The surgical suite

image of The surgical suite
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Preparation and surgical areas in a veterinary practice can vary greatly – from multi-function rooms in a lock-up branch practice, to multi-theatre suites in a purpose-built specialist referral centres. No matter the size or the financial constraints of the veterinary practice concerned, excellent aseptic technique and high operational standards must still be achieved. This chapter advises on design considerations; preparation room equipment; equipment for anaesthesia; theatre equipment; pressurized gasses and liquid nitrogen; care of surgical instruments; and managing the surgical team.

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8.1 Lightweight manoeuvrable task lights are ideal for prep areas. Note the multi-parameter monitor in use for this patient.
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8.2 Preparation room layout will be determined by the space available and the number of stations required. This large prep area has tables arranged for easy access to theatre and for staff, with wall-mounted anaesthetic machines and clippers. Note the computer message board on the far wall. In this small busy prep area, best use is made of limited space with two trolley tables and small manoeuvrable anaesthetic trolleys. Here a theatre has been formed using glass partitioning to leave an L-shaped prep room, with good visibility throughout the area.
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8.3 A central nurse station, with computer and telephone, is essential and should preferably afford a clear view of the preparation area.
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8.4 Secure lockers for ‘streetwear’ and storage for surgical attire should be situated in a changing area close to the surgical suite. Separate receptacles for soiled clothing and soiled clogs are useful. Clean, laundered scrub suits can be stored on shelving; these shelves have been designed to allow dust to fall through.
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8.6 Operating lighting with built-in camera function and sterilizable handles. Note the draping of the equipment just visible on the right of the picture.
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8.7 Head-mounted light sources are useful for lighting cavities and awkward angles. Note the digital screen displaying radiographs in this theatre.
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8.8 A binocular loupe is useful for detailed work and may also have a light source.
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8.10 A double scrub sink with elbow-operated taps. Note the wall clock, which is useful in timing pre-surgical hand preparation, and the whiteboard on the wall to the right, which is used to organize the surgical list. A hand-washing station with sensor-activated scrub solution and taps.
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8.11 A wall-mounted cable reel device provides a permanent neat and flexible solution to storing clipper cables safely. The clipper handpiece can be stored separately.
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8.12 Clippers must be cleaned between patients. It is important to clean both the blades and the clipper body, particularly the head area. The spray used is bactericidal, fungicidal and viricidal; a COSHH risk assessment is required for its use. Note the spare blades (left); replacements are fitted as required, following the manufacturer’s instructions, and pushed down into place with the clippers running. A spare clipper filter is also shown (bottom right); filters should be in place before use to prevent hair build-up within the internal mechanism of the handpiece.
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8.13 An anaesthetic patient trolley for transporting anaesthetized patients. Note the buffers to prevent finger trapping and damage to walls and door frames during transport. A non-surgical team member handing a patient over on an anaesthetic trolley to a coordinator at a cross-point between the preparation room and the non-surgical clinical areas.
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8.14 A patient lift should ideally be large enough to accommodate the patient trolley, personnel, and any ancillary equipment such as drip stands.
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8.15 Transporting a large patient on a stretcher. Effective team coordination is vital.
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8.16 The correct surgical attire should be worn by all personnel entering an operating room or the surgical suite.
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8.17 Some examples of commercially available sterile gloves, including non-latex gloves for staff with latex allergies. The Biogel M gloves are designed for extra grip and touch, which is useful for grasping delicate, fine instruments for ophthalmic or neurological surgery.
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8.18 Surgical clogs can be washed on special cleaning racks within a washer/disinfector.
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8.19 Example of a crash trolley from a large veterinary hospital and a crash box from a smaller practice. A variety of endotracheal tubes, intravenous catheters, drugs and monitoring equipment is present.
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8.20 A freestanding mobile anaesthetic trolley. A = flowmeters; B = vaporizer; C = Barnsley air break receiver attached to scavenging tubing; D = patient monitor; E = spare gas cylinder (size E).
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8.21 Wall-mounted anaesthetic machines can be mounted on brackets, allowing them to be moved to different locations according to need. Brackets can be purchased separately. This machine has a circle rebreathing system in place.
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8.22 A TEC 5 sevoflurane vaporizer. Note the ‘key-filler’ which will only accept the tip of the sevoflurane bottle shown alongside the vaporizer.
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8.23 A rebreathing system (left) for larger patients and a mini-Lack (right) for smaller patients. Either system is suitable for IPPV.
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8.26 From left to right: rubber Magill endotracheal tube; two PVC cuffed tubes; uncuffed PVC tube with metal stylet to aid insertion (note the stylet would be drawn back so as not to protrude from the end of the tube during insertion into the patient); laryngoscope; local anaesthetic spray for preparing the airway for insertion of the tube (note that the bottle is wrapped to protect it from light).
