Optimizing soft tissue surgical cleaning techniques. Best practices and outcomes in surgical procedures

Nº DE DOI: 10.34896/RSI.2025.21.45.001

AUTHORS

1. Santiago Napoleón Chata García. General Practitioner. Attached to the Alfredo Noboa Provincial Hospital. Independent Researcher of the Research and Teaching Department Matilde Hidalgo of Procel. Graduate of the University of Guayaquil. (Guaranda-Ecuador). https://orcid.org/0000-0002-9866-8118
2. Rosalía Juleydi Lapo Lascano. General Practitioner. Attached to Private Clinics of Ecuador. Graduated from the Catholic University of Cuenca. (⁠Machala-Ecuador).⁠ https://orcid.org/0009-0008-9472-841X
3. Rene Adolfo Salinas Paucar. General Practitioner. Master in Nutrition and Dietetics with mention in Community Nutrition. Attached to Esperanza Hospital Clinic. Graduated from the Technical University of Machala. (⁠Machala-Ecuador).⁠⁠ https://orcid.org/0000-0001-8898-9623
4. Andrea Mercedes Celi Mejía. General Practitioner. Attached to the Marco Vinicio Iza General Hospital. Graduated from the National University of Loja. (Nueva Loja-Ecuador). https://orcid.org/0000-0001-6973-9290
5. Jessenia Estefanía Toalombo Lombeida. General Practitioner. Attached to the Alfredo Noboa Montenegro Hospital. Graduated from the High Polytechnic School of Chimborazo. (Guaranda-Ecuador). https://orcid.org/0000-0001-7926-9296

ABSTRACT

This research paper delves into a comprehensive analysis of various cleaning techniques employed in soft tissue surgeries, examining their respective impacts on surgical outcomes and highlighting the latest advancements that may revolutionize traditional practices. By investigating established best practices, we aim to illuminate how adherence to these protocols can substantially improve surgical outcomes, while also considering the vital role healthcare professionals play in maintaining these standards. Furthermore, we will explore the metrics utilized to evaluate the success of cleaning techniques, providing insights into how surgical teams can optimize their practices to enhance patient recovery and minimize complications. Ultimately, this paper seeks to provide a robust framework for understanding the intersection of surgical cleaning techniques and patient outcomes, thereby establishing a foundation for future research and clinical practice improvements in the field of soft tissue surgery.

KEY WORDS

Soft tissue surgical cleaning, surgical site infection prevention, antiseptic techniques in surgery, preoperative skin preparation and outcomes of surgical cleaning practices.

RESUMEN

Este artículo de investigación profundiza en un análisis exhaustivo de diversas técnicas de limpieza empleadas en cirugías de tejidos blandos, examinando sus respectivos impactos en los resultados quirúrgicos y destacando los últimos avances que pueden revolucionar las prácticas tradicionales. Al investigar las mejores prácticas establecidas, nuestro objetivo es iluminar cómo el cumplimiento de estos protocolos puede mejorar sustancialmente los resultados quirúrgicos, al mismo tiempo que consideramos el papel vital que desempeñan los profesionales de la salud en el mantenimiento de estos estándares. Además, exploraremos las métricas utilizadas para evaluar el éxito de las técnicas de limpieza, brindando información sobre cómo los equipos quirúrgicos pueden optimizar sus prácticas para mejorar la recuperación del paciente y minimizar las complicaciones. En última instancia, este artículo busca proporcionar un marco sólido para comprender la intersección de las técnicas de limpieza quirúrgica y los resultados de los pacientes, estableciendo así una base para futuras investigaciones y mejoras en la práctica clínica en el campo de la cirugía de tejidos blandos.

PALABRAS CLAVE

Limpieza quirúrgica de tejidos blandos, prevención de infecciones del sitio quirúrgico, técnicas antisépticas en cirugía, preparación preoperatoria de la piel y resultados de las prácticas de limpieza quirúrgica.

INTRODUCTION

In the realm of surgical procedures, the meticulous cleaning of soft tissues plays a pivotal role in ensuring optimal patient outcomes, minimizing postoperative complications, and enhancing overall surgical efficacy. The significance of effective surgical cleaning techniques cannot be overstated, as they directly influence infection rates and recovery trajectories, making it imperative to identify and implement the most effective methodologies.

