REQUIREMENTS FOR OPERATING
THE OPERATING ROOM
The ideal operating room for the plastic surgeon need not necessarily
be large, since it requires less work to render it aseptic. Furniture
and possibly amphitheater accommodation are always a means of infection
unless scrupulously cleansed, a task of time, difficult at best.
The room should be provided with large windows, with facilities for the
introduction of the air from without. Two doors, and those well fitted,
are all the room should have—but one being used, if possible.
=The Walls.=—The walls should be of plaster, smoothly laid and well
painted, so that they may be readily washed down with antiseptic
solutions—a daily morning rule. Glass or tiled walls are much used now
and add considerably to the appearance and safety of the room, as plaster
in time will crack, while the paint, owing to the heat of sterilizers
or steam, often creeps and blisters, exposing an absorbing surface
which readily wears down, exposing parts inaccessible for even acute
cleanliness.
=The Floors.=—The floors of these rooms are now usually laid with tile
mosaic or marble or a composition resembling linoleum. The base should
be curved and all corners sloped off to improve drainage and to keep off
dust and dirt.
=Skylight.=—A skylight of metal and glass is a valuable accessory. It
should be fixed or never permitted to be opened during an operation.
=Disinfection.=—Spraying the room with an antiseptic is hardly necessary,
since all germ life descends to the floor and can best be removed by
washing with a 1-1000 bichlorid solution.
Should it be necessary to perform an unusually extensive operation in
a private house, the room must be cleared of all furniture, pictures,
drapery, and carpet. After plugging up the crevices in the windows and
doors it should be well fumigated either with sulphur candles, as now
commonly furnished, or, better, with formaldehyd.
The superiority of formaldehyd as a disinfecting agent is now well
established. An illustration of an apparatus, largely doing away with the
difficulties and dangers encountered in the use of the older and ordinary
styles of the pressure or nonpressure type, is shown in Fig. 3. The main
difficulty with these has always been their almost inaccessibility for
cleansing purposes, and in such where this is not the case, the size of
the aperture has been made so small that the inside could not be reached.
In the pressure apparatus the tops are bolted on, making them exceedingly
difficult to remove, with the result that the necessary cleaning was not
properly attended to. The corrosive action of formaldehyd gas is such
that under these conditions any apparatus would soon become useless.
In the type shown a single clamp arrangement is used (_a_). By the
turning of the hand screw (_b_) two planed metal faces (the upper surface
of the boiler and under surface of the cover) are brought together and
sealed. When the cover (_c_) is removed the entire inside of the boiler
is in sight and can be thoroughly cleansed, which should be done each
time the apparatus is used. The pipes through which the formaldehyd gas
passes after generation are arranged so that they can be taken off and
cleaned.
[Illustration: FIG. 3.—FORMALDEHYD DISINFECTING APPARATUS.]
The gas is generated in the boiler (_d_) and passes out from the top,
down through the pipe (_e_), and from thence through a series of pipes
(_f_) underneath the boiler, which are subjected to direct heat from the
lamp (_g_). By this means the gas becomes superheated, the polymerization
of the formaldehyd is almost entirely prevented, and a dry gas is insured
and given off at the pipe (_h_).
The room should be left closed overnight and thoroughly aired thereafter.
The bare floor must then be scrubbed with hot water and soda and flushed
with a three-per-cent carbolic-acid solution.
As little furniture as possible should be found in an operating room, and
this preferably of undecorated enameled iron.
=Instrument Cabinet.=—For the instruments and dressings there should be a
dust-proof cabinet of iron and glass, such as is shown in Fig. 4.
[Illustration: FIG. 4.—INSTRUMENT CABINET.]
=Operating Table.=—The operating table should be of like construction
and as plain as possible. Its top can be padded with sterilized felt,
protected from moisture by rubber sheets. A surgical chair of plain
construction might suffice, inasmuch as most plastic operations cover but
a small area and are usually about the head and often performed under
local anesthesia. A chair with head rest is much more comfortable, adding
much to the moral and physical comfort of the then conscious patient. A
very desirable chair is shown in Fig. 5.
[Illustration: FIG. 5.—OPERATING TABLE.]
