SOP SurgicalFacilities
SOP SurgicalFacilities
SOP SurgicalFacilities
Furniture and Equipment
Some of the more common pieces of furniture and equipment found in a procedure room include:
OR table
The table is fully adjustable in all directions to create the positions needed for various surgical
procedures, and all personnel should be totally familiar with its operation and its corresponding
accessories. The table should be positioned directly under the overhead light fixture, and once in
position, should be locked for animal and staff safety.
Instrument (back) table
Once it is draped with a bacterial barrier, the instrument table provides a set‐up areas for sterile
supplies to be used during the procedure. The table is made of a noncorrosive metal, and has a top
and bottom shelf. The bottom shelf can be used for storage of extra supplies not immediately
needed. The table is on wheels, and can be positioned wherever necessary to provide maximum
efficiency during the procedure.
Ring Stand
The ring stand is round or square, and is used to hold basin sets and/or instrument trays. The ring
stand, once draped, should be placed close to the instrument table, since it will become part of the
sterile field during surgery.
Mayo Stand
The Mayo stand is used to hold instruments that will be used frequently during the procedure. It is
draped with a bacterial barrier, and then placed directly over, but not in contact with, the monkey
once the drapes have been applied. It is adjustable in height, and is totally portable, since it moves
on wheels. During the setup period, the stand should remain close to the other furniture to avoid
possible contamination or accidental bumping of the stand.
Waste Containers
Prior to opening any packages the properly lined waste containers should be available and placed
well away from the sterile field to avoid possible contamination during the set‐up phase. The three
types of waste containers are for washable cloth items, uncontaminated waste, and contaminated
waste. The use of kick buckets (a bucket on wheels) is restricted to soiled sponges during surgery. It
is lined with a disposable liner which can be removed and exchanged as required during the
procedure without jeopardizing the sterility of the surgical field. All other trash should be placed in a
larger trash receptacle. Once a procedure has started, no trash may leave the room.
Additional Furniture and Equipment
In addition, anesthesia machines, electrosurgical units (E.S.U.), Monopolar coagulation unit, Bipolar
Coagulation Unit, light source with headlight, heating pad, suction canisters/tubing, IV. poles, linen
receptacles for nondisposable linen, and adjustable stools should all be in their proper positions
before opening and creating the sterile field to avoid possible contamination of the field during
moving activities. Safety glasses also belong to the category of standard OR equipment and should
be available for all members of the team before the procedure begins.
Standard and Accessory Supplies
Surgical supplies can be divided into two major categories: sterile supplies and nonsterile supplies.
Each category can then be subdivided into those items that are considered essential, or standard
supplies, and those that are not required for every case (accessory supplies).
Standard Sterile Supplies
Sterile Packs and Drapes
The packs and drape sheets are made of disposable fluid‐resistant material, which acts as a bacterial
barrier against microbial infiltration. Sterile drape sheets come in various sized and forms, with or
without fenestrations, and are usually used as an added bacterial barrier for specific draping needs.
Our standard pack consists of:
Basin Sets
Basin sets contain the pots and pans necessary for a procedure. We use a Minor Basin Set composed
of 4 basins, a pan, and 2 medicine cups. The largest basin fits in the ring stand while the other 3,
each smaller than the last (so they fit inside each other with sticking), are placed on the back table.
Prep Kit
The prep kit contains a pair of gloves, two towels, two types of sponges for scrubbing, betadine scrub
solution, and betadine paint. The contents are sterile and must always be handles appropriately.
Syringes/Needles
Syringes - 1cc, 3cc, 10cc, 30cc
Needles 25ga 5/8”, 23ga x 1”, 21ga x 1”, 20ga x 1”
Catheter 22ga, 24ga
Blades
Scalpel Blades #10, #11, #12, #15
Sutures/Staplers
Stapler 35 Regular
Chromic 4-0
Vicryl 3-0 P-1
Opthalmic 6-0
Opthalmic 5-0
Opthalmic 8-0
Chromic 5-0
Sponges
4”x4” sponges and 2”x2” sponges – sterile – general usage in every procedure
Cottonoids – range in size from ¼” x ¼” to 3”x3” – soft, lint free, absorbent material
that won’t scratch delicate tissue.
Cottonoid ½
Cottonoid ¼
Cottonoid 1/8
Dissecting Sponges (Cherry, Peanut, and Triangle Dissectors) used to “push” away
delicate tissue.
Surgicel
Eye Spears
Standard Nonsterile Supplies
Suction Tubing
Suction Canister
Bovie Grounding pad
Medical Adhesive spray
Silk Tape 3 in.
