Surgical hand preparation: state-of-the-art

13.1 Evidence for surgical hand preparation

Historically, Joseph Lister (1827–1912) demonstrated the effect of disinfection on the

reduction of surgical site infections (SSIs). 506 At that time, surgical gloves were not yet
available, thereby making appropriate disinfection of the surgical site of the patient and
hand antisepsis by the surgeon even more imperative. 507 During the 19th century, surgical
hand preparation consisted of washing the hands with antimicrobial soap and warm
water, frequently with the use of a brush. 508 In 1894, three steps were suggested: 1) wash
hands with hot water, medicated soap, and a brush for 5 minutes; 2) apply 90% ethanol
for 3–5 minutes with a brush; and 3) rinse the hands with an “aseptic liquid”. 508 In 1939,
Price suggested a 7-minute handwash with soap, water, and a brush, followed by 70%
ethanol for 3 minutes after drying the hands with a towel. 63 In the second half of the 20th
century, the recommended time for surgical hand preparation decreased from >10 minutes
to 5 minutes.509–512 Even today, 5-minute protocols are common.197 A comparison of
different countries showed almost as many protocols as listed countries.513
The introduction of sterile gloves does not render surgical hand preparation unnecessary.
Sterile gloves contribute to preventing surgical site contamination 514 and reduce the risk
of bloodborne pathogen transmission from patients to the surgical team. 515 However, 18%
(range: 5–82%) of gloves have tiny punctures after surgery, and more than 80% of cases
go unnoticed by the surgeon. After two hours of surgery, 35% of all gloves demonstrate
puncture, thus allowing water (hence also body fluids) to penetrate the gloves without
using pressure516 (see Part I, Section 23.1). A recent trial demonstrated that punctured
gloves double the risk of SSIs. 517 Double gloving decreases the risk of puncture during
surgery, but punctures are still observed in 4% of cases after the procedure.518,519 In
addition, even unused gloves do not fully prevent bacterial contamination of hands. 520
Several reported outbreaks have been traced to contaminated hands from the surgical
team despite wearing sterile gloves.71,154,162,521–523
Koiwai and colleagues detected the same strain of coagulase-negative staphylococci
(CoNS) from the bare fingers of a cardiac surgeon and from a patient with postoperative
endocarditis with a matching strain.522 A similar, more recent outbreak with CoNS and
endocarditis was observed by Boyce and colleagues, strain identity being confirmed by
molecular methods.162 A cardiac surgeon with onychomycosis became the source of an
outbreak of SSIs due to P. aeruginosa, possibly facilitated by not routinely practising
double gloving.523 One outbreak of SSIs even occurred when surgeons who normally used
an antiseptic surgical scrub preparation switched to a nonantimicrobial product.524
Despite a large body of indirect evidence for the need of surgical hand antisepsis, its
requirement before surgical interventions has never been proven by a randomized,
controlled clinical trial.525 Most likely, such a study will never be performed again nor be
acceptable to an ethics committee. A randomized clinical trial comparing an alcohol-
based handrub versus a chlorhexidine hand scrub failed to demonstrate a reduction of
SSIs, despite considerably better in vitro activity of the alcohol-based formulation. 197
Therefore, even considerable improvements in antimicrobial activity in surgical hand
hygiene formulations are unlikely to lead to significant reductions of SSIs. These
infections are the result of multiple risk factors related to the patient, the surgeon, and the
health-care environment, and the reduction of only one single risk factor will have a
limited influence on the overall outcome.
In addition to protecting the patients, gloves reduce the risk for the HCW to be exposed to
bloodborne pathogens. In orthopaedic surgery, double gloving has been a common
practice that significantly reduces, but does not eliminate, the risk of cross-transmission
after glove punctures during surgery.526

13.2 Objective of surgical hand preparation

Surgical hand preparation should reduce the release of skin bacteria from the hands of the
surgical team for the duration of the procedure in case of an unnoticed puncture of the
surgical glove releasing bacteria to the open wound.527 In contrast to the hygienic
handwash or handrub, surgical hand preparation must eliminate the transient and reduce
the resident flora.484,528,529 It should also inhibit growth of bacteria under the gloved hand.
Rapid multiplication of skin bacteria occurs under surgical gloves if hands are washed
with a non-antimicrobial soap, whereas it occurs more slowly following preoperative
scrubbing with a medicated soap. The skin flora, mainly coagulase-negative
staphylococci, Propionibacterium spp., and Corynebacteria spp., are rarely responsible
for SSI, but in the presence of a foreign body or necrotic tissue even inocula as low as
100 CFU can trigger such infection.530 The virulence of the microorganisms, extent of
microbial exposure, and host defence mechanisms are key factors in the pathogenesis of
postoperative infection, risk factors that are largely beyond the influence of the surgical
team. Therefore, products for surgical hand preparation must eliminate the transient and
significantly reduce the resident flora at the beginning of an operation and maintain the
microbial release from the hands below baseline until the end of the procedure.
The spectrum of antimicrobial activity for surgical hand preparation should be as broad as
possible against bacteria and fungi.529,531 Viruses are rarely involved in SSI and are not
part of test procedures for licensing in any country. Similarly, activity against spore-
producing bacteria is not part of international testing procedures.

13.3 Selection of products for surgical hand preparation

The lack of appropriate, conclusive clinical trials precludes uniformly acceptable criteria.
In vitro and in vivo trials with healthy volunteers outside the operating theatre are the best
evidence currently available. In the USA, antiseptic preparations intended for use as
surgical hand preparation (based on the FDA TFM of 17 June 1994) 198 are evaluated for
their ability to reduce the number of bacteria released from hands: a) immediately after
scrubbing; b) after wearing surgical gloves for 6 hours (persistent activity); and c) after
multiple applications over 5 days (cumulative activity). Immediate and persistent
activities are considered the most important. Guidelines in the USA recommend that
agents used for surgical hand preparation should significantly reduce microorganisms on
intact skin, contain a non-irritating antimicrobial preparation, have broad-spectrum
activity, and be fast-acting and persistent (see Part I, Section 10).532 In Europe, all
products must be at least as efficacious as a reference surgical rub with n-propanol, as
outlined in the European Norm EN 12791. In contrast to the USA’ guidelines, only the
immediate effect after the hand hygiene procedure and the level of regrowth after 3 hours
under gloved hands are measured. The cumulative effect over 5 days is not a requirement
of EN 12791.
Most guidelines prohibit any jewellery or watches on the hands of the surgical team
(Table I.13.1).58,529,533 Artificial fingernails are an important risk factor, as they are
associated with changes of the normal flora and impede proper hand hygiene. 154,529
Therefore, they should be prohibited for the surgical team or in the operating
theatre.154,529,534

