SURGERY BLOCK — the complex of specially equipped rooms intended for carrying out surgeries.
At the beginning of development of surgery when the most widespread operations were opening of abscesses, cutting off of impractical fabrics or parts of extremities, etc., carried out them in hospital chamber on a bed of the patient that made a painful impression on surrounding patients. Emergence of special rooms for operations — operating rooms is referred to the beginning of 18 century. For the first time in Russia N. I. Pirogov in Sevastopol widely used operating rooms (1854). In the same time N. I. Pirogov came to a conclusion about need of separate operating of wounded with purulent and not purulent wounds.
N. V. Sklifosovsky, having created the operating rooms which are well equipped on that time in faculty surgical clinic Moscow un-that, and then in Ying-those improvements of doctors in St. Petersburg, one of the first in Russia introduced in them rules asepsises (see) and antiseptic agents (see). The organization of certain operating rooms for aseptic, purulent and immediate surgeries practically would be carried out by V. A. Oppel in of I. I. Mechnikov in Leningrad.
Further development of surgery, deepening of its specialization demanded creation of the pro-thinned-out operating rooms — traumatologic, neurosurgical, ophthalmologic, gynecologic, urological, stereotaxic, barooperatsionny, etc., equipped in necessary cases with microsurgical appliances, X-ray and laser machines, devices for artificial circulation, etc.
Complication of operations, saturation of operating rooms the equipment would result in need of creation of O. with accurately organized work of all links, among to-rykh the main the operating room is.
Lake., as a rule, is a part of surgical department. In large multi-profile to lay down. institutions it can service several surgical departments (clinics); sometimes several O. allocate in independent operational department. In addition to operating rooms, in O. the following specially equipped rooms are provided: preoperative, sterilizing, office of hemotransfusion, narcotic, material, plaster, office of the manager O., rooms of personnel, sanitary inspection room, etc.
O. takes place separately from other rooms of a hospital. It can be at the departments serviced by it, occupy the whole floor, the certain building or an extension to the main surgical case. At O.'s accommodation. in the certain building operating rooms it is reasonable to place on 2 — 3 floors, sterilizing both other utility and economic rooms — on the first floor. In O.'s structure. operating rooms for aseptic operations enter. The so-called purulent operating room would be placed out of O., most often as a part of purulent department, the operating room for immediate surgeries — near reception.
General requirements to modern O.: rooms it shall have a sufficient cubic capacity, illumination, to be convenient for cleaning and washing; finishing materials of rooms shall be chemical antiseptic agents and UV rays, resistant to repeated sterilization; heating and ventilation shall provide optimal conditions for work of personnel and health of patients, the equipment — to conform to modern requirements of surgery and anesthesiology and, whenever possible, to be out of the operational hall; in clinics for teaching the possibility of overseeing by the course of operation through a glass ceiling from the second tier shall be provided (tsvetn. fig. 2) or by means of television broadcasting in audience; the reliable communication of O. is necessary. with divisions to lay down. institutions by means of phone, the alarm system and system of elevators.
Appointment and floor area, entering O., widely vary depending on volume and the range of surgical interventions, and also from the volume of teaching and research work of establishment. Arrangement and interrelation of rooms of O., features of work of personnel in them are defined first of all by requirements of an asepsis. O.'s division would meet these requirements. on zones with different duties. The feed zone — sterile; carry to it operational and sterilizing for tools. The personnel of operational crew can get to this zone through the sanitary inspection room and preoperative, the patient arrives from narcotic. Nek-ry clinics designate border of a sterile zone a red line on a floor, it is possible to cross it only in operational linen, boot covers, a mask. The second zone — a high security; carry to it preoperative, washing and narcotic, directly connected with the operating room. The third zone — the limited mode; carry the room for storage of blood to it, hardware, tool and material, the room of medical personnel, express laboratory, a pure half of the sanitary inspection room, etc. The fourth zone — the all-hospital mode; carry rooms, an entrance to it in to-rye it is not connected with passing through the previous zones (offices the manager. Lake., the elder instrument nurse, the room for the used linen, etc.).
The operating room — specially equipped room for carrying out surgeries.
Operating rooms for carrying out aseptic operations in standard would be developed at the rate of two on 100 surgical beds, in clinics and others research a wedge, institutions — at the rate of 3 — 4 on 100 surgical beds. According to Construction Norms and Regulations (1971) in for one operating room with one table the room of 36 — 48 sq.m would be allocated; height shall be not less than 3,5 m, width of 5 m. In the presence of the air conditioning system height of 3 m is allowed; in clinics where show operations, the area of the operating room shall be increased to 60 — 70 sq.m. If necessary to increase capacity in the operating room install the second operating table.
