PerioperativeNursing

Introduction
Thetermperioperativenursingreferstoallactivitiesbefore,duringandafterasurgicalprocedure,whichensurethe
bestpossiblecareofananimal.BoththeinternationalandtheGermanregulationsconsideritaresponsibilityofthe
researchorteachinginstitutiontoensurethatallpersonnel,regardlessofacademicdegrees,arequalifiedand
trainedtoconductsurgicalprocedures.Personnelwhoperformsurgery,aswellasstaffmemberswhomanagethe
operatingrooms,mustbequalifiedandtrainedfortheassignedproceduresorfunctions.Inthischapterabrief
descriptionofthefundamentalconceptsofperioperativenursingisgiven,tofacilitatethetrainingoftheMPIK
personnel.Firstly,thetopicsofsurgicalasepsis,sterilizationanddisinfection,attire,andtools,arediscussed;and
secondlytheMPIKoperatingroomandtheprotocolofsurgerypreparationisdescribedinsomedetail.Finally,a
briefdescriptionisgivenofpremedicationandofthefactorsthatmaygreatlyinfluencethepresurgicalstateofthe
animal.
SurgicalAsepsis
AtMPIKallsurvivalsurgicalproceduresareperformedunderasepticconditions.Itisthereforeimperativethatall
personnelisfamiliarwiththeprinciplesofasepsis.
TermsandDefinitions
Micro-organisms or microbes:Bacteria,viruses,fungi,algae,protozoa,andspores,thatis,allthose
organismsthataregenerallyconsideredtoosmalltobeseenclearlywiththenakedeye,areknownasmicrobesor
microorganisms.ThestudyofsuchorganismsisknownasMicrobiology.Mostmicrobesareunicellular,thatis,they
consistofonlyonecellwhichcarriesoutallthefunctionsnecessaryforlife.Microbesarenamedaccordingtothe
binomialsystem.Thefirstpartisthegenericname,indicatingthegenustowhichtheorganismbelongs,andthe
secondisthespecificnameindicatingthespecies.
Parasites:Aparasiteisanorganismwhichlivesonorinanotherlivingorganism(thehost)andderives
nourishmentfromit.
Pathogen:Pathogenisaparasitethatharmsthehostbycausingdisease.
Bacteria:Bacteriaaresinglecelledorganisms.Threebasicshapesaregenerallyrecognized:cylindricalorrod
shapedcalledbacilli(singularbacillus),sphericalcellsthatarecalledcocci(singularcoccus),andspiralorhelicalcells
calledspirilla(singularspirillum)iftheyhaverigidcellwallorspirochaetes(singularspirochaeti)ifthecellwallis
flexible.Somecocciexistsinglywhileothersremaintogetherinpairsafterdivisionandarecalleddiplococci.For
ourpurposesimportantistheclassificationofbacteriaonthebasisoftheirreactiontoacombinationofstains
developedbyGram.Gramsmethodenablesustodividebacteriaintotwogroups:(a)Grampositive,whichstain
purple,and(b)Gramnegative,whichstainred.
Spores:Somespeciesofbacteria(mostcommoninthegeneraBacillusandClostridium)producedormantforms
calledspores(orendospores)thatcansurviveinunfavorableconditions.Suchsporeformingbacteriaexistalmost
everywhere,includingdust,andareextremelyresistantstructures,remainingviableformanyyears.Theycan
surviveextremesofheat,pH,desiccation,ultravioletradiation,andexposuretotoxicchemicalssuchassome
disinfectants.
Viruses:Virusesaremuchsmallerandsimplerthanbacteria.Theyareallobligateparasitesdependingonhost
cellsforreproduction(replication),andforcarryingoutothervitalprocesses.Onceavirusbeginstoreplicate,the
hostcellsdonotusuallycontinuetofunctionnormally.Sometimescellsaredamagedandkilled,othertimes
infectedcellsshownovisiblechangebutdonotfunctionproperly.Viralinfectionsareusuallydifficulttocontroland

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treatbecauseanydrugthatinterfereswithviralreplication isalmostcertaintoalsohaveaharmfuleffectonthe
hostcells.
Fungi:Fungirangeinsizefrommicroscopic,unicellularformstolargemulticellularorganismswhichcaneasilybe
seenwiththenakedeye.Somefungiarepathogenic.Theycanbeclassifiedin(a)yeaststhatareunicellularfungi
usuallyroundorovoidreproducedbyaprocesscalledbudding,and(b)moldsthataremulticellularorganisms
composedbylongfilamentscalledhyphae(singularhypha).
Toxins:Toxinsarepoisonoussubstancesthathaveadamagingeffectonthecellsofthehost.Becausethetoxin
canbetransportedthroughthetissuestheeffectsofthetoxinarefeltnotonlyintheaffectedcellsandtissuesbut
alsoelsewhereinthebody.Twotypesoftoxinsarerecognized:(a)exotoxinsthataremanufacturedbylivingmicro
organismsandreleasedintothesurroundingmedium,and(b)endotoxinswhichareretainedwithinthemicro
organismandonlyliberatedwhenitdies.EndotoxinsarepartofthecellwallofcertainGramnegativebacteriaand
releasedonlywhenthecellsdieanddisintegrate.Bloodborneendotoxinsareresponsibleforarangeofnon
specificreactionsinthebody,suchafever.Theyalsomakethewallsofbloodcapillariesmorepermeable,causing
bloodtoleakintotheintercellularspaces,whichinturncanresultinaseriousdropinbloodpressure.
Epidemic Disease:Epidemicdiseasesarethosediseaseswhoseincidenceincreasessharplyandinvolveslarge
numbersofindividualsinanarea.
Zoonoses:Zoonosesarediseasesthatcanbetransmitteddirectlytohumansbyanimals.Examplesofzoonotic
agentsthatareknowntobetransmittedfrommonkeystohumans,andwhichpresentserioushealthhazards,are
rabies,bvirus,filovirus,Qfever,tuberculosis,toxoplasmosis,andothers.
Inflammation:Ingeneralinflammationisthereactionofnormaltissuestoanirritant.Morespecifically
inflammationistheprocesswhichbeginsfollowinginjurytoatissueandendswithhealingortheeventualdeathof
thetissue.Thesignsthatcharacterizeinflammation(calledthecardinalsigns)are:(1)Redness,(2)Swelling,(3)
Heat,(4)Pain,and(5)Lossofnormalfunction.Thepainisassociatedwithinflammationisduetoincreasedpressure
onthenerveendingsbecauseoftheswelling.Lossoffunctionsresultsfrompaininducedinhibitionofmuscle
activity;themechanicaleffectsofswellingandtissuedistraction.Inflammationsmaybeacuteorchronic.Chronic
inflammationsmayoccurinthelaboratorybecauseoftherecordinghardwareimplantedontheanimalsskull.The
treatmentofsuchinflammationsisdiscussedbelow.
Resolution:Resolutionisthereturnofatissuetoitsstatepriortotheonsetofaninflammation.
Regeneration:Regenerationisthereplacementoftissuedestroyedbytheinflammatoryprocesswithsimilar
functionaltissue.
Organization:Organizationisthereplacementoftissuedestroyedbytheinflammatoryprocesswithconnective
(scar)tissue.
Sepsis:Thepresenceofpathogensortheirtoxicproductsinthebloodortissuesofananimal.Morecommonly
knownassystemicinfection.
Asepsis:Freedomfrominfectionbyexcludingallmicroorganismsandspores.
Antisepsis:Preventionofsepsisbydestructionorinhibitionofmicroorganismsusinganagentthatmaybesafely
appliedtolivingtissue.
Sterilization:Thedestructionofallmicroorganismsandspores.
Antiseptic:Achemicalagentthateitherkillspathogenicmicroorganismsorinhibitstheirgrowthaslongasthere
iscontactbetweenagentandmicrobe.Antiseptics(incontrasttodisinfectants)areappliedtothebody.The
antisepticmayactuallybeadisinfectantusedindilutesolutionstoavoiddamagetotissues.

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Drain:anydevicebywhichachanneloropeningmaybe establishedandmaintainedfortheexitoffluidor
purulentmaterialfromanycavity,woundorinfectedarea.
Drainage:thesystematicwithdrawaloffluidfromanywound,sore,orcavityinthebody.
Penrose Drain:themostcommonlyuseddrain,madeofsoft,thinwalledrubbertubing0.64to2.54cmin
diameter.
Sump Drain:alargetubewithasecondsmallertubeinthewallorwithinthelumenofthelargertube.The
smallertubeallowsairtoenterandfacilitatesdrainageoffluidfromcavity.
Infections
Asepticandsteriletechniques,basedonsoundscientificprinciple,arecarriedoutprimarilytopreventtransmission
ofmicroorganismsthatcancauseinfection.Microorganismsareinvisible,buttheyarepresentintheairandon
animateandinanimateobjects.Topreventinfection,allpossiblemeasuresaretakentocreateandmaintaina
therapeuticenvironmentforthepatient.
Infectionthatisacquiredduringthecourseofsurgeryorgeneralhealthcareisknownasanosocomialinfection.The
infectionmayoccurinthepostoperativewoundorasacomplicationunrelatedtothesurgicalsite.Postoperative
infectionisaveryserious,potentiallyfatalcomplicationthatmayresultfromasinglebreakinaseptictechnique.
Thereforeknowledgeofcausativeagentsandtheircontrolaswellastheprinciplesofasepticandsteriletechniques
isthebasisofprevention.
Infectionsmaybecausedbyoneorseveraltypesofmicroorganisms.Typesarenumerousandvaryinincidenceand
significanceofinfectionproduced.Whatfollowsisaveryshortlistofthepathogenscausinginfectionsinlaboratory
primates.
BacterialInfections
Bacteriaareclassifiedbytheenvironmentthatsustainstheirlifewithoxygen(aerobic)orwithoutoxygen
(anaerobic),andasgrampositiveorgramnegative.Gramsstain(Gentianviolet)isalaboratorytechniquefor
identifyingaprimarycharacteristicofbacteria.Thosethatstainblue/purplearegrampositivewhilethosethatdo
notstainaregramnegative.Infectionsmaybecausedbyaerobic,microaerophilic,oranaerobicbacteriaorcanbe
mixedbacterialinfections.Micoaerophilsrequirelessoxygenthanpresentinair.Thefollowingarethemost
commonbacterialpahtogens:
AerobicBacteria
(a)Grampositivecocci,suchasStaphylococcusaureus,Staphylococcusepidermidis,StreptococcusGroupB,
StreptococcusGroupD,methicillinresistantStaphylococcusaureus(MRSA).InfectionscausedbyStaphylococcus
aureusareunfortunatelyverycommoninmonkeys.Inparticular,iftheanimalsarebroughtbacktotheirhomecage
immediatelyafterthesurgicalprocedures.Gramnegativecocci,suchasNeisseriagonorrhoeae.(b)Grampositive
bacilli,suchasBacillusspeciesMycobacteriumtuberculosis.(c)Gramnegativebacilli,suchasEscherichiacoli,
Klebsiellaspecies,Pseudomonasaeruginosa,Pseudomonascepacia,Proteusspecies,Serratiamarcescens,
Salmonellaspecies,Enterobactercloacae,etc.
Micoaerophilicbacteria
Grampositivecocci,suchashemolyticandnonhemolyticstreptococci.
Anaerobicbacteria
(a)Grampositivecocci,suchaspeptostreptococcus,peptococcus.Grampositivecoccicauseoftenproblemswith
theanimalsimplants.(b)Grampositivebacilli,suchasClostridiumtetani,Clostridiumwelchii.(c)Gramnegative
bacilli,suchasBacteroidesspecies,Bacteroidesfragilis.

