The Art of Assisting in Operations
Reynaldo O. Joson, MD
First Written in April 15, 1988 (updated in October 28, 2018)
In any surgical operations, there is a main actor who is the surgeon and there are supporting actors consisting of the surgical assistants and operating room nurses. The surgeon leads in the performance of the operation and the surgical assistants and operating room nurses assist the surgeon.
An operation can only be properly performed by the surgeon together with his assistants. No surgeon can claim that he can perform all kinds of operation properly without assistants. He needs assistance from the surgical assistants and the operating room nurses. Thus, the latter are as important and as indispensable as the surgeon in the performance of an operation.
The surgical assistants can either be residents, medical students or even consultants. They are MDs assisting the surgeon. The operating room nurses are those nurses working in the operating room. They are either scrub or instrument nurses or circulating nurses.
In this lecture, I shall be discussing the art of assisting in operations, more specifically, I shall be discussing how you, the residents, interns, and nurses should properly assist the surgeons and how you should assist without getting scolded by the surgeons.
There are only 2 things that the surgeon, as the captain of the surgical team, expects from his assistants (surgical assistants and operating room nurses). First, to assist him as efficiently as possible in the operation he is performing and second, to help promote safety of the patient he is or will be operating on.
If these two roles expected from the assistants can be accomplished properly and efficiently, then there is no reason why they should be scolded by the surgeons.
Promotion of safety comes in 3 general forms:
- Strict adherence to aseptic technique to prevent infection.
- Strict adherence to principles of cancer surgical techniques to avoid tumor contamination and implantation.
- Prevention of injuries like lacerations from retraction and burns from cautery.
Efficient assisting comes in various forms. However, for both the surgical assistants and the operating room nurses, constant anticipation of the need of the surgeon and supplying this need as quickly as possible is the key to efficient assisting of the surgeons and therefore, the operation. To be able to anticipate the needs of the surgeons, the assistants should know the need of the surgeons. And to know the needs of the surgeons, the assistants should do the following:
- They should know the basic things about operations in general such as basic surgical instruments, basic surgical technique and basic assisting technique (See
- They should be familiar with the operative procedure that they are going to assist.
- They should always look at the operative field.
- They should he familiar with the idiosyncrasy and the operating habit of the surgeon.
The surgical assistants and the operating room nurses should fulfill at least these 4 requirements before they can anticipate the needs of the surgeon and this, properly and efficiently assist the surgeon and the operation.
From hereon, I shall discuss separately how surgical assistants and how operating room nurses should assist the surgeons in operation. I shall start with the surgical assistants.
During the operation, the surgical assistants help the surgeon in 3 general ways:
- Exposure of the surgical field
- Decreasing the operative load or maneuvers of the surgeon such as tying and cutting sutures
There may be 1 or 2 or even 3 surgical assistants. All of them help the surgeon in the 3 general ways mentioned above. However, there should be coordination and distribution of the functions among the assistants to avoid chaos which may hamper rather than facilitate the performance of the operative procedure.
The first assistant is usually the most senior in command among the surgical assistants. He assists the surgeon closely. Although he is directly responsible for promoting exposure and helping the surgeon in his dissection and in decreasing the work load of the surgeon, he may not be able to do all the things at the same time. He may delegate some of these jobs to the second or third assistant. However, he should continue to oversee that these jobs are done properly by the other assistants for the surgeon.
To provide some order and system in assisting, it has become a universal practice that the first assistant’s role be involved primarily with the surgeon’s dissection and that the second assistant’s primary role be in the exposure of the operative field. No assistant should hamper the smooth flow of the operation by abandoning his primary role to do other assistive jobs. For example, a second assistant should not let go his retraction, which his needed for continuous exposure at the moment, to reach out for a pair of scissor to cut a suture being tied by the surgeon. Only if the primary role of an assistant is not need, can he do other assistive jobs for the surgeon. The point is, each assistant should know his primary and secondary responsibilities. If he is free from his primary responsibilities, then he can do his secondary responsibilities.
Tying of sutures is usually done by the first assistant and the cutting of sutures by the second assistant, that is, if these operative maneuvers are delegated by the surgeon to his assistants and if their hands are free from their primary responsibilities.
Aside from the above guidelines in assisting, the other responsibilities of the surgical assistants are as follows:
- They should carry out specific instructions of the surgeon.
