Sterile means free of microorganisms including the pores while asepsis means absence of

microorganisms that cause disease. Sterile techniques are methods employed inside the
operating room to prevent contamination of organisms throughout the surgical procedure.
It is very important for nurses to know and understand the principles governing sterility to
promote safety of the patient during operation.
When are sterile techniques used or applied?
1. Preparation for an invasive procedure
2. In preparation of the sterile team to handle sterile supplies and contact to the
surgical site (gowning, gloving and scrubbing)

3. Skin preparation and draping of the patient
4. Sterility maintenance throughout the operation

Principles of Sterility
Principle Number 1: Only sterile items are used within the sterile field.
Drapes, basins, sponges are obtained from a stock room with sterile packages. The
instruments used are sterilized and are placed in a sterile table. Any person who holds the
sterile equipments should be very cautious to maintain sterility. One important
consideration in implementing sterility is this: IF YOU ARE IN DOUBT ABOUT THE
STERILITY OF A CERTAIN OBJECT, CONSIDER IT UNSTERILE. Any suspected or known
unsterile items should not be placed the sterile field.
Any sterile package found in an unsterile or contaminated area is considered
unsterile.
If the actual timing or sterilization procedure is undetermined and the nurse is
unsure about the sterilization process, the equipments sterilized with the suspected
procedure are considered contaminated.
A sterile table which has been touch or rubbed accidentally by an unsterile person
or vice versa is no longer considered sterile.
If the packaging material is broken or has missing pieces it is no longer sterile.
Microorganisms can enter a packed sterile package when it is damp or wet. Thus,
damp packages are unsterile.
A sterile package dropped on a floor is considered contaminated.
Principle Number 2: Sterile persons are gown and gloved.
When wearing a gown, the considered sterile area is the part where you can see in front
down to the level of the sterile field. Thus, gowns are only considered sterile in front of the
chest, sleeves above the elbow to the cuffs down to the level of the sterile field. Certain
methods should be employed in the OR:
Gowning is not done on the sterile table to avoid dripping water onto the sterile
equipments. Gloving and self-gowning should be done in a distinct sterile surface.
Stockinette cuffs of the gowns are absorbent and may retain moisture, thus making
it a suitable area for bacteria or microorganisms to thrive in. because of the said
principle, stockinette cuffs should be inserted beneath the sterile gloves.
Principle Number 3: Tables are only sterile at Table Level
Edges and sides of the table drape are considered contaminated. Below the table
level is also considered unsterile.
Any sterile person who touches a part of the drape hanging below the table level is
considered unsterile. Any object or equipment that drops below the table surface is
considered contaminated.
In unfolding and placing a sterile drape any portion of that falls below the table
surface is unsterile and should not be moved or touched or brought back up to the
level of the table.
To prevent cords and tubing from sliding to the edge of the table, it should be
fastened with a non-sharp device or object.
Principle Number 4: Sterile Persons Touch ONLY Sterile Items while Unsterile OR
Personnel Touch Only Unsterile Items
Sterile OR personnel comes in direct contact with persons who wears gowns and
gloves only. The items that they will touch are the sterile equipments. Any supply
brought by an unsterile staff should transfer the item in a sterile manner.
Unsterile OR personnel (circulator), should not directly come in contact with a
gowned and gloved person.
Principle Number 5: Unsterile persons avoid reaching over sterile field and sterile
persons avoid touching or leaning over an unsterile area.
In cases where a solution has to be poured into a sterile basin, the unsterile OR
personnel should only hold the lip of the bottle over the basin to prevent any contact
with the sterile area.
To prevent the circulator from reaching over a sterile area when pouring solutions,
the scrub person places the basin and glasses or any container for solutions near the
edge of the table. This prevents the circulator from reaching over the sterile area by
just standing near the edge of the table to fill the container with the liquid solution.
When surgeons perspire on their brows, he or she should to turn away from the
sterile field and have the sweat removed by the circulator.
In draping or covering an unsterile table the scrub person drops the sterile drape at
the center of the table while holding the fan-folded drape high and standing back
from the table to protect the sterile gown.
Sterile gloves are protected by cuffing a drape. The sterile OR personnel should
place the gloved hands inside the sterile part of the drape.
The scrub person unfolds the drape towards him or herself first to allow him or her
to move closer to the table when working on the opposite side of the table since the
first part of the unfolded drape now protects the sterile gown.
Principle Number 6: Edges of anything that encloses sterile contents are considered
unsterile
Sterile supplies are packed. In opening sterile packages, the area within 1 inch from
the edges is considered unsterile. Supplies are handled by the circulator. The upper
portion of the package is flapped away from the self and turns the side under. In
