DRAPING THE OPERATIVE CLIENT

Draping is the procedure of covering the patient and surrounding areas with a sterile
barrier to create and maintain an adequate sterile field. An effective barrier eliminates or
minimizes passage of microorganisms between nonsterile and sterile areas.

MATERIALS NEEDED

Towels
Disposable or reusable sterile may be used to outline the surgical site after prepping the
skin. The folded edge of each towel is placed toward the line of incision to square it off. Towels
are usually packaged in groups of four and can be secured with nonperforating towels clips or
may be sutured or stapled to skin. Some disposable types have adhesive strips to hold them in
place.
Surgical towels are traditionally used as draping material and therefore are not routinely
considered counted items. However, if surgical towels are placed in the surgical incision, it
becomes an item that must be accounted for and is listed by the same mechanism that is in place
to track counted items. The literature is replete with horror stories about surgical towels that
carelessly become retained foreign objects when the team fails to account for them.

Fenestrated Sheets
The drape sheet has an opening (fenestration) that is placed to expose the anatomic area
where the incision will be made. Many styles of disposable nonwoven or reusable woven fabrics
are available for specific uses. The size, direction, and shape of the fenestration vary to give
adequae exposure of the surgical site. The sheet is long enough to cover the anesthesia screen at
the head and extend down over the foot of the operating bed. Fenestrated sheets are usually
marked to incidate the direction in which they should be unfolded. This may be an arrow or
label designating the top or head, bottom or foot. It is wide enough to cover one or two
armboards.
Reinforcement around the fenestration for both nonwoven and woven fabrics provides an
extra thickness to minimize the passage of microorganisms by capillary action to the sterile field.
The reinforced area is usually 24 inches (60 cm) wide.
The drapes described are basis styles of fenestrated sheets.

Laparotomy Sheet.
The laparotomy sheet is often referred to as a lap sheet; the longitudinal fenestration is
placed over the surgical site on the absomen, back, or a comparable area. The opening is large
enough to give adequate exposure in the usual laparotomy. The sheet is at least 108 x 72 inches
(274 x 183 cm).

Thyroid Sheet.
The thyroid sheet is the same size as a laparotomy sheet. The fenestration is transverse or
diamond shape and is positioned closer to the top of the sheet over the neck area.
Chest Sheet.
The chest sheet is simila to the laparotomy sheet except that the fenestration provides for
a larger exposure. It is used for chest and breast procedures.

Hip Sheet.
The hip sheet is similar to the laparotomy sheet but somewhat longer to completely cover
the orthopedic fracture table.

Perineal Sheet.
The perineal sheet is of adequate size to create a sterile field with the patient in the
lithotomy porition. Some styles have large leggings incorporated into it to cover the legs in
stirrups. It may have one or two openings to accommodate the periseum and/or rectum.
Laparoscopy Sheet.
A laparoscopy sheet is a combination of laparotomy and perineal sheet. It is used for
gynecologic laparoscopy in lithotomy or combined abdominoperineal resection with the patient
in the lithotomy position.

Separate Sheets.
Although fenestrated sheets are used for most surgical procedures, they are not always
practical. The openings may be much too large for small incisions, such as taking specimens for
biopsies or procedures on the hands or fees. Smaller, separate sheets may be used for these
purposes, leaving exposed only the small surgical area, or for providing additional drapes on the
surgical field. Many of these are disposable.

Split Sheet.
The split sheet is the same size as a laparatomy sheet. Rather than being fenestrated, one
end is cut longitudinally up the middle at least one-third the length of the sheet to form two free
ends (tails). The upper end of this split may be in the shape of a U. Adhesive strips on each tail
approximately 8 inches (20 cm) from the end of the split adhere together to snug the drape
around an extremity or head. Shorter styles have adhesive strips the full length of the inner
aspect of the tails for circumferential wrapping.

Minor Sheet.
The minor sheet is 36 x 45 inches (91 x 114 cm). It has many uses. Wrapped around an
extremity, it permits the extremity to remain on the sterile field for manipulation during the
surgical procedure. It is used under an arm to cover an armboard for shoulder, axillary, arm or
hand procedures.

Medium Sheet.
The medium sheet is about 36 x 72 inches (91 x 183 cm). It is used to drape under legs,
as an added protection above or below the surgical area, or for draping areas in which a
fenestrated sheet cannot be used.

Single Sheet.
The single sheet is 108 x 72 inches (274 x 183 cm). Folded lengthwise, it is placed above
the sterile field to shield off the anesthesia provider and anesthesia machine or other equipment
near the patient’s head or operating bed. A single sheet also is used to cover the patient and
operating bed below the surgical area around the face.

