INTRODUCTION
The basic principles of surgery remain same to any branch of surgery, including the oral and maxillofacial surgery. A surgeon must have apt knowledge of anatomy, applied physiology, pathological conditions and more importantly, a very sound technique and skills. The skills are acquired through extensive practice. A correct diagnosis is the key to successful treatment. There can be a variety of treatment modalities for a single disease, but the diagnosis has to be single and accurate. Hence, sincere and thorough approach to history taking and clinical examination is required and there cannot be a shortcut to these procedures. A surgeon must train his eyes, fingers and mind and should believe in them rather than relying totally on investigations. The investigations are of great importance in making proper diagnosis, but they cannot be a substitute for the clinical methodology and skills. Even for ordering the relevant investigations a clinical diagnosis is required. Every case should be considered as a new challenge as the patient's response to a given pathology and treatment could be different. A surgeon must have regard for asepsis, sterilization, tissue respect and for all the basic principles of surgery to achieve good results, because, the result of a good surgery can get spoiled due to infection and sometimes it may prove fatal. The antibiotics are a great help in controlling the infection, but they are not a substitute for aseptic principle. Similarly, tissue respect is also of immense importance in achieving the desirable outcome of surgery.
ASEPSIS AND STERILIZATION
The surgical procedures have been revolutionized from the antiseptic methods of Joseph Lister (1865), to the aseptic technique of today. Every effort is made to prevent the entry of germs into a surgical wound by sterilization of instruments, material used for surgery and preparation of the environments. The success of surgery including the quality of healing of the wound, the amount of local and constitutional reaction, morbidity to the patient following the surgery depends upon not only the surgical skill but also upon the care exercised by the surgeon and his team during the patient care.
ASEPTIC TECHNIQUE
The word ‘asepsis’ means absence of sepsis (infection). The aseptic technique accurately describes the series of practices employed to prepare environment, the personnel and the patient before the surgery. It is impossible to sterilize the air and personnel in the operating room. The term sterilization describes the procedures employed to prepare the instruments, supplies and certain other inanimate objects (motor, hand piece, etc.) used to perform surgical procedure. These practices are designed to achieve total absence of all living microorganisms and are referred to as ‘sterile technique’.
STERILIZATION
Sterilization is a procedure by which we make an instrument or surface free from all vegetative bacteria, spores, fungi, including the viruses. This can be achieved by:
- Physical methods: Dry heat, moist heat, UV light, ionizing radiations, etc.
- Chemical methods: Formaldehyde, phenolics, quaternary ammonium compounds, chlorhexidine, sodium hypochlorite, ethylene dioxide, glutaraldehyde, etc.
Dry Heat Sterilization
Heat is the most reliable method of sterilization. The moist heat is more effective than dry heat.
Open Flaming
The instruments are held over the open spirit flame. This method is simple, not requiring any special equipment. It is particularly useful in villages, domiciliary services or in emergency when other methods are not available. The large instrument trays, surgical trolley tops can be disinfected with this means.
However, it is no more practiced in the clinical practice due to its unreliability (Figs 1.1A and B).
Hot Air Oven
This is the means of dry heat sterilization (Figs 1.2A and B). This method is widely used for the articles like anhydrous oils, petroleum products, talcum powder, etc. which cannot be penetrated by steam. The conventional ovens are electrically heated and a blower forces the hot air in motion around the items to hasten up the heating and to ensure uniform temperature in all the corners of the oven. The early models attained the temperature of 160° to 170°C for 2 hours. The fast table top models attain the temperature of 190° to 204°C with a total cycle time of 6 minutes for unwrapped items and 12 minutes for the wrapped items.
The temperature cycles for dry heat sterilization are as shown in Table 1.1.
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Articles that can be sterilized
Metallic instruments, powders, oils, greases, culture media and glass articles.
Advantages
- Does not corrode the instruments.
- It is simple.
Disadvantages
- It is time consuming
- Sharp instruments are rendered dull and brittle
- Rubber gloves, plastic, PVC rubber articles cannot be sterilized.
Moist Heat Sterilization
The moist heat is more effective means of sterilization than the dry heat. The methods of using moist heat as a means of sterilization are:
Boiling
The temperature of boiling water does not rise above 100°C (212°F) and thus, only vegetative microorganisms are killed and the bacterial spores may survive this procedure. Before the instruments are put in a boiler, it is desirable to clean all the instruments of dried, crusted secretions, blood and rust as they tend to prevent the penetration of the heat and thus, render the process of sterilization ineffective. It is achieved by thorough cleansing of the instruments by washing, scrubbing, use of fat solvents and ultrasonic cleaning.
The instruments to be sterilized are dipped in boiling water for a period of one hour. Sodium carbonate (2%) may be added to the water for alkalinization which elevates the boiling point of water, reduces sterilization time and prevents corrosion of instruments by reducing O2 content of water. Earlier boiling was a method of choice, however, it must be remembered that it is only intermediate level disinfection and its reliability is doubtful in this era of HIV and Hepatitis.
Articles that can be sterilized
- Surgical instruments
- Catheters
- Syringes, needles.
Advantage
It is simple and economical.
Disadvantages
- Not reliable
- Instruments tend to get corroded
- Time consuming
- Sharp instruments tend to get dull.
Autoclaving
This is the means of moist heat sterilization. It is a method of choice for sterilization of instruments as it reliably eliminates even resistant, spore forming microorganisms, fungi, viruses, along with vegetative microorganisms.
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It works on the principle of ‘steam under pressure’. It provides moist heat in the form of saturated steam under pressure. The pressure increases the boiling point of water. Roughly for every 5 lbs. pressure, the boiling point of water rises by 10°C by increasing the latent heat of energy for boiling of water. Hence, at 15 lbs. pressure the boiling point of water rises to 121°C.
The temperature pressure and sterilization time cycle is as shown in Table 1.2.
Mechanism of action
The steam is the mixture of heat and water vapor. When it comes in contact with any cool surface, it gets condensed and heat is released from water. This heat is taken up by the surface it comes in contact with. The heat goes on penetrating in the deeper layers of the object. Hence, the steam must come in contact with the objects that are to be sterilized and thus, the objects must not be sealed in plastic wrappers or in the non-porous metallic containers. The steam and the air move in vertical direction and therefore the movement will be quicker and thereby the penetration of the steam into the material will also be better if the articles are placed vertically in the autoclave.
Procedure
The clinician must be well acquainted with the various parts of the autoclave and their operation. The autoclaves can be vertically or horizontally loading (Figs 1.3A and B). High speed autoclaves capable of producing more pressure and the temperature thus, completing the cycle in less time are available. The articles to be sterilized are first thoroughly cleaned with tap water, spirit and solvents like ether. All the blood stains, rust should be cleaned meticulously. The instruments should be wrapped in muslin, paper or linen pouches, commercially available autoclaving pouches, porous cassettes or gauze before putting them in surgical drum. The articles should be kept loosely in the chamber/drum to facilitate proper circulation of the steam. The articles/material which require more time for sterilization must be kept on the upper part of the drum since steam penetration starts earlier in the upper part than the lower part. The muffler of the drum is eased and the perforated body of the drum (steam inlets) is exposed to facilitate the entry of steam into the drum (Figs 1.4A and B). Once the heating source is started, all the air in the autoclave should be allowed to escape by opening the outlet valve as the heated air becomes lighter it escapes through the open valve readily and the autoclave gets filled with pure, saturated steam. The saturated steam is more lethal to the microorganisms than the mixture of air and steam. The air is a bad conductor of the heat and if it surrounds the article/instruments in the drum the penetration of the heat will be adversely affected. Once the desirable pressure is achieved then the time should be counted and depending on pressure the autoclaving should be continued till the prescribed time is completed.
Figs 1.4A and B: (A) Dressing drum with open muffler showing perforations in the body of the drum for entry of the steam; (B) Muffler is closed covering the perforated area of the drum to prevent contamination
The autoclave lid must be closed tightly and it should not be opened until the steam is evacuated and the inside pressure is brought down to normal by opening the escape/release valve, after completion of the procedure to prevent accidental blowing of lid. The muffler of the drum should be immediately closed after the autoclaving is over, to prevent the entry of microorganisms in the sterile drum. During the autoclaving care should be taken to prevent entry of boiling water into the drum, as it tends to corrode the instruments. To achieve full quality of sterilization the temperature, pressure and time must be followed. Nowadays autoclaving indicators (chemical and biological indicators) are available in the market, which are placed in the drums during autoclaving, their color change is an indicator of complete sterilization (Fig. 1.5). These indicator strips may be preserved and pasted in the autoclave registers as a record and proof of autoclaving for medicolegal purpose. The autoclaved drums must be handled by aseptic care. Normally, the contents of sterile drum remain sterile for about 48 hours, however with increased handling this time decreases rapidly.
Articles that can be sterilized
Instruments, gauze, cotton, linen, needles, syringes, catheters, drains, autoclavable hand pieces, gloves, etc.
Articles that cannot be sterilized
Powders, oils, greases, thermolabile material like electrical cords of micro-motors, fiberoptic cable, etc.
Advantages
- Simple
- Economical
- Reliable.
Disadvantages
- Tends to corrode the instruments
- Makes sharp instruments dull.
Chemiclaving
It is also called chemical vapor sterilization. A combination of formaldehyde, alcohols, acetone, ketones and steam at 138 KPa (combination available commercially) is used.