Tape – 1”, ½”
Positioning Equipment in the OR
The first step in creating a suitable surgical environment is related to the preparation of the
procedure room, including the physical layout of furniture and equipment, and the placement of
supplies in a convenient location, since wasted motion is not only time‐consuming but also can add
to physical and mental fatigue. The circulator, scrub person and nurse anesthetist are all responsible
for the appropriate placement of equipment prior to starting a procedure. The operating room is
prepared before the animal is restrained with Ketamine.
The figures IV-9a and IV-9b show the operating room and the standard equipment
requisite for the surgical procedures performed in our lab. Figure IV-9a shows the
Figure IV‐9a : The operating theatre
Figure IV‐9b : Ring stand, back table and Mayo stands
Preliminary Preparation
SUPPLIES SUPPLIES
C-arm
digital
radio- Monitor
graphy and video B
and Anesthesia
flouros- machine Monitor
copy
machine
Mayo Mayo Back table
SUPPLIES
Figure IV‐10 : Overview of the placement of items and devices in the OR while preparing an operation
Before bringing in the selected surgical supplies for the case, horizontal surfaces should be damp
dusted with disinfectant solution. This includes the bed, light covers, Mayo stands, back table, and
prep tables. Damp‐dusting reduces viable microbial contamination from air and other sources by 90
to 99 percent. After dusting, the sterile items to be used during setup are brought into the room and
placed either on the bed or the prep tables, leaving the back table and Mayo stands free.
The Surgical Team
The surgical team at MPI is composed of five people: surgeon, surgical assistant, scrub person,
circulator, and nurse anesthetist.
Aside from performing the actual operation, the surgeon and surgical assistant, with the
assistance of the nurse anesthetist, are responsible for the preparation of the animal. Their
involvement in the preparation phase begins with the initial restraint of the monkey and ends after
the animal has been started on gas anesthesia, at which point the circulator takes over.
The circulating person performs those functions associated with the management of the room
before, during, and after the procedure. The circulator assists the scrub person during setup and
performs the initial scrub of the animal. The circulator remains nonsterile throughout the procedure.
The scrub person performs all tasks related to the creation and maintenance of the sterile field
before and during surgery, in addition to the care of the instruments when surgery is completed.
Before any sterile items are opened in the operating room or accepted onto a sterile field, the scrub
person must be confident about their condition. If the sterility of any item is in question, it is
considered unsterile and must be immediately removed from the field. The role of the nurse
anesthetist will be explained in detail in the Anesthesia section.
Traffic Patterns
All personnel entering the surgical suite should follow a well‐delineated traffic pattern. Movement of
animals, supplies and/or equipment should be along the most direct route that prevents cross‐
contamination and/or undue exposure by either space or time. Traffic flow within the surgical suite
is based on the principles of asepsis and infection control. In general, traffic flows both in and out of
the surgical suite, depending upon the surgical suite design, but within a specific area the flow must
be established according to principles that maintain an aseptic environment. Ideally, each pattern is
unidirectional; that is, the flow of traffic is from entry to exit and from clean to dirty. However, this
concept is ideal, and flexibility, based on acceptable principles, is required to achieve the ultimate
goal: the prevention of cross‐contamination from one area to another.
The Concept of the Sterile Field
The use of a sterile field is composed of three distinct phases: (1) creation of the sterile field, (2)
maintenance of the sterile field, and (3) termination of the sterile field.
Creating Sterile Fields
Much of the general preparation for a surgery is done by the scrub person, who is responsible not
only for the selection of instrument packs and items that will be needed during the procedure, but
also for the setup of the sterile fields and laying out of the instruments just prior to beginning a
procedure. The sterile fields are prepared by the scrub person just prior to the start of a procedure.
Preparation is divided into two phases: a nonsterile phase and a sterile phase. The purpose of the
nonsterile phase is to prepare the procedure room and position the supplies in such a way that, once
the scrub person is sterile, setup can be completed unassisted and without compromising sterility.
Sterile fields will be created first on the back table, the ring stand, and the Mayo stands, in that
order. Two of these sterile fields (back table and ring stand) are created before the scrub person is
sterile. The sterile fields on the Mayo stands are created after the scrub person has scrubbed and is
dressed in an appropriate, sterile surgical outfit.
When a nonsterile person drapes an area they do so away from themselves first, then towards
them, avoiding reaching over a sterile field. Sterile persons drape an unsterile surface first toward
themselves, protecting their gown and gloves at all times.
The following is a brief description of the creation of the various sterile fields. (Prior to setup of
the sterile fields, however, it is important that all the requisite equipment be appropriately
positioned in the OR and that the proper waste containers are present for the disposal of paper and
contaminated goods.)
