7.4 Surgical Scrubbing, Gowning, and Gloving

Surgical Scrubbing, Gowning, and Gloving

Asepsis is the cornerstone of successful veterinary surgery. Adhering to strict aseptic technique in the operating room (OR) minimizes the risk of post-operative surgical site infections (SSIs), which can severely compromise patient health. The veterinary assistant plays a vital role in this environment, whether they are scrubbing in as a sterile assistant or acting as a non-sterile circulating assistant. This section details the procedures for surgical hand scrubbing, gowning, and gloving, alongside the rules governing the maintenance of the sterile zone.

Pre-Scrub Preparation

Prior to beginning the surgical hand scrub, the veterinary assistant must perform several preliminary steps. These preparations ensure that the physical scrub is as effective as possible and that the scrubbed individual does not introduce contaminants into the clean surgical environment.

1. Surgical Attire: Put on a clean scrub suit, tucking the top into the pants to prevent loose fabric from brushing against sterile surfaces. Put on dedicated surgical shoes or disposable shoe covers (booties). All hair, including facial hair, must be entirely enclosed within a surgical cap or hood. Finally, put on a fresh surgical mask, ensuring it fits snugly over both the nose and mouth.
2. Remove Jewelry: All rings, watches, and bracelets must be removed from the hands and wrists. Jewelry harbors microscopic organic debris and bacteria, and blocks the antiseptic agent from making direct contact with the skin.
3. Fingernail Care: Fingernails should be kept short (not extending past the fingertips) and must be free of nail polish. Chipped nail polish can harbor bacterial colonies, and long nails can easily puncture sterile surgical gloves.
4. General Wash and Nail Clean: Perform a brief, non-aseptic wash of the hands and forearms up to the elbows using warm running water and a standard non-medicated soap to remove gross dirt and oil. Use a disposable plastic nail pick under running water to clean beneath each fingernail, where the subungual space holds the highest concentration of microorganisms. Once completed, discard the nail pick.

Surgical Antiseptic Agents

The surgical hand scrub does not sterilize the skin (which is biologically impossible without destroying tissue), but rather removes transient flora (superficial bacteria acquired from the environment) and reduces resident flora (bacteria residing in deeper skin layers). The two most common antiseptic agents used are:

• Chlorhexidine Gluconate (CHG): CHG is widely favored in modern veterinary practices. It acts by disrupting bacterial cell membranes. CHG has rapid bactericidal action and, crucially, offers excellent residual activity by binding to the keratin in the skin, keeping bacterial counts low for up to 6 hours. Its effectiveness is minimally reduced by the presence of organic material like blood.
• Povidone-Iodine: This halogen agent penetrates bacterial cell walls, oxidizing key structural proteins and nucleic acids. While highly effective against a broad spectrum of pathogens (bacteria, fungi, viruses, and some spores), it has shorter residual activity than CHG. Additionally, povidone-iodine can cause contact dermatitis or skin irritation in some patients and veterinary staff.

Hand Scrubbing Procedures: Timed vs. Stroke-Count

Surgical scrubbing must follow a highly structured, systemic progression from the cleanest area (the fingertips) to the dirtiest area (the elbows). Two standardized scrubbing methods are utilized. Both require a sterile scrub brush-sponge assembly pre-loaded with the chosen antiseptic.

The Timed Method

The timed method ensures that the skin remains in contact with the antiseptic agent for a specified length of time.

• Total Duration: Usually a minimum of 5 minutes (often 10 minutes for the first scrub of the day, depending on hospital protocol).
• Anatomical Breakdown: The time must be split evenly between both arms. For a 5-minute scrub, spend 2.5 minutes on the first hand and arm, then 2.5 minutes on the second. The scrub begins at the fingertips, moves to the fingers, the hand, the wrist, and progresses down the forearm, ending 2 inches above the elbow. Never return to a previously scrubbed area once you have moved proximally.

The Stroke-Count Method

The stroke-count method ensures that every surface of the skin receives a standard number of physical brush strokes to mechanically disrupt bacterial colonies.

• Fingernails: 30 strokes with the scrub brush.
• Fingers: Treat each finger as a four-sided object. Apply 10 strokes to each of the four surfaces (inner, outer, top, bottom) of each finger.
• Hands and Palms: 10 strokes to the palm, the back of the hand, and the lateral sides.
• Arms: Divide the forearm into three or four sections from the wrist to 2 inches above the elbow. Treat each section as having four surfaces and apply 10 strokes per surface.