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NonbacterialInfections
Infections may be caused by fungi, protozoa, or viruses. With nonhuman primates the most of the
nonbacterial infections are caused by viruses. Possible pathogens are the hepatitis virus, simian
immunodeficiency virus, herpes B virus, cytomegalovirus, Epstein-Barr virus, etc.
ViabilityofOrganisms
Microorganismsneedmoisture,food,propertemperature,andtimetoreproduce.Whentransferredfromoneplace
toanother,theypassthroughadormantorlagphaseofabout5hoursorlonger.Theneachorganismdivideditself
aboutevery20minutes.Mostbacteria,fungi,andvirusesarekilledeasilybytheprocessesofsterilizationand
disinfection,butbacterialsporesarenot.
Sporesaretheresting,protectivestageofsomerodshapedbacilli.Denselayersofproteinformwithinthecellsthat
canbecomparedtotheshellofanut.Thethickerthewall,themoreresistantthesporeistodestruction.When
conditionssuitableforbacterialgrowtharereestablished,thesporereleasescellsforactivegrowthand
reproduction.Althoughsporesareformedbyonlyabout150speciesofbacilli,theyareuniversallypresentinthe
environment.
SourcesofContamination
ManysourcescontaminatetheORenvironment.Mostmicrobesgrowinawarm,moisthost,butsomeaerobic
bacteria,yeasts,andfungicanremainviableintheairandoninanimateobjects.Peopleandanimalsthemselvesare
alsomajorsourceofmicroorganismsinthesurgicalenvironment.Everythingonoraroundahumanbeingandof
courseanythingonandaroundthemonkeyiscontaminatedbytheminsomeway.Inadditions,theactionsand
interactionsofpersonnelandanimalscontributetotheprevalenceofvariousmicroorganisms.Themostcriticalarea
fortheintroductionandspreadofmicroorganismsisobviouslytheareaoccupiedbytheoperatedanimalandthe
surgicalteam.Usualsourcesare:
Skin
Thefurandskinoftheanimals,aswellastheskinoftheORteammembersconstitutesahazard.Hairfolliclesand
sebaceousandsweatglandscontainabundantresidentmicrobialflora.Anestimated4000to10,000viableparticles
areshedbyanaverageindividualsskinperminute!Somepeopledisperseupto30,000particlesperminute.
Sheddersarepersonswhopresentanadditionalhazard,andmustbethereforealwaysappropriatelydressedwhen
closetooperatedanimals.Truesheddersareestimatedtobe1in50persons.Majorareasofmicrobialpopulation
onallpersonsarethehead,neck,axillae,hands,groin,perineum,legs,andfeet.
Hair
HairisagrosscontaminantandmajorsourceofvariousspeciesofStaphylococcus.Hairfolliclesandfilamentsharbor
richresidentandtransientfloras.Theextenttowhichthemicrobialpopulationisattractedtoandshedfromhairis
directlyrelatedtothelengthandcleanlinessofthehair.
Nasopharynx
Organismsforciblyexpelledbytalking,coughing,orsneezinggiverisetobacterialadendustandlintasdroplets
settleonsurfacesandontheskin.Personsknownascarriersharbormanyorganisms,notableGroupA
StreptococcusandStaphylococcusaureus,whichmaybecarriedpharyngeallyorrectally.Suchorganismsareusually
transmittedbydirectcontact.Surgeonsandanesthesiologistscanbeoftencarriersbecauseofintimatecontactwith
theanimalsrespiratorytract(intubation,etc.).Carriersdonotpresentarealthreatintheabsenceofanovert
lesion.However,theycanbeaserioussourceofinfectioninpresenceofanopensurgicalwound.
Fomites
Contaminatedparticlesarepresentoninanimateobjectssuchasfurniture,ORsurfaces(walls,floors,cabinet
shelves),equipment,supplies,andfabrics.Covertcontaminationmayresultfromimproperhandlingofequipment

5
suchasanesthesiaapparatusorintravenous(IV)linesand fluids.Contaminationmayalsoresultfromthe
administrationofunsterilemedicationsoruseofunsterilewatertorinsesterileitems.
Air
ThousandsofsubmicronsizedparticlespercubicfootofairarepresentintheOR.Duringalongsurgicalprocedure
particlecountcanrisetomorethanamillionparticlespercubicfoot.Airanddustarevehiclesfortransporting
microorganismladenparticles.Airmovementandthermalcurrentsentraindustandmicrobialparticulates.TheOR
lightsandotherheatgeneratingequipmentproduceconvectiveupcurrents.Particulatesthatbecomeairbornecan
thensettleonanopenwound.Between80%and90%ofmicrobialcontaminationfoundinanopensurgicalwound
comesfromambient(room)air.Becauseairbornecontaminationisgeneratedbypersonnel,everymovement
increasespotentialforwoundinfection.
Microorganismshaveanaffinityforhorizontalsurfaces,ofwhichtheflooristhelargest.Fromit,theyareprojected
intotheair.Endogenousflorafromthepatentsskin,oropharynx,tracheobronchialtree,andgastrointestinaltract,
aswellasexogenousflora,aresignificant.Microorganismsfrompatentsorcarrierssettleonequipmentandflat
surfaces,thenbecomeairborne.Airborneparticlesincreasesignificantlyduringactivitybeforeincisionandafter
woundclosure.Aneffectiveventilationsystemisessentialtopreventpatentsandstafffrombreathingcontaminated
air,whichwouldpredisposethemtorespiratoryinfectionandcouldincreasetheincidenceofmicrobialcarriers
amongORpersonnel.
InfectionofProstheticImplants
Acommonphraseinbothresearchandclinicalsituationisinfectedimplant.Thisisamisnomer,sinceitisthe
tissuesurroundingtheimplantthatisinfectedratherthantheimplantitself.Threetypesofinfectionareassociated
withprostheticimplants.
Thefirsttypeisthesuperficialimmediateinfection,whichisduetothegrowthoforganismsonorneartheskinin
associationwithanimplant.Examplesincludetheheadfixationdevices,therecordingchambers,aswellasburn
dressingsandsimplesuturesthathavenotbeenremovedintime.Thesecondtypeisthedeepimmediateinfection,
whichisalowfrequencyinfectioncommonlyseenimmediatelyaftersurgery.Thebacteriaresponsibleareusually
skinresidentscarriedintotheimplantsiteduringthesurgicalprocedure.Thethirdtypeisthedeeplateinfection,
whichmayoccuryearsafterthesurgeryinsiteswithnohistoryofinfection.Thelattertypeofinfectionmaysome
timesoccurinmonkeysthathaveimplantedelectrodeguidetubes,orinfrequentlyaroundthesearcheyecoil.
PrinciplesofAsepsis
Modernsurgeryisbasedonaseptictechnique.Asepsismeanstheabsenceofanyinfectiousagents,andtherefore
aseptictechniqueisaimedateliminatingmicroorganismspresentinthesurgicalenvironment.Thisincludesthose
microorganismslivingharmlesslyonthebodysurfaceorwithinit.Aseptictechniqueisalwaysappliedincombination
withsteriletechniques,whichpreventthetransferofmicroorganismsfromtheenvironmentintothebodytissues.
Thewordsasepticandsterilealthoughsoundverysimilartheyareverydifferentinpractice.Aseptictechniques
controltheenvironmentwhilesteriletechniquespreventthecontaminationofanitemorareafromthe
environmentbymaintainingsterilityofthatitemorarea.
Aseptictechnique,forexample,includesthecontroloftheORsairsystem,thetrafficandmovementwithintheOR,
theestablishmentofasepticbarriers,suchastheusageofcaps,hoods,andgloves,andtheappropriate
housekeepingpracticesthatincludethecleaninganddisinfectingoftheoperatingroomsandsuite,thehandlingof
soiledlaundry,andthedisposingofsolidwastes.
Steriletechniqueontheotherhandincludesthesterilizationofinstruments,thecreation,maintenance,and
terminationofthesterilefield,thedrapingofthepatientoranimalwithsterilizeddrapes,etc.
Principlesofbacteriologyandmicrobiologyareappliedindevelopinginfectioncontrolprogramstobefollowedbyall
operatingroompersonnel.SuchprogramsinvolvespecificguidelinesforORattire,sterilizingandpackagingsupplies,

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scrubbing,gowningandgloving,andmethodsof housekeeping.Thefollowingpracticesstemfromthe
originalinfectioncontrolprinciples:
1.Allitemsusedwithinasterilefieldmustbesterile.Ifthereisanydoubtaboutthesterilityofanitem,itis
consideredunsterile.
2.Asterilebarrierthathasbeenpermeatedmustbeconsideredcontaminated.Inotherwords,youhavetochange
gown,drapes,orglovesifanyofthemispermeated.
3.Gownsofscrubbedteammembersareconsideredsterileinthefrontfromshouldertowaistlevel,andthesleeves
toapproximately5cmabovetheelbow.Unsterileareasofgownsareshoulders,neckline,axillaryregion,andback.
Ifyouarescrubbed,donotallowyourhandsoranysterileitemtofallbelowwaistortabletoplevel.
4.Tablesaresterileattablelevelonly.Anyitemthatextendsoverthetableedgeisconsideredcontaminatedand
cannotbebroughtbackuptotabletoplevel.
5.Scrubbedpersonsmuststayclosetothesterilefieldandiftheychangepositions.Ifyouneedtochangeposition
whilescrubbed,youmustmovebyturningbacktobackorfacetofacewithothersterileteammembers.
6.Theedgesofasterilecontainerareconsideredunsterileoncethepackageisopened.Becausesterileboundaries
arenotalwayswelldefined,followtherulesbelow:
Capedgesofabottleofsterilesolutionareconsideredcontaminatedoncethecapisremoved.Becausethecap
cannotbereplacedwithoutcontaminatingthepouringedges,thesterilityofthebottlecontentsisnotlongercertain
andtheremaindermustbediscarded.
Packagewrappersareusuallyconsideredtohavea3cmsafetymarginaroundtheedge.Theflapendsaresecuredin
thehandofthepersonopeningthemtoavoiddanglingtheflapendsloosely.
Peelbackpackagesshouldnotbetornopenbutratherpulledbacktoexposesterilecontents.Theinneredgeofthe
heatsealisconsideredtobetheboundarybetweensterileandunsterile.
7.Thesterilefieldshouldbecreatedasclosetothetimeitisgoingtobeusedaspossible.Thedegreeof
contaminationisproportionaltothelengthoftimeitemsareleftuncovered.Sterileareasarekeptcontinuouslyin
viewandoncesuppliesareopened,someonemustremainintheroomtoensuresterility.
8.Sterilepersonsanditemstouchonlysterileareas;unsterilepersonsanditemstouchonlyunsterileareas.
Finallyonehastokeepinmindthatthemorepeopleinthesurgicalsuite,thegreaterthelikelihoodofinfection.In
ourfacilitysurgicalproceduremaybeobservedthroughourinternalvideosystem.Thereisnoneedforpeopletobe
directlypresentintheORunlesstheyabsolutelyhaveto.Inallcasesvisitorsshouldalsopreparetheirhands
asepticallyandwearsterilegownsandgloves.
DecontaminationofSurgicalSupplies
Decontaminationisthefirststeptowardreducingthepotentialhazardofdirectcontactwithblood,fluidsortissues
leftonORsurfaces,equipment,orinstruments.Decontaminationreferstotheprocessbywhichthecontaminants
areremoved,eitherbymanualormechanicalmethods,usingspecificsolutionscapableofrenderingbloodand
debrisharmlessandremovingitformthesurfaceofanobjectorinstrument.
Theinstruments,alongwiththeothernondisposablesuppliesexposedtothepatient/procedureareplacedina
properreceptacleandcoveredfortransferencetothedecontaminationroom.Itisimportanttonotethatthe
contaminatedinstrumentsandnondisposableequipmentmustbecoveredwhentraversinghallwaysleadingintothe
decontaminationarea.Allinstrumentsusedduringtheprocedureshouldbeinspectedforgrossdirtanddebris,and
cleanedwithwaterand/orascrubbrush,andsoakedwithanantimicrobialorbleachsolution.Thisprocessmustbe
doneunderthewaterlevel,preventingsplashdisseminationofharmfulmicroorganisms.

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Oncetheinstrumentshaveundergonetheinitialwashing, thesecondstepintheprocessbegins,whichinvolves
theterminalcleaningoftheinstrumentsandinitialsterilizationbeforetheassemblyofthetray.Amanualcleaning
procedure,fordelicateandheatsensitiveitems,isrecommendedtopreservethelifeoftheinstrumentsandto
decontaminatethembeforethesterilizationprocess.Ifmanualwashingisrequired,allpersonnelmustbeprotected
fromexposuretocontaminantsduringthecleaningprocess.
Themostcommoncleaningmethodismechanicalcleaningwhichcanbeaccomplishedusingseveraldifferenttools:
ultrasonicwasher,washersterilizer,orthewasherdisinfector.
UltrasonicWasher
Theultrasoniccleaningprocessremovesbloodanddebrisleftontheinstrumentbyaprocessknownascavitation,
whichoccurswhensoundwavesarepassedthroughwater,creatingwithinitcavitiesranginginsizefrom
submicroscopictoverylarge.Thesebubblesexpanduntiltheyimplode.Thisimplosiongeneratesminutevacuum
areasontheinstruments,which(vacuums)areresponsiblefortheactualcleaningprocess.Duringthisprocessthe
smallparticlesfloattothetop,whilethelargerparticlessettleonthebottomofthetankandareeventuallyflushed
away.Theparticleswillremaininsuspensionaslongasthewateranddetergentarefresh.Itisforthisreasonthat
thewatermustbechangediftheultrasoniccleanerisusedfortheinitialcleaningprocess.
WasherSterilizer
Whenthewashersterilizerisused,thesoiledinstrumentsarecleanedbymechanicalagitationinabathcontaininga
detergent,rinsed,andthensterilizedfor3minutes.inoneprocess.However,itmusthaveacoldcycleortheitems
mustbewashedbyhandfirst.
WasherDisinfector
Thenewestmethodfordecontaminatinginstrumentsisthewasherdecontaminator,whichremovesexcessamounts
ofdrieddebrisfromtheinstruments,eliminatingthehandcleaningphaseofthedecontaminationprocess.The
numerouswaterjetsandtheincreasedpHofthedetergentallowforthoroughcleaningofevengrosslysoiled
instruments.InitialcleaningisfollowedbyaneutralizingrinsetorestorethepHtoitsneutralstate.Sincethe
agitationofthewaterisminimal,itcleanswithouttossingtheinstrumentsaroundinthetray,therebyreducingthe
riskofdamagetoevendelicateinstruments.Thewashercontaminatorcleansinstrumentssothoroughlythatitnot
onlyeliminatestheneedforhandcleaning,butitcanalsoreplacetheultrasonicwasher.
Sterilization
ByTorstenTrinath
TheoreticalandPracticalConsiderations
Ifanypracticalortheoreticalquestionsremainafterreadingthisdocument,pleasecontacttheHygieneInstituteof
theUniversityofTbingen(Tel.:07071/292354),thedirectoroftheCentralSterilizationFacilitiesoftheUniversity
HospitalsofTbingen,Mr.Zanette(Tel.:07071/2980095,Fax:295716),orthehygienedirectoroftheUniversity
HospitalsofTbingen,Priv.Doz.Dr.Heeg(Tel.:07071/292026,Fax:295867).
BasicConceptsandDefinitions
Tosterilizemeanstorenderanitemtotallyfreeofalllivingmicroorganisms,includingspores,throughoneofthree
processes:(1)steamsterilization,(2)chemicalsterilizationor(3)physicalsterilization.Eachmethodhasitsown
characteristicsandrequiresspecificparametersforeffectivecompletionoftheprocess.Additionally,theprocess
mustbecontinuouslymonitoredtoensurethatallproceduralparametersandspecificationshavebeenmet,
assuringthesterilityandtraceabilityoftheitemaswellastheproperfunctioningoftheequipment.
Steamaloneisincapableofsterilizinganitem.However,whensteamisplacedunderpressure,itstemperature
rises,andthemoistheatproduceddestroystheproteinwithinthecell,renderingitharmless.Itis,therefore,the

