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Procedure
April 2026
Scrubbing & Gowning
Setting
Operating Theatre
Operation
Elective laparoscopic cholecystectomy
Year Group
Y2 / Y3
Duration
10 minutes
Clinical Scenario
Candidate Briefing
You are a medical student attending an elective laparoscopic cholecystectomy. The scrub nurse has set up the sterile instrument trolley. The consultant has asked you to scrub in and assist.
A scrub sink, nail pick, sterile scrubbing brush, chlorhexidine surgical scrub solution, sterile towels, a sterile gown and two pairs of sterile gloves (size 7.0) are provided.
Please demonstrate the full surgical scrub, sterile gowning and double-gloving technique. Talk the examiner through each step as you go.
Equipment Checklist
Theatre scrubs & hatMust be worn before entering the scrub area
Surgical mask & eye protectionApplied before beginning the scrub
Nail pickUsed first to clean under nails
Sterile scrubbing brushFor nails only in many protocols — check local guidance
Chlorhexidine gluconate 4% surgical scrub solutionOr povidone-iodine per local policy
Sterile towels × 2For drying — one per hand/arm
Sterile surgical gownWrapped and opened onto a clean surface
Sterile gloves × 2 pairs (correct size)Double-gloving is standard for surgical scrub
Technique Overview
Phase 1 — Before Approaching the Sink
1.
Ensure theatre scrubs, hat, mask and eye protection are on. Remove all jewellery, watches and nail varnish. Ensure nails are short and clean.
2.
Open sterile gown and glove packs onto a sterile field without contaminating contents. Touch only the outer wrapping.
Phase 2 — Surgical Hand Wash (WHO / Timed method — 3–5 minutes)
3.
Turn on water using elbow or foot control. Wet hands and forearms up to 2 cm above the elbows.
4.
Use nail pick to clean under all fingernails under running water. Discard pick.
5.
Apply chlorhexidine scrub solution. Using the sterile brush, scrub nails and nail beds of both hands (30 strokes each hand).
Many modern protocols omit brushing the skin — nails only. Follow local policy.
6.
Without using the brush, use hands to work chlorhexidine solution methodically over all surfaces — fingers, palm, back of hand, wrist, forearm — working from fingertips proximally toward the elbow. Never move distally once you have moved proximally.
7.
Rinse by holding hands above elbow height, letting water run from fingertips down to elbows. Do not shake hands dry.
8.
Repeat the scrub for the second hand/arm. Total scrub time should be 3–5 minutes.
Phase 3 — Drying
9.
Back away from the sink with hands held above waist level. Pick up the first sterile towel by touching only the corner. Dry one hand and forearm using a rotating motion, working from fingers to elbow. Do not go back distally.
10.
Use the second towel (or opposite end of the same towel) for the second arm. Discard towels without contaminating hands.
Phase 4 — Gowning
11.
Pick up the folded sterile gown by the inside neck/shoulder area — only touch the inner surface. Step back from the sterile field.
12.
Allow the gown to unfold gently in front of you. Identify the armholes. Slide both arms simultaneously into the sleeves, keeping hands inside the cuffs (do not push fingers through).
13.
A scrub nurse or assistant ties the back of the gown. Do not touch the outer surface of the gown with ungloved hands.
Phase 5 — Double Gloving
14.
First (inner) glove: Using the closed-gloving technique — keeping fingers inside the gown cuff — pick up the first glove through the gown fabric. Place it palm-down on the opposite cuffed wrist. Fold the glove cuff over the gown cuff and slide the hand through.
15.
Repeat for the second inner glove.
16.
Second (outer) glove: Now that inner gloves are on, pick up the second pair using the open-gloving technique — touch only the inner surface of the glove cuff. Don and adjust both outer gloves.
17.
Secure the front gown ties by handing the card/tag to the scrub nurse (they hold it while you rotate) or using the instrument tie method. Do not allow the ties to fall below waist level.
