HISTORY OF OPERATING ROOM

EFORE THE OPERATING ROOM: MAGICIANS, PRIESTS AND PHYSICIANS

The development of surgery occurred in different regions at different times, in China, India, South
America, Mesopotamia, Persia, Arabia and finally Europe. The early surgeons were either priests,
magicians, physicians or barber-tradesmen who understood anatomy and were comfortable with the
common practices of amputation and trephination.
Trephination is perhaps the oldest of surgeries that we know of. Because it involved cutting or
grinding a hole in the skull, remnants are plentiful, as human skull bones have lasted for as many as 12,000
years intact. Neolithic evidence of trephination has been found in many disparate civilizations, from the pre-
Incas in South America (2000 BC), to the early Europeans in France (5100 BC), to the Egyptians extending
back as far back as 8,000 BC. The practice was probably originally performed for spiritual and magical
reasons, and was performed by kings, priests and magician-physicians. It later was used to relieve pressure
for head injuries, seizures and mental disorders such as psychosis.
During these times, the most common practitioner was the battlefield surgeon, who removed arrows,
applied bandages, performed amputations and dispensed rugged hope to both the wounded and those who
continued to fight. He was, at times, highly valued by both the men and their officers. A surgeon “who
knows how to cut out darts and relieve the smarting of wounds by soothing unguents was to armies more in
value than many other heroes.” (Iliad, Book XI)
The word ‘physician’ was probably coined by Homer. The name derives from the Ionian dialect
spoken in the Greek colonies of the eastern Aegean meaning “Extractor of arrows.”

MESOPOTAMIA
Witch doctors (“ashipu”) worked seamlessly with physical healers (“asu”) in a mix of magic,
religious imprecations, administration of salves and plasters, and surgical procedures. Practiced surgeons
became revered teachers who drained infections, controlled bleeding, performed amputations and
trephinations, and accepted liability for failed operations. The Law Code of Hammurabi (c. 1700 BC) called
for a surgeon’s hand to be cut off if the life of a person of high social order was lost as a result. Many of
them specialized in the knowledge and the magic of particular anatomic spirits and therefore surgical areas
of interest. They were the skilled technicians of the art of surgery who established the practical traditions
that were passed on to Greeks.

EGYPT
While the Babylonians were magicians and generalists, the Egyptian physician-surgeons became
specialists, some concentrating on the head, others eyes, yet others on the abdomen. They had extensive
knowledge of anatomy, and performed dissections as well as mummification. They performed trephinations
as early as 8000 BC.
The word “brain” was first observed in Edwin Smith Papyrus in 1700 BC. The convolutions of the
freshly dissected brain surface were compared to “molten copper” when they were seen shining in the hot
Egyptian sun.
Egyptian surgical instruments were some of the most sophisticated to be found until well after the
Middle Ages.

INDIA
The phrase, “To cut of your nose to spite your face” is familiar to all of us. However, very few know
where it came from. In India, a common punishment for such crimes as stealing a large animal, abetting a
thief and fornication was to cut off the nose of the offender. The North Indian Hindu poem, “Epic of Rama
Prince of India,” dating from 1200 – 1000 BC, was retold in the Ramayana, by Valmiki, around 400-200
BC. The hero Sri Rama’s brother Lakshmana, when confronted by the female demon Shrupanakka, who
dared to make love to him, cut off the nose of his consort to spite her and not to kill her.
Buddha Ghosa, in the 4th Century, in the Dhammapada Athakata, tells the story of a husband who
committed fornication with a woman-servant in his house. His wife bound that guilty servant’s hand and
foot and cut off her nose. This practice continued for many centuries.
Indian physicians were thus confronted with a large number of patients with a problem. They learned
the detailed anatomy and the surgical techniques that would lead to the development of both ENT (ear nose
and throat) surgery and plastic surgery.
Sushruta Banaras, now referred to as the “Father of Surgery” in the Indian tradition, worked and
taught along the Ganges River in India around 600 BC. His many volumes of surgical descriptions, known
as the Susrutha Samhita, were the basis of Indian surgical practice for many centuries after. He was the first
to establish a surgical practical laboratory, or workshop, using clay objects and various fruits to mimic
human surgical situations.

