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Surgical First Assistant: The Essentials of Practice, First Edition. Edited by Julie Quick and Mark Owen.
© 2025 John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 8
Instrument Handling forthe
Surgical First Assistant
Susan Hall
1
and Mark Robertshaw
2
1
Anglia Ruskin University, Chelmsford, UK
2
Manor Hospital Bedford, Bedford, UK
INTRODUCTION
The majority of Surgical First Assistants (SFAs) will be experienced perioperative
practitioners who are already familiar with handing surgical instruments to the
operating surgeon and their assistants. This includes both registered practitioners and
undergraduate Operating Department Practitioners. Making the transition from ‘pro-
vider’ to ‘user’ of this equipment, however, requires a change of focus for the practi-
tioner. For members of the extended surgical team (EST) whose route into non- medical
assisting was through a non- perioperative background (this relates to practitioners
such as Advanced Nurse Practitioners and Advanced Clinical Practitioners), there may
well be a longer learning curve to ensure familiarity with surgical instrumentation and
the correct way to manage it while protecting patients and team members from harm.
To provide good instrument handling as part of the provision of safe and effec-
tive assistance, it is important to develop both strength and dexterity in both hands.
It may not be possible to change hands in order to use the dominant hand for activ-
ities such as the cutting of sutures and removal of artery forceps. Rui etal. (2018)
discuss the benefits of manual strength and dexterity, considering a variety of strat-
egies to strengthen the non- dominant hand. The authors have found that the use of
a ‘stress ball’ or conscious use of the hand for everyday tasks normally undertaken by
the dominant hand can be helpful with this. As strength is developed, manual dex-
terity can be introduced. For example, within the operating department and away
88 Chapter 8 Instrument Handling forthe Surgical First Assistant
from the sterile field, one can regularly practice opening and closing ratcheted instruments
with the non- dominant hand; one should not, however, open sterile sets simply to
practice these skills as this uses valuable resources. It is advisable to enquire of, for
example, the education lead for the department if there is an unsterile instrument set
kept for training purposes.
Working as a member of the extended surgical team may be physically demanding
for the SFA and, to allow the instruments to be handled correctly, the practitioner
should insist on being at an appropriate height in relation to the operating table.
Where necessary, one should plan ahead and make certain that a suitable step on
which to stand, or a stool on which to sit, is available. This will mean that one does not
stoop over the patient which could increase the risk of musculoskeletal injury to the
assistant or struggle to manage instruments. Ideally, one’s elbows should be at the
height of the operating table. Regardless of the instrument being used, the assistant
should consider their body posture keeping the upper arms and shoulders as relaxed
as possible (American College of Surgeons n.d.).
There is an increasing awareness of the physical impact that surgical assistance
can have on the practitioner providing this support to the surgeon. Linden etal. (2019)
identified that musculoskeletal risks to the assistant have the potential to affect patient
safety with the authors arguing for the inclusion of ergonomic education and aware-
ness in teaching programmes for all surgical assistants.
The SFA’s knowledge of the anatomy and physiology associated with their spe-
cialist area of practice will contribute to safe and effective instrument handling, while
ensuring that the practitioner appreciates the risks associated with, for example, the
required placement of retractors or use of suction devices.
THE USE OFHANDHELD RETRACTORS
Surgical First Assistants undertake, as an identified, delegated activity, the retraction
of wound edges to provide a good field of vision for the surgeon (Perioperative Care
Collaborative2018). Retractors differ widely in design and size (Crumplin2023). They
require varying techniques to ensure effective utilisation.
Selection of the appropriate retractor for the SFA by the operating surgeon will
depend on a variety of factors. These include the following:
• The operation being performed and its associated complexity.
• The stage of the operation being assisted and depth of the wound.
• The tissues that are to be retracted.
• The predicted length of the operation, as this may suggest the use of a self- retaining
rather than handheld retractor.
Consideration should be given to the placement of the instrument and the amount
of force that will be required of the assistant when retracting; this should be planned
carefully so as to avoid damage to underlying structures (Crumplin2023) and limit
The Use ofHandheld Retractors 89
the risk of cellular anoxia
1
in the tissues being retracted, while adequate access for the
surgeon is provided.
The choice of the retractor to be used is usually made by the surgeon; however,
the design of the retractor selected will impact the assistant’s ability to use it effec-
tively. While some handles sit comfortably in the assistant’s hand, others generate
more ergonomic challenges for the practitioner using them. Strategies to ensure effec-
tive wound exposure are required.
Before exploring specific approaches to retraction, there are some factors for the
SFA to consider:
• A retractor with a ‘flat’ handle may sit less comfortably in the hand and become
uncomfortable when used for any length of time.