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relationshipbetweentemperature,pressure,andtimeof exposurethatbecomesthecrucialfactorindestroying
microbes,anditistheseprinciplesthatareusedintheoperationofthesteamsterilizer.Sterilizersdesignedtouse
steamunderpressurearereferredtoasautoclavesandaregenerallymanufacturedtoperformthistaskbyoneof
threemethods:(1)gravitydisplacement,(2)prevacuum,or(3)highspeedpressure.
Gravitydisplacementsterilizer
Thegravitydisplacementsterilizerusestheprinciplethatairisheavierthansteam.Ithasaninnerchamberwhere
thegoodsaresterilizedandanouterheatedjacketthatejectssteamintothechamber.Whenthesterilizeris
activated,pressurizedsteamentersthetopoftheinnerchamberfromthejacket,andexertspressureontheair
insidethechamber,displacingtheairdownwardtothebottomofthechamberwhereitisreleasedthrougha
temperaturesensitivevalve.Whenthevalvecloses,thepressureinsidethejacketchamberincreases,raisingthe
temperaturetotherequiredlevel.Atthispoint,thetimingofthesterilizationcyclebegins.Thelengthofthecycle
dependsonthetemperaturereachedinsidethejacket.Mostgravitydisplacementsterilizersworkinarangefrom
250F(121C)to254F(123C)at15to17poundspersquareinch(psig),andtakeanywherefrom15minutesfora
conventionalpackto55minutesforlarge,tightlypackedcontainers.Thehigherthetemperature,theshorterthe
cycledurationrequired.
Prevacuum(highvat)sterilizer
Theautomaticprevacuum,hightemperaturesterilizerhasgenerallyreplacedthegravitydisplacementmethod,
sinceitdoesnotrelyongravitytoremovetheairfromthechamber.Instead,theairisremovedbyaventurivalve
thatuseswatermovementtocreatethevacuum,whichsimultaneouslydrawstheairoutwhilesteamisinjected
intothechamber,replacingtheair.Thismechanismreducesthetimenecessarytoaccomplishthesterilizationcycle
toaslittleas5minutes,butthetimevarieswiththesizeofthesterilizer,theadequacyofthesteam,andthesupply
ofwater.Thissterilizer,ifefficientinpreventingairpockets,hasagreaterpenetratingabilitythanthegravity
displacementtype.Therecommendedexposuretimeforprevacuumsteamsterilizersisfourminutesat
temperaturesrangingfrom250F(121C)to274F(134C).Thissterilizer,likethegravitydisplacementsterilizer,is
usedprimarilyforwrappeditems.
PreparingGoodsfortheAutoclave
Althoughsterilizationwithhighpressuresteamisaverysafe,effectivemethod,certainrulesmustbeobservedto
ensuresterility.Thefirstruleisthatbeforeanyinstrumentisputintotheautoclaveitmustbeabsolutelyclean.
Forthisreasonallinstrumentsarecleanedanddriedinthelaboratorydishwasher(MieleDesinfektor)before
beingsterilized.Iftheinstrumentsareextremelysoiled,theymustbewashedbyhandbeforebeingputintothe
dishwasher.Thedirtcanalsobeloosenedwithultrasoundtomakethetaskofhandwashingeasier.Caution!Notall
instrumentsaresuitedforultrasoniccleaning.Problemscanbecausedespeciallybygluedpartsandcertaincheaper
surfacefinishessuchasmostchromeplating.Eachinstrumentmustbeinspectedcloselybeforeitisputintothe
dishwasher,especiallyatanyjointsorteeth.
Oncetheyhavebeenwashedanddriedinthedishwasher,theinstrumentsmaynolongerbetouchedwithbare
hands.Eachfingerprint,eachdropofwaterandeachcalciumdepositonaninstrumentisanexcellenthidingplace
forpotentialgermsandcanjeopardizethesuccessofthesubsequentsterilization.
Theemptysterilizationcontainers,whichhavealsobeenwashed,arefittedwiththeappropriatefiltersinthelid
andsometimesonthefloor.Nowtheycanbeloadedwiththeinstrumentstobesterilized.Donotpacktootightly.
Theappropriateindicatorstrip(whichchangescolorwhenthesterilizationtemperaturehasbeenmaintainedfora
certainlengthoftime)isputintothecontainer.Tobesafe,anindicatorstripisalsoputalongwiththeinstruments
intotheclothroll,ifoneisused.Afterthecontainerisclosedisitsealedwiththeindicatorclampmadeforthis
purpose.
WeusetheMMMVakulabHP446withachambervolumeof140liters.Thisautoclavemayonlybeoperatedby
personswhohavebeeninstructedinitscorrectuse.

9
Ourautoclavehasfoursterilizationcycles:
Cycle1: Solidmaterials.134C,cycledurationapprox.35minutes.Forheatresistantinstrumentswithoutcloth
instrumentrolls.
Cycle2: Solidmaterials.121C,cycledurationapprox.50minutes.Fortemperaturesensitivematerialssuchas
steamresistantplastics.Nocloth.
Cycle3: Porousmaterials.134C,cycledurationapprox.45minutes.Forpackagedinstruments,laundryand
materialswhicharedifficulttodeaerate.
Cycle4: Porousmaterials.121C,cycledurationapprox.1hour.Forfirm,temperaturesensitivematerialswitha
poroussurface.
Beforetheautoclaveisfilledavacuumtest(cycle8)mustberunand,ifthisisthefirsttimethesterilizerisbeing
usedonthatparticularday,apreheatingphase(cycle7).Preheatingisparticularlyimportantwhensterilizing
heavy,tightlypackedcontainers.
Afterthishasbeendonethechambercanbefilledwiththegoodstobesterilized.Thecycleisstartedbypressing
theappropriatenumberandthenthestartbutton.Oncethecycleiscompletethedoormustbeopenedallthe
way.Otherwisetheautoclaveisnotreleasedforthenextcycle,evenwhenthedoorisclosed.Carefulthefreshly
sterilizedcontainersarehot!Wearprotectivegloves!
Rightafterthesterilizationcycleiscompletedthebatchdocumentationisprinted(pressureandtemperature).
Sincetheairinthesterilizationroomisquitehumid,theprinterpapershouldbestoredoutsidetheroom.Thepaper
isputintotheprinteronesheetatatimeandcheckedtomakesurethatitfeedsproperly.Thedocumentation
shouldbecompletedbyfillinginthenameoftheoperator,date,andabriefdescriptionofthesterilizedgoodsand
thenfiledintheappropriatenotebook.
Ifthesterilizedcontainersarestoredinacleanplaceitissafetoassumethattheywillremainsterileforseveral
months.Airtightcabinetscanextendthisperiodofsterilityto2yearsandlonger.
Chemical(gas)sterilizers
GassterilizationusingE.T.O.(ethyleneoxide)gas,isdependentupon(1)theconcentrationofthegasbeingused,(2)
thetemperatureinsidethechamber,(3)thehumiditylevel,and(4)theexposuretime.Ingeneral,E.T.O.gas
concentrationsrangebetween450and800mg/Lofchamberspace,andoperatingtemperaturesrangefrom108F
(42C)to132F(55C)withatleast50%humidity,butnotlessthan30%percentinordertohydratetheitemsduring
theprocess(forty(40%)percentisrecommendedduringthesterilizationcycle).Thedurationofthecyclevaries;it
usuallytakes2to6hoursforthesterilizationcycletobecompleted.However,theprocessdoesnotendhere.The
itemsmustbeaeratedbeforereturningtheitemforanimaluse.
Preparingitemsforethyleneoxidesterilization
ItemstobesterilizedbyE.T.O.requirespecialpreparationbeforebeingexposedtothegassterilant.Allitemsmust
becleanedandcompletelydried,aswatermayunitewithE.T.O.toformethyleneglycol,whichisnoteliminatedby
aerationandmayresultintoxicreactionsinanimalsandpersonnel.Lumensoftubings,needles,andsoonshould
beairdriedandleftopenatbothendstoavoidanyaccumulationofgasinsidetheitem.
Someofourinstrumentsandseveralitemsrelatedtotheimplantsmustbesterilizedinethyleneoxidebecause
autoclavingcancauseblunting,corrosion,and/ordeformationduetoextremeheat.Onlythoseobjectsaretobe
sterilizedinthegassterilizerthatcannotbereliablysterilizedbyanyothermethodandwhosesterilityand
desorptioncharacteristicsareknown.Asarule,thisinformationmustbesuppliedbythemanufacturer.Goods
sterilizedwithethyleneoxidecanonlybeusedwithoutposingarisktousandtheanimalsifthemandatory
desorptiontimesareobserved.

10
Allitemsthataretobeethyleneoxidesterilizedmust bewashedanddried.Ifatmospherichumidityisless
than30%,rewashtheitemsorplacetheminaclosedpackwithawettowelforanhour.Itemstobesterilizedare
packedinthepaper/plasticpouchesmadeforthispurposeTheseareavailableinavarietyofsizes.Oneindicator
stripisplacedinoneofthepouchesandanotherisputinloosewiththeentirebatch.Theindicatorchangescolor
whenexposedtoE.T.O.Afterbeingfilled,thepouchesarecarefullysealedwithaheatsealer.Donotoverstuffthe
packagesandalwaysbesurethatsharpitemsarepackagedinsuchawaythattheydonotpuncturethepouchwhile
beinghandled.Sincecondensationcanformthathastobeabletodrain,hollowobjectsmustbeplacedinthe
sterilizerbasketwiththeopenenddown.Tubesaretobeplacedsothatbothendsfacedown.Ifatallpossible,
everythingshouldbeplacedupright,foiltopaper,andnotpackedtootightlyintheopenwirebasket.Thegoodsto
besterilizedmustnottouchthewallsofthesterilizationchamber.
ForgassterilizationweusetheMMMKombimat349withachambersizeof110liters.Itisfullyautomaticand
usesthenegativepressuremethodwithacombustionunittodisposeoftheE.T.O.Thismakesitsubstantiallysafer
thanoldermodels.Thedoorcanonlybeopenedafterthecompletionoftheprogramcycle.Thissafetyfeature
functionsevenwithapoweroutage.
Thegassterilizermaybeoperatedonlybypersonstrainedinitscorrectusageandundersupervisionofan
expert!
Weusetwosterilizationcycles:
Cycle1: E.T.O.sterilizationatapprox.42C(durationapprox.5hoursexcludingaeration)
Cycle2: E.T.O.sterilizationatapprox.55C(durationapprox.3hoursexcludingaeration)
Themandatoryaerationfollowingsterilizationtakesabout6hours.
Tostartthecycle,pressthenumberedbuttonforthedesiredcycleandopenthechamberdoor.Theethylene
oxidegascartridge(upto20cartridgesmaybestoredunderthesterilizer)iscarefullyplacedintheholderonthe
insideofthedoor.Donotpuncture!Placetwooneliterbottlesofdistilledwaterinthedispensercompartmentand
snapintoplace.Closethedoor.
Thesterilizerheatsupautomatically.Whenthereadylightcomeson(betriebsbereit),pressthestartbutton.
Thecyclewillnowrunautomaticallyuntiltheaerationperiodiscompleted.Thedisplaywillthenshowthemessage
EndeTastebettigen(pressstopbutton)andabuzzerwillsoundofffor5seconds.Whenthestop(Ende)
buttonispressedthesterilizerisquicklyevacuatedandventilatedonemoretime.Thebuzzerwillsoundagain.The
doorunlatchesfortwominutes,afterwhichitlocksagainandanotheraerationcyclestarts.
Thismeansthatatthispointthesterilegoodscanremaininthesterilizeruntiltheyareneeded.Whenthe
chamberhasbeenemptiedandtheemptycartridgeputintothegarbagelabelledRestmll,thechamberdoorcan
beclosedandtheresetbuttoncanbepushed.Thesterilizerisnowreadyforthenextbatch.
Thesterilizationparameterstemperature(blue,giveninC)andpressure(red,giveninmbar)areautomatically
recordedduringthesterilizationprocess.Theprintedprotocolistobelabelledwithnameofoperator,dateanda
shortlistofthegoodsterilized.Itisthenfiledinthelooseleafnotebookprovidedforthispurpose.
Gassterilizationrequiresatleast9hoursandisusuallystarted48hoursbeforesurgerytoallowampletimefor
ventilation(includingmultipleaerationcycles).Metalandglassitemsdonotneedtoair,butanythingabsorbent
(plastic,rubber,etc.)mustairout.Ifthemanufacturerdoesnotsupplythisinformation,thesafetimesforaeration
ofitemssterilizedinethyleneoxidecanbefoundintheTextbookofSmallAnimalSurgerybySlatter(Slatter,1985).
DoublepackagingdoesnotsubstantiallyprolongsterilityandisnotusedbytheUniversityofTbingenhospitals.
Sterileshelflifeisatleast4weeks.AccordingtostudiescarriedoutattheUniversityofHeidelberg,itcanbeaslong
as7years.

