A Surgeon's Assistant (SA), also referred to as a 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)and 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;
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:
- 1 Qualifications and Credentials of Surgeon's Assistants
- 2 Surgeon's Assistant/Surgical Assistant Employment
- 3 Description of Surgeon's Assistant/Surgical Assistant Responsibilities
- 3.1 Positioning the patient
- 3.2 Providing visualization of the operative site by the following
- 3.3 Utilizing appropriate techniques to assist with hemostasis
- 3.4 Utilizing appropriate techniques to assist with closure of body planes
- 3.5 Selecting and applying appropriate wound dressings, including the following
- 4 Surgeon's Assistant/Surgical Assistant Education
- 5 References
- 6 Links to Surgeon's Assistant/Surgical Assistant Requirements
- 7 Surgeon's Assistant/Surgical Assistant Professional Organizations links
Qualifications and Credentials of Surgeon's 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)
Surgeon's Assistant/Surgical Assistant Employment
Surgeons's Assistants/Surgical Assitants 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 Surgeon's Assistants) may specialize in areas such as orthopedic, cardiovascular, neurologic, genitourinary, general, obstetric & gynecologic, and oral/maxillofacial surgery. Many of these Surgeon's Assistants/Surgical Assistants are employed by hospitals; however, a growing number are employed by physician groups, private SA practices, medical travel agencies, or are self-employed.
Description of Surgeon's Assistant/Surgical Assistant Responsibilities
For the Surgeon's Assistant/Surgical Assistant that are PA's and NP's in addition to intraoperative surgical responsibilities they may also be doing history and physicals, discharges and rounds not limited to only the operating room. For the non PA & NP which include RNFAs, licensed and or certified Surgeon's Assistant/Surgical Assistant intraoperative 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:
- 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
- Applying tourniquets and demonstrating awareness of the indications/contraindications for use with knowledge of side effects of extended use.
- Applying vessel loops
- Applying noncrushing clamps
- 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
Surgeon's Assistant/Surgical Assistant Education
The educational requirements for certification, registration and licensure for Surgeon's Assistant/Surgical Assistant vary greatly depending on the professional credentials obtained by the practitioner. Minimal educational degree is usually an Associate Degree and master level programs (PA's/SA's) and doctorate degrees (MD) from US and abroad (International Medical Graduate) are held by many practitioners. Many practicing Physician Assistants have completed a surgical residency and devote their scope of practice exclusively to surgery. Registered Nurses with additional training become RNFA's and are certified to work as Surgeon's Assistants/Surgical Assistants. The practitioners exclusively working in surgery as Surgeon's Assistants/Surgical Assistants come from diverse healthcare and medical backgrounds and include such professionals as medical doctors (US & foreign graduates), surgical residents, certified surgical assistants, surgical physician assistants, registered nurse first assistants, licensed surgical assistants and graduates of surgical assistant training programs.
Regulations of Surgeon's Assistants/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 Assistants/Surgical Assistants are credentialed as Surgical PA's, RNFA's, NP and Licensed and or Certified Surgical Assistants (SA). When deciding which professional certification, registration or licensure to pursue, the Surgeon's Assistant/Surgical Assistant practitioner should consider state regulation, 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.
Surgical PA's, RNFA's and NP's have their own licensure and certification requirements to practice as Surgeon's Assistants/Surgical Assistants. For the non PA, RNFA or NP Surgeons Assistant/Surgical Assistant there are only two states in the US that grant Surgeon's Assistant/Surgical Assistant a licensure to practice as a Surgeons Assistant/Surgical Assistant. The two states are: The District of Columbia (DC) and Texas. The Texas Medical Board grants Surgeon's Assistants/Surgical Assistants a license(LSAs) once the following requirements have been met:
- Minimum education of an Associate's Degree from a 2 or 4-year institution or greater:
- One of the four educational pathways outlines below:
- Graduation from a CAAHEP accredited Surgical Assisting educational program
- Registered Nurse First Assisting program
- Surgical Physician Assistant program
- Full Medical School (and receipt of a Physician's Degree).
- Worked 2000 hours within the last 3 years as a Surgical Assistant.
- Taken and passed one of the three national certifying exams.
- Have a current national Board Certification.
- Have never been convicted of a felony or crime of moral turpitude.
- 100% honest and forthcoming on the application.
All of the above are requirements to become licensed as a Surgeon's Assistant in Texas.
Links to Surgeon's Assistant/Surgical Assistant Requirements
District of Columbia
American Board of Surgical Assistants
National Board of Surgical Technology and Surgical Assisting
National Commission for the Certification of Surgical Assistants
American College of Surgeons (Affiliate Membership)
American Association of Surgical Physician Assistants
Association of periOperative Registered Nurses (RNFA)
Association of Surgical Assistants
National Surgical Assistant Association