Operating Theatre Setup 
Maziar Nourian, Rachel Baker, Jason Fader 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
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Editor’s Note: In this article, we have tried to 
describe the standards for an operating room in a 
high-resource setting. After each paragraph, we 
provide a commentary by one of the authors (JF) 
with compromises, tips and other suggestions for 
adapting these standards to a low-resource setting.  
 
Introduction:  
Safety in operating room environments is 
paramount to surgery regardless of setting. The 
operating theater poses unique risks to patients and 
staff members, and it is important to understand how 
to properly set up a functioning operating theater to 
minimize these. In this chapter, we will discuss basic 
principles of how to set up an operating theater, 
including an overview of medical gasses, electrical 
and fire safety, theater environment control, and 
anesthesia machine requirements. Additionally, we 
will 
outline 
basic 
operating 
theater 
layout, 
equipment, technology, and maintenance standards. 
We have divided this chapter into five 
sections:  
1. Setup 
2. Gasses and Vacuum 
3. Electricity 
4. Safety 
5. Anesthesia Machines 
 
1. Setup 
Layout and Physical Requirements 
The 
operating 
theater 
should 
be 
accommodating to safe surgery and anesthesia and 
should be at least 7x7m with a ceiling height of 3.5m. 
This is to allow adequate space for operating theater 
equipment, intraoperative imaging and patient 
monitoring.  
The typical design and layout of the operating 
theater involves a patient bed with an anesthesia 
machine at the head, surgeons and assistants standing 
to the right and left of the patient and a scrub 
technician near the feet of the patient or to one side 
with a sterile table full of surgical equipment.  
There should be adequate room for various 
patient positions for the various sub-specialties and 
types of surgeries as well as space to adequately 
allow an anesthesia machine and various instruments 
to come in and out of the operating theater.  
In order to allow for intraoperative patient 
positioning, a safety strap shall be placed above the 
patient's knees to prevent movement if the bed is 
tilted or moved. Safety straps shall also be placed on 
patients arms to prevent unintended injury from an 
arm falling off the arm table. In the supine position, 
the operating table should be able to tilt and rotate 
into various positions including Trendelenburg and 
reverse Trendelenburg positions. These positions 
will place pressure on various parts of the body, 
therefore it is important to provide padding to 
pressure points along the patient. We discuss the 
approach to patient positioning and various surgical 
positions elsewhere in this Manual.  
 
A suggested layout for a single operating room. The baby 
warmer can be portable and moved to another room, or a 
neonatal resuscitation area, as needed. There should be outlets 
on all four walls (220 and 110V).   
 
Each operating room fits into a well- 
designed system that meets the various needs of 
operative patient care. In addition to easy access to 
the operating rooms themselves, a theater area should 
include:   
● A waiting room for patients and family with 
reception 
● Patient changing areas 
● Examination rooms 
● A pharmacy 
● Storage areas for surgical and anesthesia 
equipment 
Operating Theatre Setup 
Maziar Nourian, Rachel Baker, Jason Fader 
 
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● A central supply store for non-reusable items 
● A surgical instrument storage area 
● Decontamination and sterilization facilities 
● A postoperative recovery area 
● Dressing rooms for theater staff 
● Lounge for theater staff 
● Clinicians’ work and documentation area 
 
Suggested layout of an operating room. Consideration is given 
to sterile areas and the exit of contaminated linens, entry of 
clean linens, and the entry and exit of theater personnel through 
the changing rooms. If there is enough space, consider adding 
extra exam rooms. These can double as patient changing rooms 
so that several patients can enter at once, or family rooms when 
needed for private discussions.  
 
