wearer from contamination with body fluids, e.g. sprays of blood. Protective goggles are also recommended as personal protection. Their meaningfulness or otherwise has been repeatedly discussed since the introduction of face masks. Already back in 1936, Riese  achieved the lowest wound infection rates during so-called silent operations without a mask. It is a known fact that the release of germs during speaking can be significantly reduced by wearing a mask . Face masks should fit tightly over the mouth and nose. They should be worn in the operating theatre and, for disciplinary reasons, in the immediately adjacent ancillary rooms as well. Multi-layer masks with fleece and polyester inlays are superior to single-layer masks and gauze masks, because the latter are too permeable . As the mask becomes increasingly damp, the filter resistance is increased. The so-called edge leak rate increases, i.e. the passage of germs between the edge of the mask and the face. Damp masks must therefore be replaced (between two surgical procedures). If the face mask has been loosened (e.g. in the day room), it must be replaced. This should be followed by hygiene disinfection of the hands to eliminate contamination of the hands from the used mask.
In the traumatology Department at the Medical University Hannover (UCH-MHH), hair covering is worn throughout the complete operating suite. The face mask is only obligatory in the operating theatre and is always disposed of on leaving the operating theatre after an operation. A face mask is not required in the operation preparation room, in the corridors or ancillary rooms. This rule ensures that a fresh face mask is fitted in the scrub room before every further operation.
Going to the toilet. The guidelines for hospital hygiene and preventing infection  recommend going through the complete operating suite sluice procedure after going to the toilet (7 above). Adam & Daschner  do not find any scientific indication that the genital region of the surgeon or any other member of staff in the operating suite would constitute a special risk for postoperative wound infection. This presumes that the clothing is not soiled and that the operating staff wash their hands after going to the toilet and also disinfect them before every operation.
UCH-MHH: access to the toilets is only possible through the staff sluice, i.e. outside the actual operating suite. This means that the staff have to go through the complete operating suite sluice procedure again after going to the toilet.
Sterile surgical clothing. The surgical team enters the actual operating theatre through the scrub room where the surgical hand disinfection procedure takes place (7 there). On entering the operating theatre, the sterile ankle-length operating gown is fitted. It is important that the gown fits closely around the neck and that the sleeves are long enough and also fit tightly around the wrists. The requirements for sterile surgical clothing depend essentially on the liquid levels. For high-moisture procedures, linen and cotton quickly lose their function as germ barrier. In such cases, the surgical clothing must be impervious to liquid at least in the sleeves and front of the body .
Sterile operating gloves are generally accepted as protection for patient and staff alike. It goes without saying that defective gloves must be replaced. The use of double gloves does not protect from punctures or cut injuries but does reduce the risk of contaminating the hands with blood. Everyone should be advised to use two pairs of gloves.
UCH-MHH: two pairs of gloves are not obligatory. 2.3.2 Cleaning and disinfecting the hands
Most infections in hospitals are transferred with the hands. Washing and disinfecting the hands are therefore the simplest, safest, most effective and cheapest means of controlling infection . Jewellery worn on the hands and lower arms make the measures less effective. Surgeons should ensure that their hands are not impaired by stubborn dirt and soiling from work performed in their free time, e.g. from oil, grease and lubricants.
Washing hands. Washing hands with detergents cleans the hands and reduces the germ count by a factor of 100. One millilitre of pus contains about 100,000,000 germs, which can be reduced to about 1,000,000 germs by washing.
The rule for washing hands is: first disinfect, then wash. This should prevent the spread of germs by the actual washing procedure. But no one can be expected to treat for example hands contaminated with sputum by rubbing with disinfectant first. In the case of coarse soiling, the hands can be cleaned first with a disposable wet-wipe soaked in disinfectant.
Disinfecting hands. The word disinfection refers to the actual disinfection process, which always consists of the actual disinfectant, a reaction time and the means in which the disinfectant is applied. When disinfecting hands, it is necessary to distinguish between hygienic and surgical (preoperative) disinfection. Hygienic hand disinfection (3 ml alcoholic solution rubbed in for 30 s) kills off the transient skin flora and reduces the germ count by a factor of 10,000 (i.e. in the example given above, reduction to approx. 10,000 germs). Surgical hand disinfection aims at achieving an essential reduction in skin flora to rule out the risk of the hands being a source of infection.
