Welcome to the Operating Theatre

Stepping inside an operating theatre can be daunting for anybody. It is a unique, somewhat uncomfortable environment where people have an unusual sense of humour and a rare degree of multi-tasking competence. The sterile field, everyone dressed in the same scrubs with masks covering their faces makes telling staff apart impossible.

What is the role of the medical student in the operating theatre? The answer varies from useless to critical. If you're in a fully staffed operating theatre (i.e. one surgeon, one registrar, one resident, two nurses, one anaesthesiologist, one anaesthesiology registrar and two technicians), one could argue a medical student is relatively useless and their education comes second to... well everything else. In the far corners of the world (i.e. one surgeon and one nurse; if that), a medical student holds the potential of shifting the potential risks down from patient mortality to morbidity, and receiving a flood of knowledge from the surgeon. That all depends on the experience and competence of the medical student, which goes without saying.

But it's always confusing the first time. The basic assumption of fitting right in with everybody around you, who are dressed the same in every sense can be abandoned. Nurses in particular can easily tell when a rookie enters the theatre and immediately assumes the authoritative role. "Stand at least 50 centimetres away from this table. Don't touch this. Keep your hands between your chest and umbilicus. No no, go and scrub again. Hold this. Shut up." Although this could be interpreted as nurses exercising their right to power before the student graduates, it must not be forgotten that they are also responsible for maintaining infection control in an operating theatre. If you are new to the environment, you may very well be seen as a risk rather than a benefit, especially if you are only there to absorb information.

There is an unspoken language in the operating theatre and a dialect of body language that is foreign to all newcomers. It can be hard to pick, even if your thighs are hard-pressed against the operating table. For instance, there is a very particular way a nurse holds equipment compared to that of a surgeon. Equipment is given in such a way that the surgeon can use the instrument the moment his or her fingers wrap around it. This might seem obvious when written down, but may go unnoticed in the middle of surgery. If the nurse knows the operation well, they will know exactly what instrument to give the moment the surgeon raises their hand. Instruments may also appear to be simple, but often have multiple functions and surgeons almost always have multiple grip techniques.

Among all the operations I've seen and the myriad of interactions between theatre staff I've witnessed and participated in, I ask myself who's role is the most difficult. It is not the surgeon, but actually the assistant across the operating table.

To be a competent assistant, one must have theatre experience but must also know the theory behind the operation. However, due to overwhelming demands and lack of resources, the assistant usually is a junior doctor or a senior medical student. In this situation, it is very uncommon to "know" the operation and even if one knows the theory, they might not understand their role at certain phases of the operation.


How a surgeon communicates with their assistant(s) is very interesting. The surgeon asks for a retractor, receives it and places it in the correct anatomical plane. Then, he or she applies tension in a specific direction such that the relevant tissues are correctly demonstrated. Once this is maneuvre is complete, the surgeon presents the instrument to the assistant and they assume control (and responsibility) of the instrument. This process can take place without a word... The unspoken language of theatre.

Assisting requires patience but also stamina - following an operation carefully whilst holding retractors larger than one's own hands can be very painful and distracting.

Most importantly, the role demands the assistant to assume the surgeon's visual perspective whilst remembering their own. In other words: as an assistant, you must understand what structures the surgeon must see and display these correctly with the accurate application of tension on the instruments (i.e. retractor, suture, clamp etc.), even if the correct position obstructs your own field of view. The assistant's field of view comes second to the surgeons' and unfortunately, the mind constantly prioritises its own view. So you are constantly battling with your own instincts. If you apply too much tension, you damage the superficial tissues and may cause bleeding. Too little tensions results in lack of retraction. And when the medical student assumes the role of the assistant, they must avoid getting yelled at, constantly corrected and answer all questions related to the anatomy correctly - even if the anatomy being asked has nothing to do with the operation.