13.4 Surgical hand antisepsis using medicated soap

The different active compounds included in commercially available handrub formulations

are described in Part I, Section 11. The most commonly used products for surgical hand
antisepsis are chlorhexidine or povidone-iodine-containing soaps. The most active agents
(in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and
plain soap.282,356,378,529,535–537 Triclosan-containing products have also been tested for
surgical hand antisepsis, but triclosan is mainly bacteriostatic, inactive against P.
aeruginosa, and has been associated with water pollution in lakes.538,539 Hexachlorophene
has been banned worldwide because of its high rate of dermal absorption and subsequent
toxic effects.70,366 Application of chlorhexidine or povidone-iodine result in similar initial
reductions of bacterial counts (70–80%), reductions that achieves 99% after repeated
application. Rapid regrowth occurs after application of povidone-iodine, but not after use
of chlorhexidine.540 Hexachlorophene and triclosan detergents show a lower immediate
reduction, but a good residual effect. These agents are no longer commonly used in
operating rooms because other products such as chlorhexidine or povidone-iodine
provide similar efficacy at lower levels of toxicity, faster mode of action, or broader
spectrum of activity. Despite both in vitro and in vivo studies demonstrating that it is less
efficacious than chlorhexidine, povidone-iodine remains one of the widely-used products
for surgical hand antisepsis, induces more allergic reactions, and does not show similar
residual effects.271,463 At the end of a surgical intervention, iodophor-treated hands can
have even more microorganisms than before surgical scrubbing. Warm water makes
antiseptics and soap work more effectively, while very hot water removes more of the
protective fatty acids from the skin. Therefore, washing with hot water should be
avoided. The application technique is probably less prone to errors compared with
handrubbing (Table I.13.2) as all parts of the hands and forearms get wet under the
tap/faucet. In contrast, all parts of the hands and forearms must actively be put in contact
with the alcohol-based compound during handrubbing (see below).

Table I.13.2 Protocol for surgical scrub with a medicated soap

Procedural steps
Start timing. Scrub each side of each finger, between the fingers, and the back and front
of the hand for 2 minutes.
Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps
to avoid recontamination of the hands by water from the elbows and prevents bacteria-
laden soap and water from contaminating the hands.
Wash each side of the arm from wrist to the elbow for 1 minute.
Repeat the process on the other hand and arm, keeping hands above elbows at all times.
If the hand touches anything at any time, the scrub must be lengthened by 1 minute for
the area that has been contaminated.
Rinse hands and arms by passing them through the water in one direction only, from
fingertips to elbow. Do not move the arm back and forth through the water.
Proceed to the operating theatre holding hands above elbows.
At all times during the scrub procedure, care should be taken not to splash water onto
surgical attire.
Once in the operating theatre, hands and arms should be dried using a sterile towel and
aseptic technique before donning gown and gloves.

13.4.1 Required time for the procedure

Hingst and colleagues compared hand bacterial counts after 3-minute and 5-minute
scrubs with seven different formulations.378 Results showed that the 3-minute scrub could
be as effective as the 5-minute scrub, depending on the formula of the scrub agent.
Immediate and postoperative hand bacterial counts after 5-minute and 10-minute scrubs
with 4% chlorhexidine gluconate were compared by O’Farrell and colleagues before total
hip arthroplasty procedures.512 The 10-minute scrub reduced the immediate colony count
more than the 5-minute scrub. The postoperative mean log CFU count was slightly higher
for the 5-minute scrub than for the 10-minute scrub; however, the difference between
post-scrub and postoperative mean CFU counts was higher for the 10-minute scrub than
the 5-minute scrub in longer (>90 minutes) procedures. The study recommended a 5-
minute scrub before total hip arthroplasty.
A study by O’Shaughnessy and colleagues used 4% chlorhexidine gluconate in scrubs of
2, 4, and 6-minutes duration. A reduction in post-scrub bacterial counts was found in all
three groups. Scrubbing for longer than 2 minutes did not confer any advantage. This
study recommended a 4-minute scrub for the surgical team’s first procedure and a 2-
minute scrub for subsequent procedures.541 Bacterial counts on hands after 2-minute and
3-minute scrubs with 4% chlorhexidine gluconate were compared. 542 A statistically
significant difference in mean CFU counts was found between groups with the higher
mean log reduction in the 2-minute group. The investigators recommended a 2-minute
procedure. Poon and colleagues applied different scrub techniques with a 10% povidone-
iodine formulation.543 Investigators found that a 30-second handwash can be as effective
as a 20-minute contact with an antiseptic in reducing bacterial flora and that vigorous
friction scrub is not necessarily advantageous.

13.4.2 Use of brushes

Almost all studies discourage the use of brushes. Early in the 1980s, Mitchell and
colleagues suggested a brushless surgical hand scrub.544 Scrubbing with a disposable
sponge or combination sponge-brush has been shown to reduce bacterial counts on the
hands as effectively as scrubbing with a brush. 511,545,546 Recently, even a randomized,
controlled clinical trial failed to demonstrate an additional antimicrobial effect by using a
brush.547 It is conceivable that a brush may be beneficial on visibly dirty hands before
entering the operating room. Members of the surgical team who have contaminated their
hands before entering the hospital may wish to use a sponge or brush to render their
hands visibly clean before entering the operating room area.

13.4.3 Drying of hands

Sterile cloth towels are most frequently used in operating theatres to dry wet hands after
surgical hand antisepsis. Several methods of drying have been tested without significant
differences between techniques.256

13.4.4 Side-effects of surgical hand scrub

Skin irritation and dermatitis are more frequently observed after surgical hand scrub with
chlorhexidine than after use of surgical hand antisepsis with an alcohol-based hand
rinse.197 Overall, skin dermatitis is more frequently associated with hand antisepsis using
a medicated soap than with an alcohol-based handrub.548 Boyce and colleagues quantified
the epidermal water content of the dorsal surface of nurses’ hands by measuring electrical
capacitance of the skin. The water content decreased significantly during the washing
phase compared with the alcohol-based handrub-in phase.264 Most data have been
generated outside the operating room, but it is conceivable that these results apply for
surgical hand antisepsis as well.549

13.4.5 Potential for recontamination

Surgical hand antisepsis with medicated soap requires clean water to rinse the hands after
application of the medicated soap. However, Pseudomonas spp., specifically P.
aeruginosa, are frequently isolated from taps/faucets in hospitals.550. Taps are common
sources of P. aeruginosa and other Gram-negative bacteria and have even been linked to
infections in multiple settings, including ICUs.551 It is therefore prudent to remove tap
aerators from sinks designated for surgical hand antisepsis. 551–553 Even automated sensor-
operated taps were linked to P. aeruginosa contamination.554 Outbreaks or cases clearly
linked to contaminated hands of surgeons after proper surgical hand scrub have not yet
been documented. However, outbreaks with P.aeruginosa were reported as traced to
members of the surgical team suffering from onychomycosis, 154,523 but a link to
contaminated tap water has never been established. In countries lacking continuous
monitoring of drinking-water and improper tap maintenance, recontamination may be a
real risk even after correct surgical hand scrub. Of note, one surgical hand preparation
episode with traditional agents uses approximately 20 litres of warm water, or 60 litres
and more for the entire surgical team.555 This is an important issue worldwide, particularly
in countries with a limited safe water supply.
13.5 Surgical hand preparation with alcohol-based handrubs

