A perspective on first assisting in cardiovascular operations

Abstract

The quality of surgical assistance is an important factor affecting surgical performance and outcomes. This article gives a perspective on key principles of first assisting, specifically during cardiovascular operations. The principles start with operative techniques, then expand into concepts relating to the surgical field and operating room. By adhering to the described principles, the first assistant may enhance a surgical operation, benefiting the surgeon, the operating room team, and, most important, the patient.

Excellent first assisting adds efficiency, elegance, and quality to a surgical operation. Poor surgical assistance has been identified as a key intraoperative stressor for the primary surgeon, potentially affecting his or her surgical performance and contributing to complications.¹ During an operation, a part of the primary surgeon’s mind tracks the first assistant: What action is he or she performing? How well is the action being done? Is the action advancing or impeding the operation? The primary responsibility of a first assistant, in our view, is “do no harm.” The second responsibility is to facilitate the flow of the operation by helping the primary surgeon. The “perfect surgical assistant” has been described as “calm, confident, competent, and courageous.”² In addition to these attributes, the following principles, in our opinion, may be useful to consider, specifically when assisting in cardiovascular operations (Figure 1).

Figure 1.

The junior author (LZW) assisting the senior author (CSR) in a coronary artery bypass grafting operation.

OPERATING PRINCIPLES

Be gentle with tissues

This is a primary surgical principle, from which most others originate. Dr. William Halsted (1852–1922) of The Johns Hopkins Hospital was an early advocate of minimizing tissue trauma. Due to the improvements of anesthesia during his era, the rapid and violent handling of tissue was no longer necessary, and it became possible to dissect carefully, ligate blood vessels individually, and close incisions neatly in layers. Modern surgery is gentle surgery. Instruments and devices applied roughly cause unnecessary tissue trauma. The first assistant should keep this in mind when using various tools. The suction, for example, should be used lightly, like a bird, especially when suctioning around delicate venous grafts or vascular anastomoses. Suctions used as blunt retractors can be too rough and noisy at times, when forceps will do. Self-retaining retractors should be opened slowly and narrowly at first, with gradual expansion to allow full exposure.

Displace instead of grasp, when possible

When either exposing or sewing, gentle displacement of the tissue with closed forceps will often suffice instead of grasping and crushing with forceps. For example, the three-layer soft tissue closure anterior to the sternum can usually be accomplished without grasping subcutaneous tissue. Simple displacement causes less tissue trauma. If grasping is necessary, it should be done delicately and gently. Although considered to be an “atraumatic” instrument, the DeBakey forceps can cause damage to tissue, especially blood vessels.

Preserve the intima

Blood vessels have three layers: the intima, media, and adventitia. Virchow’s triad states that thrombosis may be a consequence of one or more of three conditions: hypercoagulability, stasis, and intimal injury. Intimal damage in a cardiovascular operation can be minimized if one handles blood vessels with delicacy by grasping the adventitia only.

Sew with the curve of the needle

Introduce the needle into tissue at 180° and advance it with the curve of the needle. When using a standard needle holder, this requires an ability to “palm”; that is, open and close the needle holder without fingers in the slots. “Palming” is necessary to pronate the wrist sufficiently to achieve the desired 180°. When fingers are fixed in the needle-holder, direction is limited, and needles are often inserted at inappropriate angles. When removing the needle from tissue, “push, push, pull” is often useful, or simply “push, pull.” This means gently pushing the needle from the posterior body with the needle driver. The needle should be allowed to rest where it lands and not be held up under tension during retrieval. It can then be grasped anteriorly with the needle driver and pulled out of the tissue, always along the curve of the needle. Tension in either needle or tissue when sewing is to be avoided.

Cut the suture at the desired level in a timely fashion

The assistant should know the level above the knot the surgeon desires the suture strands to be cut (the preference of the senior author is 1 cm for braided suture and 2 cm for monofilament suture) and should be prepared to cut with the tips of the scissors only. The senior surgeon prefers to hold the suture until cut and pass off the strands himself, so that the assistant’s hand does not suddenly block his field of vision. It should be unnecessary for the surgeon to say “cut” after completing the knots if the assistant is already poised to do so.

OPERATIVE FIELD PRINCIPLES

Keep eyes focused on the operative field

Despite one’s best intentions or efforts, the hands inevitably move when the eyes look away. If the surgeon is performing an anastomosis and the first assistant is holding the vein with forceps, a momentary look away by the first assistant, to find the suction, for example, will move the vein. Either keep both eyes and hands focused on the field or remove them. Although one is expected to make eye contact during conversations in social settings, it is contraindicated and dangerous while operating. When communication is necessary, it should be done without averting the eyes from the field. The message can then be relayed through the appropriate channels (surgical scrub technician to circulating nurse, anesthesia providers, etc.).

