Operating Theatre Etiquette - Sterile

BASIC SKILLS
Operating theatre performed. The use of surgical checklists is particularly useful

and all theatre users should be familiar with the local protocols
etiquette, sterile used. We will go on to describe the guidelines and latest evidence
relating to sterile technique used in scrubbing, preparing the
technique and surgical operation site and draping.
site preparation Theatre etiquette

Preparing for a surgical list
Amanda Roebuck Every theatre session is a training opportunity, regardless of the
seniority of the trainee. Trainees usually gain maximum benefit
Ewen M Harrison
from a theatre session if they have looked at the cases on the list
before attending. Meeting each patient, becoming involved in the
consent process and looking up scans and test results prior to the
Abstract list will all give a better understanding of the patient’s condition
The operating theatre is an unusual environment and understanding
and the need for surgical management. It is also helpful to read
the systems in place there is an important part of surgical training.
about surgical techniques and procedures on a more practical
‘Non-technical skills’ is a term used to describe everything a surgeon
level and to have an understanding of the anatomy that will be
does in the operating theatre, other than the technical aspects of the
involved to further compound learning during each case.
procedure itself. This includes communication, decision-making and
leadership. Non-technical skills have become a vital aspect of the
Introducing the team
development of a surgeon and should form part of training pro-
Good communication in theatre is crucial. It is important that all
grammes. A fundamental responsibility of the surgeon is the mainte-
members of the theatre team are introduced to each other prior to
nance of sterility. The techniques of the surgical scrub and preparing
surgery commencing. When working in a new theatre depart-
and draping a patient only become second nature after good teaching
ment for the first time, always ensures that you are wearing
and reflection by the surgeon. The purpose of this article is firstly to
correct surgical attire in line with hospital policy. Surgical
describe how a surgical trainee can get most out of an operating ses-
‘scrubs’, a theatre hat, and appropriate clean footwear that has
sion. We will describe what non-technical surgical skills are and why
not been worn outside are the essential minimum.
they are important. We will focus on safety in the operating theatre
Always wear an identification badge and on entering the
and discuss worldwide strategies such as the ‘surgical safety check-
department introduce yourself to the members of the team
list’ which aims to improve this. Finally we will present data on mea-
present that day. In particular, present yourself to the theatre
sures to reduce surgical site infection, such as which surgical scrub
sister, anaesthetist, and the operating surgeon if not a member
solution to use and whether drapes or wound protectors work.
of your usual team. Always ensure the theatre sister and scrub
Keywords Double gloving; facemask; handwash; non-operative nurse know who you are e as well as being polite and respectful
skills; NOTSS; surgical brief; surgical safety checklist; surgical scrub; as a relatively new member in their environment, these col-
theatre etiquette; wound protector leagues can make life a lot easier when you start a new post,
particularly for more junior trainees. They are likely to have
worked with the consultant for a long time and will have a good
Introduction knowledge of different surgeons’ preferences, suture and in-
The operating theatre can be an intimidating environment for the strument choice.
uninitiated. The purpose of this article is to describe the most
appropriate behaviour for the operating theatre, particularly for Surgical safety checklist
those at the beginning of surgical training. As well as the tech- As part of the World Health Organization (WHO) Safe Surgery
nical aspects of surgery, modern training emphasizes so-called Saves Lives initiative, in January 2007 the World Alliance for
‘non-technical skills’. These describe all aspects of operating Patient Safety developed the WHO Safe Surgery Checklist.1 Most
theatre behaviour other than the technical aspects of the pro- surgical departments have now implemented these checklists,
cedure itself. To maximize the educational value of time spent in and their aim is to identify and prevent the most common risks to
the operating theatre, trainees should prepare themselves patients having surgery. There are three main phases in which a
adequately. This will involve familiarization with the patients on checklist is used: before the induction of anaesthesia (‘sign in’),
the list, the staff in the theatre, and the procedures being before the incision of the skin (‘time out’, also known as the
‘surgical pause’) and before the patient leaves the operating
room (‘sign out’).1
Use of a checklist creates a culture which firmly focuses on
Amanda Roebuck MB ChB is a Clinical Research Fellow in Surgery at safety. Checklist contents (Figure 1) can be adapted to local
the Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of interest: needs and WHO provides an implementation manual to guide
none declared. users in the individual setting.
Ewen M Harrison MB ChB PhD FRCS (Gen Surg) is a Senior Lecturer in The National Patient Safety Agency (NPSA) published a
General Surgery at the Royal Infirmary of Edinburgh, Edinburgh, UK. document in December 2010 entitled “Five steps to safer sur-
Conflicts of interest: none declared. gery”. This gives guidance on the implementation of the WHO
SURGERY 35:4 177 Ó 2017 Published by Elsevier Ltd.
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BASIC SKILLS
Figure 1
checklist and also describes a briefing and debriefing stage as a Non-technical skills for surgeons (NOTSS)
time to discuss important information regarding the safety of the The NOTSS project was developed by a team of surgeons, psy-
patient.2 In 2009 there were 155,000 reports of patient safety chologists and anaesthetists and acts as a framework for training
incidents from surgical specialties in England and Wales.2 Over and assessment of ‘non-technical skills’ in the operating theatre.
1000 of these incidents caused severe harm or death. In 2009 the It is necessary for surgeons to develop these non-technical or
NPSA issued a safety alert to NHS organizations and in 2010 a non-operative skills in conjunction with their clinical and surgi-
requirement was introduced in England and Wales for all NHS cal skills. Four areas are included in the assessment framework:
trusts to implement an adapted WHO Safety checklist and to situation awareness, decision-making, communication and
record and monitor the use of this tool. teamwork, and leadership (Table 1). It incorporates ideas from
The NPSA guideline describes a 5-minute briefing ‘before the similar systems used in professional training elsewhere in in-
start of the list that will enable the core team to meet to discuss dustry and has been developed to enable surgical trainers to
the requirements of that list, including safety concerns, equip- implement it in the operating theatre with minimal difficulty. The
ment and staffing’.2 This may also include special instructions skills taxonomy shown in Table 1 can be used to assess key
for patient positioning and antibiotic prophylaxis. It also de- competencies including professionalism, interpersonal and
scribes a debriefing stage during which any concerns or in- communication skills, and systems-based practice.3
cidents can be discussed with team members to promote In a prospective observational study published in 2011, the
improvement. NOTSS system was used to assess surgical trainees’ non-technical
BASIC SKILLS
The surgical scrub is performed to remove as many resident

