Operating Room Skills and Etiquette

Medical School · Year 4 · Subinternship Surgery · includes a quiz and discussion video

Operating Room Skills and Etiquette

Year 4: Sub-Internship Surgery

Learning Objectives

By the end of this seminar, students will be able to:

Navigate the operating room environment professionally including understanding team roles and safety practices
Maintain sterile technique throughout surgical procedures including proper scrubbing, gowning, and sterile field management
Identify common surgical instruments and understand their appropriate applications
Perform fundamental suturing techniques and knot tying with proper technique
Assist effectively during surgical procedures through appropriate retraction, suction, and camera operation
Communicate appropriately in the OR and develop strategies for maximizing surgical learning opportunities

Section I: The Operating Room Environment

The operating room team functions as an integrated unit with clearly defined roles essential for safe and efficient surgery. The attending surgeon serves as primary operator and decision-maker, directing the procedure and bearing ultimate responsibility for patient outcomes. Surgical residents and fellows assist and perform portions of the procedure under supervision, progressing in autonomy with experience. The scrub technician manages instruments, maintains the sterile field, and anticipates surgeon needs throughout the case. The circulating nurse handles non-sterile tasks, documents the procedure, retrieves additional supplies, and serves as a safety advocate. The anesthesiologist or certified registered nurse anesthetist manages the airway, hemodynamics, and patient physiology throughout the procedure. The sub-intern assists, learns, and contributes according to skill level and case requirements.

Operating room setup follows consistent organization that enables efficient workflow. The operating table occupies the center of the room, with positioning accessories available for specific procedures. The anesthesia machine and monitoring equipment are positioned at the head of the table, within the anesthesiologist's workspace. The back table holds the full complement of instruments and supplies for the case, organized systematically by the scrub technician. The Mayo stand positions immediately-needed instruments within the surgeon's reach. Monitors for vital signs, imaging, and laparoscopic display are positioned for visibility by relevant team members. Electrocautery (Bovie), suction, and other equipment connect and position within reach of the surgical team.

The flow of a surgical case follows predictable phases allowing team preparation and coordination. Pre-operative activities include patient check-in, verification of identity and procedure, positioning on the table, and anesthesia induction. Preparation involves skin cleansing and sterile draping to create the operative field. The procedure itself progresses through incision, exposure, the definitive surgical maneuvers, hemostasis, and closure. Emergence from anesthesia occurs while final counts are completed and dressings are applied. Transfer to the post-anesthesia care unit completes the operating room phase. Understanding this flow allows the sub-intern to anticipate needs and contribute appropriately at each phase.

Safety practices in the operating room prevent errors and protect patients and staff. The surgical time-out, performed before incision with all team members participating, verifies patient identity, procedure, surgical site, and safety elements including antibiotic administration and equipment availability. Instrument, sponge, and needle counts prevent retained foreign bodies; counts occur before incision, before closing body cavities, and at skin closure. Fire prevention awareness recognizes the interaction of oxygen, ignition sources including electrocautery and lasers, and fuels including alcohol prep solutions and drapes. Radiation safety during fluoroscopy and x-ray requires protective equipment and minimizing exposure. Proper specimen handling with accurate labeling ensures correct pathologic diagnosis.

Section II: Sterile Technique

The surgical scrub removes transient flora and reduces resident flora on the hands and forearms to minimize wound contamination risk. Before scrubbing, jewelry including watches and rings is removed. Mask and cap are donned before entering the scrub area, with hair completely covered. Eye protection is added for cases with splash or particulate risk. The scrub itself takes three to five minutes using antimicrobial solution, beginning with the nails using a brush or pick, then proceeding systematically from fingertips to two inches above the elbows. Each surface receives attention without returning to already-scrubbed areas. Rinsing allows water to flow from fingertips toward elbows, keeping hands elevated. Entering the OR, hands remain elevated with water dripping toward elbows until dried.

Gowning and gloving transform the scrubbed person into a sterile team member. The sterile towel, offered by the scrub technician, dries each arm using one side per arm, moving from hand toward elbow without returning to cleaner areas. The gown is received with arms extended into the sleeves but hands remaining within the sleeves until gloving. The circulator ties the back of the gown without contaminating the sterile front. Closed gloving technique, where hands remain within the gown sleeves while gloves are applied, provides the most reliable sterility and is preferred. The waist tie is handed to another sterile team member or grasped with a non-sterile instrument by the circulator, allowing the scrubbed person to turn and complete the tie.