- They should anticipate needs and moves of the surgeon.
- They should create optimal exposure of the operative field for the surgeon through adequate retraction, sponging and suctioning.
- They should keep the sterile operative table clean and clear of unnecessary instrument, sponges, sutures, etc.
- They should always maintain sterility of the operative field.
For the operating room nurses, the following are some of the essential things expected of them by the surgeons.
For the scrub nurses:
- Prepare all the necessary and usual instruments needed for a particular procedure. Communicate with surgeon on these.
- Notify the circulating nurses of all the needs of the surgeon.
- Watch the operative field and try to anticipate the surgeon’s needs. Keep one step ahead of the surgeon in sponges, sutures, and instruments.
- Work as fast as possible without sacrificing accuracy and technique for speed.
- Hand the proper instruments and properly to the surgeon’s hands.
- Be adaptable, accurate and alert.
- Wipe blood or tissues from the instruments before handling them to the surgeons.
- Keep the field neat. Maintain sterility of the operative field.
- Keep a correct accounting of sponges, instruments and needles.
- Promote safety of the patient in terms of aseptic techniques and prevention of injuries like burns from cautery tips.
Note: In cancer surgery, consider the tumor removed by the surgeon as “dirty” specimen. Do not directly touch it with the gloved hands to avoid contamination with cancer tissues and cells. Catch the tumor specimen given by the surgeon into a basin.
For the circulating nurses:
- Help prepare the patient for operation.
- Once the operation has started –
2.1 Watch the progress of the case and keep the sterile members of the team supplied with necessary items and their needs.
2.2 Stay in the room as much as possible. Ask permission to go out when necessary.
2.3 Adjust and focus light on the site of operation.
2.4 Connect electrical equipment and suction apparatus.
2.5 Watch the forehead of surgeon and surgical assistants and scrub nurses for perspiration and wipe them before they drop to the operative field.
2.6 Keep the room tidy.
2.7 Collect and weigh soiled sponges as necessary.
2.8 Help scrub nurse monitor and count the sponges, instruments and needles.
2.9. Help maintain sterility of the operative field.
COMMON PITFALLS OF OPERATING ROOM NURSES
It is impossible to list all the pitfalls committed by the operating room nurses. Listed below are just some of the more common shortcomings of scrub nurses as well as circulating nurses. Included also are suggestions for the nurses on how to avoid these pitfalls and on how to assist.
For the scrub nurses:
- After scrubbing, they think that their hands are sterile. Because of this, an error is commonly committed during the gloving procedure. They use their bare hands to open the cover of the pair of gloves that they will use. They do this in such a way that the cover of the gloves touched by their bare hands touches the sterile instrument table. This is a break in the sterility of the instrument table, which they don’t realize because they think their hands after scrubbing are sterile.
- They are not familiar with the operative procedure that they are going to assist. There is no excuse for this ignorance if the nurses have been working in the operating room for more than 6 months and if the operative procedures are ones that are commonly performed in the place where they are working. All nurses should strive to familiarize themselves with the operative procedures that they are going to assist either by reading or by asking the more experienced nurses or better, the surgeons. The surgeons understand the limitations of those nurses who are new in the operating room. They also give leeway to the nurses in case they are doing uncommon operative procedures. The only thing the surgeons expect from the nurses is the mastery of the basic assisting techniques.
- They don’t prepare all the necessary and usual instruments needed for a particular procedure. There are several possible reasons for this. One, they are not familiar with the operative procedure that they are going to assist. Two, they are not familiar with the instruments needed for such procedure. Three, they don’t consult the procedure book in the operating room. Four, they don’t consult the doctor’s preference cards, especially if the surgeon is a regular operator in the operating room where they are working. And lastly, they don’t communicate with the surgeon before the operation. Remedies here are to do and to be the opposite of the don’ts and not’s mentioned above.
- They don’t anticipate the needs of the surgeons. Nurses should be familiar with the operative procedure and the operating habits of the surgeons they are assisting for them to be able to anticipate the needs of the surgeons. In Nos. 2 and 3 above, mentioned was made on the situations in which unfamiliarity of the nurses constitutes an excuse or no excuse. If the unfamiliarity of the nurses is an excuse, then the other reasons which do not constitute an excuse are that the nurses have not mastered the basic surgical instruments and the basic surgical techniques and that they don’t watch the operative field. They have to watch the field and to know the basic surgical techniques to fulfill the job of anticipation. Here are some specific examples to illustrate this point.
