Surgeon's assistant

Laparoscopic stomach surgery

A 'Surgeon's Assistant' (SA), also referred to as a Surgical First assistant or Surgical assistant is a medical or allied health practitioner that provides aid in exposure, hemostasis, and visualization of anatomic structures during the course of a surgical operation. Professionals filling this role come from diverse backgrounds and include medical doctors (MD), surgical residents, surgical physician assistants (PAs), advanced practice registered nurses (such as nurse practitioners), specialized registered nurses (such as registered nurse first assistants or RNFAs), licensed surgical assistants (LSA), certified surgical first assistant (CSFAs) and non-certified surgical assistants. States determine the requirements for practice as a surgeon's assistant-surgical assistant.

American College of Surgeons (ACS) – Statement on Principles (excerpted), relating to Surgical Assistants;

Section G. Surgical Assistants The first assistant during a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions. The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility.

The American College of Surgeons supports the concept that, ideally, the first assistant at the operating table should be a qualified surgeon or a resident in an approved surgical education program. Residents at appropriate levels of training should be provided with opportunities to assist and participate in operations. If such assistants are not available, other physicians who are experienced in assisting may participate.

It may be necessary to utilize nonphysicians as first assistants. Surgeon's Assistants (SA's) or physician's assistants (PA's) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a PA or SA should include:

Qualifications and Credentials of Assistants Specification of which surgeon the applicant will assist and what duties will be performed. Indication of which surgeon will be responsible for the supervision and performance of the SA or PA. The application should be reviewed and approved by the hospital's board. Registered nurses with specialized training may also function as first assistants. If such a situation should occur, the size of the operating room team should not be reduced; the nurse assistant should not simultaneously function as the scrub nurse and instrument nurse when serving as the first assistant. Nurse assistant practice privileges should be granted based upon the hospital board's review and approval of credentials. Registered nurses who act as first assistants must not have responsibility beyond the level defined in their state nursing practice act.

American Medical Association (AMA) - Policy, H475.986 (full statement), Surgical Assistants other than Licensed Physicians;

Our AMA: (1) affirms that only licensed physicians with appropriate education, training, experience and demonstrated current competence should perform surgical procedures;

(2) recognizes that the responsible surgeon may delegate the performance of part of a given operation to surgical assistants, provided the surgeon is an active participant throughout the essential part of the operation. Given the nature of the surgical assistant's role and the potential of risk to the public, it is appropriate to ensure that qualified personnel accomplish this function;

(3) policy related to surgical assistants, consistent with the American College of Surgeons' Statements on Principles states: (a) The surgical assistant is limited to performing specific functions as defined in the medical staff bylaws, rules and regulations. These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure. (b) It is the surgeon's responsibility to designate the individual most appropriate for this purpose within the bylaws of the medical staff. The first assistant to the surgeon during a surgical operation should be a credentialed health care professional, preferably a physician, who is capable of participating in the operation, actively assisting the surgeon. (c) Practice privileges of individuals acting as surgical assistants should be based upon verified credentials and the supervising physician's capability and competence to supervise such an assistant. Such privileges should be reviewed and approved by the institution's medical staff credentialing committee and should be within the defined limits of state law. Specifically, surgical assistants must make formal application to the institution's medical staff to function as a surgical assistant under a surgeon's supervision. During the credentialing and privileging of surgical assistants, the medical staff will review and make decisions on the individual's qualifications, experience, credentials, licensure, liability coverage and current competence. (d) If a complex surgical procedure requires that the assistant have the skills of a surgeon, the surgical assistant must be a licensed surgeon fully qualified in the specialty area. If a complication requires the skills of a specialty surgeon, or the surgical first assistant is expected to take over the surgery, the surgical first assistant must be a licensed surgeon fully qualified in the specialty area. (e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA). Other appropriately credentialed physicians who are experienced in assisting the responsible surgeon may participate when a trained surgeon or a resident in an accredited program is not available. The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added). (BOT Rep. 32, A-99; Reaffirmed: Res. 240, 708, and Reaffirmation A-00)

Employment

Surgical first assistants are commonly utilized to provide aide to surgeons during procedures spanning every branch of surgical practice and specialty. Practitioners that lend their services full-time (such as surgical PAs, SFAs, and RNFAs) may specialize in areas such as orthopedic, cardiovascular, neurologic, genitourinary, general, obstetric & gynecologic, and oral/maxillofacial surgery. Most of these surgical first assistants are employed by hospitals; however, a growing number are employed by physician groups, private SFA practices, medical travel agencies, or are self-employed.^[1][2] According to the National Surgical Assistant Association (NSAA), the average annual salary for the non-physician surgical first assistant in 2005 ranged from $50,000 (entry level) to $150,000 annually for full-time practitioners, with top wages reaching $200,000 yearly. The American Medical Association lists the average as $75,000 yearly.^[3][4]

Description of duties

For the surgeon's assistant-surgical assistants duties include but are not limited to:

Positioning the patient

• The surgeon shall convey the exact position that will give the best exposure for the surgical procedure. The surgical assistant will carry out this order. Consideration will be given to the patient’s comfort and safety.
• Points of pressure shall be padded: elbows, heels, knees, eyes, face, and axillary region.
• Circulation shall not be impaired. (A tourniquet may be required for some procedures.)
• Nerve damage shall be guarded against.
• The temperature of the patient should be discussed with the anesthesia personnel and methods employed to maintain the desired temperature range.
• The surgical assistant shall be familiar with common positions related to the surgical procedure and will be able to use the equipment necessary to provide the position. Competencies will include the following:

1. Fracture tables
2. Head stabilizers
3. Body stabilizers
4. C-arm extensions
5. Any other equipment needed

• Upon completion of the procedure, the patient shall be evaluated for any possible damage from positioning which will include assessment of the skin. The abnormal condition shall be reported to the surgeon and treatment and documentation shall be carried out.