The sterile field requires constant awareness and vigilance to maintain. The front of the gown from chest to waist, and the arms from gloves to two inches above the elbow, constitute the sterile zone. The back is not considered sterile, even if the gown material wraps completely. Hands must remain within the sterile field, typically above the waist and below the shoulders when not actively working. Moving within the OR requires announcing intention and passing back-to-back when two sterile individuals pass. Distance from the sterile table should be maintained close enough to work without reaching across non-sterile areas. Turning one's back to the sterile field risks contamination and should be avoided.

Breaks in sterility require immediate recognition and remediation. Touching any non-sterile surface with a gloved hand or gowned arm contaminates that area. Puncturing a glove, whether known or suspected, requires changing the glove immediately. Any part of the gown that falls below waist level is considered contaminated. Wet gowns allow strike-through of bacteria and are no longer sterile. When uncertain whether contamination has occurred, the safest assumption is that it has; step back from the field and either re-glove or re-gown as appropriate. Speaking up about potential contamination protects the patient and is expected of all team members regardless of hierarchy.

Section III: Surgical Instruments

Basic surgical instruments serve fundamental functions common across many procedures. The scalpel, with interchangeable blade sizes, creates skin incisions and divides tissue; blade 10 is commonly used for skin, blade 15 for finer work. Forceps provide tissue handling and manipulation; variations exist for different tissue types and purposes. Scissors cut tissue and suture; curved Mayo scissors cut heavy tissue while Metzenbaum scissors suit delicate dissection. Retractors create and maintain exposure of the surgical field. Clamps provide hemostasis by occluding blood vessels until ties or cautery can be applied. Needle drivers grasp needles for suturing and must match needle size to avoid damage.

Forceps types are selected based on the tissue being handled. Smooth forceps, such as Adson forceps, grasp tissue without teeth, suitable for delicate structures that would be damaged by teeth. Toothed forceps, including Adson-Brown and rat-tooth designs, interdigitate teeth for secure grip on skin and fascia without slipping. DeBakey forceps feature fine atraumatic tips for vascular surgery where vessel wall trauma must be minimized. Russian forceps have broad, serrated round tips for grasping heavy tissue. Bayonet forceps have an angled design for working in deep cavities where straight forceps would obstruct visualization. Selecting appropriate forceps prevents tissue damage while providing adequate control.

Clamps serve diverse hemostatic and tissue-handling functions. Hemostats (mosquito clamps) are small and fine, suitable for controlling small vessels or delicate structures. Kelly clamps are larger with heavier construction for medium vessels and tissues. Kocher clamps feature teeth at the tip for secure grasping of heavy tissue, including fascial edges. Allis clamps have multiple teeth for grasping hollow viscera without crushing or penetrating the wall. Babcock clamps provide atraumatic grasping of bowel with triangular fenestrated ends that do not crush tissue. Right-angle clamps pass around structures to facilitate placement of ties or dissection in confined spaces. Learning to identify and request appropriate clamps demonstrates instrument knowledge.

Retractors create the surgical exposure that allows the operation to proceed. Handheld retractors, including Army-Navy and Richardson retractors, require an assistant to hold throughout the procedure, providing adjustable exposure. Self-retaining retractors, such as the Balfour for abdominal cases or Weitlaner for smaller wounds, hold position mechanically, freeing hands for other tasks. Specialty retractors address specific needs: Deaver retractors reach deep into the abdomen with their broad blade, while malleable retractors can be bent to create custom exposure. The Bookwalter system provides a modular self-retaining system for complex abdominal operations. Proper retractor use maintains steady, appropriate pressure that creates exposure without damaging tissue.

Section IV: Suture Materials

Suture material selection depends on tissue characteristics, healing time, and desired function. Absorbable sutures are broken down by the body over time through hydrolysis or enzymatic degradation; they suit internal tissues that do not require permanent support. Vicryl (polyglactin 910) maintains tensile strength for approximately three weeks and absorbs completely by ninety days. PDS (polydioxanone) retains strength longer, appropriate for slow-healing tissues like fascia. Chromic gut, processed from animal intestine, absorbs more rapidly but with more tissue reaction. Non-absorbable sutures remain permanently unless removed; nylon and prolene suit skin, while silk provides handling ease for ties.