CHINA
Hua Tuo
Han, China 190 BC
Hua Tuo was the first to use anesthesia for surgical procedures, using a combination of wine and a
form of cannibis. During the Han Dynasty, he became well known for his treatments and cure of the injured
general Zhou Tai. He was the first to use the pulse as a diagnostic indicator, and he apparently developed
surgical skills that included castration and brain surgery. For this, he lost his life, as recorded in the Records
of the Three Kingdoms:
Huà Tuó told Cáo Cäo that to cure him, he would have to open up his skull to rid him of his severe,
chronic headaches (most likely due to a tumor, from which he later died). Cáo Cäo thought Huà Tuó had the
intention of killing him by opening his skull. This was due to his fear of surgeons after Ji Ping, a former
royal surgeon, attempted to assassinate him. Huà Tuó was jailed and ordered to death by Cáo Cao. Upon his
execution, Hua Tuo presented a scroll, Qing Nang Shu ( “medical practice book”), to the jailer saying “This
can save lives”. But the jailer, did not accept it, whereupon Hua Tuo asked that a fire be built and proceeded
to burn the invaluable scroll.

GREECE: THE FIRST SURGICAL TRAINING PROGRAM

“A physician is worth more than several other men put together, for he can cut out arrows and spread
healing herbs.” (Iliad, Book XI)
Greek surgeons were trained in semi-formal schools called Asklpieia. The result of this training
resulted in a uniformity of medical and surgical practices that laid the groundwork for the modern training
programs that would follow many centuries later. The Asklepion on the Aegean island of Kos was the place
of learning for Hippocrates, the most remembered of Greek physicians. Temple of Aesculapius of
Kiparissios Apollo was located on the site. It was dedicated to Aesculapius, the son of Apollo, protector of
health and medicine. The Asklepion served as a sanatorium, the spas received waters from the spring of
King Halkon and the spring of Vournika on Mount Dikeo. It soon became the preferred sanctuary for the
injured and sick. It was here that herbal remedies of all kinds (including anise, cassian, frankincense, cumin,
opium and germander from the East), and unguents for plasters (olive oil, parsnip, myrrh, honey) were
developed and enhanced. Physicians from the Levant were here as well, and lessons that were learned during
the times of the Babylonians and the Egyptians were handed down to the Greeks on this crossroad that stood
between the East and the Greek mainland.
Greek surgical techniques were mostly learned on the battlefield, where arrows were removed,
wounds covered, tourniquets and vasculature ligatures applied and amputated limb wounds were closed.
 There were surgical specialists in some areas of gynecology (abortions were preformed, children
birthed, infections drained), but most other surgeries did not include opening any cavities in the body, a
practice that would last until the 19th Century.

ROME: THE BIRTH OF THE OPERATING TENT

The modern operating room is descended from the Roman military tent and hospital system that was
perfected to a degree not matched again until the time of Napoleon. The first Roman Medical Corps was
formed by Emperor Augustus. Medical professionals were required to train at the new Army Medical School
and could not practice unless they passed stringent examinations.
The Roman military surgeon was called the “medicus vulnerarius,” the “wound doctor.” Roman
military surgeons and their counterparts, the specialist arena surgeons (who maintained the health of the
valued gladiators) were extremely proficient not only with their surgical techniques, but also in the
organization of their infrastructure. The military surgeon Pedanios Dioscorides (c. 65 AD) was not only well
known as a field surgeon, but as an author whose text on herbal medicines set the standard for another 1,500
years.
The medicus vulnerarius was in the field with the soldiers during battle, and managed a system that
included surgery in the field, an ambulance team, and 2 receiving battlefield hospital tent systems located on
opposite sides of the field. The tent system moved with the army. If the Battle of Pharsalus was any
example, it was quite elaborate. Immediately behind the field of the battle, there were 25 tents providing
space for 200 men, at the standard 8 men to the tent. There were probably 3 tents for the medical staff and
22 tent spaces for patients. At that rate, the hospital unit would have space for 176 men. Since there is a
hospital on each side, the 40,000-man army had hospital beds for 352 men.
Once the battle was over and the troops moved on, surviving patients were transported to military
hospitals located within city walls. These hospitals were quite large, and were organized around a
circumferential ward system that alternated with intervening corridors. In the center was an area that might
have been used as an operating theater, called the “refectory.” An example of this was found at Novasium,
on the lower Rhine near Dusseldorf, where many sophisticated surgical instruments were excavated within
the hospital proper.

