- Surgical first assistant
- A qualified surgical professional who, under the surgeon's direction, provides exposure, hemostasis, tissue handling, and wound closure — without making independent surgical decisions.
- CSFA
- Certified Surgical First Assistant — the NBSTSA's advanced first-assistant credential, distinct from the CST scrub-role credential.
- Aseptic technique
- The set of practices that keep the surgical field free of pathogenic microorganisms; the governing rule is that sterile touches only sterile.
- Surgical hand scrub direction
- Scrub from the fingertips toward the elbow so the hands stay the cleanest area; afterward hold hands and forearms above the waist and in sight.
- Closed gloving
- Self-gloving in which the hands stay inside the gown cuffs until the gloves are pulled over them, keeping the sterile gown sterile.
- Sterile zone of a gown
- A scrubbed person is sterile only from the chest down to the level of the sterile field (table top); the axillae and gown back are not sterile.
- Strike-through
- Contamination that occurs when moisture wicks through a sterile drape or gown, breaching the sterile barrier.
- Surgical conscience
- The honesty and discipline to recognize and correct any break in sterile technique — even when unobserved — because patient safety depends on it.
- Edge of a sterile drape
- The outer ~1 inch (about 2.5 cm) of a sterile drape or wrapper is considered nonsterile, a boundary that must not be crossed.
- Retraction
- Holding tissue or organs out of the operative field to give the surgeon clear exposure — the first assistant's defining duty.
- Traction and counter-traction
- Opposing forces applied to tissue to create even tension, opening the anatomic plane so the surgeon can dissect sharply along the correct plane.
- Halsted's principles
- Gentle tissue handling, strict asepsis, sharp dissection, careful hemostasis, preserved blood supply, no dead space, and no tension.
- Sharp dissection
- Cutting tissue with a scalpel or scissors along an anatomic plane, as opposed to blunt dissection, which separates tissue by tearing or spreading.
- Vein retractor / nerve hook
- A fine, atraumatic retractor chosen for small, delicate structures that would be injured by a larger instrument.
- Hemostasis
- Control of bleeding by mechanical, thermal, or chemical means — the first assistant's central role in keeping a dry, visible field.
- Mechanical hemostasis
- Physically occluding a vessel: direct pressure, hemostatic clamps, ligatures, vessel loops, surgical clips, bone wax, and the pneumatic tourniquet.
- Chemical (topical) hemostatic agents
- Agents that promote clotting: gelatin (Gelfoam), oxidized cellulose (Surgicel), microfibrillar collagen (Avitene), thrombin, and fibrin sealant.
- Free tie
- A single strand of suture looped and tied around a clamped vessel to occlude it; can slip off a large, pulsating vessel.
- Suture ligature (stick tie)
- Suture on a needle passed through a large vessel's wall and tied, anchoring the ligature so it cannot slip off.
- Vessel loop
- A thin silicone band passed around a vessel; doubled and snugged it can temporarily occlude blood flow or simply isolate the vessel.
- Microfibrillar collagen
- A topical hemostatic agent that works by providing a surface that triggers platelet aggregation.
- Bone wax
- A mechanical hemostatic agent smeared onto cut bone surfaces to physically occlude bleeding from the bone.
- Pneumatic tourniquet
- An inflatable cuff that occludes arterial flow to a limb for a bloodless field; the limb is usually exsanguinated first, and prep must not pool beneath it.
- Absorbable suture
- Suture broken down by the body over time (gut, polyglactin/Vicryl, poliglecaprone/Monocryl, PDS); for deep layers and ligation needing only temporary support.
- Non-absorbable suture
- Suture that retains strength long-term (silk, nylon, polypropylene/Prolene, steel); for skin, tendon, anastomoses, and permanent implants.
- Monofilament suture
- A single-strand suture with low tissue drag that resists harboring bacteria but handles stiffer (nylon, polypropylene, PDS).
- Multifilament (braided) suture
- Many strands braided together; handles and ties easily with good knot security, but interstices can wick fluid and harbor bacteria (silk, braided polyester, Vicryl).
- Interrupted suture
- Individually placed and knotted stitches; if one fails, the rest of the closure holds — more secure than a continuous suture.