Commentary: 6x6m is a very adequate size.  If it is 
much bigger than that, the equipment can have 
trouble reaching the patient.  The one exception 
might be an orthopedic operating theater where a C-
arm (portable x-ray machine) is used routinely.  3.5m 
for height is just right – much higher and the 
overhead light will need some sort of extension; 
much lower and the surgeons will hit their heads on 
the light. Putting multiple 220v and 110v outlets on 
each wall helps with flexibility.  Windows above 1.8m 
help with natural light, but prevent people from 
looking in.  Table surfaces on 2 walls which are off 
the ground ensure that the legs will not rot or rust, 
since the operating theaters get mopped multiple 
times per day.  These can be finished wood.  Side 
tables should be stainless steel and are easily found 
from medical suppliers. Tile is usually the most 
practical flooring and should go up the wall about 
20 cm.  It is always prudent to plan on expansion so 
that if it happens, it occurs in a way that maintains a 
workable environment with good patient flow.  
Consider placing the ICU near the recovery room as 
well, since they serve overlapping functions and have 
similar needs.  The lounge should include the 
possibility of having lunch served to the operating 
staff as this facilitates shorter lunch breaks and loss 
of momentum.  Clear vinyl (often used for boats) is 
very useful to cover operating theater tables to 
prolong the life of the foam mattresses, which are 
hard to replace. 
 
Environment 
Temperature:  
The temperature of the operating theater 
should be between 18°C and 24°C. Keeping the room 
above 18ºC is important to prevent intraoperative 
hypothermia. Hypothermia (patient temperature 
<35°C) has been associated with greater morbidity 
and mortality. Complications include metabolic 
changes, impaired drug metabolism, cardiovascular 
changes, effects on coagulation, etc. Patients under 
general anesthesia will typically lose 0.5ºC to 1.5ºC 
within the first hour as a result of vasodilation and 
redistribution of body heat. Most of the body’s heat 
loss happens at the skin level in the form of radiation; 
however, convective, conductive, and evaporative 
modalities can further lead to heat loss in a patient. 
Warming devices can be used to maintain 
normothermia in a patient if they meet the following 
standards. A device that forces heated air over a 
patient shall not exceed 48ºC, and the average 
contact surface temperature should be below 46ºC. If 
a fluid warming device is utilized, it shall not be 
heated past 43ºC with an average surface 
temperature of 42ºC.  
When comparing various warming strategies, 
forced air warming devices that blow air into a 
warming blanket in contact with bare skin have been 
shown to prevent hypothermia better than fluid 
warmers, warmed blankets, or increasing the 
temperature in the room. Passive coverings of 
patients, such as thermal head coverings or warm 
blankets over exposed parts of the patient’s body, are 
adequate ways to prevent heat loss. Lastly, the 
Operating Theatre Setup 
Maziar Nourian, Rachel Baker, Jason Fader 
 
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anesthesia team can decrease fresh gas flows and use 
a heat and moisture exchanger in the anesthesia 
circuit to reduce heat loss. An anesthetized surgical 
patient is also at risk for burns or cold injuries due to 
human error, such as a forced air warmer or ice being 
placed directly on patient skin. 
 
Commentary: Hot water bottles are a very cheap way 
to provide heat to patients.  Latex gloves can also be 
filled with warm water.  Sterilization should have a 
hot water source that can be used for this.  A broken 
refrigerator is an excellent way to warm blankets and 
gowns for patients by installing light bulbs inside the 
refrigerator along with a thermostat (for a 
terrarium, for example.)   
It is important to test any water with your 
own hand before placing it on a patient’s skin, as 
anesthetized patients will not be able to tell you that 
they are being burned by something that is intended 
to warm them. Portable electric “space heaters” 
have a similar danger if placed too close to an 
anesthetized patient.  
 
Humidity 
The humidity in the operating room is a safety 
concern. If the operating room is above 60% 
humidity, condensation may occur on cool surfaces 
and affect the integrity of barrier devices. If the 
humidity is less than 20%, static charge may build up 
and 
contribute 
to 
operating 
theater 
fires. 
Additionally, low humidity facilitates the spread of  
airborne disease vectors. Therefore, it is advised to 
keep the operating theater between 20-60% 
humidity.  
 
Ventilation 
The ventilation system of an operating theater should 
minimize the spread of contaminants and infectious 
agents. Therefore, the operating theater should 
maintain negative pressure, thereby preventing 
airflow out to the hall or other operating theaters. 
Additionally, the flow of fresh air into the theater 
should allow for six to ten total air exchanges each 
hour. This circulation can be achieved by exhausting 
the operating room air outside or recirculating it 
through a filtered system. 
 
Commentary: When forced air ventilation is not 
feasible, keeping some doors and windows open is an 
easy way to get air exchange.  Moving air is less 
infectious than stagnant air.  Installing exhaust vents 
in strategic locations can help pull air through very 
cheaply and effectively. 
 