11
ListofitemstobeE.T.O.sterilizedforMPI procedures
1. Used 316L Regular Weck Stapler (if exists)
2. Used 316L Wide Weck Stapler (if exists)
3. Weck Staple Remover
4. All remaining hemostatic skin clips
5. DeBakey Felts
6. Plastic tweezers
7. Bulb syringes for irrigation
8. Eyecoil test leads
9. Used monopolar coagulator cord
10. Implants and eye-coil connectors
11. Allen wrenches (if not rust-free)
SterilizingbySoaking
EyecoilscanonlybesterilizedinaliquidsuchasLysetol,becausetheTefloncoatingdoesnotrespondwellto
ethyleneoxide.Iftheprocedureinvolvestheplacementofaneyecoil,theeyecoilsshouldbeplacedintoCidexat
thebeginningofthesetupprocedure.Theyrequire45minutestosterilizeandwillbereadytoberinsedandplaced
onthesterilefieldjustbeforethestartoftheprocedure.
DisinfectionandDisinfectants
BasicConcepts
Adisinfectantisanagentthatkillsgrowingbacteriaand(tosomeextent)spores.Thetwomajorpurposesfor
disinfectionaretokillpathogenicmicroorganismsoninanimatesurfaceandobjectsthatcannotbesterilized,andto
preventorarrestgrowthofmicroorganismsonbodysurfacesthroughtheapplicationofanantisepticsolution.
Disinfectantsareidentifiedasbacteriostatic,whichactbyinhibitinggrowth,orasbactericidal,whichwillkillbacteria
(sporicides,virucides,fungicides).Thetermsgermicideandbactericidemaybeusedsynonymouslywithdisinfectant
accordingtothisdefinition.
Disinfectiondiffersfromsterilizationbyitslackofsporicidalpower,andagentsarelabeledaccordingtotheir
efficacyinkillingfungi(fungicide),viruses(virucide),and/orspores(sporicide).Disinfectioncanbeaccomplished
withchemicalandphysicalagents.Theapplicationofadisinfectionagentdependsonthelevelofriskofinfection,
andontheenvironmentalcontamination.Commonlythelevelsare:
Lowtointermediatelevel:Housekeepingdisinfectionofsurfacessuchasfloors,walls,furniture,andlarge
equipment,andnoncriticalitemsthatordinarilydonottouchthepatientorcontactonlyintactskin.
Highlevel:Disinfectionofthesemicriticalitemsthatcomeincontactwithnonintactskinormucousmembranes
butdonotpenetratebodytissues(i.e.,endoscopes,respiratoryequipment,andthermometers).Criticalitems,that
is,itemsthatwillpenetratebodytissuesmustbesterilized;notdisinfected.
Highleveldisinfectionmustnotbeconfusedwithchemicalsterilization.Arecordoftheagentandtimeof
exposureshouldbemaintainedforsemicriticalitemsthathavebeenhighleveldisinfected.Thelevelofdisinfection
thatcanbeachieveddependsonthetypeandconcentrationoftheagent,contacttime,andbioburden(the
organismsthatmustbekilled).
Thenatureofmicrobialcontaminationinfluencestheresultsofchemicaldisinfection.Bacteria,spores,fungi,and
virusesarepresentinairandonsurfacesthroughouttheenvironment.However,organicsoil,blood,plasma,pus,
feces,andtissue,absorbsgermicidalmoleculesandinactivatessomechemicals.Thereforegoodphysicalcleaning
beforedisinfectionhelpsreducethenumbersofmicroorganismspresentandenhancesbiocidalaction.

12
Itemsthataredisinfectedmustbepatientsafefor theirintendedusestominimizerisksofinfectionfor
thepatient.Anallpurposedisinfectantdoesnotexist.Thebesthousekeepingagentsarenotthebestinstrument
disinfectantsandviceversa.Allchemicaldisinfectantstobeusedinasurgicalsetting,however,mustbeeffective
againstStaphylococcusaureus(grampositive),Salmonellacholeraesuis(gramnegative),andPseudomonas
aeruginosa(gramnegative),themostresistantgrampositiveandgramnegativeorganisms.
Microorganismsdiffermarkedlyintheirresistancetochemicals.Mostvegetativebacteria,fungi,andlipoprotein
viruses,includingHIVaresusceptibletosuchlowleveldisinfectionagentssuchasMercurialcompounds,Phenolic
compounds,orChlorinecompounds.
IntermediateleveldisinfectionagentsarerequiredtokillMycobacteriumtuberculosiswhichhasawaxyenvelope
thatmakesitcomparativelyresistanttoaqueousgermicides.Agentseffectiveenoughtobetuberculocidalwillkill
HIV.HepatitisBvirus(HBV)cannotbeadaptedtolabtesting,butitisknowntosurviveexposuretomany
disinfectants.Alcohol(70%orhigher,orisopropyl)andAlcohol/formalin(8%formalinwith70%isopropylalcohol)
areeffectiveagainsttheabovementionedorganisms.
Bacterialsporesaretremendouslyresistanttodisinfectantsandahighlevelagent,suchas2%activatedalkaline
gluteraldehydeaqueoussolution,isrequiredtokillthem.Thefollowingtableindicatesthedisinfectant,its
classification,mechanismofaction,andourparticularapplicationforthedisinfectantsusedattheMPIBC.

13
DisinfectantsUsedatMPIK
Agent Classification MechanismofAction UseatMPIBC
LysetolAF
(35%Phenoxypropanole,2.5%
Benzalkoniumchloride)
AbcoCideS(2%activatedalkaline
gluteraldehyde)(US,onlytempo
raryuse)
Vegetative
Microorganisms,Tubercle
bacilli
Spores10hr
Denaturation of
proteins
Disinfectionofinstruments
(10min),sterilizationof
eyecoils(10hrs).
Terralin(20%Benzalkonium
chloride,35%Phenoxypropanol
VegetativeMicro
organisms,Tuberclebacilli,
Spores
Denaturationofproteins CleaningsurfacesintheOR
Betaisodonasoap(brownbottle,
7.5gpolyvidoneiodine=10%active
iodine)
EZScrub(1%activeiodine)

Sterilium(Propanol,Mecetronium
etilsulfate)
Antisepsis:1min
Bacteria,Fungi,Tubercle
bacilli,Herpestype1,2,
HIV,HepatitisB(5min),
Rotarviruses(30sec)
Oxidation

Denaturation
Humanskin
Scrubbingofhands
SkinseptF(70%Propanol,0,5%
Chlorhexidindigluconat,0,45%
H
2
O
2
)
Bacteria,Tuberclebacilli,
Fungi,Herpes,HepatitisB,
HBV,Aids
Denaturation Skin,Dura
Betaisodona(11%activeiodine,
greenbottle)
Dilutions:1%iodinePaint
0,75%iodineScrub
Desinfection:5min Oxidation Skinaroundimplants,
wounds,bites
Betaisodona(1%activeiodine) Oxidation Implantedchambersand
headposts
Isopropylalcohole Denaturation Prepbenchesinthesetup
rooms
DesoWash Normalmedicalsoap

SurgicalAttire
Surgicalattireisconsideredtobetheappropriateheadcovering,shoecovers,gloves,gown,andsurgicalmask.All
possibleheadandfacialhair,includingsideburnsandneckline,shouldbecoveredbeforeenteringtheoperating
room(O.R.).Longhairshouldbeup,underneaththeheadcover,andmenwithbeardsshouldwearafullhead
cover,ifnecessary,tocoverfacialhair.ShoecoversshouldalsobewornbyallpersonnelenteringtheO.R.
Sincelargenumbersofpotentiallypathogenicmicroorganismsresideintherespiratorytract,ahighfiltration
mask,coveringboththenoseandmouth,shouldbewornatalltimeswhileintheprocedureroomsornonsterileand
scrubareas.Masksmustbechangedbetweeneachprocedure,iftheybecomemoistorwet,orboth.Whilewearing
amask,conversationshouldbekepttoaminimumtopreventmoisturebuildup.Masksshouldberemovedbythe
stringsandproperlydiscardedbeforeleavingtheprocedureroom.Masksareneverwornoutsidethesurgicalsuite.
Masksshouldfitsnuglyaroundthenoseandchin,andtiedsecurelytopreventaccidentalslippingduringa
procedure.
Scrubbing
Allsterileteammembersperformasurgicalscrubbeforeenteringtheprocedureroom,toremovegrossdirtfrom
theirhandsandarmspriortoapplyingtheirsterilegownandgloves.Scrubbingisthesameforallmembersofthe

14
sterilesurgicalteam.Sincethescrubbedteammembers receivesterileequipmentfromthecirculator
(nonsterilemember),andsincesterilecanonlytouchsterile,abacterialbarrierisneededbetweenthecirculatorand
thesterileitem.Thatbacterialbarrieristhesterilegownandgloves.
Thegoalsofthesurgicalscrubinclude:(1)mechanicalremovalofsoilandtransientmicrobesfromthehandsand
forearms,(2)chemicalreductionoftheresidentmicrobialcounttoaslowalevelaspossible,and(3)reductionof
thepotentialrapidreboundgrowthofmicrobes.Allpersonnelshouldmeetspecificrequirementspriortobeginning
thesurgicalscrub.Theantimicrobialsoapordetergentshouldbeeffective.Theprocedureusedtoaccomplishthe
surgicalscrubshouldbethesameforallpersonnel.Ananatomictimescruborcountedbrushstrokemethodshould
beusedforallsurgicalscrubs.Thesurgicalscrubisperformedafterproperpreparationbythepersonperformingthe
scrub.Skinandnailsshouldbekeptcleanandingoodcondition.Fingernailsshouldbeshort(notreachingbeyond
thefingertips),andpolishfree.Jewelry,includingwatches,rings,andbracelets,shouldnotbeworn.Handsshould
beinspectedforbreaksintheskin,whichcouldbecomeanentryformicrobialcontamination.Acleanscrubsuit,a
capcoveringallhair,includingfacialhair,andahighfiltrationmaskarerequiredbyallpersonnelpriortoperforming
thescrubprocedure.Boththeiodophorsandchlorhexidinegluconatearecommonagentsusedforthesurgicalscrub
procedure.Theyarepreparedincombinationwithdetergenttogiveacleaningactionalongwiththeantibacterial
action.
Accordingtothelatestinformation,a5minutesurgicalscrubofthehandsandforearmsisadequateforremoval
ofgrossdirtandoilsfromtheskin,aslongasmechanicalfrictioncombinedwithanantimicrobialagentarepresent.
We,therefore,practiceastandard5minutescrub.
Theregiontobescrubbedextendsfromthefingertipsto2inchesfromtheelbows.Thearms,bentatthe
elbows,mustremainverticalwiththehandsalwaysbeingabovetheelbows.Thispreventscontaminatedwater
fromtheregionoftheelbowsandupperarmsfromflowingdownoverthescrubbedregion.Beforescrubbing,all
jewelry,watches,etc.,mustberemoved.Itisbestiffingernailsareclippedshort,andtheyshouldextendnofarther
thanthetipofthefinger.Itisagoodideatowashoneshandsuptotheelbowwithsoapandwaterbefore
beginning.
Openascrubpack,removethesponge/brushandnailcleanerbutdonotseteitherdown.Whilecleaningunder
thenails,letthewaterrunoventhehandsanddown,drippingofftheelbows.Itisbesttopositiononeselfsoasnot
togetonesscrubswet.Oncethenailsareclean,discardthecleaningspearandworkupalatheronthespongeby
squeezingitseveraltimes.Then,startingwiththepalmofonehand,beginninglatheringtheregiontobescrubbed.
Thehandcanbedividedinto4surfaces,ascaneachofthefingers,andthearms.Eachisconsideredtohaveatop,
bottom,andtwosides.Eachsurfaceofallthreeregionsneedstoreceiveanequalamountofattention,about510
strokesofthesponge.Thelatheringshouldproceedfromfingerstoelbowofonearm,andthenfromfingersto
elbowoftheother.Thespongeisthenflippedover,andthebrushisusedfromthispointon.
Thebrushisplacedinthestartinghand,andeachofthesurfacesofthefirsthandarescrubbedagain,spending
thesameamountoneachasmentionedabove.Thistime,however,scrubbingproceedsonlyuntil5cmbelow,the
wrist.Atthispointthebrushexchangeshands,andtheoppositehandisscrubbedfromfingertipsto5cmbelow
thewrist.Thenthebrushischangedbackandthefirstarmisscrubbedfrombelowthewristtotheelbow.The
brushagainchangeshandsandthesecondarmisscrubbedfromwristtoelbow.Thebrushisthendiscarded.While
stillholdingthehandsuprightabovetheelbows,thehandsarerinsedsuchthatthewaterflowsfromfingertips
downtheforearmanddripsofftheelbow.Ifatanypointatstartingthescrubprocedurethescrubbedregioncomes
intocontactwithanythingnonsterile,theentireproceduremustberedone.Oncescrubbed,thescrubpersonmust
gownandglovethemselves.
Gowning
Thegownmustalreadybeopenonasterilefield.Thescrubbedpersonapproachesthesterilefieldandmustnow
becarefulnottotouchanythingunsterileandnottodriponanything.Thetowelispickedbyanexposedcorner(or
handedtoanonsterilepersonbyasterileperson)andopenedbygentleshakinginanareaoftheroomwherethere
isnodangerofcontamination.Thehandsaredried,oneatatime,byusingonehalfofthetoweltopatonehand