Non-technical skills for surgeons (NOTSS) framework3 hand flora as possible.5 The agents used in this scrub are broad
Category Element spectrum and cover a range of bacteria and fungi. Studies
comparing the efficacy of different scrubbing techniques and
Situation awareness C Gathering information antiseptic solutions are limited e most practice is based on evi-
C Understanding information dence from in vitro studies or in vivo trials outwith the operating
C Projecting and anticipating future environment.
state The common surgical scrub agents contain chlorhexidine or
Decision-making C Considering options povidoneeiodine and although other agents available, these
C Selecting and communicating have fallen out of favour due to toxicity and lower efficacy.5
option Chlorhexidine and iodine are comparable when considering
C Implementing and reviewing initial reduction in bacterial count, however rapid regrowth of
decisions bacteria occurs after povidoneeiodine use but not with chlor-
Leadership C Setting and maintaining standards hexidine.5 The povidoneeiodine solutions induce more allergic
C Supporting others reactions and despite a lower efficacy, the solution is still widely
C Coping with pressure used in practice today.
Communication and C Exchanging information When performing an aqueous handwash, the warm water is an
teamwork C Establishing a shared essential catalyst facilitating the action of the scrub soaps and
understanding solutions. However, very hot water removes protective fatty acids
C Coordinating team from the skin and should be avoided.5 Health Protection Scotland
(HPS) suggest a steady flow of warm or tepid water be used.6
Table 1 The length of the surgical scrub has been the subject of much
scrutiny over the years and in the past a 10-minute scrub was
skills.4 This study found that minimally trained assessors were recommended. Initial studies showed no difference between 5-
sufficiently discriminating and consistent in their judgements of and 10-minute scrubs, with subsequent work showing that 2 or 3
trainee surgeons’ non-technical skills to provide reliable scores minutes were adequate.5 Alcohol hand rub techniques are also
based on an achievable number of observations.4 These assessors effective and require 3 minutes.5 Figure 2 outlines the recom-
included scrub nurses, anaesthetists, and surgical care practitioners. mended technique for application of an alcohol hand rub.5 HPS
suggests that manufacturer guidance be adhered to in this deci-
Positioning the patient
sion to ensure efficacy.6
An important part of the surgical brief is the positioning of the
A number of studies have failed to show the benefit of
patient and the responsible surgeon will clarify their preferences
scrubbing brushes as part of the surgical handwash.5 It has been
at this time. It is useful to assist the theatre staff in positioning the
suggested that vigorous scrubbing with a brush can damage and
patient and to become familiar with the components of the sur-
shed skin cells and so the WHO guideline recommends cleaning
gical table and how they are assembled. When operating outwith
nails with a file. If a nailbrush is to be used, it should be sterile
working hours (evenings, overnight and weekends) operating
and single use. Box 1 shows the WHO recommended steps to
theatre staff may be less experienced in certain procedures. It is
prepare for and the procedure for performing an aqueous surgical
often at these times that it is the responsibility of the surgical
scrub.
trainee to ensure proper patient positioning. Observing how this
A Cochrane review initially published in 2008 was reviewed
is done during the day will prove invaluable to avoid the diffi-
in 2015. It compared methods of surgical hand antisepsis on the
culties that can be encountered operating on a patient not
rate of surgical site infections (SSIs) and the numbers of bacteria
appropriately positioned.
present after hand antisepsis.7 There were 14 studies included
with four looking at SSI and ten reporting on colony-forming
Sterile technique units (CFU) but not SSI. It concluded that:
The surgical scrub most studies used as an evidence-base to guide surgical
Before performing a surgical scrub ensure a gown and gloves are antisepsis are regarded as poor in quality due to small
laid out. It is also polite to put out these items for other members numbers or poor data reporting and analyses
of the surgical team. It is advisable to wear appropriate eye there was no clear evidence that any one method of sur-
protection and a facemask to reduce the risk of exposure to gical antisepsis is superior
contaminated fluids. alcohol rubs with additives were potentially more effective
The WHO document ‘Guidelines on Hand Hygiene in than aqueous scrubs to reduce CFUs
Healthcare’ provides extensive guidelines for hand hygiene to there was some evidence for chlorhexidine to reduce
prevent healthcare associated infection. It describes the colony-forming unit (CFU) number more effectively than
different antiseptic solutions used, the risk of allergies and skin povidoneeiodine
reactions, and the surgical hand scrub procedure. It includes a There was limited evidence to suggest that the surgical
discussion on religious and cultural considerations and pro- scrub time of 3 minutes reduced CFU numbers more than a
vides solutions to practical barriers to implementation. 2-minute scrub
BASIC SKILLS
Figure 2 Surgical hand preparation technique using an alcohol-based hand rub.5
BASIC SKILLS
Figure 2 (Continued).
BASIC SKILLS
and in high-risk procedures where double gloving is advocated it

