and diagnostic imaging, discussion with the patient’s
family, and breaks during long procedures. The surgeon must be immediately available for recall during
Unanticipated circumstances may arise during procedures that require the surgeon to leave the operating
room before completion of the critical portion of the
operation. In this situation, a backup attending surgeon
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
If more than one emergency occurs simultaneously, the attending surgeon may oversee more than
one operation until additional attending surgeons are
Surgeon-Patient Communication (see Section II.A.)
The surgical team involved in an operation is dependent on the type of facility where the operation is
performed and on the complexity of the surgical procedure. At a freestanding outpatient surgery 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
preoperative discussion, patients should be informed
of the different types of qualified health care professionals who will participate in their operation (assistant
attending surgeon, fellows, residents and interns, physician assistants, nurse practitioners, and so forth) and
their respective role should be explained. If an urgent
or emergent situation arises that requires the surgeon
to leave the operating room unexpectedly, the patient
should be informed subsequently.
In an effort to provide some standardization of nomenclature, the following definitions are provided:
Backup surgeon/surgical attending
The qualified surgical attending who has been designated to provide immediately available coverage for an
operation, during a period when the primary surgeon
might be unable to fill this role.
Concurrent or simultaneous operations
Surgical procedures 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.
“Critical” or “key” portions of an operation
The “critical” or “key” portions of an operation are those
stages when essential technical expertise and surgical
judgment are necessary to achieve an optimal patient
outcome. The critical or key portions of an operation
are determined by the primary attending surgeon.
Reachable through a paging system or other electronic
means, and able to return immediately to the operating
room. This term should be defined more completely
by the local institution.
Described in American College of Surgeons Statements
on Principles II.A.
An example of a multidisciplinary operation is a procedure in which a surgeon of one specialty provides the
exposure required by a second surgeon who performs
the main surgical intervention (such as a general or thoracic surgeon providing exposure for a neurosurgeon or
orthopaedist to operate on the spine). Another example
would be an operation that requires the involvement
of two or more surgeons of different specialties (such
as chest wall or head and neck resection followed by
plastic surgical reconstruction, face or hand transplantation, and repair of complex craniofacial defects).
“Overlapping or sequenced” operations for surgeons
The practice of the primary surgeon initiating and
participating in another operation when he or she has