Learning Objectives
By the end of this section, you will be able to:
- Describe the various surgical settings
- Differentiate the three surgical categories
- Compare the common types of surgery by their suffixes
- Distinguish the members of the surgical team
The intraoperative phase is the second of three phases of perioperative care. The intraoperative phase begins when the patient is transferred to the operating room bed and ends when the patient is transferred to the post-anesthesia care unit (PACU). Just like the previous phase, the intraoperative phase is also broken down into distinctive responsibilities and tasks for all team members. In recent years, emphasis has been placed on adhering to strict protocols and developing best practice standards throughout the surgical procedure, ensuring the highest level of safety for each procedure. This chapter will explore the complexities involved with intraoperative care, roles of the surgical team, safety and infection prevention, and nursing management.
Surgical Settings
Surgical settings can vary based on the type of procedure, the medical facility, and the complexity of the patient’s individual scenario. There are several primary surgical settings:
- An inpatient hospital operating room is the most common surgical setting for patients (Figure 26.2). Hospitals have dedicated operating rooms with specialized equipment, surgical tools, anesthesia, and monitoring devices to perform safe and effective surgery. Inpatient facilities have strict sterilization protocols and are staffed by surgeons, anesthesiologists, nurses, and other support members of the interprofessional team. This setting can also be used for robotic-assisted surgical procedures.
- An ambulatory surgical center (ASC) is a facility designed for outpatient procedures that do not require the patient to be monitored overnight. They offer a more convenient and cost-effective alternative to the inpatient operating room setting. ASCs are equipped to perform minor and minimally invasive surgeries, such as cataract surgery, minor cosmetic surgery, colonoscopies, and minor orthopedic procedures, such arthroscopy of the knee.
- Clinics or specialty provider offices host minor surgeries such as wisdom teeth extraction, skin lesion removals, and biopsies. The types of procedures that can be done in a clinic or provider’s office are minimally invasive and require no long-term observations of the patient. These settings are equipped with the essential surgical equipment for minor surgical procedures. This type of practice promotes cost-effective care by only requiring local anesthetic, and no admission or discharge to a facility resulting in low costs to the patient.
Surgical Categories
Surgical procedures are categorized based on the timing and necessity of the operation deemed by the surgical team. Using a system to categorize surgeries can help the medical and surgical teams prioritize and manage the care needed for patients. There are three primary categories used to organize surgical procedures: elective, urgent, and emergent.
An elective surgery is defined as a non-emergent, planned procedure that is scheduled in advance based on the patient’s preference, surgical procedure, location of procedure, and surgeon’s availability. These surgeries are performed to improve a patient’s quality of life, address chronic illnesses, or address non–life-threatening medical issues. They can be scheduled in advance, giving patients time to prepare for the surgery. Procedures like joint replacements, cosmetic surgeries, cataract removal, hernia repairs, and some tumor removals may fall under this category.
An urgent surgery is a necessary procedure that must be performed promptly, usually within twenty-four to forty-eight hours. While they are not considered life-threatening, these surgeries address conditions that could worsen without intervention by the surgical team. Delaying these surgeries can lead to complications, causing the patient’s condition to turn into a life-threatening problem. Procedures such as long bone fractures, infections that require drainage devices, or acute gallstones are often considered urgent.
An emergency surgery is an immediate, unplanned procedure performed to save a patient’s life or prevent severe disability. Emergent surgeries are necessitated by acute, life-threatening conditions or injuries that require immediate intervention. Examples of emergency surgeries include perforation to the bowel or bladder, rupture of an organ like spleen or appendix, severe trauma, burns, active bleeding, or organ damage.