Cold Sterilization
Articles to be sterilized are immersed in the chemicals for achieving sterilization. The commonly used agents for chemical sterilization are absolute alcohol, carbolic acid 2 percent, glutraldehyde 2 percent (Cidex), formaldehyde, chlorhexidine gluconate, ethylene trioxide (ETO), etc.
Articles that can be sterilized
Sharp instruments like scissors, blades and suturing needles.
The following articles can be sterilized in ETO chamber, as immersion in liquids may spoil them.
- Splints
- Templates
- Handpieces
- Fibrooptic cables
- Micromotor cords, etc.
Articles that cannot be sterilized
Gauze, cotton, gloves, indwelling catheters, syringes, hypodermic needles, etc.
Advantages
- Simple
- Thermolabile articles can be sterilized
- Does not make sharp instruments dull.
Disadvantages
- It is not cost effective
- It tends to corrode the instruments
- It is time consuming.
- The residue of chemicals may be carried to the tissues along with the instruments during the surgery, which can evoke undesirable tissue reactions.
ANTISEPTIC SOLUTIONS
Relative Terms in Disinfection Level
Antisepsis
It is the process to kill pathogenic organisms in the environment of the patient. The process may be either bactericidal or bacteriostatic.
Disinfection
It is the process to kill pathogenic organisms from inanimate objects such as surgical instruments.
Antiseptic agent
It is a chemical which either kills pathogenic organisms or inhibits their growth so long as there is contract between the agent and microbe. In general, the term ‘antiseptic’ is reserved for agents applied to the living body surfaces.
Asepsis
It is the process by which environment of the patient is protected from contact with infective organisms.
Disinfectant
It is a germicidal chemical substance used on inanimate objects (non-living objects) to kill pathogenic micro-organisms but not necessarily all others.
Various Commercially Available Products
Korsolex®
- Gluteraldehyde–7 g
- 1,6 dihydroxy 2,5 dioxahexane–8.2 g (chemically bound formaldehyde)
- Polymethyl urea derivatives–17.6 g
- Rust inhibitors (trade secrets).
Prepared solution remains effective (viable) for 15 days.
For disinfection—5 percent for 30 minutes.
For sterilization—10 percent for 5 hours.
Sterillium
Alcoholic rub—it is used as a hand disinfectant.
Composition
- 2-Propanolol: 45 g1-Propanolol: 30 g
- Ethyl hexa decyl dimethyl ammonium ethyl sulphate: 0.2 g
- Skin protecting substances.
It is available in calibrated dispensers. For the hand disinfection 3 mL solution to be rubbed for 30 seconds.
Dettol®
Composition
- Chloroxylenol : 4.8 percent
- Terpineol : 9 percent
- Absolute alcohol: 13.1 percent
It is commonly used as a disinfectant in the clinics and for the household purposes. In a lesser strength it is used as an antiseptic solution.
Lysol®,1 (Concentrated Cresol Solution)
Color
Dark brown.
Dilution and use
1:100 in water. It is used for sterilization of sharp instruments, e.g. suturing needles, knives, scissors, etc.
Time
Thirty minutes for 100 percent solution (i.e. undiluted) and 1 to 2 hours for 1:100 solution.
Special remarks
Lysol is an irritant chemical and causes burns when it comes in contact with the skin. Instruments should be cleansed with sterile water before use.
Weak Iodine Solution
Composition
Iodine tincture IP | 66.2 percent |
Alcohol | 65 percent to 48 percent v/v |
Use
Preoperative painting (preparation) of the skin.
Special remarks
- Iodine should be wiped with spirit after 2 minutes of painting.
- Idiosyncrasy may occur in sensitive patient.
- Alcohol increases the permeability of the iodine.
- Savlon decreases iodine's efficiency due to its detergent action.
- Iodine-spirit is the best preparation for painting.
- It kills 90 percent of skin bacteria in one and a half minutes.
Savlon®,2 (Hospital Concentrate)
Composition
- Chlorhexidine gluconate 7.5%v/v
- Strong cetrimide 16%w/v
- Isopropyl alcohol 6.8%v/v.
Color
Tartrazine (yellow).
Properties and effects
Germicide and detergent.
Dilution and uses
1:100 (aqueous) solution
10 mL of Savlon is made up to 1 liter with water.
Uses
- Cleaning and disinfection of the equipment in the vicinity of the patient
- Storage of previously sterilized instrument
- Cleaning and disinfection of the postoperative wounds
- Swabbing in obstetrics, gynecology and urology
- Aseptic management of burns
- Scrubbing
- Cleaning and disinfection of the instrument (Immerse for 30 minutes)
- Prolonged storage of clinical thermometer.
1:30 (aqueous) solution
35 mL of Savlon is made up to 1 liter with water.
Uses
- Cleaning and disinfection of physically dirty wounds where extra detergent (action) is required
- Cleaning and disinfection of used catheters and appliances.
1:30 in 70 percent alcohol solution
35 mL of Savlon is mixed with 200 mL water and made up to 1 liter with 95 percent alcohol.
Uses
- Skin disinfection (preoperative and other invasive procedures)
- Emergency disinfection of clean instruments and equipment (immerse for 2 minutes)
- Disinfection of clinical thermometers.
Remarks
- Sodium nitrate (4% or four 1 g tablets per liter) should be added to the solution to prevent rusting.
- The solution should be changed weekly.
- Syringes and needles that have been immersed in the Savlon solution should be rinsed very carefully with sterile water before use.
- Instruments containing mirrors or other cemented glass components should not be immersed in Savlon solution.
- Prolonged immersion of rubber appliances in Savlon is not recommended.
Phenol®
Composition
0.5 percent carbolic acid.
Properties and effects
It is dark pink in color and a strong irritant and caustic. Pure form may cause skin burns.
Uses
- Disinfection of sharp instruments. In 100 percent solution, the instruments should be immersed for 2 to 3 hours and in 20 percent solution for 24 hours.
- Disinfection during cholera epidemic for disposal of excreta.
- Chemical sympathetic block (phenol in almond oil is used)
- Diluted solution is used for disinfection of dog bite wounds.
- Carbolization (cauterization) of appendicular stump and polyps.
- Phenol has antipruritic potential, so it is used in certain skin lotions.
- Phenol in almond oil is used as an injection treatment for the first degree of internal piles.
- Two percent carbolic acid solution is used to carbolize (disinfect) the objects in the OR and wards like trolleys, OR table, Boyle's machine, etc.
Hydrogen Peroxide (H2O2)
Composition
Twenty volume hydrogen peroxide (one volume of 20 volume hydrogen peroxide solution releases 20 volume of nascent oxygen).
Properties and effects
It is not an antiseptic but a cleansing agent.
Mechanism of action and uses
- It destroys anaerobic organisms by releasing nascent oxygen and therefore used for cleaning the wounds infected or contaminated with anaerobes.
- It produces frothing and brings out debris from the depth of the wound.
- It produces heat when it comes in contact with the tissues. So it prevents capillary oozing and hence it is used as hemostatic solution whenever there is capillary oozing, e.g. after incision and drainage. However, it is also believed that the infection passes to deeper tissue planes due to frothing.
- Used in cleaning wounds, bleaching, boils and as a throat spray and mouth wash. Very diluted form is used in ear syringing to remove wax and foreign body.
- Used to remove blood stains from clothes.
Spirit
Composition
Methyl alcohol (optimum concentration of 70 percent alcohol is highly effective).
Uses
- Disinfection of skin before intramuscular and intravenous injections.
- As a solvent for the removal of iodine in preparation of skin for operation.
- Cleaning the stiched wound.
- Cleaning the skin of the surrounding ulcer or open wounds.
- As it dissolves the greasy material, 50 percent spirit in water (gutta spirit) is used as ear drops.
- Used along with other disinfectants such as iodine-spirit and Cetavlonspirit, for painting the parts before operation.
Formalin Solution
Composition
30 percent aldehyde plus 10 percent methane.
Concentration
38 to 40 percent w/v solution.
Uses
- Ten percent solution in water is used as preservative for biopsy specimens.3
- Operation theater sterilization (fumigation 40% solution).
- Two to five percent solution is used for sterilization of surgical gloves and instruments.
- Tablets of formalin are available, which are used in a chamber for the sterilization of thermolabile articles.
Eusol® (Edinburgh University Solution (BP)
Composition
1.25 g of boric acid, 1.25 g of bleaching powder (chlorinated lime), sterile water up to 100 mL.
Mechanism
It releases nascent chlorine and becomes useless after 24 hours.
Uses
- To separate slough from infected wounds, ulcers, bed-sores and burn wounds.4
- Acidic in pH, therefore it is very useful in wounds infected with pseudomonas bacteria.
Cidex®
Composition
Glutaraldehyde, 2 percent acidic solution.
Properties
It kills all pathogens. It is bactericidal, tuberculocidal, pseudomonacidal, viricidal and fungicidal.
Time
Complete disinfection in 10 minutes, sporicidal within 4 hours.
Uses
- Tray system of sterilization with cidex for large instruments, fiberoptic endoscopes with lenses.
- Sterilization of small and sharp instruments, catheters and thermometers.
- Sterilization of equipment of anesthesia and of inhalation therapy.
Special remarks
- Best disinfectant with rapid action.
- Cidex is effective even in the presence of protein material.
- Recommended time is 10 hours to take care of the deep crevices in the instruments.
Glycerine Magsulf Solution
Composition
Saturated solution of magnesium sulphate (MgSO4) crystals and glycerine (sterile), the solution is boiled for a few minutes and then cooled.
