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41
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 4
Pre- operative Preparation
ofthe Patient Within the
Operating Theatre
Dave Lawson
Programme lead, Senior Lecturer, Edgehill University, UK
INTRODUCTION
The Royal College of Surgeons (RCS) identifies the surgical first assistant (SFA) as a
member of the surgical team who provides dedicated and competent assistance to the
surgeon during the procedure, while not performing any surgical intervention
(RCS2024). While this definition alludes to the SFA only providing surgical assistance
during surgery, the PCC (2018) position statement identifies that the SFA has a respon-
sibility to assist with the pre- operative preparation of the patient within the operating
theatre and the RCSEng (ND) confirms that the SFA has a role in the pre- operative
stage of the patient’s journey.
Depending upon local organisational policy, the SFA may be part of the theatre
team and have responsibilities in the preparation of the operating theatre, ready to
receive the patient for surgery. In other departments, the SFA may be part of the
surgical team, visiting the patient preoperatively and therefore, the theatre would
have already been prepared (Wicker and Dalby2017). This chapter will review the
responsibilities of the SFA in relation to attending the team brief, patient positioning,
skin preparation and draping.
42 Chapter 4 Pre- operative Preparation ofthe Patient
TEAM BRIEF
The team brief, as part of the National Safety Standards for Invasive Procedures
(NatSSIPs2), provides a forum for the sharing of information about the patient, the
anaesthetic and surgical procedure from key team members including the surgical
assistant (CPOC2024). NatSSIPS2 provides a set of standards that all team members
follow to reduce ‘never events’. The NHS (2024, p.1) defines ‘never events’ are serious
incidents that are entirely preventable because guidance or safety recommendations
providing strong systemic protective barriers are available at a national level and
should have been implemented by all healthcare providers. One aim of the team brief
is to introduce the name and role of each team member to enhance patient safety by
improving communication and enable planning. This is an appropriate time for the
SFA to introduce their name and role to ensure transparency, especially when some
practitioners may switch between the scrub practitioner and SFA roles regularly.
To plan for the immediate pre-
operative stage of the patient’s journey in the
operating theatre, the team brief also allows the SFA and other surgical team mem-
bers to identify the information detailed in Table4.1 to safely plan and complete the
pre- operative preparation of the patient once in the operating theatre. Note that due
to the introduction of Local Standards for Invasive Procedures (LoCSSIPS), the list in
this table may not be exhaustive.
It is imperative for the SFA to have a comprehensive understanding of any
information that is relayed in the team brief, to reduce risk and ensure the successful
outcome of surgical procedures (Wicker and Dalby2017). For example, knowledge of
patient allergies is essential to prevent adverse reactions (Dorfel etal.2010). Shaving
requirements of the operating surgeon enables the SFA to prepare the patient’s sur-
gical site appropriately prior to applying skin preparation and minimising the risk of
surgical site infection (SSI) (Dorfel etal.2010).
TABLE4.1 Information discussed in the team Brief for each patient (Adapted
from CPOC2024).
Diagnosis, consent, planned procedure and laterality
Relevant comorbidities or complications
Airway management plans if applicable
Additional monitoring or equipment needed
Patient communication issues or disability
Allergy status
Blood management plans
Patient positioning
Infection prevention and control issues
Implant, prosthesis, stent availability
Equipment requirements/special equipment and extras
Antibiotics and/or another drug required
Other risks, for example, lasers, fire risk and management plan
Postoperative destinations, for example, ward or critical care unit.
Patient Positioning 43
Being aware of the planned surgical procedure and familiarity with surgical
equipment including implantable medical devices prior to surgery are paramount for
the SFA to effectively anticipate the surgeon’s needs and to ensure a seamless operation.
Trainee SFAs, or SFAs transferring into a new speciality, should become familiar with
surgical procedures as well as common anatomy and pathophysiology of the speciality
they work in. Being well versed in the equipment and procedures enhances efficiency
and reduces the likelihood of errors or delays during surgery (CPOC2024).
Having an understanding preoperatively of the potential complications that may
occur during the surgical procedure, such as bleeding, equips the SFA to adapt quickly
and make necessary adjustments to support the surgical team effectively. Knowledge
of estimated blood loss is crucial for monitoring patient stability and facilitating
prompt interventions if excessive bleeding occurs (Wicker and Dalby2017). The SFA
should also have a good knowledge of available methods to control haemostasis to
prevent delays during surgery. See Chapter6 for more information on managing intra-
operative haemorrhage.
TIMEOUT
Before the commencement of surgery, all team members will pause to confirm their
name and role as well as the patient’s name, procedure, site and position (WHO2024).