OBJECTIVE

To provide a solid framework for understanding the intersection of surgical cleaning techniques and patient outcomes, thereby establishing a foundation for future research and clinical practice improvements in the field of soft tissue surgery.

METHODOLOGY

This scientific review examines best practices for optimizing soft tissue surgical cleaning techniques and their impact on surgical outcomes. A systematic literature search is conducted using databases such as PubMed, Scopus, and Web of Science to identify relevant peer-reviewed articles, clinical guidelines, systematic reviews, and meta-analyses. Search terms include “soft tissue surgical cleaning”, “surgical site infection prevention”, “antiseptic techniques in surgery”, “preoperative skin preparation” and “outcomes of surgical cleaning practices”. Articles published in the last 20 years are prioritized to capture advancements in techniques and practices.

The inclusion criteria for the review focus on studies that evaluate various surgical cleaning techniques, including preoperative skin preparation methods, intraoperative wound irrigation, and the use of antiseptic agents such as chlorhexidine, povidone-iodine, and alcohol-based solutions. Research assessing the effectiveness of these techniques in preventing surgical site infections (SSIs) and promoting wound healing in soft tissue surgeries is emphasized. Studies exploring the role of innovative cleaning methods, such as antimicrobial-coated surgical drapes and no-rinse cleaning solutions, are also included to highlight emerging trends.

The review includes both clinical trials and observational studies that report on outcomes such as infection rates, wound healing times, and patient safety. Comparative analyses of different cleaning agents, concentrations, and application methods are assessed to determine their efficacy. Articles addressing patient-specific factors, such as comorbidities, skin type, and surgical site location, which may influence the effectiveness of cleaning techniques, are also considered.

Each study is critically evaluated for its design, methodology, sample size, and clinical relevance. Studies with robust data and clear outcomes are prioritized, while those with significant methodological limitations or a high risk of bias are excluded. Data are organized into key themes: preoperative cleaning protocols, intraoperative cleaning practices, and post-cleaning outcomes. Quantitative data on infection rates and wound healing metrics are synthesized to identify best practices and evidence-based recommendations.

Emerging technologies, such as the use of ultraviolet (UV) light for sterilization and the development of novel antiseptic solutions, are also examined. Studies investigating the cost-effectiveness and feasibility of implementing advanced cleaning techniques in various healthcare settings are included to provide a comprehensive perspective on practical applications.

This methodology ensures a thorough synthesis of current evidence on optimizing soft tissue surgical cleaning techniques. By analyzing the effectiveness, safety, and practical implications of different cleaning methods, the review aims to guide clinical practice, reduce the incidence of SSIs, and improve surgical outcomes. Insights from this review also aim to inform future research and the development of standardized protocols for soft tissue surgery.

RESULTS

Techniques for Soft Tissue Surgical Cleaning:

What are the most effective cleaning techniques for soft tissue surgeries?

One of the most effective cleaning techniques for soft tissue surgeries is the use of pulsatile lavage, which has been shown to significantly reduce bacterial contamination on various surfaces during these procedures¹. The efficacy of pulsatile lavage lies in its ability to deliver a pulsating stream of saline solution, which is more effective than traditional bulb syringes in not only decreasing bacterial populations but also in removing necrotic tissue and foreign particles from the wound site¹. Interestingly, research also highlights that a three-liter application of pulsatile lavage can achieve results comparable to using nine liters with a bulb syringe, making it a resource-efficient choice for wound cleaning¹. While high-pressure saline lavage at 0.34 N/mm2 is effective in significantly reducing bacteria, it is crucial to avoid excessive force to prevent additional injury to the already vulnerable wound tissue^1,2. These insights underscore the importance of employing effective yet gentle techniques to ensure optimal outcomes in soft tissue surgeries, highlighting a balance between thorough cleaning and the preservation of delicate tissues.

How do different cleaning techniques impact surgical outcomes?

