Surgical Techniques

For 3rd year medical students

Institute of Surgical Research

University of Szeged, Medical Schoool
Hungary

2005

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1. Asepsis and antisepsis
1.1. Historical overview
19th century surgery has faced with four classic difficulties. Pain, infection, obsolete
technology and the enigmatic pathophysiological changes of the perioperative period were the
greatest obstacles. By the end of the century of surgeons three problems were solved, and
modern clinical surgery was born. The first milestone was reached on October 16, 1846 in the
Massachusetts General Hospital, when a patient of John Collins Warren (17781856) was
successfully narcotized by ether by William T. G. Morton (1819-1868) a dentist from Boston.
Within some weeks, on December 21, 1846, Robert Liston (17941847) applied ether narcosis
in London. Hungary kept in line with the developments. Lajos Markusovszky (1815-1893)
tested the ether narcosis in Vienna on January 25, 1847, and then he performed an operation on
February 8, 1847 together with Jnos Balassa in Budapest. Narcosis has quickly become a
relatively safe and generally accepted method in surgery. Vilmos Vajna reported on the 3-years
statistics of the German Surgical Society in the Hungarian Medical Weekly Journal in 1893
(the foundation of the journal (1857) and the Hungarian Medical Publishing Company (1863)
was also the merit of Markusovszky); 3098 cases were anesthetized with only one death. A new
era commenced; hence the duration of the operation was not delimited by pain.
Initial attempts to prevent wound infection were not that successful. Surgical incisions were
still followed by irritative fever, which sometimes lasted only for few days and accompanied
by pus bonum et laudabile (good and commendable pus, sec. Galen) but even the most brilliant
surgeons had to take into account the possibility of fatal postoperative infection. The terms
hospitalism and hospital gangrene were used to denominate postoperative infections. The
frequency of these infections is well-demonstrated by the incidence of the puerperal fever. The
average death rate was 9.92% in the Department of Obstetrics at the Allgemeines Krankenhaus
in Vienna, but in certain periods the incidence was as high as 29.3% (October 1842). In this
period the average mortality rate in hospitals in Edinburgh and Glasgow averaged around 40%,
and was as high as 59% in Paris. According to James Simpson (the British obstetrician who
introduced chloroform narcosis) a man laid on an operating table in one of our surgical
hospitals is exposed to more chances at death than was an English soldier on the battlefield of
Waterloo. Finally Ignc Semmelweis (18181865) identified unequivocally that decomposing
organic matter on the surgeons hands propagates infection leading to the spreading of puerperal
fever, e.g. sepsis. On May 15, 1847, Semmelweis introduced compulsory hand wash with
chlorinated lime and succeeded to reduce the mortality rate from puerperal fever from 14.5%
to 1.2% in his department. Before the era of the bacteriology this was a strike of genius.
Semmelweis has proved the effectiveness of the asepsis but the adverse circumstances
prevented the rapid spread of his theory and this recognition did not become generally known.
At the beginning of the 1860s Louis Pasteur (1822-1895) elaborated the germ theory.
Twenty years after Semmelweis Sir Joseph Lister (18271912) Scotch surgeon elaborated the
method of wound disinfection. Lister sprayed carbolic acid (fenol) in the operating theater to
the instruments, to the hand of the surgeon and also onto the wound to kill microorganisms,
thereby laying the foundation of antisepsis (1867). Robert Koch (18431910) reported his
postulates in 1881 by which it become possible to verify that infectious diseases are caused by
living microorganisms, namely bacteria:
1. After it has been determined that the pathogenic organism is present in the animal body,
2. and after it has been shown that the organism can reproduce in the body;
3. and be transmitted from one individual to another, the most important experiment remains
to be done....
4. to determine the conditions necessary for growth and reproduction of the microorganism.
In a further substantial step Ernst von Bergmann (1836-1907) introduced the sublimate-
antisepsis (1887) and the steam-sterilization (1886), then Curt Schimmelbusch (1850-1895) the

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aseptic wound management. At the end of the 1880s Lister realized that the treatment of
wounds with antiseptics has a disadvantageous effect on wound healing. Furthermore it has
been shown that the effect of chemicals is only superficial, they are not able to kill bacteria in
deep tissues. Later Lister admitted that the aseptic method elaborated by the German school of
surgeons is more advantageous than his own.
Surgical gloves were invented by William S. Halsted, chief surgeon of the Johns Hopkins
University (18521922). In 1890 Halsted requested the Goodyear Rubber Company to prepare
thin rubber gloves for the head scrub nurse (his later wife), Caroline Hampton, who suffered
from dermatitis caused by the disinfectants. J. Bloodgood the follower of Halsted used these
gloves routinely, and the method decreased not only the incidence of dermatitis but the number
of postoperative wound infections as well.
Today, asepsis is a generally acknowledged principle of modern surgery. However, serious
sepsis is still a life threatening systemic condition.

1.2. Asepsis and antisepsis in the surgical practice

During surgery the bodys major defense against infection, the skin is broken and the inner
surfaces of the body are exposed to the environment. Therefore, every attempt must be made to
prevent bacteria from entering the wound (asepsis) and to eliminate them if they have already
entered (antisepsis).

Definition of asepsis
Procedures to reduce the risk of bacterial (or other, e.g. fungal, viral) contamination. It involves
the use of sterile instruments and gloved no touch technique. It includes all of those
prophylactic methods, working processes and behavioral forms by which microorganisms
(bacteria, fungi and viruses) can be kept off the patient organism and the surgical wound. The
goal of the asepis is to prevent contamination. The asepsis can be secured by the use of sterile
devices, materials and instruments and by creating an environment that is poor in microbes.

Definition of antisepsis
Removal of transient microorganisms from the skin and a reduction in the resident flora. It
terms those techniques which are applied to eliminate contamination (bacterial, viral, fungal
and others) to be present in the objects and skin by sterilization and disinfection. Living
surfaces, the skin, the operating field and the surgeons hand can not be considered sterile.
In wider sense asepsis concern an ideal state when the instruments, skin and the surgical wound
is free from pathogenic germs antisepsis includes all prophylactic procedures which are to
secure surgical asepsis. Asepsis is what is primarily important. Asepsis = prevention!

Definition of sterility
It is a microbiologically germfree state of the materials and items. This means that they are free
from every kind of pathogenic and apathogenic microorganisms including latent and resting
forms, such as spores.

1.3. Surgical infections

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Possible sources of pathogens: 1. endogenous flora of the patient; 2. operating theater
environment; 3. hospital personnel.

1.3.1. The main cause of postoperative wound infections is the endogenous flora
Skin: Staphylococci, Streptococci
Mouth: Staphylococci, Streptococci, anaerobes
Nasopharynx: Staphylococci, Streptococci, Haemophilus, anaerobes
Large bowel: Gram-negative rods, Enterococci, anaerobes
Urinary tract: normally sterile.

1.3.2. Main pathogens of the surgical wound contaminations

Staphylococcus aureus (20%), Coagulase-negative staphylococcus (14%), Enterococcus (12%), Escherichia coli
(8%) Pseudomonas aeruginosa (8%), Enterobacter (7%), Proteus mirabilis, Klebsiella pneumoniae, Candida
albicans, Bacteroides fragilis, other streptococci (2-3%). (Source: National Nosocomial Infections Surveillance
(NNIS) System, Centers for Disease Control and Prevention (CDC), 1996)

1.3.3. Main sources of the wound contaminations

Direct inoculation
Patients residual flora or skin contamination
Surgeon's hands
Contaminated instruments or dressings
Contaminated procedure
Drains, catheters or intravenous lines
Airborne contamination
Skin and clothing of staff and patients
Air flow in operating theatre or ward
Haematogenous spread

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Intravenous lines
Sepsis at other anatomical sites
(Source: Leaper DJ. Risk factors for surgical infection. J Hosp Infect 1999; 30 S127-139)

1.3.4. Surgical site infection (SSI)

SSI is the most common nosocomial infection in surgical patients (approx. 40%). Serious
complication with 1-3% overall incidence (but the incidence ~10% following colon surgery),
and increases hospital duration 5-15 days. SSI develops within two hours after the
contamination. Oxidative processes play an important role in the defense against
microorganisms: reactive oxygen species (primarily the superoxide anion) represent the first
line of defense against surgical pathogens. As the NADPH-oxygenase of the leukocyte is pO2
dependent (Km~60 mmHg), in case of hypoxia the chance of destroying bacteria is diminished.

1.3.5. Types of surgical wound contaminations

Superficial incisional SSI. Criteria for defining an SSI as superficial:
1. Infection occurs 30 days after operation.
2. The infection involves only skin and subcutaneous tissue of incision, and
3. At least one of the following is present:
- Purulent discharge from surgical site,
- At least 1 of the signs and symptoms of infection (pain, tenderness, localized swelling,
redness, heat),
- Spontaneous dehiscence of wound or deliberate opening of wound by surgeon (unless sites
culture results are negative),
- Purulent discharge from wound or drain placed in wound,
- Abscess or evidence of infection on direct examination or reoperation or histopathologic or
radiologic examination,
- Diagnosis of infection by a surgeon or attending physician.

Deep incisional SSI. Infection involves deep tissues, such as fascial and muscle layers. This
also includes infection involving both superficial and deep incision sites and organ/space SSI
draining through incision. Criteria:
1. Occurs within 30 days after surgery with no implant (up to one year after surgery if implant
is left in place);
2. Infections involves deep soft tissues, fascia and muscle layers;
3. At least one of the following:
- Purulent drainage/organism isolated from aseptically obtained culture,
- Fascial dehiscence or deliberate opening of the fascia by a surgeon due to signs of
inflammation,
- Abscess or other evidence of infection noted below fascia during reoperation, radiologic exam
or histopathology,
- Surgeon declares that a deep incisional infection is present.

Organ/space SSI. Infection involves any part of the anatomy in organs and spaces other than
the incision, which was opened or manipulated during operation. Criteria needed to the
diagnosis:
1. Occurs within 30 days after surgery or within one year if an implant is present and infection
seems related to the operation
2. Infection involves joint/organ/space, anatomic structures opened or manipulated during the
operation;
3. At least one of the following:

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- Purulent drainage from a drain placed into the organ/space,
- Organism isolated from aseptically obtained culture from joint fluid or deep tissue,
- Abscess or other evidence of infection involving joint, organ, space during re-operation,
radiological exam or histopathology,
- Diagnosis of organ/space SSI by surgeon.

1.3.6. Prevention of the wound contamination

1. Perioperative antimicrobial prophylaxis (preventive antibiotic treatment) should be applied
in case of septic operation or in high-risk patient.
2. Blood glucose level has to be normalized.
3. Oxygen tension of the tissue has to be maintained, hyperoxygenation should be applied
during the operation.
4. Body temperature has to be maintained on normal level during the operation. Narcosis
deteriorate temperature regulation, the evolving surgical hypothermy + narcosis cause
vasodilation, therefore the temperature further decrease.
5. Before the operation fur and hair should be removed because these harbor bacteria.
6. Thorough scrubbing before the operation is highly important. If necessary, changing the
gloves and repeated scrubbing is needed. In the postoperative period hand disinfection and
the use of sterile gloves is mandatory for sterile wound management.
7. Adequate surgical technique should be applied (careful handling of the tissues, control of
bleeding, diathermy, applying absorbable sutures, proper suture technique, etc.).
8. It is important to know and control the risk factors.

1.3.7. Risk factors of wound contamination

1. Systemic factors
Age (elderly or children), undernourishment, obesity, hypovolemia, bad perfusion, steroid
therapy, immunosuppressive states. In the latter case the surgical intervention should be done
exclusively in aseptic circumstances in the sterile operating room. The patient has to be isolated,
and hospitalized in sterile circumstances, strictly maintaining the rules of asepsis. Wound
management should be performed under operating room circumstances. Diseases connected
to altered immune response: diabetes mellitus, cirrhoses, and uremia.
2. Factors related to the wound

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Dead or devitalized tissue left in the wound, hematoma, foreign body, including drains, sutures,
dead space, improper skin scrubbing, disinfection and shaving, previously existing infection
(local or distant).
3. Factors related to the operation
Bad surgical technique, inadequate handling of bleeding, long-lasting surgical interventions (>2
h); intraoperative infection, non-sterile operating room personnel, instruments, improper air-
exchange, hypothermy; long preoperative hospitalization.
4. Type of the operation
Risk factor can be the type of the operation itself, as in certain operations the risk of wound
contamination is higher than the average. Surgical wounds can be categorized according to the
hazard of the wound contamination as clean, clean infected, infected and spoiled infected
groups.

Infective
Classification Description
Risk (%)
Uninfected operative wound
No acute inflammation
Closed primarily
Clean
Respiratory, gastrointestinal, biliary, <2
(Class I)
and urinary tracts not entered
No break in aseptic technique
Closed drainage used if necessary
Elective entry into respiratory, biliary,
gastrointestinal, urinary tracts and with
Clean-
minimal spillage
contaminated <10
No evidence of infection or major
(Class II)
break in aseptic technique
Example: appendectomy
Nonpurulent inflammation present
Gross spillage from gastrointestinal
Contaminated tract
About 20
(Class III) Penetrating traumatic wounds <4
hours
Major break in aseptic technique
Purulent inflammation present
Dirty-infected Preoperative perforation of viscera
About 40
(Class IV) Penetrating traumatic wounds >4
hours
Source: CDC, 1996

1.3.8. Postoperative wound management

Decisive factor is the rigorous maintaining of the rules of asepsis. Primarily closed wound is
covered with sterile covering bandage for 48 hours. Hygienic hand washes before and after the
wound management is mandatory. Sterile technique must be applied in changing the covering
bandage.

1.4. Sterilization
Definition

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The removal of viable microorganisms (every pathogenic and apathogenic microorganisms
including the latent and resting forms such as spores), which can be achieved by different
physical (heat, steam, irradiation, etc.) and chemical means and methods (ethylene oxide, etc.)
or by their combined effects to kill or inactivate each living microorganism as well as of their
latent and resting forms.
1. Autoclaves
Autoclaves are highly effective and inexpensive tools of sterilization. Its effectiveness is based
on the fact that steam temperature under pressure > 100 C: in case of 108 kPa it means 121C
(vacuum has to be created).When the steam pressure is 206 kPa, its temperature is 134C. The
time needed to the sterilization is 15 min at 121 C and 3 min at 134 C.
To be effective against viruses and spore forming bacteria the steam must be in direct contact
with the materials. Effectiveness can be checked by the color-change of the indicator tape
placed on the packing. Disadvantage: unsuitable for heat-sensitive objects.
2. Gas-sterilization by ethylene oxide
Highly-penetrative and active against bacteria, spores and viruses. It is suitable for heat-
sensitive items. Disadvantage: flammable, toxic and expensive and leaves toxic residue on
sterilized items and therefore instruments sterilized in this way need to be stored for prolonged
period (airing) before use.
3. Sporicidal chemicals cold sterilization
Sporicidal chemicals often used as disinfectants but can also sterilize instruments if used for
prolonged period. The advantage of these methods is that inexpensive and suitable for heat-
sensitive items. The disadvantage is that they are toxic and irritants. The most widely used
liquid sporicidal chemical is 2% glutaraldehyde (Cidex). It is able to kill most bacteria and
viruses within 10 minutes (spores can survive several hours).
4. Irradiation
The gamma rays and accelerated electrons are excellent at sterilization. They are used for
industrial purposes, for cold sterilization of disposable items (plastic syringes, needles) and
materials (bandages) rather than for sterilization in hospitals.

1.5. Disinfection
The reduction in number of viable organisms, the diminution of the number of propagating
microorganisms by destroying or inactivating them on living or inanimate (nonliving) surfaces.
Can be achieved by generally used methods with the aid of chemicals (disinfectants,
glutaraldehyde, formaldehyde, quaternary detergents, etc). Some of these disinfectants are
sporicidal but generally they should not be used for sterilization because most items need very
long time (up to 10 hr or more) of soaking in order to render them sterile.
1. Low-temperature steam
Most bacteria and viruses are killed by exposure to moist heat. Usually achieved with dry
saturated steam at 73 C applied for more than 10 minutes. Effective, reliable and suitable for
instruments with a lumen or caverna. Unsuitable for heat-sensitive items.
2. Chemical disinfectants
Disinfectants are suitable for heat-sensitive items as well, however less effective than heat.
Destroys microorganisms by chemical or physicochemical means. Different organisms vary in
their sensitivity against them:
- Gram-positive bacteria are highly sensitive;
- Gram-negative bacteria are relatively resistant;
- Clostridial and Mycobacterial species are very resistant;
- Slow viruses are highly resistant.
The use of antiseptics (application, how to make the solutions, the effective concentration, the
time needed for the effective disinfection of the different chemicals, etc) is regulated in official

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guidelines (e.g. Handout of disinfection and disinfectants by the Hungarian National Health
Center -OEK). Chemicals used include clear soluble phenolics, hypochlorites, alcohols,
quaternary ammonium compounds.

1.6. Asepsis and the surgical patient

Asepsis (in a wider sense) became a fully elaborated routine procedure. The rules of asepsis
must be maintained in case of the patient, the operating room personnel, the operating theater,
operating room devices, tools and instruments as well. Surgical asepsis needs strict precautions,
working in a sterile field presupposes the understanding that violation of the technical rules may
cause fatal infections.

1.6.1. Preparation of the skin before the operation

Skin harbors resident flora (these bacteria cause no harm unless drawn into the body through a
break in the skin, e.g. Staphylococcus epidermidis) and transient flora (acquired from a
contaminated source) and this includes any type of bacteria that can live on skin.
1. Bathing
It is not unequivocal that bathing lowers germ count of the skin but in case of elective operations
pre-operative antiseptic showers/baths are compulsory. Special attention is given to the
operative site. It should be done with antiseptic soap (chlorhexidine, quaternol) the evening
prior to operation.
2. Shaving
Makes surgery, suture and dressing removal easier. Must be performed immediately prior to
operation, with the least cuticular/dermal injury, in this case the wound infection rate is only 1
%. The infection rate is increased to 5% or >5% if it is performed > 12 h prior to surgery
(abrasions can cause colonization which can lead to wound infection). Clippers or depilatory
creams reduce infection rates to < 1%.
3. Preparing the skin
It is performed the day before the operation (in elective cases). Disinfectants are applied to the
skin: 70% isopropyl alcohol (acts by denaturing proteins, bactericidal but short acting, effective
against Gram + and Gram organisms, fungicidal and virucidal); 0.5% chlorhexidine
(quaternary ammonium compound, acts by disrupting the bacterial cell wall, bactericidal but
does not kill spore forming organisms, persistent and has a long duration of action (up to 6 h),
more effective against gram-positive organisms); 70% povidoniodine (Betadine, acts by
oxidation / substitution of free iodine, bactericidal and active against spore forming organisms,
effective against both Gram + and Gram organisms, rapidly inactivated by organic material
such as blood, patient skin sensitivity is occasionally a problem).

1.6.2. Surgical skin preparation (prep)

- It is performed after surgical hand scrub, before dressing (gowning e.g. putting on sterile
gowns).
- All supplies used (towels, gauze sponges, sponge forceps and gloves) must be sterile.
- Starting at the exact location where the incision will be made, begin washing (with antiseptics)
moving outwards in a circular motion. Use a "no touch" technique.
- Scrub outward from the incision site and discard used prep sponges and begin again with fresh
ones. Do not return to an area already washed with the same sponge.