Providing visualization of the operative site by the following

• Appropriate placement and securing of retractors with or without padding
• Packing with sponges
• Digital manipulation of tissue
• Suctioning, irrigating, or sponging
• Manipulation of suture materials (e.g., loops, tags, running sutures)
• Proper use of body mechanics to prevent obstruction of the surgeon’s view

Utilizing appropriate techniques to assist with hemostasis

• Permanent

1. Clamping and/or cauterizing vessels or tissue
2. Tying and/or ligating clamped vessels or tissue
3. Applying hemostatic clips
4. Placing local hemostatic agents

• Temporary

1. Applying tourniquets and demonstrating awareness of the indications/contraindications for use with knowledge of side effects of extended use.
2. Applying vessel loops
3. Applying noncrushing clamps
4. Applying direct digital pressure

• Participating in volume replacement or autotransfusion techniques as appropriate.

Utilizing appropriate techniques to assist with closure of body planes

• Utilizing running or interrupted subcutaneous sutures with absorbable or nonabsorbable material
• Utilizing subcuticular closure technique with or without adhesive skin closure strips
• Closing skin with method indicated by surgeon (suture, staples, etc.)
• Postoperative subcutaneous injection of local anesthetic agent as directed by the surgeon

Selecting and applying appropriate wound dressings, including the following

• Liquid or spray occlusive materials
• Absorbent material affixed with tape or circumferential wrapping
• Immobilizing dressing (soft or rigid)
• Providing assistance in securing drainage systems to tissue

Education

The educational requirements for certification, registration and licensure for surgeon's assistant-surgical assisting vary greatly depending on the professional credential obtained by the practitioner. Surgeon's assistants come from diverse healthcare and medical backgrounds and include such professionals as medical doctors, surgical residents, certified surgical assistants, physician assistants, registered nurses, licensed surgical assistants and graduates of surgical first assistant training programs.

A description of the educational standards for non-licensed certified surgical first assistants (CSFA) follows:

The Commission on Accreditation of Allied Health Education Programs (CAAHEP) has established and published guidelines for the profession of surgical first assisting]. Programs which meet these criteria are able to be reviewed and obtain accreditation through CAAHEP. Currently, there are several schools in the United States which offer CAAHEP accredited surgical first assistant training programs. Additional programs are approved by the National Surgical Assistant Association (NSAA) and the American Board of Surgical Assistants]] (ABSA). These programs typically last between 12 and 24 months and lead to a Certificate of Completion or Associate of Science degree.^[5] In addition, the Association of Surgical Technologists]] (AST) has published the Core Curriculum for Surgical Assisting which must be followed by accredited programs in order to assure consistency in education throughout the nation. Although formal programs for surgical first assisting currently lead to a Certificate of Completion or Associate of Science degree, the AST and the Association of Surgical Assistants (ASA) have both adopted the bachelor’s degree in a field related to surgical technology as the preferred entry level educational model to begin a career as a surgical first assistant.^[6] However, the bachelor’s degree is not a requirement for certification, nor is it a requirement for many entry-level positions.

Educational programs for CFAs include courses in the following subject areas:^[7]

• Microbiology
• Pathophysiology
• Anatomy and physiology
• Medical terminology
• Advanced surgical anatomy
• Surgical microbiology
• Surgical pharmacology
• Anesthesia methods and agents
• Bioscience
• Ethical and legal considerations
• Fundamental technical skills
• Complications during surgery
• Interpersonal skills
• Clinical application of computers

Regulations of Surgeon's Assistant-Surgical Assistants is done through licensure, certification, or registration. Each of these regulations have different levels of educational and professional experience requirements. Licensure – applicants typically are required to pass a Board-approved professional education program and exam ◦ A Board-issued license is typically granted in order to practice (with possible exceptions for students and “grandfathered” providers). ` Certification – applicants may be required to pass a Board-approved professional education program and exam or to satisfy the requirements of a certifying body (and the Board may stipulate the certifying body or bodies that are approved) ◦ Unless certification to practice is mandatory, providers may be allowed to practice without having any certification. ` Registration – applicants typically are required to provide their names and practice locations only.

Surgeon's Assistant-Surgical Assistants are credentialed as Surgical PA's, RNFA's and Surgical Assistants (SA). SA's are certified nationally by the American Board of Surgical Assistants (ABSA), the National Board of Surgical Technology and Surgical Assisting (NBSTSA), and the National Surgical Assistant Association (NSAA). Some states, such as Kentucky, Texas, Colorado, Illinois, and Washington DC have additional state registration and licensure requirements. When deciding which professional certification, registration or licensure to pursue, the surgeon's assistant-surgical assistant practitioner should consider local legislation, facility policy, and regional practice as some credentials are preferred over others in different parts of the United States. Additionally, local laws and hospital policies may favor or require a specific credential to practice as a Surgeon's Assistant-Surgical Assistant.

References

Links to certification requirements

• ABSA grants the Surgical Assistant-Certified (SA-C) credential to candidates who meet these criteria:

• NBSTSA is the only professional credential accredited by the National Commission for Certifying Agencies (NCCA) and grants the Certified Surgical First Assistant (CSFA, formally CFA) credential to candidates who meet these criteria:

• NSAA is the oldest professional certification agency for SFAs and grants the Certified Surgical Assistant (CSA) credential to candidates who meet these criteria.

Additional Information: Surgical Assistant Resource==Other external links==

• CAAHEP guidelines for SFAs
• List of programs accredited by the NSAA and ABSA.