Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 3: Effective Assisting and OR Communication
Clinical Image
Source: Wikimedia Commons - Laparoscopic Surgery - CC BY-SA 4.0
Case Presentation
A sub-intern is assisting on a laparoscopic sigmoid colectomy. She is assigned to operate the camera while the senior resident provides retraction. Before the case, she reviewed the procedure anatomy and steps. The attending begins dissection, and she anticipates camera movements to keep the working instruments centered. When the view becomes obscured by blood, she smoothly retracts the camera, wipes the lens on a gauze sponge, and re-inserts. During a critical moment near the ureter, the attending asks for better exposure. The sub-intern notices the camera horizon has drifted and re-levels it, improving visualization. Using closed-loop communication, the attending requests "bipolar," and the scrub tech responds "bipolar" while handing it; the attending confirms "bipolar received." Later, the sub-intern notices that the insufflation pressure has dropped and alerts the team: "The insufflation pressure is down to 8; should it be 15?" The circulating nurse identifies a kinked CO2 line and corrects it. During closure, the sub-intern is asked to cut suture. She waits for the attending's signal that the knot is complete, then cuts at the appropriate length (asking "How long?" when unsure). The attending debriefs with the sub-intern afterward, noting her good camera work and situational awareness in identifying the insufflation problem.
Key Learning Points
- Camera driving skills: maintain level horizon, center the working instruments, smooth movements, anticipate surgeon's direction, keep lens clean
- Closed-loop communication (request, confirmation, verification) prevents errors in the OR, especially for instruments, medications, and specimens
- Speaking up about safety concerns (dropped insufflation, potential contamination, equipment problems) is expected of all team members regardless of hierarchy
- Effective retraction requires steady, consistent pressure; adjust to provide exposure without damaging tissue, and anticipate where the operation is heading