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- Prepped/disinfected area must be large enough for the lengthening of the incision / insertion
of a drain.
- The skin prep is generally consists of two phases (it must be made according to the accepted
and generally applied rules of the operating room). Classical: 1. removing the fat of the skin
surface with petrol; 2. antiseptic paint is applied (2x) immediately (1-5 % iodine tincture).
Currently: antiseptic paint (usually povidone-iodine) is applied twice (alcohol, Dodesept
solution could be used in case of sensitive skin)
- The preparation of the operating area is made by sterile sponges (gauze balls) mounted in a
sponge holding clamp. In aseptic surgical interventions the procedure starts in the line of the
planned incision, in case of septic, infected operations from the periphery toward the planned
area of the operation.

1.6.3. Isolation of the operating area (draping)

- After the skin preparation the disinfected operating area must be isolated from the non-
disinfected skin surfaces and body areas by the application of sterile linen textile, sterile water-
proof paper, or further sterile accessories/supplements. The isolation prevents contamination
deriving from the patients skin. Draping is performed after the surgeon has donned gown and
gloves.
- The usefulness of the sterile self-attaching synthetic adhesives (affixed to the disinfected
operating area) is questionable for the prophylaxis of postoperative wound infections, because
these can help residual bacteria to come to the surface, due to the increased perspiration during
the operation.
- Because the deeper layers of the disinfected skin always contain residual bacteria, the skin
can be touched neither by instruments nor by hands.
- The isolation is generally performed by disposable sterile sheets which are attached to the
patients skin where they cross by self-attaching surfaces. Non-disposable, permeable linen
textiles are fixed to the skin with special clips.
- In general surgical operations (e.g. abdominal operations) the scrub nurse and the assistant
make the draping with the specially folded sheets. The first sheet isolates the patients leg. Then
the Mayo-stand is moved to the end of the operating table. The second sheet is used to isolate
the patients head; this sheet is fixed by a towel-clip to the guard which shields the
anesthesiologist from the operative field. Then follows the placement of the two side-sheets.
The isolated area is always smaller then the scrubbed area. Sheets after placed to the patient can
not be moved toward the operating area, only toward the periphery, because pathogens can be
transferred from the non-disinfected parts to the surgical area. Four Backhaus towel clips are
fixing the sheets to the skin, the small puncture wounds heal quickly.
- A special full sheet may be applied, too. It is positioned so that a hole incorporated in it lies
over the operative site. Four towel clips are applied to attach the sheet to the patients skin.

1.7. Basic rules of asepsis in the operating theater

The rules of asepsis are based on very fundamental principles. Sterile surfaces, those that are
free of living microorganisms must not come into contact with non-sterile surfaces.
Contamination of equipment and personnel is prevented by sterile linen or paper covering.

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Contamination by an intermediate source such as dust and moisture is minimized by reducing
or eliminating the source.

1.7.1. Positioning of the surgical patient

The surgical patient can be positioned on his back (standard positioning, e.g. abdominal
operation), on his side (e.g. thoracic surgery), or lying on the abdomen (e.g. varix operation).
Some type of positioning must be separately mentioned.
Prone position
This position is used for craniotomy when the patient is laid face downward on the abdomen.
Modification of the prone position (lying on the abdomen). The patient lies in prone position,
with the table broken at its midsection so that the head and feet are lower than the midsection.
Supine position
Used for abdominal procedures and for those involving the face and neck, chest or shoulder.
The head is in good alignment with the body. Vascular surgery is also performed in this supine
position.
Trendelenburg-position (sec. Friedrich Trendelenburg (1844-1924) German surgeon
described it in 1881). Upside down (450 head down) position. Indication: depression of venous
pressure (varicose vein surgery), restrains small intestine from the pelvis (gynecology,
laparoscopic surgery). The goal is to allow the abdominal contents to drop in a cephalic
direction (toward the head) thus giving greater exposure to the pelvic content. Physiological
effects of Trendelenburg position: elevated venous reflow, raised intracranial and intraocular
pressure, increased intragastric pressure reflux of the gastric content, venous stagnation on
the face and neck.
Reverse (or anti) Trendelenburg position is used for surgery of the face and neck and for
procedures involving the diaphragm and upper abdominal cavity, since it allows the abdominal
contents to drop in a caudal direction (toward the feet). Physiological effects: reduced venous
reflow cardiac output falls, mean arterial blood pressure decreases, improvement in the
functional residual capacity (FRC) of the lung.
Lateral position. Indications: thoracotomies, renal, shoulder surgery and hip operations. It can
cause problems because it may change respiratory function. Lateral decubitus: the table is
flexed in the centre in addition to the lateral position. Indication: nephrectomy. Problems: direct
caval compression decreased venous return and hypotension.
Lithotomy legs up position. Indications: gynecological and anal surgery. Potential problems:
autotranfusion from the leg vessels will increase preload (the effect on CO will depend on the
patients volume status), vital capacity is decreased, and risk of aspiration is increased:
anesthesia should never be induced in this position!
Kraske (jackknife or "knee-chest") position. Indication: proctology rectal, perianal,
coccygeal surgery.

1.7.3. Surgical personnel and the asepsis

- Only those people whose presence is exclusively needed should stay in the operating room.
- Avoid activity causing superfluous air flow (talking, laughing, sneezing, walking around). The
atmosphere of the operating theater must be quiet and peaceful, movement and talking have to
be kept to a minimum during surgery. Talking releases droplets of moisture laden with harmful
bacteria into the air around the sterile field.

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- Entering the operating theater is allowed only in operating room attire and shoes exclusively
worn in the operating room. All the dresses have to be changed except the underwear. This
complete change over should apply also for the patient who is placed in the holding area to the
garments used in the operating theater. Leaving the operating area is forbidden in surgical attire.
- The doors of the operating room must be closed.
- Only in cap and mask covering also the hair, mouth and nose is allowed to move in the
operating room out of the holding area. If the mask became wet it should be replaced.

1.7.4. Personnel attire in the operating room

- Strict personal hygiene is necessary for the operating room personnel. Taking part in an
operation can be possible only after surgical hand wash and scrubbing. Scrubbing person must
not wear jewels. Watch and rings should be removed. Fingernails should be clean and short,
nail polish is forbidden. Surgical scrubbing always has to be made according to the accepted
and generally applied rules of the local operating suite.
- Surgical team members in sterile attire keep well within the sterile area; the sterile area is the
space that includes the patient, surgical team members, sterile equipment tables and any other
draped sterile equipment.
- Non-scrubbed personnel do not come close to sterile field or scrubbed sterile person, do not
reach over sterile surfaces and handle only non-sterile instruments.
- Scrubbed team members always face each other, never show back to each other. They face
the sterile field at all times.
- Airway infection or open excreting wound exclude taking part in the operation.

1.7.4.1. Scrubbing, disinfecting, gowning in general

In order to minimize the risk of infection it is essential to follow the correct procedure before
entering the surgical suites and operating areas. Wearing the proper scrub suit is required.
Surgical attire acts as a barrier that protects patients from exposure to microorganisms that could
cause postoperative infections. This barrier includes surgical gloves, caps, masks, gowns,
protective eyewear, waterproof aprons, and sturdy footwear. They all must be the right size and
properly worn.
1. Scrub suit
It is put on in the dressing room before entering into the operating theater. Scrub suit must be
changed if it becomes soiled.
2. Surgical caps
The hair, mouth and respiratory tract are rich in bacteria. The cap should completely cover the
hair.
3. Face mask
The mask should be tied securely. It must be comfortable to wear, as it will be worn throughout
the procedure. Masks should cover the nose and mouth, fitting snugly across the bridge of the
nose, at the edge of the cheeks, and under the chin. Masks should be changed between cases or
when they become wet (usually from breath). They should never be worn dangling around the
neck. Rubbing ordinary soap on glasses and polishing them is the most satisfactory way to
prevent fogging of glasses.
4. Shoes
If outside shoes are worn in the operating room shoe covers must be worn. These plastic
overshoes (booties) should be worn over normal footwear.

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5. Gowns
Long-sleeved sterilized surgical gowns or disposable coveralls are worn. Remember, surgical
gowns are considered sterile in front from the chest to the level of the sterile field. Sleeves are
sterile from 5 cm above the elbow to the cuff. The neckline, shoulders, underarms, and back of
the gown are considered to be non-sterile. Gowns should be put on after surgical scrub and
before gloving.

1.7.4.2. Detailed steps of dressing

1. Scrub suit

1. Dressing:

To put on:
scrub suit
operating room shoes/shoe cover)

To remove:
-bracelet
-ring
-wristwatch
-nail-polish

No one should enter the operating room wearing street cloth or clothes worn elsewhere in the
hospital. All surgical personnel must wear scrub suit. The scrub suit is put on in the dressing
room. Outside shoes must be changed for operating room shoes or wear shoe cover.
2. Cap and mask
The cap and mask should be donned first.

Correct position of the mask Positioning the mask

right wrong

3. The scrub preparation and surgical disinfection

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The surgical hand and arm scrub procedure must be performed in the scrub suite before entering
the surgical suite/operating room. To maintain the asepsis hand and arm scrub is performed
according to the basic rules of asepsis.

3. Scrubbing
Participation in a surgical
intervention requires the
implementation of the The goal of scrubbing
complete protocol of
scrubbing and disinfection. To reduce the number of transient
and resident bacterial flora and to
Scrubbing have to be made inhibit their activity.
according to accepted and (Green colour indicate the sterile field
generally applied rules of the as a result of scrubbing)
local surgical suite.

Simple scrubbing with soap

is not = disinfection!

Scrubbing is done according to the Ahlfeld-Frbinger-type two phase scrub (5 min mechanical
and 5 x 1 min rubbing with disinfectant hand scrub agent). A systematic approach is an efficient
way to ensure proper technique.

Scrubbing 1. Scrubbing 2.
handwash with soap Hand- and armwash with soap

Scrubbing 3.
Steps of rinsing the hands Taking out the brush

14
 Scrubbing 4. Do not touch the basin!
cleansing the nails with brush

The goal of scrubbing is to remove the outer, desquamating, oily layer of the skin which harbors
many microorganisms. The basic principle of the scrub is to wash the hands and arms very
thoroughly from a clean area the hand to a less clean area the arm. The scrub procedure must
include all anatomical surfaces from the fingertips to approximately 2 inches above the elbow.
The so-called timed-scrub should last 5 minutes and consists of the following:
1. Remove watch and rings.
2. Cut nails if necessary and clean subungual areas with a nail file. Discard the nail file in the
sink
3. Turn the tap and adjust the water to a proper temperature and flow rate.
Start timing!
4. Wash your hands and forearms with liquid- or foam soap thoroughly. Rub each side of each
finger, between the fingers, and the back and palm of the hands with soap. After the hand
is scrubbed, the arm is scrubbed. Rub the soap on each side of the forearm from the wrist to
the elbow to at least 3 finger-breaths above the elbow, keeping hand higher then the arm at
all times. This prevents bacteria-laden soap and water from contaminating the hand. If at
any time the hand touches anything non-sterile object, the scrub must be lengthened by 1
minute for the area that has been contaminated.
5. Rinse hands and arms with water, keeping your hands above the level of your elbows, and
allow water to drain off the elbows.
6. Take a sterile brush in one hand and the soap in the opposite one.
7. Make a good lather on the brush and brush your nails and finger tips only. To brush any
other part of the hand is forbidden.
8. Finishing scrubbing, put the brush aside.
9. Rinse both hands and arms thorougly with tap water. Keep the hands higher than the flexed
elbows to allow the water to drip off the elbows and to prevent it from running from the
upper forearm down on the hands. Rinse hands and arms by passing them through the water
in one direction only, from finger tips to elbow. Do not move the arm back and forth through
the water, but move only in one direction, from the fingers toward the elbow. When rinsing,
do not touch anything with your scrubbed hands and arms.
10. The taps should be turned off using the elbows and allow the hands and arms to drip dry for
a short time (or use sterile towel to dry it.).
Note: no matter what agent is used, or which scrub technique you practice, there is only one
goal: infection prevention. Effective surgical scrubs are one of the most powerful strategies of
infection prevention in the operating room. Glove usage gives a false sense of security against
bacteria. Gloves provide an ideal environment for bacterial growth, moisture and warmth,
which makes good hand-scrub techniques and aseptic gowning and gloving an important part
of the total infection prevention platform.
11. Disinfection with alcohol-based hand- and arm-rub

15
 Disinfection 1.
Steps of chemical disinfection 2.
right wrong

Here Bradosept is used which is an alcoholic detergent. 5 x5 ml should be used, each dose for
1 minute.
- Keep your palm below the tubing of the dosing wall-apparatus so that the hand is at the same
level with the eye of the photoelectric cell. Do not touch either the apparatus or the tubing. If
you keep the hand properly, one dose of antiseptic will flow into your palm.
- Rub in the hands and arms with the antiseptic thoroughly for 1 minute. Repeat the process 4
times more.
Do not rinse your hands or dry them with sterile towel. Bradosept not simply inactivates
bacteria, but it fixes skin too, i.e. a layer will be formed which prevents bacteria from coming
to the surface from crypts.
If at any time the hand touches anything non-sterile object, the scrub must be lengthened by 2
more 1 minute-long disinfecting steps for the hands.

Recent studies have shown that using a brush to scrub hands during surgical scrub provides no
greater reduction in the number of microorganisms on the hands than scrubbing with antiseptic
alone.
Surgical scrub may be performed using either a soft brush or sponge or the combination of these
and an antiseptic alone. Avoid using a hard brush, which is not necessary and may irritate the
skin.
4. Gowning
- The scrubbed personnel enter the surgical suite immediately after the scrub. The hands are
held above the elbows, in front of the chest.
- Go to the so-called Schimmelbush container that is on a stand. Open up the cover with the foot
pedal.
- Pick up a sterile gown with your right hand while keeping the others with the left hand to
prevent them from pulling out. The gown is folded so that the inner surface is exposed to you
when you pick it up. If you are gowning yourself, grasp the gown firmly and bring it away from
the container. Never touch the outer surface.
- Step far enough away from non-sterile objects while dressing to allow a wide margin of safety.
- Hold the gown at the edges of the neck piece, out away from your body and the container and
sufficiently high so that it will not touch the floor.

16
- Holding the gown by the inside at the neckline allow it to unfold gently ensuring that the gown
does not come into contact with anything non-sterile.
- Gently shake folds from gown and insert both arms into the armholes, keeping your arms
extended as you do so. Wait for the scrub nurse to assist you by pulling the gown up over the
shoulders and tying it.
- The scrub nurse grasps the inner surface of the gown at each shoulder and pulls the gown over
your shoulder and the sleeves up over the wrist. The scrub nurse assists you in fastening the
gown at the back.
Note: do not grasp the girdle of the gown but wait until the nurse helps you. Keep your hands
above the level of your waist and do not touch anything.

Keep hands above the level of your waist and below nipple line at all times.
Do not touch the sterile chest field with ungloved hands.
Do not touch the sterile operating field or anything sterile before putting on sterile surgical
gloves.

Effective sterile area

4. Gowning
Certain parts of the gown can not
be considered sterile (!)

a. the back and the axillaries

b. lateral from the axillaries

c. under the waistline

d. the sleeves 10 cm distance from

the shoulders over the elbow.

5. Gloving
Because the skin cannot be sterilized, sterile team members should put on sterile rubber gloves
if they have already been gowned. To diminish friction between the skin and the glove, sterile
talcum powder is used. The gloves have been lightly coated with powder. The gloves are packed
individually in container consisting of two pockets, one for each glove. If a sterile nurse is
available she can glove you.

Gloving of the left hand 1. Glowing of the right hand 2.

from inside! from outside!

17
 The gloved hands

- The sterile nurse holds the left handed glove open with her fingers beneath the cuff so that her
glove does not come in contact with your skin. The palm of the glove faces to you.
- Put two fingers of your right hand into the opening; pull the inner side of the glove toward
yourself so that a wide opening is created. Slip your left hand into the gloves so that the glove
cuff covers the sleeve cuff.
- When you put on the right handed glove, place the fingers of your gloved left hand under the
right glove cuff to widen the opening and thrust your right hand into the glove.
- You may now adjust your gloves so that to fit comfortably on the hands.
Now you are ready for taking part in an operation. If your gloves become soiled or damaged,
you must change them at once.

Sterile gloves are a thin barrier between sterility and contamination. Never allow bare hand to
contact the gown cuff edge or the outside of glove.
6. Removing gloves
Grasp the cuff of your dirty left-hand glove and pull it down so that it should hang over down
from your finger in inside out mode, than repeat the process with the other one. Now you can
take off both gloves one by one without touching the outer dirty surfaces.

Removing the gloves

18
Step 1. Grasp one of the gloves near the cuff and pull it partly off. The glove will turn inside
out. It is important to keep the first glove partially on your hand before removing the second
glove to protect you from touching the outside surface of either glove with your bare hands.
Step 2. Leaving the first glove over your fingers, grasp the second glove near the cuff and pull
it partly of the way off. The glove will turn inside out. It is important to keep the second glove
partially on your hand to protect you from touching the outside surface of the first glove with
your bare hand.
Step 3. Pull off the two gloves at the same time; be careful to touch only the inside surfaces of
the gloves with your bare hands.

In general, just remember, that hands must always be kept within the sterile boundary of the
gown. The hands and arms are held up in front of the body with elbows slightly flexed while
entering the operating room. Care should be taken not to touch anything with the hands or arms.
If you are sterile, do not touch anything that is not sterile and vice versa. The back of your gown
and anything below the waist is considered not sterile or contaminated. Your mask, protective
eyewear, and hat are also non-sterile.

Effective sterile area

Certain parts of the gown can not

be considered sterile (!)

a. the back and the axillaries

b. lateral from the axillaries

c. under the waistline

d. the sleeves 10 cm distance from

the shoulders over the elbow.

1.4.4. Moving in the operating room

The operating room personnel have to work according to the rules of asepsis to ensure an aseptic
germfree wound state.

19
- Sterile personnel keep well within the sterile area Operating team members should move about
the suite as little as possible. With excessive movement dust and air currents are swept about
thus spreading bacteria.
- Sterile team members face each others. They face the sterile field. The back is never turned
on the sterile field. The back of the gown should be considered non-sterile. The axillary region
is not sterile.
-When sterile team members pass each other they pass back to back or chest to chest.
- Excessive talking and laughing during surgery increases the possibility of wound
contamination by bacteria from the mouth and throat.
- Hands must be kept within the sterile boundary of the gown.
- Sterile personnel can handle only sterile equipment.

1.4.5. The general rules of asepsis related to the operating equipment

- Equipment used during a sterile procedure must be sterilized.

- Sterile personnel handle only sterile equipment.
- If the sterility of an item or a person is questionable the item or person is considered
contaminated.
- Sterile tables are sterile at table height.
- Gowns are sterile in front from the axillary line to the waist, and the sleeves to 3 inches under
the elbow.
- The edge of any container that holds sterile supplies is not sterile.
- Some operative areas (nose, throat, mouth, perineal region, digestive tract etc. can not made
sterile. Steps are taken to keep contamination to a minimum.

1.4.6. Further important duties to secure asepsis and to avoid wound contamination

- Changing gloves: during the operation (e.g. after the opening of the bowel) gloves presumably
contaminated by pathogenic microorganisms must be changed. Gloves must be replaced if the
gloves become injured, and also during sustained operation, and naturally between two
operation as well. In the latter case a repeated disinfecting or a new scrubbing procedure is
needed as well.
- Instrument change: potentially contaminated instruments must be dropped into the container
(e.g. scalpel, used to incise the skin or to open a bowel) and other instruments must be replaced.
- Covering the surgical wound: by sterile wound cover.
- Closed circuit drainage must be applied for the drainage of the confluent fluid collected in the
wound and of oozing blood.
- Easily cleanable and sterilizable metal instruments or disposable instruments and suture
materials, plastic canules, drains and vascular prosthesis must be used.
- The aseptic and septic operations must be separated in time and space as well, but at least in
time: aseptic operations (e.g. hernia operation, thyroidectomy, varix operation) must be carried
out in sterile (aseptic) operating room, pathogenic, septic operations (colon, appendectomy,
hemorrhoidectomy, fistula) in septic operating theatre. In case if these can not be separated

20
spatially, aseptic operations must be done first and thereafter the septic cases. After the finishing
of these surgical interventions operating theater must be cleaned up and disinfected.

