Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 1: Maintaining Sterile Technique
Clinical Image
Source: Wikimedia Commons - Surgical Scrub - CC BY-SA 4.0
Case Presentation
A third-year medical student is scrubbing for her first laparoscopic cholecystectomy. She arrives in the OR suite, dons a surgical cap (covering all hair) and mask, then proceeds to the scrub sink. She performs a 3-5 minute surgical scrub: starting with the fingernails using a nail pick, then systematically scrubbing from fingertips to two inches above the elbow, never returning to already-scrubbed areas. She rinses with hands elevated, allowing water to drip toward elbows. Entering the OR with hands elevated, she receives a sterile towel from the scrub tech and dries each arm (one side per arm, moving toward elbow). She gowns with arms through sleeves but hands remaining inside for closed gloving. The circulator ties the back. During closed gloving, she manipulates the glove onto each hand while keeping her hands within the gown sleeves. The waist tie is completed by having the scrub tech hold the card while she turns. During the case, she accidentally brushes her gloved hand against the anesthesia machine at the head of the table. She immediately steps back and announces, "I contaminated my glove." She is helped to remove and replace the contaminated glove while the circulator opens a new sterile glove. The attending commends her for recognizing and reporting the break in sterility rather than trying to hide it.
Key Learning Points
- Sterile zones of the gown: front from chest to waist, sleeves from gloves to 2 inches above elbow; back is never considered sterile
- Closed gloving technique (hands remain inside gown sleeves during gloving) is preferred for maintaining sterility
- When contamination occurs (or is suspected), immediately step back from the field, announce the break, and re-glove or re-gown; never try to hide potential contamination
- The surgical time-out (before incision) verifies patient, procedure, site, antibiotic administration, and safety checks with all team members participating