Back Table Figure IV‐11 : The back table serving as a sterile field
At the time the sterile cover is placed on the
back table, (see Figure IV‐11) the scrub person is not sterile. The cover is removed from its package
and placed in the center of the table. It is folded such that it can be handled normally without
contaminating what will be the sterile surface. The cover is unfolded away from the scrub person
first and then towards them. Then they must walk to either end of the table and carefully spread out
the cover being sure to grab it only in regions that are nonsterile. Starting now, one must always be
mindful of ones position with respect to sterile fields.
Once draped, the instrument table should be at least 18 inches away from walls and cabinets,
away from linen hampers, doors, garbage receptacles, anesthesia equipment, and traffic paths. Once
it is draped with a bacterial barrier, the back table provides a set‐up area for sterile supplies to be
used during the procedure. The bottom shelf can be used for storage of extra supplies not
immediately needed. The remaining sterile supplies, except the small ones and instrument packs,
can now be opened and tossed onto the back table. Figure IV‐11 shows the covered back table with
sterile supplies on it. Items that go on the back table include the drapes for the animal, towels, and
gowns and gloves for the surgeon and assistant. As a rule, blades and cottonoids are also opened
onto the back table. Blades are always placed in the lower left‐hand corner, while cottonoid is
placed in the lower right‐hand corner. At this point the back table is finished until after the scrub
person has scrubbed in.
Figure IV‐12 : The ring stand as a sterile field
Ring Stand
The next sterile field to be
established is the ring stand
(Figure IV‐12). The basin is
placed in the ring stand. The
wrap is undone completely, in a Figure IV‐13 : Mayo stands prior to scrubbing in
manner similar to the back table,
being careful that the sterile
internal surface remains sterile.
One must always be careful that
a nonsterile part of the wrap
does not fall back onto the
exposed bowl. At this point the
insides and contents of the bowl
should be visually inspected. If
any condensation is seen, the
bowl and its contents are
considered unsterile and a new
basin must be used.
Once appropriately placed, the
small, nonsterile items collected
into the miscellaneous,
nonsterile bags can be opened
into the bowl (Figure IV‐12), in preparation for placement onto the back table. With the exception of
the blades and cottonoids, all items in the bag should be opened into the basin.
Mayo stand
Prior to scrubbing in, one of the Mayo stands is used to hold the gown and gloves of the scrub
person. The scrub person opens their gown package on one of the Mayos and tosses their sterile
gloves (unpacked out of the
external container, but still
inside the internal packing
paper) onto the open gown
pack (see Figure IV‐13). This
creates a temporary sterile
field which must be treated as
all others. Once the scrub
person has gowned and gloved
and the waste paper has been
removed, the Mayo stands are
prepared for the actual
procedure.
The Mayo stand cover is
unfolded on the back table,
the opening is identified, and picked up by placing one’s hands under the cuff such that the opening
falls open slightly. Using one’s foot, pull the Mayo from the wall into a clear area. Slip the open end
over the Mayo tray, and, with one foot holding the
stand in place, begin pulling the closed end of the cover
away from the table while sliding the other end over
the tray and down the stand, being careful to touch
Figure IV‐14 : Mayo stand with cover
only the sterile surface of the cover.
Instrument Tray Layout and the Working Area of the Back Table
The placement of instruments and supplies on the sterile fields involves working on all of the existing
sterile fields simultaneously and will therefore be handled in one step rather than describing the
setup of the back table and Mayos individually.
The panels in Figure IV‐15 show the final configuration of the instruments in the four conceptual
regions into which they are organized during setup. The instruments from the cranial set are setup
on one of the Mayos and the back table first. Instruments on the Mayo stands are always arranged
with sharp edges being farthest away (when the Mayo is in position, which means nearest when
setting up), and the tools should progress in order of use from farthest to nearest (when the stand is
in position). That is to say, the farthest tools will be used first, the nearest last.
The working area of the back table (see FigureIV‐15) will be nearest the Mayo stands when they are
in their final position (diagram figure IV‐28). First a sterile towel is laid down. Then two towels
(folded in 3rds) are laid across it along the bottom and about three‐fourths of the way up. They
remain folded so items can be tucked into them. The cottonoid is placed from right to left (smallest
to largest) in the bottom fold of the upper towel. The bowls in the basin in the ring stand are placed
right to left (largest to smallest) at the back of the table, on the towel. The pan in the basin set is
placed in the lower left corner of the back table (29) where the blades were. An instrument role is
made by tightly rolling up a towel and placing it lengthwise between the square pan and the working
area along the front edge of the table (34). At this point, the drapes and gowns are moved from the
Mayo to the basin in the ring stand, and one is ready to begin laying out the instruments.