Surgical Procedures
Surgical procedures are often named for the location, body part, condition, and specific technique that is used. The suffix provides insight into the nature of the surgery. (Table 26.1) lists common surgical suffixes and their meanings.
| Suffix | Meaning | Examples |
|---|---|---|
| -graphy | Imaging or recording | Mammography (imaging of the breast tissue) Angiography (imaging of blood vessels) |
| -ectomy | Excision or surgical removal | Lobectomy (removal of a lung lobe) Hysterectomy (removal of the uterus) |
| -otomy | Cutting into or incision | Tracheotomy (incision into the trachea/windpipe) Craniotomy (surgical opening of the skull bone) Laparotomy (abdominal incision to access the abdominal cavity) |
| -ostomy | Artificial opening or creating an opening | Colostomy (creation of an artificial opening in the colon to the outside of the abdomen) Urostomy (surgical opening for urine diversion) |
| -plasty | Surgical repair or reshaping | Mammoplasty (augmentation or reduction of the breast tissue) Rhinoplasty (surgical reconstruction of the nose) |
| -scopy | Examination or visualization | Thoracoscopy (minimally invasive visualization inside the thoracic cavity) Endoscopy (examination of internal organs using an endoscope) |
Understanding the suffix at the end of the words can give an idea of the type of procedure being performed. This can help surgeons, nurses, and other medical professionals prepare the proper equipment for a safe and effective surgical procedure.
The Surgical Team
In the intricate realm of health care, the surgical team stands as a collaborative force at the forefront of medical intervention. This section explores the dynamic and multifaceted world of the surgical team, shedding light on the diverse roles, responsibilities, and expertise that each member brings to the operating room.
The Patient
First and foremost, the most important team member is the patient. The role of the patient in the operating room is fundamentally passive but essential to the success of the surgical process. As the individual undergoing surgery, the patient plays a critical role in entrusting their well-being to the surgical team. Before the procedure, the patient collaborates with health-care professionals to provide a thorough medical history, disclose any allergies, and offer pertinent information to ensure safe surgery. The surgical team trusts the patient to perform all presurgical instructions, such as washing with surgical soap the night before, not eating or drinking per instructions, and taking medications as ordered.
While in the operating room, the patient is prepared for the procedure by the anesthesia team, to induce a state of unconsciousness or sedation. While sedated the patient is relying on the surgical team to treat their body with dignity and respect, such as only exposing areas needed for the procedure, and maintaining professionalism throughout the surgery. The patient relies on the expertise of the surgical team to perform any necessary interventions if anything unexpected happens.
Following the surgery, the patient’s role shifts to more active participation in their recovery. Compliance with postoperative instructions, medication schedules, and follow-up appointments is crucial for a successful recovery. The patient’s trust, cooperation, and adherence to medical advice contribute significantly to the overall efficacy of the surgical process and the achievement of positive health outcomes.
Nursing Roles
The surgical team is comprised of several nursing roles, each with their own set of responsibilities during the surgery. This section will discuss the three main roles of a nurse within the surgical team. The RN circulator, also known as a circulating nurse, is responsible for coordinating and managing various aspects of the operating room before, during, and after surgery, which is critical in ensuring the smooth and safe functioning of surgical procedures. Before the procedure, the circulating nurse prepares the operating room by ensuring all necessary equipment, supplies, and instruments are available and in working order. During surgery, they maintain a sterile environment, monitor the team’s compliance with aseptic techniques, and manage the flow of communication and materials. The circulating nurse also advocates for patient safety and liaises between the surgical team and other health-care professionals. Post-surgery, they assist in transferring the patient to the recovery area and document the procedure for the patient’s medical records. The role demands excellent organizational skills, attention to detail, and the ability to handle high-pressure situations to ensure optimal patient outcomes and a well-coordinated surgical experience.
Link to Learning
The Association for Operating Room Nurses (AORN) has created evidence-based best practice guidelines for perioperative practice to help nurses care for surgical patients safely and effectively and to ensure workplace safety.
The role of a scrub nurse in the operating room is indispensable, contributing significantly to the efficiency and safety of surgical procedures (Russell, 2022). The scrub nurse is tasked with maintaining the sterility of the surgical environment. They play a pivotal role in preparing and organizing the sterile instruments and supplies needed for the surgery. Before the procedure, they collaborate closely with the surgical team to ensure all necessary equipment is available, sterilized, and organized. During the surgery, the scrub nurse passes instruments to the surgeon, anticipates the surgeons’ needs, and remains vigilant to preserve the sterile field. They also assist in counting surgical instruments and supplies to prevent any items from being left inside the patient. Additionally, the scrub nurse collaborates with the circulating nurse in managing the overall flow of the surgery, ensuring seamless communication and coordination among the team members. Their meticulous attention to detail, knowledge of surgical procedures, and ability to work effectively under pressure contribute significantly to the success of surgical interventions and the well-being of patients.
