Techniques in Assisting the Surgical Team During Operation

Surgical teams are made up of experts in operating, managing pain, and patient care. Teams will typically include a surgeon, anesthesiologist, nurse anesthetist and operating room nurse. Each member of the surgical team is responsible for a specific role. The surgeon performs the operative procedure, and is a physician who completed additional training after medical school. Anesthesiologists focus on pain management and safety of the patient; they usually have contact with the patient during all of the surgical phases (preoperative, operative and postoperative). The anesthesiologist is assisted by a nurse anesthetist, a registered nurse who has undergone specialized training and has passed a certification exam. The nurse anesthetist is the team member who monitors the patient's body functions during a surgical procedure. Functioning as a surgical assistant, the operating room nurse is an important part of the surgical team, and provides comprehensive care throughout the procedure.

Objectives: Understand aseptic technique, know proper OR conduct of sterile and nonsterile personnel, know how to properly open packs, know how to drape patient, know how to assist in instrument handling, hemostasis techniques, handling tissues, and post op wound care

Definitions: Asepsis: The prevention of contact with disease causing organisms Contamination: The exposure of a "sterile field" to (possible) microbes or visible debris The sterile zone: The areas surrounding and above the surgical field. (Some surgeons prefer a sterile zone of 3 ft.)

Operating room conduct: These are universal rules of surgical team conduct, certainly there is great variation between hospitals in observance of these "ideal" rules. These rules initially came from the human medicine.

Always know what items and areas are sterile and non-sterile

Only sterile "scrubbed" personnel are allowed to touch sterile items/areas.

Only unsterile "non-scrubbed" personnel are allowed to touch unsterile items/areas.

The surgery table is considered sterile only on the surface/top of table.

Non sterile (non-scrubbed) personnel yield right of way to scrubbed personnel.

Sterile personnel pass each other back to back (only the front of the surgical gown is considered sterile.)

Scrubbed personnel should hold their gloved hands upright between their waist and shoulder and should touch nothing except their other gloved hand.

Non-scrubbed personnel should never pass between the sterile field and a sterile/scrubbed surgical team member.

A wet (blood soaked or damp) drape is considered contaminated, due to the possibility of the capillary action of the moist drape pulling bacteria from the fur to the prepped area of patient. This is called strike through.

When handing wrapped sterile items to the surgical team unsterile personnel should not lean over sterile packs or the draped patient, they should unwrap sterile items carefully.

Assisting in surgery: A surgical assistant should be well prepared and have an understanding of the procedure and instruments. The surgical assistant should insure a fast moving and aseptic surgery. There are many ways to "break sterility". Scratching an itchy nose, dropping a hand below the waist or trying to catch an instrument slipping off the surgical table are all sources of contamination, scrubbed personnel must be alert at all times.

Duties of the surgical assistant may include:

Opening the inner layer of the double wrapped surgical packs: Scrubbed personnel are obviously not to touch the outer drape covering the surgical pack. That layer will be opened by an assistant being careful not to lean into the sterile zone or placing their hands over the top of the opened pack. The assistant will pull each of the 4 corners away from the center of the pack and release them. They should fall away from the pack and Some surgeons prefer the last layer of the outer wrap be opened by scrubbed personnel. The surgical assistant then pulls each corner of the 4 corners outward, keeping their hands above table level and releases the corner.

Draping the patient: If a single fenestrated drape is used for the procedure the drape is often folded and placed on top of the instruments. If more drapes are used a separate drape pack may be used. Four drape method An assistant will open the drape pack (same procedure as above). The pack maybe placed on a surgical stand or held by assistant. All drapes should be folded in the correct manner (see pack assembly lesson) with the double fold tab facing upward. The four drapes are placed in a neat pile with their double fold taps all facing the same direction. (It is frustrating to open a pack and realize that the drapes have not been folded correctly or are not placed properly in the pack.) The assistant will pick up the edge of the double fold tab with one hand, the fold should face the patient, and gently lift and unfurl the drape. With the other hand the opposite end of the double folded top of the drape is grasped and the drape stretched out.