- Continuous (running) suture
- A single strand sewn down the wound; fast and tension-distributing, but a single break can loosen the whole line.
- Equal suture bites
- Placing each bite at equal depth on both sides of a wound so the edges approximate evenly.
- Wound closure tension
- Excessive tension is avoided because it compromises blood supply to the wound edges and impairs healing.
- Skin staple removal
- Skin staples are removed postoperatively with a dedicated staple extractor (remover), not a clamp.
- Surgical drain
- A device that evacuates fluid or air from a wound; where it exits the skin the first assistant typically secures it with a suture.
- Negative pressure wound therapy (NPWT)
- Vacuum-assisted closure using foam under suction to promote healing; the foam dressing is changed on a scheduled interval (commonly every 2–3 days).
- Radiopaque marker in sponges
- Surgical sponges used in a body cavity contain a radiopaque marker so a retained sponge can be found on X-ray.
- Site marking & Time Out
- Marking the surgical site and confirming it during the Time Out helps prevent wrong-site surgery.
- Local anesthetic infiltration
- Injecting a local anesthetic into the wound margins, often before closure, to provide postoperative pain control at the incision.
- Epinephrine with local anesthetic
- Added for vasoconstriction, which prolongs the anesthetic effect and reduces bleeding; avoided in digits, nose, ears, and other end-arterial structures.
- Double gloving
- Wearing two pairs of gloves, commonly practiced by the first assistant to reduce the risk of exposure if the outer glove is punctured.
- Healing by primary intention
- A clean wound whose edges are approximated and held together, healing quickly with minimal scarring.
- Lithotomy positioning
- When moving a patient to lithotomy, both legs are raised and lowered together to protect the hips and prevent injury.
- Dispersive (return) electrode placement
- The grounding pad is applied over well-perfused muscle rather than a bony prominence to prevent return-electrode burns.
- Drape with a small tear
- A drape found to have a hole or tear after application is contaminated and must be covered or re-draped, not used as is.
- Informed consent verification
- Confirming the signed consent lists the correct patient, procedure, and site before the procedure begins.
- Exsanguination before tourniquet
- Draining blood from a limb (often with an Esmarch bandage) before inflating a pneumatic tourniquet to create a bloodless field.
- Halsted-style tissue handling
- Gentle, atraumatic handling that minimizes tissue injury, preserves blood supply, and promotes faster, complication-free healing.
- Surgical clips (ligating clips)
- Small metal or polymer clips applied to occlude a vessel quickly when a tie would be slower or harder to place.
- Sterile field at rest
- An unattended, uncovered, or out-of-sight sterile field is considered contaminated.
- Skin antiseptic motion
- Antiseptic prep is applied starting at the incision and moving outward in expanding circles, clean to dirty, without returning a used sponge to the center.
- Surgical first assistant scope
- The CSFA assists under the surgeon's direction and does not make independent surgical decisions or perform the surgeon's role.
- Electrosurgery
- Passing high-frequency current through the patient's tissue to cut or coagulate; the tissue completes the circuit.
- Electrocautery
- Heating a wire element directly with current that does NOT pass through the patient; the hot wire transfers heat to tissue.
- Monopolar electrosurgery
- Current flows from the active electrode through the patient to a dispersive return pad and back to the generator; a return electrode is required.
- Bipolar electrosurgery
- Current flows only between the two tips of the instrument, so no patient return pad is needed and the path is small and localized.
- Fulguration
- A monopolar coagulation technique that sparks the electrode across a gap to char and coagulate a broad tissue surface.
- Cut vs. coagulation waveform
- The cut mode uses a continuous low-voltage waveform for cleaner cutting; coagulation uses an interrupted higher-voltage waveform; blend combines cutting with hemostasis.
- Advanced bipolar vessel sealer
- A device that uses pressure and bipolar energy with impedance feedback to fuse vessel walls into a permanent seal, often up to a rated diameter.
- Ultrasonic (harmonic) device
- An energy device that uses high-frequency mechanical vibration to cut and coagulate tissue with little lateral thermal spread.
- Isolated electrosurgical generator
- A generator that references current to itself rather than ground, largely replacing older ground-referenced units to reduce alternate-site burns.