This should be performed prior to knife to skin and confirmed against the patient’s arm-
band, operating list, consent form and patient notes. At this stage, the team also confirm
expected blood loss, specific equipment requirements and other safety checks
(WHO2024). All checks must be completed before the actual commencement of surgery
as this provides an opportunity for anyone in the team, including the SFA, to raise concerns.
PATIENT POSITIONING
The importance of correct surgical positioning exceeds more than manual handling as
it is the cornerstone upon which patient safety, surgical efficiency and clinical outcomes
rest (Bilski 2023). Each twist, turn and tilt of the patient’s body can influence the
surgeon’s perspective, provide access to not only anatomical structures but also risk
complications. From minimising the risk of nerve injury to ensuring adequate blood
circulation and ensuring the connection to the anaesthetic machine is not interrupted,
correct proper positioning is integral to mitigating potential risks and maximising the
likelihood of a successful surgical outcome. Moreover, beyond its immediate impact on
the surgical procedure, patient positioning extends its influence into the realm of post-
operative recovery. Correct and safe positioning can reduce the risk of post- operative
complications such as pressure injuries, deep vein thrombosis and respiratory
complications, thereby, facilitating a smoother recovery trajectory for the patient
(Bilski2023). For the SFA, it is important that they have a thorough understanding
of the complexities and intricacies of patient positioning in surgery, exploring its
44 Chapter 4 Pre- operative Preparation ofthe Patient
fundamental principles, techniques and the pivotal role of the SFA in ensuring its safe
execution. Through a comprehensive understanding of the importance of correct
surgical positioning, the team aim to underscore its significance as a cornerstone of
surgical practice and advocate for its consideration in every surgical speciality to ensure
adequate surgical access for the surgeon (Wicker and Dalby2017).
While it is the surgeon’s responsibility to identify the position that is required for
surgery, the responsibility of ensuring correct patient positioning falls to the whole
team to ensure adequate surgical access for the surgeon as well as ensuring airway
and intravenous access for the anaesthetist (Wicker and Dalby 2017). Prior to
positioning, the SFA should ensure they have performed or reviewed a tissue viability
assessment to implement the correct care required and any changes in skin colour or
damage to skin are recorded and reported to the consultant surgeon. The SFA will
need to consider the patient’s body mass index and what supports or additional
equipment they may need to ensure safety and surgical access and communicate this
to the team (Wicker and Dalby2017).
There is a wide range of varied, and sometimes, complex surgical positions that
are needed to gain surgical access (Bilski 2023). Some patients may need to be
repositioned during surgery. The SFA must be aware of common surgical positions
and be able to identify which position is used for each procedure as well as surgeons’
preferences. The most common surgical positions that are used during surgery and are:
• Supine: The patient is placed on their back with their head and spine in an
aligned position with arms at either side or abducted to less than 90° to reduce
the strain on the shoulder muscles.
• Prone: The patient is placed on their front with their head and spine aligned
and their torso supported by table attachments such as a Montreal mattress to
aid security and comfort to the patient. The patient’s arms should be brought
simultaneously brought up and placed either side of the patient’s head, resting
on an arm board that slides under their chest. Pillows are placed under hips
and shins to aid support; a head ring may be used to support the patient’s head.
• Lithotomy: Initially, the patient is placed in the supine position and then the
legs are placed 30°– 45° with knees flexed and legs supported in straps held by
poles. It is commonly used for gynaecology surgery.
• Lloyd Davies: In the supine position, the patient’s legs are simultaneously
placed in stirrups or pneumatic boots with the hips flexed at 15° for the surgeon
to gain access to the rectum or genitals.
• Trendelenburg: The patient is placed in supine, lithotomy or Lloyd Davies
and the table reclined to lower the patient’s head. This position is commonly
used to move organs such as the bowel out of the way in gynaecology surgery
or reduce the risk of bleeding in varicose vein surgery.
• Reverse Trendelenburg: This time the table is moved to incline the patient’s
head. This position is commonly used in ear, nose and throat and thyroid sur-
gery. Straps may be required to secure the patient in this Trendelenburg position.
Skin Preparation 45
SKIN PREPARATION
During the pre- operative preparation of the patient, another responsibility of SFA is
preparing the skin. The first consideration is whether the patient needs to be shaved
to remove any hair from the surgical site. Not all surgical sites require hair removal
however, hair contains bacteria and if not removed when close to the surgical site,
then this may lead to an increased risk of a surgical site infection (SSI) (Spruce2021).