In Germany, the main disinfectants used are based on alcohol. These are usually combinations of ethanol, 1-pro-panol and 2-propanol at a level of 80% by volume, to which skin care components are added. The disinfectant »bible« is the so-called DGHM list in which the German Society for Hygiene and Microbiology features all products and assesses them with regard to the corresponding application (available through mhp-Verlag, Wiesbaden).
Together with preoperative skin disinfection (7 patient preparation), surgical hand disinfection is the most important antiseptic measure for surgical procedures. The hands are washed initially to remove any coarse soiling. The former practice of washing the hands thoroughly with soap and a scrubbing brush is considered obsolete today. Dirt should always be removed immediately and not only in the scrub room before operations. When the skin is scrubbed with a brush, deeper skin layers are opened resulting in a higher germ count on the skin. Frequent hand washing also encourages eczematization . The pertinent guideline for hospital hygiene and prevention of infection  dated 1991 still requires fingernails and the edges of the nails to be cleaned with a nailbrush. The washing procedure should not take more than 1 min.
After washing, any remaining soap is rinsed off thoroughly and the hands dried gently. Many hypersensitive reactions are caused by mixing remaining soap and disinfectants. Low-germ towels (textile) can be used to dry the hands. Paper towels are rejected by some authors because of possible spore contamination. It is very important for a suitable disinfectant (DGHM list) to be applied to the dry skin. (This is easily explained: damp hands carry approx. 3 ml water; together with 3 ml 80% disinfectant, the water reduces the alcohol concentration to 40%, thus making it ineffective).
During the reaction time, the hands and lower arms should be coated with the disinfectant all the time. The disinfectant should be rubbed in, devoting particular attention to the nails and between the fingers. Approx. 12-15 ml disinfectant are required, depending on the reaction time and size of the hands. Experts fail to agree on the time that should be taken to disinfect the hands. Whereas Hingst et al.  fundamentally demand 5 min, Adam & Daschner  draw attention to the fact that surgeons abroad are already operating while their German colleagues are still disinfecting their hands in the scrub room. These authors recommend 3 min before the first operation and another 1-2 min before further operations.
UCH-MHH: hands are washed before the first operation and immediately after coarse soiling, soft brush for the fingernails, total time: 1 min. Soaked well with alcoholic disinfectant, rubbed in, not waved around, time: 3 min. Subsequent operations without significant interim contamination: no washing, but disinfection for 2 min.
2.4 Preoperative patient preparation
Body flora in the patient's nose and throat, intestinal passage and skin can be the starting point for wound infection.
Day before the operation. The length of stay in hospital before the operation is closely related to the wound infection rate. One reason could be contamination of the patient with problematical hospital germs. The aim should therefore be to reduce the length of stay in hospital before the operation. A multi-centre study in various European countries has revealed that bathing in an antiseptic agent (chlorhexidine) on the evening before the operation has no influence on the infection rate .
But the procedure of shaving the site of the operation before surgery has a verified effect on the incidence of wound infections. Seropian & Reynolds  showed that the use of a depilatory cream without mechanical hair removal resulted in a far lower infection rate than after shaving (0.6% compared to 5.7%). But depilatory agents frequently cause skin irritations. Studies by Cruse & Foord  showed the wound infection rate to be 0.9% when no measures were taken, 1.7% when cutting the hair with scissors and 2.3% in shaved patients. The cause of the increased infection rate after shaving the patient on the evening before is presumed to come from germ settlement and infection of tiny skin injuries. Today the operating site is only shaved immediately before the operation (in the preparation room) if thick hair is expected to interfere with the operation and simply shortening the hair is not sufficient. A strip of approx. 2 cm along the incision should be sufficient. The skin should be shaved as gently as possible, i.e. with a disinfected, sharp razor blade and using shaving soap or cream to prevent any injuries to the skin as far as possible.
UCH-MHH: patients are not bathed or shaved on the evening before the operation. Surgical preparation room: fine down and short hair is left; interfering long hair in the immediate operating site is cut with scissors; gentle shaving is only carried out in a 2-cm strip in the case of thick hair.
Skin disinfection. The disinfectants used include alcohol, iodine preparations and more rarely, phenolic preparations (see also DGHM list, 1991). Alcohol disinfectants start to act very quickly and are ideal for wound infections caused by key germ types . Iodine preparations start to react more slowly and are used more for disinfection of the mucous membranes. The operating site must be intensively coated with disinfectant for the complete reaction time. Wiping disinfection is more effective than simply spraying. The disinfected area must extend well beyond the actual operating site. An area of 20 cm is recommended all around the operating site. In addition, all areas
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