1.4.7. Asepsis in the postoperative period

- Patients after aseptic and septic operative interventions should be separated. If it is possible,
place them in separate rooms in the hospital.
- Change of bandage is done only when indicated.
- Change of bandage is first done on the aseptic patient.
- Changing of bandage needs sterile instruments and sterile bandages.
- Before and after the change apply hand wash with antiseptics and use new sterile gloves in
every case.

1.5. The surgical antisepsis

It is much less effective than prophylaxis. Killing or inactivating pathogenic germs got to the
wound (see later) by the application of antiseptic solutions, powders (hydrogen peroxide,
povidon-jodid, boric acid etc.) locally or by antibiotic treatment.

1.6. The operating room, furniture, techniques

The operating rooms (operating suites) are similar in design. The pattern is always simple, in
order to be easy to keep clean and decontaminate, to avoid dust to accumulate in areas that
would be difficult to clean. Wall and floor surfaces are smooth and made of nonporous material.
The operating room is roomy enough to allow scrubbed personnel to move around non-sterile
equipment without their contamination.

1.6.1. The equipment of the operating room

The standard operating table
It may be manipulated in many different ways to achieve the desired position of the patient.
The table top is sectioned in several places and may be reflexed or extended. The table can be
flexed at one or more hinged sections, may be tilted laterally or horizontally and raised or
lowered from its hydraulic base. Sections of the table such as the headboard or footboard may
be removed as needed. The position and height of the table are dictated by the situation of the
organ to be exposed and by the surgeons comfort. The ideal height of the operating table places
the operative field approximately at the level of the surgeons elbow when his arm is at his side.
Small instrument stand (Mayo stand)

21
A special type of instrument table that is placed directly over (but not in contact) with the
patient's leg. It is used to hold instruments that will be used frequently during the surgical
intervention.
Back table (large instrument stand)
Extra supplies additional instruments used during the surgery are placed on the back table.
Kick bucket
Soiled (spilled) sponges and some instruments e.g. sponge holding clamp used for scrub
preparation should be dropped into containers at the side of the table.
Instruments needed during the operation
- anesthesia equipment with gas machine and physiological monitor
- monitor used to control blood parameters as blood pressure (two components), blood volume,
cardiac output and to follow electrocardiogram
- outlet for gases (oxygen, nitrous oxide)
- outlet for suction (one for the anesthesiologist to keep the patients airway clear of mucous
secretion, one for the surgical team to suction blood and irrigation fluids from the wound site),
- AMBU-balloon (manual respirator),
- endotracheal tubes,
- suction catheter (to remove body fluids)
- central venous catheter
- Ringer-lactate infusion set
- ECG-pads
- different venous catheters (Braunules-canules with wings)
- urinary sack
- Foley catheters of different size
- diathermy unit (see later: electrocautery or electrosurgery)

1.8. The operating room personnel

The position of the operating team at the table will vary depending upon individual
circumstances, the situation of the organ. The surgeon stands on one side of the operating table.
The first assistant is usually opposite the surgeon. On the other side of the table beside the first
assistant, opposite the operator, stands the scrub nurse. The second assistant stands on the left
or right of the operator.

22
 The position of the surgical team
2.
SURGEON ASSISTANT

ANESTHESIA
1.
ASSISTANT
SCRUB NURSE

The green line marks the sterile area; the red color is the border of this field. Stepping behind
this line is forbidden.

1.7.1. Duties and responsibilities of the operating room personnel

Surgeon: the person who ultimately guides the flow and scope of what happens in the surgical
suite. Primarily responsible for maintaining the asepsis; controls all the activities in the surgical
suite during the procedure.
Scrub nurse: assists in the sterile gowning and gloving of the surgeon and his/her assistant.
Responsible for the maintenance of an orderly surgical field; prevents contamination of the
surgical field by the strict practice of aseptic technique; must remind the surgeon and all
members of the operating team if she perceives any error in maintaining the asepsis.
First assistant: works under the direct supervision of the surgeon and assists in such duties as
hemostasis, suturing and wound dressing. The first assistants responsibility is to position the
operating table and the light, so that the field will be properly illuminated.
Second assistant: provides exposure of the operative field. He carries out the orders of the
surgeon or that of the first assistant. He should restrict his activities to holding instruments and
retractors as instructed by either the surgeon or the first assistant;
Circulator / surgical technologist: surgical team member who does not perform a surgical
hand scrub or don sterile attire, and thus does not work within the sterile field; he is responsible
for the non-sterile fields. His obligation is to to carry the patient to the operating room, safely
position the patient, and to keep clean the operating room.

If you finished scrubbing do not

- drop your hands below your waist,

23
- touch your face or adjust your mask and glasses,
- grab anything that falls off the table (but inform the circulating nurse),
- reach for anything on the Mayo stand (but ask the scrub nurse for it).

1.9. The operating field before and after the isolation

The operating field before the isolation of the patient

Only the Mayo stand is sterile- green color marks the sterile area.

24
 The operating field after the isolation of the patient

The Mayo stand was moved over the patient legs. Green color marks the sterile field; the red
color indicates the border of the sterile area.

1.10. Passing the instruments

Instruments should be passed in positive and decisive manner. When an instrument is properly
passed the surgeon will know he has it and will not have to move his eyes from the operative
field. The scrub nurse and the assistants have to know what he wants by his signals. When he
extends his hand the instrument should be slapped firmly into his palm, in proper position for
use when he closes his hand on it. There are some widely accepted hand signals used at the
operating table. These speed up the passage of instruments and eliminate much talking. Do not
reach for instruments on the instrument table. Make an effort to keep the operating table neat,
passing the instruments back to the scrub nurse immediately after they are used and removing
soiled sponges from the field. Sponges should be dropped into the container at the side of the
table.

25
2. Surgical deontology
Deontology = theory of moral obligations. For the technically perfect execution of operations a thorough
knowledge of surgical instruments is essential. However, a surgeon must know the use of bandages, threads and
suture materials, the maintenance of sterile environment, textiles, technique of draping, materials used for the
disinfection of the surgical site etc.; several items not directly related to the operation itself. It is essential to
recognize that the operation is not equal to surgery; it is only a station (and considering the outcome sometimes it
is not the most important one) in the chain of consecutive events. Surgeons and physicians should know the
significance of preoperative examinations, the indications for operation, the different steps of pre- and
postoperative care, the complications and the possibilities of their prevention.

2.1. Surgical instrumentation. Basic surgical instruments and their use

Surgical instruments are precisely designed and manufactured tools. The non-disposable instruments must be
durable, easy to clean and sterilize. They should withstand various kinds of physical and chemical effects: body
fluids, secretions, cleaning agents, and sterilization methods (high temperature, humidity). For this reason, most
of them are made of high quality stainless steel, chrome and vanadium alloys ensure the durability of edges,
springiness, and resistance against corrosion. Due to the constant improvements by surgeons and manufacturers,
the number of instruments is so great that only their basic categories and the main representatives of them can be
overviewed.
According to their function, basic surgical instruments are categorized into four groups:
1. Dissecting instruments
2. Grasping instruments
3. Retracting instruments
4. Wound closing instruments and materials

2.1.1. Dissecting instruments

The function of these instruments is to divide tissues, sutures, bandages, etc. These instruments have a sharp
surface, either a blade or a point. This category involves knives, scissors, saws, osteotomes, drills, chisels,
raspatories (used for the separation of periosteum), Volkmann curettes, biopsy needles, diathermy pencils, etc.
Surgical knives - scalpels

26
When dissecting tissues, scalpels cause the minimum of trauma. Instead of the conventional scalpel, nowadays
disposable scalpels of plastic handle or scalpels of detachable blade are most commonly used. Disposable blades
are attached to the stainless steel handle before the operation. A #3 handle is used to the smaller #10-15 blade, #4
handle to the larger #20-23 blades.

Wide-bladed scalpels with curved cutting edge are used for incision of skin and subcutaneous tissues. Thin-bladed
sharp tipped knives serve for opening of blood vessels, ducts and abscesses. A bistoury blade looks like a hook
and can be applied as a meniscus knife.
The use of scalpels
The incision is started with the tip of the knife and continued with the cutting edge as soon as possible. Cutting is
usually made from the left to the right or towards to the surgeon. Holding the scalpel: 1. at long straight incisions,
the scalpel is held like a fiddle bow: the knife is gripped horizontally between the thumb, index and middle fingers,
the ring and little fingers can keep the end of the handle. 2. In the case of skin and other tough tissues which are
hard to cut, the handle of the knife is held is between the thumb and middle and ring fingers and the index is placed
on the back of the blade that makes possible a strong and well controlled incision 3. At short or fine incisions, the
scalpel is held like a pencil, and cutting is made mostly with the tip. Neither the blade nor the handle far from the
blade is grasped during incision.
Amputating knives
Amputating knives of different sizes are manufactured with one- or two-sided cutting edge for limb amputations.
Scissors
Next to scalpel scissors are most often used to divide tissues. Threads and bandages are also cut with scissors.
Scissors are made in different sizes; their blades can be straight or curved. (Cooper scissors). There are special
angular scissors which are angled at the joint (e.g. Lister scissors). The tips of the blades can be blunt (as those of
the Mayo and the finer Metzenbaum scissors of longer shanks, both of which can be used for preparation of tissues)
or sharp (as those of iris scissors used in ophthalmology as well as of vascular scissors that serve for opening
vessels), but tips can also be combined (i.e., one is sharp and one is blunt).
The use of scissors
The thumb and the ring finger are put into the finger rings. The index finger is placed on the distal part of the
shanks thereby stabilizing the instrument. Contrary to scalpel, cut is made from the left to the right or away from
the surgeon. When cutting from the left to the right, the wrist is superextended. Cut is usually made close to the

27
tips of the blades. Scissors are suitable for blunt dissection and preparation of tissues also. In this case scissors are
introduced into the tissues with closed tips, then opened and dissection is carried out with the lateral blunt edges
of the blades.

2.1.2. Grasping instruments

These instruments are used to grasp, pick up, hold and manipulate tissues, tools and materials. They can be applied
for retraction, blunt dissection as well as for hemostasis or occlusion of tubular structures - such as bowels or ducts
to prevent leakage of their contents.
Non-locking grasping instruments: thumb forceps
These are the simplest grasping tools. Forceps are made in different sizes with straight, curved or angled blades
(dental forceps). They can have blunt (dressing forceps), sharp (splinter forceps, eye dressing forceps) or ring tips.
Forceps are used to hold tissues during cutting and suturing, retract them for exposure, grasp vessels for cautery,
pack sponges and gauze strips in the case of bleedings, soak up blood, extract foreign bodies. Forceps should be
held like a pencil, they grip when compressed between thumb and index finger. This makes possible the most
convenient holding, the finest handling and free movements. The forceps must be never held in the palm.
The teeth of the tissue forceps prevent tissues from slipping, due to this, only a small pressure is required to grasp
tissues firmly. Therefore, to grip skin and subcutaneous tissues, most frequently tissue forceps is used. However,
vessels, hollow viscera must not be grasped with them (bleeding, perforation). For these purposes as well as for
holding sponges, bandages, dressing forceps should be chosen. They have blunt ends with coarse cross striations
to give them additional grasping power. Skin gripped firmly with dressing forceps for a longer time can necrotize.
Locking grasping instruments: surgical clamps
To fix clamping, these tools have a locking mechanism which might be springy handles alone (e.g., towel clip,
Doyen clamp) or combined with ratchet catches (e.g., hemostatic forceps). The design of clamps with a ratchet
lock is similar to that of scissors: they have finger rings at one ends of the springy shanks that are joined with a
joint and jaws at their other ends. The ratchet catches interlocking the two shanks can be found before the finger
rings. The opposing surfaces of the jaws vary depending on the specific purpose for which the instrument has been
designed: they can be smooth (e.g., intestinal clamp), serrated (e.g., Pan, Kocher, Lumnitzer hemostatic forceps),
and may (Kocher, Lumnitzer) or may not have teeth (Pan clamp). According to these, traumatic (artery forceps)
and atraumatic clamps (e.g., Dieffenbach serrafine, Satinsky artery forceps, intestinal clamp) can be distinguished.
They should be held like scissors: thumb and ring finger should be put into the finger rings, and the clamp is
stabilized with the index finger. The lock can be opened by pressing down one of the finger rings while elevating
the other one with the ring finger, and this way the interlocking teeth are moved from one another.
Hemostatic forceps
These instruments are the main means of establishing hemostasis during an operation (also called hemostats): they
are used for stopping bleedings by grasping and clamping of the ends of cut vessels or for preventive hemostasis
by applying them before cutting the vessel.
Traumatic hemostatic forceps (crushing hemostats): Pan, mosquito, Kocher, Lumnitzer (Kocher with long
shanks). The jaws can be straight or curved, the tips are blunt. The dissector has long shanks and the end of jaws
is curved at 90. Hemostatic forceps can be used for grasping and clamping tissues and materials (e.g., threads,
sponges) as well as for blunt dissection (Pan, mosquito, dissector).
Atraumatic hemostatic forceps (non-crushing hemostats: are applied if damage of vessels or tissues should be
avoided because later function is expected, e.g., after their removal circulation is to be restored. Dieffenbach
serrafine (bulldog) belongs to this group; its rubber coated jaws are closed by the springy shanks. The Satinsky
tangential occlusion clamp makes possible a partial occlusion of the lumen of larger blood vessels. While an
anastomosis is made, blood flow is undisturbed below the clamp.
Instruments used for grasping and clamping other tissues and textiles
Towel holding clamps: serve for fixing the draping towels to the ether screen, to one another and to the skin of the
patient (towel clip, Backhaus towel clamp).
The Doyen towel clamps are used to fasten wound towels to the edges of skin incision. Mikulitz peritoneum clamp
is applied to grasp and hold the edges of the opened during draping and suturing. Cervix holding or sponge holding
clamp is used to grasp the cervix of the uterus during gynecological operations, or to hold sponges for the scrub
preparation of the surgical site or to soak up blood from the wound.

Needle holders
In surgery nowadays suturing is made almost exclusively with curved needles that are held with needle holders
designed for grasping and guiding needles. Needle holders grip the needle between the jaws developed for this
purpose, they usually have a ratchet lock. The Mathieu needle holder has curved shanks with a spring and a locking
mechanism. It should be held in the palm. The Hegar needle holder resembles a hemostatic forceps, but the shanks
are longer and the relatively short jaws are made of a hard metal. The serrations are designed to grip needles.
During suturing in deep layers, needle holders of long shanks should be used.

28
2.1.3. Retracting instruments
Retractors are used to hold tissues and organs aside in order to improve the exposure and by this means the visibility
and accessibility of the surgical field. Hand held retractors (rake retractors, plain retractors: e.g. Roux, Langenbeck,
visceral retractors) are held by the assistant. They cause minimal tissue damage because the assistant keeps tension
on tissues only until it is necessary. Self retaining retractors applied properly (Weitlaner self retractor, Gosset self
retaining retractor, etc.) provide great help, but care should be taken not to damage tissues when they are placed
and removed.

2.1.4. Wound closing instruments and materials

2.1.4.1. Surgical needles
Needles are classified according to the type of the eye, shaft (body) and point. The eye of the needle is designed
to cause minimal trauma to tissue. Needle eyes may be conventional, closed, French eye and there are eyeless
needles (atraumatic needles) also. French eyed needles are the least traumatic of the eyed needles. Thread is pulled
through the minute spring in the head that locks it into the eye. Atraumatic needles cause the very least amount of
tissue trauma. They are manufactured with suture material already inserted. Such needles are also produced that
release the thread from the head if it is pulled sharply (suture release needles).
Basic types of the needle points are cutting, taper and blunt. Shaft can be triangular, i.e. cutting which has three
edges. At conventional cutting needles the vertex of the triangle is upwards, at reverse cutting needles it is
downwards. According to their curvature 1/4 circle (skin, eye, tendon sutures), 1/2 circle (muscle, fascia sutures),
3/8 circle (skin, fascia, gastrointestinal sutures), 5/8 circle needles (muscle, urogenital sutures) are discerned.
Needles are made in different sizes. Curved conventional cutting needles are used to suture firm, tough tissues
(skin, subcutaneous, tissues, muscles, fascia). Round bodied taper point needles cause the smallest possible hole
and minimum damage in tissues, therefore, blood vessels, heart, intestines are sewed with such needles.

2.1.4.2. Suture materials

Suture materials are used to sew (approximate) wound edges and to ligate bleeding vessels. Surgical threads must
meet different requirements: small caliber, high tensile strength, easy handling properties, sterilizability, inertness
(causing minimum tissue trauma and reaction), good absorption characteristics or complete removability. They
should hold securely when knotted without fraying and cutting. Suture selection should be based on the knowledge
of physical and biological characteristics of the material, healing rates of various tissues and on factors present in
the particular patient (infection, obesity, etc.). The most important properties of the suture materials are as follows:
Physical properties
- caliber
- tensile strength
- elasticity
- capillarity
- structure (monofilament or multifilament)
- absorbent capacity
- sterilizability
Application properties
- flexibility
- slipping in tissues
- knotting properties
- knot security
Biological properties
- tolerance of tissues
- tissue reaction
Tissue reaction depends on the material: it is very strong in case of chromic catgut and catgut, moderate to linen,
silk and polyamide, mild to teflon and polyester, minimal to polypropylene, polyglicolic acid, polydioxanone, steel
and tantalum.
Threads are classified according to 1. absorbability (absorbable or non-absorbable), 2. origin of the material
(natural or synthetic), and 3. structure (monofilament or multifilament: braided or twisted). Absorbable sutures are
broken in the body by enzymatic digestion or by hydrolysis. In the case of multifilament threads, several strands
of fiber are twisted or braided to make one strand, therefore, they are stronger than monofilament ones.
Multifilament threads are easy to handle, can be knotted securely; however, due to their capillarity they facilitate
migration and proliferation of bacteria among the strands, and thus the propagation of infections. For this reason,
it is reasonable to sew with monofilament threads on an infected field. In the case of pseudo monofilament threads
the multifilament thread is coated with a homogeneous smooth layer (e.g., with polybutylate), due to this capillarity

29
is lost. Coated threads join the advantages of monofilament and multifilament threads: they are strong, easy to
handle, and noncapillary.
According to the European Pharmacopoeia the thickness of the threads are given in metric units, 1/10 mm. At
absorbable sutures size 1 means a thread of 0.1 mm diameter (the diameter of threads can change between 0.001-
0.9 mm); according to the United States Pharmacopoeia (USP) this is a 6-0 thread. At non-absorbable and synthetic
threads this corresponds to the 5-0 size. The cause of discrepancy is that catgut is thicker when stored in alcohol
than the dry thread. The higher the number is in the size, the thicker is the thread and the more 0s in the number,
and the smaller is the size. The size is ranging from 7 to 12-0. According to the Brown and Sharpe (B & S) sizing:
#20 = 5, #25 = 1, #26 = 0, #28 = 2-0, #32 = 4-0, #35 = 5-0, #40 = 6-0, etc. The length of the thread is also
standardized.
The tensile force should be adjusted to the tensile strength of the thread. If it is too great, the thread is weakened,
or broken. If the thread is pulled on a sharp surface (e.g., it is pulled through the French eye of the needle), it
becomes weaker. The thread should be cut where it was grasped with an instrument. Guiding the thread during
suturing is the role of the assistant.