 
A ventilation duct near the floor of an operating room in a 
resource-rich setting allows recirculation and maintains a 
slight negative pressure inside each room, minimizing spread 
of contamination out of the room.  
 
Noise 
The operating theater is full of various noises 
which can be damaging to patients and operating 
theater personnel. At the very least, excessive noise 
makes communication difficult. Sources of noise 
include suction machines, forced air warmers, 
alarms, and surgical equipment. The United States 
Occupational Safety and Health Administration 
(OSHA) recommends noise to be less than 80 
decibels on average (which is louder than 
conversational level). Certain equipment in the 
operating theater can get above 125 dB, and hearing 
protection may be required while those machines are 
in use. 
 
Lighting 
Lighting in the operating theater can help a 
surgeon 
visualize 
the 
surgical 
field, 
allow 
intraoperative nursing/technicians to perform their 
functions, and ensure safe anesthesia is provided. 
While 
different 
surgeries 
require 
different 
types/intensities of lighting, it is generally accepted 
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that lighting capabilities of at least 200 foot-candles 
is required.  
As light source technology improves, there 
are brighter and more affordable lighting systems in 
the form of LED technologies that can be used in 
headlamps, overhead lights, and orbit lights. The use 
of LED technologies also reduces the amount of 
infrared heat produced with other light sources.  
 
An overhead light in a resource-rich setting with multiple LED 
bulbs and a sterilizable handle that allows the surgeon to adjust 
and direct it.  
 
Finally, backup lighting in the form of battery 
powered flashlights and headlamps should be made 
available in cases of power insecurity.  
 
As LED technology has improved and become affordable, 
“camping headlights” such as this one emit 600 lumens and are 
entirely suitable for surgical use.  
 
Commentary: When buying lights, be sure and get 
many extra light handles that can be sterilized.  
Camping headlights make overhead lights almost 
unnecessary.  The operating room is one of the key 
areas that should be put on a generator back up, as 
well as the oxygen system, lab, and Casualty / 
Emergency Room.  An operating theater typically 
only uses a couple of kW of power, so a big generator 
is not necessary (depending on the size of the 
sterilizer, which likely uses the most electricity in the 
theater.) 
 
Radiation/Intraoperative Imaging 
Radiation exposure may occur due to 
diagnostic imaging done intraoperatively. This 
includes fluoroscopy, linear accelerators/beam 
therapy, computed tomography (CT), and x-rays. 
Radiation is measured in gray (gy), rads, Sievert 
(Sv), and Roentgen equivalents in man (REM). The 
goal in the operating theater is to use radiation “as 
low as reasonably practical.”  
Radiation exposure is reduced by using 
shielding techniques, decreasing the duration of 
exposure, and increasing the distance from the 
radioactive source. For example, a person may be 
exposed to 1000 millirads of radiation at a distance 
of one centimeter from the source but increasing the 
distance to 100 centimeters reduces the radiation 
exposure to 0.1 millirads.   
In order to shield organs that are highly 
sensitive to radiation (such as eyes, thyroid, gonads, 
and blood), it is recommended to wear lead shields 
or to stand behind leaded walls or shields. Leaded 
goggles are also an option for those exposed to 
radiation on a frequent basis. Leaded aprons and 
thyroid shields should be at least 0.25mm on the front 
and back whereas thyroid shields should be at least 
0.5mm. This protective equipment should be tested 
every year to ensure full protection. 
 
Commentary: When lead aprons and portable lead 
walls are not readily available, distance from the 
radiation source is a very effective way to decrease 
exposure. 
 
