The surgical first assistant

Chapter 5


The surgical first assistant



Chapter objectives


After studying this chapter, the learner will be able to:


• Identify key components of the first assistant’s knowledge and skill levels.


• List pertinent perioperative activities of the first assistant.


• Describe the patient care disciplines that with appropriate education function in the role of the first assistant.


• Discuss the legal implications of the first assistant role.



Key terms and definitions



Anastomosis 


Creating a patent connection between two tubular structures by use of suture or specialized staples.


Buzzing a forceps 


A method of applying the active electrode of a monopolar cautery against an instrument clamped to the patient’s tissue for the purpose of spot hemostasis. The flat side of a metal cautery blade is placed in contact with a clamped instrument below the level of the operator’s hand before activation of the current. The edge of a Teflon-coated cautery blade is placed against an instrument clamped to patient’s tissue below the level of the operator’s hand before activation of the current.


Cleavage lines 


Tissue planes where the natural line of tissue growth permits dissection between areas that maintain anatomic structure.


Dissection 


Separation of tissue planes by sharp or blunt means.


Dynamic tension 


The stress on skin caused by underlying musculature, joints, and body motion.


Hemostasis 


Preventing the loss of blood. Stopping the flow of blood.


Incise cut 


Scalpel is used in a perpendicular position to slice tissue in a linear direction.


Langer’s lines 


Natural lines along skin caused by tension inherent in the structure of the dermal-epidermal layers.


Ligation 


The act of tying or occluding an anatomic structure.


Palmed 


Method of holding an instrument where the working end is nested in the palm of the hand of the assistant while the fingers remain free to grasp other items in the field. The working end can be presented and made functional by a rotation of the wrist. This method can be used for countertraction with some manual retractors.


Perpendicular 


The intersection of surfaces at right angles. The scalpel is held perpendicular to the tissue during incision.


Press cut 


Scalpel is pushed into the tissue rather than slid to incise. Press cutting can be a form of intentional puncture.


Raising a flap 


Perpendicular countertraction is placed on superficial tissues as large areas are undermined by dissection. Care is taken not to disrupt vascularization of the elevated tissue.


Retraction 


Displacement of structures by use of the hand or an instrument to expose the surgical site.


Scrape-cut 


Scalpel is dragged laterally across tissues to separate cell layers rather than full tissue layers.


Skin tension 


The turgor of the skin that is either static or dynamic. Tension factors largely in the final healing of the incision and the appearance of the scar.


Splitting 


Separation of muscle tissue along the fascial layers. A form of blunt dissection.


Sponging 


A method of providing exposure by removal of blood and fluid from the surgical site. The preferred way to sponge is to blot or pat the area so as not to remove biologic clots.


Static tension 


The constant state of skin position over the framework of the body. Also known as Langer’s lines.


Suction 


Negative pressure used to clear the visual field of blood and body substances. Various styles of tips and tip protectors are used. On occasion, a rigid suction tip can be used to remove fluids and retract tissues simultaneously.


Surgical assistant 


Member of the sterile team who provides exposure and hemostasis during a surgical procedure. A physician, RNFA, SA, PA, or CST specially trained and certified as a CFA.


Suture 


(verb) The act of sewing tissues; (noun), a thread used for sewing tissue in surgery.


Thenar grip 


Method of holding an instrument in which the ring handle is secured in the palm at the base of the thumb instead of placing the thumb through the ring. A small portion of the ring finger may be situated within the opposing ring of the handle.


Traction-countertraction 


Displacement of a structure by pulling the tissue in an opposite direction to facilitate sharp or blunt dissection of tissue planes.


Transection 


Cutting across natural anatomic lines. Can be done by sharp dissection or electrocoagulation.


Triangulation 


Suturing three opposing points of a tubular structure so that the distance between two points can be approximated in a straight line.


Tripod grip 


Holding an instrument or scissors in a steady position with the index finger on the box lock hinge and the thumb and ring finger partly in the ring handles for ease of release.


Undermining 


Dissection of subsurface tissue planes. Care is taken not to devascularize upper layers of tissue.



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First assistant’s knowledge and skill level


Surgical anatomy and physiology


The patient’s body is a complex biosystem. Every surgical procedure interrupts multiple facets of a patient’s anatomic structure and physiologic function. Lack of knowledge about each structure and its function could cause untoward disruption and injury. A single injury will affect many aspects of the patient’s outcome and could progress to permanent disability or death. Anatomy and physiology are closely intertwined and should be considered as inseparable components of the whole person.


Knowledge of anatomic structures is critical to the first assistant. Tissue manipulation with instruments requires expert working knowledge of what is grossly seen and what is occluded from view. Improper retraction of tissue that has nervous and vascular structures contained within could cause complications such as neurologic dysfunction or vascular obstruction, resulting in thrombosis or embolization. Lack of this knowledge led to permanent damage to a child’s sciatic nerve as documented by Healthtrust v. Cantrell in Alabama.a In this lawsuit, the surgical technologist, who was performing in the role of surgical first assistant, was unable to identify the location of the sciatic nerve and caused serious injury with a retractor. The surgical technologist stated that he knew how to use retractors and held them where the surgeon placed them. This is an unacceptable and unsafe practice.


The surgical first assistant must absolutely know all the ramifications of every action performed in the role and its effect on the patient’s outcome. The actions of the surgical first assistant should reflect the ability to identify all of the normal and abnormal structures in the surgical site and make intelligent, informed decisions about patient safety.1,4 Each first assistant is responsible for personal liability. There is no such thing as “working under someone else’s license” as commonly misinterpreted by some surgical staff members.