Several alcohol-based handrubs have been licensed for the commercial market, 531,556,557
frequently with additional, long-acting compounds (e.g. chlorhexidine gluconate or
quaternary ammonium compounds) limiting regrowth of bacteria on the gloved
hand,377,529,558–561 The antimicrobial efficacy of alcohol-based formulations is superior to
that of all other currently available methods of preoperative surgical hand preparation.
Numerous studies have demonstrated that formulations containing 60–95% alcohol alone,
or 50–95% when combined with small amounts of a QAC, hexachlorophene or
chlorhexidine gluconate, reduce bacterial counts on the skin immediately post-scrub more
effectively than do other agents.
The WHO-recommended handrub formulations were tested by two independent reference
laboratories in different European countries to assess their suitability for use for surgical
hand preparation. Although formulation I did not pass the test in both laboratories and
formulation II in only one of them, the expert group is, nevertheless, of the opinion that
the microbicidal activity of surgical antisepsis is still an ongoing issue for research as due
to the lack of epidemiological data there is no indication that the efficacy of n-propanol
(propan-1-ol) 60 % v/v as a reference in EN 12791 finds a clinical correlate. It is the
consensus opinion of the WHO expert group that the choice of n-propanol is
inappropriate as the reference alcohol for the validation process because of its safety
profile and the lack of evidence-based studies related to its potential harmfulness for
humans. Indeed, only a few formulations worldwide have incorporated n-propanol for
hand antisepsis.
Considering that other properties of the WHO recommended formulations, such as their
excellent tolerability, good acceptance by HCWs and low cost are of high importance for
a sustained clinical effect, the above results are considered acceptable and it is the
consensus opinion of the WHO expert group that the two formulations can be used for
surgical hand preparation. Institutions opting to use the WHO-recommended formulations
for surgical hand preparation should ensure that a minimum of three applications are
used, if not more, for a period of 3 to 5 minutes. For surgical procedures of more than a
two hours’ duration, ideally surgeons should practise a second handrub of approximately
1 minute, even though more research is needed on this aspect.
Hand-care products should not decrease the antimicrobial activity of the handrub. A study
by Heeg562 failed to demonstrate such an interaction, but manufacturers of a handrub
should provide good evidence for the absence of interaction.563
It is not necessary to wash hands before handrub unless hands are visibly soiled or
dirty.562,564 The hands of the surgical team should be clean upon entering the operating
theatre by washing with a non-medicated soap (Table I.13.1). While this handwash may
eliminate any risk of contamination with bacterial spores, experimental and
epidemiological data failed to demonstrate an additional effect of washing hands before
applying handrub in the overall reduction of the resident skin flora. 531 The activity of the
handrub formulation may even be impaired if hands are not completely dried before
applying the handrub or by the washing phase itself.562,564,565 A simple handwash with soap
and water before entering the operating theatre area is highly recommended to eliminate
any risk of colonization with bacterial spores.420 Non-medicated soaps are sufficient,566
and the procedure is necessary only upon entering the operating theatre: repeating
handrubbing without prior handwash or scrub is recommended before switching to the
next procedure.

13.5.1 Technique for the application of surgical hand preparation using alcohol-
based handrub

The application technique has not been standardized throughout the world. The WHO
approach for surgical hand preparation requires the six basic steps for the hands as for
hygienic hand antisepsis, but requires additional steps for rubbing the forearms (Figure
I.13.1). This simple procedure appears not to require training, though two studies provide
evidence that training significantly improves bacterial killing.531,567 The hands should be
wet from the alcohol-based rub during the whole procedure, which requires
approximately 15 ml depending on the size of the hands. One study demonstrated that
keeping the hands wet with the rub is more important than the volume used. 568 The size of
the hands and forearms ultimately determines the volume required to keep the skin area
wet during the entire time of the handrub. Once the forearms and hands have been treated
with an emphasis on the forearms – usually for approximately 1 minute – the second part
of the surgical handrub should focus on the hands, following the identical technique as
outlined for the hygienic handrub. The hands should be kept above the elbows during this
step.

Surgical hand preparation technique with an alcohol-based handrub formulation.

13.5.2 Required time for the procedure

For many years, surgical staff frequently scrubbed their hands for 10 minutes
preoperatively, which frequently led to skin damage. Several studies have demonstrated
that scrubbing for 5 minutes reduces bacterial counts as effectively as a 10-minute
scrub.284,511,512 In other studies, scrubbing for 2 or 3 minutes reduced bacterial counts to
acceptable levels.378,380,460,529,541,542 Surgical hand antisepsis using an alcohol-based handrub
required 3 minutes, following the reference method outlined in EN 12791. Very recently,
even 90 seconds of rub have been shown to be equivalent to a 3-minute rub with a
product containing a mixture of iso- and n-propanol and mecetronium etilsulfate 557 when
tested with healthy volunteers in an in vivo experiment. These results were corroborated
in a similar study performed under clinical conditions with 32 surgeons.569
Alcohol-based hand gels should not be used unless they pass the test EN 12791 or an
equivalent standard, e.g. FDA TFM 1994, required for handrub formulations. 533 Many of
the currently available gels for hygienic handrub do not meet the European standard EN
1500.203 The technique to apply the alcohol-based handrub defined by EN 1500 matches
the one defined by EN 12791. The latter requires an additional rub of the forearms that is
not required for the hygienic handrub (Figure I.13.1). At least one gel on the market has
been tested and introduced in a hospital for hygienic hand antisepsis and surgical hand
preparation that meets EN 12791,570 and several gels meet the FDA TFM standard. 482 As
mentioned above, the minimal killing is not defined and, therefore, the interpretation of
the effectiveness remains elusive.
In summary, the time required for surgical alcohol-based handrubbing depends on the
compound used. Most commercially available products recommend a 3-minute exposure,
although the application time may be longer for some formulations, but can be shortened
to 1.5 minutes for a few of them. The manufacturer of the product must provide
recommendations as to how long the product must be applied. Manufacturer’s
recommendations should be based on in vivo evidence at least, considering that clinical
effectiveness testing is unrealistic.

13.6 Surgical handscrub with medicated soap or surgical hand preparation with
alcohol-based formulations

Both methods are suitable for the prevention of SSIs. However, although medicated soaps
have been and are still used by many surgical teams worldwide for presurgical hand
preparation, it is important to note that the antibacterial efficacy of products containing
high concentrations of alcohol by far surpasses that of any medicated soap presently
available (see Part I, section 13.5). In addition, the initial reduction of the resident skin
flora is so rapid and effective that bacterial regrowth to baseline on the gloved hand takes
227
more than six hours. This makes the demand for a sustained effect of a product
superfluous. For this reason, preference should be given to alcohol-based products.
Furthermore, several factors including rapid action, time savings, less side-effects, and no
risk of recontamination by rinsing hands with water, clearly favour the use of presurgical
handrubbing. Nevertheless, some surgeons consider the time taken for surgical handscrub
as a ritual for the preparation of the intervention 571 and a switch from handscrub to
handrub must be prepared with caution. In countries with limited resources, particularly
when the availability, quantity or quality of water is doubtful, the current panel of experts
clearly favours the use of alcohol-based handrub for presurgical hand preparation also for
this reason.
© 2009, World Health Organization.
All rights reserved. Publications of the World Health Organization can be obtained from
WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
(tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for
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noncommercial distribution – should be addressed to WHO Press, at the above address
(fax: +41 22 791

