Standard steps in the elective programme

Preparation of the patient for the planned operation begins on making the indication and planning the date. Special implants or special positioning aids, for example a cervical spine holder, must be ordered in plenty of time and be available in time for the operation, and be sterilised if necessary.

In our own procedures, it has become established practice for the medical director/senior doctor to check the indication on the day before the operation (preferably before informing the patient), with corresponding instructions for the operating nurse/orderly who is on duty with regard to the expected positioning (including position aids) or additional materials required (e.g., special implants, imaging intensifier, Iso-C3D). If necessary, the side being operated will also be indicated (for operations to the extremities or when there are two organs).

About 10-20 min before being called to the operating suite, the ward staff administer the patient's premedica-tion and the transport staff bring the patient to the operating suite, bringing all the files with the findings and necessary X-ray pictures. It is normally not necessary to wash the patient at this point because as a rule, this will already have been done by the patient or nursing staff on the ward. The patient is wearing disposable pants and a surgical gown.

9.1.1 Patient reception

Fig. 9.1. Patient transfer system

orthostatic problems (e.g. circulatory collapse). Neither should the patient suffer from unnecessary pain during the transfer, to ensure that the anaesthetic can be started gently.

On the other hand, the patient can be moved with a roll board or patient transfer system. This method should be given preference in the case of instable, painful conditions. Well instructed staff are vital in both cases (O Fig. 9.1).

On arriving in the patient sluice, the patient is welcomed by the operating staff. Firstly unambiguous identification of the patient is checked verbally or according to the files. If this is not possible, a person must be called to identify the patient. The records of the surgeon and anaesthetist informing the patient about the procedure are checked for the patient's written documented consent before moving the patient. While the patient is still awake, the side being operated should be checked according to the operating schedule. If the patient is not conscious, this is checked together with the operating surgeon.

9.1.2 Selection of the operating table and placing the patient on it

The operating table and required positioning aids are chosen according to the kind of procedure and the special aspects clarified before the operation (7 see Sect. 9.1).

The patient's bed and the operating table are adjusted to the same height. The patient can now either slide over onto the operating table from his bed; he should not have to stand up to do so, because the premedication can cause

9.1.3 Preparing the patient in the anaesthesia induction room

In the anaesthesia induction room, the patient is placed under anaesthetic. While the patient is being prepared by the team of anaesthetists, the positioning aids are put at the ready. After intubation or completion of the local anaesthetic, work starts to prepare the patient for the operation. If necessary the disposable underwear is removed (e.g. hip operation). General body hygiene has already been completed on the ward. If necessary, the operating site can be cleaned again in the anaesthesia induction room. This is always the case after removing any bandages or plaster casts and in the case of dirty operating sites, for example in the case of open injuries. If the patient has to be shaved in the incision area and area for applying the neutral electrode, this is carried out with a dry, sparse procedure after placing an absorbent disposable cloth underneath. After replacing the cloth, the operating site is washed with a washing lotion and then dried with pads. The operating site is then rubbed with alcoholic disinfectant and covered with a sterile drape. Any necessary tourniquet can be applied now, taking great care to ensure that no residual moisture collects under the tourniquet. The neutral electrode is only applied after completing the definitive positioning procedure!

9.1.4 Definitive positioning

After moving into the operating theatre, the operating table is positioned on the column, the transporter removed from the theatre and the table brought to its final position (e.g. for surgery to the arm: operating table positioned crosswise in the room). Having made all positioning aids and accessories for special positioning available in advance, work can now begin promptly on positioning of the patient (O Fig. 9.2).

The definitive positioning is brought to its conclusion with application of the neutral electrode and connecting up to the HF surgery device, connecting the tourniquet to the pressure gauge, applying adhesive drapes for preparation of the operating site and, if necessary, replacing the absorbent sheet under the extremity to be washed. The patient is always covered with warm drapes or, at the latest in this preparatory phase, with a patient warming system (O Fig. 9.3).

The operating lights are positioned so that the sterile light handles can be plugged in quickly.

Skin disinfection by the surgeon must take place with the extremity held up high (O Fig. 9.4).

After disinfecting the skin, the operating site is covered correctly by several persons in sterile clothing, or a washed extremity is handed over to sterile staff (O Fig. 9.5).

The operation can begin (O Fig. 9.6).

9.1.5 Preparing the bed and measures at the end of the operation

Meanwhile the equipment for postoperative positioning of the patient is placed at the ready. The bed is chosen according to the patient's size. There is a choice between standard beds, children's beds, cots or intensive care beds,

Fig. 9.6. At the end of the sterile covering phase

with bed extensions, extension devices or special rails which can be fitted if necessary. It has become indispensable practice to heat the bed for the patient after the operation using an electric blanket.

At the end of the operation, a sterile bandage is applied by the operating team, the patient is disconnected from the HF surgery device and any other connections are removed (e.g. tourniquet). Disposable or multiple use covers are disposed of in the normal containers. If necessary, postoperative X-rays are taken to allow for possibly necessary surgical corrections before bringing the patient round after the anaesthetic. For extubation, the patient is moved from the definitive positioning back into the supine position, and the extremities are held with body belts. It has proven effective to place the arms parallel to the body on the arm positioning supports in this phase. The patient can be extubated in the operating theatre or in the post-anaesthesia room to keep the circulation concept working in the surgical department.

If necessary, a postoperative plaster cast can be applied before the patient leaves the operating suite; for hygiene reasons, this should not be done in the operating theatre itself.

The patient is transferred to a preheated bed in the patient sluice by the surgeon and anaesthetist together. To do so, the bed is raised to the level of the operating table. Depending on the positioning and kind of anaesthetic, the patient should be transferred by sliding onto the roll board or using a patient transfer system, by rolling from the prone directly into the supine position on the bed or by the patient sliding over on his own. It is up to the surgeon to ensure that any peripheral drips, drainage tubes and thorax drains are securely positioned, even if the patient transfer phase consists of team work. The patient is placed in the middle of the bed without any contact with the edges. Any positioning cushions or rails are fitted and the drainage containers fixed to the outside of the bed. In the case of freshly extubated patients, padded side bars should be fitted to the bed initially and the patient should be monitored constantly.

The patient is then brought to the recovery room or intensive care station. In exceptional cases with regional or local anaesthetic, the patient can also be brought straight to the normal ward.

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