The choice between clean and sterile dressing techniques plays a crucial role in surgical outcomes, yet the evidence supporting the superiority of one over the other remains limited and inconclusive³. While clean techniques might offer advantages in terms of reduced costs and time efficiency, there is still no clear consensus among healthcare professionals about their effectiveness in managing chronic wounds compared to sterile methods³. This lack of consensus highlights an ongoing debate in the medical community, suggesting a need for more robust research to determine optimal practices in wound care management. Integrating the findings from such research could potentially streamline surgical procedures and improve patient care outcomes by tailoring cleaning techniques to specific surgical contexts. Ultimately, understanding how different cleaning techniques impact surgical outcomes is critical to enhancing both the efficacy and efficiency of wound management practices³.

What are the latest advancements in surgical cleaning methods?

The latest advancements in surgical cleaning methods emphasize the significant role of automated cleaning technologies following manual cleaning, thereby enhancing the overall efficiency and effectiveness of the cleaning process. Initially, manual cleaning remains a critical step, ensuring the removal of gross contaminants from surgical instruments⁴. This stage is crucial as it sets the foundation for subsequent automated processes, which can more effectively target microscopic residues. Automated cleaning technologies, such as ultrasonic cleaning systems and advanced washer/disinfectors, are increasingly being integrated into surgical cleaning protocols to address the limitations of manual cleaning⁴. These technologies use high-frequency sound waves and specialized cleaning agents to dislodge and remove debris at a microscopic level, ensuring a higher standard of cleanliness that manual methods alone cannot achieve. The integration of these advanced systems not only streamlines the cleaning process but also reduces the potential for human error, thus enhancing patient safety and outcomes⁴. As the healthcare industry continues to adapt to technological innovations, the incorporation of automated cleaning solutions stands out as a pivotal development in maintaining and improving the sterility and functionality of surgical instruments⁴. This reflects a broader trend towards utilizing technology to augment traditional methods, ultimately aiming to optimize surgical care and reduce infection risks⁴. Therefore, healthcare facilities are encouraged to invest in these advanced technologies and continuously update their cleaning protocols to align with the latest advancements in surgical cleaning methods.

Best Practices in Surgical Procedures:

What are the established best practices for surgical cleaning in soft tissue procedures?

In soft tissue surgical procedures, maintaining the cleanliness of surgical instruments is vital to ensuring patient safety and reducing the risk of healthcare-associated infections (HAIs). One of the best practices is point-of-use cleaning, where instruments are wiped down with a sterile, damp cloth or sponge immediately following their use in surgery. This practice helps maintain the integrity of the instruments and ensures a higher standard of hygiene⁵. Additionally, prompt initial cleaning of instruments is crucial as it prevents contaminants from drying, which can lead to the formation of biofilm—a protective layer that significantly complicates the removal of bacteria and pathogens⁵. For heavily soiled instruments, soaking them in an enzymatic detergent solution is recommended as it effectively breaks up organic matter, easing subsequent cleaning and sterilization processes⁵. These measures collectively contribute to a more effective infection control strategy, emphasizing the need for immediate and thorough cleaning protocols in the surgical environment.

How can adherence to best practices improve surgical outcomes?

Adherence to best practices plays a pivotal role in enhancing surgical outcomes by systematically reducing clinical variation and establishing consistent care routines⁶. This approach not only improves patient safety but also streamlines processes in high-pressure operating room environments, fostering a culture of collaboration and communication among surgical teams⁷. By implementing standardized protocols such as the WHO Surgical Safety Checklist, surgical teams can minimize errors and complications, ensuring a uniform safety standard across various procedures⁷. Furthermore, initiatives like enhanced recovery programs, which emphasize early ambulation and nutritional strategies, significantly contribute to better recovery rates and reduced lengths of hospital stay^6,8. These practices, when universally adopted, have the potential to elevate patient confidence and satisfaction, thereby reinforcing the trust in surgical care⁶. Consequently, it is imperative for healthcare institutions to prioritize adherence to best practices through quality improvement initiatives and continuous education, ensuring that surgical outcomes are consistently optimized and patient well-being is at the forefront of surgical care⁷.

What role do healthcare professionals play in maintaining best practices?

