GENERAL SURGERY

Preparation of the
Operative Site

Dr Walid Darwiche 2

PREPARATION OF THE
OPERATIVE SITE

Dr Walid Darwiche 1
 Dr Walid Darwiche 3

• Endogenous microbial flora (particularly Staphylococcus aureus

and Streptococcus spp) are the most common source of surgical
site infection (SSI).
• Incisional SSIs are classified as superficial (involving the skin and
subcutaneous tissue) or deep (involving deep soft tissue layers such
as incisional fascia and muscle).
• To be considered an SSI, an infection must occur within 30 days of
the surgical procedure, or within 1 year if it is associated with a
surgical implant and the infection appears to be related to the
operation.
• Although it is impossible to sterilize skin without impairing its natural
protective function and interfering with wound healing,
preoperative preparation reduces the number of bacteria and the
likelihood of infection.

Dr Walid Darwiche 4

DIETARY RESTRICTIONS
In adult animals, food intake is generally restricted 8 to 12 hours
before induction of anesthesia to avoid intra- or postoperative
emesis and aspiration pneumonia.

Shorter periods may be recommended in some small breed dogs

to prevent hypoglycemia.
Access to water is generally not restricted.

Operations of the large intestine often require specialized

preparations (i.e. dietary restriction for 48 hours) and/or enteric
antibiotics (i.e., oral kanamycin, neomycin, or penicillin G).

Food should not be withheld from young animals for longer than
4 to 6 hours because hypoglycemia may occur.

Dr Walid Darwiche 2
 Dr Walid Darwiche 5

EXCRETIONS
The animal should be allowed to defecate and urinate
shortly before anesthesia.

Colonic surgery may require enemas.

An empty urinary bladder often facilitates abdominal

procedures.

If urine is not evacuated naturally, the bladder may be

manually expressed under general anesthesia or a sterile
urethralcatheter passed into the urinary bladder.

Dr Walid Darwiche 6

TREATMENT OF HAIR
It is useful to bathe the animal the day before the
surgical procedure to remove loose hair, debris, and
external parasites.
Removal of hair the night before surgery is associated
with a significantly higher superficial skin infection rate
than removing the hair immediately before surgery.
Hair should be liberally clipped around the proposed
incision site so that the incision can be extended
within a sterile field.
The hair can be removed most effectively with an
electric clipper and a No. 40 clipper blade.

Dr Walid Darwiche 3
 Dr Walid Darwiche 7

Clippers should be held using a "pencil grip" and initial clipping

should be done with the hair growth pattern.
Subsequent clipping should be against the pattern of hair
growth to obtain a closer clip.
After hair removal is completed. Loose hair is removed with a
vacuum.

Dr Walid Darwiche 8

Before transporting the animal to the surgical suite, the incision

site is given a general cleansing scrub and ophthalmic antibiotic
ointments or lubricants are placed on the cornea and
conjunctiva.
In male dogs undergoing abdominal procedures, the prepuce
should be flushed with an antiseptic solution

Dr Walid Darwiche 4
 Dr Walid Darwiche 9

For limb procedures where exposure of

the paw is not required, exclude the
paw from the surgical area by placing
a glove over the distal extremity and
securing it to the limb with lope.

Wrap the glove with tape of Vetrap.

Dr Walid Darwiche 10

Commonly used scrubbing solutions are iodophors, chlorhexidine

gluconate, alcohols, hexachlorophene, and quaternary
ammonium salts.
Alcohol is not effective against spores but produces a fast kill of
bacteria and acts as a defatting agent.

Using alcohol by itself is not recommended, but it is commonly

used in conjunction with chlorhexidine or povidone-iodine.

Hexachlorophene and quaternary ammonium salts are less

effective than other available agents and are no longer
recommended for preoperative skin preparation.
It is important to avoid abrading the skin by excessive scrubbing
with gauze sponges.

10

Dr Walid Darwiche 5
 Dr Walid Darwiche 11

Properties of Antiseptics Used for Preoperative Skin Preparation

11

Dr Walid Darwiche 12

POSITIONING

Before beginning the skin preparation be sure:

• The patient is stable in dorsal recumbency with the head

toward the anesthetic machine and the head is resting
comfortably on the table
• Anesthetic tubing is properly connected and secure
• Patient is at an optimal position for lighting and instrument
access
• Warming disks are placed if the animal is small or very young.
• Warming devices should be placed under a towel or other
covering and should NEVER be placed in direct contact with
the patient as serious burns can result.

12

Dr Walid Darwiche 6
 Dr Walid Darwiche 13

Limbs are tied to help stabilize the patient.

In large, deep-chested dogs, it may help to cross the forelimbs,

securing each tie-down to the opposite side of the table.

Be careful not to over-tighten ties as nerve damage or other

complications can result.

