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Intraoperative care: theatre

Related theory

Before surgical intervention (skin incision)

The team in theatre includes the anaesthetist, surgeon, registrar, anaesthetic assistant, scrub and circulating assistant. Once the patient has been transferred and positioned on the operating table, before surgical intervention, the theatre team will complete the second section of the safety checklist which is ‘time out’ (Table 14.4). This ensures that the team is fully aware and readily equipped for any eventuality that may arise during the procedure. WHO checklist (part 2) ‘Time out’ has to be read out loud for all team members to hear and respond to and has to be completed before the start of the surgical intervention, that is skin incision (Table 14.4).

Control of infection and asepsis in the operating theatre

As part of the intraoperative care, the aim of operating theatres is to provide an area free from infectious agents. Large quantities of bacteria are present in the nose and mouth, on the skin, hair and the attire of personnel; therefore, people entering the operating theatres wear clean scrub suits and lint-free surgical hats to eliminate the possibility of these bacteria, hair or dandruff being shed into the environment (Tammelin et al. 2000). Well-fitting shoes with impervious soles should be worn and regularly cleaned to remove splashes of blood and body fluids (Woodhead et al. 2002). Facemasks are worn to prevent droplets falling from the mouth into the operating field. The extent to which face masks are capable of preventing droplet spread is disputed (Lipp and Edwards 2002). It is, however, accepted that masks offer protection to the wearer from blood splashes and for safety reasons should be worn by the scrub team. Instruments must be handled carefully and needle holders and forceps used to manipulate sutures to minimize the risk of needlestick or sharps injury.

Minimally invasive surgery (laparoscopic surgery)

Specialties using this technique are:

general surgery

gynaecology

gastrointestinal surgery

urology.

Laparoscopy involves insufflation of the abdomen with carbon dioxide (CO2). Prolonged insufflation can cause hypothermia as although the gas temperature in the hose equals room temperature, the temperature in the abdomen can decrease to 27.7°C due to high gas flow and the large amounts of gas used (Jacobs et al. 2000). Sharma et al. (1997) refer to the increased risk of hypercarbia and surgical emphysema during insufflation with CO2. Careful monitoring and recording of the patient’s vital signs, including oxygen saturation and expiratory gas levels, are therefore essential during laparoscopy. Haemorrhage can occur during the procedure and may be difficult to detect because surgeons have a limited view of the area being operated upon. Electrosurgical injuries to organs may occur as a result of capacitive coupling (the transfer of electrical currents from the active electrode through coupling of stray currents into other conductive surgical equipment) (Wu et al. 2000). Theatre staff must be aware of potential complications and ensure that equipment is used safely and according to the manufacturer’s instructions.

Evidence-based approaches

Rationale

The position of the patient on the operating table must be such as to facilitate access to the operation site(s) by the surgeon, and the patient’s airway for the anaesthetist. It will also be dependent upon the type of surgery being performed, position of monitoring equipment and intravenous devices in situ. It should not compromise the patient’s circulation, respiratory system or nerves.

Preoperative assessment will identify patients who may need extra precautions during positioning because of their weight, nutritional state, age, skin condition or pre-existing disease. Pre-existing conditions such as backache or sciatica can be exacerbated, particularly if the patient is in the lithotomy position, as the sciatic nerve can be compressed against the poles (AORN 2001). Most postoperative palsies are