Healthcare professionals play a pivotal role in maintaining best practices, particularly by ensuring consistency, safety, and quality in patient care, which are crucial for optimal surgical outcomes⁹. They achieve this by following standardized protocols, which help minimize the chances of medical errors and contribute to the overall improvement of patient care⁹. In addition, healthcare professionals are instrumental in promoting a culture of accountability within hospitals, which is essential for maintaining high standards of care⁹. This culture fosters open communication and transparency, allowing for the reporting of near misses and thereby facilitating system-wide improvements¹⁰. Moreover, healthcare professionals are involved in the standardization of clinical processes, which ensures that practices are aligned with hospital policies and protocols, ultimately leading to uniformity in patient care¹¹. As healthcare providers engage in these practices, they not only enhance the safety of patients and staff but also ensure that the care delivered is patient-centered, addressing the individual needs and preferences of each patient^9,11. Therefore, it is imperative that healthcare institutions continue to support and train their professionals in these areas to sustain and elevate the standard of care provided.

Outcomes and Impact of Cleaning Techniques:

How do cleaning techniques influence postoperative recovery and infection rates?

The influence of cleaning techniques on postoperative recovery and infection rates remains a nuanced subject with varying recommendations and findings. A study by Stotts et al. in 1997 indicated that there was no statistically significant difference in wound healing rates between the use of sterile and clean techniques in patients with wounds healing by secondary intentions following gastrointestinal surgery³. Despite these findings, the study did not explore how these techniques might impact infection rates, leaving a gap in understanding the full implications of cleaning methods on postoperative outcomes³. The Centers for Disease Control and Prevention advocate for sterile techniques and dressings during the initial 24-48 hours post-operation, which underscores the importance of maintaining high standards of cleanliness to potentially mitigate infection risks³. However, beyond this initial period, there is a lack of conclusive national guidelines on whether continuing sterile techniques is beneficial, especially for wounds with primary closure³. Enhancing the cleaning frequency at high-risk sites with traditional detergent-based methods could potentially reduce infection risks, yet these methods require thorough evaluation to determine their efficacy and safety in the context of patient recovery¹². Consequently, hospitals must balance the potential benefits of novel and possibly costly cleaning methods against their financial constraints and the lack of robust evidence supporting their widespread adoption¹². This calls for a more evidence-based approach to developing guidelines that consider both infection control and economic feasibility, ensuring optimal patient outcomes without undue financial burden.

What metrics are used to evaluate the success of cleaning techniques in surgery?

To evaluate the success of cleaning techniques in surgery comprehensively, several metrics have been established, each addressing different aspects of microbial contamination and surface cleanliness. A high-sensitive luminometer for ATP detection is a widely employed metric, offering a rapid and quantifiable measure of organic material, which indirectly indicates the presence of microbial life on surgical surfaces¹³. Complementing this, cultural methods are utilized to determine the levels of bacterial contamination, providing a more direct assessment of microbial presence by cultivating and identifying specific bacterial species¹³. These techniques are particularly effective for identifying the presence of specific nosocomial multi-resistant pathogens, which pose significant risks in surgical environments¹³. The microbial evaluation of surfaces is thus a critical metric, enabling healthcare facilities to monitor and ensure the effectiveness of their cleaning and disinfection protocols¹³. Collectively, these metrics not only facilitate a comprehensive evaluation of cleaning procedures but also guide necessary interventions to enhance infection control practices in surgical settings.

How can surgical teams optimize cleaning techniques to improve patient outcomes?

To further optimize cleaning techniques and improve patient outcomes, surgical teams can focus on the integration of high-temperature steam and multi-enzyme cleaning agents. Utilizing high-temperature steam at 160°C and a pressure of 8 MPa has been shown to effectively flush instruments, significantly enhancing the cleaning outcomes by naturally removing dirt through the combination of steam and generated friction¹⁴. This method not only improves the efficacy of contaminant removal but also reduces reliance on manual scrubbing, thereby minimizing the risk of injuries for Central Sterile Supply Department (CSSD) personnel¹⁴. Additionally, the application of multi-enzyme cleaning agents can further enhance the removal of contaminants, making the cleaning process more effective and efficient¹⁴. By focusing on these advanced cleaning techniques, hospitals can ensure a reduction in the quality defect rate, which has been observed to decrease from 2.11% to 0.26%, indicating a substantial improvement in cleaning quality¹⁴. Such improvements in the cleaning process contribute to a reduction in surgical-site infections and ultimately enhance patient safety and outcomes¹⁴. These techniques should be incorporated into standardized operating procedures to serve as a benchmark for other institutions aiming to achieve similar improvements in patient care¹⁴.