15
dryfromfingerstoelbow.Donotrubthetowelaroundor upanddownthearm.Dryaroundandbetweenthe
fingersfirst,thenproceeddownthearmtotheelbow,pattingonly,anddonotmovebackupthearm.Afterone
armisdry,useittograbtheotherhalfofthetowelinasterileregion.Flipthetoweloversotheusedportionison
thebottom,andrepeatthedryingprocedureontheotherarmusingasterilepartofthetowel.Thendiscardthe
towelintoawastebinorontothefloor.Ifoneisbeingassistedduringgowning,thegownwillbeheldupsothat
onesarmscanbesliddirectlyintothesleeves.Thepersonassistingmustbecertaintokeeptheirhandsonthe
sterilefrontofthegownatalltimesandprotectthemselvesfromcontamination.Thenecksnapwillalwaysbe
fastenedbyanonsterilememberoftheteam.If,however,oneisgowningthemselveswithoutassistance,the
followingmustbedone.
Identifythesleeveopeningsofthegown,placeyourhandsintheopenings,pickupthegownwithoutlettingit
unfold,andbackawayfromthesterilefieldintoaclearareaoftheroom.Holdthegownup,withyourhandsinthe
sleeveopenings,andallowittounfoldwhileslippingyourarmsintothesleeves.Donotgoallthewaytotheendof
thesleevesastheouteraspectofthesleeveendsmustremainsteriletomanipulatetheglovesandtieoff.The
circulatorshouldnowsnapthenecksnapandtiethesecondarytieinthebackofthegown.Withthehandsstillin
thesleeves,offeroneendoftheprimarytie(theendwiththecard)tothecirculatorwhileholdingontotheother
endofthetie.Spinaroundandpulltheendofthetie(whichisinthecardheldbythecirculator)freefromthecard
andtiethegownclosed.Alwaysbeawareofyoursurroundingstoavoidcontamination.
Theparametersofsterilityforthegownhavebeenestablished:(1)Thegownisconsideredsterileinfrontfrom
chesttothelevelofthesterilefield.(2)Thesleevesareconsideredsterilefrom2inchesabovetheelbowtothe
stockinettecuff,andthereforethecuffmustbecovered,atalltimes,bysterilegloves.Theareasnotconsidered
sterile,forvariousmonitoringreasons,includetheneckline,shoulders,areasunderthearms,andthebackofthe
gown.Topreservethesterilityoftheglovedhands,theyshouldbekeptwithinthesterileboundaryofthegown,
andsincetheaxillaryregionisnotsterile,thearmsshouldneverbecrossedwithhandspositionedintotheaxilla.
Shouldeitherofthesebarriersbecompromised,theymustbediscarded,andanewgown,glovesorbothapplied,
dependingonthenatureofthebreakintechnique.
Gloving
Sterileglovescanbeappliedusingoneoftwomethods:theopenmethodortheclosedmethod.Theclosedglove
methodshouldbeusedanytimethepersonisinitiallyapplyingsterilegownandgloves,whiletheopenglove
methodshouldbeusedwhenchangingagloveduringaprocedure(selforteammember),orwhenasterilescrubor
gownisnotrequired(asepticprocedures).Thescrubpersonmustperformunassistedgowningandgloving,while
therestofthesterileteammemberswillbeassistedbythescrubperson(assistedgowningandgloving).
Whenglovingoneselfusingtheclosedglovemethod,theproceduregoesasfollows.Withyourhandsstillinthe
sleevesofthegown,opentheglovepackagecompletely.Thefingersoftheglovesshouldbepointingtowardyou.
Youwillgloveyourpreferredhandfirst.Reachacrossthefieldwithyourpreferredhandtotheappropriateglove,
andslipyourthumbunderthecuffwithyourfingersextendedtowardtheopening(awayfromthefingersofthe
glove).Pickuptheglove,andgrabbingtheoppositesideofthecuffwiththeotherhand,slipyourfingersintothe
openingwhilepullingthegloveontoyourhandwiththeoppositehand.Alwaystouchingthesurfaceoftheglove
throughthegown(notthestockinetcuff,asitisconsideredunsterile),pullthegloveontoyourhand,maneuvering
yourfingersandthumbappropriately.Itisbesttotouchthedistalregionsofthegloveaslittleaspossible.The
gowncanbepulledoutfromunderthegloveinordertohelpgetiton,however,thestockinetshouldnotbe
exposed.Oncethefirsthandisgloved,thesecondglovecanbepickedupbyslippingthefingersoftheglovedhand
underthecuffedregionoftheotherglove.Thefingersofthesecondhandarenowexposedfromthegownsleeve
andslippedintothegloveopening,beingcarefulnottotouchanyexternalsterilesurface(inparticularthehand
doingthegloving).Nowtheglovecansimplebepulledonandoverthestockinetcuffofthegownsleeve.
Whenglovinganothermemberoftheteam,thesterileinternalpackagecontainingtheglovesisofferedtothe
sterilememberoftheteamwhowilldotheglovingoristransferred,maintainingsterility,ontothesterilefield
whereitcanbeaccessedbyasterilememberoftheteam.Thepackageisopened,andagloveisremoved.The
gloveisheldbythecuffwiththefingersofthesterilepersonunderthefold.Thegloveisheldwiththefingers

16
danglingdownward,andthecuffisstretchedopen allowingthenonsterilememberoftheteamtoreach
intotheglovewithoutdangeroftouchingthefingersofthesterilemember.Thegloveispulledupoverthe
stockinetteofthegownandthenreleased.Theprocedureisrepeatedfortheotherhand.
SurgicalTools
InstrumentMetals
Today,allqualitysurgicalinstrumentsarefabricatedfrommedicallygratedstainlesssteel.Ofthestandardstainless
steelsproduced,onlyafewareusedinhospitals.Ofthese,the300and400seriesstainlesssteelsaremostoften
selectedforsurgicalinstrumentproduction.
Stainlesssteelsconsistprimarilyofiron,chromium,andcarbon,withotherelementssuchasnickelcombinedin
differentproportionstoachievedesiredproperties.Thehighercarbon,lowerchromium400series(martensitic)
stainlesssteelsprovidegreaterhardnessthroughheattreatment.Thisimpartswearresistancewhichisespecially
importantforcuttingsurgicalinstruments;theymustmaintainfineedgesandexhibitingthestrengthanddurability
ofstainlesssteel.Thehardmartensiticstainlesssteelsareusedmostcommonlyinthemanufactureofsurgical
instruments.
Theaustenitic,or300series,stainlesssteelsarenothardenablebyheattreatmentbutareoccasionallyusedfor
surgicalinstrumentmanufacture.Thelackofhardnessexhibitedbythesealloysisoffsetsomewhatbytheirhigher
resistancetocorrosion.Austeniticsteelsareofgreatestvaluewhensomedegreeofmalleabilityinaninstrumentis
desired.
Afewsurgicalinstrumentsaremadeprimarilyoftitaniumalloys.Theyareusedmostcommonlyinmicrosurgical
instruments.Theyaresaidtohaveexcellentcorrosionresistance(comparabletothatofstainlesssteels)andhigh
temperaturestrength(comparabletothatofausteniticstainlesssteel).Theinternalstructuremakesthesealloys
somewhatbrittle,andthiscanpresentmanufacturingproblems.Itsgreatestusemaybeasasubstituteforstainless
steelswhenweightsavingisimportant.
Tungstencarbideinsertsaddanewdimensiontogrippingandcuttingsurfaces.Thesesubstancesareveryhard
andveryresistanttowear.Theinsertsareattachedtothestainlesssteelinstrumentsbyvariousmeansandcanbe
removedandreplacedbythemanufacturer.
ResistanceToCorrosion
Producingasurgicalinstrumentthatisresistanttostainingandcorrosionbeginswithselectingthepropersteel.A
smoothsurfaceisdesiredandisachievedbybuffingandpolishing.Threetypesofinstrumentfinishesarepresently
available.Thehighlypolishedfinishseemsmostresistanttospottinganddiscoloration;however,itreflectslight
easilyandcancausemildeyeirritation.Morerecentlyadullorsatinfinishhasbecomepopular;itsgreatest
advantageisreducedeyestrain.Thedullfinishesareappliedbysiliconeorglassbeadsandblastingorbyfine
abrasionusingvarioustypesofpolishingwheels.Thethirdtypeoffinish,a(black)ebonizingfinish,isachievedby
coatingtheinstrumentinachemicalbath.
Thefinalprocessinstrumentsgothroughtobecomecorrosionresistantispassivation.Thisprocess(nitricacid
bath)removesanyforeignparticles(iron)imbeddedontheinstrumentsurface.Additionally,athinlayerof
chromiumoxidesformsonthestainlesssteelsurface,providingmorecorrosionresistance.Asubsequentpolishingis
usuallyneededtoproduceaverysmoothsurface,removinganyroughsiteswherecorrosioncouldbegin.
Onceaninstrumentisuseditcanfurtherpassivateitself.Exposureofaninstrumenttotheatmosphereorto
certainoxidizingagentsduringitshandlingandusecancontinuethisoxidationprocess,buildingandmaintainingthe
continuityofthechromiumoxidelayer.Certaincleaningandhandlingprocessescandamagethisprotectivelayer
andshouldbeavoided.Abrasivecleanersandinstrumentmarkingwithvibratingetchingequipmentcandisturbthe
oxidelayer,promotingthedevelopmentofcorrosion.Oncethechromiumoxidelayerisalteredandcorrosion
begins,repassivationandrepolishingbythemanufacturerbecomenecessary.

