Surgical Assisting

Surgical Assisting is 3% of the COA exam. In the minor procedure room and the OR, the assistant prepares the room and the patient, keeps the field sterile, anticipates the surgeon's next instrument, and documents what happened.

Aseptic principles — sterile touches only sterile; the field stays in view; anything below the waist, behind the back, or crossed by an unsterile arm is contaminated. When in doubt, it's contaminated — say so and re-prep.

Sterile zones on a gowned team member — the gown's front between chest and field level, and the sleeves from the cuff to just above the elbow. The back, the neckline, and everything below the field are unsterile, so sterile team members keep their hands in view above the waist and never turn their back to the field. The outer edge of a sterile drape (about an inch) is treated as unsterile.

Working around the field — no unsterile arm or object passes over it, supplies are added from the edge by sterile transfer, and a field is never left unattended.

Skin prep — dilute povidone-iodine is the ophthalmic standard (and lowers endophthalmitis risk); chlorhexidine and alcohol stay away from the ocular surface.

Consent — the physician performing the procedure explains the risks, benefits, and alternatives. The assistant confirms the form is complete and signed and may witness the signature, which attests to the patient's identity and voluntary signing, not to the explanation.

Site marking and the time-out — the operative eye is marked per protocol. Immediately before the procedure, everything stops, and the team confirms aloud the correct patient, procedure, and site or eye, checked against the consent and the marking. The time-out exists because wrong-eye surgery happens.

Pre-procedure checks — confirm allergies and the current medication list, flagging blood thinners for the physician (the assistant never tells a patient to stop one), and take vital signs per protocol.

Opening sterile supplies — check package integrity, sterilization indicators, and any expiration date before opening. Open a wrapped pack by unfolding the far flap first, then the sides, then the near flap, so your arm never passes over the exposed contents.

Two roles, one field — the scrubbed (sterile) assistant scrubs, gowns, and gloves, sets up the sterile tray, and passes instruments to the surgeon inside the field. The circulator stays unsterile and outside the field: opens packages and adds their contents by sterile transfer (flipped on from the edge or presented to the scrubbed assistant), fetches anything else needed, documents the case as it happens, and remains in the room until the procedure ends rather than leaving to work up other patients.

Preparing the patient — explain what they will feel, ask them to hold still and keep talking to a minimum, and offer a hand to squeeze.

How an item is reprocessed depends on what it touches (the Spaulding classification):

Clean first — sterilization cannot reach through dried blood or debris. Wipe instruments at the point of use, keep debris from drying, clean thoroughly, inspect, then package and sterilize.

Steam autoclave — steam under pressure sterilizes. Chemical indicators show that a pack was exposed to sterilizing conditions; biological (spore) tests show that the cycle actually killed highly resistant test organisms. A pack that comes out wet is treated as contaminated.

Storage — a sterile package stays sterile until something compromises it: a tear, moisture, or a drop on the floor.

Suture sizes — the more zeros, the finer the strand: 10-0 nylon closes corneas, while 6-0 and heavier close lids and skin. Absorbable sutures dissolve; nonabsorbable skin sutures are removed at follow-up.

Sharps — count them before and after, pass them safely (using a neutral zone where your clinic does), never recap a needle by hand, and drop used sharps straight into a rigid sharps container. Document lot numbers and implants per protocol.

Chalazion incision and curettage — after the physician anesthetizes the lid, the clamp everts it to expose the inner surface for incision and curettage. The assistant passes instruments, manages bleeding with gauze as directed, and reassures the patient.

Lid lesion excision, biopsy, and laceration repair — the assistant preps and drapes, passes instruments, manages the light, and reassures the patient. A specimen goes into a labeled container at the table (patient, date, site, and eye) with its requisition; label at the moment of collection, never later.

Intravitreal injection — check the drug, the eye, and the signed consent against the physician's order. The eye gets topical anesthetic and a lid speculum to keep lashes and lid margin away from the needle. The site is measured with calipers behind the limbus, commonly 3.5 mm in an eye with an implant and 4.0 mm in an eye with its natural lens. Povidone-iodine on the ocular surface is the final step before the needle. Keep talking over the field to a minimum. Afterward, confirm the patient can still see (a quick check such as counting fingers), check pressure per protocol, and teach the warning signs.

Laser procedures — staff in the room wear protective eyewear rated for that laser's wavelength (a slit-lamp laser's built-in filter protects only the operator), and the door is posted while the laser is in use.

After any procedure — give written instructions, and make sure the patient knows to call right away for increasing pain, decreasing vision, or increasing redness or discharge.

When the patient has trouble — for fainting, recline the patient, raise the legs, and call for help. Pulling on an eye muscle or pressing on the eye can trigger the oculocardiac reflex, a sudden drop in heart rate. If the pulse falls or the patient suddenly feels faint or nauseated, say so aloud so the surgeon can release traction, and alert whoever is monitoring the patient.

Be ready to identify what contaminates a field, describe a gown's sterile zones, name the standard ophthalmic skin prep, sort items into critical, semicritical, and noncritical, tell autoclave indicators from spore tests, recognize the common instruments, compare suture sizes, describe the time-out, and outline the assistant's role in chalazion surgery and intravitreal injections.