Suture construction affects handling characteristics and tissue interaction. Monofilament sutures consist of a single strand, providing smooth passage through tissue with minimal tissue drag and bacterial harbor. However, they tend to be stiffer and have memory, making knot security more challenging. Braided sutures, composed of multiple filaments woven together, handle smoothly and tie securely but may harbor bacteria in their interstices and cause more tissue drag. The choice between monofilament and braided depends on tissue requirements, infection risk, and knot security needs. Natural materials like silk and gut have largely been replaced by synthetic sutures with more predictable properties.

Suture size follows a standardized system inversely related to diameter. Sizes from 2 through 2-0 (written 2-0 or two-ought) represent larger diameters suitable for fascia and heavy tissue. Size 3-0 works for many deep tissue applications. Sizes 4-0 and 5-0 suit skin closure and smaller vessels. Fine work including microsurgery employs 6-0 through 10-0 sutures. Larger tissues require larger sutures to maintain strength, while delicate tissues require smaller sutures to minimize trauma. Selection matches suture tensile strength to the forces the closure will encounter, typically equaling or exceeding the tensile strength of the tissue being approximated.

Needle types match tissue characteristics and desired suture path. Cutting needles have sharp edges that cut through tough tissue like skin, fascia, and scar. The cutting edge may face conventionally (inside the curve) or reverse (outside the curve); reverse cutting is preferred for skin to direct the cutting edge away from the wound edge. Tapered needles part tissue without cutting, reducing tissue trauma and bleeding; they suit gastrointestinal tract, vessels, and peritoneum. Specialty needle shapes include spatula needles for corneal surgery and blunt needles for friable tissue. Needle size and curve must be appropriate for the depth and access of the tissue being sutured.

Section V: Knot Tying

The two-hand technique provides the foundation for surgical knot tying. The first throw crosses the suture ends, with hands positioned to create a half-hitch. The second throw must alternate direction to create a square knot; two throws in the same direction create a slip knot that will not hold. Maintaining tension throughout prevents loosening between throws. A properly tied square knot lies flat rather than rolling to one side. Additional throws add security, particularly with monofilament sutures that have more memory and may loosen. Practice with a knot-tying board builds muscle memory and speed that transfers to the operating room.

The one-hand technique allows faster knot tying and suits situations where one hand maintains tissue position or tension. The technique uses finger movements of one hand to wrap the suture around and catch the free end, pulling it through to create the throw. Speed and efficiency develop with practice. As with two-handed technique, alternating throw direction maintains square configuration. This technique is particularly useful for tying over hemostats after clamping vessels, where the non-dominant hand holds the clamp steady. Proficiency in one-handed ties significantly increases operating room utility.

Instrument ties use the needle driver or hemostat to grasp and pull the suture through, creating throws without directly manipulating suture with fingers. The suture is wrapped around the needle driver, which then grasps the short end and pulls it through. Alternating wrap direction (one wrap, then opposite direction) creates a square knot. Instrument ties work well for superficial closures where hand access is easy and for completing the tie after placing a suture with needle-on. This technique is often faster for skin closure and requires less suture length than hand ties. The knot must still lie flat and square to hold securely.

Deep ties present challenges requiring adaptation of basic techniques. Longer instruments, including long needle drivers and tying forceps, allow reaching into deep cavities. Maintaining consistent tension while advancing throws into the depth is essential; throwing too loosely allows slippage while throwing too tightly can cut through tissue. Clear visualization ensures the knot seats properly against the intended structure. Safety considerations include avoiding injury to adjacent structures while advancing and tightening. Practice on simulation and progressive participation in deep closures builds skill before independent performance is expected.

Section VI: Assisting in Surgery

Retraction creates and maintains the surgical exposure that allows the operation to proceed. Effective retraction requires steady, consistent pressure without unexpected movement that could injure tissue or disturb the surgeon's work. The force applied should be adequate for exposure but not excessive, which can damage tissue or fatigue the assistant. Positioning for sustained retraction requires a comfortable stance that can be maintained without fatiguing or shifting. Anticipating where the operation is heading allows adjustment of retraction before being asked, demonstrating engagement and understanding. When uncertain about desired exposure, asking clarifying questions is preferable to guessing incorrectly.