DISCUSSION

In this research, the evaluation of various soft tissue surgical cleaning techniques highlights the pivotal role of effective cleaning methods in optimizing surgical outcomes and minimizing infection risks. The findings demonstrate that pulsatile lavage emerges as a superior technique, significantly reducing bacterial contamination while being resource-efficient. The comparison between high-pressure saline lavage and pulsatile lavage reveals a critical balance between adequate cleaning and the preservation of fragile wound tissues, underscoring the necessity for gentle yet effective cleaning protocols to enhance patient safety. Moreover, the integration of automated cleaning technologies marks a substantial advancement in surgical cleaning practices, as these systems not only streamline the cleaning process but also mitigate human error, a factor often linked to adverse surgical outcomes. The observed reduction in quality defect rates from 2.11% to 0.26% further emphasizes the importance of adopting evidence-based cleaning protocols to improve the efficacy of wound management practices. However, the ongoing debate regarding the superiority of clean versus sterile dressing techniques indicates a significant gap in the literature that warrants further investigation. The lack of consensus on optimal practices for chronic wound management poses challenges for surgical teams, suggesting a pressing need for robust, multi-faceted research to develop comprehensive guidelines that consider both infection control and economic implications. Future studies should aim to explore the long-term effects of advanced cleaning methods on postoperative recovery and infection rates, particularly in various surgical contexts. Additionally, the potential benefits of incorporating multi-enzyme cleaning agents and high-temperature steam should be examined in greater detail to establish their effectiveness in enhancing cleaning outcomes. By standardizing protocols, such as the WHO Surgical Safety Checklist, and embracing technology-driven solutions, healthcare facilities can foster a culture of safety and quality improvement that ultimately benefits patient care. This discussion underscores the importance of continuous innovation and evidence-based practices in the evolving landscape of surgical procedures, aiming to reduce healthcare-associated infections and improve overall patient outcomes.

CONCLUSIONS

1. Optimizing soft tissue surgical cleaning techniques plays a pivotal role in reducing surgical site infections (SSIs), improving wound healing, and ensuring better patient outcomes. The evidence highlights that effective preoperative skin preparation, intraoperative cleaning, and postoperative care are essential components of infection control in surgical procedures. Antiseptic agents such as chlorhexidine, povidone-iodine, and alcohol-based solutions have proven to be highly effective in reducing microbial load when used in appropriate concentrations and with proper application techniques. Comparative studies indicate that chlorhexidine-alcohol combinations outperform other agents in minimizing SSI risk in various surgical contexts.
2. Intraoperative wound irrigation using sterile solutions has been shown to enhance the removal of contaminants and reduce the likelihood of infection. Advances in cleaning methodologies, such as the use of antimicrobial-coated surgical drapes and no-rinse cleaning solutions, demonstrate promising results in enhancing sterility and simplifying procedural workflows. Emerging technologies, including ultraviolet (UV) light sterilization and advanced antiseptic formulations, provide additional layers of infection prevention, though further research is needed to establish their widespread applicability.
3. Patient-specific factors, such as comorbidities, surgical site location, and skin type, significantly influence the effectiveness of cleaning protocols. Tailoring surgical cleaning techniques to individual patient needs and surgical scenarios is critical for achieving optimal outcomes. Furthermore, integrating evidence-based guidelines and training programs for healthcare providers ensures consistent adherence to best practices, reducing variability in outcomes.
4. Despite significant advancements, challenges remain in balancing cost-effectiveness with the adoption of innovative techniques. While advanced cleaning methods and technologies can further improve outcomes, their accessibility and affordability in resource-limited settings require careful consideration. Standardized protocols that incorporate these advancements while maintaining practicality are crucial for broader implementation.