Key steps before starting surgical hand preparation and would be uncomfortable and potentially affect performance if
the recommended procedure for an aqueous surgical accustomed to only one pair of gloves.
scrub with medicated soap5
Facemasks
Key steps A Cochrane review first published in 2002 and reviewed in 2011
C Keep nails short and pay attention to them when washing your then 2016, looked at only three trials including a total of 2106
hands e most microbes on hands come from beneath the participants to assess the efficacy of surgical facemasks in pre-
fingernails vention of surgical wound infections. With these limited data,
C Do not wear artificial nails or nail polish there was no ‘statistically significant difference in infection rates
C Remove all jewellery (rings, watches, bracelets) before entering between the masked and unmasked group in any of the trials’,9
the operating theatre but it was noted that this result was limited by low numbers
C Wash hands and arms with a non-medicated soap before entering included in the review.
the operating theatre area or if hands are visibly soiled From a practical point of view, the facemask provides a
C Clean subungual areas with a nail file. Nailbrushes should not be physical barrier between the surgeon and the patient’s bodily
used as they may damage the skin and encourage shedding of fluids. As such many surgeons wear a facemask to prevent
cells. If used, nailbrushes must be sterile, once only (single use) ingestion of such fluids in case of splash injury.
Reusable autoclavable nail brushes are on the market
Procedural steps Approaching the table