doing so, the end of the flaps is secured by the band of the circulator to prevent it
from dangling loosely. The other flap is pulled towards the circulator; hence, the
contents are exposed yet away from the unsterile hands.
To open a sterile package, the flaps on peel-open packages should be pulled not
torn. The sterile contents should be flipped and lifted upward. The circulator should
prevent the sterile contents to slide over the unsterile edges.
When lifting contents from packages, sterile personnel should lift the object straight
up while holding their elbows high.
In cases where a sterile wrapper is used as a table cover instead of a drape, it should
cover the entire table surface. Only the interior surface of the wrapper is considered
sterile.
Sterile bottles when opened cannot be recap without contaminating the pouring
edges. Thus, all contents must be used or in cases where there is still a solution left,
it should be discarded.
Principle Number 7: Sterile field is set-up just before a surgical procedure
The longer a sterile item is exposed to air and environment, the higher the
possibility of contamination.
The practice of covering a sterile set-up does is not in the best interest of the patient.
Sterility cannot be guaranteed by just covering a sterile set-up, unless it is under a
constant surveillance.
Covering and uncovering a table may contaminate the sterile items.
Principle Number 8: Sterile areas are continuously kept in view.
Sterility cannot be guaranteed by just covering a sterile set-up, unless it is under a
constant surveillance.
Sterile persons should face the sterile area.
While waiting for the patient to come inside the OR, someone must stay in the sterile
area to maintain vigilance on the sterile set-up.
Direct observation ensures sterility.
Principle Number 9: Sterile persons keep well within sterile area.
In draping the patient, sterile persons stay at a safe distance from the operating
table to maintain sterility.
Movements in a sterile area are done by passing with each other back to back at a
360 degree turn.
When a sterile person passes by an unsterile person or area, he or she should turn
back to maintain sterility.
When sterile persons pass by a sterile field or area, they face towards it.
To prevent contamination during movements in an area, the sterile person asks the
unsterile personnel to step aside.
Movement inside the sterile area is kept at a minimum to avoid contamination.
Sterile persons stay inside the sterile field or area.
Principle Number 10: Sterile persons keep in contact with sterile areas to minimum.
Inside the operating room or within a sterile field the following are strictly observed:
Sterile persons avoid leaning over sterile tables or drapes.
Sterile personnel who lean over or sit on an unsterile area is considered
contaminated.
Principle Number 11: Unsterile persons avoid sterile areas
Unsterile personnel should have the knowledge on the proximity to the sterile field.
They must be aware of their distance to the sterile area or field to prevent
contamination. A distance of at least 1 foot or 30 cm from a sterile field should be
maintained and observed by the unsterile staff.
Unlike the sterile persons who turn their back towards the unsterile surface,
unsterile personnel (circulator) face the sterile area (within 1 foot) when passing by
to observe and maintain the distance and to avoid touching any sterile objects.
All activity of a circulator should be kept to a minimum.
Principle Number 12: Destruction of integrity of microbial barriers result in
contamination
A sterile packages integrity is destroyed by the following instances:
Perforation
Puncture
Strike-through soaking of moisture through unsterile or sterile layers or vice
versa.
Before opening a sterile package to be used in a certain procedure or operation the package
should be checked thoroughly before opening. The following principles should also be
employed in handling packages:
To prevent strike-through all sterile packages should be placed on a dry surface.
If any part of the package becomes damp or wet it is considered unsterile and
should be discarded or re-sterilized.
Tables used for operation should be dried before draped.
If the sterile drape is soaked with a solution the wet area should be covered with an
impermeable sterile towels or drape.
Sterile items should be placed not only in clean but also in dry areas.
In handling sterile packages, the hands should be dried first.
Air can also cause contamination. Thus, undue pressure on sterile packs should be
avoided. This prevents the ejection of sterile air and the entry of unsterile air into
the pack.
Principle Number 13: Microorganisms must be kept to irreducible minimum
Sterilization is the process of removing ALL microorganisms including the bacterial spores.
However, not all things or area can be sterilized. The following principles are employed to
employ sterile technique in:
Skin
Skin cannot be sterilized thus, it can be very good source of contamination in any
operation. To prevent entrance of microorganism to the patients wound the following are
done:
1. Surgical hand washing
2. Chemical antisepsis of the skin around the surgical site
3. Gowning and gloving
4. Application of sterile draping.
Air
Air contains dust, droplets and shedding that may cause contamination. Environmental
control measures include:
1. Movement around the sterile field is kept to a minimum.
2. Drapes are not flipped and fanned to avoid the spread of dusts.
3. Talking inside the operating room is kept to a minimum because moisture droplets
are expelled with force into the mask when a person is talking.




