# Clinical Cases: Operating Room Skills and Etiquette ## Case 1: Maintaining Sterile Technique ### Clinical Image ![Surgeon performing surgical scrub at scrub sink](case_01_image.jpg) *Source: [Wikimedia Commons - Surgical Scrub](https://commons.wikimedia.org/wiki/Category:Surgical_instruments) - CC BY-SA 4.0* ### Case Presentation A third-year medical student is scrubbing for her first laparoscopic cholecystectomy. She arrives in the OR suite, dons a surgical cap (covering all hair) and mask, then proceeds to the scrub sink. She performs a 3-5 minute surgical scrub: starting with the fingernails using a nail pick, then systematically scrubbing from fingertips to two inches above the elbow, never returning to already-scrubbed areas. She rinses with hands elevated, allowing water to drip toward elbows. Entering the OR with hands elevated, she receives a sterile towel from the scrub tech and dries each arm (one side per arm, moving toward elbow). She gowns with arms through sleeves but hands remaining inside for closed gloving. The circulator ties the back. During closed gloving, she manipulates the glove onto each hand while keeping her hands within the gown sleeves. The waist tie is completed by having the scrub tech hold the card while she turns. During the case, she accidentally brushes her gloved hand against the anesthesia machine at the head of the table. She immediately steps back and announces, "I contaminated my glove." She is helped to remove and replace the contaminated glove while the circulator opens a new sterile glove. The attending commends her for recognizing and reporting the break in sterility rather than trying to hide it. ### Key Learning Points - Sterile zones of the gown: front from chest to waist, sleeves from gloves to 2 inches above elbow; back is never considered sterile - Closed gloving technique (hands remain inside gown sleeves during gloving) is preferred for maintaining sterility - When contamination occurs (or is suspected), immediately step back from the field, announce the break, and re-glove or re-gown; never try to hide potential contamination - The surgical time-out (before incision) verifies patient, procedure, site, antibiotic administration, and safety checks with all team members participating --- ## Case 2: Suturing and Knot Tying ### Clinical Image ![Surgical suturing technique with needle driver](case_02_image.jpg) *Source: [Wikimedia Commons - Surgical Suturing](https://commons.wikimedia.org/wiki/Category:Sutures) - CC BY-SA 3.0* ### Case Presentation A surgery sub-intern is asked to close the skin after an open appendectomy. The attending provides Vicryl 3-0 for subcutaneous closure and nylon 4-0 for skin. The sub-intern demonstrates proper technique for subcutaneous closure: using the needle driver to grasp the needle at the junction of the middle and back third, she places buried interrupted sutures to approximate the dermis without tension. For each suture, she performs an instrument tie: wrapping the suture around the needle driver, grasping the short end, and pulling through. She alternates wrap direction with each throw to create a square knot (first throw, then opposite direction, then same as first). She cuts the suture, leaving appropriate tail length (short for braided Vicryl). For skin closure, she places simple interrupted nylon sutures, entering perpendicular to the skin, curving through the dermis, and exiting perpendicular on the opposite side. She everts the skin edges slightly to optimize healing. The attending notes her sutures are evenly spaced but the bites are slightly unequal. She provides feedback: "Try to enter and exit at equal distances from the wound edge and equal depth on each side." The sub-intern incorporates this feedback on the remaining sutures. Post-operatively, the wound heals well with minimal scarring. ### Key Learning Points - Suture selection depends on tissue: absorbable (Vicryl, PDS) for deep tissue, non-absorbable (nylon, prolene) for skin; size matches tissue strength (larger for fascia, finer for skin) - Square knots require alternating throw direction; same direction creates a slip knot that will not hold - Instrument ties use the needle driver to wrap and pull suture; two-hand ties are used for deep ties or when more control is needed - Suture cutting: braided sutures (Vicryl, silk) can be cut short (2-3 mm); monofilament (nylon, prolene) requires longer tails (5+ mm) as they are more prone to untying --- ## Case 3: Effective Assisting and OR Communication ### Clinical Image ![Surgical team performing laparoscopic procedure with assistant retracting](case_03_image.jpg) *Source: [Wikimedia Commons - Laparoscopic Surgery](https://commons.wikimedia.org/wiki/Category: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