American College of Surgeons Statement on Principles

G. Surgical Assistants

Certified Surgical Assistants (CSA)

The first assistant in a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions. The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility.

The American College of Surgeons supports the concept that, ideally, the first assistant at the operating table should be a qualified surgeon or a resident in an approved surgical training program. Residents who have appropriate levels of training should be provided with opportunities to assist and participate in operations. If such assistants are unavailable, other physicians who are experienced in assisting may participate.

It may be necessary to have nonphysicians serve as first assistants. Surgeon assistants (SAs) or physician assistants (PAs) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a SA or PA should include the following qualifications and credentials:

  • Specification of which surgeon the applicant will assist and of the duties that will be performed.
  • Indication of which surgeon will be responsible for the supervision and performance of the SA or PA.
  • Review and approval of the application by the hospital board.
  • Registered nurses with specialized training also may function as first assistants. If such a situation should occur, the size of the operating room team should not be reduced; the nurse assistant should not simultaneously function as the scrub nurse and instrument nurse when serving as the first assistant. Nurse assistant practice privileges should be granted based upon the hospital board’s review and approval of credentials. Registered nurses who act as first assistants must not have responsibility beyond the level defined in their state nursing practice act.

Surgeons are encouraged to participate in the training of allied health personnel. Such individuals perform their duties under the supervision of the surgeon.

American Medical Association

Code of Medical Ethics Opinion 2.3.6

Certified Surgical Assistants (CSA)

Surgical co-management refers to the practice of allotting specific responsibilities of patient care to designated clinicians. Such arrangements should be made only to ensure the highest quality of care.

When engaging in this practice, physicians should:

  • Allocate responsibilities among physicians and other clinicians according to each individual's expertise and qualifications.
  • Work with the patient and family to designate one physician to be responsible for ensuring that care is delivered in a coordinated and appropriate manner.
  • Participate in the provision of care by communicating with the coordinating physician and encouraging other members of the care team to do the same.
  • Obtain patient consent for the surgical co-management arrangement of care, including disclosing significant aspects of the arrangement such as qualifications of clinicians, services each clinician will provide, and billing arrangement.
  • Obtain informed consent for medical services in keeping with ethics guidance, including provision of all relevant medical facts.
  • Employ appropriate safeguards to protect patient confidentiality.
  • Ensure that surgical co-management arrangements are in keeping with ethical and legal restrictions.
  • Engage another caregiver based on that caregiver’s skill and ability to meet the patient’s needs, not in the expectation of reciprocal referrals or other self-serving reasons, in keeping with ethics guidance on consultation and referrals.
  • Refrain from participating in unethical or illegal financial agreements, such as fee-splitting.

Surgeons are encouraged to participate in the training of allied health personnel. Such individuals perform their duties under the supervision of the surgeon.

American College of Surgeons


American Medical Association


National Uniform Claims Committee