Properties and uses
Since magnesium sulphate is hygroscopic, it pulls out the fluid from the edematous tissue across the skin or the mucosa, which acts as a semipermeable membrane and the mixture is exothermic producing vasodilatation which facilitates reabsorption of interstitial fluid from the edematous in the tissue thereby reducing edema. It is used to reduce edema in:
- This solution is used to give magnesium sulphate enema in order to reduce intracranial pressure.
- Glycerine has soothening action.
Turpentine IP
Properties
It is a highly irritant mineral oil.
Uses
- Diluted form is used to bring out and kill the maggots from the wounds and ears.5
- Used as a solvent to remove the zinc paste of sticking plaster from the skin.
Ether
Properties
It is evaporable, highly inflammable. It makes the surface cool.
Uses
- As surface and the inhalation anesthesia.
- Used to clean the dirty skin as it removes the greasy substances by dissolving them.
- Used as a solvent to remove the zinc paste of sticking plaster from the skin.
Gentian Violet
Concentration
Dilution of 1:100 and 1:1,000 are generally used.
Properties and effects
It coagulates the serous discharge on oozing surface and makes the ulcer dry.
Uses
To dress eczematous lesion with copious seropurulent discharge.
Undesirable effects
It colors the ulcer, so the progress of the healing becomes difficult to judge.
Acriflavine
Properties
It is available in crystals. It is yellow in color.
Concentration
0.5 to 2 percent solution made with sterile water.
Uses
- It is a mild antiseptic and astringent on ulcers with purulent discharge.
- Effective on wounds with gram negative bacteria.
- Acriflavine dressing on raw area is left after hemorrhoidectomy.
Potassium Permanganate (KMnO4)
It has oxidizing effect. It is available in crystal form. 1:5000 to 1:10000 solution is made with water.
Uses
- Used as mouth wash, e.g. after tonsillectomy and in stomatitis. (Condy's gargles).
- Used for urinary bladder irrigation and wash.
Mercurochrome
Concentration
0.5 to 2 percent solution is made with water; it is available in crystal form.
Properties and effects
It is an inhibitor of 5-hydroxytryptamine (5-HT). Strong solution kills white blood cells (WBCs) and damages the granulation tissue. It has an astringent action.
Uses
- Used for bed sore dressing.
- Diluted solution is applied on wounds with healthy granulation.
- Strong solution is applied on wounds with hypergranulation.
- Applied on exomphalos awaiting surgery.
- Not used on non-healing ulcer, because it stains floor of the ulcer and hence makes it difficult to judge the progress of the healing ulcer.
- Diluted solution is used as eye drops.
Silver Nitrate (AgNO3)
Concentration
Solutions with dilutions ranging from 1:100 to 1:10000 are available.
Special remarks
Impregnated cotton sticks are kept in dark container because, on exposure to light, silver nitrate gets destroyed.
Uses
- Chemical cauterization of warts and hyper/granulation tissue.
- Used for dressing burns (silver sulfadiazine)
- Useful in bladder irrigation in cases of hematuria, due to its cauterizing effect.
Chlorhexidine6 (Hibitane® Concentrate)
Composition
Contains chlorhexidine gluconate, 5 percent w/v (equivalent to chlorhexidine gluconate solution, 25% v/v) (Table 1.3).
Color
Poceau 4R, red.
Dilution and uses
1:250 aqueous solution.
Uses
- Disinfection of equipment, furniture and fittings in the vicinity of the patient.
- Storage of sterile instruments.
Antiseptic Technique
Apply liberally the diluted solution on the surface of the article to be disinfected with clean (sterile) swab or cloth. Store sterile instruments by immersing in the diluted solution up to 8 hours; rinse with sterile water before use.
Dilution and uses
1:100 aqueous solution.
Disinfection of wounds and burns, skin swabbing in obstetric patients, washing of hands and scrubbing.
Technique
Apply the diluted solution liberally on the surface to be disinfected with a sterile swab.
1:10 solution in 70 percent alcohol.
Uses
- Preparative skin disinfection.
- Emergency disinfection of instruments.
Technique
Apply the diluted solution liberally on the surface to be disinfected with a sterile swab. Clean the instruments under running water. Immerse them in the solution for 2 minutes. Rinse in sterile water before use.
Cetavlon®
Composition
Cetrimide 0.5 percent w/v, rectified spirit equivalent to 62 to 68 percent v/v of absolute alcohol.
Color
Carmoisine + erythrosin (pink).
Precautions
It should not come in contact with brain, meninges or middle ear.
Dilution and uses
As per chlorhexidine—it should not be used in open wounds and burns because it contains spirit which is an irritant.
The other important use is as a scolicidal agent in the operation of hydatid cysts7 of liver. After evacuating the cyst, 0.5 to 1 percent of cetrimide solution is instilled into the residual host cavity and left for 5 minutes. Then it is sucked out. Other scolicidal agents used are;
- Ten percent povidone–iodone (providex).
- Formalin solution–no longer used.
- Hypertonic saline.
Povidone–Iodine8 (Betadine®)
Povidone-iodine (PVP-I) is a stable chemical complex of polyvinylpyrrolidone (povidone, PVP) and elemental iodine. It contains from 9.0 to 12.0 percent available iodine, calculated on a dry basis.
Products available
Povidone-iodine (5 and 10%) topical solutions, surgical scrub (7.5% w/v) mouthwash (gargle), povidone-iodine ointment, povidone-iodine vaginal pessaries.
Properties and effect
Iodine is recognized as an effective and useful germicide. It is very effective against a variety of microorganisms such as viruses, bacteria, protozoa, yeast and fungi. However, its frequent use is11 contraindicated because of its insolubility, instability and its staining and irritating properties.
Many of these undesirable qualities of iodine could be eliminated by combining it with polyvinylpyrrolidone (Povidon). This organic polymer is water-soluble. When it is combined with iodine, a complex is formed in which iodine's toxic properties are lost without its bactericidal activity being affected. This complex, povidone-iodine (polyvinylpyrrolidone iodine, abbreviated as PVP-1), has been used effectively as a surface disinfectant.
Povidone is an effective germicide. High dilutions are active in destroying organisms within 15 seconds. Color loss is accompanied by the weakening germicidal activity.
Advantages
- Broad spectrum of action with fungistatic action.
- Non-antibiotic
- Immediate action—nonselective
- Film forming
- Extremely safe.
Uses
- As mouth rinse and gargle for dryness of mouth and minor irritation and infections.
- As a local antiseptic and for wound dressing.
- Used for irrigation of bladder, wound (subcutaneous) pyothorax and intraperitoneal cavity.
CARE OF ANTISEPTIC SOLUTION
Do's
- Always use recommended dilutions before use, as directed.
- Always prepare dilutions in small volumes, preferably not more than 1 liter.
- Always use all diluted solutions within 8 hours and discard the remaining solution at the end of the working day.
- Always ensure that the mouth of the bottle is not touched by hands or other materials while pouring.
Do not's
- Never mix up old diluted solutions with the freshly prepared ones.
- Never leave diluted solutions for more than one working day.
- Never use corks for sealing the bottles.
- Never leave bottles open.
Precautions
- Instruments with glass or metal components should not be disinfected with hibitane.
- Sodium nitrate (0.1% w/v, i.e. 1 g tablet per liter) is added to instrument storage solutions to prevent rusting. The solution should be changed at weekly intervals.
- Instruments, especially syringes and needles that have been immersed in hibitane, should be thoroughly rinsed in sterile water before use.
- Prolonged immersion of rubber appliances in hibitane is undesirable.
- Hibitane concentrate (chlorhexidine) should not come in contact with brain, meninges or middle ear.
Ethylene Oxide (EO) Gas Sterilization9
Composition
- CFC-12 (12/88).
- HCFC-124 (OXYFUME 2000).
- 100 percent EO (67–134g).
- EO/CO2 (10/90).
Temperature (85–145°F)
Humidity (30–80%)
Advantages of EO Sterilization
- Heat sensitive articles can be sterilized
- Moisture sensitive articles can be sterilized
- Automatic control
- Leaves no film on the surface
- Permeates porous packaging material.
Disadvantages of EO Sterilization
- Slow process
- Expensive
- Hazardous with repeated use
- Vesicant and burns
- EO gas is mucosal irritant
- Potential carcinogen and mutagen
- Highly flammable and explosive.
EO Gas Sterilizer
The EO sterilizer has following components:
- Capacity of chamber (12 × 12 × 24 inches to 28 ×67×78 inches).
- Automatic control.
- Vacuum pumps.
- Steam ejector.
- Digital printer.
- Sterilizer and aerator.
Preparing Items for EO Gas
- Clean and dry.
- Disassemble detachable parts.
- Remove lubricant.
- Lensed instruments, cameras and films can also be sterilized.
Packaging material used for EO gas sterilizer are:
- Woven fabric.
- Non-woven fabric.
- Peel packs and pouches.
Hydrogen Peroxide Plasma Sterilization
Advantages of H2O2
- Dry and non-toxic
- Byproducts safely evacuated
- Aeration not required
- Low temperature
- Simple design of sterilizer
- Non-corrosive
Disadvantages of H2O2
- Metal tray block radiofrequency waves
- Not compatible with cellulose
- Nylon becomes brittle.
Ozone Gas Sterilization
Advantages of Ozone Gas Sterilizer
- Simple and inexpensive to operate
- Heat and moisture sensitive
- Safe with titanium, chromium, silicon and teflon
- Low temperature
- No aeration
- Leaves no residue-converts to O2.