• One should not grip the handle of the retractor more firmly than is required to
provide appropriate exposure.
• By exerting a constant and consistent pull on the retractor, the assistant pro-
vides the surgeon with a good view and stable tissue planes for dissection and/
or wound closure. If concentration flags, retraction often becomes inadequate
and the operative field may be compromised.
• The use of a handheld retractor for extended periods of time may result in
fatigue– muscular and mental. This can have an impact on the assistant’s effec-
tiveness, and it is important to make the operating surgeon aware of any diffi-
culties that one is having, rather than simply altering the placement or tension
of the retractor without warning.
• Retractors should be held in such a way as to produce the least amount of dis-
comfort to the assistant.
• The assistant should ensure that their hand position does not interfere with the
surgeon’s view of the operative field.
• It is not uncommon for the operating surgeon to move the assistant’s
retractor– this does not mean that the practitioner is at fault, merely that a
specific view is required.
• The assistant should avoid leaning on the patient when retracting. If holding
the position is proving difficult, the operating surgeon should be made aware.
• The assistant may find that by using their own body weight (by, for example,
leaning back a little) retraction will be more effective.
• By moving one’s feet slightly if required to re- position oneself, particularly
when retracting, fatigue from a poor stance can be reduced
2
.
1
Anoxia=a lack of oxygen to the tissues leading to the death of cells may be caused by sustained
pressure on the tissues.
Ischaemia= a reduction in oxygenated blood flow to the tissues, often the result of damage or
blockage to a blood vessel, which may result in the death of tissues supplied by that vessel.
2
Those practitioners who regularly assist lengthy operations may find that they benefit from invest-
ing in thromboembolus deterrent (TED) stockings/compression stockings to reduce the risk of
90 Chapter 8 Instrument Handling forthe Surgical First Assistant
RETRACTING AWAY FROMONESELF
It is important that the retractor sits comfortably in the hand when retracting away
from oneself. With the palm of the hand in the supine position and the elbow
flexed, the assistant is well positioned to use the instrument to good effect (see
Figure8.1).
RETRACTING TOWARDS ONESELF
Practitioner comfort, and as a result, effectiveness, will be facilitated by holding the
retractor with the palm of the hand facing downwards or towards oneself
(overhand); the best position will to some extent be dictated by the size and shape
of the handle of the instrument. Care must always be taken to use no more force
than is required. This will reduce muscle fatigue and inadvertent pressure damage
to underlying tissues.
For more information on tissue retraction, see Chapter7.
TISSUE FORCEPS
The SFA may find themselves working with a surgeon who, for example, when raising
skin flaps, prefers to use tissue forceps such as a Littlewoods or Allis. In such situa-
tions, it is important that the assistant is at the appropriate working height and that
they hold the instrument comfortably. A variety of grips may be used– common ones
FIGURE8.1 Retracting away from the assistant. Source: Courtesy of Ruth Shroff.
Handling Artery Forceps 91
are the use of the ringed instrument handles or a ‘pencil’ grip on the instrument
shaft. By maintaining an even tension on the tissues, the SFA will contribute to an
effective dissection and help avoid ‘buttonholing’ of the skin flap during the dissection.
SKIN HOOKS
Popular in both plastic and oncoplastic work, skin hooks can be demanding for the
SFA to hold for any length of time and effective communication with the surgeon is
needed should one’s hands become tired. By holding the instrument towards the end
of the handle furthest away from the operative site, the assistant is able to provide
good tissue tension for the surgeon. Some practitioners prefer a ‘pinch grip’ on the
handle, while others prefer a ‘pencil grip’. Regardless of the way in which the instru-
ment is held, it is important for the SFA’s elbows to remain close to their body as this
will reduce any muscular fatigue felt.
HANDLING ARTERY FORCEPS
The manipulation of artery forceps when supporting safe and effective haemostasis is
a skill that requires manual dexterity in both the dominant and non- dominant hands
of the assistant and good communication skills.
The correct placement of any ringed and ratcheted instrument in the assistant’s
hand will contribute to its effective use. The instrument should have the assistant’s
thumb and ring finger inserted into the rings (handles). This facilitates optimal
handling of the instrument and as such reduces the risk of damage to a blood vessel
when the artery forceps are being removed.
The SFA should ensure that when assisting with haemostasis effected by the use
of a ligature or suture, they are familiar with the steps required of them. These are:
• To lift the handle of the instrument so that the operating surgeon can pass the
ligature around the instrument.
• This requires considerable care so that the instrument does not damage the
blood vessel.
