Single Surgical Field Protocol Aims to Improve Safety and Efficiency

Cleveland Clinic surgeons performing laparoscopic or robotic techniques for gynecological procedures developed a new protocol to treat the abdominal and perineovaginal areas as a unified single surgical field.

Out of concern for cross contamination, the preparation, draping and maintenance of a sterile field for each site has traditionally been treated separately. But Cleveland Clinic surgeon Cara King, DO, MS, says emerging data suggest that sterility can be maintained when a unified single-field approach is used.

“For a long time, the assumption in the OR has been that the abdominal field is clean and the vaginal or perineal field is contaminated, and that has led to repeated glove changes and a lot of workflow disruption. In some settings, if you had worked in the vaginal field and then touched the light handle, that handle had to be changed too,” says Dr. King, Section Head of Minimally Invasive Gynecologic Surgery and Medical Gynecology. “Whether this approach has served us well has been a common conversation across institutions, because many of us have seen that infection rates do not rise when those transitions are handled under a unified sterile field approach.”

Key details

The new guideline, introduced in early 2026, was developed to improve surgical efficiency, reduce cost and waste, and maintain patient safety and quality outcomes. At Cleveland Clinic, the key steps begin with administering antibiotic prophylaxis and following the health system’s universal safety checklist.

During field preparation, an alcohol-based (2% CHG/70% alcohol) antiseptic is used for the abdomen and 4% chlorhexidine vaginal prep or Providine iodine is used for the perineovaginal area. Although the two areas require different preparatory solutions and separate applicators, the operative field is considered unified. The surgeons follow the health system’s standard operating procedures for prep solution application.

The new protocol allows surgeons to use their discretion when applying drapes to separate the abdominal and perineal fields or to maintain a continuous sterile field. While the guideline stipulates that separate instrument tables or trays may be used for abdominal and vaginal instruments, they are not be considered separate sterile fields.

Under the single unified sterile field approach:

• Gloves need to be changed only if they are visibly soiled or suspected to be contaminated.
• Gloves and light handle changes are not required between abdominal and vaginal portions of surgery unless soiling occurs.
• Instrument and camera changes can be minimized unless otherwise clinically indicated.
• Contact with the uterine manipulator during laparoscopic or robotic surgery is acceptable.
• The camera and light source may be interchanged between laparoscopy and cystoscopy within the same operative field if they are not visibly contaminated. However, once introduced into a cavity, laparoscopes and cystoscopes must remain within their respective sterile fields.
• In cases of suspected contamination, the surgical team may elect to separate fields and follow standard protocols for wound protection and contamination control.
• For vaginal natural orifice transluminal endoscopic surgery, if the abdomen is not initially prepped, a new sterile field must be created. To optimize this, both the abdomen and vagina should be prepped from the start of the case.

Minimally invasive or robotic procedures for which the new guidelines might be used include:

1. Hysterectomy
2. Sacrocolpopexy, especially when combined with hysterectomy or vaginal prolapse repair
3. Endometriosis surgery involving the rectovaginal space or posterior vagina
4. Adnexal surgery when transvaginal specimen removal is planned
5. Diagnostic laparoscopy involving chromopertubation or uterine manipulator placement

“This work is really about continuous improvement,” says Dr. King. “We should always be willing to reexamine long-standing protocols when the evidence and our clinical experience show there may be a better way. If we can maintain or improve patient outcomes while also reducing unnecessary steps, saving time and using resources more responsibly, that is meaningful progress.”