Disadvantages of Ozone Gas Sterilization
- Corrosive
- Oxidizes steel, brass, copper and aluminum
- Destroys natural rubber, latex, natural fibers and some plastics
- Stearothermophilus biologic indicators are required to assess the sterilization.
- Cycle time may be up to 60 minutes after which ozone is converted back to oxygen safely released in room air.
Handling of the Sterilized Instruments
The autoclaved instruments kept in the dressing drum need to be handled carefully to prevent contamination of the instruments and preserve the sterile environments inside the drum. The drum should be in good condition and the lid should be airtight. The drum should not be opened frequently and the lid should be closed immediately after removing the sterile instruments. The more the frequency of opening the lid the lesser the time for which the inside environments of the drum are likely to be sterile. The instruments must be removed using a sterile chital forceps. The chital forceps must be sterilized daily and must be preserved properly. A sterilized chital forceps must be kept in a sterilized container/bottle, which is long enough to cover at least two-third the length of the chital forceps as while picking up the sterile instruments from the sterile drum, about 2/3rd the length of the forceps will enter the depth of the drum and only the handle shall stay out (Figs 1.6A and B). The container should contain a sterile antiseptic solution (2% gluteraldehide or savlon, 1:100 (aqueous) solution (10 mL of Savlon is made up to 1 liter with water) When the glass bottles are used to store the sterile chital forceps, cotton wool is often added to the bottle containing the disinfectant solution. The cotton wool will soak the solution and settle at the bottom of the bottle. This is done because most of the times the chital forceps is just dropped in the bottle which hits the base of the bottle and may break it. The presence of cotton wool will prevent this and also prevent noise. The container should be sterilized daily and fresh solution should be prepared daily. The water used as solvent for the antiseptic solution should be boiled and then allowed to cool to the room temperature before the antiseptic agent is added, to avoid its precipitation.
Figs 1.6A and B: The sterile chital forceps are immersed in sterile bottles containing antiseptic solution. Care should be taken to use longer bottles to ensure that 2/3rd length of the forceps is submerged
ASEPTIC TECHNIQUE
The word ‘Asepsis’ means lack of sepsis. It is the series of practices undertaken to prevent the entry of germs in the wound. This topic will be discussed under following heads:
- Planning and design of operating room.
- Preparation of environments in the operating room.
- Preparation of personnel.
- Preparation of patient.
- Preparation of surgical team.
- Disposal of hospital waste.
The location of operating room should be such that it is isolated from rest of the hospital units so that to and fro movement of the public is minimized. The air circulation and water supply must be separate. Separate overhead water tanks and separate pipelines should be laid for the operating room to prevent retrograde, cross infection from toilets and other units of hospital. The operating room (OR) should be constructed in such a way that it is divided into unrestricted (non-critical), semi-restricted (semi-critical) and restricted (critical) area (Box 1.1). This division prevents direct access into the operating room thus brings down the chances of infection. The unrestricted area is a barrier between the outside environments and the semi-restricted area. This unrestricted area harbors the preanesthetic room, office, changing rooms, etc. The outside clothing and foot wear is changed in this area before advancing into the semi-restricted area as the outside wears harbor lot of dust and germs. The personnel must change to sterile scrub suit and change the outside foot wear to the OR foot wear made up of rubber or plastic, which is easily washable and can be disinfected.
The foot wear should also be puncture proof to prevent injuries, skid proof and antistatic and nonconductor of electricity. The leather foot wear is not desirable for use in OR as it is not washable and fungal growth can take place on it. The disposable, sterile shoe covers may be worn over the OR shoes. They will protect the wearer from spills into or onto shoes during procedures when extensive fluid irrigation and/or blood loss is anticipated. Some surgeons wear plastic or rubber boots. The legs of scrub pants are tucked into boots. The hair must be covered with a cap and a mask should be put onto prevent shedding of dust and microorganisms in the operating room or surgical field.
The non-restricted (non-critical) area of the operating room (OR) is where the patients are shifted from the ward on a stretcher to the preanesthetic room for the surgery. The outside stretcher should never cross beyond this area to enter into the semi-restricted area. In the preanesthetic room, the patient's feet are covered with foot covers (leggings) and hair are also covered with caps, before shifting into semi-restricted or restricted area. The patient is essentially shifted on another stretcher, which plies between the restricted area and the non-restricted area and in no case goes out of the OR complex.
The semi-restricted (semi-critical) area contains endoscopy rooms, sterilization rooms and sterile store room, postoperative recovery, etc. and serves as a barrier between the unrestricted and restricted area.
The restricted area is a critical area where actual operating rooms are present. Scrub rooms for scrubbing the hands and areas for putting on the sterile gowns and gloves are located outside the main operating room in the critical area.
Designing of an Operating Room
The size of the operating room should be adequate for housing all the equipment and accessories. It should allow free movement of the surgical team members. Ideally the size of the OR should not be less than 500 sq ft. The operating room should be designed in such a way that the floors and walls should be absolutely plain and easily cleanable (Fig. 1.7A). They must not harbor dust, dirt and microorganisms. The material selected for making floor should have smooth finish and should have minimum and neatly made or no joints. The material used for the flooring should be non-porous, scratch proof, antiskid and antistatic (epoxy resin flooring). The walls should also be covered with smooth material like granite with minimum joints. The ideal OR room walls should be of stainless steel without sharp line angles and the corners should be molded round. The ceilings should be painted with oil paints, which give smooth finish. The walls and the floor should be washable. No offsets or projections are permitted in OR. All the electrical fittings and water pipelines in the OR must be concealed. Ceiling fans are not permitted as the blades of the fan harbor dust and when they are switched on the dust gets splashed in the surgical field. The use of exhaust fans in the OR is prohibited and if they are used they should have unidirectional air ducts to prevent entry of dust in the OR. The OR should have airconditioning and use of pedestal fans should be avoided.
The OR complex should have only one entry and all the windows should be air tight. This prevents multidirectional air flow and entry of dust in the OR. The doors of the operation theater complex which exist between critical area, semi-critical and non-critical area must not be in single line to break the air velocity. The operating room must have unidirectional air flow (desirably lamellar air flow with micro and HEPA filters) with air flow velocity of 2 meters/minute, as greater air velocity facilitates transport of light dust particles. The temperature in the OR must be maintained to around 20°C and relative humidity should be less than 40 percent. Higher temperature and humidity facilitates the growth of microorganism and fungi. If the environments are unpleasant, hot and humid they are tiring to the surgeon and his team. More importantly, it also tends to desiccate the exposed tissue during14 the surgery. It is impossible to sterilize the air, however, efforts must be made to prevent entry and restrict the growth of microorganism, both vegetative and spore forming (Box 1.1).
Preparation of Operating Room
Before commissioning the operating complex a thorough washing and dusting is required. All the walls and inanimate objects are carbolized with 2 percent carbolic acid solution. The operating room is fumigated with the help of 40 percent formaldehyde (350 mL) added with KMnO4(174 g) for a room measuring 1,000 cu Ft. This mixture procedures an exothermic reaction and should be kept in a stainless steel bowl in the OR. The fumes rapidly spread in the OR and kill the microorganisms. The OR should be closed in an air tight manner during this procedure and sealed from outside to prevent leakage of fumes. When it is done for the first time the OR should be kept closed for 48 hours and for repeated weekly fumigation it can be kept closed for 24 hours. Mechanical fumigators are also available in which 500 mL of 40 percent formaldehyde and 500 mL of water is used for a room measuring thousand cubic feet (Fig. 1.7B). The machine is switched on and kept operating overnight. When the formaldehyde and KmNO4 solution is used, it should not be kept near bottles of ether, spirit or any other inflammable substance as this exothermic reaction can precipitate accidents due to fire. After the OR is opened the fumes are allowed to settle by opening the vents of the airconditioning system (aeriation time) and then swabs are taken from different sites like floor, walls, operating table. Trolleys, etc. of OR (two from each site) and these swabs are subjected to microbiology lab for aerobic and anaerobic culture to detect dreadful micro-organism like pseudomonas, Clostridium tetani, Clostridium welchii. The OR can be commissioned only after obtaining the negative report from microbiology laboratory. If the OR is found to be contaminated with these dreaded organisms the OR should be closed and rewashing, fumigation and disinfection of the OR should be done. Periodic maintenance of the OR should be done by daily dusting swabbing and weekly washing and fumigation. The swabs used for cleaning the OR should be earmarked for the OR and in no case should be used for swabbing other areas. Similarly the outside swabs should never be permitted in the OR. The floor of the OR should be washed with soap and antiseptic solution like sodium hypochlorite of any other disinfectant like phenolics (phenyl).
Preparation of Personnel
It is impossible to disinfect personnel and their entry in the OR. However, the precautions are taken to minimize the contamination due to personnel in the OR. As mentioned earlier the outside clothing and foot wear must be change to a scrub suit and OR footwear and the hair and nose, mouth should be covered with the cap and mask respectively before entering into the critical area of the OR. The specification for the cloth to be used for making the masks, gowns and drapes is that it should be made up of cotton having a thread count of 240/sq inch to 270/sq inch for the reusable stuff and spunbond oleifin for disposables ones. The colors is usually green for better visibility (Figs 1.8A and B). The special scrub suit to be worn as a part of universal precaution kit consists of water resistant material and has double-layered protection (Fig. 1.9). Before performing the surgery the surgeon and assistants must scrub their hands and put on the sterile gown and sterile gloves.