2.4.1.2.1. Absorbable sutures

They are broken down in the body and eventually absorbed by either digestion by lysosomal enzymes of white
blood cells or by hydrolysis (synthetic absorbable sutures).
Natural materials
Surgical gut (catgut): is made of collagen processed from the submucosal layer of the beef or sheep intestine.
Catgut is absorbed relatively quickly. Its tensile strength remains unchanged for 7-10 days; it is absorbed in 70
days. Treatment with chromium salt solution prolongs the absorption time. In this case, the tensile strength is
retained for 10-14 day; the absorption time is 90 days. It is made in monofilament and multifilament form. It can
be applied in an infected field. The plain catgut is used for ligation of superficial blood vessels and suturing mucous
membranes, subcutaneous tissues, the chromic catgut is applied for sewing fascia and peritoneum. Collagen: It is
produced from the collagen fibers from the flexor tendon of cattle in plain and chromic form and can be applied
in the same fields as surgical gut.
Synthetic materials
They are extremely inert, and have great tensile strength. They can be used to suture and ligate in nearly all tissues
(peritoneum, fascia, subcutaneous tissue, joints). One of their disadvantages is that they tend to drag through tissue
rather than passing through smoothly. They are rigid and slippery, and therefore they need extra knots (up to 6 half
hitches) to obtain a secure ligature.
Dexon: It is a braided suture made of polyglycolic acid and coated with polycaprolate. It has an excellent tensile
strength (remaining unchanged for about three weeks) and knot security. It is completely absorbed in 60-90 days.
Vicryl: braided suture manufactured from polyglactin 910 (and coated with polyglactin 370 copolymer) which is
similar to Dexon. Its tensile strength 65% on day 14, absorption is minimal until 40 days, complete after 56-70
days. It can be used to ligate or suture tissues except where approximation under stress is needed (soft tissue
surgery, vessel ligation).
PDS II: It is made of poly-p-dioxanon. It is a monofilament thread, the tissue reaction is minimal, tensile strength
is 70% on day 14. Absorption is minimal until 90 days, complete within 6 months. It is applied in soft tissue,
pediatric, plastic, gastrointestinal (colon) surgery.
Maxon (polytrimethylen carbonate): It has similar characteristics.

2.4.1.2.2. Non-absorbable sutures

Their material effectively resists enzymatic digestion. They can be monofilament or multifilament, coated or
uncoated threads. They are used in tissues that heal more slowly, or if a very secure tightening is required. They
are either left in the body where they become embedded in scar tissue, or they are removed when healing is
complete.
Natural substances
Silk: a braided thread made of the protein fibers spun by the silkworm. Silk is strong and easy to handle. It can be
applied in most tissues. It should be used dry, and causes significant tissue reaction. Tensile strength is preserved
for more than one year; it is absorbed by proteolysis in two years.
Linen is a twisted thread. It is weaker than silk; however, it is straightened when wet. Therefore, it must be dipped
into saline solution before use. Tensile strength is 50% up to 6 months, 30-40% for 2 years. Linen can also be
applied in most tissues. It is sized from thick to thin as follows: No. 25 (0.4 mm), 40 (0.25 mm), 60 (0.167 mm),
80 (0.125 mm), 100 (0.1 mm), 120 (0.083 mm).
Cotton: It is made from twisted cotton fibers. It should also be dipped into saline solution. Its application is identical
to that of silk and linen.

30
Stainless (surgical) steel: causes almost no tissue reaction. It is manufactured in monofilament and twisted form.
It is rarely used because it is difficult to handle, it may break up and can easily cut tissues. It can be used for tendon
and bone repair, nerve and retention sutures, skin closure. It is numbered according Brown and Sharpe.
Synthetic materials
Polyester: it can be monofilament (Miralene, Mirafil), but it is mostly braided, either uncoated (Dacron, Mersilene,
Dagrofil), or coated with teflon (Ethiflex, Synthofil) or polybutilate (Ethibond). This is the strongest suture except
surgical steel. It can be used in a wide variety of tissues, primarily in cardiovascular surgery.
Polyamide (Nylon): it is manufactured in monofilament (Ethilon, Dermalon) or in braided, coated form (Surgilon,
Nurolon, Supramid). Braided nylon can be used in all tissues where multifilament non-absorbable suture is
acceptable (general closure, microsurgery). Its tensile strength is 80% for 1 year, 70% for two 2 years, 66% for 11
years and it causes minimal inflammatory response.
Polypropylene: monofilament suture material (Prolene, Surgilen), it does not adhere to tissues and causes only
minimal tissue reaction, it has a high tensile strength (100% for 2 years) and holds knots better than most other
synthetic materials. It is used in general, cardiovascular (blood vessel sutures) and plastic surgery. It can be applied
in an infected field also.

2.2. Basic wound closing methods: sutures, clips

At the end of the operation wounds are closed with sutures or clips. During suturing tissues are approximated with
stitches, and then threads are knotted. The basic prerequisites of wound healing are: tissues should be precisely
approximated without tension, no dead space must be left, and the optimal blood supply of the wound should be
secured. As few sutures should be applied as possible and only as much as necessary. Sutures can be used to stop
bleedings (see 4.5.3.2.1).

2.2.1. Types of sutures

According to the number of the layers: one layer (only one layer is sewed), two or multiple layers (retention suture).
According to the number of rows: one or two rows (seldom multiple rows).
According to type: interrupted or continuous.

2.2.2. Rules of wound closure

- Sutures must not be placed too close to the wound edges otherwise the thread can tear them. Stitches should be
placed 0.5-1 cm far from the wound edges on both sides. (Suturing is usually made towards ourselves).
- Stitches should be placed at equal distances (approximately 1-1.5 cm).
- Knots should be on one side of the wound and never on the wound line.
- Stitches should be placed opposite each other, thus no wrinkling and gaps occur.
- During suturing the curvature of the needle should be followed.
- Wound edges must not be inverted (the inverted wound edge heals with thick scar).
- In the case of superficial wounds stitches should be inserted to the base of the wound not leaving dead space, in
which blood and wound secretion may accumulate (wound infection, other complications).
- Threads must not be stretched too much to avoid ischemia.
- Deep wounds should be closed in more layers.
- When suturing skin, the stitch must be wider at the bottom of the wound (including more tissue) than in the
superficial layer.

2.2.3. Correct position of the needle holder

31
2.2.3.1. Interrupted sutures
1. Simple interrupted suture (sutura nodosa). It is frequently used to suture skin, fascia and muscles. After each
stitch a knot should be tied. All sutures must be under equal tension. The advantage is that the remaining sutures
still secure an appropriate closure and the wound will not open if one suture breaks or removed. The disadvantage
is that it is time consuming since each suture must be knotted.
2. Vertical mattress suture (sec. Donati)
It can be used for skin closure. It is a two row suture: it consists of a deep suture that involves the skin and the
subcutaneous layer (it closes the wound) and of a superficial back stitch placed into the wound edge (it
approximates the skin edges). The two stitches are in a vertical plane that is perpendicular to the wound line.

3. Allgwer suture
It is a special form of vertical mattress suture: on one side of the wound the thread does not come out from the skin
but it runs intracutaneously. In this case a thin scar is formed.
4. Horizontal mattress suture
It is a double suture: the back stitch is 1 cm far from the first one, parallel to it in the same layer.

32
2.2.2.2. Continuous sutures
1. Simple continuous suture (furrier suture, sutura pellionum).
It can be applied to suture tissues without tension, the wall of inner organs, stomach, intestines and mucosa.
Advantages: 1. it can be performed quickly, since knot should be tied only at the beginning and the end of suture
(here only a part of the thread is pulled through and the strands of the opposite sides are knotted); 2. the tension is

distributed equally along the length of the suture. During suturing the assistant should continuously hold and guide
the thread (with hands or forceps) to prevent it from getting loosed.
2. Locked continuous suture

3. Subcuticular continuous suture

It runs in the subcuticular plane parallel to the skin surface, it enters the skin at the beginning and comes out at the
end (no sutures are visible). It is used in skin with minimal wound tension and produces a fine scar. Starting from
one end of the incision, insert the needle through the dermis taking small bites alternately on one side and then the
other. At both ends the thread can be tied or taped to the skin.

33
4. Purse string suture
The openings of the gastrointestinal tract are closed with this suture, an atraumatic needle and thread is used. It is
a suture for a circular opening, running continuously around it, then the wound edges will be inverted into opening
with dressing forceps and the threads are pulled and knotted.

2.2.3. Methods of wound closure

2.2.3.1. Suturing with simple interrupted knotted stitches (subcutaneous tissue)
For simple interrupted stitches a needle holder, a curved needle (1/2 circle cutting needle) and 30-35 cm long
thread is needed. The needle holder should grasp the needle closer to the eye than to the tip. The subcutaneous
tissue must be stabilized by gently grasping it with tissue forceps 0.5 cm deep on the far side of the wound. The
surgeon should insert the needle towards him- or herself obliquely downward 1-2 cm deep. Suturing should be
started with the hand pronated, and the needle should be driven following its curvature by progressively supinating
the hand until the point of the needle appears. The needle should exit the tissue perpendicular to the wound. At
deep stitches it can occur that the needle should be released and regrasped. The surgeon must always see the point
of the needle when possible. On the close side of the wound, he or she should grasp the same layer with the forceps
retracting it upward and outward. The needle should be inserted approximately the same distance as on the former
edge, and suturing should be continued towards oneself. When the point of the needle exits the tissue, the needle
should be grasped and stabilized with the forceps, then released and regrasped with the needle holder under the
forceps and removed from the tissues. The point of the needle must never be grasped. The free end of the thread
is held by the assistant, and the thread is pulled out from the needle. The needle closed in the jaws of the needle
holder is passed to the scrub nurse. The distance from one suture to the next should be approximately 1-1.5 cm.
Elevating tissues with the knotted sutures by the assistant may provide help to insert the next suture. All the stitches
are cut only after tying the last one, just above the knots. (See also Interrupted Wound Closure in the Suture Tutor
computer program.)

2.2.3.2. Suturing with Donati type stitches (skin closure)

Skin wound is usually approximated with Donati type knotted sutures. No. 40 linen thread or nylon thread, skin
needle (3/8 or 1/4 cutting needle) are used. The stitch takes both deep and superficial bites and is useful in closing
deeper wounds. The superficial bite makes for a more exact apposition of the skin edges, and the inversion of
wound edges can be avoided. It may be interrupted or continuous. The wound edge is grasped and stabilized with
tissue forceps on the far side, and the needle is inserted approximately 1 cm distance from the edge close beside
the forceps. The stitch is continued on the other side. The needle should exit the other skin edge at the same distance
(1 cm) from the wound. The needle should be removed from the skin and the point is turned into the opposite
direction to make a back handed stitch (the inner curvature of the needle and the point is up). Then the needle is
grasped with the needle holder again. During these steps, the position of the needle holder remains unchanged.
The closer wound edge is elevated with the tissue forceps and a back handed stitch is inserted 1-2 mm far from the
edge. The needle should leave the tissues between the cutis and subcutis. The stitch is repeated in the far side

34
wound edge from inside to outside. The point of the needle exits at 1-2 mm distance from the skin edge. The thread
is removed from the needle and tied as usual. The distance from one suture to the next should be approximately 1-
1.5 cm. The stitches should be perpendicular to the wound and run parallel to each other. Cut the threads after
closing the wound completely, but leave some 0.5-1 cm above the knots. The stitches must be tied just tight enough
to appose the edges, taking into account that edema will occur during the next few days. The wound should be
disinfected with povidon-jodid or iodine tincture and covered with a bandage. (See also Mattress and Pulley
Sutures in the Suture Tutor computer program.)

2.2.3.3. Wound closure with metal clips

Metal clips produced from stainless steel or titanium can also be used for approximation of tissues. They can be
applied to close skin wounds and, e.g., to make gastrointestinal sutures. In the case of skin they can be used on
fields without wound tension and where wounds tend to heal quickly (e.g., after appendectomy, strumectomy or
hernia repairs). Clips can be applied to close the lumen of different tissues and organs (vessels, ducts, etc.). This
method is used in video-endoscopic surgery also.
1. Clips fit into the jaws of a special grasping instrument designed for their handling, the Michel clip applicator
and remover. The clip is grasped with the forceps like part of the applicator. The assistant approximates and lift
up the opposite wound edges with two tissue forceps. The surgeon inserts the clip with the applicator between the
two tissue forceps perpendicular to the incision with a definite movement. When compressed, the toothed tips of
the clip are closed with the instrument. The distance between the clips is 1-1.5 cm. Clips are removed with the
other end of the instrument. It is forbidden to close the wounds of the hand and the hairy skin of the head with
clips. Closure of skin wounds can be made with a modern, clip applicator also.
2. Staplers: They approximate tissues with staples in one or two rows. The metal clips are pressed by the apparatus
into the anvil of the opposite side where they will become crooked and be closed without crushing the tissues.
Linear stapler: it closes tissues with double rows of staples in a straight line, it can also cut the tissues between the
two rows (gastrointestinal and lung surgery). Circular staplers: they can be used to approximate tubular structures
(esophagus, intestinal surgery). It is suitable for making purse string sutures (intestinal surgery).

2.2.3.4. Other wound closing methods

1. Surgical adhesives: They are usually produced from fibrin, collagen, thrombin and induce the last phase of blood
coagulation, thus a firm fibrin mesh is produced. Application fields: anastomosis, securing vascular and nerve
sutures, fixation of skin transplants, stopping bleedings (see 4.5.2.3.3.).
2. Wound closure with self adhesive strips (steri-strip): They can be applied if the wound edges can be easily and
well approximated in the case of smaller wounds not requiring suturing. They are also used for fastening
subcuticular sutures.

Disadvantages: less precision than suturing, body parts with secretions (armpits, palms, or soles) are difficult areas,
areas with hair are not suitable for taping.

2.3. Sutures in the different tissues

Skin: Usually non-absorbable sutures (silk, synthetic material) are used. Suture types applied: simple interrupted
suture, vertical mattress suture, (Donati, Allgwer suture), subcuticular continuous suture. Metal clips, clip
applying machine, self adhesive strips (steri-strips) (small children, supplementary fastening of subcuticular
sutures), surgical steel (in the case of delayed wound healing) can also be applied.
Mucosa: Thin absorbable sutures (earlier catgut) are used.
Gastrointestinal tract: The danger of suture insufficiency is great. Lembert (involving the seromuscular layer on
both sides), Albert (passing through all layers), Czerny sutures (double row: Albert suture followed by Lembert
suture) can be applied. Often different staplers are used (see above).
Muscles: In most cases muscles are closed with absorbable (earlier catgut) sutures together with the fascia.
Fascia: It is closed with simple interrupted stitches using silk or synthetic suture materials.
Tendons: Surgical steel or other non-absorbable monofilament sutures are applied.
Blood vessels: They are sewed with non-absorbable synthetic thread (Prolene) often by using microsurgical
techniques.
Nerves: They are approximated with microsurgical techniques using non-absorbable monofilament threads.

35
Parenchymal organs (liver, spleen, and kidney): They are sewed with absorbable material and mattress sutures.

2.4. Failures of suturing technique

Dead space: Insufficient depth:

Inversion of wound edges: Knot in the wound line:

2.5. Removing sutures

The time of removal (usually within 3-14 days) depends on the place of suture (sutures are removed later from a
field which is under tension), the blood supply of the operative field (sutures can be removed earlier from an area
that has good circulation) and the general condition of the patient. Sutures can be removed after 3-5 days on the
face, 7-10 days on the skin of the head and the abdominal wall, 10-14 days on the trunk and from the joints, 10
days on the hand and arm, and 8-14 days on the leg and foot.

2.5.1. Removing simple interrupted, continuous sutures and wound clips

After careful disinfection of the wound site, the suture is grasped and gently lifted up with a thumb forceps. The
thread should be divided as close to the skin as possible that no thread which was outside of the skin should be
pulled through the wound. Thus, infection of the wound can be avoided. In the case of continuous subcuticular
sutures one end of the suture is cut above the skin and the other end is pulled out in the direction of the wound.
Michel clips are removed with the Michel clip applicator and remover. The ring of one end of the clip is grasped
with a tissue forceps, the edge of the remover is placed between the clip and the wound line, beneath the apex of
the clip. The instrument is closed, the clip will open and the teeth of the clip will come out of the skin. (See also
Removing Sutures in the Suture Tutor computer program.)

2.6. Surgical knots

In surgery the ends of threads used to sutures or ligatures are tied with surgical knots. Basic requirements of tying
knots are that they could be ligated quickly, knots should hold securely and they should be safe. Incorrectly tied
knots may cause serious postoperative complications: loose knots can result in thicker scar formation. Too tight
knots can decrease or stop local blood circulation that slows down wound healing and can lead to loosing sutures
and even to suture insufficiency. The knot must be as small as possible to prevent tissue reaction when absorbable
sutures are used, or to minimize foreign body reaction to non-absorbable sutures. The two ends of the threads
should be cut as short as possible, just above the knots (except skin sutures where longer threads are left making
easier the removal of the sutures).

36
2.6.1. Types of tying surgical knots
There are different types of tying knots. The granny knot used in everyday life is made of two identical simple half
hitches tied above each other: in the second half hitch the direction of ends of the thread is identical with that of
the first one. As it has the tendency to slip and can open up spontaneously, therefore, it must not be used in surgery.
The common knot used in surgery is the square (or reef) knot, a symmetrical knot which consists of at least two
half hitches, one placed on the other: the base half hitch and then the second half hitch which is the mirror image
of the first one. A half hitch is one revolution of one end of a thread around the other. The first half hitch is made
by crossing the segments, and the second half hitch is in the opposite direction to that of the first one, so the knot
has two mirror image half hitches. The number of half hitches depends on the type of surgical materials (synthetic
monofil threads require extra knots 5 or 6 knots).
Techniques of tying knots in surgery: two-handed knots, one-handed knots (one hand is active, the other only holds
the thread, then the knot is tightened with both hands), instrument tie.

2.6.1.1. Two-handed knots

Both hands take an active part in the formation of the knot. They are mostly applied on tissues under tension.
The most important types of two-handed knots: the two-handed square knot (reef knot or sailors knot), the
surgeons knot and the Viennese knot.

37
 1. Reef knot or sailors knot

1. The two strands of the thread are crossed, 2. The upper strand is pushed with the right index finger
the upper (white) strand is held in the right to the left side over the blue strand.
hand. The ends of the thread are held firmly
against the palm with the last three fingers, the
thumbs and the index fingers are free.

3. The right thumb is inserted between the 4. The left handed strand is placed on the pulp of the
strands upwards from below. right thumb.

5. The thread is grasped with the right thumb 6. The thread is released from the left hand and transferred
and index finger. with the two fingers through the loop.

38
7. The thread is grasped with the left hand 8. The base half hitch is taken down and tightened
again. with two hands.

9. The two strands are crossed (exchanged 10. The upper strand is pushed with the left index
between the two hands) in the opposite finger to the right side over the blue strand.
direction: the upper (white) strand is held in
the left hand.

11. The right thumb is inserted between the 12. The right handed strand is placed on the pulp of
strands upwards from below. the left thumb.

39
13. The thread is grasped with the left thumb 14. The thread is transferred with the two fingers
and index finger and released from the right through the loop and grasped with the right hand
hand. again.

15. The second half hitch is taken down and

tightened with two hands.

40
2. Surgeons knot
The technique of tying this knot is identical with that of the reef knot, however, during tying the base half hitch
the thread is transferred two times through the loop, and then similarly to the reef knot the base half hitch is secured
with a second half hitch of opposite direction. It results in a strong, safe knot that is used mainly in tissues under
tension (skin, fascia).