Suction and irrigation maintain the clear surgical field necessary for safe operation. The suction tip follows the surgical action, clearing blood and fluid that would otherwise obscure visualization. The tip should stay near but not directly on the dissection plane, close enough to clear emerging fluid but not obstructing the surgeon's view or instruments. Irrigation washes debris from the field and helps identify bleeding sources. The assistant must balance keeping the field clear with not obstructing access or creating distraction through constant suction noise. Learning when to suction and when to wait comes with experience and observation of surgeon preferences.

Cutting suture after ties is a common assistant task requiring attention to proper technique. Cutting occurs only after the surgeon signals completion of the knot, preventing premature cutting before knots are secure. The tail length left depends on suture material and location: silk and other braided sutures can be cut short (two to three millimeters), while monofilament sutures need longer tails (five millimeters or more) because of their tendency to untie. Fascial closures often leave longer tails than skin for security. The scissors should be held flat against the knot to cut at the desired length without cutting the knot itself or poking tissue. When uncertain about desired length, asking is appropriate.

Camera driving in laparoscopic surgery requires specific skills that develop with practice. Maintaining a level horizon keeps the image oriented consistently, preventing disorientation. Centering the instrument tips keeps the working area in view without excessive searching. Smooth movements avoid jerky, disorienting changes in view. Anticipating where the dissection is heading allows proactive camera movement. Keeping the lens clean by wiping on gauze or using anti-fog solutions maintains image quality. Appropriate zoom balances wide view for orientation with close view for detailed work. These skills develop through simulation practice and supervised operative experience.

Section VII: Operating Room Communication

Speaking up in the operating room serves patient safety and personal learning, but timing and manner matter. Safety concerns, such as potential contamination, equipment problems, or observed errors, should be stated clearly and promptly regardless of hierarchy. Questions for learning are welcome but should be timed appropriately: complex teaching questions suit quiet moments rather than critical operative phases. Admitting uncertainty about a task or asking for clarification is preferable to guessing and potentially causing harm. Announcing movement, such as stepping away from the table or passing behind another scrubbed person, prevents accidental contamination. When uncertain whether to speak, erring toward communication generally serves better than silence.

Closed-loop communication improves accuracy and prevents errors in the operating room. When the surgeon requests an instrument or suture, the request is acknowledged verbally, confirmed while being handed, and acknowledged again upon receipt. This three-step communication (request, confirmation, verification) ensures both parties share understanding and items are correctly identified. The format applies to medication administration, specimen handling, and other critical communications. Closed-loop communication may feel redundant initially but prevents misunderstandings that can lead to errors. Practicing this communication style demonstrates professionalism and commitment to safety.

Knowing when to ask questions and when to remain silent develops with experience and observation. Good times for teaching questions include before the incision when the surgeon may be waiting for anesthesia, during routine portions of the procedure, when the surgeon explicitly invites questions, and during closure when complexity is often lower. Times to avoid questions include during critical maneuvers, when bleeding is being controlled, when tension is palpable in the room, and when the surgeon is clearly focused intensely. Reading the room and adapting to the situation demonstrates social awareness and respect for the team. Following the surgeon's lead in conversation usually provides good guidance.

Maximizing learning in the operating room requires preparation, engagement, and follow-through. Reading about the procedure beforehand, including relevant anatomy, typical steps, and potential complications, allows intelligent questions and understanding of what is being observed. Asking oriented questions that demonstrate preparation shows engagement without displaying ignorance of basic concepts. Watching carefully for technique details, including tissue handling, knot security, and decision-making at critical moments, builds observational knowledge. Requesting opportunities to suture or perform other tasks when appropriate demonstrates initiative. Following up after cases by reading about encountered pathology or complications reinforces and extends learning.

Section VIII: Common Operative Procedures

Opening for abdominal surgery follows systematic layers with hemostasis at each level. The skin incision is made with the scalpel, with bleeding controlled by electrocautery. Subcutaneous tissue is divided with electrocautery or sharp dissection. The anterior rectus sheath or linea alba is identified, and fascia is incised with scalpel or cautery. The rectus muscle is separated in the midline or retracted laterally depending on incision type. Posterior fascia and peritoneum are entered carefully to avoid underlying bowel injury. Retractors are placed to create and maintain exposure. Understanding these layers and their appearance helps the sub-intern anticipate steps and provide appropriate assistance.