Leggings.
Leg drapes are supplied in pairs to cover the legs of a patient in the lithotomy position. A
rectangle, approximately 36 x 72 inches (91 x 183 cm), is closed on two sides to form a tentlike
pocket goves from contamination during application.

Stockinette
Stockinette is used to cover an extremity. This seamless tubing of stretchable woven
material contours snugly to the skin. The material is very porous and absorbent, so it is not a
microbial barrier. Therefore it may be covered with a layer of plastic. A two-ply tubular
disposable drape is available that has an inner layer of stockinette and an outer layer of vinyl.
An opening is cut through the material over the line of incision. Edges may be secured with a
plastic incise drape before the incision is made, or it may be clipped to the wound edges after the
incision. Rolled elastic bandage is sometimes used for this purpose. Care is taken to use
nonlatex materials for patients sensitive to latex.
 PROCEDURES IN DRAPING THE CLIENT

Laparotomy
1. Hand up four towels and towel clips. Within practice, these can be held in the hands at
the same time and separated one by one as the surgeon takes them. Go to the side of the
operating bed on which the surgeon is draping to avoid reaching over the nonsterile table.
The surgeon places these towels within the prepped area, leaving only the surgical area
exposed.

2. Hand one end of a fan-folded medium sheet across the operating bed to the assistent,
supporting the folds, keeping the sheet high, and holding it taut until it is opened; the lay
it down. Place this medium sheet below the curgical site with the edge of it at the sking
edge, covering the draping towel. This sheet provides an extra thickness of material
under the area from the Mayo stand to the incision, where instruments and sponges area
placed, and closes some of the opening in the laparotomy sheet if necessary. This sheet
may be elimiated if a self-adhering incise drape or impermeable drapes are used.

3. Place a laparotomy sheet with the opening directly over the prepped area outlined by the
towels, in the direction indicated for the foot or head of the operating bed. Drop the folds
over the sides of the table. However, if an armboard is in place, hold the folds at table
level until the sheet is opened all the way. Open it downward over the patient’s feet first
and then upward over the anesthesia screen.

Sheets with appropriate fenestrations are used to expose the surgical site.
a. For the neck, use a thyroid sheet.

b. For the chest, with the patient in either the supine or lateral position, use a bed sheet.

c. For the flank, with the patient in the kidney position for transverse incision, use a
kidney sheet.

d. For the back, use a laparotomy sheet, the same as for the abdomen.

4. Place a large, single sheet crosswise on the operating bed above the fenestrated site. This
sheet provides an extra thickness above the area and closes some of the opening in the
laparotomy sheet if necessary. It also covers the armboard if one is in use. A single sheet
may be needed for this latter purpose even if an impermeable laparotomy sheet is used.

Head
1. The surgeon places four towels around the head and secures them with towel clips or
affixes them in place with sutures or skin staples. Towel clips and staples are not
used if x-ray films will be taken during the surgical procedure.

2. Hand one end of a half-folded medium sheet to the assistant. Holding it taut, unfold
and secure it over the head end of the operating bed below the surgical site at the skin
edge of the draping towel.

3. Place a fenestrated sheet with the opening over the exposed skin area of the head.
Unfold the sheet across the front edge of the overhead table, and secure it before
allowing the remainder of the drape to drop over the head o the operating bed toward
the floor. Some disposable fenestrated head sheets have transparent plastic adhesive
inside sheeting to cover the incisional site. The incise sheet may be impregnated with
iodophor for additional would protection during the procedure.
Face
Even if the surgical site is unilateral, the surgeon may want the entire face exposed for
comparison of skin lines. The draping procedure is as follows:
1. The surgeon places a drape under the head while the circulator or assistant elevates
the head. This drape consists of an open towel placed on a medium sheet. The center
of the towel edge is 2 inches (5 cm) in from the center of the sheet edge. The towel is
drawn up on each side of the face, over the forehead or at the hairline, and fastened
with a small, nonperforating towel clip. This leaves the desired amount of the fact
exposed.
2. Hand up three additional towels and four towel clips. These towels frame the surgical
site.
3. Place a medium sheet just below the site. This sheet must overlap the one under the
head.
4. A fenestrated drape may be placed to complete draping.
5. Cover the remainder of the foot of the operating bed, as necessary, with a single
sheet.
If the patient is receiving inhalation anesthesia, use a minor sheet instead of a towel on a
medium sheet for the first drape under the head. A minor sheet is large enough to draw up on
each side of the face and to enclose the endotracheal tube and oropharyngeal monitoring probes
from the anesthesia machine for a considerable distance, thus keeping them from contaminating
the sterile field.
If the surgical procedure on the face is unilateral, the anesthesia provider may sit along
the unaffected side, near the patient’s head, with the anesthesia screen placed on the same side of
the operating bed.
Skin staples or sutures may be used to affix towels around the contours of the face and
neck of the patient under general anesthesia. Each staple or stitch overlaps the skin and edge of
the drape.

