INTRAOPERATIVE

PHASE
Operating Room Set Up
Villa San Agustin OR 1
VSAC OR 2
Villa San Agustin OR3
 INTRAOPERATIVE PHASE

THE SURGICAL TEAM

– personnel performing direct
patient care during a
surgical procedure in both
the sterile and non sterile
positions.
Members of the Surgical Team

a. Sterile Members
1. The Surgeon
2. First Assistant to the
Surgeon
3. The Scrub Assistant
 The Surgeon
 Performs the surgical procedure & heads the surgical
team.

 The primary decision maker regarding surgical

technique to use during the procedure

 May assist in with positioning & prepping the patient or

may delegate this task to other members of the team

 He/she is a licensed physician (MD), osteopath (DO),

Oral surgeons (DDS or DDM)

 Qualification include certification from a specifically

board, adherence to Joint Commission on Accreditation
of Healthcare Organization (JCAHO) standards

 Adherence to Hospital standards & admitting practices

& procedures
 First Assistant to the Surgeon
 may be a resident, intern, physician’s assistant or
a perioperative nurse

 practice under direct supervision of the surgeon

 Responsible in handling tissue, providing

exposure at the operating field, suturing,
providing homeostasis & other tasks requested by
the surgeon to facilitate speed while maintaining
quality during the procedure.

 needs to be aware of the objectives of the

surgery, needs to have the knowledge & ability to
anticipate needs & to work as a skilled member of
a team, and needs to be able to handle any
emergency situation in the OR.
 The Scrub Assistant
> may either a nurse or a surgical technician
Activities include:
– performing a surgical had scrub,
– setting up the sterile tables,
– preparing sutures, ligatures, sponges & special
equipment
– maintaining the sterility of the surgical field through
aseptic practices.
– Assist the surgeon & surgical assistants during the
procedure by anticipating the instruments that will
be required
– As the operation is about to close, the scrub person
& the circulator counts all needles, sponges, &
instruments to be sure all are accounted for & not
retained as foreign body in the patient.
– Tissue specimen obtained during the surgery must
be labeled by the scrub nurse/person & sent to the
laboratory by the circulator
 The Unsterile Members
Circulating
Anesthesiologist/ Anesthetist Nurse
1. ANESHESIOLOGIST – is a physician who
specializes in the administration & monitoring
of anesthesia while maintaining the overall
well-being of the patient. A physician who
specifically trained in the art & science of
anesthesiology
2. ANESTHETIST – a qualified health care
professional who administers anesthetics
– Interviews & assess the patient prior to
surgery, selects the anesthesia, administers
it, intubates the patient if necessary,
manages any technical problems related to
the administration of the anesthetic agent.
– Supervises the patient condition throughout
the surgical procedure
– Reassess the patient physical condition
immediately prior to initiating the anesthesia
– During surgery: monitors the patient’s blood
pressure, pulse & respirations as well as the
ECG, blood oxygen saturation level, tidal
volume, Blood Gas level, Blood pH, alveolar
gas concentrations & body temperature.
Anesthesia Machine
3. CIRCULATING NURSE (Circulator)
- an RN w/ additional education & training or
specialization in perioperative nursing practice.
– Manages the OR & protects the patient’s safety & health
by monitoring the activities of the surgical team,
– checking the OR conditions
– continually assessing the patient for signs of injury &
implementing appropriate interventions.

– Main responsibilities:
 Verifying consent, coordinating the team by managing
the flow of information to and from the surgical team
members scrubbed at the field & ensuring cleanliness,
proper temperature, humidity & lighting, the safe
functioning of equipment & availability of supplies &
materials.
 Monitors aseptic practices to avoid breaks in technique
while coordinating the movement of related personnel,
as well as implementing fire safety precautions.
 Monitor the patient & documents specific activities
throughout the operation to ensure that patient safety &
well-being.
 Nursing activities directly relate to preventing
complications & achieving optimal patience outcomes.
*Paraprofessional /
Ancillary Positions

1. Sterilization, processing &

distribution (S.P.D.) technicians
(instrument room aids)

2. Orderlies/nursing assistants

3. Environmental services personnel

4. Clerical personnel
 provide effective barrier that prevent
dissemination of microorganism to
patient

 Prohibits contamination of surgical

wound & sterile field by direct contact

 Protects personnel from infected

persons
 Invasive Attire
 involves entry into the tissue,
organs or body cavities in the OR,
DR, ER, physician or dentists
offices, radiologist department or
cardiac laboratory.
 Any procedure during which
bleeding occurs or potential for
bleeding exists.
– Apron – fluid resistant
– Eyewear/Face shields
– Gloves
 Sterile
 Unsterile
Different Scrub Suits
 Areas of the Operating Room
a. Unrestricted