Closing reverses the opening sequence with attention to hemostasis and anatomic restoration. The fascia receives the strongest closure, typically with absorbable suture in running or interrupted fashion, as fascial strength ultimately prevents incisional hernia. Scarpa's fascia in the subcutaneous layer may be closed to reduce dead space. Skin closure options include staples for speed, subcuticular suture for cosmesis, or simple interrupted sutures. Dressings protect the wound during initial healing. Throughout closure, hemostasis at each layer prevents hematoma formation. The sub-intern commonly participates in skin closure, which provides excellent suturing practice.

Laparoscopic entry establishes the pneumoperitoneum and port access that enable minimally invasive surgery. The Veress needle technique blindly introduces a spring-loaded needle to insufflate carbon dioxide before trocar placement. Open (Hasson) technique creates a small incision with direct visualization of peritoneal entry before trocar insertion, reducing injury risk. The initial port allows camera insertion to visualize subsequent port placements. Working ports are placed under direct vision, with location determined by the target anatomy and ergonomic considerations. Fascial closure at port sites greater than ten millimeters prevents port-site hernia. Understanding these steps allows meaningful participation and anticipation of needed supplies.

Drain placement evacuates fluid collections and allows monitoring for complications such as anastomotic leak. Jackson-Pratt (JP) drains provide closed suction through a fenestrated soft silicone tube connected to a compressible bulb. Blake drains feature solid core construction with external channels for drainage. Penrose drains provide passive drainage through a flat latex tube. Sump drains allow simultaneous air ingress and fluid egress for high-volume drainage. Drains exit through separate stab incisions rather than the main wound. Securing with suture prevents accidental dislodgement. Understanding drain types and purposes enables appropriate post-operative management and documentation.

Section IX: Intraoperative Troubleshooting

Bleeding during surgery requires systematic response proportional to severity. Minor oozing responds to direct pressure, electrocautery, or topical hemostatic agents. Moderate bleeding from identifiable vessels is controlled with clamps followed by suture ligation or cautery. Major bleeding requires immediate direct pressure while communicating with the team, calling for assistance if needed, and systematically identifying and controlling the source. In severe cases, packing the area allows temporary control while the patient is resuscitated and resources are gathered. Maintaining composure and systematically addressing the bleeding serves better than panic. Learning to assist during bleeding episodes builds skills for eventual independent management.

Injury recognition during surgery requires knowledge of normal anatomy and attention to unexpected findings. Bowel injury appears as visible luminal contents, blue-gray bowel wall, or breach of the serosal surface. Ureteral injury may be recognized by seeing peristalsis, urine in the field, or the presence of a previously placed stent. Bladder injury reveals urine in the field. Vascular injury manifests as bleeding or pulsatile flow. Nerve injury may be recognized by seeing characteristic fascicular structure or may only become apparent post-operatively. Early recognition allows immediate repair and reduces complications; reporting unexpected findings or concerns to the senior surgeon is always appropriate.

Equipment problems require troubleshooting skills and backup plans. Electrocautery failure may result from incorrect settings, poor grounding, or unit malfunction; check settings and connections before assuming unit failure. Suction obstruction often results from tissue or clot blocking the tip or tubing; clearing the obstruction or changing tubing usually resolves the problem. Stapler malfunction may result from tissue exceeding stapler capacity or device failure; having backup staplers available prevents delays. Poor laparoscopic visualization may result from a dirty lens, fogging, or light source problems; each has specific solutions. Knowing basic troubleshooting steps reduces delays and demonstrates practical knowledge.

Maintaining composure during unexpected events demonstrates professional maturity and supports the team's function. Taking a breath and pausing for assessment prevents reflexive actions that may worsen the situation. Asking for help when needed is expected and appropriate; attempting to manage beyond one's capability risks patient harm. Following the lead of the senior surgeon during crises channels experience to the situation. Learning from events afterward, through reflection and reading, builds knowledge for future situations. Surgical training specifically includes progressive exposure to complications to develop these skills in a supervised environment.