Mark Scheme
| Competency | Marks | Awarded |
|---|---|---|
| Preparation | ||
| Confirms theatre scrubs, hat, mask and eye protection are on; removes all jewellery, watches and nail varnish; checks nails are short | 1 | |
| Opens sterile gown and glove packs onto sterile field without contaminating contents; touches only outer wrapping | 1 | |
| Surgical Hand Wash | ||
| Turns on water using elbow/foot; wets hands and forearms to 2 cm above elbow | 1 | |
| Cleans under all fingernails with nail pick under running water; discards pick | 1 | |
| Scrubs nails and nail beds with sterile brush; applies chlorhexidine solution and works methodically over all surfaces of both hands and forearms | 2 | |
| Maintains correct directionality throughout — always working fingertips to elbow; never moves distally once proximal Moving back distally re-contaminates a clean area
|
2 | |
| Rinses with hands above elbow level, water running fingertips to elbows; does not shake hands dry; backs away from sink | 1 | |
| Drying | ||
| Picks up sterile towel by corner only; dries each hand and forearm with separate towel/end, fingertips to elbow | 1 | |
| Gowning | ||
| Picks up gown by inner surface only; steps back; allows it to unfold without touching unsterile surfaces | 1 | |
| Slides both arms into sleeves simultaneously; keeps fingers inside cuffs; does not push fingers through | 1 | |
| Allows assistant to tie back; does not touch outer gown surface with bare hands | 1 | |
| Double Gloving | ||
| First (inner) pair — uses closed-gloving technique correctly: glove placed palm-down on cuffed wrist through gown fabric, cuff folded over, hand slid through | 2 | |
| Second (outer) pair — uses open-gloving technique; touches only inner glove cuff surfaces; adjusts both gloves without contaminating | 2 | |
| Secures front gown ties via scrub nurse or instrument method; keeps tie ends above waist at all times | 1 | |
| Maintains sterility throughout — hands held at waist level or above; does not touch non-sterile surfaces at any point | 2 | |
Total
20 marks
Examiner Questions
Why do we double-glove for surgical procedures?
Double-gloving significantly reduces the risk of inner glove perforation going undetected — studies show the outer glove perforation rate during surgery can be as high as 15–20%, but the inner glove perforation rate when double-gloving is under 2%. It protects both the patient from the surgeon's skin flora and the surgeon from blood-borne pathogen exposure. Indicator systems (inner glove is coloured) can make perforations immediately visible.
You accidentally touch the outside of the scrub sink with your elbow during drying. What do you do?
You have contaminated the elbow of that arm. You must re-scrub from the point of contamination — in practice this means a full re-scrub of that arm from fingertips to elbow. Inform the scrub nurse. Do not proceed with gowning until re-scrubbed. Attempting to proceed with a contaminated arm is a serious breach of aseptic technique.
What is the sterile zone on a gowned and gloved surgeon?
The sterile zone extends from the chest to the waist (anteriorly) and from the gloves to 5 cm above the elbow. The back of the gown is not considered sterile (you cannot visualise it). Below the waist is not sterile. This is why hands must always be kept above waist level — if your hands drop below the waist, they are considered contaminated and you must re-glove.
During the operation you notice a small tear in your outer glove. What do you do?
Inform the scrub nurse and step away from the sterile field. The torn outer glove must be removed and replaced with a new sterile glove immediately — this can be done without re-scrubbing as the inner glove remains intact. If the inner glove is also torn or contaminated, you must fully re-scrub and re-glove. Document the glove change. If there was a needlestick or sharps injury with patient blood contact, follow the trust's sharps injury protocol.
What is the difference between the timed scrub and counted stroke method?
The timed method involves scrubbing for a set duration (typically 3–5 minutes for the initial scrub, 2–3 minutes for subsequent scrubs on the same operating list). The counted stroke method involves a prescribed number of brush strokes to each surface (e.g. 30 strokes per nail, 10 per skin surface). Most modern guidelines favour the timed method as the evidence for stroke counting is weak. For subsequent cases on the same list, an alcohol-based surgical handrub can replace a full re-scrub if hands are visibly clean and unsoiled.
Safety Points
Fail
Pushing fingers through the gown cuffs before gloving contaminates the cuff and makes closed-gloving impossible. Fingers must remain inside the cuff throughout gowning until the inner glove is applied.
Fail
Allowing hands to drop below the waist at any point after scrubbing is a contamination event. Hands must remain between waist and shoulder level — visible to you at all times.
Key Point
Directionality during the scrub is critical. You are moving contamination away from the clean operative field — always scrub and rinse from fingertips toward elbows. Moving back toward the hands after you have reached the elbow re-contaminates the hand.
Key Point
When drying, use each sterile towel on only one hand/arm. Using the same end of a towel on both arms transfers contamination from the first dried arm to the second.
Top Tip
Narrate your technique throughout. Examiners want to see that you understand why each step exists, not just that you can mechanically perform it. For example: "I'm rinsing from fingertips to elbow to carry any contamination away from the operating site."