Hand Scrubbing
The surgeon must keep his hand clean to prevent any dermatological infections. The nails should be trimmed and rounded off (Figs 1.10A to C). The hands are washed under running tap water with antiseptic soap solution (phenolic soaps like Lifebuoy, cetrimide soaps like Savlon, povidon iodine 10 percent like beta scrub, chlorhexidine gluconate scrub 4%, etc.) starting from tips of the finger up to 2 cm above the15 elbow (Figs 1.11A to F). Foam is generated by vigorous scrubbing the nail beds and clean with soft brush kept in a sterile container containing antiseptic solutions. The method followed for the hand scrubbing is the “Time-Stroke method”. The time is about 3 minutes and the strokes applied at different sites of the palm (Fig. 1.11) range between 20 to 30 strokes at each site. The purpose of this exercise is to make the hands surgically clean by removing dirt and colonies of vegetative microorganisms from the skin creases, hair and nail beds thus reducing the count of microorganism as it is impossible to sterilize the hands (Fig. 1.12A). During this whole exercise, hands are held at a higher level than the elbow to prevent the water from contaminated arms to roll back on the cleaned forearms and hands (see Fig. 1.10).
Figs 1.10A to C: (A) Watch the hands, nails trimmed and rounded off; (B) Surgical scrub; (C) Holding the hands up so that the water trickles down the elbows
The scrub area sink should be wide enough to facilitate easy scrubbing without touching anywhere and it should have depth of about 3 feet, which prevents splashing of rebound water onto the clean hands (Fig. 1.12B). The scrub sinks are fitted with doctors’ taps (Fig. 1.12B) rather than ordinary taps, to facilitate its operation with the help of arms to prevent contamination of scrubbed hands during closing the tap. The peddle operated taps are ideal in scrub areas as it permits hand free operations.
The cleaned hands are mopped with sterile towel and disinfected with antiseptic solution.
Alcoholic hand rubs are increasingly available as alternative products for hand hygiene forward use. The application of alcohol as a gel, foam or as a liquid to clean hands is highly effective at destroying microorganisms on skin surfaces. Ethanol or isopropanol, 60 to 80 percent, are even more effective than detergents or antiseptic soaps, if applied to clean hands. These products may be considered by infection control teams for specific situations within operating theater practice.
Application of Sterile Gown
After the hand scrubbing the sterile gown is applied by no touch technique. The gowns are folded inside out during autoclaving. The sterile gown is picked up by the assistant with the help of sterile chital forceps. The surgeon holds the gown with clean hands touching the inside of the gown which is folded outside (Fig. 1.13).
He opens the gown and slides the gown over his hands and the body without touching the outside of the gown. The straps of the gown are tied by the assistant at the back and the straps of the gown are tightened by the surgeon himself around his wrists (Figs 1.14A and B). The front portion of the gown between the chest and the waist is considered to be sterile and should always face the operating field and sterile trolley on which sterile surgical equipment are kept.
Putting on Gloves
The gloves are pre-powdered and folded in such a way that the inside of the cuff faces outside during autoclaving. The surgeon applies sterile gloves powder over his scrubbed hands and then picks up the left glove with bare right hand, touching the inside out folded cuff only. He slides the left glove over the left hand without unfolding the cuff. Then with the gloved left hand he picks up the right glove touching only the outside of right glove. He slides it over the right hand and unfolds the cuff over the cuff of the sterile gown. Then with the gloved right hand he unfolds the cuff of left glove over the cuff of gown of the left hand, touching only out side of left glove. This is called as ‘open method’ of17 gloving. The surgeon is now prepared to undertake the surgical procedure (Figs 1.15, 1.16, 1.17).
Figs 1.16A and B: Closed gloving technique—note the left glove is slided over the hand with the right hand overed by sterile gown. The right cuff is then adjusted with gloved left hand and the right glove is slided using left gloved hand without touching the outside of the gloves with bare hands
Preparation of Patient
The preparation of patient is divided into two phases:
- Preparation of patient in the ward and
- Preparation of the part on table.
Preparation of Patient in the Ward
In Indian circumstances the patient are often poor, illiterate, ignorant about personnel hygiene. Thus, they require a good preparation before shifting to the operating room. The preparation comprises of:
- Hospitalization 2 to 3 days prior to surgery for acclimatization to the hospital environment for preoperative and to relieve anxiety.
- Bath: The patients should be asked to take a good bath to clean all the dirt from the body.
- Clothing: The outside clothing should be discarded and the patient should be provided clean hospital clothing.
- When the patient is unable to do these things of his own due to illness good nursing care should be provided to him to complete this job.
- Preparation of part: The part to be operated should be washed thoroughly with soap and water. The hair should be removed by shaving at least 12 hours prior to the surgery as on time shaving can produce scratches on the skin, which breaks the barrier and facilitates the entry of microorganism in the operating area. The clean and shaved part is vigorously scrubbed with antiseptic solution like Savlon, chlorhexidine or povidon iodine and mopped with sterile gauge. The cleaned part is painted with solution like mercury chrome or 2 percent picric acid, covered with sterile pad and sealed with adhesive taps to isolate it and prevent contamination from fomites.
- Preparation of oral cavity: In maxillofacial surgery preparation of oral cavity is very important to prevent wound infection. The oral cavity should be thoroughly inspected for any septic foci, calculus, tarter, infected carious teeth, infected periodontal pockets, etc. and they should be treated/removed.Fig. 1.17A: Open method of gloving: Left glove is picked up with bare, scrubbed right hand, touching its inside and slided over left hand without uncuffing it
Antiseptic mouth washes should be prescribed (chlorhexidine, povidon, iodine, etc.) for periodic mouth rinsing to reduce the count of microorganism. Loose teeth should be extracted as they may come in the way of intubations of patient and may get knocked out and aspirated during the intubation.
Preparation of Part on Operation Table
The part which is preliminary prepared in the ward preoperatively is finally prepared on the table before the surgery is started. The part on which the surgery is to be performed and its adjoining area is scrubbed vigorously using a sterile swab holding forceps with a no touch technique, i.e. the surgeon does not touch the swab or any other area with his gloved hands. The scrubbing is started from the center and goes to periphery and the swab is discarded (Fig. 1.18). In no case the swab from periphery should touch the central area. This exercise is first done with swab soaked in antiseptic soap solution like savlon, cetrimide or povidon iodine (beta scrub) for about 2 minutes. The detergent facilitates reduction of surface tension of the dirt particles and their easy removal. The mechanical removal of microbiological colonies and reducing their count of due to antiseptic action is achieved by scrubbing. The area is then mopped with dry sponge or sponge soaked in sterile normal saline to remove the residue of the antiseptic agent and detergent, which could be irritating or harmful to the exposed deeper tissue during surgery. Finally the area is painted with 5 percent povidon iodine solution and this should not be wiped off because microbial activity is sustained by release of free iodine as the agent dries and color fades from skin. It should remain on skin for at least 2 minutes. To hasten drying of skin, alcohol may be painted on the area without friction before a self–adhering drape is applied. Isopropyl and ethyl alcohol are broad spectrum agents that denature proteins in cells. A 70 percent concentration with continuous contact for several minutes is satisfactory for skin antisepsis if the surgeon prefers a colorless solution that permits observation of true skin color. Because alcohol coagulates protein, it is not applied to mucous membranes or used on an open wound. Isopropyl alcohol is more effective fat solvent than ethyl alcohol. Both are volatile and flammable. They must not pool around or under the patient, especially if an electrosurgical unit or laser will be used.
The oral cavity should be prepared again with chlorexidine or povidon iodine 5 percent solution to achieve maximum antisepsis and prevent wound contamination.
The prepared area is the surgical area/field and needs to be isolated from rest of the body area and environments to prevent cross contamination. Hence, the area is isolated by draping the other parts with the help of sterile surgical towels exposing only the surgical field (Figs 1.19A and B).
Fig. 1.19B: Sequential part preparation and draping, note the eyes are well protected by applying chloromycetin eye applicaps to prevent drying and covered with sterile pads to prevent the antiseptic solution from entering in eyes to cause chemical injuries
Removing Gown
The gown is always removed before the gloves at the end of the surgical procedure.
The circulator unfastens the neck and back closures of the gown so the20 wearer does not contaminate his or her scrub suit. If wearing a wrap around gown, the wearer unfastens the waist closure in front. The gown is always removed inside out to protect the arms and scrub suit from contaminated out-side side of the gown. To remove:
- Grasp the right shoulder of the loosened gown with the left hand and pull the gown downward from the shoulder and of the right arm, turning the sleeve inside out.
- Turn the outside of the gown away from the body with flexed elbows.
- Grasp the left shoulder with the right hand and remove the gown entirely, pulling it off inside out (Figs 1.20A to D).
- Discard in a laundry hamper or in a trash receptacle (if disposable).
Removing Gloves
The cuffs of gloves usually turn down as the gown is pulled off the arms. Use glove-to-glove, then skin-to-skin technique to protect the clean hands from the contaminated outside of the gloves, which bear cells of the patient (Figs 1.21A and B).
- Grasp the cuff of the left glove with gloved fingers of the right hand and pull it off inside out.
- Slip the ungloved fingers of the left hand under the cuff of the right glove and slip it off inside out.
- Discard gloves in a trash receptacle.
- Wash the hands thoroughly using antiseptic soap.