Pharmacology


Medications taken by the patient can cause complications in the perioperative environment. The first assistant should have a clear understanding of each drug the patient takes and its effect on the surgical procedure. Anticoagulants, for example, could cause intraoperative bleeding or postoperative hematoma. Other drugs such as birth control pills can predispose the patient to deep vein thrombosis, which in turn could lead to pulmonary embolism. Patients who take hypoglycemic medication may be predisposed to metabolic problems during the procedure and poor healing or infections postoperatively. Knowledge of each drug’s pharmacologic use and action can help prevent complications throughout the perioperative care period. The first assistant and the circulating nurse should collaborate concerning patient sensitivities and allergies.



Psychomotor dexterity


Precise, purposeful movement at the sterile field is important for the maintenance of the sterile field and the protection of the patient and team. Many instruments used could cause puncture injury if mishandled, and the resultant contamination could cause transmission of a serious illness such as human immunodeficiency virus (HIV) or hepatitis B or C. Clumsiness can cause instruments to fall from the field to the floor, resulting in damaged equipment. Use of an item for a purpose other than its intended function can create liability for the facility if someone is harmed.


Efficiency is important to facilitate the procedure. The surgeon relies on the first assistant to help manipulate tissues with instrumentation in both open and endoscopic procedures. For open procedures, the surgical site is visually larger and requires the first assistant to be a “second set of eyes.” The surgeon’s attention may be focused on a particular organ system, and the first assistant helps by providing exposure and observing for problems in the periphery.


For endoscopic procedures, the visual field is limited to the image on the video monitor.2 The first assistant needs a steady hand when using endoscopic instruments, because even the slightest motion can cause the entire surgical field to shift, placing the patient at risk for injury and causing nausea in team members who are viewing the video monitor. Extreme caution is exercised to prevent injury to tissue not in the direct visual field.



Procedure knowledge and techniques


The first assistant needs to know each step that will be encountered during the surgical procedure. It is important to anticipate and think in advance about each step to help the procedure move smoothly. The first assistant should have clear knowledge about not only the functional steps but also the indications for the procedure. Refer to Table 1-1 for the most common indications for a surgical procedure.


When the surgeon incises tissue, the first assistant usually provides a clear field by retraction (traction or countertraction), sponging, or suction. Some circumstances require the use of hemostatic actions, such as clamping, suturing, cauterizing, or application of some other pharmacologic preparation to stop bleeding.


The surgeon may request the first assistant to “buzz the forceps,” which means placing the active electrode against a forceps that is holding patient tissue and delivering electrical current after the tip is in complete contact with the instrument (Fig. 5-1). The gloved hand holding the forceps should have as much contact with the instrument as possible before the current is delivered. This decreases the amount of current passing over the holder’s hand and prevents concentration of electricity at a focal point on the hand. The current is delivered below the holder’s hand and as close to the actual patient tissue as possible to minimize the risk of alternate current pathway. The forceps is not permitted to touch any other part of the patient’s tissue or other instrumentation during this process or the patient will suffer burns to nontarget tissue.


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FIG. 5-1 Buzzing the forceps. The active electrode tip is placed against the forceps to deliver current to a specific spot of bleeding.

Knowing how and when to perform each action is part of the knowledge base of the first assistant. Random clamping or cautery can cause serious tissue damage.




What does the first assistant do?


Position, prep, and drape the patient


The first assistant is frequently responsible for positioning the patient on the table after the anesthesia provider indicates it is safe to do so. In the absence of the first assistant, other members of the team may perform this function. Provision for safe exposure of the surgical site without compromising the physiology of the patient is the key to a successful procedure.


The dispersive electrode is placed after the patient is in the final resting position for the procedure. Positioning the patient after the pad is in place can cause the pad to slip or gape, preventing full contact with the skin. It should not be removed and reapplied for any reason. The prep solution should not be permitted to pool or drip under the pad. Alcohol-based preps are flammable so care is taken that the prep is completely dry before drapes are applied. Be sure that the safety straps are correctly positioned. The straps should be over the patient’s blanket where they are visible before the drapes are applied.


Keep in mind that the height of the OR bed should be adjusted to suit the reach of the tallest person at the sterile field. Shorter individuals should stand on steps or platforms for ergonomic comfort and adequate visualization of the surgical site. Sitting is only appropriate when the entire team is seated as to not change the level of the sterile field. Chapter 26 describes the processes for positioning, prepping, and draping the patient.



Handle instrumentation


The role of the first assistant involves knowledge, skill, and dexterity in handling and using surgical instrumentation. A skilled first assistant can make the role look easy, but in fact his or her skill is reflected by precise action. Fumbling or struggling indicates lack of knowledge and skill in the role. The standard of care for the use of equipment or instrumentation in the role of first assistant includes the following:



• Knowledge of the equipment and instrumentation


• Knowledge of how and when to use the equipment and instrumentation


• Dexterity of holding and using basic instrumentation (Figs. 5-3, 5-4, 5-5, and 5-6)


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FIG. 5-3 A, Holding a needle holder correctly in dorsal view. B, Holding a needle holder correctly in palmar view. C, Incorrect way to hold a needle holder, with finger in.

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FIG. 5-4 A, Correct way to hold forceps. B, Incorrect way to hold forceps. C, Palming a forceps.

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FIG. 5-5 A, Correct way to hold scissors, using the tripod grip showing dorsal hand view. B, Correct way to hold scissors with tripod grip showing the palmar hand view.

Related posts:

  1. Physiologic maintenance and monitoring of the perioperative patient
  2. Ambulatory surgery centers and alternative surgical locations
  3. Surgical incisions, implants, and wound closure
  4. Urologic surgery

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Apr 6, 2017 | Posted by in GENERAL SURGERY | Comments Off on The surgical first assistant

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