Walls, a floor and a ceiling of the operating room shall be smooth, joints between them rounded off. A floor is usually spread by kafelnsh tiles of light tones. For prevention of a possibility of formation of a spark from blow by a metal subject about a stone floor (that can lead to accident) more reasonable to cover a floor with electrowire technical plastic, epoxy or linoleum. In the center of the operating room or in one of corners in a floor there is an opening with a grid for a drain of dirty water during the cleaning.
Walls and a ceiling of the operating room spread a tile or paint an oil paint in light tone (light green, light yellow, light orange). These colors well reflect light that is important for illumination of the room. Besides, light coloring facilitates control of cleaning of the room. The coloring applied in nek-ry clinics in black color of distribution did not receive.
Water and sewers lay in walls; all engineering communications providing electro-and gas supply, heating and vacuum, shall be hidden. Electric wires shall pass in safety bergmannovsky tubes.
In large O. power supply is carried out from two separate sources. Because in sublayers of air of the operating room accumulation of the combustible gases or vaporous substances applied to an anesthesia is possible to-rye can blow up from an insignificant spark, a switchboard with sockets and switches have not lower than 1,6 m from a floor; their device shall exclude sparking. During cleaning of the socket and switches close latches. The board has 3 pairs of marked sockets for a supply of electric current of 36, 127, 220 in, one socket on 380 in and terminals of grounding. If sockets or switches are at the height less than 1,6 m from a floor, they shall have the iskrozashchitny case. Also grounding of all large objects and devices (including the operating table) accumulating static electricity is provided. For normal work of electronic devices the screen version shall be provided with an operational steel grid or planimetric grounding.
Oxygen, gaseous anesthetics move to the narcotic device from the collectors located out of the room or from cylinders. The most rational installation of gas communications from a ceiling with their eyeliner to the operating table on mobile brackets is considered. Tubes shall have marking in order to avoid mistakes at connection of gas. The vacuum system is located out of the operating room and is brought to it besides a switchboard, as gases.
For lighting of the operating room use natural (day) light and an artificial light source. At a design the operating room is oriented concerning parts of the world so that windows came to the North, the northeast or the northwest. The operating table is installed perpendicularly to a window. In southern latitudes in order to avoid strong heating of the operating room establish by sunshine from the outer side of windows the corrugated sun blind disseminating and absorbing solar heat, from above pull a linen tent. Norms of the natural lighting of the operating room defined as the relation of the area of windows to the area of a floor shall be not less than 1:3.
Most successfully the problem of natural lighting of the operating room is solved thanks to the device of the big windows, rectangular from whole mirror glass, occupying 2/3 spaces of walls (tsvetn. fig. Z). Glass is fixed in thin metal frames with the rubber gasket providing full sealing from dust and water. Frames during the opening of windows rotate on a vertical or horizontal axis. In winter time of glass of windows protect from formation of moisture and ice, placing between frames a vessel with a chamois to - that and warming this space by means of a radiator of heating or an electric heater. Daylight is most evenly distributed in the operating room having the square or round shape. At a rectangular shape depth of the room shall not exceed height of window frames more than in 2V2 of time.
For artificial lighting of the operating room use panel fluorescent lamps of 400 lx or plafonds with filament lamps of 200 lx. Nek-rye is mute. and amer. surgeons consider that in operating rooms it is more reasonable to use only artificial lighting therefore they suggest to darken operating rooms for operations, and to build new operating rooms without windows.
Illumination of a surgery field is of great importance; to it the following a gigabyte is shown. requirements: sufficient illumination; the minimum blinding actions of a light source and brightness; uniformity of lighting, lack of sharp and deep shadows, and also differences of lighting in the course of operation; approach of a radiation spectrum of an artificial source to a range of natural light; lack of heating of a lamp. Illumination on a surface of a surgery field shall be within 3000 — 5000 lx, increase it to 10 000 lx is in some cases admissible. Color temperature shall equal 4000 — 4500 ° To. Temperature increase of air in a zone of the operating table at the height of 0,5 m from a surgery field shall not exceed 2 — 3 °. Uniformity of lighting, i.e. the relation of the minimum illumination to the surface, maximum throughout 0,75 m, shall not be lower than 0,3. The considerable fluctuations of artificial lighting in connection with change of tension in electric network reaching sometimes 8 — 10% and more are unacceptable at illumination of a surgery field; in these cases use the voltage stabilizer. The lighting meeting the listed requirements is provided by shadowless lamps, to-rye are suspended over the operating table.