1. After transferring the thread with right thumb 2. The base half hitch is taken down and
and index finger through the loop, the index tightened with two hands, then the second half hitch
finger is left in the loop, and the thumb is pushed is tied.
back behind it. Grasping the thread (held in the
left hand) with the two fingers, it is transferred
through the loop once again.

41
3. Viennese knot
The technique of tying knot is different, but it results in the same knot as reef knot. It is faster, more elegant; it can
be applied well in tissues under minimal tension (e.g., subcutaneous tissues, skin).

1. The two strands of the thread are crossed; 2. The left hand is placed over the thread, the ulnar
the lower (blue) strand is in the left hand. The side of the small finger is laid on the thread and the
ends of the thread are held between the tips of wrist is supinated so that the small finger rolls along
the thumbs and the index fingers. the strand. The left palm looks upwards.

3. The right handed (white) strand is placed on 4. The left handed strand gets between the middle and
the pulp of the extended left middle finger, index fingers.
and then the distal phalanx is flexed and
pulled beneath the left handed strand.

5. The two fingers are closed and the thread is 6. The thread is brought through the loop with the two
grasped by them. Then the end is released by fingers.
the thumb and index finger.

42
7. Holding the two strands of the thread in the
palms, the tips of the index fingers are placed
on them, and the half hitch is taken down and
tightened.
9. The right hand is placed over the thread, the
ulnar side of the small finger is laid on the
thread and the wrist is supinated so that the
small finger rolls along the strand. The right
palm looks upwards.
11. The two fingers are closed and the thread
is grasped by them. Then the end is released
by the thumb and index finger.
43
8. The two strands of the thread are crossed
(exchanged between the two hands) in the opposite
direction (from the left to the right. The lower (blue)
strand is held between the right thumb and index
finger.
10. The left handed (white) strand is placed on the
pulp of the extended right middle finger, and then the
distal phalanx is flexed and pulled beneath the right
handed strand.
12. The thread is brought through the loop with the
two fingers.
13. Finally the second half hitch is taken
down and tightened.

44
4. Instrument tie
It is used when knots should be tied in deep tissues or in a deep cavity or the thread is short (by this technique
thread can be saved) or when working with atraumatic needle and thread. It can be tied with a needle holder (this
is used most frequently), with a hemostatic forceps (Pan), or with other grasping instruments.

1. The instrument is placed on the long thread 2. The thread is wrapped around the needle holder
held in the left hand. once when tying a reef knot and twice if a surgeons
knot is tied.

3. The short free end of the thread is grasped 4. Then the base half hitch is taken down and
in the needle holder and pulled through tightened.
loop(s).

5. The instrument is placed under the long end 6. The thread is wrapped around the needle holder
of the thread. once.

45
7. The short free end of the thread is grasped 8. Then the second half hitch is taken down and
and pulled through the loop. tightened.

2.7. New surgical instruments

Ultrasound cutting Argon-plasma coagulator Cryosurgery instrument

2.7.1. Minimally invasive surgery

Disadvantages of conventional surgery (minimally invasive methods: see B module later)
- large incision, great surgical trauma
- postoperative pain depends mostly on the size of the wound
- open body cavities (evaporation, drying, cooling, etc)
- danger of secondary damages during incisions (intestines, liver, lungs), and incidence of adhesions is great;
- larger wounds increase the risk of complications (infections, hernia, etc.)

2.7.2. Tele/robotic surgery

- planned with advanced diagnostics, computer-guided intervention
- minimally invasive method
- manipulators (laser, diathermia)

2.8. Operations (see later)

The parts of the operation are 1. opening (entering), 2. intervention and 3. closure. According to its aims curative
(radical) and symptomatic (palliative) operations are distinguished.

2.8.1. Preparations for an operation

Indication and contraindication (indicatio et contraindicatio): decision making to carry out a given operation,
i.e., the decision before the intervention. It has different levels. The indication for surgery should be clearly known,
as it will determine the urgency of the procedure.

46
Vital indication (indicatio vitalis): in case of life saving procedures. The patient can be treated only with an
operation (100% mortality without operation). The timing has narrow limits, the possibility of evaluation and
deliberation is very limited.
Absolute indication (indicatio absoluta): urgent procedures. The disease can be treated primarily with an
operation. The time can be chosen (the operation can usually be delayed 12-24 hours to accommodate further
evaluation). The surgeon makes a decision on the type of the operation which is considered to be the most effective,
and in accordance with the anesthesiologist determine the optimal time of the operation.
Relative indication (indicatio relativa): elective procedures. These are programmed operations, the aim of which
is curing the patient or improving a condition (the disease can be treated with surgery also). The condition leaves
time for full evaluation and optimization before operation.

2.8.2. Informed consent

1. To obtain an informed consent that meets ethical obligations and is acceptable to a court, the following
information must be provided:
- Nature of the disease and the proposed treatment or surgery;
- Chances of success based on medical knowledge;
- Risks of the proposed treatment or procedure;
- Adverse effects of the proposed treatment or procedure;
- Reasonable alternatives and their chances of success, risks, and adverse effects;
- Consequences of deciding not to proceed with the recommended course of treatment.
2. The physician makes an effort to educate a patient capable of learning. The physician who makes this effort and
obtains such consent has met both the legal and ethical obligations imposed upon him or her by society. In case of
surgery, the complication rate in percentage of all operations is as follows:

Infection: 14.3%
Wound infections: 5.1%
Pneumonia: 3.6%
Urinary infection: 3.5 %
Sepsis: 2.1%
Intubation: 2.4%
Respiration > 1 day: 3.0%
Acute myocardial infarct: 0.7%

2.8.3. Operative risk

This refers only to the risk related to the operation itself. It excludes the risk of the disease prior to the surgery and
complications which arise after the patient has left the hospital. Operative risk is related to anesthesia, the actual
operation and the immediate postoperative events. Risk can refer to complications in general or to the risk of death
in particular.
1. Low risk surgery: minor operations (blood loss is < 200 ml) belong to this group (e.g., inguinal hernia repair,
arthroscopy).
2. Medium risk surgery: surgical interventions of medium severity (blood loss is <1000 ml) can be classified
here (e.g., tonsillectomy, cholecystectomy, TURP).
3. High risk surgery: extended abdominal, thoracic, intracranial operations fall into this category. Blood loss is
>1000 ml. The patient needs intensive postoperative observation and treatment. The rate of postoperative
morbidity and mortality is high (e.g. liver resection, pulmonal lobectomy).
4. Life saving operations: mortality is 100% without surgical intervention (e.g., bleedings).
5. Urgent operations: the patient suffers permanent organ lesions without surgery. The intervention can be delayed
for a short time to improve the patients condition. The postoperative morbidity and mortality is high (e.g. bone
fractures).
6. Elective operations: the intervention can be delayed in the interest of the arrangement the patients state (e.g.
hernia repair).
7. The classification of patients according to the ASA (American Society of Anesthesiologists) grading system
(which is the most commonly used grading system) accurately predicts operative morbidity and mortality:
- 50% of patients of elective operations belongs to ASA grading I;
- operative mortality of these patients is < 1:10.000;
- co-existent diseases of the patient increase operative mortality.

Grading Health state of the patient Mortality

47
 I Healthy 0.1%
II Mild systemic disease 0.5%
III Severe systemic disease 4.4%
IV Decompensated life-threatening diseases 23.5%
V Moribund states* 50.8%

*not expected to survive 24 hours with or without surgery

2.8.4. Acute risk factors in surgery

Hypovolemia
Dehydration
Inflammation
- bronchial
- kidney
- gastrointestinal
- interstitial diffuse or localized purulent
- body cavities diffuse or localized purulent
- sepsis
Thromboembolism
Acute organ imbalance
Acute endocrine imbalance
- pancreas (diabetes)
- thyroid (hyperthyreosis)
- adrenocortical (insufficiency: Addison disease)

2.8.5. Chronic risk factors in surgery

Hypovolemia (anemia)
Age (over 65 years)
Malnutrition, obesity
Immunological dysfunction (allergy, immunodeficiency)
Cardiovascular disease
Pulmonary disease
Cerebrovascular disease
Chronic renal insufficiency
Chronic endocrine insufficiency
Bleeding disorders
Malignancies
Chronic alcoholism
Drug abuse

2.8.6. Preoperative investigations

- Every specialty (e.g. surgery, anesthesiology) has its own special considerations.
- Preoperative investigations should correspond to the demands of each participant.
- It is reasonable to put down consultation and cooperation in writing.
- In a stable condition, a one-month-old finding can be accepted.
- In emergency cases the minimum of investigations should be carried out.

Recommended investigations Patient groups

Minimal (routine) laboratory ASA I, ASA II

Routine hematological testing Males over 60 years, every adult female, cardiovascular hematological
diseases

48
Chest X ray Cardiovascular and thoracic diseases, malignancies, upper abdominal and
thoracic surgery

Complete urine test Over 60 years, cardiovascular, kidney and urological diseases, diabetes,
steroid therapy, ACE inhibitors

Quantitative hematological tests Every adult female and males over 60 years

ECG Males over 40 years, females over 50 years

cardiovascular diseases, diabetes

2.8.7. Evaluation of preoperative investigations

- Preoperative investigations rarely (<5%) uncover unsuspected disease conditions;
- They are inefficient as a means of screening for asymptomatic disease;
- 0.1% of these investigations ever change the patients management;
- 70% of pre-operative investigations could be eliminated without adverse effect.
(Reference: Barnard NA, Williams RW, Spencer EM. Preoperative patient assessment: a review of the literature
and recommendations. Ann Royal Coll Surg Eng 1994; 76: 293-297)

2.8.8. Preoperative preparation

Definition: A series of procedures carried out on the patient that makes him or her suitable for the planned
intervention and ensures the optimal conditions for the operation.
The preoperative preparation of an individual patient depends on the results of a thorough clinical assessment and
on the particular operation to be undertaken. This will allow specific measures to be taken so that the patient may
be in the best possible condition for both anesthesia and surgery.
The function of the organ and organ systems should be controlled and restored if necessary:
- Cardiovascular system
- Respiratory system
- Metabolic status
- Renal function
- Liver function
- Endocrine balance
- Ion homeostasis
- Immunological status
- Energetics
The goal of preoperative preparation is that the surgeon may operate the right patient, in the right time, by the right
method.

2.8.8.1. General preparation

1. Rules, procedures
Psychological support (to release fear, anxiety), informations
Setting aside cosmetics, removing contact lenses, dental prosthesis
Menstruation (it is not a contraindication; the operation should not be postponed)
Toilette (bath, shaving) (see later)
Diet (fasting: empty stomach to prevent vomiting and aspiration) (see later)
2. Medication
Premedication: for sedation, analgesia, and inhibition of undesired reflexes
Antibiotic prophylaxis (if necessary, e.g. septic operation)
3. Instrumental preparation (see later)
Injections, securing veins (see later)
Fluid therapy, drug administration (see later)
Transfusion (if necessary) (see later)
Emptying intestines (enemas, laxatives)
Nasogastric catheter (if necessary) ((see later)
Permanent urinary catheter (if necessary) (see later)
Thrombosis prophylaxis

49
2.8.8.2. Special preparation
1. According to the type of the operation
- Before strumectomy in case of hyperthyreosis: -blocker, sedatives, Plummer-solution (iodined),
securing airways
- Operation due to mechanical icterus: K, C vitamines, FFP (fresh frozen plasma), placing stents to secure
bile draining
- Removing stomach tumor: gastric lavage, acid replacement
- Colon surgery: laxatives, enemas, potassium replacement (hypokaliemia)
2. According to (organ) system
a. Acid-base system (see later)
b. Respiratory system
Lung diseases predisposes to respiratory complications:
- bronchospasmus
- atelectasis
- bronchopneumonia
- hypoxia
- respiratory insufficiency
- pulmonary embolism
General preoperative investigations should be supplemented with:
- chest X ray examination
- spirometry
- arterial blood gas analysis
The airway infections increase the risk of postoperative chest complications; in this case the elective operation
should be postponed with 2-4 weeks. In case of smoking the risk of postoperative chest complications is doubled.
The increased risk persists for 3-4 months after giving up smoking; smoking increases blood carboxyhemoglobin,
its concentration is still elevated for 12 hours after the last cigarette.
c. Endocrine system - diabetes mellitus
Pre- and perioperative management depends on the severity of the disease.
1. Diet controlled diabetes: there are no specific precautions; checking of blood sugar and consideration of
Glucose-Potassium-Insulin (GKI) infusion if >12 mmol/l (15 U insulin + 10 mmol KCl + 500 ml 10%
dextrose/100 ml/hour)
2. Oral antidiabetics: long acting sulphonylureas are stopped 48 h prior to surgery; short acting agents should be
omitted on morning of operation; earlier treatment should be restarted when eating normally; GKI infusion for
major surgery.
3. Insulin-dependent diabetes: conversion of long acting insulins to 8-hourly Actrapid; placement early on
operating list; GKI infusion until eating normally.
d. GI system (see later)
e. Circulatory system (see later)

2.9. Postoperative complication

Definition
A postoperative complication may be defined as any negative outcome appearing during or after the operation as
perceived either by the surgeon or by the patient that can influence healing of the patient.
Prevention
In the preoperative phase a proper investigation-preparation is needed.
During operation careful anesthesiology methods and fine surgical techniques should be used.
Postoperatively careful control, attention, checking up temperature, blood pressure, heart rate, respiration, urine
output, bowel movements, etc., early mobilization, regular check up of drains, catheters, wounds are needed.
Classification of complications
They can be associated with
- medical specialties, e.g. anesthesiology, surgery
- time of development (before, during or after operation)
- site of operation (e.g. thorax, abdomen)
- primary disease (external conditions)
- type of the operation (vital - elective)
1. Complications of anesthesia
Nerve injuries
- Brachial plexus
- Ulnar nerve
- Radial nerve

50
- Common peroneal nerve
Tissue injuries
- Corneal abrasion (during controlling cornea reflex)
- Fracture of teeth or crowns etc. (during intubation)
- Diathermy burns
- Dislocations, fractures
Narcosis
- Drug reactions
- Hypoxia
- Awareness
- Temperature changes (hypo-, hyperthermia)
2.1. Intraoperative complications
- Bleeding (see later)
- Organ lesions
- Circulatory, respiratory, secretory disturbances, etc.
2.2. Postoperative complications
- Postoperative fever
- Wound healing complication
- Respiratory disorders
- Cardiovascular complications
- Urinary excretion disorders
- Ion and water homeostasis disorders
- Hemostasis disorders
- Gastrointestinal function disorders
- Neurological disorders
- Metabolic disorders
a. Postoperative fever
Postoperative subfebrility is common within 48-72 hours. If prolonged, it can indicate an inflammatory process
(phlebitis caused by intravenous cannula, infection caused by urinary catheter etc.), but it can be associated with
the primary disease also.
Fever within 24 hours is most frequently caused by atelectasis, rarely by Streptococcus and Clostridium infection
of wounds.
Fever appearing between 24-48 hours is caused by long-lasting atelectasis, bacterial pneumonia, aspiration
pneumonia, septic thrombophlebitis.
Fever developing after 72 hours is caused by urinary tract infection (between days 3-5), wound inflammation
(between days 4-7), insufficiency of intestinal anastomosis, abscess in the abdominal cavity (approximately after
the first week).
b. Complications of wound healing
Hematoma
Cause: Inefficient control of bleedings, short time drainage, anticoagulation therapy. The risk of infection is high.
Signs: tender, swelling, fluctuation, pain, redness. Treatment: in the early phase: sterile punction, later surgical
exploration is required.
sterile sodium chloride solution.
Seroma
Cause: collection of serous fluid under the suture line, may occur in areas of extensive undermining or dead space.
Signs: fluctuation, swelling, pain, subfebrility.
Treatment: seromas may be drained to alleviate pain and tension on the wound by using a large-bore needle and
syringe to withdraw the fluid; compression, later drainage
Cause: wound cavity is filled up with serous fluid and lymph. Signs: fluctuation, swelling, redness, pain,
subfebrility. Treatment: sterile puncture, compression, if repeated, suction drain, in case of infection antibiotics.
Wound infections (see SSI)
Acute wound disruption
First the deeper layers are affected; skin disruption is the final sign. Types: partial (dehiscentia); complete
(disruption), sterile abdominal disruption with eventeration (Platzbauch). Causes: inappropriate surgical
technique (fascia closure with continuous suture), increased intraabdominal pressure, wound infection. Treatment:
in the operating theater, in narcosis with U type retention sutures.
Chronic wound disruption
Incisional hernia
3. Complications associated with the operative field
Abdominal cavity*

51
- Bleeding
- Hemoperitoneum
- Peritonitis
- Biliary leakage
- Foreign body
- Acute complications of drains
- Anastomosis insufficiency
- Ileus (small and large intestine)
- Gastric atonia
- Abscess
- External fistulas (enterocutaneous fistulas: gastric, duodenal, pancreatic, small and large intestines)
- Internal fistulas (entero-enteral, entero-vesical, etc.)
- Postgastrectomy syndromes: dumping, afferent loop, reflux gastritis
- Gastrointestinal bleedings
- Postoperative pancreatitis, cholecystitis

* Other complications (thoracic cavity, skull, joints, etc. - see during the courses of appropriate specialties).

52
3. Operations
Surgery operation
Definition of surgery
Branch of medicine concerned with the diagnosis and treatment of injuries, excision and repair of pathological
conditions by means of operative procedures:
1. Closing (incision, wound, cavity)
2. Opening (skin, cavity - tomy, -punction)
3. Moving (organs, tissues - transplantation)
4. Removing (tissue, obstruction, blockade resection, amputation, - ectomy)
5. Connection (within organ, between organs - stomy, anastomosis)
6. Separation, elimination (pathological connections (exstirpation)
7. Restoration, repair (normal anatomy -plasty)
Definition of operation
Therapeutic procedure with instruments to repair damage or arrest disease in a living body; act or series of acts
performed upon the body to remedy deformity or injury, cure or prevent disease, or relieve pain.
Definition of surgical research
Branch of medical sciences aimed at investigations of surgical methods and surgical pathophysiology = research
for principles of safe surgery.

3.1. Minor surgical operations

Background
By the end of 19th century general anesthesia made surgery safe. The scopes of surgery expanded; methods of
narcosis have progressed and became more and more complex. Finally, anesthesiology divorced form practical
surgery and became a separate subject during the second part of 20th century. However, overcoming local pain
(local anesthesia) is still the duty of the surgeon.
A short historical overview of anaesthesia localis:
1860 Isolation of cocaine from erythroxylum coca
1884 Koller: local cocaine (topical) anaesthesia
1885 Halsted: peripheral nerve blockade
1899 Bier: spinal anesthesia

3.4.1. Definition of local anesthesia

Reversible regional loss of sensation; ~ a substance, which reversibly inhibits nerve conduction when applied
directly to tissues at non-toxic concentrations.

3.4.2. Mechanism of action of local anesthetics

53
By limiting Na+ influx, local anesthetics inhibit the depolarization of the membrane - thereby interfering with
propagation of the action potential. The action potential is not propagated because the threshold level is never
attained.

