Responsible surgery

The American College of Surgeons defines the intraoperative responsibility of the primary surgeon

The American College of Surgeons has released a Statement on Principles on the responsibility of the primary surgeon during surgery. Recent news reports had raised questions about the primary surgeon initiating a second surgery before the first surgery was fully completed. These reports led to a larger discussion of the reasons why surgeons may leave an operating room during the course of a surgery and the appropriate actions that need to be taken to inform the patient and ensure continued safe care.

General statement

The primary attending surgeon is personally responsible for the patient’s welfare throughout the operation. In general, the patient’s primary attending surgeon should be in the operating suite or be immediately available for the entire surgical procedure. There are instances consistent with good patient care that are valid exceptions. However, when the primary attending surgeon is not present or immediately available, another attending surgeon should be assigned as being immediately available.

The definitions at the end of this Statement provide essential clarification for terms used herein.

Concurrent or simultaneous operations

Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key components of an operation are determined by the primary attending surgeon. A primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.

Overlapping operations

Overlapping of two distinct operations by the primary attending surgeon occur in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed and there is no reasonable expectation that there will be a need for the primary attending surgeon to return to that operation. In this circumstance a second operation is started in another operating room while a qualified practitioner performs non-critical components of the first operation allowing the primary surgeon to initiate the second operation, for example, during wound closure of the first operation. This requires that a qualified practitioner is physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively impact the seamless and timely flow of either procedure.

Multidisciplinary operations

Contemporary surgical care may require multidisciplinary operations. During such operations, it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, an attending surgeon must be immediately available for the entire operation.

Delegation to qualified practitioners

The surgeon may delegate part of the operation to qualified practitioners including, but not limited to residents, fellows, anesthesiologists, nurses, physician’s assistants, nurse practitioners, surgical assistants or another attending under his or her personal direction. However, the primary attending surgeon’s personal responsibility cannot be delegated. The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety.

Procedure-related tasks

A primary attending surgeon may have to leave the operating room for a procedure-related task. Such procedure-related tasks could include review of pertinent pathology (“frozen section”) and diagnostic imaging; a discussion with the patient’s family; and breaks during long procedures. The surgeon must be immediately available for recall during such absences.

Unanticipated circumstances

Unanticipated circumstances may occur during procedures that require the surgeon to leave the operating room prior to completion of the critical portion of the operation. In this situation, a backup surgical attending must be identified and available to come to the operating room promptly.

Circumstances in this category might include sudden illness or injury to the surgeon, a life-threatening emergency elsewhere in the operating suite or contiguous hospital building, or an emergency in the surgeon’s family.

If more than one emergency occurs at the same time, the attending surgeon may oversee more than one operation until additional attending surgeons are available.

Surgeon-patient communication (Section II.A.)

The surgical team involved in an operation is dependent on the type of facility at which the operation is performed and the complexity of the surgery. At a free standing outpatient surgical center, many procedures are performed solely by the primary attending surgeon with no assistant. In contrast, a complex procedure at an academic medical center may involve multiple qualified medical providers in addition to the primary attending surgeon. As part of the pre-operative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained. If an urgent or emergent situation arises that require the surgeon to leave the operating room unexpectedly, the patient should be subsequently informed.