Eye
After skin preparation, the unaffected eye is protected by covering it with a sterile eye pad
before draping the patient. The draping procedure is as follows:
1. The surgeon places two towels and a medium sheet under the head while the circulator
holds the head up, as described for a face drape. One towel is drawn up around the head,
exposing only the eyebrow and affected eye, and fastened with a clip without pressure on
the eyes.
2. Hand up four towel clips to isolate the affected eye. Some surgeons prefer a self-
adhering aperture drape.
3. Cover the patient and remainder of the operating bed below the surgical area with a single
sheet.
If local anesthetic will be administered, the drapes are raised off of the patient’s nose and
mouth to permit free breathing. A Mayo stand or anesthesia screen positioned over the lower
face before the draping is one method used to elevate the drapes. Oxygen, 6 to 8L/min, can be
supplied under the drapes by tube or nasal cannula. Take extreme caution that oxygen does not
build up under the drapes. An ignition source such as a cautery or laser could spark a fire
beneath the drapes.
For a microsurgical procedure, sterile, padded U-shaped steel wrist rest for the surgeon
and assistant is fastened to the head of the operating bed. Towels are put around the patient’s
head before the rest of the facial and body draping is completed.
If irrigation will be used, a plastic fenestrated drape is placed over the four towels to keep
them dry if an aperture drape is not preferred.

Ear
The basic draping procedure is the same as for draping a face or eye, except that only the
affected ear is exposed. The head will be turned toward the unaffected side. Oxygen can be
supplied under the drapes, as previously described. The anesthesia provider is usually positioned
at the side of the operating bed near the patient’s face.
Chest and Breast
While the arm is still being held up by the assistant after skin preparation:
1. Place a minor sheet on an armboard, under the patient’s arm, extending the sheet under
the side of the chest and shoulder. The prepped arm is lowered to the sterile draped
armboard. The distal portion of the arm may be encased in sterile stockinette so that the
arm can be manipulated during the surgical procedure.
2. The patient’s body is draped with a sterile medium sheet.
3. Hand up towels and towel clips; five or six are required.
4. Apply a breast sheet so that the axilla is exposed for anticipated axillary dissection.

Shoulder
While the arm is still being help up by the assistant after skin preparation:
1. Place medium sheets over the chest and under the arm.
2. Place a minor sheet under the shoulder and side of the chest.
3. The surgeon outlines the surgical site with towels and secures them with clips.
4. Place a minor sheet over the patient’s chest, covering the neck. Keep this sheet even with
the edge of the towel that borders the surgical site laterally.
5. Wrap the arm in a minor sheet or encase it in sterile stockinette, and secure it with a
sterile gauze or elastic bandage. At this point, a sterile team member relieves the
unsterile person who has been holding the arm.
6. Place a medium sheet above the area, the secure these sheets together with towel clips.
7. A laparotomy or breast sheet may be used. Pull the arm through the opening. Or a single
sheet may be placed above the area, and the foot of the operating bed is covered with a
medium sheet.

Elbow
While the arm is still being held up by the unsterile assistant after the skin preparation:
1. Place a sterile medium sheet across the chest and under the arm, up to the axilla.
2. The surgeon defines the surgical area on the upper (proximal) arm by placing a towel
around the upper arm and securing it with a towel clip.
3. Wrap the hand in a sterile towel. At this point, a sterile team member relieves the
unsterile person who has been holding the arm by grasping the wrapped hand,
maintaining the arm in an elevated position.
4. The hand is grasped with a sterile stockineete, which is pulled down over the entire arm
toward the axilla, over the surgical site. An elastic bandage is wrapped around the arm
starting at the distal end (hand) to the proximal area (axilla).
5. Place a medium sheet across the chest, on top of the arm, even with the towel on the
upper arm and covering it. Secure this sheet around the arm with a towel clip.
6. An extremity sheet is drawn over the hand and the arm. The extremity sheet is opened in
its entirety across the patient’s body.