3.4.3. Main classes, the I rule

Amide Ester
Bupivacain Cocaine
Lidocain Clorprocain
Ropivacain Procaine
Etidocain Tetracain

Amino esters: metabolized in the plasma via pseudocholinesterases, unstable in solution, likely to cause true
allergic reactions. Amino amides: metabolized in the liver, very stable in solution, true allergic reactions are rare

3.4.4. Local anesthesia toxicity

True allergy is very rare. Patient reports of allergy are frequently due to previous intravascular injections. Most
reactions are from ester class - ester hydrolysis (normal metabolism) leads to formation of PABA like compounds
Tissue toxicity is rare. It can occur if administered in high enough concentrations (greater than those used clinically
can). Usually related to preservatives added to solution
Systemic toxicity is rare. It is related to blood level of drug secondary to absorption from site of injection, could
range from tinnitus to seizures and CNS/cardiovascular collapse.

3.5. Main types

Local topical anaesthesia
Modification or loss of pain sensation caused by an agent that is applied topically to the skin/mucous membranes.
Indications: awake oral, nasal intubations, in case of superficial surgical procedure. Pros: technically easy; minimal
equipment; Cons: potential for large doses leading to toxicity;
Regional anesthesia
Definition: Rendering a specific area of the body, e.g. foot, arm, lower extremities, insensate to stimulus of surgery
or other instrumentation. Peripheral nerve blocks are achieved by injecting anesthetic solution around a nerve root
to produce anesthesia in the distribution of that nerve (e.g. foot, hand, extremity).
A. Peripheral nerve block
Injecting local anesthetic near the course of a named nerve. Indication: Surgical procedures in the distribution of
the blocked nerve. Pros: relatively small dose of local anesthetic to cover large area; rapid onset. Cons: technically
more complex, neuropathy can evolve.
B. Spinal
Central neuron-axial blockade = injection of local anesthetic solution into the cerebrospinal fluid. Indications:
profound anesthesia of lower abdomen and extremities. Pros: technically easy, rapid onset. Cons: high spinal
hypotension due to sympathetic block, headache (dura puncture).
C. Epidural
Central neuro-axial blockade = injection of local anesthetic solution into the epidural space at any level along the
spinal column. Indications: thorax, abdomen, lower extremity anesthesia/analgesia. Pros: controlled onset of
blockade, long duration when catheter is placed, post-operative analgesia. Cons: spinal headache, technically
complex, toxicity.

3.6. Dosage and duration of local anesthetics

Drug Onset Maximum Dose Duration
(with Epinephrine) (with Epinephrine)
Lidocain Rapid 4.5 mg/kg (7 mg/kg) 120 min (240 min)
Mepivacain Rapid 5 mg/kg (7 mg/kg) 180 min (360 min)
Bupivacain Slow 2.5 mg/kg (3 mg/kg) 4 h (8 h)
Procain Slow 8 mg/kg (10 mg/kg) 45 min (90 min)
Chloroprocain Rapid 10 mg/kg (15 mg/kg) 30 min (90 min)
Etidocain Rapid 2.5 mg/kg (4 mg/kg) 4 h (8 h)
Prilocain Medium 5 mg/kg (7.5 mg/kg) 90 min (360 min)
Tetracain Slow 1.5 mg/kg (2.5 mg/kg) 3 h (10 h)

54
3.6. The perioperative period
Exploration of physiological pathophysiological processes of perioperative period (term) begun at the end of
19th century and still going on in these days. These observations lead to the safe pre- and postoperative procedures
of todays surgery, pre-and post-treatments, methods used before and after the operation which ensure the safe
recovery of patients. The surgical preparation expands to all organs, exposition of which in detail is duty of
anesthesiology. Henceforth, we are going deal with the linkage of circulation and perioperative fluid therapy,
respecting the fields of other organ systems.

3.6.1. The empty stomach

Goals: preventing aspiration through decreasing gastric content, avoiding thirst and dehydration. Aspiration is
serious, frequently lethal complication. Elective cases: incidence = 1:10.000; without death = 1:200.000 (Warner
MA et al. Anesthesiology 1993; 78: 56-62.)
Origin of process (Lister, 1909): there should be no solid matter in the stomach, but that patients should drink
clear liquid about 2 hours before surgery. (Lister J. On Anaesthetics. In: The Collected Papers of Joseph, Baron
Lister, Volume 1 Oxford: Claridon Press 1909: 172.)
1960: solid food 6 h fasting, fluid: 2-3 h before operation.
1974: Roberts and Shirley demonstrated: 0.4 ml/kg (adults 25 ml) gastric content and pH <2.5 = high risk for
aspiration. (Roberts RB, Shirley MA. Reducing the risk of gastric aspiration during cesarean section. Anesthesia
and Analgesia 1974; 53: 859-68.)
According to the present rules, the order 'nothing by mouth after midnight' should apply only to solids for patients
scheduled for surgery in the morning. An early light breakfast is permissible for afternoon cases. Clear liquids
should be allowed until 3 h before the scheduled time of surgery. For patients with true gastroesophageal reflux,
whether or not they drink, an H2-receptor blocker (ranitidine) or proton pump inhibitor (omeprazole) may be
advisable to minimize gastric acid secretion

American Society of Anesthesiologists fasting guideline

Ingested material Minimum fasta

Clear liquidsb 2 hours
Breast milk 4 hours
Infant formula 6 hours
Non-human milk 6 hours
Light mealc 6 hours

a: Fasting times apply to all ages.

b: Examples: water, fruit juice without pulp, carbonated beverages, clear tea, black coffee. Most people can
safely drink clear liquids until two hours before surgery, although more research is needed for some groups of
people. The Cochrane Database of Systematic Reviews 2005 Issue 3;
c: Example: dry toast and clear liquid. Fried or fatty foods may prolong gastric emptying time. Both amount and
type of food must be considered.

3.6.2. Post-operative nausea and vomiting

One of the most common side effects of narcosis associated with surgical procedures (incidence: 5-30%); delayed
recovery and discharge, increased medical care, occasionally re-operation. The medical complications of post-
operative nausea and vomiting are possible wound disruption, oesophageal tears, gastric herniation, muscular
fatigue, dehydration, electrolyte imbalance.
Etiology: dehydration (extracellular fluid loss). 8 hr preoperative fasting = 1 l volume minus/70 kg bw.
Increased risk (patient related, procedural, anesthetic, post.op), gender, age (geriatry, infants), obesity, ascites,
burn, trauma, ileus, peritonitis, late operative programs, anesthetic gases using without wetting, perspiration, blood
loss, urine, loss of other body fluids (ascites, GI content) during surgery.

3.6.3. Perioperative fluid therapy

Careful planning and maintenance of peri-operative fluid balance is mandatory; regular review of fluid therapy is
essential after surgery. Measuring the central venous pressure (CVP; see later) should be always considered with
large fluid shifts. Patients are more often underfilled than overloaded, although care should be taken to avoid fluid
overload: excess fluids can cause pulmonary oedema. Dehydration (which can be difficult to assess in the elderly)
can precipitate renal failure.

55
Perioperative fluid therapy requires the knowledge of body water compartments. Total body water (TBW) varies
with age, gender, body habitus. In case of males TBW is 55% of bodyweight, 45% in females and 80% in infants.
TBW is less in obese (fat contains less water). The approx. ratio of body water compartments:
- intracellular water is 2/3 of TBW, extracellular water is 1/3 TBW.
- extravascular water is 3/4 of extracellular water while intravascular water is 1/4 of extracellular water.

3.6.4. Preoperative evaluation of fluid status

Factors to assess:
- oral intake and output
- blood pressure: supine and standing
- heart rate
- skin turgor
- urinary output
- serum electrolytes/osmolarity
- mental status

3.6.5. Orthostatic hypotension

Definition: systolic blood pressure decrease of > 20 mmHg from supine to standing positions. This change
indicates a fluid deficit of 6-8% bodyweight (!) It is important to note that heart rate should increase as a
compensatory measure. If the heart rate does not increase this may indicate autonomic dysfunction or
antihypertensive drug therapy.

3.6.6. Perioperative fluid requirements

It is determined by several components, to assess the needs several points should be considered.
1. Basic or continuous fluid requirements
Loss occurs continually, in case of adults approx 1.5 ml/kg/hr, in case of infants the 4-2-1 rule is valid: 4 ml/kg/hr
for the first 10 kg of bw; 2 ml/kg/hr for the second 10 kg bw; 1 ml/kg/hr subsequent kg bw. In addition extra fluid
loss is calculated for fever, tracheotomy, denuded surfaces.
2. Colon preparation may result in up to 1000 ml fluid loss.
3. Measurable other fluid losses (e.g. nasogastric suctioning, vomiting, diarrhea, colostomy).
4. Third space losses: isotonic transfer of extracellular fluids from functional body compartments to non-
functional compartments. Depends on location and duration of surgical procedure, amount of tissue trauma,
ambient temperature, and room ventilation.
Replacement of third space losses:
Superficial surgical trauma: 1-2 ml/kg/hr
Minimal surgical trauma: 3-4 ml/kg/hr (head and neck, hernia, knee surgery)
Moderate surgical trauma: 5-6 ml/kg/hr (hysterectomy, chest surgery)
Severe surgical trauma: 8-10 ml/kg/hr or more (aortic repair, nephrectomy)
5. Blood loss: replace 1 ml of blood loss with 3 -4 ml of crystalloid solution (crystalloid solutions leave the
intravascular space). When using blood products or colloids replace blood loss volume per volume (1:1).

3.6.7. Perioperative fluid requirements, intravenous fluids

Choices: conventional crystalloids, colloids, hypertonic solutions, blood/blood products and blood substitutes.
A. Crystalloids: combination of water and electrolytes. Isotonic crystalloids, balanced salt solutions: electrolyte
composition and osmolarity is similar to plasma:
Saline (0.9%, normal) salt: Na + 154 meq/L, Cl- 154 meq/L
Lactated Ringers (Hartman solution): Na+ 130 meq/L, Cl- 109 meq/L, K+ 4 meq/L, lactate- 28 meq/L, Ca++ 3
meq/L
Normosol-R: Na+ 140 meq/L, Cl 90 meq/L, K+ 5 meq/L, Mg++ 3 meq/L
Plasmalyte: Na+ 140 meq/L, Cl- 98 meq/L, K+ 5 meq/L, Mg++ 3 meq/L
Hypotonic salt solution: electrolyte composition lower than that of plasma; example: dextrose 5%.
B. Colloids: fluids containing molecules sufficiently large enough to prevent transfer across capillary
membranes. Solutions stay in the space into which they are infused. Natural colloids (protein-containing): e.g.
5% albumin, 25% albumin, plasma protein fraction (Plasmanate). Artificial colloids (non-protein containing):
gelatin, hydroxyethyl starch, dextran.

56
 Perioperativ fluid replacement

Colloids Crystalloids
Isotonic:
Salsol
Artificial Natural Ringer-lactate
albumin

gelatin 4% (35 kDa; Gelofusine)

hydroxiethyl-starch 6% (HES; 130 kDa; Voluven)

HES 6 and 10% (200 kDa; HAES-sterile)

dextran 10% (40 kDa; Rheomacrodex)

dextran 6% (60-70 kDa; Macrodex)

C. Hypertonic solutions: fluids containing sodium concentrations greater than normal saline. Available in 1.8%,
3%, 5%, 7.5%, 10% solutions. Hyperosmolarity creates a gradient that draws water out of cells; therefore,
cellular dehydration is a potential problem.

3.6.8. Clinical evaluation of the effectiveness of fluid replacement

- urine output: at least 1.0 ml/kg/hr;
- vital signs: blood pressure and heart rate are normal;
- physical assessment: skin and mucous membranes are not dry; no thirst in an awake patient;
- invasive monitoring: measurement of central venous pressure or pulmonary wedge pressure (PCWP);
- laboratory tests: periodic monitoring of hemoglobin and hematocrit.

3.6.9. When is transfusion necessary?

Transfusion trigger: Hgb level at which transfusion should be given. Tolerance of acute anemia depends on:
- type of surgical procedures,
- maintenance of intravascular volume,
- ability to increase cardiac output and heart rate,
- increases in 2,3-DPG to deliver more of the carried oxygen to tissues,
- Hgb and oxygen delivery (DO2).

1. DO2 = the oxygen that is delivered to the tissues

2. DO2 = Cardiac Output (CO) x oxygen content (CaO2)
3. CaO2 = Hgb is the main determinant
4. CO = heart rate (HR) x ejection fraction (SV)
The consequence of (4): if HR or SV are unable to compensate, Hgb is the major determinant factor in DO 2.
Healthy patients have good compensatory mechanisms and thus can tolerate Hgb levels of 7 gm/dL. Patients with
compromised perfusion may require Hgb levels above 10 gm/dL.

3.7. Acid-base disturbances in surgery

Capillary or arterial blood should be taken for determination of blood gas values. If a blood sample was obtained
the examination has to be finished within 10 min. If it is not possible, samples have to be frozen. Venous blood
may be used to pH determination.
Important: the pH = negative logarithm of H+ ion concentration. Due to the logarithmic alterations small pH
changes will mean large change in H+ ion concentration (e.g. during 7.4 to 7.0 pH the acidity becomes 2.5 fold
higher).

pH H+ concentration
7.0 1/10 000 000
7.1 1/12 589 254
7.2 1/15 848 931

57
 7.3 1/19 952 623
7.4 1/25 118 864

Among the human buffer systems, the bicarbonate system regulates most effectively the pH of whole body, since
it acts at two different points: HCO3- through the kidney and CO2 through the lung: H+ + HCO3-<=> H2CO3 <=>
H2O + CO2.

3.7.1. Hypoxemia and hypercapnia

Hypoxemia (arterial pO2 kPa) Hypercapnia (arterial pCO2 kPa)

Mild 11 6.16.6

Moderate 67.9 6.78

Heavy <6 >8

3.7.2. Standard acid-base parameters

Parameter Normal value Unit Remark
pH 7.35-7.4-7.45 No unit

pCO2 4.8-5.3-5.9 kPa Respiratory component

36-40-44 mmHg Can not be determined from capillary blood
pO2 11.9-13.2 kPa At sea level, FiO2 = 21%. At higher altitudes the value is
90-100 mmHg higher. It shows the oxygenization of a patient; do not mix
with acid-base balance.
HCO3- 22-24-26 mmol/l Renal component. Normal values vary if pCO2 is
(actual abnormal.
bicarbonate)
Standard 22-24-26 mmol/l The [HCO3-] after the sample has been equilibrated with
bicarbonate CO2 at 40mmHg (5,3kPa).
Base excess -2, 0, +2 mmol/l Renal, metabolic component. A negative number is a base
deficit.

3.7.3. Most frequent causes of acid-base disturbances in surgery

Respiratory PaCO2 increased Inadequate ventilation and CO2 production is greater than
acidosis CO2 elimination: airway obstruction, respiratory
depression due to drugs or head injury, lung diseases, etc
Respiratory PaCO2 decreased Hyperventilation in response to hypoxaemia and hypoxic
alkalosis respiratory drive. The lungs are more efficient at
eliminating CO2 than at absorbing O2 so patients with
diseased lungs frequently have hypoxaemia with a normal
or low CO2. Mechanical ventilation with a large minute
volume also leads to respiratory alkalosis.
Metabolic HCO3- decreased (base deficit) Loss of bicarbonate due to GIT losses or chronic renal
acidosis disease;
Addition of inorganic acids such as diabetic ketoacidosis,
lactic acidosis associated with tissue hypoxia, salicylate,
ethylene glycol and other toxins;
Decreased acid excretion in renal failure.
Metabolic HCO3- increased (base excess) Loss of gastric acid (e.g. pyloric stenosis) and diuretic
alkalosis therapy.

Mixed acidosis: PaCO2 increased and HCO3- decreased. Dangerous - may occur in severe diseases such as septic
shock, multiple organ dysfunction, cardiac arrest.

3.7.4. Restoration of acid-base balance

Discrepancy Answer Blood pH Blood pCO2 Blood BE Urine pH

58
 Metabolic acidosis Decompensated decrease normal decrease decrease

Fully compensated normal decrease decrease

Metabolic alkalosis Decompensated increase normal increase

Fully compensated normal increase increase increase

Respiratory acidosis Decompensated decrease increase normal decrease

Fully compensate normal increase increase

Respiratory alkalosis Decompensate increase decrease normal

Fully compensate normal decrease decrease decrease

3.7.5. Interpretation of the blood gas data

Is the overall picture
pH < 7.35 = acidaemia [...go to step 2]
1 normal, acidaemia,
pH > 7.45 = alkalaemia [... go to step 5]
alkalaemia?
If there is an acidaemia:
CO2 high = respiratory acidosis [...3]
is the primary defect
2 Bicarbonate low or BE negative = metabolic acidosis. [...4] Both of the above
metabolic or respiratory or
= mixed metabolic and respiratory acidosis.
mixed?
If there is respiratory
The CO2 is high (resp. acidosis) but the metabolic component is going in the
acidosis:
3 opposite direction (BE or SB high, towards metabolic alkalosis) then there is
is there metabolic
metabolic compensation.
compensation?
If there is metabolic
BE is negative (metabolic acidosis) but the respiratory component is going in
acidosis:
4 the opposite direction (CO2 low, towards resp. alkalosis), then there is
is there respiratory
respiratory compensation.
compensation?
If there is an alkalaemia, The primary defect will go in the same direction as the pH (towards
5 is the primary defect alkalosis): respiratory alkalosis will have low CO2 metabolic alkalosis will
respiratory or metabolic? have high SB and positive BE.
If metabolic or respiratory
alkalosis, is there any
6 Same principles as above
compensation by the other
one?
Is the pO2 consistent with the FiO2? If it is lower than expected, it either
indicates lung disease, right to left shunt, or venous sample. (A venous sample
usually has pO2 < 40mmHg, saturation < 75%).
7 Look at the oxygenation The lung is much more efficient at eliminating CO2 than absorbing oxygen so
lung disease will show in the low pO2 but the pCO2 is often normal or even
low.
If the CO2 is very high, the O2 will also be low.
Summarize the eg. There is a metabolic acidosis (because the pH is low and BE is negative)
8
interpretation with respiratory compensation (because the pCO2 is low).

3.8. Surgical nutrition

Malnutrition leads to delayed wound healing, reduced ventilatory capacity, reduced immunity and increased risk
of infection. Clinical assessment of nutritional status: weight loss (10% = mild malnutrition, 30% = severe
malnutrition); anthropometric assessment (triceps skin fold thickness, mid arm circumference, hand grip strength);
blood indices (reduced serum albumin, prealbumin or transferring, lymphocyte count).

3.8.1. Methods of nutritional support

Enteral or parenteral, use gastrointestinal tract if available, early enteral nutrition reduce post-operative morbidity.

59
3.8.1.1. Enteral feeding
Prevents intestinal mucosal atrophy, supports gut associated immunological shield, attenuates hypermetabolic
response to injury and surgery, and cheaper than TPN and has fewer complications. Enteral feed can be taken
orally or by nasogastric tube.
Long term feeding can be performed by surgical gastrostomy, jejunostomy, percutaneous endoscopic gastrostomy,
and needle catheter jejunostomy.
Complications of enteral feeding: malposition and blockage of tube, gastrooesophageal reflux, feed intolerance.

3.8.1.2. Parenteral nutrition

Intestinal failure = reduction in functioning gut mass below the minimal necessary for adequate digestion and
absorption of nutrients it is a useful concept for assessing need for total parenteral nutrition (TPN). Can be
given by either a peripheral or central line.
Indications for total parenteral nutrition: enterocutaneous fistulas (absolute indication); relative indications:
moderate or severe malnutrition, acute pancreatitis, abdominal sepsis, prolonged ileus, major trauma and burns,
severe inflammatory bowel disease.

3.8.1.2.1. Peripheral parenteral nutrition

Hyperosmotic solution, significant problem with thrombophlebitis. Need to change cannulas every 24-48 hours,
and there is no evidence to support it as a clinically important therapy. Usual composition is 12g nitrogen, 2000
calories.