b. Semi-restricted

c. Restricted
 Application of Principles of Aseptic &
Sterile Techniques

 Asepsis
– defined as absence of infectious or disease producing
microorganism
 Types of Asepsis
1. Medical Asepsis
> exclude or reduce the number and transfer of
pathogens
> clean technique (handwashing)
2. Surgical
> renders & keep objects & areas free from
microorganism
> sterile technique
– Required for
 All surgical procedures
 All procedures that invade the blood stream
 Procedure causing a break in the skin or mucous membrane (e.g. IM
injection)
 Complex dressing changes and wound care
 Insertion of tubes, catheters r devices into sterile body cavities (e.g. urinary
bladder)
 Care for high risk groups ( e.g. transplant recipients, burns)
 Aseptic Technique
 practice that restricts microorganism in the environment,
equipment and supplies. Controls the environment.
– Goals
 Each aseptic practice is to optimize primary wound healing
 Prevent surgical infection
 Minimize length of recovery from surgery
Sterile Technique
– prevents transfer of microorganism into body tissue
Infection
– invasion and proliferation of microorganism in the tissue
Sepsis
– presence of infection
Intact skin & mucous membrane
– body’s first line of defense
 Types of Microorganisms
that inhabits the skin

a. Transient – acquired by direct contact (temporary like

scabies, fungal infection)
b. Resident – below the skin surface (like staphylococcus,
E. Coli)
 Process used in Removing
Microorganisms

a. Mechanical – removes soil and transient organism by friction

1. Handwashing – single most important infection control practice

2. Surgical Handscrubbing
– process of removing many microorganisms as possible from the hands
and arms by mechanical and chemical asepsis before a particular surgical
procedure
– done before donning on the sterile gown and sterile gloves
Handwashing Handscrubbing
 PREPARATION FOR SURGICAL SCRUB

 Do: Properly trim nails

Clean under nails
 Don’t: Don’t have long nails
Don’t wear jewelry or watches
 Methods of Surgical Handscrubbing

1. Anatomical Timed Scrub

– scrub from the nails, fingers each side and
web space, palm, dorsal surface and
forearm for around 5 minutes. Scrub
vigorously using vertical strokes.
2. Counted Brush Stroke
– starting from the fingertips, scrub each
anatomical area for the designated number
of strokes according to policy.
 SCRUBBING GOWNING CLOSE GLOVING
 Types of Gloving
Open Gloving Closed Gloving
b. Chemical – reduces resident flora & inactive
microorganism with a microbidicidal or antiseptic agent.

Types of Antiseptics
1. Chlorhexidine gluconate
2. Iodophores
3. Triclosan
4. Alcohol
5. Hexaclorophene
 Principles of Aseptic Technique
1. All articles used in an operation have been previously sterilized.
2. Persons who are sterile touch only sterile articles and vice versa.
3. If in doubt of the sterility of anything, considers it not sterile
4. None-sterile persons avoid reaching over a sterile field, sterile person avoid
leaning over a non-sterile area (1 foot away)
5. Tables are sterile only at table level (top)
6. Gowns are considered sterile only from waist to shoulder level in front and
the sleeves.
7. The edge of anything that enclosed sterile content is not considered sterile.
8. Sterile persons keep well within sterile areas.
9. Non sterile persons keep away from sterile area.
10. Sterile person keeps contact with sterile areas to a minimum.
11. Moisture may cause contamination.
12. When bacteria cannot be eliminated from a field, they must keep to an
irreducible minimum.
 Skin Preparations
 Decreases the number of bacteria on the patient’s skin, thus decreasing
the chance of the patient acquiring a post operative wound infection.

 Duration usually is 5 minutes depending on the size of the area to be

prepped.
 Always start the prep at the incision site, working to the outer
boundaries. Boundaries are bedside to bedside; nipple line to mid thigh.
 New sponges should be used when returning to incision site (cleanest to
dirtiest)
 Should be done with firm but not rough movements. Observe for skin
reactions.
 Skin prep is institutional. Latest practice is the 12 balls technique.
 Nurse must not reach over the prepped area.
 Draping
 Draping of the operative area is done immediately after the skin
preparation is completed.
– Special consideration: If surgery is on an infected area or an
area where there are increased number of bacteria (e.g. rectal,
perianal, etc.) skin prep must be modified.
– Bacteria must not be spread over a cleaner surface from an
infected or dirty area even though the incision site is in the
unclean area. Therefore, skin preparation starts from the outer
boundaries, working towards the incision site.
 Arrangement of Instruments
in Mayo Tray
The Doctors’ Hospital Inc.
Arrangement Major Set
 6 Kelly Straight Forcep
 12 Kelly Curve Forcep
 1 Mets Scissor
 1 Mayo Scissor
 1 Scalpel Holder #4 w/ blade
 1 Scalpel Holder #3 w/ blade
 2 Tissue Forcep w/ Teeth
 2 Tissue Forcep w/o Teeth
 1 Allis Forcep
 1 Babcock
 2 Army Navy
 3 Rolled Gauze
 Arrangement of Instruments in Kidney Table

The Doctors’ Hospital Inc. Other Instrument and Supplies in the

Arrangement Kidney Table
 1 Instrument Holder
 5 Kelly Curve Forcep
 1 Adson Forcep w/ Teeth
 3 Needle Holder
 2 Babcock
 5 Towel Clips
 1 Long Tissue Forcep w/ Teeth
 4 Rolled Gauze
 10 Cherries
 3 Bowls
 4 Small Towels
 Drapes, Lap Sheets ,Gowns
 Gloves
 Arrangement of Instruments in Mayo Tray
Corazon Locsin Montelibano Memorial
Regional Hospital Arrangement Major Set for General Surgery