Tissue Handling and Tissue Respect
“Respect the tissue and it will reward you by providing uncomplicated healing”. The gentle handling of the tissue during the surgery is of paramount importance for uneventful wound healing and achieving desirable results out of the surgical procedure. The forceful retraction of the tissue, rough handling, injudicious dissection, excessive use of electrocautery, using dull scissors/ knife for incision and allowing the tissue to desiccate during the surgery amount to tissue insult, which is bound to be reacted with more tissue reaction (inflammation) delayed healing, tissue necrosis and thus, chances of infection.
Figs 1.20A to D: De-gowning process, note that the gown is removed first without removing glove, the inside of the gown is not touched with contaminated gloves. Gown is always removed first and then gloves are removed
Figs 1.21A and B: De-gloving process, the contaminated gloves are removed without touching the outside of the glove with bare hands
The surgeon should handle the tissue minimally and exercise sound discipline and principles to avoid tissue insult (injudicious handling). The ‘tissue respect’ can be optimized and the chances of wound related complications can be significantly minimized if the precautions are taken during each step of the surgery as mentioned below.
Incision
During the surgery the tissue needs to be incised for creating an access. The incision is made with sharp Bard-Parker knife. In oral and maxillofacial surgery, the commonly used BP handled number 3 to 5 on which 15 blade is mounted. Stab knife (No. 11 blade) is used for incision and drainage of abscess, inserting drains or taking gingival crevicular incisions (Figs 1.22A and B). The skin incisions are not made with electro cautery knife as there are chances of tissue necrosis and impaired healing however, the deeper tissues and the mucosal incisions can be made using it. During taking the incision following principles must be followed:
- Always mark the incision with marking ink first to avoid mistakes (Figs 1.23A and B).
- The incision should be taken in normal skin folds or along the Langer's lines to prevent tension across the incision line, to ensure good quality of healing and a cosmetic scar, to prevent dehiscence of the wound due to tension and to camouflage the scar.
- The incision should be long enough to facilitate easy passive access to the deeper structures. This avoids tissue trauma due to forceful retraction in case of short incision, which subsequently leads to more tissue reactions and inflammation. It is a false notion that short incision heals faster however the healing along the incision is a simultaneous process and is independent of the length of the incision.
- While taking incision, precautions must be taken to avoid injury to vital structures like major blood vessels and nerves.
- The cross serrations (cross hatching) are marked across the incision with the blunt side of knife blade by scratching superficially, which serves as guidance for proper approximation of the skin during closer especially when the skin is likely to be lax following the surgery.
- The knife is held with a pen grip and the hand is given proper rest to have a better control over the knife (Figs 1.24A and B).
- The knife blade is held perpendicular to the tissues to be incised unless indicated otherwise.
- Controlled, uniform pressure is applied during making an incision depending on the consistency of the structure to be incised and the structure should be incised to its full thickness is one and single stroke, as repeated incisions may lacerate the edges of the wound which would subsequently compromise the healing process.While the surgeon makes an incision the assistant should stretch the skin to facilitate the incision (Box 1.2).
Flap Designing
Whenever a flap is required to be reflected during the surgery for creating an access to the surgical site following basic principles of flap designing must be adhered to:
- The base of the flap must be wider than the apex to ensure good afferent and efferent vascularity (Fig. 1.25).
- The flap should be wide enough to facilitate free, passive and direct access and should cover the surgical defect adequately.
- In case of mucoperiosteal flaps the edges of the flap must not lie on bony defects as the flap is unsupported from below and tends to collapse to create dehiscence of the wound.
- The flap should be full thickness.
- In case of intraoral mucoperiosteal flaps which include marginal gingival, the inter dental papilla should be either included or excluded from the flap to give better cosmetic results (Box 1.3).
Dissection of Tissue
The tissues are dissected by two ways:
- By blunt dissection or
- By sharp dissection.
The sharp dissection is less traumatic and is preferred for tough and tenacious tissues. It should be avoided when vital structures are in vicinity and can get traumatized. The blunt dissection is preferred in the tissues which are soft, fragile and friable and where there is anatomical proximity with the vital structures. The sharp dissection is done with the help of knife. The sharp dissection is less traumatic to tissues than the blunt dissection as there is less tissue handling. Further, the cutting of the tissue with knife is less traumatic than the cutting with the help of scissors, as the latter crushes the tissue while cutting. The blunt dissection is done with the help of non-cutting edge of scissors, blades by opening action or with the help of opening action of the hemostat tips. The tips of the dissecting scissors used for blunt dissection should be preferably rounded and appropriate curvature of scissors should be selected to gain proper access. Cautery tips can also be used for the dissection, its advantage is that it incises the tissue and simultaneously coagulates the smaller blood vessels to provide dry surgical field. The disadvantage with the cautery dissection is that it inflicts more tissue necrosis due to heat and compromises the quality of healing.
Tissue Retraction
The tissues are required to be retracted during the surgery to facilitate good visibility and access to the surgical site. Soft, friable tissues tend to get lacerated if retracted forcefully or using traumatic retractors like Allie's forceps or cat's paw retractor. Instead atraumatic retractors like Langenbeck's (L) retractor should be used. Tough, tenacious tissues should be retracted with retractors like Allie's forceps or cat's paw retractor (e.g. skin, tendons, periosteum, muscle, etc.) While applying the Allie's forceps to the skin it should never be applied on the outer surface of the skin but, should be applied to the inner surface of the skin flap to avoid ugly bite marks on skin. The slippery, glandular structures are held with the help of Babcock's gland holding forceps (lymph nodes, salivary glands). During fine plastic surgical work on the skin the tiny edges of flaps should be retracted using skin hooks. The same can be used for stretching the edges of the incision during the suturing for better approximation of skin edges. A nerve is retraced with the help of blunt nerve hooks. During intraoral procedures the mouth is kept open using a mouth prop or a self-retaining Doyen's, Hyster's or Dingman's mouth gag (Figs 1.26A and B, 1.27, 1.28A and B). During laparotomies or thoracotomy the edges of abdominal incision or the ribs are retracted with the help of self-retaining retractors. Some special retractors are designed for different sites and surgeries. Some commonly used retractors in oral and maxillofacial surgery are condylar retractor (for condylectomy), mastoid retractor (self-retaining), copper malleable retractor for the retraction of the eyeball, coronoid retractor (forked L retractor) for coronoidectomy of ramal osteotomies, chin retractor for the genioplasty, channel retractor during osteotomies and the Austin's retractor during third molar surgeries, etc. (Figs 1.29 to 1.41).
Bone Removal
In oral and maxillofacial surgery bone removal is often required for gaining access, osteotomies or during resections of jaw. This can be done with the help of:
- Rotary instruments like motor and bur.
- Osteotomes.
- Chisel and mallet.
- Gigli saw.
- Power saw having reciprocating, oscillating and sagittal blades.
- Bone cutter, rongeur/nibbler, etc.
The rotary instruments include motor and burs. While doing bone cutting with these instruments, care should be taken to avoid excessive heat generation by avoiding very high speed and by doing copious irrigation with cold normal saline. The ideal speed of the bur should be 20,000 RPM. The outline of the bony incision should be marked by drilling serial holes with a round bur (post-stamp incision) which are later joined by using flat fissure bur (Figs 1.42A to D). The incision should be started with a round bur as it gets good purchase on the bone and does not slip and injure the adjoining soft tissue. The bur should be sharp, as dull burs produce more frictional heat. If the temperature rises above 40°C, alkaline phosphatase is released from the osteoblasts and bone necrosis takes place. The bur should be made up of either stainless steel or carbide as they cut the bone with cutting edges unlike the diamond bur, which does abrasive cutting and tends to generate more heat. The diamond burs may be used for odontectomy rather than bone cutting. While doing bone cutting with a rotary instruments precaution should be taken not to keep any cotton wool or gauze piece in the vicinity to prevent accidental entangling and tissue injury. The soft tissue should be protected from accidental injury due to slipping of the bur by proper retraction and keeping a guard. The operator must use protective eye glasses as the saline used during the bone cutting may get splashed in the eyes.
The power saws have different types of handpieces and blades like oscillating, reciprocating and sagittal which are useful in different indications. They often produce more precise and fine cuts.
The bone cutting with the help of bone cutter requires a sharp instrument or else the bone tends to get crushed. The nibbler takes out small bites of thin, sharp bone. It is available as single action and double action and with fine and heavy beaks.
A gigli saw is a wire saw and it is held with the help of gigli saw holders and the bone cutting is done by a see saw action. During the cutting, constant irrigation with the cold normal saline is done to dissipate the heat. While cutting the bone with gigli saw care should be taken to ensure that the saw slides smoothly, long strokes are applied so that the entire length of the saw is used for cutting rather than a limited area, as it can lead to make that portion dull and the saw breaks. While cutting the bone with the gigli saw the adjoining soft tissue should be retracted and guarded and copious saline irrigation should be done to avoid over heating of the bone. The bone/jaw needs to be supported during bone cutting.
An osteotome splits the bone and the chisel cuts the bone in a controlled manner. Following precautions must be taken while the bone with a chisel or osteotome.
- It should be sharp.
- Too heavy blows should not be applied as it may result into a fracture.
- The action of mallet should be with wrist movement.
- A mallet with appropriate weight should be selected (200 Oz, 500 Oz) depending upon the density of bone to be cut.
- The vertical stop cuts must be marked before actual bone removal as the bone tends to get split along with bone grains.
- The bone/jaw must be wellsupported to prevent fracture or dislocation.