The last of the three main nursing roles in the operating room is the RN first assist. The registered nurse first assist (RNFA) controls bleeding during surgery, sutures incisions and wounds, and assists in stabilizing patients when necessary. RNFAs must earn additional education and credentials that certify their ability to perform in this expanded role. To become an RNFA, students must take advanced coursework, earn certifications, and undergo an extensive training process. According to the Association of Perioperative Registered Nurses (AORN). RNFAs practice intraoperatively at a surgeon’s direction while not concurrently functioning as scrub nurses (Croke, 2020).
Medical Providers
The operating team has two types of medical providers. The first type, and the lead of the surgical team, is the surgeon. The surgeon is a medical doctor with extensive training in performing surgical procedures. The role of the surgeon in the operating room is central to the success of any surgical procedure. Surgeons are highly trained medical professionals with the expertise to diagnose, plan, and execute a variety of surgical interventions. In the operating room, the surgeon is responsible for leading the surgical team, providing guidance, and making critical decisions throughout the procedure. They are tasked with performing the surgery which requires skill, precision, and knowledge to address the patient’s medical condition. Surgeons work collaboratively with the other surgical team members to ensure a smooth and coordinated process. Communication is crucial, as the surgeon directs the team, communicates with the patient when necessary, and collaborates with colleagues to optimize patient outcomes.
Beyond the operating room, surgeons are involved in preoperative and postoperative care, obtaining informed consent, discussing treatment plans, and monitoring the patient’s recovery. The surgeon’s role demands a combination of technical proficiency, decision-making skills, and effective communication to navigate the complexities of surgery and provide the best possible care to patients.
The second type of provider on the surgical team is the anesthesiologist. The role of anesthesiologists in the operating room is paramount in ensuring the comfort, safety, and maintenance of the patient’s airway throughout the surgical process. An anesthesiologist is a highly trained professional responsible for administering anesthesia, monitoring the patient’s vital signs and airway, and managing the patient’s pain during surgery. Before the procedure, the anesthesia provider evaluates the patient’s medical history, assesses the patient’s overall health, and develops an anesthesia plan tailored to the individual’s needs. During the surgery, they administer the appropriate type and amount of anesthesia, ensuring the patient is in a controlled state of unconsciousness or sedation. Anesthesia providers continually monitor vital signs, such as heart rate, blood pressure, and oxygen levels, adjusting the anesthesia to maintain stability. Their expertise extends to managing potential complications and responding to emergencies, contributing significantly to patient safety.
Another anesthesia provider that works directly under the guidance of the anesthesiologists includes the certified registered nurse anesthetist (CRNA), who is a master prepared and board-certified advanced practice nurse in the specialty of anesthesia. Additional roles include anesthesia assistants, and resident physicians. Postoperatively, anesthesia providers oversee patients’ recovery from anesthesia and manage pain control. Their crucial role in optimizing the patient’s experience in the operating room underscores the importance of their skill, knowledge, and vigilance in ensuring a successful and comfortable surgical outcome.
Other Personnel
In addition to the core members of the surgical team, the intraoperative phase involves the collaboration of various other personnel who play crucial roles in ensuring the smooth progression and success of surgical procedures. These include surgical assistants, who provide invaluable support to the surgical team and contribute to the seamless execution of surgical procedures. Their responsibilities encompass a wide range of tasks, from ensuring the sterility of instruments and supplies to actively participating in the surgical procedure. Surgical assistants collaborate closely with the surgeon, anticipating needs, providing instruments, and aiding in complex aspects of the surgery. With a keen understanding of anatomy, instrumentation, and aseptic techniques, they contribute to the precision and efficiency of the surgical process. Beyond technical proficiency, surgical assistants serve as liaisons between team members, fostering effective communication and maintaining a harmonious workflow. Their role is dynamic, adapting to the specific demands of each procedure, and their contributions significantly enhance the overall success and safety of the intraoperative experience for both the surgical team and the patient. Their comprehensive nursing knowledge and attention to detail ensure that patients receive optimal care from preoperative preparation to postoperative recovery. Collectively, these dedicated personnel form an integral part of the intraoperative team, working collaboratively to uphold the highest standards of patient care and safety in the operating room.