Surgical Asepsis

Surgical asepsis refers to the use of sterile instrumentation and technique before entering the body. This technique prevents introduction of microorganisms into the body. (Medical asepsis refers to the proper disposal of biohazardous waste after it leaves the body.) You must be familiar with the general principles of sterile technique and comfortable with the setup of a sterile field. A sterile field is a work area specially prepared with sterile draping that will hold instruments used in a procedure.

Principles to remember in any minor surgery include the following:

Know which items are sterile and which are nonsterile, and keep them separated.
Take precautions to prevent accidental contamination of the sterile field once it is prepared. It is best not to leave the sterile field unattended but if you must, cover it with a sterile towel.
Any contamination of your sterile clothing, gloves, or the sterile field must quickly be addressed by replacing the contaminated items.
Carefully examine sterile objects prior to use. Check the expiration date of each object and ensure that the wrapping is intact and dry. If there is any doubt about the sterility of the object, re-sterilize.
The outside of sterile gloves must not be touched with bare hands. Once you have put on sterile gloves, you must not touch any nonsterile items. Nonsterile persons must not touch any sterile items unless they are using sterile transfer forceps. Once these forceps are used, they are considered contaminated and must be re-sterilized prior to being used again.
The sterile field, all sterile items, and your sterile gloved hands must be kept at or above waist level.
Keep movements around the sterile field to a minimum. Make sure that air currents are kept to a minimum. Avoid drafts and fans. Do not reach across a sterile field. Avoid coughing, sneezing, or talking directly over a sterile field. It is advisable to stand with your hands clasped in front of you above waist level when idle.
Avoid spilling anything wet on the sterile field. Areas that become wet allow microorganisms to migrate into the sterile area. Wet areas are considered contaminated and must be covered with sterile towels or the sterile field must be dismantled and set up again.
Outer wrapping of sterile packs are not sterile and must be opened by someone not wearing sterile gloves. The flaps of the sterile pack must be opened away from the body, being careful not to touch the inner wrappings with your clothing, your hand, or any other object. Once the outer wrapping is opened, the inner pack may be added to the sterile field by placing it in the center of the field without letting the outer wrapping touch the field.
Instruments in peel packs may be opened by peeling downward and allowing the article to be picked out by someone wearing sterile gloves or allowing the articles to slide from the pack onto the sterile field.

Setting Up a Sterile Field

A sterile field is set up on a flat, secure surface. The sterile field is often set up on a metal stand on wheels called a Mayo stand. The stand must be cleaned with disinfectant prior to use. Its outer one inch and any material that falls below the level of the sterile field are considered nonsterile. Liquids must be added to the sterile field in a specific manner. First the medical assistant must check the label of the bottle to make sure that it is the right solution. The lid is removed and held in the hand or placed on a hard surface with the lid downward without contaminating the sterile field. The label is rechecked and then placed in the hand to protect it. The liquid is poured from about six inches above the sterile field very carefully to prevent spilling onto the sterile field. The label is rechecked again and the lid replaced carefully without contaminating the bottle.

Surgical Hand Wash

A surgical hand wash should be done prior to gloving. All jewelry should be removed and hands and nails inspected. Ideally the water and soap will be controlled by foot pedals. A sponge and brush combination that is impregnated with antiseptic soap may be used. A file should be used to clean under fingernails. Hands should be pointed upward so that water runs off toward the elbows. The hands and arms (up to the elbows) should be washed for a total of 6 to 10 minutes. Avoid touching the inside of the sink. After washing for the proper amount of time, rinse well from fingertips to elbows. Turn off the water using the foot control. Dry your hands on a sterile towel using a patting motion. Use a separate end of the towel for each hand. Make sure hands are completely dry so that sterile gloves can easily be applied.

Applying Sterile Gloves

Applying sterile gloves must be practiced until the skill is mastered. It is important to make sure that you have the correct size of gloves. After opening the peel pack, carefully open the inner sterile pack using the tabs and avoid touching the inner surface of the paper. Pick up the cuff of the glove for the dominate hand. Lay the thumb flat against the palm of the hand and slip the hand into the glove. With the gloved hand, slide the fingers under the cuff of the other glove, taking care not to touch the inside surface of the glove. Again tuck the thumb into the palm and slide the hand into the glove. After both gloves are on, you may adjust the fit and link the fingers together to remove air and wrinkles in the gloves.

It is very important to properly remove soiled gloves after performing a procedure. Grasp the palm of the glove of the nondominant hand with the dominant hand and pull it into the gloved hand carefully in order to prevent splattering of any infectious material. Once the first glove is removed, insert the finger of the bare hand under the other glove and peel the glove in and down to prevent contact with the outside of the contaminated glove. Dispose of the gloves in a biohazard waste container. Wash your hands thoroughly.

Applying a Sterile Gown

After doing the hand scrub, you may need to apply a sterile gown. You should be gowned prior to putting on sterile gloves. The sterile gown should be carefully opened and picked up by the collar. It is then held away from the body to prevent contamination and allowed to unfold. Then slip your hands into the sleeve and touching only the insides of gown pull it onto the shoulder area. The hands should remain inside the sleeves to prevent contamination. An assistant should then come behind you and fasten the neckline and secure the ties around the waist. Sterile gloves are applied as described here and the cuffs pulled up over the cuffs of the gown.

Preparation of the Skin

The medical assistant is responsible for preparing the skin prior to the surgical procedure. Supplies to assemble in advance include draping materials, antiseptic soap, sterile sponges, sterile forceps, razor, and antiseptic solution. You must carefully check allergies prior to cleaning the skin. Betadine is frequently used as an antiseptic solution. Alternatives are available if the patient has an allergy to iodine. Cleaning should start from the inside of the affected area and move outward in a circular motion. If the area must be shaved, it should be done after cleaning. Shave in the direction of the hair growth to help prevent cuts in the skin. The area should then be rinsed and painted with the antiseptic solution using a sterile cotton swab. The surgical area should be draped in preparation for the procedure.