomy position. Other operations of the

abdomen are usually done in spine position.

Preparation of the skin:

Before every operation the operating field is painted with an antiseptic solution applied on
gauze, held in long swab-holding forceps. Firstly, the solution is painted along the line of the
incision and continued to apply it in a centrifugal manner over a wide area which should be
from the level of the nipples to the groin in case of upper abdominal incisions, from the level
of the xiphoid process to the upper part of thigh in case of lower abdominal incisions and
from the level of the umbilicus to the mid-thigh in case of inguinal hernia incisions.

Draping of the abdomen:

Sterile sheets are applied leaving the line of proposed incision. The towels are clipped to the
skin with towel clips, but when local anaesthetic is used, the towels are clipped to each other.
An adherent transparent sterile plastic sheet (steri-drap) is applied on the exposed skin and
the surrounding towels so that no exposed skin is left.

OPENING OF ABDOMEN

After cleaning and draping the skin of the abdomen is incised by any of the incisions with the
belly of the knife.

A clear perpendicular cut is made right down through subcutaneous tissue to the anterior
rectus sheath or aponeurosis.

The inner aspect of the two margins of the incision are picked up with the tissue forceps and
retracted.

The bleeding vessels are held by artery forceps and tied with chromic catgut.

The incision is gradually deepened to expose the intact vessels, which are held by artery
forceps first and then divided till they reach aponeurosis. This definitely lessens the bleeding.
Again, some surgeons prefer to use diathermy coagulation instead of ligatures. Now the
muscles are dealt according to the incisions to reach the peritoneum.

While opening the peritoneum, care must be taken not to damage the underlying viscous.
Firstly, a small bite of peritoneum is taken with a pair of artery forceps and held up. This will
form a tent with another pair of artery forceps the side of the tent is caught with a small bite
and held up, so that no viscous is caught within the bite. To be sure of this, one can feel the
side for the tent first before applying the artery forceps. The first pair artery forceps is now
released and grasped. The first pair of artery forceps is now released and re grasped. This
change of grip will allow the viscous to escape if it be caught by the first application of the
forceps. The tent of peritoneum, held between the two pairs of artery forceps, is boldly cut
with the belly of the knife. The upper of the wound is retracted to expose the peritoneum
which is incised between the two fingers insinuated through the rent in the peritoneum. The
fingers protect the viscera from being injured inadvertently. Now the lower end of the wound
is retracted and similarly the peritoneum is also cut with a pair of scissors right up to the end
of the incision.

ABDOMINAL INCISIONS

Midline Incision:

This incision offers equal access to both sides of the linea Alba. In this incision, the skin,
subcutaneous tissue and linea alba are divided to expose the transversalis fascia, which covers
the peritoneum. Tranversalis fascia and peritoneum are divided in one layer. So practically
the incision goes through three layers- The skin, the linea alba and the peritoneum covered by
transversalis fascia. Closure of the incision is performed by suturing three layers- the
peritoneum with transversalis fascia, the linea alba and the skin. Traditionally the peritoneum
and transversalis fascia are sutured with round bodied needle and number zero (0) catgut.
Cutting needle and number one (1) catgut are used for suturing linea alba. For skin, straight
cutting needle and black silk are used. Sometimes tension sutures may be required if there be
difficulty in bringing together the layers. These tension sutures are applied before the linea
alba is sutured.

a. Paramedian Incision:

This incision is made parallel to the midline at a distance of about one inch lateral to it. The
skin, subcutaneous tissue and anterior rectus sheath are divided along the line of the incision.
The medial margin of the divided rectus sheath is held by a few artery forceps and lifted up.
With sharp dissection the tendinous intersections are divided. So that the rectus muscle
becomes free from its anterior sheath. The rectus muscle is now retracted laterally thus intact
its nerve supply to expose the posterior rectus sheath. The posterior rectus sheath, the
transversalis fascia and the peritoneum are incised in one layer, in the line of incision. The
incision is closed in three layers.

b. Rectus Muscle Splitting Incision:

This incision is made about a 3-4 cm lateral to the midline; the skin subcutaneous tissue and
the anterior rectus sheath are divided along the line of incision. The rectus muscle is split
longitudinally along the line of the incision and finally the posterior rectus sheath,
transversalis fascia and peritoneum are divided in one layer. Closure is done in three layers.

c. Oblique Subcostal Incision (Kochers’s):

This incision provides good access to the upper abdominal organ such as gallbladder and bile
duct on right side and spleen on left side. This incision gives a better access in obese patients
with wider costal angles. Incision starts in the midline just below the xiphoid process and
runs downwards and laterally about 2cm below and parallel to the costal margins. The skin,
subcutaneous tissue and all the muscles including the rectus are divided along the line of the
incision. Obviously, the peritoneum is also opened through same line. Though few
intercostals nerves are damaged in this incision, yet no weakness of the scar is found
practically. So this incision is attaining popularity for gallbladder operations. Closure is
carried in three-layer fashion. Drain is placed in hepatorenal pouch of Morison. But this drain
is inserted through a separate stab wound lateral and below the Kocher’s incision.

d. Grid Iron Incision:

This muscle splitting incision is commonly used for Appendicectomy. The main advantage of
this incision is that it does not damage any nerve and being muscle splitting it heals quickly.
Inadvertently the subcostal nerve may be injured giving rise to inguinal hernia, but this is
very rare. The incision is oblique one and perpendicular to the right spinoumblical line
(which extends from the right anterior superior iliac spine to the umbilicus) through
McBurney’s point (i.e. the junction between lateral third and medial two-third) of about 3-4
inches in length, whose one third will be above the spinoumblical line and two third below
the same line. Though this is the classical position of McBurney’s Gridiron incision, yet the
surgeon should try to feel the caecum first before planning the position of the incision, as
sometimes the caecum with appendix may lie higher up or even subhepatic. The skin, fascia
of Camper and fascia of Scarpa are incised along the line of the incision. The fibres of
external oblique aponeurosis will be seen running along the line of incision. They are simply
split. The two margins of the divided aponeurosis are retracted. The muscle fibres of the
internal oblique will be seen running perpendicular to the line of the incision. These fibres
and the muscle fibres of the transverses abdominis are running in the same direction and
should be split by inserting the tip of the artery forceps and then opening it by handle of the
scalpel.

e. Rutherford Morrison’s Muscle Cutting Incision:

As the name suggests this is a muscle cutting incision. Otherwise it is similar to the
McBurney’s Gridiron incision. The skin and the superficial fascia are incised along the same
line as in McBurney’s incision. The muscles are cut along the line of the incision to get
access to the peritoneum. The incision is mainly used for exposure of the ureter and can be
performed on both sides of the abdomen. This is also used for exposure of the external iliac
vessels. Closure is carried in the same way as has been described in McBurney’s incision.

f. Lanz’s Incision:

This incision is the cosmetic counterpart of McBurney’s incision. This is mainly employed in
performing Appendicectomy. Instead of making an oblique incision, as the gridiron, a
transverse incision is made on the interspinous crease. The deeper layers are incised and split
in the fashion as that of McBurneys incision.