The hinged, balanced by counterbalances devices of these lamps allow to change the direction of rays of light. Thanks to dispersion of heat by means of system of glasses and to existence of an air gap between them these lamps almost do not heat up. On the same principle are arranged, lamps of JIOMO of the Sverdlovsk plant of the electromedical equipment.
In need of additional illumination of side surfaces of a surgery field use mobile and portable lamps. Lighting is duplicated by the emergency network operating from accumulators and joining automatically.
The special device for illumination of a surgery field is required at microsurgeries, in x-ray operating rooms, etc.
In operating rooms of small policlinic or out-patient clinic the lamp (it is desirable with luminous intensity not less than 200 cd) with a reflector can be applied to illumination of a surgery field.
For broadcast of operations in audience in shadowless lamps mount a television camera. Television installation consists of three main nodes: 1) cameras structurally integrated with group of lamps of a shadowless lamp; 2) operating console installation; 3) groups of the viewing devices placed in audience. Shooting is made depending on a condition of a luminescence of lamps. Transferring (operating room) and reception (audience) points of television installation are connected among themselves by two-way loud-speaking telephone communication.
Features of a microclimate of the operating room are that during operation temperature and air humidity increases, there is a pollution its anesthetic gas and a bacterial flora, static electricity accumulates. All this adversely affects on health operated and medical staff, but it is especially dangerous in connection with a possibility of droplet infection, edges became one of the main reasons for pyoinflammatory complications of the postoperative period. All this would dictate need of observance of increased requirements to O.'s microclimate., especially operational.
Temperature in the operating room shall be within 22 — 23 ° without noticeable fluctuations at normal indicators of air humidity. More high temperature of air (to 25 — 30 °) is necessary at operations at burned, and also at the long widely opened pleural or abdominal cavity operations. Heating of the modern operating room is carried out by the electric stoves which are built in in lower is frequent walls, and constancy of temperature is regulated by automatically thermorelay devices.
Ventilation of the operating room on minimum a dignity. to requirements shall be forced pritochnovytyazhny with dominance of the inflowing filtered air over sucked away from rooms, at 10 — 20-fold air exchange in an hour. Windows are supplied with transoms, to-rye open during cleaning of rooms. The centralized or local air conditioning equipments with repeated air exchange were widely adopted, from to-rykh the warmed-up, moistened sterile air comes to the operating room. Ventilation in operating rooms with a linear (laminar) flow of air (fig.) is most effective, in to-rykh a conditioned air arrives through the air vents located in a wall, and is removed through the exhaust openings located at a floor and a ceiling of a pas to an opposite wall. Operating rooms with laminar (usually horizontal) air flow around the operating table are already created, in a zone to-rogo 500-fold exchange of air in an hour is provided thanks to what the aseptichnost of air of this zone is practically reached.
Equipment of each operating room is made: the operating table (see. Operating tables ), the narcotic equipment, the device for diathermocoagulations (see), the equipment of a workplace of the instrument nurse, operational furniture, lighting system, the alarm system, the special equipment and the equipment determined by a profile of operation, vacuum system for suction of blood from an operational wound and a phlegm from pneumatic ways, germicidal lamps, etc.
Enter into anesthesiology equipment the narcotic device (see. Inhalation anesthesia, devices , Electroanesthesia, devices ), an eyeliner of oxygen and gaseous anesthetics, a narcotic little table, thermodevices for operations under a hypothermia (see. Hypothermia artificial, devices ), etc.
Small mobile tool little tables on a high leg are necessary for work of the scrub nurse, to-rye the big mobile tables like a dressing table of Bobrov for a reserve of sterile tools and dressing means which are on nek-rum a distance from the operating table have near the operating table. On separate tables there are a suture material, solutions, alcohol. In sterile drums on supports near a big table there is necessary operational linen (sheets, dressing gowns, etc.) and dressing material. Through a window in a wall between operational and sterilizing the nurse receives a grid with sterile tools, solutions, blood and other means, necessary for operation. Through the second window on the elevator are removed the used operational linen and a dressing material.
The most progressive is the method of preparation of materials and tools for operative measures in the form of special sets (linen and tools in separate packagings). They are in advance sterilized and supplied with passports with the instruction like set and terms of its validity. Gradually metal steam sterilizers of Shimmelbush give way to extra standard packings disposable.