C Start timing. Scrub each side of each finger, between the fingers, After gloving and gowning it is important not to contaminate
and the back and front of the hand for 2 minutes the sterile field created. Gloved hands should be held in front of
C Proceed to scrub the arms, keeping the hand higher than the arm the body above waist height and not underneath arms or behind
at all times. This helps to avoid recontamination of the hands by the back. Care should be taken to move around the theatre
water from the elbows and prevents bacteria-laden soap and environment with your back to non-sterile surfaces and people,
water from contaminating the hands especially if in close proximity or limited spaces. Ask for help if
C Wash each side of the arm from wrist to the elbow for 1 minute a piece of equipment could be moved to make your route to the
C Repeat the process on the other hand and arm, keeping hands operating table easier to avoid contaminating yourself. When
above elbows at all times. If the hand touches anything at any you approach the table, it is obviously safe to touch sterile
time, the scrub must be lengthened by 1 minute for the area that drapes and the sterile operating field. Take care to ensure that
has been contaminated light handles and cables are sterile if uncertain before touching
C Rinse hands and arms by passing them through the water in one them, and never be afraid to ask for new gloves or to completely
direction only, from fingertips to elbow. Do not move the arm re-scrub if you feel you have been contaminated. It would be
back and forth through the water much more embarrassing to be linked to a surgical wound
C Proceed to the operating theatre holding hands above elbows infection.
C At all times during the scrub procedure, care should be taken not When passing cables and equipment to un-scrubbed theatre staff
to splash water onto surgical attire take care and time to keep essential parts sterile. This may require
C Once in the operating theatre, hands and arms should be dried communication with team members when unfamiliar equipment is
using a sterile towel and aseptic technique before donning gown being used, or inexperienced staff are handling equipment.
and gloves
Box 1 Surgical site preparation

Preparing the skin
Before applying drapes to surround the surgical field, the skin
Double gloving must be prepared with a sterile solution to minimize risk of
Wearing a protective outer glove in theory reduces the risk of contamination of the surgical field with the patient’s skin
tears to the inner glove and thus protects the patient from surgical commensal organisms. As with the surgical scrub, the main
site contamination and the wearer from exposure to body fluids. agents used to sterilize the skin are chlorhexidine and povidone
In specialties where sharp structures are encountered, such as in eiodine containing solutions. A Cochrane review of preoperative
orthopaedics and dentistry, this practice is already widely adop- skin antiseptics updated in 2015 found that use of chlorhexidine
ted. A Cochrane review updated in 2009 showed that an outer in alcohol led to a reduced rate of SSI in comparison to a
glove had a protective effect, reducing the number of tears to the povidoneeiodine in alcohol solution,10 However, this study did
inner glove in comparison to a single glove.8 It also looked at the not report important details such as strength of iodine solution
use of coloured indicator gloves, which made perforations in the and as such bias may have influenced the result.
outer glove more apparent, use of a cloth outer glove which There are a few practical considerations depending on which
reduced perforations to the inner glove. There was no evidence solution is chosen and this usually depends on the responsible
that an additional glove protected the patient from SSI. consultant or departmental preference. Chlorhexidine is usually
From a more practical point of view, as a trainee, it is good prepared with alcohol and is therefore highly inflammable. Care
practice to become accustomed to the practice of double gloving. should be taken not to allow pools of the liquid to form. Skin
The tactile feedback when wearing two pairs of gloves is reduced should be dried with sterile swab, paying particular attention to
BASIC SKILLS
Examples of surgical drape techniques
Incise panels of clear Panel over

