Evidence-based Sterility: The Evolving Role of Field Sterility in Skin and Minor Hand Surgery

Abstract

Summary: Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.

Infection Rate Comparison during Transition from Hospital to Office WALANT Enabled by Virtual Reality

“…Over the past 20 years, several studies have supported that simplified field sterility alone is suitable for many hand procedures. [6][7][8][9][10] To address the patient experience whilst undergoing WALANT, we have applied the developing technology of wide-awake virtual reality. 11 Procedures done in the office are also significantly less costly than those performed in the main operating room.…”

Carbon footprint of dermatologic surgery

“…37,38 This is further supported by a recent meta-analysis where no substantial evidence exists to support the use of sterility practices such as head covers, gowns, full-patient draping, laminar airflow and footwear to reduce surgical site infection on skin and minor hand surgery. 37,39 The need for sterile surgical gowns and excessive full-e174 E. Tan and D. Lim patient sterile draping should be questioned. Dermatologic surgery is a clean procedure and evidence points to the patient's endogenous bacteria as the source of surgical site infection rather than factors pertaining to the surgeon and the operating theatre.…”

“…In Australia, hospitals have a large carbon footprint (about half the total for all health care) 6 . Sterile surgical gowns are effective barriers for the surgeon and are most helpful in the setting of joint replacement surgery, but their role in reducing surgical site infection is unproven 37,38 . This is further supported by a recent meta‐analysis where no substantial evidence exists to support the use of sterility practices such as head covers, gowns, full‐patient draping, laminar airflow and footwear to reduce surgical site infection on skin and minor hand surgery 37,39 .…”

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery

“…In a single-institution prospective study of 217 patients undergoing upper extremity surgery in a minor procedure room, the 14-day surgical site infection (SSI) rate was 0% while the 30-day rate was 0.4% 37 . Moreover, in a systematic review, Yu et al opined that field sterility is appropriate for minor hand surgery performed in procedure rooms, finding no evidence to support the use of full patient draping to reduce the likelihood of SSI 38 .…”