Operating Theatre Setup 
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2. Gasses and Vacuum 
Oxygen 
Oxygen delivered to patients should be 99% 
oxygen. Oxygen is typically stored as a gas at room 
temperature or liquid when refrigerated. Oxygen can 
be stored in high-pressure cylinders (H-cylinders) 
and connected to a manifold that will reduce the 
cylinder pressure of 2000 pounds per square inch 
(psi) down to an appropriate line pressure of 55 psi. 
Oxygen at 55 psi can be routed to operating theaters 
and recovery areas to be safely used. Each anesthesia 
machine should have the capability of hooking up to 
an emergency cylinder (E-cylinder) in case of 
hospital gas system failures. E cylinders should have 
a pressure of about 2000 psi and never be filled above 
5000 psi. 
In high-resource settings, oxygen can also be 
stored at -119C in liquid form in a large tank.  
Oxygen concentrators are an alternative to 
liquid storage or tank oxygen. Concentrators can 
deliver a concentration of 90-96% by absorbing 
nitrogen and other trace gasses through a pressure 
swing adsorber. Oxygen concentrators are governed 
by the international standards (ISO 8359 and ISO 
10083.) The benefit of such devices is that they are 
compact and can be easily transported from the 
operating theater to ICU and other locations. These 
can also be utilized in case of pressure malfunctions 
of a pipeline system. Of note, it is key that air 
filtration systems be changed or cleaned regularly 
and humidity be controlled in the operating theater; 
a concentrator’s performance may decrease if used in 
very high humidity. (Recall that at maximum 
performance a concentrator can deliver only 96% 
oxygen.)  
 
A portable, wall-powered oxygen concentrator 
 
 
A hospital’s oxygen concentrator. Note that this size machine is 
not sufficient for the hospital’s needs- the tanks on the right side 
are connected in-line to the system and changed as needed, to 
add to the system’s capacity. 
 
Commentary: Obtaining a high-quality oxygen 
concentrator should be a priority.  This oxygen is 
piped to the key services through copper tubing.  If 
that is not an option, portable concentrators should 
be fixed in one place (as they break easily) and the 
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patients moved to the beds which are served by the 
concentrator.   
 
Medical Air 
Medical air is utilized mostly in operating 
theater settings and consists of blending oxygen and 
nitrogen to provide a dehumidified (unsterile) air 
mixture. This allows the anesthesiologist to decrease 
the amount of oxygen given while a patient is on a 
ventilator. 
 
Commentary: Centralized Oxygen Concentrators 
require compressed air, so this air can be used as the 
“driving gas” for ventilators thereby decreasing the 
consumption of oxygen. 
 
Vacuum Systems 
Suction is essential to both safe surgery and 
anesthesia. Suction is usually created by creating 
negative pressure using a vacuum system. This can 
help the movement of liquids, solids, and other 
gasses through the vacuum system. Suction exists in 
many forms, such as pipeline suction with terminal 
inlets and portable devices.  
The International Standards Organization 
produces a guideline for pipelines for compressed 
medical gasses and vacuum (ISO 7396.) This 
guideline states that a vacuum must be able to 
maintain suction of 40.6 kPa (12 inches of mercury.) 
The basic setup for a piped vacuum system is a 
pump, receiver, piping and vacuum inlets. The 
pumps should have the capability to connect to 
emergency electrical supply, and there should be 
backup pumps in case of pump malfunction. The 
receiver should help maintain the pressure within the 
system and drain exhaust and byproducts. The 
pipeline system is described below, and is comprised 
of shut off valves, pressure gauges, and alarms. 
Lastly, vacuum inlets will allow users to access the 
system via Y connectors that cannot be interchanged 
with anesthetic gasses.  
Portable suction can be used where there is 
no pipeline vacuum and can either be electrically 
powered or manually powered. Portable suction 
devices shall have a vacuum regulator to control the 
amount of negative pressure and not cause harm to 
the patient. Suctioned contents can be collected into 
a container to be either disposed of or measured. It 
should be ensured that the canister is upright and 
unlikely to be tipped over. Usually, the canister is 
placed below the patient to allow for drainage. If 
suction canisters and tubing are to be reused, proper 
sanitization must be followed to prevent cross 
contamination between patients. 
Most suction canisters that originate in high-
resource settings are intended for single use. When 
such canisters are reused several times, leakage of 
suction is the usual result. This leads to decreased 
effectiveness of the suction.  
 
A wall-powered portable suction machine. Note that this 
machine runs on 110 volts and needs a separate outlet, as it is 
being used in a country where 220 volts (Blue outlet) is more 
commonly used. 
 
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A glass suction canister such as the one on the left is intended 
to be cleaned and reused. The rubber seal in the cap can be 
replaced as needed. The plastic suction canister on the right 
was originally intended for single use in a high-resource 
setting. As it has been reused multiple times, “patchwork” is 
needed to repair it and maintain suction. Such canisters are 
probably more trouble than they are worth in a low-resource 
setting.  
 
