Sterilization
By:
Dr. Yasser El Basatiny
Prof. of Laparoscopic Surgery
Antisepsis
• Definitions:
Antisepsis = against putrefaction
To eliminate or reduce the germs
• Antisepsis: use of antimicrobial chemicals on
human tissue
• Disinfection: use of antimicrobial chemicals on
inanimate objects
Historical background
• In 18th and 19th century , serious infections among
hospitalized patients, morbidity and mortality was very
high nearly all trauma and surgical wound got infected
and suppuration
• Hand wash and clothing change policy reduced
maternal mortality from 11.4% in 1846 to 1.3% in 1848
• Pasteur’s discovered bacterium and it’s role in wound
infection.
• Lister published 1st antiseptic principle in 1867
• Kocher reported 2.3% infection rate in clean wound by
1899.
Aseptic technique
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Hygienic hand wash
Preoperative preparation of patient’s skin
Gloving
Sterile draping
Isolation precaution
Autoclaving of instruments
Proper waste disposal
Principles of sterilization
Operating room:
• Minimum size is 5x5 meter
• Appropriate ventilation, changing room air 20 to
25 times per hour.
• Passing inflow air through “high efficiency
particulate air” HEPA filter
• All doors of OR. should be closed
• Air pressure should be positive
The primary source of perioperative infection is the
patient and the secondary source are the OR team
A CFD simulation of a Cleansuite installation in an operating room shows
laminar air flowing from diffusers in the ceiling, down and away from the
patient, and out vents near the floor
Patient as a source of infection
Wounds:
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Clean wounds
Clean contaminated
Contaminated
Dirty
Intrinsic resistance to contamination
• Age, obesity, diabetes, cirrhosis, uremia and
immunodeficiency.
Methods of sterilization
• Iodophors (Betadine) broad spectrum
antimicrobial against fungi, viruses, gram
positive and gram negative.
Operative team
• Scrub the hands and arms with antiseptic
solution like iodophors and chlorhexidine
• Face mask over the mouth and nose, head
cover and shoe covers
• Disposable sterile gloves
• Sterile gown: impermeability to moisture.
• Sterile drapes impermeable to bacteria
Methods of sterilization
• Steam heat (Autoclave)
• Chemical solution: used for instruments
tolerate moisture but not heat. 2%
glutaraldehyde
• Dry heat: for items can tolerate heat and not
penetrated well by steam
• Gas sterilization: for delicate instruments
Autoclave sterilizer
Surgical technique
Gentle handling of tissues, careful hemostasis and
appropriate irrigation.
• Incisions: along normal skin line, adequate
exposure, same incision in reoperation
• Atraumatic handling: minimize necrosis of skin
margin
• Dissection: least amount of trauma in dissecting
in natural tissue planes
• Debridement: the most important single factor in
management of contaminated wounds
Surgical technique
• Hemostasis: to minimize blood loss and
prevent hematoma formation
• Wound closure: primary closure for clean
wounds, delayed primary closure should be
considered on or after 4th day in contaminated
wound
• Suturing: simple interrupted sutures, mattress
suture, subcuticular suture
Surgical technique
• Dressing: protect the wound from mechanical
trauma and bacterial invasion, sterile dressing
applied before removal of drapes, moist dressing
speed up epithelization 10 folds, infected wounds
needs dressing that absorb exudates.
• Immobilization: it reduce lymphatic flow and
minimizing the spread of wound flora, more
resistance to bacterial growth, elevation reduces
interstitial edema.
• Suture removal: proper timing for suture removal
• Prophylactic antibiotics: before skin incision
Operative equipments
Electrocautery:
• High frequency alternating
current
• For hemostasis and incise
tissue
• Unipolar, rapid
dehydration of the cell and
the blood vessels within
the tissue coagulate
• Bipolar, more precise and
confines the damage to
the tissue between the tips
of forceps
Operative equipments
Argon beam coagulator (ABC):
• For parenchymatous organs, unipolar coagulation non
touch technique. Less depth of penetration 2-3 mm
Surgical lasers:
• Argon Laser, ophtalmogic tratment and vascular
anastomosis.
