10/10/17

Basic Surgery
Christina Strand Thomsen DipECVS DVM

Veterinary surgeon
AniCura Dyresykehuset Bergen Nord
Vetzup

Overview

Part 1
• Surgical site infection (SSI)
• Classification
• Risk factors
• Aseptic preparation
• Patient
• Surgeon

Part 2
• Basic surgical techniques

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Surgical site infection

Definition – Surgical Site Infection

AN INFECTION THAT OCCURS ANYWHERE IN THE

OPERATIVE FIELD FOLLOWING SURGICAL
INTERVENTION

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Classification
(U.S. Centers for Disease Control and Prevention Criteria for Defining Surgical Site Infection)

INCISIONAL SURGICAL SITE INFECTIONS (1)

• Superficial (skin and subcutaneous tissue of the incision)

• Within 30 days

• Purulent discharge
• Positive culture
• At least one of the following
• Pain or tenderness
• Redness or heat

Classification
INCISIONAL SURGICAL SITE INFECTIONS (2)

• Deep (deep soft tissues of the incision – fascia/muscle layers)

• Within 30 days if no implants utilized
• Within 1 year if implants utilized

• Purulent discharge from deep incision

• Deep incision spontaneously dehisces or is opened by surgeon when
fever or localized pain is present
• Abscess in deep tissues identified by examination, reoperation,
histopathology, or radiologic examination

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Classification
ORGAN/SPACE SURGICAL SITE INFECTION

• Any part of the body that is manipulated during the procedure (except
skin, fascia, or muscle layers)
• Within 30 days if no implants utilized
• Within 1 year if implants utilized

• Purulent discharge from drain into organ/space

• Abscess in deep tissues identified by examination, reoperation,
histopathology or radiologic examination

Classification of surgical wounds

National Research Council, Division of Medical Sciences

• Clean
• Clean-contaminated
• Contaminated
• Dirty

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Classification of surgical wounds

CLEAN

• Nontraumatic, noninflamed operative wounds

• Respiratory, gastrointestinal, genitourinary, and oropharyngeal tracts are
not entered

Classification of surgical wounds

CLEAN-CONTAMINATED

• Operative wounds in which respiratory, gastrointestinal, or genitourinary

tracts are entered under controlled conditions, without unusual
contamination
• An otherwise clean procedure in which a drain is placed

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Classification of surgical wounds

CONTAMINATED

• Operations on traumatic wounds without purulent discharge

• Procedures in which spillage of gastrointestinal contents or spillage of
infected urine occurs
• Procedures in which a major break in aseptic technique occurs

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Classification of surgical wounds

DIRTY

• Operations on traumatic wounds with purulent discharge, devitalized

tissues or foreign bodies
• Procedures in which a perforated viscus or fecal contamination occurs

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Surgical site infection

OCCURRENCE IN SMALL ANIMAL PRACTICE

• Clean • Example – TPLO

• 2-4.8% • Clean
• Clean-contaminated • 4.7-12%
• 3.5-5%
• Contaminated
• 4.6-12%
• Dirty
• 6.7-18.1 %

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Rats
BEHAVIORAL AND PHYSIOLOGIC EFFECTS OF INAPPARENT WOUND INFECTION IN RATS

• Bradfield JF et al, Lab Anim Science, 1992

• Craniotomies and laparotomies; bacteria inoculated & control group
• Results:
• “Although no clinical signs were detected by postoperativ
observation, rats inoculated with bacteria were significantly less
active in the open field and the duration of freezing behaviour was
shorter. Plasma fibrinogen, serum glucose, total WBC, and wound
histology scores were significantly altered in the bacteria-inoculated
rats.”
• “These findings underscore the need for sterile techniques in rat
surgery to avoid confounding experimental data”.

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Risk factors

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Risk factors
DEGREE OF BACTERIAL CONTAMINATION

• Increased risk with > 105 bacteria/gram tissue

• Depending on procedure, patient and the environment

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Risk factors
CLIPPING OF THE SURGICAL SITE

• Can produce cuts into which bacteria can colonize over time
• Clipping of the skin anytime other than immediately preoperatively
should be avoided whenever possible
• Even just the morning of surgery

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Risk factors
DURATION OF SURGERY

• The risk of surgical site infection approximately doubles for every hour of
surgery

• 30% increased risk of wound infection for each additional hour of

anesthesia – risk factor independent of duration of surgery

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Risk factors
NUMBER OF PEOPLE IN THE OPERATING ROOM

• Shedding from operating room personnel is the primary source of

contamination in the operating room
• Men are worse shedders than women

• For each additional person in the surgical suite, the risk of SSI can
increase by as much as 30%
• Greater amount of airborne contamination

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Risk factors
OTHER POTENTIAL RISK FACTORS

• Concurrent disease/active infection distant from the surgical site

• Endocrinopathies
• Sex, age
• Immunosuppressive medication
• Hypotension, hypothermia
• Body condition (malnutrition, obesity)
• Blood loss
• Suture material
• Propofol (induction agent)

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Aseptic preparation

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Antiseptics
ALCOHOL

• Rapid bactericidal activity

• Variable efficacy against viruses
• Generally ineffective against spores
• Denaturing proteins
• Interference with metabolism and lysis of cells
• The efficacy of alcohols is decreased substantially in the presence of
organic debris (e.g. blood)
• 60-70% (etanol)