ISLAMIC MEDICINE: THE FIRST SURGICAL SUITES

Abu Bakr Muhammad ibn Zakariya al-Razi (865-925 AD), known as Rhazes, was one of the most
prolific Muslim doctors and probably second only to Ibn Sina in his accomplishments. He was born at Ray,
Iran and became a student of Hunayn ibn Ishaq and later a student of Ali ibn Rabban. He wrote over 200
books, including Kitab al-Mansuri, ten volumes on Greek medicine, and al-Hawi, an encyclopedia of
medicine in 20 volumes. In al-Hawi, he included each medical subject’s information available from Greek
and Arab sources and then added his own remarks based on his experience and views. He classified
substances as vegetable, animal or mineral while other alchemists divided them into “bodies,” “souls” and
“spirits.”
Al-Razi was first placed in charge of the first Royal Hospital at Ray, from where he soon moved to a
similar position in Baghdad where he remained the head of its famous Muqtadari Hospital for a long time.
He found a treatment for kidney and bladder stones, and explained the nature of various infectious diseases.
He also conducted research on smallpox and measles and was the first to introduce the use of alcohol for
medical purposes. A unique feature to his medical system was that he greatly favored cure through correct
and regulated food intake. This was combined with his emphasis on the influence of psychological factors
on health. He also tried proposed remedies first on animals in order to evaluate their effects and side effects.
He was also an expert surgeon and the first to use opium for anesthesia.
Abu Ali al-Hussain Ibn Abdallah Ibn Sina alone wrote 246 books, including Kitab-al Shifa (The
Book of Healing) consisting of 20 volumes and Al- Qanun fit Tibb (The Canons of Medicine). He
approached philosophy, logic, mathematics, astronomy, psychology, medicine and surgery all as part of a
whole. The Qanun was a predominant text for medicine in the West from the twelfth to the seventeenth
century. Containing over one million words, it surveyed the entire medical knowledge available from
ancient and Muslim sources, and preserved the knowledge of the Greeks and Levant for eventual
transmission through the Middle Ages to the Renaissance. It continued to be a relied upon source of medical
knowledge until the early 19th Century.
Ibn Sina determined that tuberculosis was infectious, and was the first to describe meningitis and to
institute quarantine as a method for limiting the spread of infections by the air.
He had to escape to Isafan, in Persia. After having been vizier and having been forced into hiding by
a change in the political landscape upon the death of the Buyadid prince who had appointed him. Once in
Isafan, he wrote his many medical (approximately 40) works and had a school of medicine and philosophy.
Here surgeries were set up and the sick came for diagnosis and surgery that was performed on site. Suites of
surgeries were located together, and individual types of surgical procedures were regulated to each. No
detailed description of these operating rooms is extant.
His surgical operations to remove cancers were among the first.
Abul Qasim Khalaf ibn al-Abbas al-Zahravi (known in the west as Abulcasis) was born in 936 C.E.
in Moorish Spain near Cordoba. He became one of the most renowned surgeons of the era and was
physician to King Al-Hakam-II of Spain. He is best known for his early and original breakthroughs in
surgery as well as for his Medical Encyclopedia, called Al-Tasrif, a thirty-volume treatise, with three books
dedicated to surgical techniques, cauterization, kidney stone removal, eye, ear, and throat surgery. His
surgical books contained over 200 surgical illustrations.
Cauterization of wounds, tumors, bleeding and open infections became standard as a result of his
methods.
He was the first to separate surgery as a separate area of concentration, and developed such advanced
techniques as those for the division of the temporal artery to relieve headaches, diversion of urine into the
rectum, reduction mammoplasty for excessively large breasts and the extraction of cataracts.
Translated into Latin, the books were an important link between Europe in the Middle Ages and past
medical knowledge of the Greek, Indian and Egyptian traditions, becoming part of the established surgical
curriculum for centuries thereafter.