17
InstrumentCleaning
Instrumentcleaningandhandlingtechniqueisextremelyimportantforeitherhospitalsorlaboratories,asitsaves
enormoussumsofmoneyinyearlyinstrumentreplacement.Proprietorsofhospitalsandlaboratorytechniciansare
usuallyawarethatsurgicalinstrumentsareexpensive,delicate,andmustbehandledcorrectlyintheoperatingroom
toensurelongevity.Asometimesforgottenfact,however,isthatinappropriatecleaningandsterilizinghavea
significantimpactoninstrumentlife.Mostinstrumentmanufacturersprovidedetailedinformationonthecleaning
andhandlingoftheirproduct.Theirrecommendationsshouldbefollowed.Herewegiveabriefdescriptionofthe
techniquesthatwillbeusedinourlaboratory.
ManualCleaning
Grossvisibledebrisshouldberemovedfromtheinstrumentsimmediatelyaftertheiruse.Salinesolutionisvery
corrosivetostainlesssteel;consequently,distilledordeionizedwatershouldbeusedfortheinitialremovalof
debris.Subsequentinstrumentcleaningwillthenbeeasier,asbloodandtissuedebrisdonothaveachancetodryin
serrationsandboxlocks.Iffurtherprocessingisnotimmediatelypossible,instrumentsshouldbesubmergedin
warmdeionizedwaterthatcontainsamildnoncorrosive,lowsudsing,neutraldetergent.Adequatesoakingtime
allowsthedetergenttolooseninaccessiblesoilfilms.Prolongedsoakingmustbediscouraged,however,asdetergent
actionontheinstrumentsurfacemaycausedamage.
Thefinalcleaningprocessshouldbeconductedwithcare.Eachinstrumentiscarefullyscrubbed,includingthe
boxlocks,ratchets,serrations,andotherareasnoteasilyexposed.Ahandbrushwithstiffplasticbristlesis
appropriateforcleaning.Abrasivetoolsorcleanersshouldbeavoided,however,asrepeatedcleaningscandamage
theinstrumentssurfaceandpromotecorrosion.Amoderatelyalkaline(pH<8),lowsudsingdetergentismost
satisfactory.Ordinarysoapshouldnotbeused,especiallywithhardwater,asinsolublealkaliearthfilmscanformon
theinstruments,protectingtrappedbacteriafromsterilization.
Thefinalrinseshouldbecarriedoutthoroughlywithdistilledordeionizedwater.IthasapHof6.7to7.2and
leavesaneutralsurfacepHasthealkalinewashwaterresidueisrinsedaway.Alkalineearthdeposits(calcium,
magnesium,phosphate)andmetals(iron,copper,cadmium)willnotdepositthemselvesonthesurfacetopromote
corrosion.Distilledwateralsocontainsnodissolvedorundissolvedsolidstoadheretotheinstrumentsurface.
Theinstrumentmustbedriedcompletely,especiallyifitistobestoredforaperiodoftimepriortosterilization.
Theheatofhotrinsewatermayaidthedryingprocess.Inadequatedryingwillresultinrustingduringstorage.
WasherSterilizer
Institutionsthatprocesslargevolumesofsurgicalinstrumentshaveadoptedmechanicalmethodsforroutine
cleaning.Thewashingprocessisaccomplishedinaninstrumentwashersterilizerbymeansofavigorouslyagitated
detergentbath,theresultofacombinationofhighvelocityjetstreamsofsteamandair,whichproducesviolent
underwaterturbulence.Themachinehaspresoak,wash,andsterilizecycles,afterwhichtheinstrumentsmaybe
removedandimmediatelyusedorstoredforfutureuse.Manyfactorsinfluencetheeffectivenessofsoilremoval
fromsurgicalinstrumentscleanedinawashersterilizer,includingthekindofsoil,qualityofwater,typeof
detergent,concentrationofdetergent,typesofinstrumentstobecleaned,timethedetergentsolutionispermitted
toact,andefficiencyofthewashersterilize
Blood,tissuefats,andotherorganicmatterarecommontypesofsoilencounteredonsurgicalinstruments.
Bettercleaninginthewashersterilizerisachievedwhensoilisnotallowedtodryontheinstrumentsandprocessing
occursshortlyafteruse.
Waterplaysamajorroleincleaningandaloneaccountsformuchofthesolventactionthatoccursduring
instrumentcleaning.Thequalityoftapwaterinmanyareasispoor,andcarefulconsiderationshouldbegivento
matchingwaterqualitywiththeappropriatedetergent.Softened,demineralized,ordistilledwatershouldbe
consideredtoeliminatethedepositionofhardwatersaltsoninstruments.

18
Agood,lowsudsing,neutraltoslightlyalkaline detergentisstronglyrecommended.Accordingto
Perkins,someofthecommonphosphatedetergentsrecommendedformechanicaldishwashersareineffectivein
washersterilizers.Cleaningoftheinstrumentsisnotadequate,andthepolyphosphateddetergentshavea
solubilizingeffectoninternalcopperinthewashersterilizer.Theresultisabrassymetallicstainingofthe
instrumentsduetocopperdepositionbyelectrolyticaction.
Thetypeofsurgicalinstrument,itsconfiguration,anditsconditionplayamajorroleincleaningeffectiveness.It
hasbeendemonstratedquantitativelythatsoilretentionisgreatestwithinstrumentswithapoorgeometric
configurationandthosewhoseserratedtipsshowedvisiblecorrosion.Theyshowedthatcorrodedserrationsand
cavitiesnearthehingesofwornjointswereparticularlyeffectiveinretainingsoilandthatthereisaclearcorrelation
betweensoilretentionandthemicroscopicstateoftheinstrumentsurface.
Finally,thewashersterilizeraffordsadegreeofprotectiontothosewhocleansurgicalinstruments.Manual
cleaningcontributestothedisseminationofmicroorganismsbyaerosolsanddropletsduringthecleaningprocess,
whereasautomatedmechanicalcleaningcontrolsthisproblem.
UltrasonicCleaner
Ultrasoniccleanerscanremoveupto90percentofinstrumentsoilinfiveminutesandfarsurpassmanualcleaning
procedures.Thisisdemonstratedbytheeffectiveremovalofsoilfromareasthatareinaccessibletobrushingsuchas
boxlocks,deepgrooves,serrations,andevencracksintheinstrument.Ultrasoniccleanersdonotsterilize.
Ultrasonicinstrumentcleanersproducesinusoidalenergywavesateitheroftwofrequencies.Ifmetallic
transducersareused,thefrequencyofvibrationsis600persecond.Ifcrystaltransducersareused,thefrequencyof
vibrationsis38,000persecond.Thelatterunitisbelievedtobethemoreefficient.
Theeffectivenessofultrasoniccleaningisbasedonaprocesscalledcavitation.Ultrasonicenergyformsminute
bubblesfromgasnucleiwithinthecleaningsolution.Theseminutebubblesformoneverysurfaceofsoiled
instruments.Thesizeofthegasnucleiandsubsequentbubblesformeddependsonthesurfacetensionoftheliquid,
temperatureofthesolution,wettingactionofthedetergent,andthefrequencyoftheultrasonicenergyused.These
bubblescontinuetoexpanduntiltheirsurfacebecomesunstable.Theythencollapsebyimplosion(burstinginward).
Thebubblesimplodeasfastastheyform,creatingsmallvacuumareas.Thisprocessreleasesenergythatbreaksthe
bondsthatholdsoiltoinstrumentsurfaces.Thesoilandbindingmaterialaredislodgedordissolvedintothe
solution.
Theeffectivenessofanultrasoniccleanercanbealteredbymanyvariables,includingtemperature,gascontentof
thesolution,andthedetergentused.Thetemperatureofthebathsolutionshouldbekeptbelow60Ctoprevent
proteincoagulation.Coagulatedproteintendstoabsorbultrasonicvibrations,whichreducestheenergyavailablefor
bondbreakingandmakesthesoilmoredifficulttoremove.Bathsolutionscontainingtoomuchdissolvedgaslose
cleaningeffectivenessbecausethegasfillsthecavitationbubbles.Thiscushionstheshockduetoimplosionand
reducestheenergyreleased.Watercanbedeaeratedbyrunningtheultrasoniccleanerforfiveminutesbeforeuse
orlettingthewaterstandovernight.Detergentspecificallyformulatedforultrasoniccleanersshouldbeused
becausetheydecreaseaerationproblems.Inaddition,thedetergentischosenforitscleaningabilitiesandits
chemicaleffectsontheinstrumentsbeingcleaned.Highlyalkalineorhighlyaciddetergentshouldnotbeused,as
theycaninducecorrosionorcracking,whichcanleadtoearlyinstrumentfailure.Thedetergentshouldhavea
neutralpH,containawettingagent,andbelowsudsingandfreerinsing.Finally,theproperconcentrationofcleaner
shouldbeemployed,sincetheheatoftheultrasoniccleanerincreasesthestrengthofthecleaner.Iftoomuch
detergentorheatisemployed,thecleaningsolutioncanbecomeverycaustic.Thisleadstoremovalofthe
chromiumoxidelayer,whichissoimportantincorrosionresistance.Theimpassivatedinstrumentisthensusceptible
torustingandbreakage.
Instrumentsremovedfromanultrasoniccleanermustberinsedthoroughly.Thecleanereffectivelyremovesthe
soilintosolutionorsuspension,andwhentheinstrumentsareremovedtheybecomecoveredwiththisfinely
dispersedsoil.Thissoil,althoughnotalwaysvisibletotheeye,mustberinsedaway.Rinsingalsoremovesresidual

19
detergentthatmaybepresent.Dissimilarmetalsshould notbeprocessedtogetherinanultrasoniccleaner.
Stainlesssteelshouldnotbemixedwithbrass,copper,oraluminum,otherwiseelectrolyticetchingandredeposition
mayoccur.Chromeplatedinstrumentsthatshowpittingorflakingcanbefurtherdamagedinanultrasoniccleaner.
InstrumentLubrication
Surgicalinstrumentswithboxlocksoftenbecomestiffwithrepeateduse,especiallyifcleanedinadequately.Dried
blood,alkalinedeposits,anddebriscanbuildupinboxlocksandserrations.Autoclavingbakesthismaterialonthe
instrument,furtherretardingmovement.Cleaningprocedures,whenemployedproperly,helptopreventthis
problem.
Instrumentlubricationiscommonlypracticedbutcanpresentproblemsifnotproperlyperformed.Mineraloil,
machineoils,grease,andsomesiliconesmustbeavoided,astheyleaveanoilyfilmontheinstrumentsurface.This
canpreventadequatesteamcontactwithorganisms,andsporescanbecometrappedintheoilfilmduringsteam
sterilization.Continuoususeofthesematerialscanalsoleaveundesirableresiduesontheinstrumentsthatbecome
gumlikeandretardboxlockmovement.
Instrumentmanufacturersrecommendtheroutinelubricationofinstrumentswithantimicrobialwatersoluble
lubricants(instrumentmilk).Theselubricantsarewateroilemulsionpreparationsthatdonotinterferewithsteam
sterilization.Manyalsocontainantimicrobialmaterialsinhibitingorganismgrowthinbathpreparations.Rust
inhibitingagentsprovideanadditionalmeasureofprotectionbyretardingelectrolysisandpreventingmineral
depositiononinstrumentsurfaces.
Mechanicalinstrumentprocessingespeciallywithultrasoniccleaners,removesalltracesoflubricant.Lubrication
shouldthereforebecarriedoutaftercleaning.Thelubricantbathshouldbepreparedwithdeionizedordistilled
wateratthemanufacturersrecommendedconcentration.Instrumentsshouldbedippedinthebathfor30seconds
withboxlocksopen.Afterremovalfromthebath,thelubricantsolutionshouldbeallowedtodrainawaywithout
rinsingormanualdrying.Thelubricantremainsontheinstrumentduringsteamsterilizationandstorage.Thisgives
addedprotectionagainstrusting,staining,andcorrosion.
InstrumentPackaging
Properinstrumentpackagingandstorageareimportantconsiderationsforveterinaryinstitutionsandsmallclinics.
Universallyacceptedstandardsforinstrumentpackaginghavenotbeenestablished.Problemsarecompoundedby
manufacturerswhoarecontinuallydevelopingnewandoftenbetterpackagingproducts.Packagingmaterialsused
frequentlytodayareclassifiedastextiles(linenandmuslin),nonwovenfabric,paper,plastic,andpaperandplastic
combinations.
Textiles
Linenormuslinwrappersaremostcommonlyusedforinstrumentsetpackaging.Standard,doublethickness,140
threadcountlinenisflexible,easytouse,memoryfree,andlonglasting.Theweaveofonethicknessis
perpendiculartotheother,andthewrapissewnattheedgesonly.Linenpacksareeasilycontaminatedbycontact
withmoisture,andthecontaminationbecomesundetectableafterthemoisturedries.Laundryproceduresmustbe
carefullymonitored.Ifharshdetergentsnotadequatelyrinsedfromthefabriccomeincontactwithstainlesssteel
instruments,stainingandcorrosioncanbeinduced.
Thenecessityofdoublewrappingsurgicalpackswithtwolayerlinenhasbeenrepeatedlydemonstrated.
Photographsofasinglethicknessstandardmuslinat40Xmagnificationdemonstrateasmallopeningatalmost
everythreadjunction.Singlewrappingwithtwolayerlinencanallowmicrobialpenetrationofthepackwithinthree
days.Doublewrappingwithtwolayerlinenincreasessafestoragetimetothreetofourweeks.Longerstoragetime
maybeobtainedbyusingoutside(dustcover)wrapsofwaterrepellentpaperdrapefabricsorsterile3mlplastic
bags.