• CO2 Laser, to cut tissue
• Nd:YAG Laser, flexible quartz fiber can be used for
paranasal sinus and tracheobronchial tree
• Er:YAG Laser, very strongly absorbed by the water of tissue
can vaporize cartilage, fibrous tissue and bone
Harmonic scalpel
• Use of ultrasonic power for cutting and coagulation
Sutures and needles
Needles
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Open French eye needle
Swaged on needle (eye less)
Straight or curved
Cross section: can be round triangular or
flattened
• Needle point: cutting, tapered or blunt
Sutures and needles
Absorbable sutures
• Absorption and disappearance of the suture from the tissue
implantation site
• Catgut: made from the intestine of cattle or sheep,
absorption of plain catgut is about 10 days. Chromic catgut
(treated by chromium salt) its absorption is delayed up to
20 days.
• Polyglycolic acid (Dexon): absorbable braided, synthetic
suture, higher tensile strenght, reabsorption by hydrolysis at
60 to 90 days.
• Polyglyconate ( Maxon): synththetic monofilament.
• Polyglactic acid (Vicryl): braided synthetic suture, very high
tensile stenght, absorbed in 60 days
• Polydioxanone (PDS): monofilament absorbable
Sutures and needles
Non absorbable sutures
• Silk: protein filament from the silkworm larva, dyed,
treated by polybutilate and braided. Good tensile
strength
• polyester (Dacron): superior strength and durability
• Nylon: synthetic polyamide polymer, monofilament
and multifilament.
• Polyprolene (Prolene): monofilament, minimal tissue
reaction
• Stainless Steel: low carbon iron alloy, monofilament or
multifilament. Used for bone suturing
Sutures and needles
Staplers
• TA Instruments: linear everting double line,
length 30, 55, 90 mm. staple size 3.5 and 4.8 mm.
3.2 mm for vessel closure.
• GIA Instruments: two double rows of staples and
divide the tissues in between.
• EEA Instruments: end to end or end to side
circular staplers
• Skin staples: speed of skin closure and efficacy.
Drains
Historical aspects
• Dates back to Hippocrates
• Metal tubes, glass tubes, bone, gauze and
combination of gauze and rubber
• Tapered lead and bronze tubes to drain
abdominal cavity by Celsus in 1st century
• Penrose drain 1890, cigarette drain 1897
• Air vent suction by Heaton 1889
Principles of wound drainage
• To drain cavity or soft tissue to prevent
collection of serum or blood
• It is not a substitute for hemostasis or
meticulous technique
• Either passive or active, prophylactic or
therapeutic.
• It should be soft, nonirritating, firm, smooth
and resistant to decomposition.
Types of drains
Penrose drain (obsolete)
• Efficient but there is significant risk of secondary
infection.
• Soft, flexible latex rubber wick
• To drain purulent material, blood or serum from
body cavity
• Brought out through a separate stab at
dependant area
• Anchored to the skin with a non absorbable
suture
Types of drains
Closed suction drain
• Lower infection rate, might clog and cease
function
• Firm multi-holed catheters made of polyvinyl
chloride or silicone.
• Effective to drain soft tissue under large skin
flaps
Types of drains
Sump drain
• Large and bulky
• Double or triple lumen allow irrigation and
aspiration
• Rely on continuous flow of air from outside
predisposes to secondary infection.
• Less likely tissue occlusion
• For high volume enteric fistula
Types of drains
Closed suction Penrose drain
• Combination of closed suction drain and Penrose
drain which uses capillary action
• Low secondary infection, effective in abdominal
cavity
• Ideal drainage system
Percutaneous catheters
• Inserted by radiologists CT or US guided to drain
accessible localized collection
Minimal invasive surgery
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Laparoscopic surgery
Thoracoscopic surgery
NOTS “natural orifice transluminal surgery
Single port laparoscopic surgery
Minimal invasive surgery
• To reduce tissue injury, fast post operative
recovery, short hospital stay
• Pneumo-peritonium to create room to work
Thank you