Abdomen plastic along inner legs middle chest
Leg drapes Perianal area
1. Draping of abdomen – drapes applied to make 2. Lithotomy position for perianal 3. Cardiothoracic surgery – incise panels
a ‘square’ to allow variety of approaches procedures – use of leg drapes on chest and inner legs to allow sternotomy
for abdominal access incisions and harvesting of long saphenous veins
during coronary artery bypass grafting
Figure 3
umbilicus, as diathermy can cause sparks which may ignite. cover the patient and secured carefully without contaminating
Povidoneeiodine solutions (such as Betadine) are sticky and can the sterile drape surface or the sterile field.
cause skin irritation and allergic reaction. There are different types of drapes and set-ups depending on the
More recently incise drapes such as OpSite (Smith and type of procedure. For example, abdominal and breast surgery use
Nephew, UK) Ioban (3M Company, USA), and Steridrape (3M, square-draping technique, where four drapes are applied over-
UK) have been used with the aim of immobilizing bacteria on the lapping in a square to expose the surgical field centrally. In peri-
skin to prevent migration into a surgical wound. The Cochrane anal surgery, the patient will likely be placed in the lithotomy
Wounds group updated a review in January 2013 looking at use position where the legs are held elevated in stirrups. This requires
of plastic adhesive drapes in the prevention of SSI. They found draping of the legs to prevent contamination of the operator sitting
no benefit in reduction of SSI and perhaps some evidence that between the legs. In coronary artery bypass grafting, access is
infection may be increased.11 often needed to the legs to obtain long saphenous vein. Pre-formed
When preparing the skin prior to surgery, the scrub nurse will drapes are available with incise panels over the chest and legs
usually have the solution and swabs/forceps ready to begin which cover the whole patient. The trainee should ensure they are
preparing the skin. The solution should be applied to the skin in able to prepare the patient depending on the responsible surgeon’s
a methodical manner, to cover the whole surgical field and an preference or department policy. The theatre nursing staff are a
area outwith the likely border of the drapes. This will ensure that very useful resource when learning these techniques.
unprepared skin is not exposed during surgery in the event that a
surgical drape is disturbed. Consideration should also be given to Wound protection
possible complications of surgery requiring extension of wounds Wound protection devices are inserted into an open abdominal
or conversion from laparoscopic to open if necessary and pre- wound to provide a barrier between the skin edge and the open
paring the skin in advance may be useful. The solution is applied operative field. Designs vary but are based on a semi-rigid plastic
to skin at least twice, using a fresh sterile swab each time. A dry ring placed into the abdomen through the laparotomy wound to
swab is used to prevent pooling of liquid, particularly when using which an impervious drape is circumferentially attached. The
alcohol based solutions, and to dry the area for drapes to stick. aim is to prevent damage to this skin edge during the procedure
and to minimize contamination of the wound, particularly in
surgery involving bowel where faecal contamination is likely.
Surgical drapes (Figure 3)
However, the ROSSINI trial published in the BMJ found that
Surgical drapes should surround the surgical field without
these devices do not in fact reduce the rate of SSI in patients
exposing unprepared and hence unsterile skin. After the anti-
undergoing laparotomy.12
septic solution has been applied and the skin appropriately dried,
the drapes are applied usually by the scrub nurse and either
Conclusions
operating surgeon or their assistant. Drapes can be made of cloth
requiring towel clips to secure them in place, or disposable paper The operating theatre environment is unlike any other. It is
with adhesive to adhere to skin. The drapes of choice are passed important to become proficient in non-operative surgical skills in
over the patient to allow two practitioners to spread the drape to addition to the practical skills required to perform an operative
BASIC SKILLS
procedure. This concept should now be firmly embedded in surgeons (NOTSS) [Internet]. Available from: http://www.rcsed.ac.
