Intraoperative Surgical Technique and Assisting
Intraoperative surgical technique and assisting tests first-assistant judgment at the field: exposure, tissue handling, hemostasis, suturing, and anticipatory instrumentation. The RNFA must be able to describe why a maneuver is safe, not merely perform it.
Core rules and concepts
- Exposure: retract along tissue planes, pad retractors, and avoid sustained pressure on nerves and vessels; reposition retractors periodically.
- Tissue handling: use fine-toothed forceps for skin and atraumatic forceps for bowel and vessels; keep tissues moist; divide with sharp dissection or an energy device appropriate to the structure.
- Hemostasis: direct pressure first, suction to identify the source, then precise ligation, clip, or cautery; avoid blind clamping near nerves, ducts, or major vessels.
- Suturing: choose suture size and needle shape for the tissue; enter at 90 degrees, follow the needle curve, avoid backhanding and excessive bites; close dead space and approximate layers.
- Counts and closure: reconcile sponges, needles, and instruments before closure; verify drain security and layer-by-layer closure.
Worked example
During dissection, a small arterial bleeder obscures the field. The RNFA applies sponge pressure, suctions the edge, and asks the surgeon to identify the vessel before any clamp is placed. Once seen, the vessel is clipped or ligated under direct vision and the field is checked for pulsatile flow and hematoma. Blind clamping risks injury to an adjacent nerve or duct.
Traps
Over-retracting to improve the view; using bowel forceps on vessels; clamping a bleed before identifying it; ignoring a needle that changed hands; and closing without a final count.