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  • Title

Opening Sterile Surgical Packs


Brandon Buckner, CST, CRCST
Lamar State College Port Arthur (TX)

Main Text

Surgical site infection (SSI) poses a significant risk to patients undergoing surgery. The prevalence of SSI is influenced by various factors.12 Within an ideal perioperative environment, exclusively sterile surgical instruments are employed. Care should be taken to thoroughly explore all methods of maintaining a contamination-free operating room (OR) environment. The proper opening of sterile surgical instrument packs has critical importance in maintaining aseptic conditions in the OR. This video demonstrates all the nuances of this process, emphasizing the importance of package integrity checks and adherence to strict protocols for sterile surgical attire.

The method of packaging, whether in rigid containers or paper, significantly influences the approach to opening and ensuring the sterility of the instruments. One key element in determining the sterilization status of a surgical package is the external chemical indicator tape.3 Various sterilization methods, such as steam sterilization, ethylene oxide (EtO) sterilization cycle, or Sterrad system, employ distinct chemical indicators, represented by color-changing inks. However, the presence of indicators alone does not guarantee sterility. The black lines on the tape only indicate the exposure to steam, but do not specify the duration or temperature used during the procedure.

The external package undergoes a thorough examination before opening. This inspection involves a check for perforations, tears, and labels. As part of the sterilization process, the packages should be labeled before being sterilized. Most facilities use a felt-tip, quick-dry marker for labeling, ensuring the information is clear and durable.4

All the necessary information, including autoclave details, load number, and the sterilization date, can be recorded on the chemical indicator tape or on the plastic portion of the peel packs. This information is essential for tracking sterilization parameters. Many institutions use a label gun to discharge printed labels, providing an efficient and consistent method of labeling. These labels are attached to the package, offering additional information that is often provided and easily accessible upon inspection. This comprehensive approach to labeling and tracking ensures the highest standards of safety and quality control in the sterilization process.4

In cases where paper wrappers may be prone to damage, a secondary wrapping in linen is employed. The contents of a pack can be accessed by either opening a single layer or by opening both layers. If only the first layer is opened, the second layer will be opened by sterile gowned and gloved personnel. One should never reach over a pack. Instead, move around to prevent contamination. Before initiating the process of opening, personnel should wear sterile masks and sterile clothing. The orientation of the package, typically folded in an envelope fold, is crucial. The pack is positioned as close to the surgical technologist as possible before opening. This reduces the risk of contamination when the technologist leans over the Mayo stand to reach the pack. It also helps to cover the front corners of the stand. Then the pack is opened by unfolding the outermost paper wrapper tip away from oneself, followed by unfolding of the two inside tips to the sides (in a side-to-side motion), and is concluded by moving the innermost tip back toward oneself. It is crucial to acknowledge the presence of an imaginary 1-inch border that runs along the perimeter of the table. This border is considered non-sterile and should be avoided when placing items onto the field. Anything below table height is likewise considered to be non-sterile and should be avoided.5

The inclusion of safety measures, such as the "time out" cards, ensures patient safety and enhances the performance of the surgical team.67 This practice serves as a reminder to the surgical team to conduct essential safety checks before initiation of incision, emphasizing the verification of patient identity, procedure details, and the presence of required materials.

To summarize, the process of opening sterile surgical instrument packs involves a comprehensive understanding of chemical indicators, package integrity checks, and adherence to strict protocols. By focusing on these key elements, surgical teams can maintain aseptic conditions and patient safety during surgical procedures.

Check out the rest of the series below:

  1. Scalpels
  2. Surgical Sutures
  3. Surgical Staplers
  4. Opening Sterile Surgical Packs
  5. Opening Sterile Surgical Instrument Containers
  6. Laparoscopic Instruments


  1. Alfonso-Sanchez JL, Martinez IM, Martín-Moreno JM, González RS, Botía F. Analyzing the risk factors influencing surgical site infections: the site of environmental factors. Can J Surg. 2017;60(3). doi:10.1503/cjs.017916.
  2. Papadopoulos A, MacHairas N, Tsourouflis G, et al. Risk factors for surgical site infections in patients undergoing emergency surgery: a single-center experience. In Vivo (Brooklyn). 2021;35(6). doi:10.21873/invivo.12660.
  3. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008; Miscellaneous Inactivating Agents. CDC website. 2013;(May).
  4. Tennant K, Rivers CL. Sterile Technique. 2022 Sep 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.
  5. Frey KB Association of Surgical Technologists. Surgical Technology for the Surgical Technologist : A Positive Care Approach. 5th ed. Cengage Learning; 2018.
  6. Freundlich RE, Bulka CM, Wanderer JP, Rothman BS, Sandberg WS, Ehrenfeld JM. Prospective investigation of the operating room time-out process. Anesth Analg. 2020;130(3). doi:10.1213/ANE.0000000000004126.
  7. Papadakis M, Meiwandi A, Grzybowski A. The WHO safer surgery checklist time out procedure revisited: strategies to optimize compliance and safety. Int J Surg. 2019;69. doi:10.1016/j.ijsu.2019.07.006.

Cite this article

Buckner B. Opening sterile surgical packs. J Med Insight. 2024;2024(300.4). doi:10.24296/jomi/300.4.

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Lamar State College Port Arthur (TX)

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Publication Date
Article ID300.4
Production ID0300.4