A Guide to "Scrubbing In" OT By : David Alexander George, Moninder Bhabra

Introduction
 Members of the Surgical Team
 Removing Outdoor Clothing
 Staff Room Etiquette
 Entering the Surgical Theatre
 Preparing to “Scrub In”
 The Surgical Hand Scrub
 Gowning
 Gloving
 Conclusion
 References

The Surgical Hand Scrub

The fact that hand cleaning with an antiseptic agent is more effective than simply using
plain soap and water was first recognised in 1846 by Hungarian physician Ignaz
Semmelweis. Semmelweis introduced hand disinfection into his practice and immediately
[3]
mortality rates associated with infections fell. The surgical hand scrub continues to be
one of the most important procedures in infection prevention.
Before starting, ensure that your facemask is comfortable and secure (this is non-sterile
so cannot be adjusted once you are scrubbed) and your hands and arms are completely
bare (unless you have been allowed to wear your wedding band). Your fingernails must
be free of polish and of medium length.
Currently, three main types of preparations for hand hygiene are used: chlorhexidine
gluconate (clear/pink solution); iodine based preparations (brown); and aqueous alcoholic
[4]
solutions (clear). Multiple studies have compared the effectiveness of these
[5]
preparations but the evidence for all forms is mixed. Iodine based preparations have
been known to cause skin irritation; therefore, use an alternative preparation if this
occurs. Start the water taps and get a comfortably warm and adequate flow of water.
During washing, use your elbows to release the soap and turn the taps off, because your
hands must remain decontaminated.
Scrubbing begins at the fingernails, and a nail file and brush from a sterile pack can be
used. Scrubbing then occurs in three washing cycles: ( a) hands and arms extending to
two inches above the elbow; ( b) hands and half way up the forearms; and ( c) hands only
(fig 4). This follows the principle of washing from a clean area (the hand) in the direction
of the less clean area (the arm). Your hands should always be held above the level of your
elbows at all times in order to prevent dirty water from dripping from the upper arm onto
lower sterile areas.
Steps to wash your hands and ensure that all areas of the hand are cleaned thoroughly.
The steps for each cycle of the hand scrub should be repeated for each of the tree washing
cycles. Reproduced with permission from the Health Protection Agency 6
[7,8]
An effective surgical hand scrub should take no longer than five minutes. If your
hands touch anything at any time, the scrub must be restarted.
After scrubbing, use the sterile hand towels to dry each arm, starting at the hand and
making your way up your arm, using one towel per arm in a dabbing motion.

When should we wash our hands in the perioperative setting?

Answer:

Hands should be washed:

• upon entering the perioperative setting,
• before and after every patient contact, (contact in this situation is intrerpreted as an
esposure to a patient and not each time you touch a patient).
• before putting on or after removing gloves or other personal protective equipment,
• any time there has been contact with blood or other potentially infectious materials,
• before and after eating,
• before and after using the restroom,
• before leaving the health care facility, and
• when hands are visibly soiled.
Recommended practices for hand hygiene in the perioperative setting. In: Perioperative
Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74. Updated
January 28, 2013

Can nail polish be worn by personnel in the operating room?

Answer:

Nail polish that is unchipped may be worn by staff in the operating room. Studies have
demonstrated that nail polish begins to harbor microorganisms when it is chipped or worn
more than four days. In the event of a glove tear or perforation, the health care
practitioner's chipped nail polish could potentially go into the surgical wound. Chipped
nail polish should be removed to prevent contamination of the environment or the patient.
Nail polish that is unchipped may be worn by staff in the operating room. Studies have
demonstrated that nail polish begins to harbor microorganisms when it is chipped or worn
more than four days. In the event of a glove tear or perforation, the health care
practitioner's chipped nail polish could potentially go into the surgical wound. Chipped
nail polish should be removed to prevent contamination of the environment or the patient.
Recommended practices for hand hygiene in the perioperative setting. In: Perioperative
Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74. Updated
January 28, 2013

Can artificial nails be worn by personnel in the operating room?

Answer:

Artificial nails should not be worn in the perioperative environment. Any nail other than a
natural nail is considered artificial. Artificial nails are defined as any fingernail
enhancement, resin bonding, extensions, tips, gels, or acrylics. Studies have shown higher
microbial counts under artificial nails than under natural nails before and after hand
washing.

Recommended practices for hand hygiene in the perioperative setting. In: Perioperative
Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74. Updated
January 28, 2013

Does the first surgical hand scrub of the day have to be soap and water before using
surgical hand rub products?

Answer:

A standardized surgical hand scrub with a soap (antimicrobial agent), nonabrasive

sponge, and water does not have to be the first surgical hand scrub of the day before an
alcohol-based surgical hand rub product is used, unless it is recommended in the
manufacturer's instructions for use. The surgical hand scrub reduces the transient and
resident flora of the hands, which also may reduce health care-associated infections. A
standardized surgical hand scrub using an alcohol-based hand rub product will decrease
transient and resident flora on the hands. Hand washing does however need to be
performed before the first surgical hand scrub of the day.
Ogg, MJ. First surgical hand scrub of the day. [Clinical Issues]. AORN Journal.
2011;93(3):397-398. Updated January 28, 2013
Can a bar of plain soap purchased at the local market be used for surgical hand
antisepsis?

Answer:

Perioperative personnel should not use plain soap for surgical hand antisepsis. Surgical
team members should perform a surgical hand scrub with either an antimicrobial surgical
scrub agent approved for surgical hand antisepsis or an alcohol-based surgical hand rub
with a persistent and cumulative antimicrobial activity accoring to US Food and Drug
Administration regulatory requirements for surgical hand antisepsis before donning a
sterile gown and gloves.
Surgery
From Wikipedia, the free encyclopedia
This article is about the medical specialty. For other uses, see Surgery (disambiguation).

Two surgeons and a surgical technician repairing a ruptured Achilles tendon

Surgery (from the Greek: χειρουργική cheirourgikē (composed of χείρ, "hand", and ἔργον, "work"),
via Latin: chirurgiae, meaning "hand work") is an ancient medical specialty that uses operative
manual and instrumental techniques on a patient to investigate and/or treat a pathological condition
such as disease or injury, or to help improve bodily function or appearance.
An act of performing surgery may be called a surgical procedure, operation, or simply surgery. In
this context, the verb operate means to perform surgery. The adjective surgical means pertaining to
surgery; e.g. surgical instruments or surgical nurse. The patient or subject on which the surgery is
performed can be a person or an animal. A surgeon is a person who practises surgery. Persons
described as surgeons are commonly physicians, but the term is also applied to podiatrists, dentists
(known as oral and maxillofacial surgeons) and veterinarians. A surgery can last from minutes to
hours, but is typically not an ongoing or periodic type of treatment. The term surgery can also refer to
the place where surgery is performed, or simply the office of a physician, dentist, or veterinarian.
Elective surgery generally refers to a surgical procedure that can be scheduled in advance because it
does not involve a medical emergency. Plastic, or cosmetic surgeries are common elective procedures.