2 Allis 1 Army Navy

2 Straight Forcep 1 Richardson Retractor
8 Curve Forcep 1 Deaver Retractor
2 Tissue Forcep w/ teeth 2 Ovum Forcep
1 Tissue Forcep w/o teeth 2 Needle Holder
1 Mayo Scissor 10 4x4 Sponges
1 Metz Scissor 1 Bowl
1 Scalpel Holder #4 w/ blade 1 Suction Tube w/ Tip
1 Scalpel Holder #3 w/ blade 1 Cautery Tip
Serving Instruments to Surgeon
 Categories of Surgical Instruments
1. Sharps – usable part has a sharp, or cutting edge
a. Scalpel – incising tissues; dissection
b. Dissecting scissors – dissection
Curved mayo (heavy) - heavy or tough tissue
Metzenbaum (narrow) - delicate tissue
Straight Mayo - to cut sutures
2. Clamps – used for hemostasis. May be used as graspers or retractors
a. Straight clamps
b. Curved clamps
3. Graspers or Holding Instruments – commonly used to grasp and hold tissues as in
retraction for suturing.
4. Retractors – used to hold tissues away from the operative site.
a. Self-retaining
b. Non-self-retaining
Different Types of Scalpel Blades
Scalpel Holder & Blades
 Clamps
> used for hemostasis. May be
used as graspers or retractors

a. Straight clamps

b. Curved clamps
 Graspers or Holding Instruments
> commonly used to grasp and hold tissues as in retraction for suturing.
 Retractors
– used to hold tissues away from the operative site.
a. Self-retaining
b. Non-self-retaining
 Classification of Suture Needles
1. Cutting needles – used for
stitching the tough structures
like the skin and the fascia
2. Round needles – used for
suturing soft an delicate
structure
3. Straight needles – used for
giving mattress in the skin
 Sutures
 used to tie off a clamped vessel to prevent
bleeding & approximate tissue
– Factors in influencing the choice of sutures
used in surgery:
 Desired length of time sutures is to
remain in place whether to be absorbed
or not.
 Types of tissue to be sutured. Some
tissues absorb suture faster than others.
 Nutritional status of patient. Absorb
faster (malnourished, older, anemic or
obese)
 Disease condition present. Increased
when infection is present.
 Clasification of Sutures
1. Absorbable – digested by body enzymes during wound healing
a. Surgical gut / catgut – made from sheep intestine
Plain – used in tissues like the subcutaneous that will
heal rapidly (10 days)
Chromic – used for tissues such as the muscle &
peritoneum that require longer added support
(20 days)
Collagen – made from deep flexor tendon of cattle
Synthetic – Dexon/Vicryl
Dexon – has minimal absorption at 15 days and
maximal absorption in 30 days
2. Non absorbable – made from various material not affected by
body enzymes (Ex. Silk, cotton, prolene, ethilon, Dacron,
nylon, polyethelene, Ti-cron, Tevdec)
 Methods of Closure

1. Continuous – running stitch, tied at

the ends of the incision only

2. Interrupted – each stitch is taken

and tied separately
 Stapler

3. Subcuticular – stitches are beneath

the skin
Other types of Wound Closure
 Types of Needles used in Suturing or Closing
of Wound
1. Traumatic – needle with a
hole, a suture is guided into
the eye of the needle

2. Atraumatic – needle with a

built-in suture, ready to use
– needle and suture us one
continuous unit.
 Tissue Layer of the Abdomen
1. Skin
2. Subcutaneous
3. Fascia
4. Muscle
5. Peritoneum
 Different Incision Sites
 Collar - Thyroidectomy
 Sternal split – Cardiovascular surgery, thoracic surgery like
lobectomy
 Subcostal – Gallbladder & biliary
 Right Rectus – Appendectomy, small bowel resection
 Mc Burney - Appendectomy
 Pfannenstiel – Gynecologic surgery
 Midline – Female reproductive tract, Exploratory
Laparotomy
 Right Paramedian – Gallbladder, biliary
 Left Paramedian – Spleenectomy, Gastrectomy, Hiatal
Hernia repair
 Transverse -Gastrectomy
 Sterilization
 complete destruction of microorganism
 complete sterilization of instruments & equipments is
used in the surgical practice
 there is no midway between sterile and unsterile
 Sterilization by Heat
1. Autoclaving (moist heat) or steam under
pressure
> most effective means of sterilization
steam kills organism by coagulations of the cell
protein
suitable for fabrics e.g. gowns, towels, dressings
and instruments
2. Dry Heat
> kills microorganisms by oxidation (exposed at
160ºC or 320ºF for 1 hour) suitable for all types
of glassware and some instruments
3. Boiling
> all pathogenic organism in their vegetative
form and many spore forms are killed by 5
minutes immersion in boiling water, although
there are resistant spores that withstand long
periods of boiling