Deciding the right type of surgical incision is extremely important.
The ideal incision allows:
ease of access to the desired structures
can be extended if needed
ideally muscles should be split rather than cut
heals quickly with minimal scarring
aesthetically pleasing

It is also important that incisions are placed in the direction of lines of cleavage of the skin
(Langer's lines) so that a hairline scar is the outcome. These lines correspond to the
direction of collagen fibres in the dermis and epidermis.
Incisions should also be placed as far as possible from stoma sites in order to avoid
interfering with the stoma site and causing complications such as retraction and prolapse
of the stoma.
Surgical incisions on the abdomen can be divided into transverse, vertical and
oblique incisions.

Vertical incision 1: Midline incision

Use: Virtually all abdominal procedures may be performed through this incision.
Location: in the midline of the abdomen, and can extend from the xiphoid process to just
above the umbilicus. It can be continued to below the umbilicus by curving the incision
around the umbilicus.
Layers of the abdominal wall: skin, fascia (camper's and scarpa's), linea alba,
transversalis fascia, extraperitoneal fat and peritoneum.


Advantages
1. Adequate exposure of most if not all of the abdominal viscera
2. Minimal blood loss as the incision is through the linea alba
3. Minimal nerve injury
4. Minimal muscle injury
5. Can be quickly made, such as in an emergency and quickly closed with a mass closure
technique

Disadvantages
1. Care needs to be taken just above the umbilicus where the falciform ligament is
2. Midline scar

Vertical incision 2: Paramedian incision

Use: provides laterality to the midline incision, allowing lateral structures such as the
kidney, adrenals and spleen to be accessed.
Location: about 2- 5cm to the left or right of the midline incision. Incision is over the
medial aspect of the transverse convexity of the rectus.
Layers of the abdominal wall: skin, fascia (camper's and scarpa's) and the anterior rectus
sheath are incised. The anterior rectus muscle is freed from the anterior sheath and
retracted laterally. The posterior rectus sheath (if above the arcuate line) or transversalis
fascia (if below the arcuate line), extraperitoneal fat and peritoneum are then excised
allowing entry to the abdominal cavity.


Advantages
1. Provides access to lateral structures
2. Rectus muscle is not divided
3. Incisions in anterior and posterior sheath is seperated by muscle which acts as a
buttress, therefore closure is more secure
4. Can be extended by a curvilinear incision towards the xiphoid process if required

Disadvantages
1. Takes longer to make and close
2. Incision needs to be closed in layers
3. Difficult extension superiorly as limited by the costal margin
4. Tends to strip the muscles of their lateral blood and nerve supply resulting in atrophy of
the muscle medial to the incision

Vertical incision 3: Mayo-Robson incision

This is really a paramedian incision that has been curved towards the xiphoid process. It
allows a bigger and wider opening. Dissection continues in the same fasical planes as the
paramedian incision.

Transverse incision 1: Transverse incision

Use: right or left colon, duodenum, pancreas, subhepatic space.
Location: This incision is made just above the umbilicus, dividing one or both of the rectus
muscles.
Layers of the abdomen: skin, fascia, anterior rectus sheath, rectus muscle (+/- internal
oblique, depending on the length of the incision), transversus abdominus, transversalis
fascia, extraperitoneal fat and peritoneum. The medial aspect of this incision will be
through the layers just like as in the midline incision.


Advantages
1. Less pain than a midline incision
2. Good access to midline upper GI structures
3. Transverse incisions cause the least amount of damage
4. As the recti have a segmental nerve supply, it can be cut transversely without weakening
a denervated segment
5. Muscular segments can be rejoined
6. Commonly used in children and the obese as greater abdominal exposure is gained in
comparison with the vertical midline. This is due to the longer transverse length of the
abdomen in children and the obese.

Disadvantages
1. Limited lateral access in comparison with midline incisions that can then be extended
2. More wound infections compared to midline thought to be due to greater difficulty in
controlling bleeding and haematoma formation.