Contents
1 Definitions
o 1.1 Types of surgery
o 1.2 Terminology
2 Description of surgical procedure
o 2.1 Location
o 2.2 Pre-operative preparation
o 2.3 Staging for surgery
o 2.4 Surgery
o 2.5 Post-operative care
3 In special populations
 o 3.1 Elderly people
o 3.2 Other populations
4 History
o 4.1 Early modern Europe
o 4.2 Modern surgery
 5 Surgical specialties and sub-specialties
6 See also
o 6.1 Governing bodies
o 6.2 Qualifications in the UK and Ireland
 7 Notes and references
 8 External links

Definitions
Surgery is a technology consisting of a physical intervention on tissues.
As a general rule, a procedure is considered surgical when it involves cutting of a patient's tissues or
closure of a previously sustained wound. Other procedures that do not necessarily fall under this
rubric, such as angioplasty or endoscopy, may be considered surgery if they involve "common"
surgical procedure or settings, such as use of a sterile environment, anesthesia, antiseptic conditions,
typical surgical instruments, and suturing or stapling. All forms of surgery are considered invasive
procedures; so-called "noninvasive surgery" usually refers to an excision that does not penetrate the
structure being excised (e.g. laser ablation of the cornea) or to a radiosurgical procedure (e.g.
irradiation of a tumor).

Types of surgery
Surgical procedures are commonly categorized by urgency, type of procedure, body system involved,
degree of invasiveness, and special instrumentation.
 Based on timing: Elective surgery is done to correct a non-life-threatening condition, and is
carried out at the patient's request, subject to the surgeon's and the surgical facility's availability.
Emergency surgery is surgery which must be done promptly to save life, limb, or functional
capacity. A semi-elective surgery is one that must be done to avoid permanent disability or death,
but can be postponed for a short time.
 Based on purpose: Exploratory surgery is performed to aid or confirm a diagnosis.
Therapeutic surgery treats a previously diagnosed condition.
 By type of procedure: Amputation involves cutting off a body part, usually a limb or digit;
castration is also an example. Replantation involves reattaching a severed body part.
Reconstructive surgery involves reconstruction of an injured, mutilated, or deformed part of the
body. Cosmetic surgery is done to improve the appearance of an otherwise normal structure.
Excision is the cutting out or removal of an organ, tissue, or other body part from the patient.
Transplant surgery is the replacement of an organ or body part by insertion of another from
different human (or animal) into the patient. Removing an organ or body part from a live human
or animal for use in transplant is also a type of surgery.
 By body part: When surgery is performed on one organ system or structure, it may be classed
by the organ, organ system or tissue involved. Examples include cardiac surgery (performed on
the heart), gastrointestinal surgery (performed within the digestive tract and its accessory organs),
and orthopedic surgery (performed on bones and/or muscles).
 By degree of invasiveness: Minimally invasive surgery involves smaller outer incision(s) to
insert miniaturized instruments within a body cavity or structure, as in laparoscopic surgery or
angioplasty. By contrast, an open surgical procedure or laparotomy requires a large incision to
access the area of interest.
 By equipment used: Laser surgery involves use of a laser for cutting tissue instead of a scalpel
 or similar surgical instruments. Microsurgery involves the use of an operating microscope for the
surgeon to see small structures. Robotic surgery makes use of a surgical robot, such as the Da
Vinci or the Zeus surgical systems, to control the instrumentation under the direction of the
surgeon.

Terminology
 Excisionsurgery names often start with a name for the organ to be excised (cut out) and end in
-ectomy.
 Procedures involving cutting into an organ or tissue end in -otomy. A surgical procedure
cutting through the abdominal wall to gain access to the abdominal cavity is a laparotomy.
 Minimally invasive proceduresinvolving small incisions through which an endoscope is
inserted end in -oscopy. For example, such surgery in the abdominal cavity is called laparoscopy.
 Procedures for formation of a permanent or semi-permanent opening called a stoma in the
body end in -ostomy.
 Reconstruction, plastic or cosmetic surgery of a body part starts with a name for the body part
to be reconstructed and ends in -oplasty. Rhino is used as a prefix for "nose", therefore a
rhinoplasty is reconstructive or cosmetic surgery for the nose.
 Reparation of damaged or congenital abnormal structure ends in -rraphy. Herniorraphy is the
reparation of a hernia, while perineorraphy is the reparation of perineum.

Description of surgical procedure

Location
At a hospital, modern surgery is often done in an operating theater using surgical instruments, an
operating table for the patient, and other equipment. The environment and procedures used in surgery
are governed by the principles of aseptic technique: the strict separation of "sterile" (free of
microorganisms) things from "unsterile" or "contaminated" things. All surgical instruments must be
sterilized, and an instrument must be replaced or re-sterilized if it becomes contaminated (i.e. handled
in an unsterile manner, or allowed to touch an unsterile surface). Operating room staff must wear
sterile attire (scrubs, a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves and
a surgical mask), and they must scrub hands and arms with an approved disinfectant agent before each
procedure.

Pre-operative preparation
Prior to surgery, the patient is given a medical examination, certain pre-operative tests, and their
physical status is rated according to the ASA physical status classification system. If these results are
satisfactory, the patient signs a consent form and is given a surgical clearance. If the procedure is
expected to result in significant blood loss, an autologous blood donation may be made some weeks
prior to surgery. If the surgery involves the digestive system, the patient may be instructed to perform
a bowel prep by drinking a solution of polyethylene glycol the night before the procedure. Patients are
also instructed to abstain from food or drink (an NPO order after midnight on the night before the
procedure, to minimize the effect of stomach contents on pre-operative medications and reduce the
risk of aspiration if the patient vomits during or after the procedure.
Some medical systems have a practice of routinely performing chest x-rays before surgery. The
premise behind this practice is that the physician might discover some unknown medical condition
which would complicate the surgery, and that upon discovering this with the chest x-ray, the physician
would adapt the surgery practice accordingly.[1] In fact, medical specialty professional organizations
recommend against routine pre-operative chest x-rays for patients who have an unremarkable medical
history and presented with a physical exam which did not indicate a chest x-ray.[1] Routine x-ray
examination is more likely to result in problems like misdiagnosis, overtreatment, or other negative
outcomes than it is to result in a benefit to the patient.[1] Likewise, other tests including complete blood
count, prothrombin time, partial thromboplastin time, basic metabolic panel, and urinalysis should not
be done unless the results of these tests can help evaluate surgical risk. [2]

Staging for surgery

In the pre-operative holding area, the patient changes out of his or her street clothes and is asked to
confirm the details of his or her surgery. A set of vital signs are recorded, a peripheral IV line is
placed, and pre-operative medications (antibiotics, sedatives, etc.) are given. When the patient enters
the operating room, the skin surface to be operated on, called the operating field, is cleaned and
prepared by applying an antiseptic such as chlorhexidine gluconate or povidone-iodine to reduce the
possibility of infection. If hair is present at the surgical site, it is clipped off prior to prep application.
The patient is assisted by an anesthesiologist or resident to make a specific surgical position, then
sterile drapes are used to cover all of the patient's body except for the head and the surgical site or at
least a wide area surrounding the operating field; the drapes are clipped to a pair of poles near the head
of the bed to form an "ether screen", which separates the anesthetist/anesthesiologist's working area
(unsterile) from the surgical site (sterile).
Anesthesia is administered to prevent pain from incision, tissue manipulation and suturing. Based on
the procedure, anesthesia may be provided locally or as general anesthesia. Spinal anesthesia may be
used when the surgical site is too large or deep for a local block, but general anesthesia may not be
desirable. With local and spinal anesthesia, the surgical site is anesthetized, but the patient can remain
conscious or minimally sedated. In contrast, general anesthesia renders the patient unconscious and
paralyzed during surgery. The patient is intubated and is placed on a mechanical ventilator, and
anesthesia is produced by a combination of injected and inhaled agents.