3.8.1.2.2. Central parenteral nutrition

Hyperosmolar, low pH and irritant to vessel walls
Typical feed is 2.5L and contains 14g nitrogen as L amino acids, 250g glucose, 500 ml 20% lipid emulsion, 100
mmol Na+ , 100 mmol K+ , 150 mmol Cl-, 15 mmol Mg2+ 13 mmol Ca2+ 30 mmol PO42- 0.4 mmol Zn2+, water and
fat soluble vitamins, trace elements.

3.9. Tools of volume correction: injections, canules, tubes

3.9.1. Injection techniques
The parenteral routes of drug delivery are applied when 1. the drug delivery is impossible through the GI tract, 2.
the drug is altered by ingestion (braked-up in the intestine), 3. the patient requires faster or prolonged action.
Giving an injection may lead to infection, therefore it requires the adherence to aseptic procedures to assure
sterility. Requirements of injection: syringes, needles.
The single-use, sterile products must be packaged in a way that maintains the sterility until time of use and prevents
contamination of contents during opening. If the package is damaged, the product must not be used.

3.9.1.1. Syringes
Syringes are devices for injecting or withdrawing fluids, and made of glass or plastic. Parts: a
glass or plastic barrel, a tight-fitting plunger at one end and a small opening at the other end
which accommodates the head of a needle. Syringe tips may be in two main types: Record and
Luer. Nowadays Luer syringes are used exclusively. Luer syringes are made of plastic, sterile,
and single-use. Syringe volume ranges from 1 (Tuberculin with 0.01 ml gradations) to 2, 5, 10
20, 50, or 60 ml. Insulin syringes have unit gradations rather than volume gradations.
3.9.1.2. Hypodermic needles
Hypodermic needles are stainless steel devices that penetrate the skin for the purpose of
administering a parenteral product.
Single-use Luer needles: metal + plastic, sterile, they can be connected to Luer-type syringes.
Size of the needles can be classified according to a color-coded scale (G=gauge). Needle gauge
refers to the outside diameter of the needle shaft, the larger the number, the smaller the diameter.
Needle lengths range from 1/4 to 6 inches. Choice of needle length depends on the desired
penetration. The end of the needles is beveled to facilitate injection through tissues or the rubber

60
vial closures.
Butterfly needles: with plastic wings to be attached to the skin.

Butterfly needles with canule

Braunle: most often used needle + catheter combination. Commercial names are: Abbocath, Introcan, Jelco,
Mecath, Surflo, Vasofix-Braunle, Venflon, etc. Parts: plastic catheter (its end is smoothly beveled so that it
dilates the opening made by the needle), a metal needle which is a bit longer than the catheter (to pierce the skin),
injection port (with a valve which allows infusion or medications but the blood cannot flow out, after use the valve
closed automatically), plastic wings.

Valve mechanism of injection port

Parts of a Braunle
Blood collecting chamber (translucent)

Injection port with locker cap

Blood barrier
Plastic fixing wings

61
Plastic catheter
Stopper (fixing to the hypodermic needle firmly)
Scabbard (pod)
Facet needle
Luer-Lock connector

3.9.1.3. Selecting the adequate i.v. canule

There are different i.v. canules with various long and diameter for suiting the various requirements. The table
below shows information on B.Braun (Melsungen, Germany) canulas. (ISO=International Organisation for
Standardisation).

Colour code Outer Flow Examples for practice

(ISO standard) diameter
Yellow 0.7 mm 13 ml/min Infant (neonate)
Blue 0.9 mm 36 ml/min Infant
Pink 1.1 mm 61 ml/min Thin veins; child
Green 1.3 mm 96 ml/min > Adults
White 1.5 mm 128 ml/min
Grey 1.8 mm 196 ml/min > Quick volume replacement
Orange 2.2 mm 343 ml/min Transfusion

3.9.1.4. Types of injection techniques

Ampoules: made entirely of glass; for single use only. After opening the ampoules the drug must be utilized in
short time (sterility, degradation). Wrap the ampoule with thick gauze, and make a file cut on the neck. Brake off
the ampoule by applying pressure on the side opposite to the file score. Suck out the drug so that the needle does
not touch the outside of the ampoule.
Vials: glass or plastic containers closed with a rubber stopper and sealed with an aluminum shield. May be liquid
vials or powder vials with diluents (mostly distilled water or physiological salt solution) containers. First add the
diluent into the vial, after shaking push air equal volume of the solution and then, suck the solution into the syringe.
Air removal: giving an injection may lead to air embolism, so before drug administration remove air from the
syringe: push the plunger into the syringe to remove air from the liquid.
There are four main types of injection techniques: intracutaneous (ic.), subcutaneous (sc.), intramuscular (im.) and
intravenous (iv.).

3.9.1.5. Intracutaneous injection (i.c.)

It is administered to layers of the skin, used mainly for diagnostic purposes (allergy testing, tuberculosis screening,
local anesthetics). A tuberculin type syringe and a thin needle (25-27G) are used for administering small volume
(max. 0.5 ml) of medication. Sites: inner forearm, posterior-back of upper arm. The needle should be inserted at a
10 to 20 degrees angle, bevel up, and medication is administered just under the epidermis.

3.9.1.6. Subcutaneous injection (s.c.)

It is administered into the fat and connective tissue underlying the skin with a thin (25-27G) needle. Sites: external-
upper third of upper arm, external-medial of thigh, abdomen (insulin, heparin). The skin should be gently pinched
into a fold to elevate subcutaneous tissue which lifts the adipose tissue away from the underlying muscle. The
injection should be given at a 45 degrees angle into the raised skin fold.

62
 The places of s.c and i.c. injections

3.9.1.7. Intramuscular (i.m.)

It is used for injection of a larger volume (max. 5 ml) of medication into the muscular tissue. Sites: gluteal muscle
(gluteus maximus) with the ventrogluteal Hochstetter technique (sec. Ferdinand von Hochstetter - 1829-1884); in
infants the lateral side of femoral muscle. Giving an i.m. injection should be to stretch the skin over the site to
reduce the sensitivity of nerve endings, and to insert the needle (20-25G) at a 90 angle. The skin needs to be
stretched using the Z track technique. If this does not happen the fluid injected will come back out of the hole
made. The Z track technique can be achieved by stretching the skin gently between the thumb and index finger.

The place of i.m. injection in adults (left) and infants (right)

3.9.1.8. Intravenous injection (i.v.)

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During an i.v. injection, the needle is inserted through the skin into a vein, and the contents of the syringe are
injected through the needle into the bloodstream. Sites for i.v. injections: v. mediana cubiti, v. cephalica, dorsal
veins of hand and foot. It is necessary to use a tourniquet centrally to the vein to make the vein bulge. Use needles
of 18-23G, butterfly or Braunle and the vein must be puctured with the bevel up) at 30 to 45 degrees angle and
in the direction of the vessel. Once the needle is in place, it is helpful to draw blood, thus verifying the real place
of the needle; then release the tourniquet before giving the injection slowly.

The places of i.v. injection (left) and implementation (right)

3.9.2. Complications of injections

The skin should be intact, never give injection to injured or infected skin. Non-sterile devices (needle, syringe,
solution) can cause skin infection. Drugs injected into the tissue with wrong injection technique can damage the
tissue or cause a nerve injury. Improperly given intragluteal injection can injure the ischiadic nerve.
Complications of i.v. injections:
- hematoma (blood gets into the surrounding tissue from the vein through the sting channel);
- paravenous injection ("para" - the needle slips out from the vein and drug solution gets into the tissue causing
pain and tissue necrosis). This can be decreased by Novocain infiltration or watery fomentation;
- In case of allergic patients toxic reaction, oedema, fever can evolve. Stop immediately the administration of the
drug.
- Sterile venous inflammation (hyperosmolar compound;
- Intraarterial injection.

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3.9.3. Peripheral venous access
Indications
- volume replacement, i.v. drug delivery, blood sampling;
- if the pH of solution is pH 7.2 - 7.6;
- if osmolarity > 1100 mosm/l;
- if therapy is not longer than 3 days.
Contraindications
- thrombophlebitis, local inflammation.

3.9.3.1. About veins

Preferable
Large lumen, branches of veins, introducing at the branching, the dorsum of the hand (here the veins could be
strained better), the dominant side (in case of right handed patient the right hand).
Should be avoided
Infected skin area, inflamed veins. Never made puncture at the medial-upper sector of the crook of the arm, to be
proximity at artery. Thrombosis of veins (without flow). Paralytic arm (after stroke), since the lack of muscle pump
the blood flow could be inhibited. Blockage of lymph flow (i.e. following breast operation), joint region (danger
of inflection), vein valve.
Localization of veins
Hang the arm down. Ask to patient to clench his fists several times (muscle pump). Massage the veins with yours
finger. Applying ten min hypothermia (by warm water). Sprinkle/spray alcoholic solution to the skin above the
vein.
Fixing of veins
Strain the skin above the vein so it do not moving until introducing an i.v. catheter. There are three possibilities to
insure a successful puncture:
- stretch the skin opposite to direction of puncture (dorsal hand);
- push the skin to the direction of puncture (forearm);
- strain the skin on side with a C maneuver, grasping the arm underhand;

3.9.3.2. Technique of blood sampling

1. Materials:
compressing cuff;
disinfection solution (alcoholic spray);
sponges;
sampling tubes;
needle with syringe with closed cap, Braunle;
adhesive tape/sticking plaster;
container for used needles, sponges);
gloves
2. Position of patient:
Sitting with reached out arm
3. Localization of vein:
(see above)
4. Vein compression / tourniquet:
Compress the cuff centrally to the vein so the arterial pulse would be palpable. Ask the patients to clench
theirs fists and wait several seconds. Tourniquet pressure could be precisely controlled following blood
pressure measurement using the inflated cuff. The optimal counter pressure is between 60 -80 mmHg
normally, under the level of diastolic pressure. Arterial pulsing should be always palpable, to avoid intra -
arterial puncture.
5. Disinfection
Use alcoholic spray or a sponge with alcohol for disinfection and scrub the skin area of puncture. You have to wait
15-30 seconds to reach the effect of disinfection.
6. Fixing the vein
Strain the skin above the vein to block the moving of the vessel (see above).
7. Puncture
In case of a needle, introduce it with a face turned upward into the skin in a 30 angle to the skin surface,
parallel with the axis of the vein.
When applying i.v. catheter or Braunle, grasp the injection port with the index and middle fingers while
holding the stopper with the thumb. Push slowly the catheter into the vein in 30-45 angles until some blood

65
appears in the blood chamber. Advance about 1 cm with decreased angle of puncture to insure that the needle
and catheter are in the lumen of the vein.
8. Blood retraction
Hold the needle with your left hand while the other hand draws back the plunger of syringe.
9. Blood sampling
Fix the needle with one hand while change the blood sampling tubes by the other hand.
10. Release of the tourniquet
When the last sampling tube is full with blood release the cuff.
11. Removing the needle or Braunle needle
In case of needle: first press an alcoholic sponge onto the site of puncture and then push the sponge while
removing the needle. After this press again the alcoholic sponge on the place of puncture until the bleeding
is stopped (about 1 min). The arm of patient remains extended.
In case of Braunle: firstly press down the vein with your ring finger above the end of catheter while drawing
back the needle about 1 cm, until the appearance of blood in the plastic catheter. It means that the catheter is
positioned in the vessel lumen. Push forward the catheter into the vein lumen. Put a sponge under the end of
Braunle. Touch the catheter tip by the right hand finger under the skin and press it gently. Hold the catheter with
thumb and index fingers while removing the needle by the other hand and connect it to a closing cap or infusion
set.
12. Blood sampling tubes
Shake the sample gently to avoid damage of blood cells and mix it with anticoagulant. The coagulation
(green), sedimentation (purple) and hematocrit (red) tubes should be filled exactly to achieve the correct
dilution.
Sequence of sampling: first take a sample into the serum (white) tube, since serum potassium level can be
elevated within 30 min as a consequence of stress. The second tube is green and serves for determination of
coagulation factors. Other tubes should be filled thereafter.
13. Fixation of Braunle
Fix the catheter by strips of adhesive tapes at the plastic wings. Fixation of Braunle is mandatory to avoid
slipping out during arm movement.

14. Final fixation

Form a loop from the infusion set and fix it by strips of adhesive tape (see below).

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3.9.4. Central venous catheters
Possibilities for central venous access
1. Venasection
Cannulation of femoral/jugular (vena mediana cubiti or other) veins by surgical exploration. Indication: if
percutaneous vena cava catheter can not be introduced / introduction is contraindicated.
2. Percutaneous puncture of a central vein.
Peripherally inserted central catheters (PICC) are subject of anesthesiology. Percutaneos puncture of vena jugularis
interna or vena subclavia with aseptic Seldinger technique. Catheter puncture with wire-in-tube technique is a
method of choice in case of the vena cava superior.

The sites of puncture. 1. internal jugular vein lateral to the pulsing carotid artery; 2. vena subclavia: at 1/3 2/3
part of the clavicula

For applying the needle-catheter combination two methods are prevalent. In case of catheter on needle, a thicker
plastic catheter is pulled on the hypodermic needle. After puncture and removal of the needle the catheter stays in
the veins lumen. This method is used to puncture superficial vessels.
In case of catheter in needle variation the puncture is performed by a thicker needle and the catheter will be lead
into the lumen. If the catheter is correctly positioned, the needle would be pulled back from it.
The Seldinger technique for central venous catheterization is insertion of a flexible guide-wire into the lumen
(catheter on needle) following puncture. After removing the needle/catheter, a guide-wire is dwelled in the central
vein, and the central venous catheter will be drawn onto the wire and then positioned in the lumen (see below).

Steps of Seldinger technique:

1. Introduce a Braunle (needle + canule) into a peripheral vein

2. Remove needle

67
3. Insert a flexible guide-wire into the central vein

4. Remove the Braunle cannula

5. Insert then remove a dilator cannula

6. Insert the central venous cannula through the guide-wire

7. Remove guide-wire;

3.9.4.1. Central venous catheter

Indications
- compounds damaging the endothelial layer (> 1100 mosmol/l; > 15 % glucose, < pH 7.2 (e.g. cc. K+
solutions), > pH 7.6 (e.g. Protamin).
- longer (3-5 days) volume therapy, i.v. therapy, parenteral nutrition.
- circulatory shock, drug infusion, live-saver drugs
- measurement of central venous pressure
- pacemaker implantation.
- if there is no peripheral venous access, but a vein is indicated.
Relative contraindication
- anticoagulant therapy
- carotid artery stenosis
Forbidden
The introduction of central venous catheter is forbidden in case of thrombosis, thrombophlebitis, or bacterial
vegetation on the tricuspidal valve.
Complications: 10% of central lines develop significant complications (!)
- thrombosis, thrombophlebitis
- catheter embolus.
- sepsis.
- PTX

68
- local inflammatory infiltration
- volume overload
- bleeding
Problems of insertion: failure to cannulate, pneumothorax, haemothorax, arterial puncture, brachial plexus
injury, mediastinal haematoma, thoracic duct injury.
Problems of care: line and systemic sepsis, air embolus, thrombosis, catheter breakage

3.9.4.2. Central venous pressure (CVP)

Clinically, it is useful as an indication of right ventricular preload, but it does not inform about the left ventricular
work. CVP is influenced by several factors, and in critically ill patients its predictive value to give a measure of
the filling of intravascular space is limited. In extreme situations it correctly shows severe hypo- or hypervolemia.
A volume challenge of 250-500 ml crystalloid causing an increase in CVP that is not sustained for more than 10
min suggests hypovolaemia. Serial readings (i.e. the trend of CVP measurements) are more useful than single
readings.

Pressure curve of a central vein

A wave: due to atrial contraction. Absent in atrial fibrillation. It is enlarged in tricuspid stenosis, pulmonary
stenosis and pulmonary hypertension.
C wave: due to bulging of tricuspid valve into the right atrium or possibly transmitted pulsations from the
carotid artery.
X descent wave: due to atrial relaxation.
V wave: due to the rise in atrial pressure before the tricuspid valve opens. It is enlarged in tricuspid
regurgitation.
Y descent: due to atrial emptying as blood enters the ventricle.

Traditionally the CVP is measured by water column manometer with the patient lying flat; it is expressed in cmH 2O
above a point level with the right atrium. The normal value is 0-8 cmH2O.
Current (modern) methods include measurement with electromanometer. The measurement of pressure is
performed continuously in close system with mechanical-electronic energy transducer.

Measurement of CVP with water column manometer

69
 Measurement of CVP with electromanometer

Raised CVP
- increased intrathoracic pressure
- impaired cardiac function (failure, tamponade). Informative only on the right side of the heart.
- hypervolaemia
- superior vena cava obstruction
Decreased CVP
- hypovolaemia
- reduced intrathoracic pressure (e.g. inspiration)

3.9.5. Infusions, infusion pumps

Indications
- maintenance of fluid or electrolyte balance
- continuous or intermittent medications
- administration of blood or blood components
- correction of nutritional status
- monitor hemodynamic functions.
The iv. route is a fast way to deliver medications/drugs into a vein. Some medications, as well as blood
transfusions, can only be given into the veins. During iv. therapy the rate of infusion can be controlled easily.

3.9.6. Infusion therapy is proposed

- acute myocardial infarction
- acute left heart failure
- pulmonary embolism
- stroke
- hypertensive crisis
- status asthmaticus
- acute bleeding
- shock
- unconscious state
- acute artery blockade in extremities
- acute metabolic comas (hyperglycemia)
- addison, hyper- and hypothyroid crisis.
Infusions are usually delivered into superficial veins; most often into the forearm veins. If a vein cannot be reached
by punctures, it has to be exposed surgically. In case of a long-term continuous infusion, etc, a catheter may be
inserted into the superior vena cava after exposing and dissecting the cubital or jugular veins. This catheter can
also be used for measuring central venous pressure. The iv. infusion therapy has many risks, and should only be
performed according to the rules of asepsis.

3.9.7. Devices for the i.v. infusion

Sterile plastic infusion bag (infusion glass bottle), sterile iv. administration set, hypodermic needles (butterfly,
Braunle), disinfecting solution, gauze, tapes, infusion stand, sterile disposable gloves. The sterile set is wrapped
in a double package (plastic, paper). The package should be opened just before use. Damaged packages must not
be used (sterility)!
Parts of the iv. administration set

70
Spike, drip chamber (flexible), long tubing with the flow regulator (a plastic roller clamp for controlling flow rate):

Preparation of the set

Remove protecting coverings from the port of the infusion bag and from the spike of the set, and insert the spike
into the bag. Hold the bag higher than the drip chamber (hang the bag on the stand); squeeze the drip chamber to
start the flow (drip chamber approx. one-third full). If the chamber is overfilled, lower the bag below the level of
the drip chamber and squeeze some fluid back into the bag. If the level of the fluid is too low, squeeze the chamber
to remove air to the bag. Open the flow regulator and allow the fluid to flow into the tubing (removing air). Connect
the end of the tubing to the iv. catheter in the patients vein, and adjust the flow rate as desired. Secure the catheter
and the loop of the tubing on the skin using strips of tape. During infusion the patient, the administration set and
flow of the fluid have to be controlled continuously.
There are two types of drip chambers: microdrip (60 drops/ml; for medication administration or pediatric fluid
delivery), macrodrip (10-15 drops/ml; for routine/rapid fluid delivery or keep the vein open).
The volume of infusion fluid/drugs can be calculated. A formula to calculate drops: volume of infusion fluid, ml
x drop factor (drops in a ml), drops/ml / time to infuse, min = drops/min. E.g. infusion of 1000 ml saline during
12 hour with a microdrip chamber should be delivered with: 1000 x 60/720=83 drops/min rate.
The amount of infusion depends on different factors (body surface are, physical condition, age, osmolarity of the
infusion fluid).
At the end of infusion, clamp the tubing, and remove the tapes, and the needle or Braunle catheter, and use sterile
gauze on the place of puncture.
Other i.v. administration sets
1. Set with hydrophobic bacteria filter

2. Dual drip infusion iv. set (with a micro- and a macrodrip chamber)

71
3.9.8. Risks and complications of iv. infusion therapy
- in case of peripheral iv. therapy the place of the vein puncture should be changed in 48 or 72 hours, and the
catheters must be changed in 24 hours.
- hematoma: during the vein puncture the wall of the vessel can be damaged (therapy: compression).
- inflammation
- thrombosis (during long term infusion)
- the vessel wall may be damaged by the tip of the needle (compress).
- air embolism (remove air!)
- fever (rules of asepsis!).
- circulatory insufficiency (in heart or renal failure during too fast infusion rate!).