Figure IV‐15 : Placement of the surgical inbstruments on the Mayo stands and the back table
The Cranial Set
The upper right panel in Figure IV‐15 shows the layout of the cranial Mayo. The upper tray in the
cranial set contains the stringer of forceps, a number of items for opening and closing, and a role of
heavy tools. The upper tray is removed and placed in the back left‐hand corner of the back table.
The stringer of forceps (35) is placed on the instrument role (34) and the stringer is removed. One
must be careful while removing tools from the row so as not to knock them off the table. All forceps
should be closed (locked) when handed to the surgeon, so it is a good idea to lock them, after
removing the from the stringer, before placing them on the field. Select one large (46) and one small
(47) needle holder and place them in a fold of the lower towel (49) on the working field. The suture
scissors (48) are placed in the lower left corner of the working field, the curved scissors (17) are
placed in the near right corner of the Mayo, and the towel clips (43) are placed in the center of the
working field. The Raney skin‐clip holders (36) are placed in the smallest bowl, along with the
medicine cup. The remaining loose instruments in the tray that will be needed, for example the
small suction tips (45) and the ruler (38), are removed and placed on the field. The roll of tools is
then unrolled and the heavy tools are placed on the field. This includes the #3 scalpel handles (27),
with the appropriate blades on them, the Langenbeck (26), Love‐Adson (24), and the raspatories (25),
and the larger suction tips (45). There are also several heavy tissue forceps in the role. The two
Adson without teeth will be used during opening and should be placed with the Cushing (16). The
Adson with teeth (42) will be used during closing. When the needed tools from the upper tray have
been placed, the drapes, gowns and gloves on the other Mayo are placed in the tray and the tray is
placed on the ring stand over the basin in the ring stand.
The Ophthalmic Set
Now the instruments from the ophthalmic set are placed on the sterile field of the ophthalmic Mayo
(Figure IV‐15, upper left panel). If the procedure does not involve the placement of an eyecoil the
upper tray will not be needed, however, the lower tray will always be needed as it contains the tools
for manipulating and placing both headposts and chambers. The upper tray is again placed in the
back left corner of the back table. All of tools needed from the upper tray are placed on the empty
Mayo. The #7 scalpel handle with its blade, and other cutting instruments, are again placed in what
will be the farthest position away from the scrub person, and then the instruments are arranged in
order of use. The tenotomy, Metzenbaum, and Steven’s scissors (2) are placed together with the
curved conjunctival scissors (5), one left, one right, and one straight. Bipolar forceps (4) are placed in
the center of the tray. The specula (9a and 9b) and Castroviejo calipers (8) are placed near the front
as they will be used first. The tissue forceps (.12 Castroviejo (1) and curved jewelers and half angle
(3)) and the needle holders (6) are placed in the back. The baby mosquito (7) forceps are placed on
this Mayo as are the carpet needles (11). The remaining instruments are left in the tray and the tray
is left in the back left corner of the back table. The ophthalmic Mayo is now finished and a close‐up
of it can be seen in the upper left panel of Figure 1‐7. The ophthalmic irrigation bulbs and tips are
assembled, filled and left in the largest saline bowl (39). The lower tray in the ophthalmic set
contains the Synthes instruments, bending tools, and the bipolar cord. This tray is removed from the
pan and placed temporarily on top of the first ophthalmic tray. It is later moved onto the basin in the
ring stand where it will remain for the duration of the procedure.
The Synthes tools (the screwdrivers (18), the taps (19), the countersink (20), the depth gauge (21),
the drills with bits (22), and the drill guides (23)) are placed on the cranial Mayo. The bipolar cord
(33) is placed in the extra tool area of the back table, and an Alice forceps (32), used to hold the
cords on the field, is placed nearby. The rest of the tools remain in the tray.
The second tray is removed from the cranial pan, placed in the space previously occupied by the
upper tray, and the needed tools are placed on the sterile field. The Cone scalp retractors (12), the
hand‐held muscle retractors (13), and the hand‐held muscle/tendon hook retractors (14) are placed
together. If a craniotomy is to be made, the trephine is place in the center of the cranial Mayo.
When all of the tools from this tray have been selected, place the upper tray on top of it and place
both on the basin of the ring stand, leaving the second Mayo clear.
Draping the Animal
The final sterile field to be created is over the animal on the OR bed itself. Three types of sterile
drapes are used to cover the animal completely, providing adequate protection against
contamination, while also allowing appropriate access to the incision site. The body of the animal,
from its feet up to and around its neck is covered with a fanfold sheet. This is secured in front with a
towel clip. The head is then draped with the appropriate window drape. The window of this drape,
which is laid down by the surgeon before starting, goes directly over the incision site. This provides a
complete bacterial barrier between the animal and the rest of the sterile field while allowing visual
identification and inspection of the surgical site prior to opening.