13

Dr Walid Darwiche 14

STERILE SKIN PREPARATION

Sterile preparation begins after the animal has been transported
and positioned in the surgical suite.

Sponges are handled with sterile sponge forceps or a gloved

hand using aseptic technique.

Scrubbing is started at the incision site, usually near the center of

the clipped area.

A circular scrubbing motion is used, moving from the center to

the periphery.

Sponges should not be returned from the periphery to the center

because bacteria could be transferred onto the incision site

Sponges are discarded after reaching the periphery.

14

Dr Walid Darwiche 7
 Dr Walid Darwiche 15

Frequently, when using povidone-iodine and alcohol, the site is

scrubbed alternatively with each solution three times to allow for
5 minutes of contact time.
When the final povidone-iodine scrub is completed, a 10%
povidone-iodine solution should be sprayed or painted on the
site.
If chlorhexidine is the preparation solution, it remains in contact
with the skin at the end of the preparation procedure or may be
rinsed with saline.
Because chlorhexidine binds to keratin, contact time is less critical
than with povidoneiodine.

Two 30-second applications have been advocated as being

adequate for antimicrobial activity.

15

Dr Walid Darwiche 16

Alcohol-based solutions that require shorter prep times

than previously used solutions (e.g., PVI, CHG) are now
commonly used in human medicine, and their use is
increasing in veterinary medicine.

These newer solutions, which typically combine

alcohol with PVI, CHG, or zinc pyrithione, appear to
have better antimicrobial activity than PVI, CHG, or
alcohol alone and provide a more persistent
reduction in the baseline number of bacteria.
One study found a greater than 40% reduction in total
surgical site infection among patients undergoing
clean-contaminated surgery who had received a
single chlorhexidine-alcohol scrub (Darouiche et al,
2010).

16

Dr Walid Darwiche 8
 Dr Walid Darwiche 17

With the new one-step

alcohol-based solutions, the
solution is applied with a
sterile applicator, working
from the center outward.

Once a uniform application

has been applied, the
surgical site is allowed to
dry approximately 2 to 3
minutes before draping or
use of an electrosurgical
unit.

17

Dr Walid Darwiche 18

18

Dr Walid Darwiche 9
 Dr Walid Darwiche 19

If using povidoneiodine, spray or paint a 10%

solution on the operative site after preparation has
been completed.

19

Dr Walid Darwiche 20

Characteristics of an Ideal Preoperative

Antiseptic
The ideal agent would:

• Kill all bacteria, fungi, viruses, protozoa, tubercle

bacilli, and spores
• Be hypoallergenic
• Be nontoxic
• Have residual activity
• Not be absorbed
• Be nontoxic and be able to be used repeatedly
and safely
• Be safe to use on all parts of the body and in all
body systems

20

Dr Walid Darwiche 10
 Dr Walid Darwiche 21

DRAPING
• The purpose of drapes is to create and maintain a sterile
field around the operative site.
• Draping is performed by a gowned and gloved surgical
team member and begins with placement of field drapes
(quarter drapes) to isolate the unprepared portion of the
animal.
• These towels should be placed one at a time at the
periphery of the prepared area.
• Field drapes may be surgical towels or disposable,
nonabsorbent towels.
• Drapes should not be flipped, fanned, or shaken because
rapid movement of drapes creates air currents on which
dust, lint, and droplet nuclei can migrate.

21

Dr Walid Darwiche 22

• Drapes, supplies, and equipment that extend over or

drop below table level should be considered
nonsterile because they are not within the visual field
of the surgeon and their sterility cannot be verified.
• Towels are secured at the corners with sterile
Backhaus towel clamps.
• The tips of the towel clamps, once placed through
the skin, are considered nonsterile and should be
handled appropriately.
• Once the animal and the incision site are protected
by field drapes, final draping can be performed.
• A large drape is placed over the animal and the
entire surgical table to provide a continuous sterile
field.

22

Dr Walid Darwiche 11
 Dr Walid Darwiche 23

• Secure field drapes at the corners with sterile Backhaus

towel clamps.
• The tips of the towel clamps, once placed through the
skin, are considered nonsterile and should be handled
appropriately.

23

Dr Walid Darwiche 24

• If the drape does not have a fenestration, cut one to the

appropriate size.
• The edges of the drape can be secured to the field drapes with
Allis tissue forceps (not towel clamps).
• Do not put holes through the outer drape.

24

Dr Walid Darwiche 12
 Dr Walid Darwiche 25

• When performing a hanging-leg preparation, place

field drapes around the limb and secure them with
towel clamps.

25

Dr Walid Darwiche 26

• The limb is placed through

a fenestration of a lap or
fanfold drape, and the
drape is secured.
• A plastic adhesive drape
has been applied to the
skin and surrounding
drapes.

26

Dr Walid Darwiche 13
 Dr Walid Darwiche 27

27

Dr Walid Darwiche 14