Commentary: Whereas centralized oxygen is very 
helpful, centralized vacuum is rare and not 
necessarily advisable.  A much better system is to buy 
multiple portable suction units of the same kind and 
build a cart which supports the canisters as well.  
Each operating theater should have a portable 
suction unit fixed to the wall (ideally in a noise-
reducing box.) 
We discuss elsewhere in this Manual how to 
convert an aquarium pump motor into a suction 
device and how to integrate it into patient care, such 
as for a wound vac, NG tube suction or chest tube 
suction.   
 
Scavenging 
Scavenging of anesthetic gasses can help 
prevent unintended exposure to health care personnel 
in the operating theater. Removal of gasses exhaled 
by the patient and reduction of exposure of 
administered gasses is the purpose of the scavenging 
system. Gas should be collected at the site of 
emission (anesthetic circuit,) transferred to a gas-
collecting assembly, and interact with a scavenger 
interface (open and/or closed interface systems,) and 
finally exhausted into either the vacuum system or 
atmosphere. 
The 
International 
Standards 
for 
Anesthetic gas scavenging systems (ISO 8835-3) 
should be followed.  
 
Here, the scavenging system of this anesthesia machine sends 
the gas through a hole in the wall (Red circle,) to the open air 
outside the operating room.  
 
Piping Systems 
Having contained piping that leads to 
individual patient beds is much more convenient than 
having an individual suction machine or oxygen tank 
at every bed. However, this approach increases the 
complexity of the system and the potential to lose 
gasses through leaks as the piping gets longer.  
 
A simple but effective ward setup of an oxygen system. Note that 
the oxygen concentrator is connected to a flowmeter (both 
inside the red circle) with five outlets, which send oxygen to 
each patient through tubing mounted on the wall. Also note the 
spare oxygen tank (blue circle) in case of oxygen concentrator 
Operating Theatre Setup 
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failure. Source: Oxygen System Installation Guide Version 2.1 
April 2020 
https://www.ghspjournal.org/content/ghsp/suppl/2020/09/29/
GHSP-D-20-00224.DCSupplemental/20-00224-Graham-
Supplement4.pdf  
 
There are certain set standards for piping 
systems to allow for medical gas delivery for 
multiple operating rooms. Several regulatory 
agencies have published standards: National Fire 
Prevention Association (NFPA,) Compressed Gas 
Association (CGA,) Canadian Standards Association 
(CSA,) and International Standards Organization 
(ISO.)  
Central supply of gasses can come in various 
forms, however it is either through cylinder supply 
or cryogenic supply systems. The cylinder supply 
unit commonly has two banks. Each bank will have 
the daily supply, a check valve, pressure relief 
valves, regulators, and shut off valves. These serve 
to deliver continuous gas supply, prevent over-
pressurized gas delivery to a patient, and prevent 
system failure. A detailed schematic of a cylinder 
supply system and a cryogenic oxygen supply system 
are displayed below which is adopted and recreated 
from Understanding Anesthesia Equipment by 
Dorsch and Dorsch. 
 
Example of a cylinder supply system. 
 
 
Example of a cryogenic oxygen supply system. 
 
Commentary: Cryogenic oxygen is likely unrealistic 
for most of the developing world.  Creating an 
oxygen manifold which is then piped to key places is 
a much simpler method of delivering oxygen in a 
limited space (i.e. labor and delivery.)   
 