Surgery
An incision is made to access the surgical site. Blood vessels may be clamped or cauterized to prevent
bleeding, and retractors may be used to expose the site or keep the incision open. The approach to the
surgical site may involve several layers of incision and dissection, as in abdominal surgery, where the
incision must traverse skin, subcutaneous tissue, three layers of muscle and then peritoneum. In
certain cases, bone may be cut to further access the interior of the body; for example, cutting the skull
for brain surgery or cutting the sternum for thoracic (chest) surgery to open up the rib cage. Whilst in
surgery health and safety is used to prevent infection or further spreading of the disease. The surgeon
will remove hair from the face and eyes, using a head hat. Hands, wrists and forearms are washed
thoroughly to prevent germs getting into the operated body, then gloves are placed onto the hands. A
PVC apron will be worn at all times, to stop any contamination. A yellow substance – typically an
antiseptic iodine solution – is lighly coated onto the located area of the patient's body that will be
performed on, this stops germs and disease infecting areas of the body, whilst the patient is being cut
into.
Work to correct the problem in body then proceeds. This work may involve:
 excision – cutting out an organ, tumor,[3] or other tissue.
 resection– partial removal of an organ or other bodily structure.
 reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as
intestines involves reconnection. Internal suturing or stapling may be used. Surgical connection
between blood vessels or other tubular or hollow structures such as loops of intestine is called
anastomosis.
 Reduction – the movement or realignment of a body part to its normal position. e.g.
Reduction of a broken nose involves the physical manipulation of the bone and/or cartilage from
their displaced state back to their original position to restore normal airflow and aesthetics.
 ligation– tying off blood vessels, ducts, or "tubes".
 grafts– may be severed pieces of tissue cut from the same (or different) body or flaps of tissue
still partly connected to the body but resewn for rearranging or restructuring of the area of the
 body in question. Although grafting is often used in cosmetic surgery, it is also used in other
surgery. Grafts may be taken from one area of the patient's body and inserted to another area of
the body. An example is bypass surgery, where clogged blood vessels are bypassed with a graft
from another part of the body. Alternatively, grafts may be from other persons, cadavers, or
animals.
 insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be used.
Sections of bone may be replaced with prosthetic rods or other parts. Sometime a plate is inserted
to replace a damaged area of skull. Artificial hip replacement has become more common. Heart
pacemakers or valves may be inserted. Many other types of prostheses are used.
 creation of a stoma, a permanent or semi-permanent opening in the body
 in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the
recipient's body and reconnected to the recipient in all necessary ways (blood vessels, ducts, etc.).
 arthrodesis– surgical connection of adjacent bones so the bones can grow together into one.
Spinal fusion is an example of adjacent vertebrae connected allowing them to grow together into
one piece.
 modifying the digestive tract in bariatric surgery for weight loss.
 repair of a fistula, hernia, or prolapse
 other procedures, including:
o clearing clogged ducts, blood or other vessels
o removal of calculi (stones)
o draining of accumulated fluids
o debridement- removal of dead, damaged, or diseased tissue
 Surgery has also been conducted to separate conjoined twins.
 Sex change operations
Blood or blood expanders may be administered to compensate for blood lost during surgery. Once the
procedure is complete, sutures or staples are used to close the incision. Once the incision is closed, the
anesthetic agents are stopped and/or reversed, and the patient is taken off ventilation and extubated (if
general anesthesia was administered).[4]

Post-operative care
After completion of surgery, the patient is transferred to the post anesthesia care unit and closely
monitored. When the patient is judged to have recovered from the anesthesia, he/she is either
transferred to a surgical ward elsewhere in the hospital or discharged home. During the post-operative
period, the patient's general function is assessed, the outcome of the procedure is assessed, and the
surgical site is checked for signs of infection. There are several risk factors associated with
postoperative complications, such as immune deficienty and obesity. Obesity has long been considered
a risk factor for adverse post-surgical outcomes. It has been linked to many disorders such as obesity
hypoventilation syndrome, atelectasis and pulmonary embolism, adverse cardiovascular effects, and
wound healing complications.[5] If removable skin closures are used, they are removed after 7 to 10
days post-operatively, or after healing of the incision is well under way.
Postoperative therapy may include adjuvant treatment such as chemotherapy, radiation therapy, or
administration of medication such as anti-rejection medication for transplants. Other follow-up studies
or rehabilitation may be prescribed during and after the recovery period.
The use of topical antibiotics on surgical wounds does not reduce infection rates in comparison with
non-antibiotic ointment or no ointment at all.[6] Antibiotic ointments will irritate the skin, slow healing,
and greatly increase risk of developing contact dermatitis and antibiotic resistance.[6] Because of this,
they should only be used when a person shows signs of infection and not as a preventative. [6]

In special populations
Elderly people
Older adults have widely varying physical health. Frail elderly people are at significant risk of post-
surgical complications and the need for extended care. Assessment of older patients before elective
surgeries can accurately predict the patients' recovery trajectories. [7] One frailty scale uses five items:
unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking
speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people,
people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications,
spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing
facility instead of to their own homes.[7] Frail elderly patients (score of 4 or 5) have even worse
outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-
frail elderly people.

Other populations
This section requires expansion. (November
2012)
Children
Surgery on children requires considerations which are not common in adult surgery. Children and
adolescents are still developing physically and mentally making it difficult for them to make informed
decisions and give consent for surgical treatments. Bariatric surgery in youth is among the
controversial topics related to surgery in children.
Persons with health conditions
A person with a debilitating medical condition may have special needs during a surgery which a
typical patient would not.
Vulnerable populations
Doctors perform surgery with the consent of the patient. Some patients are able to give better informed
consent than others. Populations such as incarcerated persons, the mentally incompetent, persons
subject to coercion, and other people who are not able to make decisions with the same authority as a
typical patient have special needs when making decisions about their personal healthcare, including
surgery.

