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ACS Addresses Intraoperative Responsibilities

Publications - Client Alert | May 31, 2016

In light of recent news reports about surgeons leaving an operation before it is fully completed, the American College of Surgeons (“ACS”) issued a revised “statement on principles” addressing intra-operative responsibilities of a primary surgeon. This guidance, which was released by ACS on April 12, 2016, covers the situations in which a primary surgeon may leave the operating room during the course of a surgery and the steps that must be taken to maintain safety and ensure the patient is appropriately informed.

General Rule

In this guidance, ACS states that the primary attending surgeon is personally responsible for the patient’s welfare throughout the operation and, in general, should be in the operating room, or immediately available, for the entire surgical procedure.

However, according to ACS, exceptions to this general rule do exist and can remain consistent with good patient care. In all cases where the primary attending surgeon is not present or immediately available, another attending surgeon should be assigned as immediately available.

Patients should be informed before their operations of the different types of medical providers who will participate in their surgery; if situations arise that require the surgeon to suddenly leave the operation, the patient should be subsequently informed.

Concurrent or Simultaneous Operations

Concurrent or simultaneous operations occur when the key or critical elements of the procedures (as determined by the primary attending surgeon) for which the primary attending surgeon is responsible occur at the same time, in whole or in part. ACS states that it is not appropriate for a primary attending surgeon to be involved in concurrent or simultaneous operations on two different patients in two different operating rooms.

Overlapping Operations

Overlapping of two distinct operations by one primary attending surgeon can occur under two general sets of circumstances:

1.      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 the operation. The primary attending surgeon is able to begin a second operation in another operating room while a qualified practitioner performs non-critical components of the first operation. This is the most common overlapping scenario.

2.      The key or critical elements of the first operation have been completed; the primary attending surgeon is in another operating room performing the key or critical elements of a second, separate surgery. This second, less common scenario is allowed provided the primary attending surgeon assigns immediate availability to the first operating room to another attending physician.

In both situations the patient must be informed of the overlapping operations, and the performance of such overlapping procedures cannot negatively impact the seamless and timely flow of either procedure.

Multidisciplinary Operations

It is appropriate for surgeons to be present only during the portion of the operation that requires their surgical expertise, provided that an attending surgeon is immediately available during the entire operation.

Delegation to Qualified Practitioners

Surgeons may delegate part of the operation to qualified practitioners. According to ACS, “qualified practitioners” include, but are not limited to, the following practitioners: residents, fellows, anesthesiologists, nurses, nurse practitioners, physician assistants, surgical assistants or another attending surgeon under his or her personal direction. The primary attending surgeon may not, however, delegate personal responsibility and must be an active participant throughout the key or critical elements of the operation.

Procedure-Related Tasks

A primary attending surgeon may leave the operating room for a task related to the procedure, such as review of pertinent pathology and imaging, discussion with the patient’s family and necessary breaks. The surgeon must be immediately available during such procedure-related absences.

Unanticipated Circumstances

If unanticipated circumstances require the primary attending surgeon to leave an operation before the completion of the key or critical portion of such operation, a backup attending surgeon must be identified and available to be present in the operating room promptly.


The American Hospital Association and the Association of American Medical Colleges have jointly issued a statement of support and urge hospitals to review the new ACS guidance. Hospitals should review their policies and procedures and make any necessary changes to ensure consistency with the above guidance. 

 Additional Information

If your organization has questions regarding the ACS’ revised statement of principles, please contact your Kutak Rock attorney, the authors of this article (Mark Sappington and Jeanne Evans), or other members of our National Health Care Group listed below.