3. Electricity 
Electrical Safety 
Medical equipment that requires electricity 
can help improve surgical care and is becoming more 
common in operating theaters around the world. 
While electric medical equipment has made many 
advances in the medical field, it also comes with risks 
to the patient and user. It is important for all 
personnel in the operating theater to understand the 
basic principles of electrical safety.   
Electricity can pose a threat to operating 
room personnel and patients through electrical 
shocks. These can occur when a body part comes into 
contact with conductive materials at different voltage 
potentials, thereby closing the circuit. Electricity is 
produced by flow of electrons in either the same 
direction (DC) or in alternating directions (AC.) 
Both AC and DC types of electricity can cause harm 
to a patient, though AC is more dangerous.  
Electrical shock is broken down into two 
categories: 
Macroshock 
and 
microshock. 
Macroshock refers to a high current flowing through 
a person in which harm and death may occur. 
Microshock is a small amount of current which can 
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become dangerous if in direct contact with the heart 
(i.e. pacing wire.)  
Typical medical equipment in most of the 
world will use 220V electricity. Hospitals that rely 
on donated or refurbished equipment from the United 
States, which uses 110V electricity, should have 
additional 110V outlets in areas where this 
equipment will be used.  
Power provided to operating theaters is 
usually ungrounded power and will require an 
isolation transformer. The isolation transformer adds 
another layer of safety – a person who comes into 
contact with a live current does not complete a loop 
and will not receive a shock. The high current (from 
the power plant) will instead flow into the ground.  
To protect the Isolation Transformer, it is 
important that operating theaters have a Line 
Isolation Monitor which monitors the integrity of the 
Isolation Transformer and prevents faulty equipment 
from performing in an ungrounded system.  
 
A Line Isolation Monitor in a resource-rich hospital.  
 
Another form of safety comes from a Ground 
Fault Circuit Interrupter (GFCI), which prevents 
electrical shock by interrupting current if unequal 
flow is occurring.  
 
Commentary: Electricity in many developing 
countries often fluctuates, so a stabilizer for key 
areas of the hospital with sensitive equipment (i.e. 
theater, lab, administration wing) is a good idea to 
have as well. 
Diathermy 
Diathermy units are becoming widely used 
around the world due to the ability to maintain 
hemostasis through cautery and cutting modes. 
Details about the different modes and uses will be 
discussed in another chapter. Diathermy comes with 
many risks as it is the most common ignition source 
in operating theater fires. The basic (monopolar) 
design is to have an active electrode which is 
connected to the generating electrosurgical unit: This 
is commonly called the “pencil.” The circuit is 
completed by a dispersive electrode pad which 
collects current from the patient and returns it to the 
generator: this is commonly called the “grounding 
pad.”  
A large surface area of contact between the 
dispersive electrode and the patient provides the 
lowest impedance and therefore less potential 
damage to a patient. If the dispersive electrode is not 
in proper contact with the patient, risk for burn is 
present. Situations where this may happen include 
when the patient’s skin is wet, tape/clothing is 
present between the skin and the pad, or the 
conductive “sticky” substance on the pad is 
malfunctioning. 
 
A diathermy burn injury at the dispersive electrode 
(“grounding pad,”) likely due to reuse of an electrode which is 
intended for single use.  
 
More modern diathermy units will have an 
active electrode monitoring system that is triggered 
when currents are not balanced and can deactivate 
the unit if an electrical leakage is detected. It is 
important to understand the diathermy device in your 
operating theater and its safety implications and 
potential contribution to fires or patient injury.  
 
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Commentary: Applying petroleum jelly 
(Vaseline) to the grounding pad ensures a reliable 
connection with the patient and prevents burns, as 
does drying the pooling betadine/chlorhexidine on 
the bed after prepping the patient.  A 15x15cm 
stainless steel plate serves as an excellent reusable 
grounding pad. 
 
4. Safety 
Fire Safety 
With the increased use of diathermy and 
alcohol-based sterile preparing solutions, the risk of 
operating theater fires becomes a significant concern. 
All fires have three common elements shown in the 
“fire triangle,” which includes: a fuel source, an 
oxidizing agent, and an ignition. Fuel sources in the 
operating theater include alcohol-based solutions, 
drapes and gowns, blankets, dressings, gauze, airway 
equipment, etc. Oxidizers found in the operating 
theater include oxygen and nitrous oxide. Lastly, 
ignition sources include diathermy, lasers, drills, 
fiber optic light sources (e.g. for laparoscopic 
surgery,) or malfunctioning electrical equipment.  
 
The “Fire Triangle” shows the three elements needed for 
combustion: Fuel, an Oxidizer, and Ignition. All three elements 
are readily available in an operating room.  
 
High risk operations include tracheostomy 
with electrocautery, electrocautery in mouth surgery, 
medical-grade laser ENT surgery, neurosurgery (in 
which the patient’s hair is soaked in ethanol-based 
cleaning solution,) and laparoscopic surgery (due to 
fiber optic light sources.) 
 
