Aseptic Surgical Technique

The surgical hand scrub is a vigorous wash with antimicrobial soap to remove bacteria, viruses, and fungi from hands and forearms before gowning and gloving. Technique: (1) wet hands and forearms under running water up to the elbows; (2) apply antimicrobial soap (chlorhexidine or iodine-based) and scrub for 3–5 minutes with a brush, working between fingers, under nails, and up the forearms; (3) pay special attention to the nailbed (scrub under the nails with a nail pick) because bacteria hide there; (4) rinse thoroughly under running water, keeping hands above elbows so water runs downward (not back onto clean hands); (5) dry with a sterile towel, patting rather than rubbing; (6) apply alcohol-based hand sanitizer if using a waterless scrub protocol. Timing: full surgical scrub takes 3–5 minutes. Many hospitals now use a waterless, alcohol-based scrub (takes 2–3 minutes) on non-visibly soiled hands, which is faster and equally effective. After the initial scrub at the start of your shift, subsequent scrubs between cases can be shorter (1–2 minutes) because your baseline bacterial count is lower. Never re-contaminate your hands after the scrub: keep hands above waist and away from your face.

Gowning and gloving is a choreographed sequence to avoid touching non-sterile items with sterile hands. Standard gowning order: (1) the circulating (non-sterile) nurse opens the sterile gown package on a clean surface; (2) you (in sterile attire) reach in without touching the package edges and grasp the gown by the neckline, lifting it away from the package; (3) step into the armholes carefully, sliding your arms into the sleeves without touching the outside of the gown (the circulating nurse pulls the gown up and over your shoulders, ties the back); (4) the gown is now on but not yet considered fully sterile (the back of the gown is non-sterile because you cannot see it). Gloving: open-gloving (standard method) — (1) hold your gloved left hand open, palm up; (2) slide the fingers of your right hand (non-gloved) under the glove cuff, grasping the inside of the left glove; (3) guide the left glove onto your left hand, keeping your right hand's fingers inside the cuff (so your bare hand never touches the outside of the glove); (4) now your left hand is gloved; use the gloved left hand to help don the right glove by sliding the fingers of your gloved left hand under the right glove's cuff, lifting and guiding it onto your right hand; (5) interlock fingers once both gloves are on to settle them in place. Closed-gloving (for surgeons in the OR) — keeps your hands inside the gown sleeves while donning gloves, never exposing bare skin. Either method works if done carefully; the key is never touching the outside of the glove with bare skin.

A sterile field is a designated area (surgical tray, surgical site area draped with sterile drapes, or the entire surgical team in sterile attire) that is kept free of microorganisms and is considered safe for contact with a patient's open wound or for placing sterile instruments and supplies. Sterile field rules: (1) Only sterile items touch sterile items — if a sterile item (gloved hand, instrument, drape) touches something non-sterile (your gown back, the table edge, a non-sterile surface), it is contaminated and must be replaced or re-sterilized. (2) Keep hands and arms within the sterile field and above waist level — do not let your hands drop to your sides or touch your face. (3) Face the sterile field at all times — never turn your back or step away; if you must leave, remove your sterile attire and re-gown on return. (4) Do not reach across the sterile field (air currents and gravity can bring contaminants down); reach around the edges. (5) Keep the field covered when not actively in use — drape with a sterile cover. (6) Do not talk or cough over the field; if you must talk, minimize and angle away. (7) Monitor all team members — if you see a breach (an instrument touching non-sterile skin or table), speak up immediately and the item is replaced. Maintaining sterility is everyone's job; a culture of accountability is essential.

Surgical site infections (SSI) occur when microorganisms enter the surgical wound and cause localized or systemic infection. Sources: (1) the patient's own skin flora (usually Staphylococcus aureus, Staphylococcus epidermidis, or Streptococcus), which is why the skin is prepped with antiseptic; (2) the surgical team's skin (bacteria on the surgeon's or assistant's hands despite scrubbing) — hence the importance of hand scrub and gloves; (3) the environment (dust, bacteria in the air), countered by laminar airflow and high-efficiency air filtration in modern ORs; (4) contaminated instruments or supplies if sterilization fails. Infection rates are roughly 1–5% after clean surgery, but can exceed 20% for contaminated or emergency cases. Aseptic technique prevents SSI by: (1) aggressive hand scrubbing to minimize skin flora; (2) proper gloving so bacteria on hands do not reach the wound; (3) prepping the skin with chlorhexidine or iodine to kill surface bacteria; (4) draping to isolate the surgical area and create a sterile zone; (5) using sterile instruments and supplies (verified by sterile packaging, expiration dates, and sterilization indicators); (6) minimizing air currents and movement in the OR; (7) avoiding talking and unnecessary traffic; (8) using antibiotic prophylaxis (given pre-operatively) to kill bacteria that do enter the wound. Even with perfect aseptic technique, some patients develop SSI due to diabetes, immunosuppression, or other factors, but lapses in technique dramatically increase the risk.