Furniture of the operating room, in addition to operating tables, consists of metal chairs with the rotating seats, aluminum supports, supports for ampoules with infusional solutions, etc. Legs of furniture are supplied with rubber tips that it could be rearranged silently from place to place. The special supports, frameworks or Tazy wrapped by a sheet for clearing of noise during the falling of the tool establish from each party of the operating table and near the instrument nurse. On one of walls of the operating room install the wall clock with the large dial and a big second hand produced especially for operating rooms.
For fight against bacterial pollution in the operating room and other rooms of O. establish bactericidal lamps (see) — powerful sources of the Uv-radiation (OBN, OBP, OBPE). Usually in operating rooms of 40 sq.m at the height not less than 2 m from a floor place two lamps on opposite walls.
From the special equipment at separate operations surgeons and anesthesiologists most often use various measuring and data-acquisition equipment (the electrocardiograph, a cardioscope, a tonometer, etc.), a defibrillator, the equipment for extracorporal blood circulation (see. Artificial circulation), microsurgeries (see. Microsurgery ) and operations using laser (see), rentgenol, equipment, etc.
It is necessary to aim at that in operating time in the operating room there were only those devices, to-rye are necessary for performance of the planned operations.
In the centers and large departments of purulent surgery there is the surgery block for various operations at suppurative processes.
In the others-tsakh and clinics the operating room for purulent operations is located in a part of clinic opposite to aseptic operating rooms. It is reasonable to place it near purulent department. Quite often to the purulent operating room the purulent dressing room and the material prilezhit.
The area of the operating room intended for purulent operations (as well as for emergency), can be a little smaller, than for aseptic (usually 30 sq.m), in connection with its rather smaller loading the equipment and, as a rule, smaller volume of work. For the rest the device and equipment of the operating room for purulent (and emergency) operations shall meet the same requirements, to-rye are shown to the aseptic operating room.
The operating room would be the main division of O. Other rooms carry out subsidiary, but too very important functions aimed at comprehensive providing carrying out surgeries.
Preoperative intends for processing (washing) of hands of surgeons and sisters. In the departments servicing less than 250 beds it can be combined with material and tool rooms.
Sterilizing — the room where sterilization of linen, gloves, a dressing material, tools is made for the operating room. It is equipped with sterilizers (autoclaves), boilers - sterilizers, dry-heat sterilizers, etc. As a rule, it would be placed separately from other rooms of O. In small-tsakh can be in O.'s limits., being connected with the operating room through the window closed by a transom.
The office of transfusion a shelter is also equipped usually at service of 100 — 150 surgical beds. In it blood and blood substitutes is stored (in refrigerators). In those a case, when at O. there is no special laboratory, there has to be all necessary for blood typing and a Rhesus factor.
Narcotic it is equipped when O. services more than 200 surgical beds. Serves for introduction of the patient to a condition of an anesthesia. The intubation of the patient out of the operational hall considerably reduces danger of infection of the last therefore creation of narcotic is of great importance.
Material — the room for storage of stocks of tools, a suture material and medicines. It would be equipped usually at O. with a considerable volume of work. At the small volume of work the specified stocks are stored in the cases which are in the sterilizing or preoperative room.
Plaster (usually in O. orthopedic or traumatologic departments) it is equipped with all necessary for production of plaster bandages, special tables (see. Orthopedic tables ) and appliers of bandages.
The office of the manager of a surgery block and the room of the senior nurse are in a zone of the all-hospital mode and are connected with preoperative through a dignity. propusknik.
The sanitary inspection room has 2 rooms divided among themselves shower with two entrances. The first room is in a zone of the all-hospital mode. It is equipped with lockers for personal clothes of the personnel participating in operation. The second room is connected with a zone of a high security. In it the personnel which passed through shower put on in a special operational suit and put shoes on in special footwear. After operation personnel, having passed upside-down a dignity. the propusknik, puts on in the clothes.
The organization of work of a surgery block and rule of conduct of personnel in it are strictly regulated. Would will organize O.'s work. its managing (surgeon) and the senior scrub nurse. Access to O. it is strictly limited; the persons which are not belonging to its personnel are allowed only accompanied by responsible persons. Persons are not allowed to be in the operating room with acute respiratory diseases and pyoinflammatory processes. The entrance to the operating room in woolen or synthetic clothes is forbidden. For all participants of the operating crew the special clothes (a hat, a shirt, trousers, boot covers, an apron and a mask) differing on color from the accepted clothes of other divisions are used to lay down. institutions, including also the purulent operating room. Instead of the traditional gauze mask closing a mouth and Nov surgeons put on a transparent hermetic helmet, in to-ry sterile air constantly moves, and removal of expired air is provided with a vacuum system.