Fire Prevention & Management 
Fire prevention in the operating theater starts 
with reducing all aspects of the fire triangle. This 
involves minimizing an oxidizing source, safely 
managing fuel sources, and ensuring that ignition 
sources are well controlled. Risky surgeries should 
be identified ahead of time and a fire management 
plan should be discussed with the entire theater team. 
A multidisciplinary fire prevention team with an 
established protocol is crucial to not only prevent but 
also manage intraoperative fires. If a fire does occur, 
personnel involved should debrief and revisit 
hospital established protocols.  An example of a 
protocol can be found at the end of this chapter.  
Airway fires during ear, nose & throat (ENT) 
operations can be mitigated by decreasing FiO2 to 
less than 30%, using appropriate endotracheal tubes 
if electrocautery or lasers are being used, and an 
appropriate airway fire safety plan.  
If ethanol-based disinfecting substances are 
being used to prepare a patient's skin, it is imperative 
to wait at least three minutes before the solution has 
dried on the patient’s skin before an ignition source 
(diathermy) is used. At least 30 minutes is required 
if the patient’s hair is prepped into the surgical field. 
Access to a CO2 fire extinguisher is necessary 
for all operating theaters. Fire extinguishers must be 
checked yearly for adequate pressure.  
 
Radiation Safety 
 
Radiation damage is a cumulative process. 
Operating theater personnel in many hospitals may 
be 
considered 
separate 
from 
the 
radiology 
department and not be subject to this department’s 
safety measures. This is especially true for 
fluoroscopy used in orthopedic procedures, where 
theater technicians will activate the machine and take 
static and dynamic images during surgery on a daily 
basis. Ideally these personnel should be given the 
following:  
● Training in radiation safety 
● Devices for tracking cumulative radiation 
exposure  
● Radiation safety equipment that is checked at 
least annually 
● Leaded glasses to prevent irreversible cornea 
damage and loss of vision 
Operating Theatre Setup 
Maziar Nourian, Rachel Baker, Jason Fader 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Housekeeping 
including 
Personal 
Protective 
Equipment 
Operating theater personnel should have 
access to personal protective equipment (PPE), 
which includes protective hair coverings, fluid 
resistant masks, eyewear, gloves, waterproof aprons, 
and non skid shoes (which are ideally waterproof and 
easily cleanable).   
The 
Association 
for 
PeriOperative 
Registered Nurses (AORN) and the Association for 
Healthcare Environment (AHE) set out guidelines 
for setting up facility procedures and practices to 
ensure proper cleaning and disinfecting of the 
operating theater.  
Areas that need to be cleaned on a regular 
schedule include walls, ceilings, waiting rooms, 
lounges, storage areas, and locker rooms. Dedicated 
cleaning equipment and tools should be set aside just 
for the operating theater. Types of cleaning supplies 
suitable for the operating theater include liquid 
detergents in a pour-top or squeeze-top bottle. 
Aerosolized cleaning agents are not suitable for the 
operating theater due to potential risk to cleaning 
personnel. Mopping of surfaces should be done with 
microfiber mops or disposable wipes. Dipping 
repeatedly into cleaning solutions should not occur 
as it degrades the chemicals and reduces the ability 
to properly clean.  
Cleaning of operating theaters should be 
done in between cases and at the end of the day with 
periodic deep cleans. Operating room cleaning staff 
should 
wear 
appropriate 
personal 
protective 
equipment and follow standard precautions while 
using cleaning chemicals. Chemicals shall never be 
mixed.  
Theater turn-overs shall be completed in 
between cases. This involves removal of prior 
instruments, trash bags, and linens that have come in 
contact with the previous patient. All materials in the 
room from the prior patient should be considered 
soiled or contaminated and should be disposed of or 
processed accordingly. Cleaning and disinfection of 
the room cannot begin until after the patient has 
vacated. It is important to wipe down the operating 
theater table, control box, joints, frames, rails, etc. 
Proceed with routine mopping of surfaces in the 
operating theater. Spot-clean any areas that appear to 
have blood or biohazardous waste. 
After the last case of the day, the routine 
cleaning should be followed by a scan for any 
electrical cord damage. Remove any unnecessary 
equipment and wipe all surfaces including patient 
monitors and the anesthesia machine. 
For a “terminal clean” at the end of the day, 
don appropriate PPE and clean areas which are not 
regularly cleaned such as scrub rooms, utility rooms, 
sinks, instrument processing rooms, and operating 
theater lights. Lastly, ensure vents are free of dust or 
blockages. 
 