- A proper purchase should be created for engaging the chisel or else it will slip and injure the soft tissue or vital structures. The soft tissue should be adequately retraced and guard should be kept to prevent its laceration. After the bone cutting all the sharp bone ends should be rounded off, using a bone rasp/bone file. The bone file is used in a pull motion only as the serrations facilitate filling in this direction. To and fro motion leads to clogging of the bone and causes necrosis.
Drains
A drain is the material that acts as a channel for escape of fluid. It is the material used to drain fluids (exudates, transudate, hematoma, pus, blood, etc.) from the tissue dead spaces or cavities.
Purpose
- Prophylactic.
- To prevent accumulation of fluid (bile, lymph, blood, exudates).
- To encourage the obliteration of the dead space otherwise the accumulated fluid acts as a separating agent and prevents the collapse of raw surfaces.
- Therapeutic.
To promote escape of the fluid already collected, e.g. blood, exudates, pus (Box 1.4).
The drain is kept in situ (indwelling) to facilitate free, passive and uninterrupted drainage of fluids along it. When the abscess is drained, to allow the drainage of pus a drain is used.
After removal of tumors, the dead space existing in the tissue is drained with a drain, as exudates, blood accumulates in this dead space and can lead to hematoma and wound infection. The vacuum drain exerts negative pressure and facilitates very good drainage even if the drain is placed at a non-gravity dependent site. The corrugated rubber dam or PVC (portex), drains are required to be kept at a gravity dependent site to be more effective. The corrugations prevent it from getting clogged and permit free drainage. The gauze drains are not ideal as they have capillarity and absorb fluids, swell in size and obstruct the drainage. They are suitable only for packing the cavities for achieving hemostasis (e.g. abscess cavity, cystic cavity which heals by secondary intention). The tube drains also facilitate irrigation of the cavity.
The time for removal of the drain is not fixed it should be left in place till the drainage from the wound stops completely. It is advisable to displace the drain first, when the soakage becomes negligible, as there could be blockage of the drain due to the thick exudates or slough, before it is finally removed. If the drain is kept unduly long or if the aseptic precautions are not taken the infection can travel into the wound along it.
Advantages
- Drainage of the collected fluid removes the nidus of infection.
- It helps in monitoring the hemorrhage or leakage at the suture line, thus, gives warning of future complications.
- It obliterates the tissue dead space and removes the separating fluid and allows the raw surfaces to collapse and come in contact so that the healing is faster.
Disadvantages
- It forms portal of entry for infection.
- It can delay the healing.
- It can lead to breakdown of the suture line thus used judiciously.
- It can initiate tissue reaction.
- It can get blocked and become no functional.
Drain Placement
- The drain used should be
- Soft, so as not to erode the surrounding tissues,
- Smooth, so as not to permit fibrin to cling to it.
- Preferably radio-opaque or having radio-opaque line along the tube.
- Made up of a material that will not disintegrate and leave foreign bodies in the wound.
- Be brought out through a separate stab wound and fixed properly and
- It should be non-irritant.
- The stab wound that gives access to the drainage cavity should be large enough to permit free drainage.
- The drain must be placed in the dependent position if gravity alone is to accomplish drainage. Sump tube must be used to remove drainage ‘uphill’, i.e. against the force of gravity.
- The drain should be brought out through the shortest route to avoid kinking.
- Proper daily dressing of the drainage site should be done to prevent infection.
- When prosthesis is present, closed tube system should be used to lessen the risk of infection.
- It should not damage the nerve or blood vessel.
- The inner end should not be placed near the suture lines.
- The drain should be secured properly.
Precautions
- Drains act as two-way conduits. The benefits of prophylactic use of a drain must be weighed against possible ensuing infection.Figs 1.37A and B: Austin's retractor, traumatic and atraumatic, retractor in use during third molar surgeryCareful dressing of the wound and drain should be removed as soon as the purpose is over. It reduces the likelihood of significant infection.
- It should never be brought out through the operative incision, but through separate stab incision. If drain is brought out through the operative wound, it not only permits bacterial ingress and infection of the operative wound but also prevents its closure.
- Fix the drain properly with skin stitches. If it is detached from skin surface, refix it. Otherwise, it may come out or disappear into the drainage cavity.
- A drain should not be placed through an area where fibrosis will cause impairment of function, e.g. across the joint or near tendon sheaths, etc.
- Do not drain bowel/vascular anastomotic suture line, since this may increase chances of anastomotic leak.
- Too hard or stiff drain may cause pressure necrosis of the surrounding tissues, especially one near a large blood vessel, tendon, nerve or solid organ.
Removal of Drain
- The prophylactically placed drain should be removed as soon as drainage has subsided, usually after 48 hours.
- The therapeutically placed drain is kept in position until the drainage subsides. The lack of drainage could be due to blockade of the pores due to tissue contact or fibrinous plug, in such cases before removing the drain it should be displaced to observe if any drainage is still present. If the drainage is not present then it is removed gradually, a 3 to 4 cm of drain is withdrawn each day and refixed to allow closure of the drainage tract from its depth, thus preventing pocketing.
- Tube drains are removed when drainage output is minimal or ceased.
- Corrugated drains are usually removed on the third day or when there is cessation of discharge.
Types of Drains
Cotton gauze
Gauze acts as a drain by capillary action in the fabric, which absorbs the fluid (Fig. 1.43). Once it becomes saturated, it acts as a plug rather than as a drain, hence, it should be changed twice every 24 hours.
Uses
To pack a cavity to prevent its closure and allow healing from floor or to control diffused oozing, e.g. after incision and drainage of:
- Injection abscess in gluteal or deltoid region.
- Breast abscess, enucleated and infected odontogenic cysts, etc.
The gauze drain can also be inserted in an abscess cavity as a pack cum drain if the oozing of blood is present for achieving hemostasis. However, it must be remembered that gauze has an undesirable property of capillarity which impedes the patent drainage and thus, it should be replaced by corrugated rubber dam drain once the purpose of hemostasis is achieved, to facilitate proper drainage.
Advantage
It acts as a temporary drainage.
Disadvantages
- Gets soaked rapidly.
- Gets sealed within 6 hours by fibrin network.
- When soaked it acts as a moist channel for the penetration of bacteria.
- When a soaked gauze is removed, it is often followed by a gush of accumulated fluid from the cavity.
- When a pack is left in contact with the raw surfaces, it damages the raw surfaces since it becomes adherent to it. When gauze is soaked in liquid paraffin the damage to the raw surface can be avoided, but it decreases the absorption capacity.
Wicks
The wick is formed from gauge or threads of ligatures or suture material twisted together or bound loosely. Where the source of drainage cannot be brought to the surface, then a wick can be passed down to it.
Advantages
- When the oozing of the blood is present from the abscess cavity due to presence of friable granulation tissue, wicks can be packed in the cavity to achieve hemostasis. The wick can be replaced by corrugated drain after 24 hours.
- The wick can be impregnated with antiseptic solution or antibiotics to ensure local drug delivery in adequate concentration.
- It is economical and easily available and can be made of a required size in the OT.
Disadvantages
- It becomes soaked by the fluid.
- When a wick is made of folded gauze, it swells upon soaking which will obstruct the tract.
- It can adhere to the surface.
- It requires frequent change because it becomes ineffective due to the soaking.
Red rubber corrugated drain (sheet drain)
It is made up of red rubber which is available in the form of unsterile sheets, from which the strips of required length and breadth are cut and sterilized by autoclaving. With this drain, fluid reaches the surface by gravity hence it must be covered with the gauze pad (Figs 1.44A and B).
Advantages
- Drainage of the fluid occurs along the grooves of the drain, so chances of blockage are less.
- Red rubber is an irritant. It forms a fibrous tract around itself, which is advantageous.
- This drain is used only when there is minimal amount of discharge.
Disadvantages
If it is used for a prolonged period and removed at a time, the track of the drain will start healing from superficial and deep aspects while the middle part remains infected. This leads to sinus formation or pocket formation. Prolonged insertion leads to release of sulfur from red rubber drain evoking adverse tissue reactions.
Being a tough material, it can injure intestine and can cause fistula, if kept for a longer period, because when the drain is in the vicinity of the suture line, it may break up the suture line.
It might be sucked into the wound when it is not fixed properly to the surface or not removed carefully.
Currently portex drain is used instead of red rubber drain as it is less irritant than the red rubber and it also has a radio opaque line which helps in detecting the drain radiographically in case the drain is lost in the cacity (Fig. 1.45).
Uses
- Drainage of the peritoneal cavity after an operation is done for any of the following: enteric perforation, perforated appendicitis, biliary surgery and sever peritonitis (Table 1.4).
- Drainage of perirenal areas after pyelolithotomy.
- Drainage of large abscess cavity, e.g. after incision and drainage of the submandibular space abscess.
- To drain retropubic space after surgery on the bladder, e.g. cystolithotomy, suprapubic prostatectomy.
- To drain subcutaneous tissue after removal of multiple enlarged nodes in neck, groin, etc.
- After mastectomy, removal of tumors.
- Tube Drain: When the fluid enters the tube, it can be guided into a collecting apparatus.
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Advantage
Tube drain forms the closed drainage system so that raw surface cannot be contaminated due to entry of bacteria.
Disadvantages
- It drains only in the direction of the gravity.
- If the tube is too thin, the force of capillarity tends to retard the free flow of fluid through it.
- It cannot drain viscous fluid.
- It drains the fluid only when the tube is larger; so the fluid can be replaced by the air.