MIDDLE AGES: THE BARBER SURGEON

The barber-surgeon was first and foremost, one who traveled with caravans, perused battlefields and
put up shops in towns and cities, working outside in the field or street. When they were not treating patients,
they often maintained other jobs, such as traveling road shows complete with entertainment, magic and
liniments and potions and “cures” from “far away” places. They dispensed practical advice and treated
various ailments at the end of these entertainments, gradually enhancing both their practical knowledge and
stature among the people. Physicians, usually affluent and educated, were most often medical doctors,
dispensing herbs and medications. Because of their perception of the limitations of surgery and the Church’s
proscriptions against anatomic dissection, they more often than not left the difficult work of amputations and
wound closures to the barber-surgeons. Thus was born the “Town-Gown” dichotomy that lives on today in
the practices of modern physicians and surgeons.
As time went on, the barber-surgeon rose further in stature. A person of importance, a member of the
upper classes needed not only his physician, but also his barber-surgeon.
The most common form of surgery was bloodletting, in an effort to restore the balance of the body’s
four humors. Surgery for breast cancer, fistula, hemorrhoids, gangrene, and cataracts, as well as tuberculosis
of the lymph glands in the neck (scrofula) was performed. Some of the potions used to relieve pain or induce
sleep during the surgery were themselves potentially lethal. One of these consisted of lettuce, gall from a
castrated boar, briony, opium, henbane, and hemlock juice, something that more often than not resulted in
death of the patient.
 During this time, the concept of the dispensary evolved, as the outdoor activities of the barber-
surgeon moved indoors. There were no formal operating theaters, but bare rooms filled with shelves of herbs
and poultices, along with a wooden table that could be used to perform surgery.
Barber surgeons became so proficient at surgery, while the academic surgeons fell behind (especially
after their numbers were decimated during the plague) that the union of the two groups was inevitable. In
England, King Henry VIII signed a decree merging the Fellowship of Surgeons with the Company of
Barbers in 1540, into the Great Company of Barbers and Surgeons.
Ambrose Pare, a French surgeon, was apprenticed to a barber-surgeon before he went on to become
the famous battlefield surgeon and aide to the chief of surgery at the Hotel Dieu in Paris.

NAPOLEONIC WARS
Dominique Jean Larrey (1766-1842) was Napoleon’s army surgeon. He reintroduced the Roman-
style hospital tent system to the battlefield. Injured soldiers were brought from the field by “flying
ambulances” (ambulances volantes), horse-drawn carts that scoured the scene and rapidly brought the
wounded to the tents situated in the rear. The hospital tents included a wooden table surrounded by billets.
The wounded were brought in along a “corridor” that was made among the patients and the injured were
carried onto the table. Once there, their bullets were removed (Larrey invented a porcelain-tipped probe to
“hear the missiles”) or their limbs were amputated immediately. Larrey advocated early amputation as a
preventative to infection. For example, during the Battle of Borodin, he performed around 200 amputations
in a single day.

CIVIL WAR
The Larrey ambulance system and battlefield tent system was retained by American surgeons, and
the Roman military hospital system was reintroduced as well. Again, the primary operation was that of
amputation. However, advancements in surgical techniques and the use of anesthetics allowed for improved
closure of other wounds, such as abdominal injuries.
Overall, however, as witnessed by one soldier, the scene was one of great difficulty:
“In the operating tent, the amputation of a very bad looking leg was witnessed. The surgeons had
been laboring since the battle to save the leg, but it was impossible. The patient, a delicate looking man, was
put under the influence of chloroform, and the amputation was performed with great skill by a surgeon who
appeared to be quite accustomed to the use of his instruments. After the arteries were tied, the amputator
scraped the end and edge of the bone until they were quite smooth. While the scraping was going on, an
attendant asked: ‘How do you feel, Thompson?’ ‘Awful!’ was the distinct and emphatic reply. This answer
was returned, although the man was far more sensible of the effects of the chloroform than he was of the
amputation.”

GERMANY, FRANCE, AUSTRIA, ENGLAND, AMERICA 1800 – 1900

Large, city-based charitable hospitals arose out of the medieval monetary medical care system in
Europe during the late 1700’s to care for the poor and indigent. Leading cities in Europe developed the
operating theater as the venue for both operating and teaching. These theaters were modeled after the
dissection theaters that gained fame in Padua, Leiden and other largely Italian cities. In 1822 the St Thomas’
Hospital built its operating theater, and in 1824, in Boston, what was to become known as the Ether Dome
was built.
These theaters remained the standard until the full acceptance of Semmelweis’ and Lister’s antisepsis
regimens lead to the inclosure of the operating room and the introduction of sterile technique.
WORLD WAR I
By this time, antisepsis was accepted, and the wearing of gowns, gloves and masks, washing of
hands and the use of antiseptics lead the army surgical team indoors whenever possible. Houses were
commandeered and used as battlefield hospitals.
In the university setting, however, the operating theater concept persisted.