surgical training and assessment. The guidelines for sterile uk/education/patient-safety-and-notss/notss.aspx.
preparation preoperatively suggests a surgical scrub with alcohol 4 Crossley J, Marriott J, Purdie H, Beard JD. Prospective obser-
based chlorhexidine in preference to povidoneeiodine solutions vational study to evaluate NOTSS (Non-Technical Skills for Sur-
for a duration of 2e3 minutes.5 Alcohol rub agents should be geons) for assessing trainees’ non-technical performance in the
used for 3 minutes.5 There is no real evidence to support the use operating theatre. Br J Surg 2011; 98: 1010e20.
of facemasks in prevention of SSI.8 Double gloving is beneficial 5 WHO. WHO guidelines on hand hygiene in health care [Internet].
to prevent tears of the inner glove when compared with single WHO. [cited 2016 July 31]. Available from: http://www.who.int/
latex gloves only.8 For preparation of the skin at the surgical site, gpsc/5may/tools/9789241597906/en/.
alcohol-based chlorhexidine is also advocated although povidone 6 Health Protection Scotland. SICP literature review: hand hygiene:
eiodine is still used.10 Incise drapes developed to immobilize surgical hand antisepsis in the clinical setting. Version 2.1,
resident bacteria to prevent migration to wounds are unlikely to November 2015.
reduce SSI and may in fact contribute to infection.11 Wound 7 Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand
protectors are also used to cover the edge of laparotomy wounds, antisepsis to reduce surgical site infection. Cochrane Database
but evidence suggests that these do not reduce the rate of SSI.12 Syst Rev 2016. Issue 1. Art. No.:CD004288.
By continuing to review current evidence with regard to SSI, 8 Tanner J, Parkinson H. Double gloving to reduce surgical cross-
sterile technique and surgical site preparation, the surgical infection. Cochrane Database Syst Rev 2006. Issue 3. Art. No.:
trainee can adapt and develop practice. The integration of non- CD003087.
technical skills into training programmes will also ensure that 9 Vincent M, Edwards P. Disposable surgical face masks for pre-
the surgeons of the future have appropriate behaviours required venting surgical wound infection in clean surgery. Cochrane
of the modern theatre environment. A Database Syst Rev 2016. Issue 4. Art. No.:CD002929.
10 Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Lui Z.
Preoperative skin antiseptics for preventing surgical wound in-
REFERENCES fections after clean surgery. Cochrane Database Syst Rev 2015.
1 WHO. WHO surgical safety checklist and implementation manual Issue 4. Art. No.:CD003949.
[Internet]. WHO. [cited 2016 July 29]. Available from: http://www. 11 Webster J, Alghamdi A. Use of plastic adhesive drapes during
who.int/patientsafety/safesurgery/ss_checklist/en/. surgery for preventing surgical site infection. Cochrane Database
2 NPSA. Patient safety resources [Internet]. [cited 2016 July 29]. Syst Rev 2013. Issue 5. Art. No.:CD006353.
Available from: http://www.nrls.npsa.nhs.uk/resources/? 12 Pinkney TD, Calvert M, Bartlett DC, et al. Impact of wound edge
EntryId45¼92901. protection devices on surgical site infection after laparotomy:
3 The Royal College of Surgeons of Edinburgh and the School of multicentre randomised controlled trial (ROSSINI Trial). Br Med J
Psychology Aberdeen University. Non-technical skills for 2013; 347.: f4305.

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BASIC SKILLS

Operating theatre performed. The use of surgical checklists is particularly useful

technique and surgical operation site and draping.

site preparation Theatre etiquette

SURGERY 35:4 177 Ó 2017 Published by Elsevier Ltd.

SURGERY 35:4 178 Ó 2017 Published by Elsevier Ltd.

The surgical scrub is performed to remove as many resident

SURGERY 35:4 179 Ó 2017 Published by Elsevier Ltd.

Figure 2 Surgical hand preparation technique using an alcohol-based hand rub.5

SURGERY 35:4 180 Ó 2017 Published by Elsevier Ltd.

SURGERY 35:4 181 Ó 2017 Published by Elsevier Ltd.

and in high-risk procedures where double gloving is advocated it

Procedural steps Approaching the table

Box 1 Surgical site preparation

SURGERY 35:4 182 Ó 2017 Published by Elsevier Ltd.

Examples of surgical drape techniques

Incise panels of clear Panel over

SURGERY 35:4 183 Ó 2017 Published by Elsevier Ltd.

SURGERY 35:4 184 Ó 2017 Published by Elsevier Ltd.

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