- When continuous negative suction is applied to a tube drain, the tissue is drawn into the inner hole.
The types of tube drains are as follows:
Catheters (Red rubber catheter, Malecot's catheter and Foley's catheter): Use of catheters is similar to that of sheet drain, but they are used particularly when the amount of drainage is high.
Advantage
Catheters can be directly connected to the apparatus, so that the contamination on wound with the drainage is less.
Disadvantage
The inner end of a catheter can be blocked, due to the obstruction caused by the draining material.
Uses
- To drain large abscess cavity.
- To drain pyogenic abscess.
- To drain the infected hydatid cyst of the liver (drain should be put near the incision on liver and not in the cavity itself).
- To drain retropubic area after prostatectomy. This prevents the soiling of the skin, if leakage persists.
- To drain after thoracocentesis, cholecystostomy, cecostomy, cystostomy.
- To drain pelvic abscess.
- To drain peritoneal abscesses.
- To drain bladder after Freyer'sprostatectomy to give an alternative pathway, if clot retention occurs.
Portex drainage tube: It is made up of soft portex material. It is elastic and has side holes as well as terminal holes at the tip. It causes least irritation, therefore can be used for a prolonged period. It has a radio-opaque line along its length. Presterilized tubes are available.
Uses
- To drain pleural cavity in:
- Empyema
- Hydropneumothorax
- Pneumothorax
- Hemothorax.
- To drain postoperatively after an operation on heart or lungs.
Precaution
Portex intercostals drainage tube should be connected to underwater seal bottle by extension tubing.
Penrose drain
It is a hollow tube of latex rubber with thin wall, and can be made by cutting the finger stall of surgical glove. Its tip is cut so that both the ends are open.
Uses
- As a cigarette drain.
- As a simple drain.
- For sump drainage of the peripancreatic retroperitoneal tissue in patients with infected pancreatic abscess. For this, special drain is made as follows:No. 24 or 22 Foley's catheter is taken, bulb and the valve of balloon channel are cut. Multiple side holes are made on half the length of the catheter. Two or three layers of ribbon gauze are placed around it and then it is put in penrose drain after cutting side holes onto it.
Cigarette drain: Penrose drain that has a gauze within it is called a cigarette drain in cigarette drain; the ooze exists along and not through the gauze. The rubber acts as conduit.
Advantages and uses are same as for penrose drain.
Disadvantages
- Secretions cannot be collected in bags, so they cannot be measured.
- Chances of infection are more than in penrose but less than those in corrugated rubber drain.
- Skin irritation and excoriation may occur due to seepage of irritant effluent.
Vacuum drain/suction drain (redivac drain, romovac drain)
Principle: Active suction is applied in a continuous manner. So it does not allow the secretions to collect inside and also maintains patency of the drainage tube; it does not allow the secretions to dry and occlude the drain site (Figs 1.46A to C).
Purposes
It serves two purposes:
- The provision of access for accumulated pus or intestinal contents.
- The prophylactic removal of any fluid within the peritoneal cavity (e.g. bile) before its presence can lead to complications. This prophylactic drainage may be best accomplished by the use of close wound suction drainage. As, it is more important where small amount of drainage and non-dependent drainage is required.
Advantages
- Less irritating to the tissues.
- Less likely to cause infection because it is a closed system.
- It is particularly effective under large skin flaps, e.g. after radical neck dissection, modified radical mastectomy.
- Closed suction drainage decreases the incidence of infection that occurs secondary to contamination of the drain itself and is mandatory in the presence of a foreign body.
- It can be placed at a non-dependent site.
Disadvantage: The continuous negative pressure may induce bleeding.
Dressing
A dressing is an adjunct used by a person for application to a wound to promote healing and/or prevent further harm. A dressing is designed to be indirect contact with the wound, which makes it different from a bandage, which is primarily used to hold a dressing in place. Dressings are frequently used in first aid and nursing.
The ideal wound dressing should have the following characteristics:
- Provide mechanical and bacterial protection.
- Maintain a moist environment at the wound/dressing interface.
- Allow gaseous and fluid exchange.
- Remain nonadherent to the wound.
- Safe in use—nontoxic, non-sensiti zing, and non-allergic (both to the patient and the medical personnel).
- Well acceptable to the patient (e.g. providing pain relief and not influencing movement).
- Highly absorbable (for exuding wounds).
- Absorb wound odor.
- Sterile.
- Easy to use (can be applied by medical personnel or the patient).
- Require infrequent changing (if necessary).
- Available in a suitable range of forms and sizes.
- Cost effective and covered by health insurance systems.
Purpose of Dressing
- Controlling the moisture content, so that the wound stays moist or dry, to maintain the optimal wound humidity to prevent wound from becoming dry and forming eschar preventing direct cell migration across the wound bed.
- Protecting the wound from infection.
- Removingslough, and
- Maintaining the optimum pH and temperature to encourage healing. To provide thermal insulation by maintaining a constant temperature of 36 to 37°C to optimize the mitotic activity.
Indications
- Surgical and traumatic wounds.
- Donor site wound dressing.
- Fungating growth.
- On abrasions.
Types of Dressing
- Glycerine magsulf dressing: It is the saturated solution of magnesium sulphate (MgSO4) crystals and glycerine, since magnesium sulphate is hygroscopic, it is used to reduce edema in the cases of cellulitis, excessive postsurgical edema.
- Vaseline gauze dressing: The vaseline gauze dressing is used to accelerate wound healing. It is nonadhesive and thus ideal for dressing the healthy, raw, granulating wound surfaces. It is also used to cover the raw areas created following the harvesting of split thickness skin grafts.
- Dry dressing: Dry dressing is used in wound without granulation, e.g. postoperative sutured, healing incision line.
- Wet dressing: Wet dressing is used when ulcer with granulation tissue, i.e. eusol, betadine, saline.
- Biological dressings: Such as amniotic membrane dressings, collagen membrane or a skin graft are the best dressings as they prevent wound contamination and promote the healing. The other examples of the biological dressings are aminiotic membrane, collagen membrane, fascia. Amniotic membrane (AM), or amnion, is the innermost layer of the placenta and consists of a thick basement membrane and an avascular stromal matrix. Its properties such as lack of immunogenicity, fluid loss controlling, pain relieving, re-epithelialization and granulation and its stimulating, anti-inflammatory, antifibrotic and antimicrobial properties make it an ideal biological dressing. It has the advantage of ready availability at no extra cost to the patient. It provides secure coverage to the wound site, which reduces exudation from the wound. The AM stimulates epithelialization from the ulcer bed and/or the wound edge, which is considered to be mediated by growth factors and progenitor cells which are released by it. One of the most striking effects is its granulation stimulating effect. This is due to some angiogenic and growth factors which are produced by the membrane. Despite being a human derivative, it is not rejected, because the AM does not express the HLA A, B, C and the DR antigens.
Collagen materials have been utilized in medicine and dentistry because of their proven biocompatibility and capability of promoting wound healing. Biological dressings like collagen are impermeable to bacteria, and create the most physiological interface between the wound surface and the environment. Collagen dressings have other advantages over conventional dressings in terms of ease of application and being natural, nonimmunogenic, nonpyrogenic, hypoallergenic, and pain-free. Collagen is a biomaterial that encourages wound healing through deposition and organization of freshly formed fibers and granulation tissue in the wound bed thus creating a good environment for wound healing. Collagen sheets, when applied to a wound, not only promote angiogenesis, but also enhance body's repair mechanisms. While acting as a mechanical support these reduce edema and loss of fluids from the wound site, along with facilitation of migration of fibroblasts into the wound and enhancing the metabolic activity of the granulation tissue. Moreover, it is easy to apply and has the additional advantage of stopping bleeding.
- Occlusive dressing: An occlusive dressing is an air and water-tight trauma dressing used in first aid. These dressings are generally made with a waxy coating so as to provide a total seal, and as a result do not have the absorbent properties of gauze pads.
Table 1.5 Different types of material used for dressing and their examples and properties TypePropertiesPassive productsTraditional dressings that provide cover over the wound, e.g. gauze and tulle dressingsInteractive productsPolymeric films and forms which are mostly transparent, permeable to water vapor and oxygen, non-permeable to bacteria, e.g. hyaluronic acid, hydrogels, foam dressingsBioactive productsDressings which deliver substances active in wound healing, e.g. hydrocolloids, alginates, collagens, chitosanThey are typically used to treat open, or “sucking,” chest wounds to alleviate or prevent a tension pneumothorax (a serious complication of a simple pneumothorax). They are also used in conjunction with a moist sterile dressing for intestinal evisceration. - Occlusive dressings come in various forms, including Vaseline Gauze, which sticks to the skin surrounding the wound using Vaseline.
Classification of Wound Dressings
Synthetic wound dressings would broadly categorized into the following types:
- Passive products
- Interactive products
- Bioactive products
The properties and examples of these products are given in Table 1.5.
Bandage
The bandage is the piece of material used to cover, support, immobilize or exert pressure to the part (Box 1.5).
Bandages commonly used in oral and maxillofacial surgery
- Simple roller bandage—single or double headed.
- Barrel bandage to retain the dressing and support the lower jaw.
- Four-tailed bandage to support the lower jaw (Figs 1.47A and B).
- Mastoid bandage for compression after TMJ surgeries.
- Compression bandage with simple roller bandage, crepe bandage or with elastoplasts. It helps in achieving hemostasis, obliterates tissue dead space and prevents formation of the hematoma.
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