- Surgical smoke (plume)
- Vaporized mixture of fine particulates, chemicals, and possibly viable cells released when energy thermally destroys tissue — a respiratory and biological hazard.
- Smoke evacuator placement
- Hold the evacuator wand close to the source (within about 2 cm) to capture plume effectively, with in-line filtration.
- Plume biological hazard
- Surgical plume from some lesions can carry viable viral particles (e.g., HPV DNA), adding a biological risk beyond the chemical one.
- Negligence
- An unintentional tort — harm resulting from failing to act as a reasonably prudent professional would.
- Four elements of negligence
- Duty, breach of that duty, causation, and damages — all four must be proven, or the claim fails.
- Respondeat superior
- A doctrine holding an employer liable for an employee's negligent acts within the scope of employment; the individual remains personally accountable.
- Patient confidentiality
- A legal and ethical duty of the first assistant; breaching it violates patient privacy obligations and exposes the assistant to liability.
- Consent verification (legal)
- From a legal standpoint, the assistant verifies the consent form lists the correct patient, procedure, and site and is properly signed.
- Fire triangle in the OR
- An OR fire needs an ignition source (electrosurgery, laser), fuel (drapes, prep, gauze), and an oxidizer (oxygen, nitrous oxide).
- OR oxidizer hazard
- Supplemental oxygen and nitrous oxide accumulating beneath the drapes create the oxidizer-enriched atmosphere that makes OR fires especially dangerous.
- PASS (fire extinguisher)
- Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep side to side.
- Alcohol prep fire prevention
- Let alcohol-based prep dry completely before draping or activating energy, because pooled prep is a fire and burn hazard.
- Incident command system
- The structured command framework a facility activates during an external disaster or mass-casualty event to coordinate the response.
- Power failure response
- During an intraoperative power failure, the team relies on backup power and stabilizes the patient while maintaining the sterile field and safety.
- Laser plume hazard
- Smoke from a laser case carries a laser-specific hazard in addition to the chemical and biological risks of surgical plume.
- Documenting energy modality
- Accurate charting distinguishes electrosurgery (current through tissue) from electrocautery (heated wire) — they are not interchangeable terms.
- Standard Precautions
- Treating all blood and body fluids as potentially infectious and using appropriate barriers and practices with every patient.
- Subject matter expert role
- Within Ancillary Duties the CSFA may serve as a technical resource to the surgical team on equipment and assisting technique.
- Vessel sealer vs. metal clip
- An advanced bipolar vessel sealer is chosen over a metal clip when a durable seal is wanted without leaving a foreign body or interfering with later imaging.
- Malignant hyperthermia (MH)
- A rare, inherited hypermetabolic crisis triggered in susceptible patients by volatile anesthetics or succinylcholine.
- Earliest sign of MH
- A rapidly rising end-tidal CO₂ (ETCO₂) is the earliest and most sensitive sign; a temperature rise is a late sign.
- MH triggers
- Volatile inhalational anesthetics (e.g., sevoflurane, isoflurane) and the depolarizing relaxant succinylcholine.
- Dantrolene
- The specific antidote for malignant hyperthermia; many vials must be reconstituted quickly, so several people mix it at once.
- MH inheritance
- Susceptibility is largely inherited, so a family history of anesthesia problems is relevant preoperatively.
- Masseter rigidity
- Generalized muscle rigidity, especially of the masseter (jaw), in a patient given a triggering agent is an early warning of MH.
- Shock
- Inadequate tissue perfusion; classified as hypovolemic, cardiogenic, distributive, or obstructive.
- Hypovolemic shock
- Loss of intravascular volume — from hemorrhage or fluid loss — dropping circulating volume; the most common surgical cause is blood loss.
- Cardiogenic shock
- Pump failure — the heart cannot pump effectively (MI, arrhythmia, heart failure), so cardiac output falls despite adequate volume.
- Distributive shock
- Massive vasodilation dropping systemic vascular resistance; includes anaphylactic, septic, and neurogenic shock.
- Obstructive shock
- A mechanical block to blood flow — tension pneumothorax, cardiac tamponade, or massive pulmonary embolism.