- If they see blood covering the operative field, they should realize that either a sponge or a suction apparatus may soon be asked by the surgeon. They should be ready with these equipments.
- If they see that the surgeon has clamped two sides of a blood vessel in preparation for transaction and ligation, they should get ready to hand the surgeon a cutting instrument and a suture for ligation.
- The nurses should be familiar with the preference of the surgeon in his choice of instruments. In the example mentioned here, they should be familiar with the cutting instrument preferred by the surgeon, whether a pair of scissor or a knife. I
- f they sense that the surgeon is going to make a series of suture ligation or suturing, then they should be ready with at least two needles with sutures threaded on them.
- If they sense that the surgeon is going to suture the skin, they should be ready with the proper needle, a cutting needle.
Watching the operative field and being familiar with the basic surgical techniques as well as with the operating habits of the surgeons are all needed for the nurses to be able to anticipate the needs of the surgeons. The nurses should always be one step ahead of the surgeon in sponges, sutures, and instruments. This way, they facilitate the operation, not only in performance but also in terms of operating time.
- They don’t watch the operation. This was mentioned in No. 4 but it is being repeated here for emphasis. Nurses should watch the operative field not only to anticipate the needs of the surgeons but also to see the following:
- To see the hand signals of the surgeon. A lot of surgeons try to minimize talking in the operative field by using hand signals. Nurses should be familiar with these hand signals.
- To see the type of an instrument that maybe needed for a particular situation. For example, if a surgeon is dissecting in a deep field and asks for instruments like retractors, clamps, scissors, and ligatures, the nurses should know very well to give long retractors, long clamps, long scissors, and long ligatures and not short instruments. Adaptability and common sense are needed of the nurses in such a situation.
- To see to it that the operative field is maintained neat and tidy.
- To watch for any break in aseptic technique.
- To see the procedure itself and become familiar with it.
- To see the operating habit of a particular surgeon and become familiar with it.
- They don’t work as fast as possible. It is either they are congenitally slow in body movement or they don’t know what to do or how to assist.
- They don’t hand the proper instruments. It maybe that they don’t hear the surgeons. In which case, they have to tell the surgeons to speak louder. It maybe that they don’t watch the operative field to get a clue as to what the surgeons needs; in which case, they have to watch the field as discussed in Nos. 4 and 5. It may be that they don’t know the names of the instruments. They have to know at least the basic instruments and those commonly used. For the names of other instruments, they just have to ask the surgeons before or early during the operation.
- They don’t hand the instruments properly to the surgeon. In handling an instrument, the scrub nurses should place it in the surgeon’s hand in the position in which the surgeon is going to use it, so he will not need to make any readjustments.
- They don’t wipe blood or tissues from instruments before handling them to surgeons. They don’t always keep the instruments clean. Not only that, they should always have a neat and orderly arrangement of the operative tools in their instrument table so that they can readily hand to the surgeons whatever instruments is asked for.
- They don’t know which instruments are contaminated. They have to look at the operative field or to ask the surgeons to know which instruments are contaminated with bacteria and cancer and which instruments are not contaminated. They have to know which instruments should be set aside, which instruments have to be discarded, and which instruments can be used again.
For the circulating nurses, the main problem encountered by the surgeons is that they don’t stay in the room as much as possible and they don’t inform the surgical team when they go out of the room. They are always not around when they are needed most. Circulating nurses should always inform the surgeon when they go out of the operating room to do something other than run errands and to get the needed items for the operation. The surgeon will understand their absence if he is informed ahead of time.
In this day and age, where the cost of operating expenses has soared up, proper economizing is needed for the sake of the patient. This proper economizing should be a concerted effort of the surgeons and the nurses. For the nurses, here are some advices:
- Save on sponges. Don’t readily discard sponges not fully soaked and which can still be used.
- Save on sutures. Don’t discard sutures which can still be used.
- Don’t open operating materials which may not be needed.
- Open correct operating materials.
- Consult the surgeons.
It is my hope that with this lecture, I have imparted to you the importance of assisting in an operation, how you should assist and how not to get scolded by the surgeon when assisting. The surgeon will surely appreciate good assisting from surgical assistants and operating room nurses.