Hand
While the arm and hand are still being held up after skin preparation:
1. Place an impervious minor sheet, folded in half, on the extremity table.
2. The surgeon places a towel around the lower arm, limiting the exposed area to the
affected hand, and secures it with a towel clip.
3. Pull stockinette over the hand and up over the length of the arm. At this stage in draping,
the unsterile person is relieved of holding the arm. The draped arm is laid on the draped
extremity table.
4. Place a minor sheet across the extremity table just above the surgical site.
5. Place an extremity sheet over the hand. Do not drop folds below the level of the
armboard. Open the sheet across the patient’s body toward the feet first. Attach the top
end to the IV poles at the head of the bed.
Perineum
With the patient in the lithotomy position for a genital, vaginal, or rectal procedure:
1. Place a medium sheet under the buttocks. The circulator can grasp the underside and
assist in placement. With the patient’s legs elevated in stirrups, this drape hangs below
the level of the operating bed and covers the lowered section of the operating bed.
2. Slide legging over each leg, protecting the gloved hands in the folded cuffs.
3. The anus is covered if it is not part of the surgical site. An adhesive towel drape may be
used for this purpose.
4. Place a medium sheet across the abdomen, from the level of the pubis, extending over the
anesthesia screen or attached to IV poles at the head of the bed.
5. A fenestrated perineal sheet may be used rather than a medium sheet over the abdomen.
To use a perineal sheet with built-in leggings, hand one end of the sheet to the assistant,
opening out folds, and draw the leggings over the feet and legs simultaneously. The
hands are kept on the outside of the sheet to avoid contaminating the gloves and gown.

Hip
The patient is in a lateral position. If the leg will be manipulated during the surgical
procedure, while the leg is still being held up after skin preparation:
1. Place a medium sheet on the operating bed under the leg, up to the buttock.
2. Place another medium sheet on the operating bed, overlapping the first one, to cover the
unaffected leg. Some surgeons prefer to use an incise sheet or a lower extremity
stockinette.
3. The surgeon wraps the foot and leg with an elastic bandage, covering the stockinette.
The leg, held up to this point, is laid on the operating bed.
4. Place a minor sheet lengthwise on the operating bed on each side of the exposed area,
even with the skin. The sheets under the leg and above the site do not overlap. Some
surgeons prefer to draw the leg through the opening of a hip sheet or place a split sheet
under the leg with the tails crossed over it toward the patient’s head.
5. Place a medium sheet above the exposed area. Secure these last three sheets with towel
clips.
6. Place a single sheet above the surgical area and over the anesthesia screen.
If manipulation of the leg is not necessary during the surgical procedure, drape the same
as for a laparotomy, using a hip sheet instead of a laparotomy sheet.

Knee
While the leg is still being held up after skin preparation:
1. Place a medium sheet lengthwise on the operating bed, under the leg, up to the buttock.
Take care not to contaminate sterile gloves on the unsterile tourniquet if used.
2. Place another medium sheet on the operating bed, overlapping the first sheet, to cover the
unaffected leg.
3. The surgeon limits the sterile field above the knee by placing a towel around the leg and
securing it with a towel clip.
4. Lay a minor sheet on the sterile sheets under the leg. The person who has been holding
the leg lays it on this minor sheet. The surgeon wraps the leg in the minor sheet and
secures it with a sterile bandage. Stockinette may be preferred for this step.
5. Place a medium sheet above the exposed area, at the skin edge, over the draping towel
and fasten it with a towel clip.
6. Place a laparotomy or extremity sheet, with the opening on the foot and the longer part of
the sheet toward the head of the operating bed. Open it, and draw the leg through the
opening. A split sheet may be used.
Lower Leg and Ankle
While the leg are still being held up after skin preparation:
1. Place a medium sheet under the leg and over the unaffected leg to above the knees.
2. The surgeon limits the sterile field by placing a towel around the leg above the area of the
intended surgical site and securing it with a towel clip.
3. Put stockinette over the foot and draw it up over the leg to above the skin edge of the
towel. The person who has been holding the leg is relieved, and the leg is held by a
sterile team member.
4. Place a medium sheet above the surgical area, and secure it around the leg with a towel
clip.
5. Place a laparotomy, extremity, or split sheet with the leg drawn through the opening.
6. Cover the remainder of the operating bed over the anesthesia screen with a single sheet as
necessary.
Foot
1. Place a medium sheet on the operating bed under the foot.
2. The surgeon limits the exposed area to the foot by placing a towel around the ankle and
securing it with a towel clip.
3. Enclose the foot in stockinette. The sterile team member relieves the unsterile person
who has been holding the leg.
4. Place a medium sheet above the foot, and secure dit around the ankle with a towel clip.
5. Place a laparotomy or extremity sheet with the opening over the foot and longer part of
the sheet toward the head of the operating bed.