Transverse incision 2: Subcostal incision

Use: gallbladder and biliary tract, spleen. It is also known as the Kocher subcostal incision,
after the person who discovered it. With the roof top or Chevron modification, access to
oesophagus, stomach, kidney and adrenals and liver is also possible. Another modification
is theMercedes
Location: starts in the midline, 2-5 cm below the xiphoid, extending in parallel with the
costal margin at about 2.5 cm below the costal margin. A rooftop of Chevron incision is a
double Kocher incision. The mercedes incision involves a vertical incision from the rooftop
incision, like a mercedes sign.
Layers of the abdominal wall: Skin, rectus sheath, rectus muscle, internal oblique,
trasnversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum.


Advantages
1. Greater lateral exposure
2. Less painful to midline incision
3. Less post-operative complications such as PE to a midline incision
4. Heals well

Disadvantages
1. Longer operation time as the incision is closed in 2-3 layers
Transverse incision 3: McBurney's incision and the Lanz incision

Use: This is the incision of most appendicetomies and can be used in the left lower
quadrant in left sided colonic pathology.
Location: McBurney's point, as described by Charles McBurney in 1884, is two thirds from
the umbilicus and a third from the right anterior superior iliac spine. The incision is
oblique beginning laterally from above and ending medially.
If palpation reveals a mass, perhaps an appendiceal abcess, then the incision is made
directly over the mass.
Nowadays, the incision is made transverse and placed in a skin crease, the so called
transverseLanz incision as this is more aesthetically pleasing and the scar is hidden in the
bikini line.
If it is anticipated that the incision will need to be extended, the oblique incision is used
with lateral extension and as a muscle splitting (gridiron) surgical technique. Muscle
splitting involves spitting the muscles fibres in a direction that is parallel to the direction of
the muscle fibres.
Layers of the abdominal wall: skin, fascia, internal oblique medially and external oblique
laterally, transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum.


Advantages
1. Aesthetically pleasing incisions as they both follow Langer's skin lines
2. A wide range of pathologies in the right and left lower quadrants can be dealt with, with
room for extension if required
3. Minimal damage to muscles as muscle splitting techniques can be utilised
4. Avoids damage to local nerves

Disadvantages
1. The ilioinguinal and iliohypogastric nerves cross the appendicectomy incision and there
is a risk of injury. This can then predipose to inguinal hernia formation post-operatively.
This is more evident with the Lanz incision.

Transverse incision 4: Pfannenstiel incision

Use: Allows exploration of the lower GI and UT, as well as the pelvic reproductive organs.
Location: A convex 12cm incision, located a the suprapubic skin crease about 5cm above
the pubic symphysis. Once the peritoneum is reached, it is incised vertically, taking care to
avoid the bladder.
Layers of the abdominal wall: skin, fascia, anterior rectus sheath, rectus muscle,
transversalis fascia, extraperitoneal fat, perineum.
NOTE: this incision is below the arcuate line and this there is no posterior rectus sheath.
EXTRA: MAYLARD INCISION
This incision is placed a couple of cm's above the pfannenstiel and also provides good
exposure of the pelvic organs. It cuts through the rectus fascia and muscle as well as
external and internal obliques. Once transverse abdominus and transversalis fascia are
reached, a muscle splitting technique is employed.


Advantages
1. A convex incision is made instead of a transverse as this parallels the course of the
segmental nerves that are cut and so minimising muscle parasthesia and paralysis post-
operatively. It also follows the cleavage lines in the skin resulting in less scarring
2. Location of incision means it is hidden in the pubic hair line

Disadvantages
1. Limited exposure of the abdominal organs. Use of incision is therefore restricted to the
pelvic organs
2. High risk of injury to the bladder especially because the fascia thins towards the lower
abdomen, leaving the bladder relatively exposed, and if the bladder is not catheterised
during surgery
3. Extension of the incision is difficult laterally
4. Exploration of the deep pelvic organs is difficult making dissection in the obese difficult

Oblique incision: Thoraco-abdominal incisions

Thoracoabdominal incisions may be located in the RUQ or LUQ. They convert the pleural
and peritoneal cavities into one. They allow good access to the lungs, liver and spleen. The
left incision can also provide good exposure to the oesophagus and the stomach.


