Instrument Handling and Maintaining Sterile Field Setup Instructions

The learner and the assistant playing the surgeon role should stand on opposite sides of the operating table with a draped mound representing the patient, in their usual operative positions. The “patient’s” abdomen represents the operative field.

Place the Mayo stand over the “patient's” lower legs/feet position, within normal reach of the scrub nurse and surgeon. Arrange the instruments needed during the examination on the draped Mayo stand or on the back table where they would be during a laparotomy.

The learner's back table should be adjacent to the patient’s feet, positioned so that the learner can turn to manage instruments easily without leaving the sterile field. The “operative field”, the Mayo Stand, and the back table should all be considered the “sterile field”.

A kidney dish for scalpel transfer and the materials needed for cleaning instruments should be readily accessible on the back table. Establish a separate location (such as a basin) visible to the observer but away from the “sterile field” for instruments that become contaminated and will not be returned to the sterile field.

A typical arrangement viewed from above would be:

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The observer or camera stands at the patient's feet, facing toward the operative field.

This position should provide a clear view of:

• both the surgeon's and scrub nurse's hands during instrument passage;
• the Mayo stand and the orientation of instruments on it;
• the kidney-dish transfer of the scalpel;
• receipt of the loaded needle holder;
• placement of returned instruments on the Mayo stand.

By turning slightly to the right, the observer should also be able to see the learner working at the back table, including wiping/cleaning returned instruments, reorganizing them, isolating contaminated instruments, managing sharps, and performing final field breakdown.

The assistant should behave like a surgeon concentrating on the operative field rather than like another nurse or an examiner. For most passes, the ‘surgeon’ should continue looking toward the simulated incision and present a receiving hand in a consistent position.

The assistant should not compensate for a poor pass by reaching for the instrument, rotating it into the correct orientation, or changing hand position to make the learner successful. This allows the observer to distinguish an instrument that is merely safely offered from one that is placed correctly into the surgeon's functional grip.

For returns, the assistant should use standardized movements. For the scalpel transfer, the surgeon should retain it until the learner presents the kidney dish, then place the scalpel into the dish.

During practice and examination, the learner should deliberately work between the Mayo stand and back table, rather than conducting every exchange from one surface.

As is explored in “Setting up the Operative Field”, frequently used instruments should be on the Mayo stand. Other instruments should remain on the back table so the learner may demonstrate selecting an instrument, bringing it into use, receiving it back, cleaning it when necessary, and returning it to an appropriate location.

After the procedure is declared complete, the learner will demonstrate securing sharps, consolidating instruments, separating items requiring different disposition, and breaking down the sterile field. Note, for this exercise it is assumed that the final counts have been done and are complete and correct.

For in-person practical examination and practice purposes, the exercises in the “Surgical Counting” module can be done with this same setup and practiced together, however for assessment purposes with the PeerReview App, the steps of this exercise should be recorded separately in the order in which they are specified in the practice instructions and assessment rubric.