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Openshelfstorageofsterilepackshasbeenshownto allowuptotentimesmoreviablemicrobial
contaminationoftheoutsideofthepackthanclosedshelforcabinetsstorage,thusreducingsafestoragetime.
Otherfactorsalsohavebeenincriminatedinsurgicalpackcontamination.Unnecessaryhandlingandvibration
shouldbeminimizedalongwithrapidlychangingatmosphericconditions.
Finally,doublewrappingofsterilepackagesprovidesamarginofsafetyduringpackageopening.Microbiological
contaminationthathassettledonapackageisthrownintothesurroundingairduringopeningmaking
contaminationofcontentsverylikely.Asecondwrapgreatlyreducesthisrisk.
Considerationcanbegiventotheuseof288threadcountlinen.Thismaterialhastwicethethreadperinchas
thestandard140threadcountgeneraluselinen.Asinglethicknessofthismaterialcanreplacethestandarddouble
layerwrappers.Thiswrapisagoodmoistureretardantandisanimprovedbarriertomicrobiologicalandliquid
penetrationover140threadcountlinen.Goodpenetrationofsterilantsisallowed,althoughasageneralrulethe
higherthethreadcountthelesspenetrationbysteam.Themajordisadvantageofthismoistureretardantlinenisits
highercost.
NonwovenFabrics
Nonwovenwrapsareaproductofdisposablesurgicaldrapeprogramsandoffersomeadvantagesovergeneraluse
linen,includingreducedlaborandlaundrycosts.Nonwovenwrapsarewaterresistant,strongandtearresistant.
Sterilantssuchasethyleneoxideandsteampenetratereadilyanddonotchangethehandlingcharacteristicsor
qualityofthematerialforuseasawrapperordrape.Althoughproductqualityexcellent,nonwovenfabricsshould
beusedasdisposableitems.Repeatedsterilizationcanresultinbreakageoffibers,especiallyalongfoldsinthe
material,whichcouldresultinpackcontamination.
Nonwovenfabricsareavailableinlight,medium,orheavyweight.Thelightweightmaterialdoesnotwithstand
handlingwellandisnotrecommendedforoperatingroompackaging.Themediumweightwrappermaterialisbest
suitedforsterilepackagingwraps.
PaperWraps
Paperwrapshavecomeintowideuseasreplacementforlinen.Severaldisadvantagesarerecognized,however.Like
linen,paperhasgoodwickactionandcanabsorbmoistureanddryquickly,makingitdifficulttodetecta
contaminatedpack.Also,paperhasmemoryandwillnotopenflatly.Thepaperflipsbackalongfoldlines,often
resultingincontaminationduringopening.Paperwrapsshouldnotbereused,asminutecracksinthepaperfabric
aredifficulttodetectandcaneasilycompromisesterility.Personnelshouldbeawareofthesesourcesof
contaminationwhenusingpaperdrapes.
PlasticWraps
Plasticwrapsusuallycomeinpouchespresealedbythemanufacturerontwoorthreesides.Theirgreatestuseisin
individualarticlepackaging.Polyethylene,polypropylene,andpolyvinylchloridepouchesareproducedonlyfor
ethyleneoxidesterilization,astheymaybeheatsensitiveandimpermeabletosteam.Detailedopeninginstructions
arenecessary,assterileremovalofitemsfromthesepouchesisdifficult.Plasticwrapscanalsobeusedasdust
coversonpreviouslysterilizedmuslinorpaperwrappedsurgicalpacksthatarestoredforvariableperiodsbefore
use.Anyplasticcoverusedforthispurposethathasaccumulateddustshouldberemovedbeforethesurgicalpackis
placedinsidethecleanzoneoftheoperatingroom.
PlasticandPaperWraps
Plasticandpapercombinationsareusedextensively.Theyofferseveraladvantages.Materialsareavailablethat
withstandsteamandethyleneoxidesterilization.Goodsteampenetrationandaerationisevidentthroughthepaper
backing,andthearticleisvisiblethroughtheplastic.Peelbackopeningforpresentationofsterileitemslessensthe
possibilityofcontamination.Sealingofthepouchcanbeaccomplishedbysterilizerindicatortapeorheat.

21
Datingandlabelingofthesepackageswithfelttip markersshouldhedoneontheplasticsideonly,as
punctureorinkbleedthroughthepaperispossible.Also,sterileindicatortapeshouldbeplacedontheplasticside,
asthesterilizeindicatingdeviceincorporatedintothepaperisoftenoverlookedduringopening.
NeurosurgeryInstruments
SurgicalKnifeHandles
Surgicalknifehandles(FigureIV1)withdetachablebladesaremostpopular.TheBardParker#3mediumhandleis
availablewithvariousscalpelbladeattachments(#10,11,12,15).Thishandleseemstobethemostapplicablefor
smallanimalsurgery.The#3handleisalsoavailableinalongerform.Finehandles#7and#9receivethesame
blades.The#4BardParkerhandleislargerandusesdetachableblades#20,21,22.Thishandleandblade
combinationismoreappropriateforlargeanimalsurgery.
Scissors
Manytypesofsurgicalscissorsareavailableformanydifferentuses(FigureIV2).Thosemostapplicableforgeneral
surgicaluseinveterinarysurgeryaretheMayoandtheMetzenbaum.Eachsurgerypackshouldhaveascissors
designatedasasuturescissors.Repeatedcuttingofsuturematerialwithdelicatetissuescissors,suchasthe
Metzenbaum,leadstodullingand/ormisalignmentofblades.Ashort(5inches)straightMayodissectingscissors
withouttungstencarbideinsertscanfunctionwell.Itisdurableandwilllastalongtime.Specialwirecuttingscissors
shouldbeemployedfororthopedicwirecutting.Tissuedissecting(bluntandsharp)requiresahighqualitytissue
scissors.
ThecurvedMayodissectingscissorswithorwithouttungstencarbideinsertsisexcellentforconnectivetissue
dissectionandseparationoftougherfacialplains.TheMetzenbaumtissuedissectingscissorsismoredelicateand
shouldbereservedforlessstrenuousdissectingandcutting.ItwouldseeminappropriatetouseafineMetzenbaum
toopenthelineaalba.Fine,delicatecutting,asrequiredinholloworgansurgeryorcontrolleddelicatedissecting,
wouldbemoreapplicabletoMetzenbaums.Tungstencarbideinsertsandgoldcoloredhandlesdesignatethefinest
qualitysurgicalscissors.
Retractors
Manytypesofsofttissueretractorsareavailable(FigureIV3).Amostusefulclassificationwoulddistinguish
betweenhandheldandselfretainingretractors.Thegreatestdisadvantageofhandheldretractorsistheneedfor
anassistanttomanuallyretractthetissue.Thisinconvenienceissignificantinveterinarysurgicalprocedures,where
extrasurgicalassistantsareoftennotavailable.
Selfretainingretractorsoffertheadvantageofmaintainingtissueseparationonceplacedwithoutadditional
assistants.TheFinochiettoribretractorforthoracicsurgeryandtheBalfourretractorforabdomina1surgeryare
sturdyandveryeffective.Theseselfretainingretractorsarenecessitiesifadequateexposuretothoracicand
abdominalvisceraistoheachievedandmaintained.TheGelpiandWeitlanerretractorsaretwosmallerself
retainingretractorsthatofferversatilityintissueseparationandexposureduringsurgicalprocedures.
Forceps
HalstedMosquitoHemostaticForceps
Mosquitoforcepsareavailablein3%and5inchlengthsinbothcurvedandstraightconfigurations.These
instrumentsareverydelicateandshouldbeusedonlyforthecontrolofpointbleeders.Stumporpedicleligations,
whereadditionaltissueisoftenincludedintheligature,shouldbeavoided,asdamagetotheinstrumentcanresult.
Mosquitoforcepshavebeenrecentlyintroducedwithrattooth(1X2)teethlocatedattheverytipofthegripping
blades.Thismodificationpreventstheinstrumentfromslippingfromthetissueitisholding.Iftheinstrumentsarein
goodworkingorderandareusedfortheirintendedpurpose,thisadditionmaybeunnecessary.

KellyorCrileHemostaticForceps
22
Thesetwoforcepsareverysimilarindesignanduse.Theonlydifferenceisintheextentofthetransversegrooves
ontheirgrippingsurfaces.TheKellyforcepshasonlythedistalhalfofitstipsgrooved.Theintendeduseofthese
hemostaticforcepsissimilartothatofthemosquitoforceps.However,theyarelarger(5,5inches)andmuch
sturdiersothattheycanwithstandmoreaggressiveuse.
RochesterCarmalfHemostaticForceps
TheRochesterCarmalthemostaticforcepsisprimarilyusedinveterinarysurgeryinstumporpedicleligations.Itis
sturdyandthegroovesonthegrippingbladesrunlongitudinally(withafewcrossgroovesatthetip),allowingfor
easyremovalduringligation.WhenaCarmaltclampisplacedonapedicleoftissueforcrushingpriortoligation,the
tissueisforcedoutwardintheclampandis,ineffect,spread.Whenligationoccurs,theclampmustbeloosened
beforetheligatureissecuredorthetissuecannotbedrawntogethertocollapsethevesselbeingligated.Onemust
alsokeepthisspreadingeffectinmindwhenligatingclosetoasecondCarmaltclampthathasbeenplaced.This
spreadingeffectontissuebytheclampcanresultinlooseligatures.
TissueForceps
Tissueforcepsofvarioussizes,shapes,andusesareavailable.Severalhavefoundextensiveuseasgeneralsurgical
tissueforcepsinsmallanimalsurgery.
AllisTissueForceps
Allistissueforceps(Fig.IV5,bottom)areverypopularinveterinarysurgery.Theplaneofgripisperpendiculartothe
directionofpull.ThetipoftheAllisforcepshasintermeshingteeththatprovideasecuregripontissue.TheAllisis
saidtobeatraumatictotissue;however,thisfeatureseemstobecommonlyabused.TheAllisshouldbeusedtogrip
connectivetissueandfacialplanesonly.Itshouldneverbeusedtograsptheskinortogripholloworganssuchas
thestomach.Thecrushingeffectofthisgripistootraumatizingforthesedelicatetissues.
BabcockTissueForceps
TheBabcockforcepsissimilarindesigntotheAllisexceptthattherearenogrippingteeth.Itsuseswouldbesimilar
tothoseoftheAllis.TheBabcockhasreceivedsomeuseinholloworgansurgery;however,itsgripmaybe
excessivelytraumatizing.Themoreappropriateuseofstaysuturestomanipulateholloworganswouldseem
prudent.
KocherOschnerTissueForceps
TheKocherOschnertissueforceps(Fig.IV5)isverysturdyandcanwithstandaggressiveuse.The2x1rattoothtip
allowssecuregrippingoftissue.Thisinstrumenthasverylimitedsofttissueuse;however,orthopedicsurgeonsfind
theinstrumenthelpfulinmanipulatingbonefragmentsinfracturerepair.
AlligatorTissueForceps
Thisspecialinstrumentisverydelicatebutprovidesaneededcapability.Thelongshaftandpivotpointnearthetip
oritsjawsallowintroductionandgraspingthroughasmallnarrowopening.Removalofforeignbodiesfromear
canalsanddiscmaterialduringthoracolumbarfenestrationsareappropriateapplications.
RightAngleTissueForceps
Therightangletissueforceps(Laheygallductforcepshaslongitudinalgroovesonitsgrippingsurface.Itisvery
suitablefordelicatedissection,especiallyinhardtovisualizeareas.Theinstrumentisexcellentfordissectingbehind
apatentductusarteriosusandisusedextensivelyinotherthoracicsurgeries.