History
Main articles: History of surgery, Prehistoric medicine, and History of general anesthesia
Surgical treatments date back to the prehistoric era. The oldest for which there is evidence is
trepanation,[8] in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order
to treat health problems related to intra cranial pressure and other diseases. Prehistoric surgical
techniques are seen in Ancient Egypt, where a mandible dated to approximately 2650 BCE shows two
perforations just below the root of the first molar, indicating the draining of an abscessed tooth.
Remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BCE) show
evidence of teeth having been drilled dating back 9,000 years.[9] Instruments resembling surgical tools
have also been found in the archaeological sites of Bronze Age China dating from the Shang Dynasty,
along with seeds likely used for herbalism.[10]
Hippocratesstated in the oath (c. 400 BC) that general physicians must never practice surgery and that
surgical procedures are to be conducted by specialists.
The oldest known surgical texts date back to ancient Egypt about 3500 years ago. Surgical operations
were performed by priests, specialized in medical treatments similar to today.[11] and the use of sutures
to close wounds.[12] Infections were treated with honey.[13] In ancient Greece, temples dedicated to the
healer-god Asclepius, known as Asclepieia (Greek: Ασκληπιεία, sing. Asclepieion Ασκληπιείον),
functioned as centers of medical advice, prognosis, and healing.[14] In the Asclepieion of Epidaurus,
some of the surgical cures listed, such as the opening of an abdominal abscess or the removal of
traumatic foreign material, are realistic enough to have taken place.[4] The Greek Galen was one of the
greatest surgeons of the ancient world and performed many audacious operations—including brain
and eye surgery—that were not tried again for almost two millennia.

12th century medieval eye surgery in Italy

In the Middle East, surgery was developed to a high degree in the Islamic world. Abulcasis (Abu al-
Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who practised in
the Zahra suburb of Córdoba, wrote medical texts that influenced European surgical procedures. [15]
In Europe, the demand grew for surgeons to formally study for many years before practicing;
universities such as Montpellier, Padua and Bologna were particularly renowned. Guy de Chauliac
(1298–1368) was one of the most eminent surgeons of the Middle Ages. His Chirurgia Magna or
Great Surgery (1363) was a standard text for surgeons until well into the seventeenth century." [16] In
the 15th century, Rogerius Salernitanus composed his Chirurgia, laying the foundation for modern
Western surgical manuals. Barber-surgeons generally had a bad reputation that was not to improve
until the development of academic surgery as a specialty of medicine, rather than an accessory field. [17]
Basic surgical principles for asepsis etc., are known as Halsteads principles.
Early modern Europe

Ambroise Paré (ca. 1510–1590), father of modern military surgery.

There were some important advances to the art of surgery during this period. The professor of
anatomy at the University of Padua, Andreas Vesalius, was a pivotal figure in the Rennaissance
transition from classical medicine and anatomy based on the works of Galen, to an empirical approach
of 'hands-on' dissection. In his anatomic treatis, De humani corporis fabrica, he exposed the many
anatomical errors in Galen and advocated that all surgeons should train by engaging in practical
dissections themselves.
The second figure of importance in this era was Ambroise Paré (sometimes spelled "Ambrose"[18]), a
French army surgeon from the 1530s until his death in 1590. The practice for cauterizing gunshot
wounds on the battlefield had been to use boiling oil; an extremely dangerous and painful procedure.
Paré began to employ a less irritating emollient, made of egg yolk, rose oil and turpentine. He also
described more efficient techniques for the effective ligation of the blood vessels during an
amputation.

Modern surgery
The discipline of surgery was put on a sound, scientific footing during the Age of Enlightenment in
Europe. An important figure in this regard was the English surgical scientist, John Hunter, generally
regarded as the father of modern scientific surgery.[19] He brought an empirical and experimental
approach to the science and was renowned around Europe for the quality of his research and his
written works. Hunter reconstructed surgical knowledge from scratch; refusing to rely on the
testimonies of others he conducted his own surgical experiments to determine the truth of the matter.
To aid comparative analysis, he built up a collection of over 13,000 specimens of separate organ
systems, from the simplest plants and animals to humans.
Exhibit room of the Hunterian Museum in 1853, housing the collection of John Hunter, a father of
modern surgery.
He greatly advanced knowledge of venereal disease and introduced many new techniques of surgery,
including new methods for repairing damage to the Achilles tendon and a more effective method for
applying ligature of the arteries in case of an aneurysm.[20] He was also one of the first to understand
the importance of pathology, the danger of the spread of infection and how the problem of
inflammation of the wound, bone lesions and even tuberculosis often undid any benefit that was
gained from the intervention. He consequently adopted the position that all surgical procedures should
be used only as a last resort.[21]
Other important 18th and early 19th century surgeons included Percival Pott (1713 -1788) who
described tuberculosis on the spine and first demonstrated that a cancer may be caused by an
environmental carcinogen - (he noticed a connection between chimney sweep's exposure to soot and
their high incidence of scrotal cancer. Astley Paston Cooper (1768-1841) first performed a successful
ligation of the abdominal aorta, and James Syme (1799-1870) pioneered the Symes Amputation for
the ankle joint and successfully carried out the first hip disarticulation.
Modern pain control through anesthesia was discovered in the mid-19th century. Before the advent of
anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift
as possible to minimize patient suffering. This also meant that operations were largely restricted to
amputations and external growth removals. Beginning in the 1840s, surgery began to change
dramatically in character with the discovery of effective and practical anaesthetic chemicals such as
ether, first used by the American surgeon Crawford Long, and chloroform, discovered by James
Young Simpson and later pioneered by John Snow, physician to Queen Victoria.[22] In addition to
relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the
human body. In addition, the discovery of muscle relaxants such as curare allowed for safer
applications.
Unfortunately, the introduction of anesthetics encouraged more surgery, which inadvertently caused
more dangerous patient post-operative infections. The concept of infection was unknown until
relatively modern times. The first progress in combating infection was made in 1847 by the Hungarian
doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were
causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition,
introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with
a plunge in maternal and fetal deaths, however the Royal Society dismissed his advice.

Joseph Lister, pioneer of antiseptic surgery.

Until the pioneering work of British surgeon Joseph Lister in the 1860s, most medical men believed
that chemical damage from exposures to bad air (see "miasma") was responsible for infections in
wounds, and facilities for washing hands or a patient's wounds were not available.[23] Lister became
aware of the work of French chemist Louis Pasteur, who showed that rotting and fermentation could
occur under anaerobic conditions if micro-organisms were present. Pasteur suggested three methods to
eliminate the micro-organisms responsible for gangrene: filtration, exposure to heat, or exposure to
chemical solutions. Lister confirmed Pasteur's conclusions with his own experiments and decided to
use his findings to develop antiseptic techniques for wounds. As the first two methods suggested by
Pasteur were inappropriate for the treatment of human tissue, Lister experimented with the third,
spraying carbolic acid on his instruments. He found that this remarkably reduced the incidence of
gangrene and he published his results in The Lancet. [24] Later, on 9 August 1867, he read a paper
before the British Medical Association in Dublin, on the Antiseptic Principle of the Practice of
Surgery, which was reprinted in The British Medical Journal.[25][26][27] His work was groundbreaking
and laid the foundations for a rapid advance in infection control that saw modern antiseptic operating
theatres widely used within 50 years.
Lister continued to develop improved methods of antisepsis and asepsis when he realised that
infection could be better avoided by preventing bacteria from getting into wounds in the first place.
This led to the rise of sterile surgery. Lister introduced the Steam Steriliser to sterilize equipment,
instituted rigorous hand washing and later implemented the wearing of rubber gloves. These three
crucial advances - the adoption of a scientific methodology toward surgical operations, the use of
anaesthetic and the introduction of sterilised equipment - laid the groundwork for the modern invasive
surgical techniques of today.
The use of X-rays as an important medical diagnostic tool began with their discovery in 1895 by
German physicist Wilhelm Röntgen. He noticed that these rays could penetrate the skin, allowing the
skeletal structure to be captured on a specially treated photographic plate.