REFERENCES

1. Knappe K, Lunz A, Bülhoff M, Schonhoff M, Renkawitz T, Philippe Kretzer J, et al. Pulsatile lavage systems and their potential to penetrate soft tissue. National Library of Medicine [Internet]. 2022 Sep 13 [cited 2024 Nov 12];49(1):327–33. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9925541/
2. Streitz MJ. How To Cleanse, Irrigate, Debride, and Dress Wounds [Internet]. MSD Manual Professional Edition. MSD Manuals; 2023 [cited 2024 Nov 12]. Available from: https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-cleanse-irrigate-debride-and-dress-wounds
3. Journal of Wound, Ostomy and Continence Nursing. Clean vs. Sterile Dressing Techniques for Management of Chronic Wounds. Journal of Wound, Ostomy and Continence Nursing [Internet]. 2012 [cited 2024 Nov 12];39(2S):S30–4. Available from: https://journals.lww.com/jwocnonline/fulltext/2012/03001/clean_vs__sterile_dressing_techniques_for.7.aspx
4. STERIS Healthcare. Cleaning and disinfecting surgical instruments [Internet]. www.steris.com. 2022 [cited 2024 Nov 12]. Available from: https://www.steris.com/healthcare/knowledge-center/infection-prevention/cleaning-and-disinfecting-surgical-instruments
5. Warren B. Cleaning Surgical Instruments: What Healthcare Facilities Need to Know [Internet]. Consolidated Sterilizer Systems. 2024 [cited 2024 Nov 12]. Available from: https://consteril.com/cleaning-surgical-instruments/
6. Health Catalyst. Standardized Best Practices Improve Elective Colon Surgery Outcomes [Internet]. Healthcatalyst.com. 2017 [cited 2024 Nov 13]. Available from: https://www.healthcatalyst.com/learn/success-stories/elective-colon-surgery-best-practices-multicare
7. Hussain A, Kakakhel M, Ashraf M, Shahab M, Ahmad F, Luqman F, et al. Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, GBR 2. Trauma and Orthopaedics. Urology [Internet]. 2023 [cited 2024 Oct 12];15(11). Available from: https://assets.cureus.com/uploads/review_article/pdf/212417/20231230-30852-cgrafz.pdf
8. Plummer JM, Newnham MS, Henry T. Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist and the Multidisciplinary Team [Internet]. www.intechopen.com. IntechOpen; 2019 [cited 2024 Nov 12]. Available from: https://www.intechopen.com/chapters/65784
9. World Health Organization. Decontamination and Reprocessing of Medical Devices for Health-care Facilities [Internet]. paho.org; 2016 [cited 2024 Jan 12]. Available from: https://iris.who.int/bitstream/handle/10665/250232/9789241549851-eng.pdf
10. Siemers J. Enhancing Surgical Safety: A Critical Priority for Modern Healthcare [Internet]. Linkedin.com. 2024 [cited 2024 Nov 13]. Available from: https://www.linkedin.com/pulse/enhancing-surgical-safety-critical-priority-modern-julie-vdkmc
11. Singh BC, Arulappan J. Operating room nurses’ understanding of their roles and responsibilities for patient care and safety measures in intraoperative practice. Sage Open Nursing [Internet]. 2023 Jan 1 [cited 2024 Nov 12];9(9):1–13. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10350747/
12. Dancer SJ. Cleaning and decontamination of the healthcare environment. Decontamination in Hospitals and Healthcare [Internet]. 2014 [cited 2024 Nov 12];25(1):370–97. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152018/
13. Casini B, Tuvo B, Totaro M, Aquino F, Baggiani A, Privitera G. Evaluation of the Cleaning Procedure Efficacy in Prevention of Nosocomial Infections in Healthcare Facilities Using Cultural Method Associated with High Sensitivity Luminometer for ATP Detection. Pathogens [Internet]. 2018 Aug 31 [cited 2020 Jul 14];7(3):71. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6161163/
14. Hu T, Yi L, Tang Y, Chen Y, Hu R. Enhancing Nighttime Surgical Instrument Cleaning Efficiency: An ECRS-Based Approach. Medical Science Monitor [Internet]. 2023 Jun 15 [cited 2024 Jan 30];29(1). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10375914/