AdsonTissueForceps
23
TheAdson(delicate)(Fig.IV6)isprobablythemostcommontissueforcepsinuse.The2x1rattoothtipsaresmall
andprovidegoodtissuegripwithminimalpressureontheblades.Itismostapplicablewhensuturingskinandfacial
planes.Althoughitisrelativelyatraumaticwhenusedproperly,bettertissueforcepsareavailableforholloworgan
surgery.
BrownAdsonTissueForceps
TheBrownAdson(Fig.IV6)alsohasextensiveuse.ItissimilartotheAdsonexceptforitstip.Multipleintermeshing
fineteethprovideabroadtipforsecuregripping.Whensuturing,thisfeaturemakesgrippingofaneedlebeing
pulledthroughtissueeasierthanwiththeAdson.TheBrownAdsonisrelativelyatraumaticifusedproperlyi.e.,on
skinandfacialplanesonly.
DeBakeyTissueForceps
Everysurgerypackshouldhaveadelicatethumbforcepsforatraumaticwork.TheDeBakeytissueforcepswas
initiallydevelopedforcardiovascularsurgery.Thetipsareslightlyribbedinalongitudinaldirection.Variouswidths(1
to2mm)onthetipandweights(delicatetoregular)areavailable.Thisinstrumentisexcellentforthoracicand
abdominalsurgery.Verydelicatehandlingofatissuebeingsuturedispossible.
TowelForceps
TheBackhaustowelforceps(Fig.IV7)isusedforsecuringsurgicaldrapestoskin.Itisalsousedtosecuresuction
lines,electrocauterycables,andpowerequipmentlinestodrapes.Twosizesarecommonlyseen,andthesmaller
(3%inches)ismoreappropriateforsmallanimalsurgery.Sometowelforceps(Roeder)haveametalbeadorball
stopontheirtipstopreventthedrapesfrommovingup.TheJonestowelforcepsmaybeusedinmoredelicate
applications.
NeedleHolders
ThemostcommonneedleholderusedinveterinarysurgeryistheMayoHegarneedleholder(FigureIV8).Various
lengths(5to12inches)areavailable.Thesmallerneedleholdersaremoredelicateandprobablyfindgreaterusein
smallanimalsurgery.Nosurgicalinstrumentreceivesgreaterabusethantheneedleholder.Itsuserequiresconstant
metaltometalcontact.Thesizeandweightoftheneedleholderselectedshouldmatchthoseoftheneedlebeing
used.Smallneedleholderscanbedamagedwhenusedtogriplargeneedles.Iftheratchetistightlyappliedthebox
lockorshankcanbedamaged.Smallneedlescanbedamagedorinadequatelygrippediflargeneedleholdersare
used.Thereisagreattendency,especiallyinorthopedicprocedurestousetheneedleholderinappropriately.Using
theneedleholdertotwistwireoraspliersleadstoearlyfailure.
Thebetterqualityneedleholderscaneasilyheidentifiedbythetungstencarbideinsertsoftheirgrippingjaws.
Theseinsertsgreatlycreasegripanddurability.Somemanufacturersalsoidentifytheirbetterqualityinstrumentsby
goldcoloredhandles.OlsenHegarneedleholdersareacombinationneedleholderandscissors.Theymayhavean
advantagefortheindividualwhoisdoingsurgeryalone.Thesuturematerialcanbecutafterplacementwithouta
suturescissors.Thedisadvantageofaccidentalcuttingofsuturematerialduringsuturingcanbetroublesome.
Tungstencarbideinsertsareavailablewiththeneedleholderportionoftheinstrument.
MaintenanceofNeurosurgeryInstruments
Periodicevaluationofinstrumentperformancemayindicatethatpreventivemaintenanceisneeded.Instrument
manufacturersstresstheeconomicsofpreventivemaintenanceprograms.Costsforrestorationsvarybutcanbeas
lowasonefifthreplacementcostsandonehalfrepaircosts.Apreventivemaintenanceprogramincludesevaluating,
refurbishing,adjusting,andrefinishingeachinstrument.Carbideinsertsarereplacedifwornorcracked,tipsof
instrumentsarerealigned,shanksandspringsareadjustedforpropertensionandconformation,ratchetsandjaws
areredefinedandreset,cuttingedgesaresharpened,andallmissingpartsarereplaced.Afterthiscomplete

24
refurbishingeachinstrumentisultrasonicallycleaned. Preventivemaintenanceprogramsforgoodquality
surgicalinstrumentsreducecostsandincreaseinstrumentlongevity.
OphthalmicSurgeryInstruments
EyelidSpecula
Eyelidspeculaaredesignedtoretracttheeyelidsandmaximizetheopeningofthepalpebralfissure.Theidealeyelid
speculumshouldbestrong,lightweight,andshouldnotcontributetodirectpressureontheglobe.Partofeach
bladeshouldextendovertheeyelidmarginalongthepalpebralconjunctivaforseveralmillimeterstoavoidthe
untimelydislodgmentofthespeculum.Thelargereyelidspeculausuallyhaveslightlycurvedarmstoconformtothe
palpebralfissure.Occasionallythecurvatureofthesespeculaisalteredslightlytoobtainthebestfitforthemonkey.
ThepediatricsizeBarraquerspeculummayisusuallyappropriateformonkeys.
TissueFixationForceps
Alargenumberofspecialtissueforcepshavebeendevelopedtominimizetraumatichandlingoftheoculartissues.
Theirhandlesareusuallyflatwithserrationorknurlingtofacilitategraspandareusually50100mmlong.These
instrumentsareheldlikeapenduringsurgery.Severaldifferenttipshavebeendevelopedforthesefixationforceps.
Thehandleorthetipsofmostfixationforcepsformicrosurgeryhavesomeangulationtopreventblockageofthe
surgeon'sviewduringuse.Forhandlingoftheeyelidsatleasttwodifferenttypesoftissuefixationforcepsare
useful.Whenhandlinglargeamountsoftissue,theGraefefixationforcepswith3.5or4.5mmjawswithfineteeth
areuseful.Whenmanipulatingsmallamountsofeyelidandconjunctivaltissue,oneofseveraltypesoffixation
forcepswitha1x2teethtipisrecommended.Thebulbarconjunctivaishandledwithfine,plainforcepswithout
teethtoavoidexcessivetraumaandtearing.Ifthetissueisslipperyorishandledatitsmargin,suchastheedgeofa
cornealwound,tissueforcepswithfineteeth(ColibriorBonntype)areindicated
Knives
ThemostfrequentlyusedknivesinophthalmicsurgeryofsmallanimalsaretheBardParkerandBeaverhandles.
TheBardParkerscalpelhandlewithNos.10and15bladesisusedprimarilyfororbitalandeyelidsurgery.The
smallerBeaverhandlewithNos.64,65andotherspecialpurposebladesisusedforeyelid,conjunctival,andcorneal
surgery.Bothtypesofhandlesarepositionedinthehandlikeapen,forbestresults.
OphthalmicScissors
Therearealargenumberofophthalmicscissorsavailable,andseveralhavebeendevelopedforspecialized
purposes.Nosinglepairofscissorscanperformadequatelyonthewiderangeofoculartissuesthatonecommonly
confronts.Forthemajorityofeyelidandconjunctivaldissections,theSteven'stenotomyscissorsarerecommended.
Thestandardsizeringhandlewithstraightorslightlycurvedblunttipsisthemostversatile.Theoveralllengthof
theringhandlesisabout100110mm,andthebladesareabout1820mmlong.Forcuttinganddissectionofthe
bulbarconjunctiva,curvedscissorsconformtotheglobe'scurvatureandarelesslikelytobuttonholethe
conjunctiva.Cuttingwiththesescissorsshouldbereservedforthedistaltipoftheblades.Theseconjunctival
scissorsarealsousedtocut40to120ophthalmicsutures.
OphthalmicNeedleHolders
Themajorityoftheophthalmicneedleholderspossessadesignverysimilartocornealandcorneosclerascissors.
Theserratedflatorroundknurledhandlesare100120mmlongandaredesignedtobeheldlikeapen.The
proximalportionsofthehandlearehighlyflexibleandfunctionasaspring,therebymaintainingtheneedleholder's
jawsopen.Thestraightorgentlycurvedjawsare712mmlongandhaveeithersmoothorserratedsurfaces.The
lockingmechanismsaremountedontheinsideofeachhandleandaredurabletoprovidelongtermuse.
Compressingthehandleslocksandclosesthetips;compressingthelockedhandlesasecondtimereleasesthelock
andopensthetips.Inmodelswithoutthelockingmechanism,apinstopisusuallyaddedtopreventexcessive
compressionofthehandles.

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Forgeneralextraocularsurgery,theCastroviejoneedle holderwithflatserratedhandlesandalockis
recommended.Thejawsareabout9mmlongandmaybestraightorgentlycurved.Formicrosurgeryinvolvingthe
cornea,theStorzorBarraqueneedleholderwithcurvedjawsandnolockpreferred.Allophthalmicneedleholders
aredesignedforonlythesmallophthalmicneedlesandsutures;largeneedlesandsutureslargerthan40will
graduallydistortthejawsoftheseneedleholders,renderingtheinstrumentuseless.
Spatulas
Spatulasaresemisharptodullinstrumentsdesignedtomanipulatetheirisfromthecornea,forexampleiniris
prolapse,orteasethevitreousfromtheposteriorlenssurfaceduringintracapsularlensremoval.Threebasictypes
ofspatulatipsareavailablewithafairlystandardroundorflatserratedhandleof120140mminlength.Some
spatulaspossessspecialtipsatbothendsofthehandle.Themostversatilespatula,designedtosweeptheirisfrom
thecorneaorthevitreousfromtheposteriorlens,hasaroundblunttipthatis1012mmlong.Thesespatulashave
alsobeenincorporatedintocannulaethatpermittheinjectionofsolutionorairwiththesameinstrument.
Calipers
Occasionallyineyelid,cornealandintraocularprocedures,precisemeasurementsareneeded.EithertheJameson
orCastroviejocaliperpermitsmeasurementsin1mmincrementsandbotharerelativelyinexpensive.
Sutures
Asingeneralsofttissuesurgery,continuedrefinementoftheswagedneedlesandsuturespermitteduseof
progressivelysmallersutureswithlesstissuereactivitybutexcellentholdingstrength.Thesesmallerneedlesand
sutureshavealsobeenvitalforthedevelopmentofophthalmicmicrosurgery.Forsurgeryoftheorbit,suturesize
approximatesthatofgeneralsofttissuesurgery,with20to40absorbablesuturesusedforligationandclosureof
thedeeperorbitalfasciatissues.Skinclosureisusuallywithnonabsorbable30to40nylon,polypropylene,
polyester,Dacron,orsilk.
Forsurgeryoftheeyelids30to40suturesarerecommendedwiththeabsorbablesuturesburiedandtheskin
apposedwithnonabsorbable30to40singleinterruptedsutures.Mostconjunctivalandcornealsuturesare
absorbable9toeliminatedtheneedforsutureremoval),and30to70insizetominimizetissuereaction.Buried
suturesinvolvingthenictitatingmembranemaybeeitherabsorbableornonabsorbabledependingonthe
procedure.
Thegeneralrulestatingthatthestrengthofthesutureshouldapproximatethesurroundingtissuesalsopertains
toophthalmicsutures.Oftenthechoiceoftheskinsuturesispersonalpreferenceandnearlyalwaysthenon
absorbabletype.Silkskinsuturesareusuallyblack,softandpliable;ifsuturecontactwiththeeyeoccursocular
irritationisunlikely.Unfortunatelysilksuturesarebraidedandbacteriacanpenetratethesutures,hencesuture
removalshouldbeperformed1014dayspostoperatively.Whennylonandpolypropylenemonofilamentsare
employedforskinsutures,thesurgeonandsquareknotsareusuallycombinedtosecureeachknot.Asthesesutures
arefairlystiff,suturecontactwiththeconjunctivaand/orcorneausuallycausesocularirritation.Thisstiffnesscan
howeverbeanadvantageduringparotidducttranspositionwhenthesesuturesareinsertedintotheduct'slumento
facilitateitsdetectionandhandling.TheDacronpolyestersutureismorepliablethannylonorpolypropylene
sutures,butitsknotstendtoloosen.
Absorbablesuturesaremostfrequentlyusedforthedeeperlayersoftheeyelids,alllayersoftheconjunctivaand
nictitatingmembrane,andthecornea.Ourpreferenceispolyglactin,amultifilamentoussuture,withstrengthand
resorptionratesthatapproximatesurgicalgut(about6weeks).Thissuture,dyedviolet,isnonantigenicand
producesminimaltissuereaction.Theuncoatedpolyglactinisassociatedwithexcessivetissuedragduringsuturing;
coatinggreatlyreducesthisdragbutadditionaltiesareindicatedforknotsecurity.Polyglactinsuturesarestablein
septicwounds,andcanbeusedininfectedcorneas.

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Needles
Ingeneral,reversecuttingsemicircleneedlesarerecommendedforthemajorityoftheextraocularsurgical
procedures.Skinclosuregenerallyemploystheconventionalcuttingneedles;thesubcutaneousanddeeperorbital
fasciallayersareapposedusingspatulaandtaperneedles.Cornealandscleraltissuesrequirereversecutting
needles,andtheG6semicircularneedleisthemostuseful.
MaintenanceofOphthalmicSurgeryinstruments
CareandStorage
Allophthalmicinstrumentsarequitedelicateandwhetherinstorageandnotsterile,orreadyforuseandsterile,
specialophthalmicholdersarerecommended.Allfixationforcepsshouldbecovered,withsmallpiecesof
intravenoustubing,toprotecttheirdelicatetips.Flatfeltlinedtraysprovideinexpensivestorageandseveraltrays
canbeaccommodatedinaninstrumentstoragebox.
Specialstainlesssteeltrays,witheitherfoamorrubberlinings,providethemostconvenientmethodforsafe
handlingofsterileophthalmicinstruments.Thelinersholdeachinstrumentseparatelyandpreventcontactwith
otherinstrumentsthatcoulddamagethedelicatetipsandblades.Thesetraysareeasilysterilizedandcanbeused
indefinitely.
CleaningandSterilization
Becauseofthedelicatetipsofophthalmicinstruments,cleaningisgenerallyachievedbyultrasoundandthe
appropriatecleaner.Eachinstrumentiscarefullyplacedonthebottomoftheultrasoniccleaner(andnotpiledon
topofotherinstruments).Someofthelargersoiledinstrumentscanbeeasilycleanedmanually,usuallyusinga
smalltoothbrush.Theinstrumentsshouldbedriedusingahotairblowerratherthanriskingdamagebyhanddrying
withtowels.Occasionaltreatmentwithinstrumentmilkwillpreservetheinstrument'sfinish,andlubricationofthe
scissors'andneedleholdershingeswillfacilitatelongtermuse.Sterilizationofallophthalmicinstrumentsisusually
achievedbythestandardmethodsusinghotair,autoclaving(steam),orethyleneoxidegas.