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8.27 Murphy pattern endotracheal tube with an oval hole just proximal to the distal tip. Armoured tubes.
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8.28 A multi-parameter monitor showing pulse oximetry and capnography traces. The ECG leads are not being used. Along the lower part of the screen (left to right) are measurements for blood pressure, body temperature and gases (oxygen, nitrous oxide and isoflurane).
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8.29 An oesophageal stethoscope is simple and reliable. The appropriate size should be selected for each patient and the tubing cleaned and disinfected after use.
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8.30 A selection of pulse oximeter sensors. A pulse oximeter in use. This model has a rubber jacket to protect it from damage.
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8.31 Older style multi-parameter monitors showing capnography, pulse oximetry, ECG, blood pressure, oxygen and anaesthetic gas monitoring. Note the Manley ventilator on top of the monitors.
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8.32 Indirect blood pressure monitors: oscillometric; Doppler.
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8.33 This patient’s body temperature is being maintained using several methods: it is lying on a black thermal mattress (control unit fixed to drip stand); bubble wrap is being used as an insulator; the intravenous drip line is being passed though a line warmer (in the nurse’s hands) and a thermovent is in place between the breathing system and the endotracheal tube. The infusion pump can be seen on the worktop to the right. The patient is being monitored with a multi-parameter monitor (on worktop to left); the pulse oximeter probe is visible attached to the tongue.
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8.34 Precisely thermostatically controlled heated padded beds are expensive but are easy to maintain, very durable and do not carry the risk of thermal burns associated with many electric heated pads. A variety of sizes is available.
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8.35 A circulating warmed air system is an efficient way to provide supplementary warmth, but has some disadvantages in the surgical environment.
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8.36 Thermostatically controlled heated operating tables can be useful for maintaining patient body temperature. This picture also shows gas scavenging routed under the floor.
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8.37 Instruments with tungsten carbide tips have gold-coloured handles.
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8.38 Monopolar (centre) and bipolar (right) handpieces and electrodes; a patient plate electrode is shown on the left. (Reproduced from )
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8.39 Three common commercially available surgical lasers: (left to right) Accuvet 25D-980 Diode Surgical Laser; Novapulse 20 watt CO laser; Cutting Edge ML030 30 watt CO laser.
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8.40 A portable suction machine should be ready to use at all times in case of emergency. The disposable filter is fitted where the suction tubing enters the machine on the top. A mobile suction unit for attachment to a central suction source.
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8.42 An oxygen cylinder bank in a large practice.
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8.43 Two benchtop type B autoclaves suitable for general practice. Although some benchtop vacuum autoclaves will fit well on to standard depth worktops, increasing the depth to 700 mm or more is advisable. A large type B built-in autoclave.
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8.44 An ethylene oxide sterilization cabinet. A sign on the door warns that only trained operators should use this equipment.
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8.45 Sterilization indicators. Clockwise from top left: ethylene oxide chemical indicators; Bowie Dick tape; TST strip; small and larger versions of chemical indicator stickers for surgical containers.
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8.46 Sterile packs should be dated and initialled (see top left corner of the pouch).
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8.47 An illuminated magnification lamp is useful for close inspection of instruments prior to packing and sterilization.
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8.48 An instrument washer/disinfector, with racking and location points for delicate instruments.
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8.50 The nurse coordinator is identified by a pink surgical cap.
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8.51 An example of a basic handwritten day list for surgical procedures.
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8.53 An example of an anaesthetic monitoring chart. (Courtesy of Langford Veterinary Services Ltd and reproduced from the .)
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8.54 Mobile trolleys are useful for transporting dirty instruments safely to the cleaning area.
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8.55 Gas cylinders should always be moved safely using a dedicated cylinder trolley.
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8.56 Size F and larger cylinders should be stored vertically and restrained securely, such as with cylinder locks as shown here.
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8.57 PPE for laser surgery. Protective goggles for CO laser surgery use. The pair shown are rated OD6 because they reduce the intensity of 10.6 µm laser light by a factor of 10. High-filtration particulate surgical masks have a pore size of <1 µm. This small diameter protects the surgeon and assistant from inhaling heavy plume material.
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8.58 Where floors have to be mopped whilst an area is in use, clear warning signs should be used.
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8.59 Fireproof box for storing flammable liquids such as ethylene oxide vials.


Examples of SOPs and charts

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