The edge of the drape is positioned to wrap around the hand to protect the sterile gloves from touching the patient when the drapes are placed. The edges of the drapes are held between the index and middle fingers, the hand is rotated inward which covers the last three fingers and the palm of the hands with the drape The assistant should know approximately the location of the incision, and how close the surgeon wants the drapes to the surgical incision. Drapes are placed with the double fold facing inside (creating two drapes near the incision). The double folded edge is placed on the prepped area below the proposed incision line and moved towards the incision line. The drape should not be moved back over the proposed incision line, this might drag germs from the exposed skin over the incision. Each surgeon has their preference concerning the order of drape placement. Drape forceps are placed at the four corners of the surgical site. The forceps must include all layers of the two drapes and penetrate the skin. The handles of the forceps should be facing away from the incision. The surgical site should appear neat with the incision site "framed" by drapes held firmly in place by the 4 forceps.

Fenestrated drape method: The properly folded drape with the fenestration visible is placed on top of the proposed incision site. The two folds on the top of the drape are pulled in opposite directions, one cranial and the other caudal. The assistant is careful not to touch the patient while doing this. The other two folds are then pulled in opposite directions to each side and released to cover the rest of the surgical site. Forceps are placed (often only two forceps are needed cranial and caudally to keep the drape in place).

Organization of instruments: Usually every surgeon has their own preference. If the instruments are packed in a systematic method then they can be organized quickly, the surgeon does not want to wait to make the incision! 1) Which ever method is employed the assistant should know each instrument, what it is used for and exactly where it is located.

2) Instruments are usually grouped by: a) type b) frequency of use c) size 3) Instruments should be neatly arranged 4) The sponges should be counted at the beginning of the procedure and again at the end. 5) The scalpel blade and suture materials will be opened by a non-sterile assistant, and placed carefully on the instrument tray or handed to the surgical assistant. The surgical assistant may be expected to place the blade on the handle (hold the blade with a forceps) or prepare suture materials on the needle or needle holder.

Hemostasis: The control of bleeding. Remember, its hard to find a bleeder in a pool of blood! 1) Sponge technique: The sponge is placed with steady, firm pressure on the area of bleeding for at least 5 seconds. This tissue should be "blanched". This should be long enough to begin the clotting process. 2) Forceps technique: The bleeding vessel is identified and clamped with the smallest possible instrument (mosquito forcep). Ideally only the bleeder is isolated and clamped and not an excessive amount of adjacent tissue. A ligature can then be placed on the vessel or elecrocautery can be used to seal it.

Passing instruments to surgeon: The goal when passing instruments is to promote a fast moving, accurate procedure, the surgeon should be able to ask for an instrument and expect to simply hold their open hand out and have the instrument placed in the middle of their palm firmly and

hear the name of the desired instrument repeated. They should not have to take their eyes off the surgical procedure. Ideally the assistant will be one step ahead of the surgeon and know what instrument will be needed in advance and where it is located on the tray. 1) Pass instruments so the handles are placed in the surgeons palm. 2) Pass instruments "crisply" with some force so the surgeon knows that the instrument is in their hand. 3) The tip of a curved instrument should be pointing upward. 4) Repeat the name of the instrument you handed the surgeon.

Retraction of tissue: Be gentle! Unfortunately when assistants are asked to handle tissue the procedure is often complicated or the surgeon may be having a problem. The tissue maybe friable and the situation is challenging! 1) Instruments: Various types of instruments can be used to hold or retract tissue depending on what is needed, ranging from a Mosquito forceps to a hand held blade retractor. It is the assistants responsibility to know how the instrument works and how it might be used to retract tissue. 2) Techniques: If the tissue is friable or diseased even the smallest amount of pressure may cause it to bleed or tear, the assistant should be aware of this and handle the tissue with care and follow instructions from the surgeon. G) Tissue hydration: During long surgeries the tissue can dry out and die, by keeping it moist there is less possibility of tissue injury or death. 1) Moist sterile sponges placed on tissue 2) Lavage with warm sterile solution, either using mechanical device or bulb type syringe.

Post surgical duties related to the patient and procedure might include: 1) Care of sutures, cutting off long tags and aliening sutures neatly for easy removal at a later date. 2) Surgical wound care, cleaning blood tinged areas or bandaging surgical wounds. 3) Post operative monitoring of patient 4) Writing a surgical report or entering important information in patient record, such as the length of the surgery, suture materials used, any complications, type of anesthesia, etc. 5) Care of surgical instruments

REFERENCE: http://loudoun.nvcc.edu/vetonline/vet121/surgicalAssisting.htm

Techniques in Assisting the Surgical Team During Operation NCM 106A

Submitted by: Karen M. Aldam

BSN IV-J

Submitted to: Filomena Demoni

NCM 106A Adviser