Surgical specialties and sub-specialties

General surgery
o Cardiothoracic surgery
o Vascular surgery
o Plastic surgery
o Paediatric surgery
o Colorectal surgery
o Transplant surgery
o Surgical oncology
o Trauma surgery
o Endocrine surgery
o Breast surgery
o Skin surgery
 Otolaryngology
 Gynaecology
 Oral and maxillofacial surgery
 Dental Surgery
 Orthopaedic surgery
 Neurosurgery
 Ophthalmology
 Podiatric surgery
 Urology
Some other specialties involve some forms of surgical intervention, especially gynaecology. Also,
some people consider invasive methods of treatment/diagnosis, such as cardiac catheterization,
endoscopy, and placing of chest tubes or central lines "surgery". In most parts of the medical field, this
view is not shared.
 Anesthesia
 ASA physical status classification systemor pre-operative physical fitness
 Biomaterial
 Cardiac surgery
 Surgical drain
 Endoscopy
  Fluorescence image-guided surgery
 Hypnosurgery
 Jet ventilation
 List of surgical procedures
 Minimally invasive procedure
 Operative report
 Perioperative mortality
 Robotic surgery
 Surgical Outcomes Analysis and Research
 Surgical Sieve
 Trauma surgery
 Reconstructive surgery
 WHO Surgical Safety Checklist

Governing bodies
 American College of Surgeons
 American College of Osteopathic Surgeons
 American Academy of Orthopedic Surgeons
 American College of Foot and Ankle Surgeons
 Royal Australasian College of Surgeons
 Royal Australasian College of Dental Surgeons
 Royal College of Physicians and Surgeons of Canada
 Royal College of Surgeons in Ireland
 Royal College of Surgeons of Edinburgh
 Royal College of Physicians and Surgeons of Glasgow
 Royal College of Surgeons of England

Notes and references

 ^ Jump up to: a b cAmerican College of Radiology. "Five Things Physicians and Patients
Should Question". Choosing Wisely: an initiative of the ABIM Foundation (American College of
Radiology). Retrieved August 17, 2012, citing"American College of Radiology ACR
Appropriateness Criteria". American College of Radiology. 2000. Retrieved 4 September
2012.Last reviewed 2011.
 Gómez-Gil, E.; Trilla, A.; Corbella, B.; Fernández-Egea, E.; Luburich, P.; De Pablo, J.; Ferrer
Raldúa, J.; Valdés, M. (2002). "Lack of clinical relevance of routine chest radiography in acute
psychiatric admissions". General hospital psychiatry 24 (2): 110–113. PMID 11869746. edit
 Archer, C.; Levy, A. R.; McGregor, M. (1993). "Value of routine preoperative chest x-rays: A
meta-analysis". Canadian Journal of Anaesthesia 40 (11): 1022–1027. doi:10.1007/BF03009471.
PMID 8269561. edit
 Munro, J.; Booth, A.; Nicholl, J. (1997). "Routine preoperative testing: A systematic review of
the evidence". Health technology assessment (Winchester, England) 1 (12): i–iv; 1–62. PMID
9483155. edit
 Grier, D. J.; Watson, L. J.; Hartnell, G. G.; Wilde, P. (1993). "Are routine chest radiographs
prior to angiography of any value?". Clinical radiology 48 (2): 131–133. doi:10.1016/S0009-
9260(05)81088-8. PMID 8004892. edit
 Gupta, S. D.; Gibbins, F. J.; Sen, I. (1985). "Routine chest radiography in the elderly". Age
and ageing 14 (1): 11–14. PMID 4003172. edit
 Amorosa JK; Bramwit MP; Mohammed TL; Reddy GP; et al. "ACR Appropriateness Criteria
routine chest radiographs in ICU patients.". National Guideline Clearinghouse. Retrieved 4
September 2012.
 Jump up ^American Society for Clinical Pathology, "Five Things Physicians and Patients
Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Society for
Clinical Pathology), retrieved August 1, 2013, which citesKeay, L.; Lindsley, K.; Tielsch, J.; Katz,
J.; Schein, O. (2009). Routine preoperative medical testing for cataract surgery. In Keay, Lisa.
"Cochrane Database of Systematic Reviews". The Cochrane database of systematic reviews (2):
CD007293. doi:10.1002/14651858.CD007293.pub2. PMID 19370681. edit
 Katz, R. I.; Dexter, F.; Rosenfeld, K.; Wolfe, L.; Redmond, V.; Agarwal, D.; Salik, I.;
Goldsteen, K.; Goodman, M.; Glass, P. S. A. (2011). "Survey Study of Anesthesiologistsʼ and
Surgeonsʼ Ordering of Unnecessary Preoperative Laboratory Tests". Anesthesia & Analgesia 112
(1): 207–212. doi:10.1213/ANE.0b013e31820034f0. PMID 21081771. edit
 Munro, J.; Booth, A.; Nicholl, J. (1997). "Routine preoperative testing: A systematic review of
the evidence". Health technology assessment (Winchester, England) 1 (12): i–iv; 1–62. PMID
9483155. edit
 Reynolds, T. M.; National Institute for Health Clinical Excellence; Clinical Scince Reviews
Committee of the Association for Clinical Biochemistry (2006). "National Institute for Health and
Clinical Excellence guidelines on preoperative tests: The use of routine preoperative tests for
elective surgery". Annals of Clinical Biochemistry 43 (Pt 1): 13–16.
doi:10.1258/000456306775141623. PMID 16390604. edit
 Capdenat Saint-Martin, E.; Michel, P.; Raymond, J. M.; Iskandar, H.; Chevalier, C.;
Petitpierre, M. N.; Daubech, L.; Amouretti, M.; Maurette, P. (1998). "Description of local
adaptation of national guidelines and of active feedback for rationalising preoperative screening in
patients at low risk from anaesthetics in a French university hospital". Quality in health care :
QHC 7 (1): 5–11. doi:10.1136/qshc.7.1.5. PMC 2483578. PMID 10178152. edit
1 Jump up ^Wagman LD. "Principles of Surgical Oncology" in Pazdur R, Wagman LD,
Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11 ed.
2008.
2 ^ Jump up to: a bAskitopoulou, H., Konsolaki, E., Ramoutsaki, I., Anastassaki, E. Surgical
cures by sleep induction as the Asclepieion of Epidaurus. The history of anesthesia: proceedings
of the Fifth International Symposium, by José Carlos Diz, Avelino Franco, Douglas R. Bacon, J.
Rupreht, Julián Alvarez. Elsevier Science B.V., International Congress Series 1242(2002), p.11-
17. Jump up ^Doyle, S. L., Lysaght, J. and Reynolds, J. V. (2010), Obesity and post-operative
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