- Anaphylactic shock
- A severe, rapid allergic reaction (distributive shock) with hypotension, hives, and bronchospasm; common triggers are latex and antibiotics; treat with epinephrine.
- Septic shock
- A form of distributive shock in which infection causes widespread vasodilation and impaired perfusion.
- Synergism
- A drug-drug interaction in which two medications together produce an effect greater than the sum of their separate effects.
- Atropine effects
- An anticholinergic; expected effects include a dry mouth and dilated pupils.
- Monitored anesthesia care (MAC)
- Sedation in which the patient breathes spontaneously while an anesthesia provider monitors and titrates the medications.
- Diphenhydramine
- An antihistamine sometimes given for a mild allergic drug reaction to counter histamine-mediated symptoms.
- Topical vs. infiltration anesthesia
- Topical anesthesia is applied to a surface (skin or mucosa); infiltration anesthesia is injected into the tissue.
- Benign vs. malignant tumor
- A benign tumor remains localized and does not invade or metastasize; a malignant tumor invades and can spread.
- Carcinoma
- A malignant tumor arising from epithelial tissue — the linings and coverings such as skin and organ linings.
- Sarcoma
- A malignant tumor arising from connective or mesenchymal tissue, such as bone, cartilage, fat, muscle, and blood vessels.
- Fistula
- An abnormal connection or passage between two structures or organs that are not normally connected.
- Peritonitis
- Inflammation of the peritoneum, the lining of the abdominal cavity — relevant to abdominal surgery.
- Pathologic fracture
- A fracture through bone already weakened by disease (e.g., tumor, osteoporosis), sometimes from minimal force — unlike a traumatic fracture.
- Osteoporosis
- A pathologic loss of bone density that weakens bone and increases fracture risk, raising surgical and positioning concerns.
- Deep vs. superficial incisional SSI
- A deep incisional surgical site infection involves the fascia and muscle layers; a superficial one involves only skin and subcutaneous tissue.
- Aerobic bacteria
- Bacteria that require oxygen to grow; thrive in oxygen-rich environments.
- Anaerobic bacteria
- Bacteria that grow without oxygen and may be harmed by it; favor deep, poorly oxygenated tissue and abscesses.
- Fungi vs. bacteria
- Fungi such as Candida are eukaryotic (have a true nucleus), unlike bacteria, which are prokaryotic.
- Wound healing & tissue oxygenation
- Adequate tissue oxygenation is one of the most important local factors in wound healing.
- Smoking & wound healing
- Nicotine and carbon monoxide cause vasoconstriction and reduced oxygen delivery, impairing healing of the surgical wound.
- Pfannenstiel incision
- A low transverse abdominal incision often chosen over a vertical midline for a stronger, more cosmetic closure with less herniation.
- Open vs. laparoscopic approach
- An open procedure may be chosen over laparoscopy for extensive disease, dense adhesions, bleeding, or other complicating conditions.
- Metabolic alkalosis from vomiting
- Prolonged vomiting and gastric suction lose acid and chloride, putting the patient at risk for metabolic alkalosis and fluid/electrolyte imbalance.
- Hypovolemia in surgery
- The most common surgical cause of shock — another reason meticulous hemostasis and blood-loss monitoring matter.
- Tension pneumothorax
- A buildup of air in the pleural space that mechanically blocks venous return, a cause of obstructive shock.
- Cardiac tamponade
- Fluid in the pericardial sac compressing the heart and limiting filling — a cause of obstructive shock.
- Pulmonary embolism (obstructive)
- A large clot obstructing pulmonary blood flow, which can produce obstructive shock.
- Latex anaphylaxis
- Latex is a classic intraoperative trigger of anaphylactic (distributive) shock — recognize hypotension with hives quickly.
- End-tidal CO₂ (ETCO₂)
- The CO₂ measured at the end of exhalation; a rapid, unexplained rise is the earliest sign of malignant hyperthermia.
- Mesenchymal tissue
- Connective tissue of mesodermal origin — bone, cartilage, fat, muscle, and blood vessels — the origin of sarcomas.
- Epithelial tissue
- The linings and coverings of the body (skin, glands, organ linings) — the origin of carcinomas.