Hair can make sanitisation of the skin difficult when using antiseptic solutions
(NICE 2020). Hair can also prevent dressings from adhering to the skin. If hair
removal is required, then evidence suggests that the use of a fixed razor increases the
risk of SSI and therefore clippers should be used to reduce this (Tanner and
Melen2021). The timing of when to shave is also important and can have an adverse
effect on reducing the SSI; therefore, a shaving window of a maximum of two hours
prior to the operation is advised otherwise this increases the risk of SSI (Tanner and
Melen2021).
The essence of skin preparation is twofold. Initially, it assists with the removal of
transient microorganisms from the patient’s skin and then has a residual effect by
reducing regrowth (Spruce2021). The SFA must know the different types of skin
preparations and any contraindications. Several factors influence the selection of an
appropriate prepping solution including its antimicrobial efficacy, compatibility with
the patient’s skin, safety profile, cost- effectiveness and the surgeon’s preference. Local
availability will also influence selection.
Care must be taken when using alcoholic solutions in the presence of diathermy
as there is a risk of a surgical fire. Pooling of alcoholic solutions should be avoided to
reduce the risk of burns to the patient but NICE (2020) suggests the use of antiseptic
solutions to reduce this risk.
Chlorhexidine Gluconate
Chlorhexidine gluconate (CHG) commonly used as pre- operative skin disinfection is
a broad- spectrum antiseptic agent successful against a wide range of bacteria including
both Gram- positive and Gram- negative organisms, and certain fungi and viruses
(Hasegawa etal.2022). CHG is available in a water- based or alcohol solution and is
mostly well endured by most patients and suitable for use on external skin. Precau-
tions should be taken to avoid contact with CHG on mucous membranes and other
sensitive areas (Hasegawa etal.2022).
Povidone- Iodine
Povidone- iodine (PVP- I) is also available in a water- based or alcohol solution and
displays broad- spectrum antimicrobial action against bacteria, viruses and fungi. It
rapidly kills pathogens upon contact; however, while it may be the antiseptic of
choice in patients who have an allergy to CHG, PVP- I may cause irritation or
46 Chapter 4 Pre- operative Preparation ofthe Patient
allergic reactions in individuals and caution should be exercised in patients with
iodine sensitivity (Shi etal.2022). Evidence suggests that PVP- I is generally safe for
use on intact skin but should be avoided in certain populations such pregnant
women and individuals with thyroid disorders (Vercammen et al. 2021; Shi
etal.2022).
When applying the antiseptic solution, it is the best practice to work from the inci-
sion site to the periphery to prevent cross-
contamination of the surgical site. In the
presence of a wound that is contaminated, such as an abscess, it is best to start at the
periphery and work towards the wound (Whalan2006).
DRAPING THEPATIENT
Surgical draping is a fundamental factor in creating and retaining a sterile environ-
ment during surgical procedures (Sworn etal. 2023). Draping involves covering the
patient and surrounding areas with sterile barriers to prevent contamination and
minimise the risk of SSIs (AfPP2021). The choice between reusable and disposable
drapes is an important consideration for the SFA and wider team members as selec-
tion can impact on patient safety, cost- effectiveness and environmental sustainability
(Wedmore2023). The SFA must have a good knowledge and understanding of the
differences between reusable and disposable surgical drapes, advantages and disad-
vantages to ensure a sterile field is secured.
Reusable surgical drapes are typically made from durable fabrics such as cotton
or polyester blends and are designed to withstand multiple cycles of sterilization
and use (McQuerry etal.2021). Some of the key qualities of reusable drapes include
the durability. It has been shown that by using reusable drapes that are fabricated
from high- quality materials that they can withstand laundering, sterilisation and
repeated use without compromising their integrity or barrier properties (McQuerry
etal.2021). Another factor to consider is the cost- effectiveness of using reusable
drapes (Wedmore2023). While reusable drapes may have a higher upfront cost,
they can be more cost- effective over time compared to disposable drapes. With
proper maintenance and reuse, the per- procedure cost of reusable drapes may be
lower than that of disposable alternatives. However, reusable drapes require water,
energy and chemicals for laundering and sterilisation, which can have
environmental implications. Sustainability should be a consideration to meet, for
example, the new statutory emissions and environmental targets organisations
(NHS England2022).
In comparison, the surgical team could use disposable surgical drapes. Disposable
drapes are made from non- woven materials such as polypropylene or polyethylene
and are intended for single use only (AfPP2021). One drawback of these is in the gen-
eration of additional clinical waste that adds to the accumulation of non- biodegradable
waste in landfill sites (Wedmore2023). Disposable drapes, however, offer convenience
and time savings for healthcare facilities as they eliminate the need for laundering,
sterilization and storage (Wedmore2023). Evidence suggests that there is no difference