=Instrument Table.=—An instrument table, such as is shown in the next
illustration, is quite necessary, upon which dressings and instruments
are laid during operation. In this the frame is of white enameled iron
and the top and shelf of plate glass.
[Illustration: FIG. 6.—INSTRUMENT TABLE.]
=Irrigator.=—An irrigator is often of service, especially in washing
out the fine pieces of bone resulting from chiseling or drilling. In
skin-grafting it may be used with sterilized three-per-cent salt solution
as described later. The best irrigators are those of germ-proof or
ground-glass stopper type. They are suspended from the wall by means of
an iron bracket or pulley service or placed upon a movable enameled stand
as shown in Fig. 7.
Irritating antiseptic solutions are to be avoided, their especial
indication will be found under antiseptic care of wounds.
CARE OF INSTRUMENTS
[Illustration: FIG. 7.—IRRIGATOR.]
All instruments should be of modern make, devoid of clefts or grooves,
and having separating locks when possible. Wooden or ivory handles
should be entirely discarded. They should first be rendered free of
dirt or dried blood by scrubbing briskly with a stiff nailbrush and hot
water; then dried and placed in the sterilizer. The immersed instruments
are boiled for five or ten minutes. There are many of such sterilizing
apparatuses to be obtained, all made on the same plan, however, and
consist of a copper or brass box and cover well nickel plated. Folding
legs are placed beneath. A perforated tray is placed within for the
immersion of instruments. An alcohol lamp with asbestos wick furnishes
the heat.
One per cent of carbonate of soda added to the water prevents them from
rusting. The simple subjection of instruments to carbolic-acid solutions
or antiseptics of like nature is useless. (Gärtner, Kümmel, Gutch,
Redard, and Davidsohn.)
From the sterilizer the instruments are placed in a glass tray containing
a one-per-cent lysol solution. Knives, needles, and scissors should be
immersed in a tray with alcohol, as a great number of antiseptics destroy
their cutting edges. Glass or porcelain trays are best for this purpose.
A sterilized towel being placed in the bottom of each for the better
placing of instruments.
After operation all instruments should again be scrubbed with soap and
hot water, immersed a moment in boiling water or a jet of live steam,
dried with an aseptic cloth, and returned to the case.
A very effectual means of rendering instruments sterile is to place them
in a metal box and bake them in the ordinary oven (200° F.) for one hour.
To preserve needles Dawbarn advises keeping them in a saturated solution
of washing soda. Albolene has an unpleasant oiliness, but is otherwise
good. Calcium chlorid in absolute alcohol is efficacious, but expensive.
All rust accumulating on instruments must be carefully removed with fine
emery cloth; this, however, is unnecessary if the soda solution is used
as previously mentioned. It is well to occasionally dip the instruments
(holding them with an artery forceps) into boiling water as they are used
during operation.
[Illustration: FIG. 8.—INSTRUMENT STERILIZER.]
PREPARATION OF THE SURGEON AND ASSISTANTS
CARE OF THE HANDS
The hands of the surgeon and his assistants must always be thoroughly
prepared before operation or dressing a wound. The mere immersion of the
hands into an antiseptic solution is not sufficient to remove germ life.
The oily secretions of the skin and its folds, as well as the cleft about
the nails and the nails themselves, are common carriers of infection and
are cleansed only by the vigorous method of scrubbing with soap and water
and then rendered aseptic by the use of proper media.
The aseptic hospital washstand, as shown in Fig. 9, will be found an
ideal piece of furniture; it has a frame constructed of wrought iron,
white enameled. The top is of one-inch polished plate glass, with two
twelve-inch holes.
[Illustration: FIG. 9.—ASEPTIC WASHSTAND.]
The entire stand can be moved away from the wall, to permit of thorough
cleaning of basins, supply pipes, etc. The basins are the best annealed
glass, and are supported by nickel-plated traps, with connections for
vent pipes. The water supply is controlled by foot valves, which enable
the operator to draw either cold, medium, or hot water at will. The waste
is also controlled by a foot valve, as shown.