Section X: Building Technical Skills

Simulation provides a safe environment for skill development without patient risk. Suturing boards with foam or synthetic skin allow unlimited practice of needle handling, tissue approximation, and knot tying. Knot-tying boards develop speed and technique for two-hand, one-hand, and instrument ties. Laparoscopic box trainers build the hand-eye coordination and triangulation skills required for minimally invasive surgery. Virtual reality simulators provide increasingly realistic procedure-specific practice. Time invested in simulation directly translates to improved operating room performance and creates opportunities for greater participation as skills demonstrate readiness.

Deliberate practice principles distinguish effective skill development from mere repetition. Focused attention on specific elements of technique, such as needle angle or knot tension, allows targeted improvement. Immediate feedback, whether from an instructor, self-assessment, or simulation feedback, guides correction. Progressive challenge increases difficulty as skills develop, preventing plateau. Reflection on performance, identifying what went well and what needs work, directs future practice. These principles apply to technical skills, communication skills, and clinical judgment. The learner who practices deliberately advances faster than one who merely accumulates experience without reflection.

Opportunities in the operating room should be recognized and requested appropriately. Skin closure represents the most common opportunity for suturing practice; asking to close demonstrates initiative without excessive boldness. Any chance to tie knots, whether during the procedure or tying off the ends of sutures, builds speed and technique. Camera driving in laparoscopic cases provides direct learning through doing. As skills develop, first assisting positions involve greater responsibility and learning. Expressing interest in learning, while respecting the pace and priorities of the case, communicates engagement without being demanding. Building reputation as an eager, prepared learner generates more opportunities over time.

Self-assessment identifies strengths to maintain and weaknesses to address through targeted practice. Evaluating knot quality (are knots square and secure?) provides feedback on tying technique. Assessing suture spacing and tension identifies areas for improvement in closure technique. Comparing tissue handling (did tissue trauma occur?) guides refinement. Efficiency assessment (was movement economical?) identifies wasted motion. Communication evaluation (was information exchange clear and timely?) addresses team interaction. Honest self-assessment, supplemented by feedback from residents and attendings, guides focused improvement efforts. This habit of self-evaluation, begun as a student, serves throughout a surgical career.

Summary

Operating room skills develop through understanding the environment, mastering sterile technique, learning instruments, and practicing fundamental procedures. The OR team includes the attending surgeon, residents, scrub tech, circulator, and anesthesia, each with defined roles contributing to safe surgery; the sub-intern assists and learns according to skill level. Safety practices including time-out, counts, and fire prevention protect patients. Sterile technique requires proper scrubbing, gowning, and gloving, with constant awareness to maintain the sterile field and immediate response to contamination. Basic instruments serve cutting, grasping, retracting, clamping, and suturing functions, with forceps, clamps, and retractors selected for specific tissue types and applications. Suture selection matches absorbable or permanent material, monofilament or braided construction, and appropriate size to tissue requirements. Knot tying with two-hand, one-hand, and instrument techniques must produce secure square knots. Assisting effectively requires steady retraction, appropriate suction, correct suture cutting length, and smooth camera operation in laparoscopic cases. Communication in the OR balances speaking up for safety with appropriate timing of learning questions, using closed-loop communication for accuracy. Common procedures from opening through closure and laparoscopic entry follow predictable sequences that enable anticipation. Troubleshooting bleeding, injury recognition, and equipment problems requires systematic approaches and maintained composure. Skills build through simulation practice, deliberate practice principles, operating room opportunities, and honest self-assessment.

Key Terms

Sterile Field: The area maintained free of microorganisms through proper preparation and technique, including the gowned front of scrubbed team members and the draped operative area.

Time Out: Pre-procedure pause in which all team members participate to verify patient identity, procedure, surgical site, and safety measures before incision.

Closed-Loop Communication: Communication technique using request, confirmation, and verification to ensure accurate understanding between team members.

Electrocautery (Bovie): Device using electrical current to cut tissue and coagulate bleeding vessels, named after the inventor but commonly used generically.

Laparoscopy: Minimally invasive surgery performed through small incisions using a camera and long instruments, providing magnified visualization and reduced tissue trauma.

Insufflation: Introduction of carbon dioxide gas into the abdominal cavity to create working space for laparoscopic surgery.

Retraction: Creating and maintaining surgical exposure by holding tissue away from the operative field using handheld or self-retaining instruments.

Needle Driver: Instrument designed to securely grasp suture needles for passing through tissue, with jaws matched to needle size.

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