5. Anesthesia Machines 
The function of anesthesia machines will be 
discussed in depth in a separate chapter. In this 
section we introduce the basics of an anesthesia 
workstation and criteria that deem an anesthesia 
machine obsolete.  
 
Every anesthesia machine should be checked 
daily with a “leak test” and system check. The proper 
function of the following should be evaluated:  
● A master on/off switch which activates electrical 
portions and alarms. 
● An alarm that is activated in the event of a power 
failure. 
● The capability to run on reserve power in case of 
power disruption. 
● The ability to provide a safe and constant 
pressure suitable for a patient, using high 
pressured gas from a cylinder or wall outlet – this 
is usually achieved through a yoke check valve 
and pressure regulators. 
● An oxygen pressure safety device to assure no 
delivery of hypoxic mixtures to patients. Gasses 
delivered to patients are usually controlled with 
flow control valves arranged to deliver normoxic 
mixtures in the setting of a leak or failure. Safety 
features are designed to permit for minimum 
oxygen flows before other gasses. 
 
The American Society of Anesthesiologists 
has developed the Equipment and Facilities 
Committee Guidelines for Obsolescence. In brief, 
Operating Theatre Setup 
Maziar Nourian, Rachel Baker, Jason Fader 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
this is a useful guide to help determine if an 
anesthesia machine is obsolete. Below we have listed 
absolute safety features an anesthesia machine must 
contain. If any of the absolute criteria are not met, 
this anesthesia machine should not be used. 
 
Absolute Criteria:  
● Diameter Index Safety System (DISS) for gas 
pipeline inlets  
● Pin Index Safety System  
● Vaporizer interlocking device (to allow for only 
one vaporizer to be used at once)  
● Oxygen supply pressure failure alarm 
● Oxygen failsafe device 
● Oxygen ratio device for machines that use N2O 
Below is a list of unacceptable features of an 
anesthesia machine.  
 
Unacceptable Features:  
● Copper kettle and verni-trol vaporizers  
● More than one flow knob to a single gas 
● Vaporizers that increase concentrations turned 
clockwise (counterclockwise is the convention)  
● Scavenging system hookups with the same 
diameter as the breathing system 
● An anesthetic machine which can no longer be 
serviced by the manufacturer or certified 
personnel  
 
Lastly, these are relative criteria which should urge a 
hospital system to replace an anesthesia machine. 
 
Relative Criteria:  
● No means to isolate the Adjustable Pressure 
Limiting (APL) valve during mechanical 
ventilation  
● An oxygen flow control knob that is larger than 
other knobs  
● An oxygen flush control that can be activated 
accidentally 
● Lack of anti-disconnection device at the fresh gas 
outlet  
● Lack of airway pressure alarm  
 
A maintenance record and log should be kept for all 
anesthesia machines and should be reviewed 
regularly.  
 
Commentary: Periodic maintenance of anesthesia 
machines is very difficult to put into practice.  There 
are often limited biomedical technicians who are 
competent to do this task in many developing 
countries.  One thing that frequently breaks on 
machines that have not had periodic maintenance 
done are the hoses.  When that happens, the oxygen 
or air is depleted very quickly in a given system.  It 
is imperative that operating theater staff know how 
to disconnect the oxygen hose from the wall if they 
hear a loud leak from within the machine. 
 
Maziar Nourian, MD 
Vanderbilt University 
Tennessee, USA 
 
Rachel Baker, MD 
University of Florida 
USA 
 
Jason Fader, MD 
Kibuye Hope Hospital 
Kibuye, Burundi 
 
April 2023 
 
Supplemental Internet Resources:  
Anesthesia Patient Safety Foundation “Surgical Fire 
Prevention: A Review” 
https://www.apsf.org/article/surgical-fire-
prevention-a-review/ 
 
Review Article: “Cleaning the Operating Theatre” 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC85
28056/  