The systematic law of cleansing the hands should be insisted upon at all
times. Rules for the method followed might be displayed in abbreviated
form in the operating room by glass or enameled signs hung on the wall
over the basin and reading as follows:
+----------------------------------------------------------+
| YOUR HANDS |
| |
| I. Clean nails. |
| II. Scrub with very hot water and soap for five minutes.|
| III. Wipe in sterile towel. |
| IV. Brush with eighty per cent alcohol. |
| V. Dip into antiseptic solution. |
+----------------------------------------------------------+
Green soap is commonly used and is to be preferred to powdered or cake
soap. The powder cakes and clogs the container in damp weather, while
the latter collects impurities from the air. Synol soap, also liquid,
is perhaps the most ideal, a two per cent solution of which forms an
excellent lavage for cleaning instruments, as well as washing down
furniture in the operating room.
The brushes to be used are of the common wooden-back, hard-bristle make,
which can be boiled without injury. There should be several of these,
marked on their backs as desired, so that one brush can be used for
the one purpose only. In cleansing the hands, the forearms, and even
the elbows, should be similarly treated. After scrubbing with soap, as
directed, they are to be rinsed, dried with a sterilized towel, again
scrubbed with alcohol, and then dipped or flushed with a bichlorid
solution.
GOWNS
No woolen garments should be allowed to come in contact with the site of
the operation, nor is it well to allow such material in the operating
room while working.
Freshly laundered linen gowns of Von Bergman’s pattern, reaching to the
shoes, should be worn. They should contain half sleeves and be buttoned
on the back. See Fig. 10. These may be sterilized in the steam sterilizer
or washed in one-per-cent soda solution. When soiled or blood-stained
they should be relaundered.
The operator may substitute the gown with a rubber apron of the Triffe
pattern, reaching as high as the collar, but continuous washing quickly
ruins them. See Fig. 11.
[Illustration: FIG. 10.—VON BERGMAN OPERATING GOWN.]
[Illustration: FIG. 11.—TRIFFE RUBBER APRON.]
PREPARING THE PATIENT
GENERAL PREPARATION
The patient for all plastic operations should be carefully examined as to
general health and past history. His healing powers should be at their
best, as much depends on primary union. If he presents a syphilitic
history, it is well to place him under treatment, for a time, at least,
before an operation is undertaken. The bowels should be regular. Sulphate
of magnesium should be given each morning, before breakfast, for at
least two days prior to operating, while his general condition may be
improved by the employment of bitter and alterative tonics. Nux vomica
with tinct. cinchonæ com., associated with essence of pepsin aromat.,
or lactopeptone, are very useful. This treatment is also carried on for
several days, _post operatio_.
The success of an operation depends, first, upon the selection of the
case; second, the selection of the method employed, and, third, upon the
hygiene under which the patient undergoes convalescence. The patient
must be given to understand, in many cases, that it is often necessary
to reoperate, even to the extent of seven or eight operations, to bring
about the desired result. The first result obtained with many cosmetic
operations is not at all gratifying to the patient, and unless this is
explained to him beforehand he may become discouraged awaiting the next
operation and disappear, thus losing the opportunity of being pleased
finally, while the surgeon is misunderstood and underestimated by
narrow-minded judges and the ever-willing friendly advisers and critics—a
consummation much to be avoided.
PREPARATION OF THE OPERATIVE FIELD
The part to be operated upon should first be closely shaven. The oily
secretions of the area are next rubbed off with an absorbent cotton
sponge saturated with alcohol or ether. Next, the skin is washed with hot
water and soap or three-per-cent synol suds, then rinsed, and finally
rendered aseptic with a bichlorid solution.
If the operation is to be done about the face a rubber cap is so adjusted
as to cover the hair. If this is not obtainable sterilized bandages can
be employed.
In operations about mucous membranes, as in the nose and mouth, the parts
must be cleaned at short intervals with a solution of permanganate of
potash or boric acid. The teeth must be cleansed with antiseptic soap,
tartar is scraped off, and the mouth rinsed with a proper disinfectant.
The corrosive sublimate, or carbolated solutions, owing to their toxic
qualities, cannot be used. The preparation of wounds for reoperation, or
where an operation is secondary to injury, is referred to later.
All clothing about the site of operation should be removed and rubber
cloth placed to surround the field and cover the clothing. This should be
covered again with sterilized towels. Everything that touches the patient
after this has been done should be aseptic; indeed, hands employed during
operation must be immersed from time to time in 1-500 bichlorid solution,
and allowed to remain wet.