The Hand Position Rule

Throughout the entire scrub and rinse process, the hands must be held above the level of the elbows at all times (arms bent, hands at chest level). This position forces water to drain from the clean fingertips down toward the unsterile elbows. If hands are dropped below the elbows, water contaminated by contact with the upper arm will run down onto the clean hands, immediately contaminating them and requiring a complete restart of the scrub.

Drying the Hands and Arms

After the final rinse, the assistant must enter the OR holding their arms bent and hands high. They must dry their hands and arms using a sterile hand towel before gowning.

1. Retrieve the Towel: Reach down to the sterile gown pack and pick up the sterile towel by the corner. Lift it straight up and step back from the table to prevent the towel from touching any unsterile surface.
2. Dry the First Arm: Unfold the towel completely. Use the top half of the towel to pat dry the first hand. Wrap the towel around the wrist and dry the forearm, moving in a continuous direction toward the elbow. Never backtrack: once the towel has moved down to the forearm, it must never touch the clean hand again.
3. Dry the Second Arm: Fold the towel over so that the dry, unused lower half is exposed. Grasp the dry half with the clean hand and use it to dry the second hand and forearm, moving down to the elbow. Discard the towel into the designated laundry hamper.

Surgical Gowning

Gowning creates a sterile barrier between the team member's clothing and the patient/sterile field.

1. Unfold the Gown: Lift the sterile gown straight up from its wrap by the inside collar/neckband area. Step back into a clear area.
2. Allow to Drop: Let the gown unfold downward naturally. Do not shake or flap the gown, as this creates air currents that can lift dust and bacteria.
3. Insert Arms: Locate the armholes and slide both arms into the sleeves. If performing closed gloving, do not push the hands through the elastic cuffs; the hands must remain entirely inside the sleeves.
4. Fastening the Gown: A non-sterile circulating assistant stands behind the gowned person. They reach inside the gown, grasp the collar and waist ties, and tie them securely. The circulator must only touch the inside of the gown, which is considered unsterile. For wrap-around gowns, the sterile team member hands a sterile card attached to the outer waist tie to the circulator, rotates 360 degrees, and pulls the tie free of the card, tying it to the other strap in front.

Gloving Techniques

Gloving completes the sterile hand barrier. There are two primary methods: closed gloving and open gloving.

Closed Gloving

Closed gloving is the gold standard for sterile surgical team members and is performed immediately after gowning.

1. Position the Glove: While keeping the hands inside the gown cuffs, open the sterile glove pack. Use the covered hand to pick up the left glove. Place it palm-down on the left gown cuff, with the fingers of the glove pointing toward the shoulder.
2. Stretch the Cuff: Grasp the glove's cuff through the gown material and stretch it over the elastic cuff of the gown sleeve.
3. Insert Hand: Push the hand forward through the gown's cuff and into the glove, ensuring the glove's cuff completely overlaps and seals the elastic gown cuff. Repeat the process for the right hand.

Open Gloving

Open gloving is used for minor, non-gowned sterile procedures (e.g., urinary catheterization, sterile skin preps, or minor laceration repairs).

1. Dominant Hand: Open the glove pack on a clean surface. Grasp the folded inner cuff of the first glove (this part will touch the skin, so bare-hand contact is allowed). Slide the dominant hand into the glove, leaving the cuff folded.
2. Non-Dominant Hand: Slide the gloved fingers of the dominant hand under the sterile outer cuff of the second glove. Slide the non-dominant hand into the glove, avoiding any contact with the skin of either arm. Unfold both cuffs over the wrists.

Maintaining the Sterile Zone

Once gowning and gloving are completed, the scrubbed assistant must protect the sterile field:

• The Gown's Sterile Field: The sterile area extends from the chest level to the level of the sterile field (waist), and the sleeves from 2 inches above the elbow to the cuffs.
• Unsterile Areas: The collar, shoulders, armpits, back of the gown, and any area below the waist are considered unsterile.
• Hand Placement: Hands must be kept clasped in front of the chest, above the waist and below the shoulders. Never drop hands to the sides or raise them above the face.
• Movement: Always face the sterile field. When passing another sterile team member, pass back-to-back or front-to-front. Maintain at least a 1-foot buffer when passing unsterile objects or personnel.