Medical asepsis (clean technique) aims to reduce the number of microorganisms in a non-sterile environment (hospital room, outpatient clinic) to prevent transmission of infection from patient to patient or patient to staff. Practices: hand hygiene, using clean (not sterile) gloves, covering coughs/sneezes, keeping equipment clean and disinfected. Used in nursing care, patient hygiene, medication administration, and non-surgical wound dressing changes. Surgical asepsis (sterile technique) aims to eliminate ALL microorganisms from a sterile field to prevent contamination of an open surgical wound or sterile device. Practices: hand scrubbing with antimicrobial soap, sterile gowns and gloves, sterile instruments and drapes, maintaining a sterile field, using a sterile technique for handling instruments and supplies. Used in the operating room, during sterile procedures (central line placement, spinal tap), and in sterile dressing changes of open wounds. The stakes are higher in surgical asepsis because an open surgical wound is a direct pathway to the bloodstream and internal organs, so even a small contamination risk is unacceptable.

Skin preparation (surgical site antisepsis) is performed by the anesthesia team or surgical nurse in the immediate pre-operative period, usually after the patient is anesthetized and positioned on the operating table. Steps: (1) clip (do not shave, as shaving causes microtrauma) any hair in and around the surgical area — clipping is done with a clipper, not a razor, to minimize skin injury; (2) cleanse the skin with an antiseptic scrub (chlorhexidine, iodine-based, or alcohol-based) in concentric circles starting at the intended incision site and working outward — this removes dirt, bacteria, and organic material; (3) allow the antiseptic to dry completely (important for effectiveness and to prevent skin irritation); (4) apply a second application of antiseptic (often a alcohol-based or iodine solution) and allow to dry again; (5) drape the prepped area with sterile drapes, leaving only the surgical site exposed. Why it matters: the patient's own skin flora is the primary source of SSI; a vigorous prep with effective antiseptic reduces the bacterial count from millions to thousands or fewer, dramatically lowering infection risk. Allowing the antiseptic to dry is critical because it prolongs contact time and allows the chemical to penetrate the skin. Proper skin prep is one of the highest-yield interventions to prevent SSI.

If you notice a glove is torn, punctured, or visibly contaminated during surgery: (1) stop your activity immediately; (2) hold your hand up (do not touch anything) and announce 'Contamination' so your team knows; (3) the circulating nurse will help you change your glove without breaking the sterile field — you extend your hand, the nurse removes the contaminated glove by grasping the outside and peeling it off, then places a new sterile glove on your hand (you insert your fingers into the glove without touching the outside); (4) if the gown is torn or contaminated on the front (the sterile part), remove the entire gown and re-gown with a fresh one — do not attempt to patch or repair it. If you contaminate your glove and do not notice, there is risk of introducing bacteria into the surgical field; that is why the circulating nurse and other team members watch you and speak up if they see a problem. If contamination is discovered only after the fact (a glove puncture is found after surgery), the contamination is documented and the patient is monitored for signs of infection (fever, surgical site drainage, redness). Most cases do not result in infection due to the patient's immune system, but the incident is reported and reviewed.

Surgical instruments and supplies must be sterile (free of all microorganisms) before use. Sterilization is performed in hospital sterilization departments (autoclave — high heat and pressure — is the most common method for metal instruments and textiles; gas sterilization is used for heat-sensitive items; chemical sterilization for items that cannot tolerate heat). Sterile items maintain their sterility until: (1) the package is opened (once opened, the contents are considered contaminated after the end of the procedure); (2) the package is torn, punctured, or wet (moisture is a vector for bacterial entry); (3) the package is dated and past its expiration date (sterile packages are marked with the date of sterilization and typically have a 30-day shelf life, though some are valid for 1 year depending on the packaging); (4) the package has been stored improperly (exposed to heat, humidity, or contamination). Verification of sterility: (1) check the sterile package label for the date of sterilization — if past the expiration, do not use it; (2) visually inspect the package for tears, moisture, or discoloration — if any are present, do not use it; (3) look for a sterile indicator (a small chemical indicator inside the package that changes color if exposed to the sterilization process) — the color change confirms the package was sterilized; (4) some surgical teams use sterile biological indicators (bacterial spores) periodically to verify the autoclave itself is functioning correctly. If you open a package and later discover it was not actually sterile (the indicator shows it was never sterilized, or the expiration date was misread), you must inform the surgeon immediately and delay the procedure while a sterile replacement is obtained; proceeding with a non-sterile instrument risks SSI.