3.9.9. Variations of iv. infusion

Infusion of two different solutions: with two infusion sets connected with a Y tubing under the drip chambers.
Medication administration with iv. infusion: delivered slowly together with the infusion fluid to evoke constant
drug level in the blood.

3.10. Infusion pump (IP)

IPs are used for accurate, continuous, long term and slow delivery of infusions, medical fluids, enteral feeding
products, blood and medications to reach a constant blood level. They are designed to allow precise control over
the flow rate and total amount of fluids for both clinician and patient use.
Types of IPs
Volumetric IP: accurate, reliable, continuous, long term and non-pulsatile iv. or ia. delivery of medical fluids
(infusion, blood, enteral feeding products) to patients.

An electric or battery operated peristaltic mechanism drives the fluid. Flow rate and volume infused can be preset.
The pump is equipped with different optical and sound alarms including air detection, empty container sensing,
and occlusion alarm pressure setting (automatic shutoff). Volumetric IP can also be used for keeping the vein open
(slow iv. infusion with 1 ml/h rate).
Syringe IP: long term, continuous iv. or ia. delivery of small volume of infusions or medications with different
sizes of syringes.

72
Flow rate (e.g. depending on the type of syringe from 0.1 to 1200 ml/h) and volume infused can be preset.
Automatic shut off at the end of infusion or at occlusion. Electric or battery operated.
Patient controlled analgesia (PCA) pump: for pain management. This is a microprocessor operated, portable IP
for patient use at home. It is easy to wear by the patient. PCA pump allows the patient to give the pain killing drug
whenever he needs it.

3.12. Perioperative monitoring

Physical and technical background of monitoring
Physical signals are converted to electrical signals by transducers. The steps of the process: sensing of signals
transformation amplification and screening of signals signal/data displaying (analog/digital) data
processing (alarm function) data storage.

3.12.1. Control of circulation

ECG monitoring: see in pathophysiology/ internal medicine courses

3.12.1.2. Heart rate monitoring

a/ by palpation on arteries (number of pulse waves/min): a. radialis, a. carotis, a. temporalis, a. dorsalis pedis;
b/ by ECG monitor;
c/ from arterial blood pressure curve;
d/ by finger pletismograph

3.12.1.3. Monitoring arterial blood pressure

Non invasive, indirect pressure measurement by the Riva-Rocci or oscillometric methods (automatically).
Direct, invasive measurement: through catheters introduced into the arterial lumen. Currently used method
is electromanometry. The measurement of pressure signals is continuous in a close system using mechanical-
electronic energy transducers. The arterial catheter is a flexible but rigid tube which transmits the arterial
pressure signals as mechanical energy to a transducer. This mechanical energy is converted to electrical
energy by a semiconductor transducer. The mechanical signal generates a resistance change in a
semiconductor (transducer) which is calibrated by a Wheetstone-bridge system. The zero point of system has
to be defined at the beginning of measurement and later on. To avoid the blood coagulation the intravascular
catheters should be continuously flushed with saline containing 3 mU/h heparin.

73
3.12.1.4. Measurement of pulmonary artery pressure with Swan-Ganz (SG) catheter
A SG catheter permits estimation of left ventricular work and preload through direct measurement of the
pulmonary pressures. It is possible to measure directly the cardiac output (by thermodilution method) and besides,
a mixed venous blood sample can be taken.
This flow-directed thermodilution balloon catheter is introduced through the femoral vein and the tip of catheter
is positioned into the pulmonary artery. It contains four lumens to monitor:
- Right atrial pressure, right ventricular pressure; Pulmonary artery pressure; Pulmonary capillary wedge pressure;
(distal, yellow branch);
- CVP measurement trough the proximal blue branch; It is also used for injecting the thermal bolus into the right
atrium. The end of the blue lumen is located 29 cm from the tip of catheter.
- Balloon (red lumen), provides a means for inflating and deflating the balloon located near the tip of the catheter.
If the balloon is inflated pulmonary capillary wedge pressure can be measure.
- Thermistor (white wire) provides electrical connection to the temperature-sensitive thermistor bead. It is located
3,5 cm from the tip of catheter. Used to measure the blood temperature
- Cardiac output computed from the pulmonary thermodilution (TDp) curve, following a thermal bolus of saline
into the right atrium.

3.12.1.5. Measurement of cardiac output

Principles of thermodilution methods (other methods include transoesophageal Doppler-method, impedance-
pletismography)
1. Cardiac output (CO) determined by using the Stewart-Hamilton method.
In case of thermodilution, a known volume of cold (at least 10C lower than blood temperature) solution is injected
intravenously, as fast as possible. The temperature change recorded downstream is dependent on the flow and on
the volume through which the cold indicator has passed. As a result, a thermodilution curve can be obtained. The
system detects the cold indicator in the pulmonary artery, and thus CO is calculated as follows:
COpa = [(Tb Ti) x Vi x K] / [ Tb x dt]
Tb = Blood temperature before the injection of cold bolus
Ti = Temperature of the injected solution
Vi = Injection volume
Tb x dt = Area under the thermodilution curve
K = Correction constants, made up of specific weights
and specific heat of blood and injected solution
2. Transpulmonary thermodilution techniques (TDa) based on pulse contour analysis.
The effect of thermal bolus injected into the central vein is registered by a thermistor catheter positioned in the
femoral artery. In case of pulmonary thermodilution (TDp) the arterial side of pulmonary circulation is considered
as a representative of total circulation, but transpulmonary thermodilution (TDa) extrapolates data from the total
pulmonary circulation and the arterial part of total circulation.
The latest method is based also on the Stewart-Hamilton theory. This extended (in time and in spatial) sample
taking decreases the effects of breathing but for the CO measurement another algorithm is needed. From the
integrated curve of bolus-effect computed CO and from the time-dependent change of thermodilution curve (based
on the Q = V/t equation) we can get different, (characterized) representative volume date of different parts of
circulation. These are together the pressures (CVP, arterial pressure) give an exact picture from the circulation.
The most important volume parameter is the global end-diastolic volume (GEDV), which is the sum of the end-
diastole volumes in the four cavities of heart and a good parameter for volumetric preload determination.

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 Central venous catheter
Injected temperature
sensor housing

DPT Monitor

Injected temperature sensor

PULSION disposable pressure transducer

Arterial thermodilution catheter

Transpulmonary cardiac output (TDa) measurement

CV bolus injection arterial TD catheter

ETV

Right Right Pulmonary Left

Left
Atrial Blood Atrial Ventricu
Ventric lar
EDV ular Volume ED
EDV
ETV
-D T ETV=Extravascular lung
water
[C] 0,6

0,4

0,2

0,0
0 10 20 30 40 50 [s
]
Injectio
n

The total peripheral vascular resistance (TPR) can provide important information on the afterload of the
heart. It is calculated by using the formula:
TPR= (mean arterial pressure CVP)/cardiac output

3.12.2. Control of respiration

3.12.2.1. Monitoring of ventilation (respiratory rate)
- by thermistor (in the nose of a spontaneously breathing patient)
- by measurement of thoracic impedance changes,
- by airway pressure changes
- by capnometry

3.12.2.2. Measurement of the efficiency of ventilation

- In capnometry an instrument determines the carbon dioxide concentration of the exhaled air from the decrease
of light intensity at the absorption wavelength of carbon dioxide. The capnogram demonstrates clearly the
respiratory and ventilation parameters (frequency, volume, rate of expiration/inspiration).
- Arterial blood gas analysis (see above)
- In pulse oxymetry the light absorption difference of oxyhemoglobin and reduced (deoxy)hemoglobin is
measured. Red and infrared lights (which are fitted for both hemoglobin types absorption maxima) are emitted

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through the capillary bed and the rate of percentage of oxyhemoglobin is determined from the rate of light
absorption. The place of measurement: finger tips, middle hand and foot (infants), external ear.

3.12.3. Control of tissue oxygen supply

- oxygen tension of mixed venous blood sample (see above)
- indirect intramucosal pH determination in the gastrointestinal tract (tonometry)
- control of plasma lactate level.

3.13. Catheterization of the urinary bladder (Gbor Ers, Andrs Thoman, Zoltn Bajory)
3.13.1. Background
Catheterization means the artificial emptying of the bladder. Several diseases may disturb normal bladder
emptying, hyperplasia of the prostate gland, tumor, strictures, drugs (e.g. opiates), spinal cord injuries, polyposes
and calculi are the most frequent disorders, which change the normal voiding. Catheterization is very common
intervention in chronic diseases as well in emergency states for both diagnostic and therapeutic purposes.
Diagnostic goals
- assessment of fluid status in critically ill patients
- obtaining of urine sample for microbiological examinations
- obtaining residual urine in the bladder
- obtaining exact results in urological diagnostic tests
- calibration of the diameter of urethra
Therapeutic goals
- treatment of urine retention
- maintenance of incontinence
- lavage of the bladder
- preoperative preparation
- prevention of urinal obstruction
- tamponade of bleeding

3.13.2. Principles of catheterization

- patients should not be catheterized, unless if it is absolutely necessary
- catheterization must be performed in accordance with the rules of asepsis
- catheterization must be carried out carefully in order to prevent injuries
- make sure, that the package of the catheter is intact
- catheterization should be avoided in case of urethral injuries
- catheterization must be performed by an experienced person

3.13.3. About catheters

Several types of catheters are known and used. Plastic and latex catheters are suggested for a short time
catheterization and silicone catheters for a long time. The use of a silicone catheter decreases the risk of peri-
catheteric urine leakage, urinary infection, and catheter obstruction. Efficacy of catheters with silver and
antimicrobial coating is studied to date.
External diameter of catheters is given in French (F) or Charrire (Ch) according to Charrires French scale. 1
F = 1 Ch = 0.33 mm. e.g. 3F comes to 1 mm.
The type of applied catheter depends on the aim of catheterization. Straight catheters (Nelaton, Robinson) are
usually used for single or intermittent catheterization in size of 16-20 F. Foley catheter at the same size is suggested
in case of continuous urinary drainage. A longer use of catheters of bigger caliber in males may lead to retention
of urethral secretion and accordingly urethral inflammation, strictures and epididymitis. Despite, it is advisable to
insert a thicker (20-24 F) catheter after endoscopic operations of bladder and prostatic gland in order to eliminate
clump. The use of Thiemann catheters (catheter with curved tip) can be advantageous in the case of urethral
obstructions and/or in male catheterization (due to the physiological curve of the male urethra).
Catheters can be divided into three groups by their material:
1. Soft catheters
Soft catheters are made of latex or plastic. Nelaton catheter (see below) is a straight tube with blunt end and an
oval window. Thiemann catheter (see below) has a tip which is 1-1,5 cm long and is curved in 45 degree. When
inserting, the tip should be set towards the patients face. A small fin on the external end of the catheter can help
to find the right direction for the tip. Pezzer catheter is made of latex as well. Its end is round and flat (looks like
a knob) with few windows. This device was used to be placed into the urethra after urological operations. Today
it is seldom applied.

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Foley catheter (named according to a medical student discoverer) is a frequently used soft catheter (see below). A
balloon can be found at the end of it in order to fix in the bladder. The balloon must be filled up with sterile fluid
to avoid the infection in the case of balloon injury.
2. Medium catheters
Mercier catheters are made of silk with special impregnation. They are soft at body temperature and become rigid
when mercury is falling. This attribute may facilitate insertion in case of urethral strictures.
3. Hard catheters
Hard catheters can be made of metal, plastic or glass (in the past). Metal catheters are slightly curved tubes with
oval window. Glass catheters were used formerly for female catheterization.

1. Nelaton catheter

2. Thiemann catheter

3. Foley catheter

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3.13.4. Technique of catheterization
Before catheterization all required devices should be prepared in advance. It is advised to take the help of an
assistant especially when the patient is not able to cooperate. If necessary put the unconscious patient into an
adequate position. The legs should be fully abducted and the knees flexed in female, but this position is not
necessary in the case of a male.
Devices for catheterization:
- Catheter in appropriate size (14-24 Fr)
- Urine container sack
- Sponges for the cleaning of genital area
- Disinfectant
- Syringe filled with sterile saline or water (in the case of use a Foley catheter)
- Sterile lubricant
- Sterile gloves
- (sterile forceps)
Female catheterization
Wash your hands and put the sterile gloves on. The patient is lying in supine position, her legs are abducted and
the knees are flexed. Spread the labia gently with your left hand. Urethra is located above the vagina, under the
clitoris. Take sponges (the right hand is used), and clean the introitus with disinfectant three times. Important:
sponge is used only once, and clean front to back to avoid contaminating the area. Put some water-soluble lubricant
onto the first 7-8 cm of the catheter. (Help of an assistant is often needed!) Grasp the catheter as you would a
pencil (or with the use of a forceps), and insert it into the urethra. If you meet resistance, ask the patient to take a
deep breath. The first part of the catheter, which is inserted into the urethra, must not touch any non-sterile area!
When the urine begins to drain from the catheter, pinch it closed, and insert further 5-10 cm, so that the balloon of
the catheter get into the bladder. Connect the urine container sack to the catheter. Fix the catheter by injecting 10
ml of sterile saline or water into the balloon port.
Male catheterization
The male urethra is long and curved twice thus catheterization may be more difficult than in female. It is strongly
advised to perform the catheterization with assistance (except in emergency situations). The male patient should
be lying with his leg slightly abducted. With your left hand lift the penis and retract the foreskin. Clean the urethral
meatus and insert the well-lubricated catheter as above mentioned. All of your actions should be done in
accordance with the rules of asepsis! Hold the penis in the erect position. After 15-20 cm you may meet resistance
because of prostate gland. Insert the catheter gently and carefully. Ask the patient to breathe deeply. If you cannot
manage the difficulty, choose a better size of catheter. Another suggestion: inject some sterile lubricant into the
catheter, so that the fluid may dilate the way for it. At the end of catheterization the foreskin should be moved back
to the glans.
Remarks
By choosing a catheter the goal of catheterization and the individual features of the patient must be considered.
The use of smaller caliber catheters is usually suggested, because it results in less complication than a bigger one.
Advantage of thicker catheters (No. Fr 20-22) is that they are less prone to perforate the urethral wall. Constriction
of internal sphincter may be a cause of resistance when catheter is inserted. After a few seconds the sphincter can
relax, and the insertion becomes easier. Hyperplasia of prostate gland and urethral strictures can make
catheterization more difficult. You must always insert the catheter gently in order to avoid edema and perforation.
If the patient reports pain during filling the balloon up, you must realize, that balloon is still in urethra. Thus, few
more cm must be inserted. The catheterization is forbidden in the case of urethral injury. In case of urethral injury,
bleeding or unsuccessful catheterization the retropubic puncture of the bladder is mandatory.
Overfilled bladder
It can be recognized by palpation. Hiccough and abdominal pain are characteristic symptoms. Seemingly the
patient often urinates. In truth, it is a leakage from overfilled bladder. This symptom can be noticed by 600-800
ml of retention.
Therapy
Empty the overfilled bladder slowly, because rapid vasodilatation of bladders vessels can result in bleeding or
hypotension. At first allow 500-800 ml of urine to drain. Then close the catheter for 15 minutes. Continue
decompression with allowing 100 ml to drain in every 15 minutes, until bladder will be empty.
Males are seldom catheterized for diagnostic aims nowadays. In case of females urine sample can be obtained for
diagnostic tests, if urethral meatus is cleansed as above mentioned. However, this sample is not always eligible for
microbiological examinations. Catheterization provides sterile urine for these tests. Patients with shock or in
unconscious state should be catheterized for monitoring fluid status and renal function.
Care
Catheters should be changed once in every two weeks. Complications necessitate more frequent changes. Silicon
catheters can be used longer. Remove catheter carefully in order not to hurt the urethral wall. If you apply a

78
Thiemann catheter, make sure that its tip is in the right direction (as mentioned above). Do not attempt to
catheterize with this device unless you have practiced its technique before.

3.13.5. Long-time catheterization

Long-time catheterization is often used in elder, chronically ill population in case of voiding problems.
Indications
- urine retention which cannot be maintained by medication or surgical interventions
- to prevent overinfection of decubitus
- end stage diseases
Complications of long time catheterization must be considered and you should choose this solution only when
absolutely necessary. Antibiotic prevention is necessary.

3.13.6. Complications
Complications
- urinary tract infections
- urethral injuries
- shock (in case of draining too much urine)
- bleeding
If rules of asepsis are not kept, patients are threatened by danger of urinary tract infections. Fever and shivering
can be the first signs and symptoms of infection; may appear in a few hours. More than 60% of fever episodes in
elderly patients with long-time catheter originate in urinary tract infection. Thus, temperature of catheterized
patients must be regularly checked. Changes in mental state, sweat, abdominal pain, tachycardia, hypotension,
nausea, vomitus, agitation can also be present in bacteriaemia and urinary sepsis. In case of this kind of infection
the choice of antibiotics should be based on appropriate microbiological tests because many uropathogen bacteria
are resistant against conventional antimicrobial medication. If case of presumed urethral or prostatic injury
immediate urological consultation is mandatory. To detect the site of injury, urethrography is mandatory.

3.13.7. Catheter dysfunction

- Encrustation means deposition of detritus around the end of the catheter and this process may lead to obstruction.
This state can be prevented if the catheter is regularly changed. Besides, it is advisory to keep the pH of urine in
the acidic range. Appropriate dietary, which contains meat, corn, egg, plum and raisin, may contribute to the
required urine pH. Intake of fluid of 2000-3000 ml is suggested in order to decrease the chance of obstruction by
continuous urine flow in the catheter. Antibiotic prevention of infections is mandatory in the case of a longer
period of catheterization.
- Urine leakage occurs in connection with catheter obstruction and spasm of the bladder. Several diseases may
lead to irritability and spasm of bladder. Urinary tract infection, obstipation, calculi and oversized catheter balloon
are the most frequent causes. In case of urine leakage the cause must be found and treated. If it proves to be
unsuccessful, spasmolytic drugs should be applied.
- Effluvium can be prevented by careful nursing. Perineal region should be cleaned every day and it is suggested
to change the urine container sack with the catheter.

3.13.7. Other methods for catheterization

- When the urethra cannot be catheterized, percutaneous suprapubic catheterization is very useful. This technique
is often applied after urological and gynecological operations and in the case of urethral injury. Infection is the
primary complication of this intervention as well. These catheters must be maintained like the mentioned long
time catheters.
- External catheters are suggested for managing of bladder dysfunctions, when other anti-incontinence treatments
are proved to be unsuccessful. The external catheter designed for male has a cone, which can be fixed to the pubic
bone. Other types have a condom which is secured with an elastic band. These catheters may lead to edema,
irritation of the skin, strangulation of penis and urethral diverticula. External catheters for females are available,
but their efficacy is still unproven.

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