Maintaining a Sterile Field
According to the principles of basic aseptic technique mentioned earlier, a sterile field, once
established, must be constantly monitored and maintained. This monitoring process is the
responsibility of every member of the surgical team, and each must watch for events that may
compromise the sterility of the field, and take appropriate corrective action.
Once the animal is placed on the operating table, prepped and draped, it becomes the center of
the sterile field, and all movement and activities in and around the field must be performed without
compromise to that field.
All sterile supplies and equipment should be grouped around the sterile field on the OR table, and
must be kept in view at all times by both the sterile and nonsterile members of the team. All items
used within the sterile field must be sterile. Sterile persons and items may touch only sterile areas,
while unsterile persons and items may touch only unsterile areas.
Sterile items should be presented to the scrub person or placed securely on the sterile field
without reaching over the field, which would cause immediate contamination. Sharp or heavy
objects should be opened on a separate surface to avoid injury or possible contamination of the
objects during transfer.
Some materials appear resistant to moisture but should liquid be spilled, creating strike‐through,
the area must be reinforced with a sterile towel or drape, since strike‐through of fluids constitutes
contamination of that sterile surface.
As always, if the sterility of an item, be it a towel, instrument, or needle, is in doubt it must be
considered contaminated, removed from the field, and replaced by another sterile item.
All personnel entering the area of the surgical suite should be in proper O.R. attire. Operating
room attire is an important factor in controlling the potential spread of infection to the surgical
animal and to the population outside the protected area. By restricting the clothing worn within the
suite, the first barrier to infection has been established, and it is an essential component for the
maintenance of an aseptic environment.
Air currents can become a source of contamination; thus, movement within or around a sterile
field should be minimal to avoid contamination of the field. Sterile persons (in gown and gloves)
should not wander in and out of the sterile area while in sterile attire, since the gown is considered
contaminated below waist level. Nor should sterile persons sit while in sterile attire, unless the entire
procedures is performed in a sitting position, or leave the procedure room/sterile area in gown and
gloves (either during or after the procedure).
Unsterile equipment, furniture, and personnel should remain a safe distance from the sterile field
(at least 12 inches) to avoid accidental contact with the field. Unsterile personnel should approach
the field facing it and never walk between two sterile fields. The general rule is never turn your back
on a sterile field, always maneuver in such a way as to face it. Tables are sterile at table level (on the
upper surface) only.
Sterile supplies should never be opened and then covered or left unguarded during the
preliminary phase of the sterile field’s creation. Chances for contamination of an unguarded sterile
field are numerous, and without direct observation, there is no way to ensure sterility.
Termination of the Sterile Field
It is important to terminate the sterile field in a safe and logical manner, and at the proper time. Until
the animal has been prepared for transfer to the postoperative area, the environment must be
maintained in an aseptic manner, in case an unforeseen emergency occurs that necessitates
immediate action. Therefore, all members of the surgical team should keep their masks in place
during the transition period.
After the last stitch is in place, and the area cleaned, the sterile dressing is applied by the scrub
nurse and held in place while the drape sheets are removed with assistance from the circulator,
rolling the drape sheet inside out toward the foot of the table. The scrub nurse, with the equipment,
should then step back to a position away from the operating table, where the actual termination
procedure will take place.
It is a good idea to leave the sterile fields on the Mayo stands and back table intact until the
animal has left the room and been placed in the recovery area in case an emergency requiring sterile
instruments arises.
All instruments, whether used or not, are considered contaminated and must be decontaminated
according to protocol. However, instruments that have been used during the procedure should be
cleaned using a basin of sterile water and a sponge or brush before terminal decontamination. This
action provides safety for those persons handling the instruments during the cleaning phase. Before
disposing of drape material, it should be checked for instruments, since they may be still attached to
the drapes during the dismantling phase. Disposable linen and cloth items are then placed in their
respective bags for disposal. Gloves must be worn during this process, even by the circulating nurse,
since blood and fluids may still be present on the drape sheet. All sharps, including cautery tips,
blades, and hypodermic needles should be placed in a container and disposed of according to
protocol.
The last step is the removal of the scrub person’s gown and gloves. The scrub person should
remain sterile to the end in case emergency intervention is required. By following the process of
creating, maintaining, and terminating the sterile field, the patient and personnel working in and
around the sterile field can be assured of a safe and therapeutic environment, before, during and
after the surgical procedure.