• To lower the instrument, thus fixing the ligature ready for the surgical knot
to be tied.
• This action will elevate the instrument tip for the surgeon, making it easier for
them to place the first throw of the knot.
• When the first throw of the surgical knot has been placed and tightened, the
instrument should be removed slowly and with care being taken to avoid causing
undue trauma to the vessel or surrounding tissues.
• The surgeon should give some indication that the instrument should
be removed.
92 Chapter 8 Instrument Handling forthe Surgical First Assistant
• Opening artery forceps requires that the assistant exerts pressure on the instrument
in order to release the ratchet closing the forceps. This is followed by a gentle
action to open the instrument (see Figure8.2).
• Care should be taken to remove the instrument in such a way that the surgeons’
view is not impaired.
Surgical First Assistants and others new to the assisting role should familiarise
themselves with the technique required to open artery forceps and practice applying
pressure in such a way as to ensure that they are able to open instruments smoothly
with both their left and right hands as the application of pressure when opening the
instrument differs depending on the hand being used (see Figure8.3).
SUTURE SCISSORS
Scissors are predominantly manufactured for individuals who are right- hand dominant
and those who are left handed should take time to learn the modifications to instrument
grip that will ensure effective assistance. This strategy will also benefit those who are
right dominant so that they are able to use scissors in both hands.
As with other ringed instruments, the thumb and ring finger are inserted into the
instrument handles with the index finger placed on the hinge of the instrument being
used to steady it (see Figure8.4). Myint (2018) considers that the following instrument-
handling strategies are effective:
FIGURE8.2 Opening an artery forceps with the right hand. Source: Courtesy of Ruth Shroff.
Suture Scissors 93
With the right hand hold the scissors by inserting the thumb into a ring of the
scissor handle no further than the (interphalangeal) joint. This will provide
control of the moving blade of the instrument.
The ring finger should also be inserted as far as the first (distal interphalangeal)
joint of the digit, allowing the rest of the hand to support the instrument’s
handle. The use of the index finger to steady the instrument can help to offset
any hand tremor; so too can the use of the other hand (if free) to steady the
instrument.
FIGURE8.3 Handling of artery forceps with the left hand. Source: Courtesy of Ruth Shroff.
FIGURE8.4 Suture scissors being held in the right hand. Source: Courtesy of Ruth Shroff.
94 Chapter 8 Instrument Handling forthe Surgical First Assistant
FIGURE8.5 Suture scissors being ‘palmed’. Source: Courtesy of Ruth Shroff.
Scissors should be kept closed when not in use, only being opened when required
to cut suture/ligature material.
When using the left hand, the thumb should be inserted into the ring beyond the
joint. This enables one to flex the joint and produce greater force between the
blades of the instrument. The ring finger should be inserted as before.
Most SFAs will find that their supervising surgeon will have a preferred tech-
nique for the left-
handed use of suture scissors. This is something to be learned
and practiced.
The SFA should ensure that they are familiar both with the requirements imposed
by the suture material being cut and the number of ‘ends’ to be cut. This latter is
indicated by the way in which the ligature or suture to be cut is presented by the
surgeon– one end being held usually requires that this is all that is to be cut, while
both ends being held up indicates that both are to be cut. However, one should always
take a moment to check if at all unsure. By using only the tips of the scissors to cut the
suture/ligature material, damage to surrounding tissues is avoided. The knowledge of
suture materials that the SFA brings to the assisting role will help them to appreciate
the different handling and knotting characteristics of suture and ligature materials
and enable them to ensure that they cut to an appropriate length, for example, mono-
filament suture material requires that longer ‘ends’ be left than when cutting braided
material so that the knot does not become unstable.
Whilst instruments should be handed back to the scrub practitioner once they
have been used, there may be situations where the SFA is required to have suture
scissors readily available, for example, if numerous blood vessels are being ligated in
succession.
In such situations, it may be necessary for the scissors to be retained and ‘palmed’
so as to have them available but out of the way and with the rest of the assistant’s hand
able to hold other instruments (see Figure8.5).
Minimal Access Surgery 95
MINIMAL ACCESS SURGERY
Minimal access surgery brings increased challenges for both the surgeon and the
assistant. The most important of these are the two- dimensional nature of the view of
the operative field, lack of tactile feedback and the fulcrum effect of the laparoscopic
entry ports.
In laparoscopic surgery, the surgeon and assistant both see the same thing. If the
camera assistant is unable to see clearly, the surgeon will not have the necessary view
of the area being operated upon. When acting as the camera assistant, the SFA should
consider the position of the laparoscopic stack system monitors, ensuring that they
can see the operative field clearly and are thus able to provide the surgeon with the
best possible view.