Utilize basic hand signals for basic instruments

Simple, silent hand signals to the nurse or surgical scrub technician keep things quiet and peaceful. Use three signals routinely: scissors are the straight index and middle fingers coming together and apart; forceps are the index fingertip and thumb tip brought together repeatedly; and needle holder (with suture) is a closed hand moving with a slight twist repeatedly, as if placing a stitch. These three hand signals are universal and lessen the verbal sensory input at the table.

Optimize the surgeon’s perspective first

The primary surgeon’s and first assistant’s visual perspectives are different, as each one views the field from a different angle. The assistant may have to adjust his or her body to obtain the appropriate visual field to assist the primary surgeon. Given this, it is helpful for the assistant to be familiar with the various steps of the operation and the goals of each step. For example, when performing aortic cannulation for cardiopulmonary bypass, the surgeon will need to place a stitch on the aorta. To assist with exposure and facilitation of this step of the operation (via suctioning or tissue retraction), the assistant will need to lean forward (and toward the head) from the left side of the table and peer under the shelf of the divided sternum. This will allow the assistant to see what the surgeon sees.

Mind the planes of separation when working

When adjusting one’s body as in the above situation, it is important to maintain spatial awareness. Knocking heads is to be avoided. Spatial awareness should also be maintained when performing simultaneous tasks. For example, when closing a midline wound together from each end, avoid placing hands and instruments in the way of the surgeon closing from the opposite direction.

Minimize disruptive movements

Try to minimize any sudden movement, including shaking of the table, that may be disruptive to the operation. Periodically jarring the table to lean in, for example, can also be distracting. The best endoscopic harvesters of vein in the leg, to use one example, are economical in movement. Endoscopic probe manipulation, trauma to the vein and the leg, and harvest time are minimal.

OPERATING ROOM PRINCIPLES

Scrub in before the surgeon

The assistant should be scrubbed in and ready prior to the surgeon. This will allow the assistant adequate time to prepare and become comfortable (adjust lights, request a step stool, etc.) prior to the commencement of the operation. This can minimize disruptions during the case and allow the circulating nurse and surgical scrub technician to focus on the surgeon and the operation itself. In addition, scrubbing in before the surgeon conveys a message of enthusiasm, initiative, and respect to the surgeon.

Tend toward quiet

Subdue personality to the task at hand. Let the surgeon lead when it comes to initiating conversation and follow his or her cues. If the surgeon is totally focused, a friendly question such as “How was your weekend?” may be untimely. During critical parts or transition phases of an operation, be silent. For example, in a cardiac operation, when cannulating and de-airing, when going on or coming off cardiopulmonary bypass, or during application of an aortic cross-clamp, extraneous communication can be distracting and dangerous. Personal noises such as singing, humming, yawning, and sighing can also distract.

Ask permission to do anything unusual

Any change in routine justifies a discussion with the primary surgeon, who may or may not wish to add a new variable to the operation. For example, although both the surgeon and first assistant may love to teach, the surgeon should decide whether a first assistant can delegate a task to another. In addition, if the first assistant is aware that he or she will have to leave during part of the operation (as may happen in a surgical training program given conference requirements), the primary surgeon should be notified prior to starting the operation so that arrangements can be made.

Share clinical opinions judiciously

Good surgeons appreciate input, especially, for example, when pondering a challenge or posing a question, but only to a point. Routine maneuvers require no comment or advice. It should be emphasized, however, that if the assistant notices something abnormal or an error about to be committed, he or she should point this out, in line with the duty to “do no harm.”

Be an agent of harmony

A positive personality provides an intangible benefit to the surgeon and team. The operating room is no place to introduce sensitive, provocative, or negative subjects. Discussing previous complications or other patients is to be avoided. Stressful moments may occur in major surgical operations but will pass with peaceful silence and complete focus. “Keep it clinical” is a good conversational motto to follow if personal conflicts arise.

CONCLUDING PRINCIPLE

There is always something to do

During a fellowship year abroad, the senior author once stood motionless at the surgeon position and was reminded of this final principle by a senior anesthesiologist. The junior author recalls her surgical mentor saying that “idle hands are the devil’s workshop” early in her training when she stood with no instruments in her hands. They both are indeed right. There is always something to be done. From wheels-in to wheels-out of the operating room, the assistant should be proactive, anticipating how he or she can facilitate the progress of the operation. The primary surgeon will be deeply grateful for constant attentiveness. By adhering to this concept along with the above principles, the first assistant can greatly enhance a surgical operation, benefiting the surgeon, the operating room team, and, most important, the patient.