Laporoscopic incisions

These incisions are small cuts in the skin made in the abdominal wall to allow the
instruments of laparoscopy access to the contents of the abdominal cavity.
Their location will depend on the organ being operated on. Generally there will be 3-4.
One is always at the umbilicus to allow a port for the camera. The other incisions will be
located in one of the 4 quadrants for tools such as the griper, cutting and dissecting scissors
and so on.


Care of the surgical incision

Surgical incisions may be closed with sutures, staples, steri-strips or local tissue glue.
It is important to keep the wound site clean and incisions are often covered with a
protective dressing. Patients are encouraged to keep the wound as dry as possible to limit
wound infection. Showering and bathing can resume after a couple of days. Wounds that
are closed with nonabsorbable sutures and staples require removal of these materials first.
While gentle exercise is encouraged, it is important to avoid pressure, pulling and
stretching on wounds.
As wounds heal, it is common for patients to see their wounds becoming itchy, red, swollen
and wounds may even ooze sero-sangiunous fluid. These all represent the healing process.
It is important to know what is normal so that abnormalities in wound healing that may
represent infection, wound dehiscence, hypertrophic and keloid scars may be detected.






Tissue Layers
Tissue Layers: Skin, subcutaneous tissue, superficial fascia, muscle, extraperitoneal fascia
(deep fascia), peritoneum

Layers of the abdomen, from interior to exterior as follows: peritoneum, extraperitoneal
fascia, muscle, deep fascia, superficial fascia, subcutaneous tissuek and skin.

A: Fascial closure, B: Looping the 0-PDS at the vertex, C: Continuous suture, D: Two PDS
meet in the middle of the incision, tie together, and cut.


The skin is the largest organ of the body, with a total area of about 20 square feet. The skin
protects us from microbes and the elements, helps regulate body temperature, and permits
the sensations of touch, heat, and cold.
Skin has three layers:
The epidermis, the outermost layer of skin, provides a waterproof barrier and
creates our skin tone.
The dermis, beneath the epidermis, contains tough connective tissue, hair follicles,
and sweat glands.
The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.
The skins color is created by special cells called melanocytes, which produce the pigment
melanin. Melanocytes are located in the epidermis.

The subcutaneous tissue is the third of the three layers of skin. The subcutaneous layer
contains fat and connective tissue that houses larger blood vessels and nerves. This layer is
important is the regulation of temperature of the skin itself and the body. The size of this
layer varies throughout the body and from person to person.
Superficial fascia is found in the subcutis in virtually all regions of the body, blending with
the reticular layer of the dermis. It is present on the face, over the upper portion of
the sternocleidomastoid, at the nape of the neck, and overlying the sternum. It is mainly
loose areolar connective tissue and adipose and is the layer that primarily determines the
shape of a body. In addition to its subcutaneous presence, this type of fascia surrounds
organs and glands, neurovascular bundles, and is found at many other locations where it
fills otherwise unoccupied space. It serves as storage medium of fat and water; as a
passageway for lymph, nerve and blood vessels; and as a protective padding to cushion and
insulate
Characteristics of muscle:
excitability - responds to stimuli (e.g., nervous impulses)
contractility - able to shorten in length
extensibility - stretches when pulled
elasticity - tends to return to original shape & length after contraction or extension

Functions of muscle:
motion
maintenance of posture
heat production

Types of muscle:
skeletal:
o attached to bones & moves skeleton
o also called striated muscle (because of its appearance under the microscope,
as shown in the photo to the left)
o voluntary muscle

smooth (photo on the right)
o involuntary muscle
o muscle of the viscera (e.g., in walls of blood vessels, intestine, & other
'hollow' structures and organs in the body)
cardiac:
o muscle of the heart
o involuntary
Extraperitoneal fascia (deep fascia) fascial plane of mainly loose areolar tissue between
the parietal peritoneum and the internal muscular (iliopsoas and inner lamina of
thoracolumbar fascia) and transversalis fascia of the body wall; its quality and quantity
vary considerably, being very thick and fatty posteriorly, as pararenal fascia around the
kidneys, but thin and fibrous anteriorly, deep to the linea alba of the anterior abdominal
wall.
The peritoneum is the serous membrane that forms the lining of the abdominal cavity or
the coelom it covers most of the intra-abdominal (or coelomic) organs in
higher vertebrates and some invertebrates (annelids, for instance). It is composed of a
layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both
supports the abdominal organs and serves as a conduit for theirblood and lymph vessels
and nerves.
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