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Antiseptics
IODOPHORS

• Iodine-containing compounds (Povidine-iodine)

• Various aqueous solutions – antimicrobial efficacy is largely due to
molecular iodine (I2)
• Mechanism of action incompletely understood
• Bacteria, spores, viruses and fungi
• The efficacy is decreased substantially in the presence of organic
debri (e.g. blood)
• Adverse skin reaction

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Antiseptics
CHLORHEXIDINE

• Bactericidal
• Sporicidial at higher temperatures
• Activity reduced in organic material, but better than povidine-iodine
• Surgical scrub formulations are 2-4%
• Wound treatment are 0.05% or less
• Disinfectant 0.5-2%

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Preparation of the animal

CLIPPING OF HAIR
REMOVAL OF DIRT AND OILS
REMOVAL OF MICROBES

PRIMARY GOAL
• Removal of transient organisms and reduction in the number or
resident flora

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Preparation of the animal

CLIPPING OF HAIR

• Immediately prior to surgery

• Clippers (not razors, associated with higher incidence of SSI)
• Clean blade
• Sharp blade
• Heat!

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Preparation of the animal

SURGICAL SCRUB

• Many different protocols

• Usually chlorhexidine- or idodine-based combined with alcohol as a
rough prep in the induction area, followed by a similar sterile scrub
procedure in the operating room
• 20% of the skin flora remains protected in deeper layers and follicles.
(No matter which protocol is chosen)
• Contact time

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Preparation of the animal

SURGICAL SCRUB

• Spray
• Will make the area wet, but have a very little
cleaning effect

• Concentric movements
• Circle movements - penetrating into cracks and
fissures?

• Careful back and forth movements

• reduces the bacterial count

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Preparation of the animal

SURGICAL SCRUB

• Chlorhexidine vs iodine - veterinary studies

• Have NOT been able to detect a significant difference in bacteria
number, but povidine-iodine might give more skin irritations

• What we do
• Rough scrub (chlorhexidine)
• Diluted povidine-iodine around the eyes
• Chloraprep (2% chlorhexidne gluconate + 70% isopropyl alcohol)

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Preparation of the animal

CHLORAPREP

• Human hospitals
• Proven to be better than povidine-iodine
• Easy to use
• Single-use

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Preparation of the animal

DRAPING

• Barrier that prevents microbial spread from the patient into the surgical
field or onto surgical personnel
• Should be
• Resistant to penetration by bacteria
• Resistant to penetration by fluids (blood, flush water)
• Should not tear with normal use
• Secured in such a way as to remain effectively in position during the
surgery
• Not easily flammable

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Preparation of the surgeon and supporting

staff

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Preparation of the surgeon

SCRUB SUITS

• Worn to decrease dissemination of bacteria into the operating room

environment and to promote a clean surface on clothing

• Closely weaved fabric decreases the degree of bacterial dissemination

• The overall effect of scrub suits on the environment is questionable
• Footwear
• Clinical significance unknown
• Headcovers and surgical face mask
• Controversial

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Preparation of the surgeon

HAND WASH

• Many protocols
• The ideal protocol
• Quick and efficient
• None irritating
• Economical
• With residual effect

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Preparation of the surgeon

HAND WASH

• Recommended to remove rings/jewelry

• Chlorhexidine >> povidine-iodine

• Alcohol rub vs scrub change in trend

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Preparation of the surgeon

ALCOHOL-BASED RUB

• Alcohol-based formulations
• Scrub brush have minimal effect and possibly a negative effect

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Preparation of the surgeon

ALCOHOL-BASED RUB

• Sterilium®
• best peer-reviewed hand-disinfectant
– quality since 1965
• possesses an excellent immediate
effect
• provides very good residual effect
• excellent skin tolerability even with
long-term use

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• Initial study
• Hibiscrub (H), Povidine-iodine (P), Sterilium® (S)
• Sampling prior to hand wash, immediately after and after 3 hours
• H and S significantly better than P immediately after
• S signifacntly better than H and P after 3 hours

• Reduction better for sterilium

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• Clinical study
• Sterilium vs Hibiscrub
• Prior to hand wash, immediately after hand wash and after surgery
• Routine and acute surgeries (small animals and equine)
• Similar results pre and post hand wash
• Sterilium® significantly better than hibiscrub after surgery

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• Conclusion
• The alcoholic-based rub used in this study performed better than
disinfecting soaps and was suitable for veterinary surgical hand
disinfection. Alcoholic-based rubs are cheaper, can be applied more
rapidly, have greater skin tolerance and cause less environmental
impact

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Preparation of the surgeon

GOWNS

• Worn to decrease the spread of bacteria and other particles from the
surgeon´s skin and clothes to the environment
• Reusable
• Single use
• Reduces SSI
• More economical

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Preparation of the surgeons

GLOVES

• Perforations
• Single glove
• 12.7-31%
• Double glove
• Outermost
• 11.5-44%
• Innermost
• 3.8-13%

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Preparation of the surgeon

GLOVES

• 80% of the perforations go unnoticed

• Non-dominant hand – index finger
• Change after draping the patient
• Staff-assisted

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Summary
ASEPTIC PREPARATION OF THE ANIMAL + ASEPTIC
PREPARATION OF THE SURGEON/STAFF

= MINIMIZE THE RISK OF SURGICAL SITE

INFECTION AND OTHER CO-MORBIDITIES

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