In the operating room for planned operations first of all pure operations (on a thyroid gland, vessels, joints, concerning hernias, etc.), and only are carried out then make the operations connected with possible microbic pollution (a cholecystectomia, a resection of a stomach, etc.).
Nek-ry additional requirements are imposed to an operating procedure in the purulent operating room. Surgical instruments, a dressing material and linen store separately and under no circumstances do not use at aseptic operations. Combination of work of personnel (nurses, nurses) in the pure and purulent operating room is excluded. The used dressing material is burned in the furnaces with gas burners installed in the basement of the operational case (materials arrive on burning on a refuse chute, to-ry carefully disinfect solution of lysol).
The X-ray operating room — specially equipped room intended for rentgenol. the researches connected with operative measures (angiography, sounding of cardial cavities, to lay down. embolization, a rentgenobronkhologichesky research, a miyelografiya, etc.), carried out under local or general anesthesia. Usually it is a part of a X-ray diagnostic office (see. X-ray department ). The narcotic and respiratory equipment, devices of functional and endoscopic diagnosis, tools for capture tsitol, and gistol, tests, the resuscitation equipment shall enter into equipment of the X-ray operating room, except the x-ray equipment and the negatoscope. Lighting of the X-ray operating room shall provide a possibility of switching off of a shadowless lamp at simultaneous automatic turning on of the screen of X-ray equipment and vice versa.
A floor in the X-ray operating room shall have an additional water tight coating (tiled, polyvinyl chloride), walls are revetted with a ceramic tile on all height of the room. Ventilation shall provide not less than 10-fold exchange of air in an hour. The eyeliner of oxygen, nitrous oxide, a hose from vacuum system is necessary.
Cleaning of a surgery block is made in the wet way. Distinguish cleaning: preliminary, at a cut daily in the morning prior to operations by a wet rag remove the dust which accumulated in a night from horizontal surfaces (tables, a floor); current, edges it is carried out to time of operation (remove the gauze balls which fell to a floor, napkins, wipe the floor soiled with blood); after the end of the next operation remove all used dressing material and tools, process an antiseptic agent of an oilcloth of the operating table; final, carried out after operations (washing and disinfection of a floor, furniture with inclusion for 1 hour of germicidal lamps); general, made at the end of the working week — the ceiling, walls, windows and the floor of rooms wash from hoses hot water with soap and antiseptic agents. After drying of the room and wiping dry include germicidal lamps on 12 — 14 hours.
Bacteriological control. In O.'s rooms. monthly produce bacterial, crops of air, a suture and dressing material, washouts from tools. At least once a week make crops from hands of participants of operations (see. Processing of hands ). At increase of cases of suppurations of postoperative wounds make extraordinary crops, if necessary — extraordinary clear-out of O. with its temporary closure.
The personnel working in the operating room periodically undergo profound inspection and bacterial. control.
Bibliography: Akzhigitov G. N. Organization and work of a surgical hospital, M., 1979; Ananyev M. G. and of e with e of l of e in and the p A. M. The modern surgical equipment and small-scale mechanization in the operative-dressing block, M., 1963; Anisimova I. G. Influence of the air environment of surgery blocks of hospitals on health of medical personnel, Klin, hir., No. 1, page 27, 1981; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 1, page 134, M., 1962; Portnovf. And Korneev V. N. Superpure operating rooms with a laminar air flow, Surgery, No. 4, page 113, 1973; V. I Pods. General surgery, page 44, etc., M., 1978; Chirurgische Operations-lehre, hrsg. v. J. Littmann, Stuttgart — N.Y., 1979; Feagin J. A. Bacteriology of the operating room with the use of helmet aspiration systems, Arch. Surg., v. 114, p. 790, 1979; Lauf-m a n H. Airflow effects in surgery, ibid., p. 826; O’ B r i e n B. Microvaseular reconstructive surgery, Edinburgh, 1977; Operating room techniques for the surgical team, ed. by L. C. Crooks, Boston, 1979; S with h y r a B, Grundsatze der farblichen Gestaltung des Operationssales, Zbl. Chir., Bd 89, S. 781, 1964; Spezielle Chirurgie, hrsg. v. H. J. Serfling, Lpz., 1978.
M. H. Anichkov, B. A. Sakharov; B. B. Kitayev (rents.).