Surgical First Assistants are regularly required to act as camera assistants – an
active rather than passive role which requires the practitioner to have a good
knowledge of the anatomy of the area being operated on, an understanding of the
flow of the operation and a steady hand to avoid unnecessary camera movement. This
reduces the risk of inadvertent damage to key anatomical structures. The development
of a steady hand will ensure that the assistant is able to provide a stable image for the
surgeon and reduce the risk of frustration due to a poor view of the operative field
(Wicker and Dalby2016). By giving a stable view, the SFA will also avoid inadver-
tently triggering symptoms of motion sickness in susceptible members of the multi-
disciplinary perioperative team.
By familiarising themselves with the operation of the camera telescope unit, par-
ticularly in the context of white balancing and focus adjustment, the SFA will con-
tribute to a more relaxed operative environment.
The camera telescope unit can, during the course of an operation become heavy,
contributing to fatigue for the assistant and an unstable picture for the surgeon. A
good stance at the operating table and comfortable grip on the camera head can reduce
fatigue. Holding the camera from below, so that it sits in the angle of the hand bet-
ween the base of the thumb and index finger is a strategy that avoids undue stress on
the muscles of the assistant’s upper arm.
Laparoscopic instruments have handles made to a standard size and while many
SFAs will be able to simply place their hands in the spaces provided (thumb in the
posterior ring and other fingers in the forward ring), others may, as discussed by
Green etal. (2022), struggle to manage a comfortable grip. Practitioners with a glove
size of 6.5 or less have been found to be most affected by these findings. Zihni etal.
(2016) showed that the assistant is at considerable risk of ergonomic stress, particu-
larly in the non- dominant trapezius during laparoscopic operations. This will be more
noticeable if the camera assistant is also required to provide intraperitoneal retraction
during a procedure. These findings demonstrate the importance of the assistant tak-
ing adequate care of their physical well- being, finding the best hand position when
holding laparoscopic instruments and making the surgeon aware if they are starting
to struggle physically during the procedure.
96 Chapter 8 Instrument Handling forthe Surgical First Assistant
The SFA should ensure that if required to move an instrument within the bound-
aries established by the Perioperative Care Collaborative (2018), this is carried out
under direct vision, minimising the risk to surrounding structures.
It is advisable for the SFA to take any opportunities that are presented to under-
take simulated laparoscopic activities. These will develop confidence in instrument
and camera handling and provide an appreciation of the human factors associated
with this type of operation.
OTHER INSTRUMENTS REQUIRING CONSIDERATION
During open operations, the SFA may be required to undertake active suction under
the direction of the operating surgeon– an understanding of the anatomy, likely to be
hidden by any collection of blood will help to prevent inadvertent injury to the patient.
Holding the suction handpiece like a pencil will support fine control of the instru-
ment; this frees up the index finger of the supporting hand for situations where the
device requires closure of a suction control hole.
The use of a mounted swab, often on a sponge holding forceps, can be used as an
aid to either haemostasis or retraction– the instrument holding the swab should be
held comfortably in the hand, and the assistant may find that supporting the shaft of
the instrument provides good control while avoiding pressure damage to surrounding
structures. When using a ‘swab on a stick’, the practitioner must be able to recognise
when the swab has become saturated with blood / fluid and is no longer effective for
the task. They should have the confidence to be able to ask for a replacement at a suit-
able time or natural pause in the operation, swabs can be very abrasive and a dabbing
rather than scraping motion should be used when maintaining a clear operative field
so as to limit any trauma to the tissues.
The Perioperative Care Collaborative (2018) has identified that the SFA may
contribute to wound haemostasis using indirect or so- called passive diathermy-
related skills only. If required to hold a diathermy handset for passive diathermy
use (commonly known as ‘touch and buzz’), the SFA should hold the instrument
like a pencil. This will allow the use of the index finger to operate the coagulation
switch and enable the fine motor movements required to ensure that only an
appropriate metal- to- metal contact is made, thus avoiding damage to surround-
ing tissues. Once the surgeon has identified and grasped the blood vessel to be
sealed with an instrument, the blade of the diathermy handset should make
contact only with the part of the forceps furthest away from the blood vessel.
Activation of the diathermy hand switch should take place only once metal- to-
metal contact has been made as this avoids the risk of inadvertent thermal injury
to the patient or members of the surgical team. The assistant should be mindful
of the need for the surgeon to always retain a clear view of the operative field and
plan their placement of the diathermy blade on the instrument to be touched so
that this is facilitated.