WORLD WAR II AND THE KOREAN WAR

By World War II, the military hospital tent system was expanded to include the peripheral-style
design for operating rooms that allowed for multiple patients to be operated upon simultaneously. All
necessary components could be powered and supported from any location within the tent, so that a single
tent had the flexibility to allow for a variable number of casualties to be operated upon at any time.
This peripheral design reached its zenith during the Korean War, with the development of the MASH
(mobile army surgical hospital) concept. This format was the basis of modern operating room design, with
support systems coming into the room from the periphery.

ASEPSIS AND STERILE TECHNIQUES

1.5 Surgical Asepsis and the Principles of Sterile Technique

SURGICAL ASEPSIS
Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all
microorganisms within any type of invasive procedure. Sterile technique is a set of specific practices and
procedures performed to make equipment and areas free from all microorganisms and to maintain that
sterility (BC Centre for Disease Control, 2010). In the literature, surgical asepsis and sterile technique are
commonly used interchangeably, but they mean different things (Kennedy, 2013). Principles of sterile
technique help control and prevent infection, prevent the transmission of all microorganisms in a given area,
and include all techniques that are practised to maintain sterility.
Sterile technique is most commonly practised in operating rooms, labour and delivery rooms, and
special procedures or diagnostic areas. It is also used when performing a sterile procedure at the bedside,
such as inserting devices into sterile areas of the body or cavities (e.g., insertion of chest tube, central venous
line, or indwelling urinary catheter). In health care, sterile technique is always used when the integrity of the
skin is accessed, impaired, or broken (e.g., burns or surgical incisions). Sterile technique may include the use
of sterile equipment, sterile gowns, and gloves (Perry et al., 2014).
Sterile technique is essential to help prevent surgical site infections (SSI), an unintended and
oftentimes preventable complication arising from surgery. SSI is defined as an “infection that occurs after
surgery in the area of surgery” (CDC, 2010, p. 2). Preventing and reducing SSI are the most important
reasons for using sterile technique during invasive procedures and surgeries.

PRINCIPLES OF SURGICAL ASEPSIS

All personnel involved in an aseptic procedure are required to follow the principles and practice set
forth by the Association of periOperative Registered Nurses (AORN). These principles must be strictly
applied when performing any aseptic procedures, when assisting with aseptic procedures, and when
intervening when the principles of surgical asepsis are breached. It is the responsibility of all health care
workers to speak up and protect all patients from infection. See Checklist 9 for the principles of sterile
technique.

CHECKLIST 9: PRINCIPLES OF STERILE TECHNIQUE

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
 Hand hygiene is a priority before any aseptic procedure.
 When performing a procedure, ensure the patient understands how to prevent contamination of
equipment and knows to refrain from sudden movements or touching, laughing, sneezing, or talking over
the sterile field.
 Choose appropriate PPE to decrease the transmission of microorganisms from patients to health care
worker.
 Review hospital procedures and requirements for sterile technique prior to initiating any invasive
procedure.
 Health care providers who are ill should avoid invasive procedures or, if they can’t avoid them, should
double mask.
STEPS ADDITIONAL INFORMATION
1. All objects used in a sterile field must be sterile. Commercially packaged sterile supplies are marked
as sterile; other packaging will be identified as
sterile according to agency policy.

Check packages for sterility by assessing intactness,

dryness, and expiry date prior to use.

Any torn, previously opened, or wet packaging, or

2. A sterile object becomes non-sterile when
touched by a non-sterile object.
packaging that has been dropped on the floor, is
considered non-sterile and may not be used in the
sterile field.
Sterile objects must only be touched by sterile
equipment or sterile gloves.

Whenever the sterility of an object is questionable,

consider it non-sterile.

Fluid flows in the direction of gravity. Keep the tips

3. Sterile items that are below the waist level, or
items held below waist level, are considered to be
non-sterile.
4. Sterile fields must always be kept in sight to be
considered sterile.
of forceps down during a sterile procedure to
prevent fluid travelling over entire forceps and
potentially contaminating the sterile field.
Keep all sterile equipment and sterile gloves above
waist level.
Table drapes are only sterile at waist level.
Sterile fields must always be kept in sight
throughout entire sterile procedure.

Never turn your back on the sterile field as sterility

cannot be guaranteed.
5. When opening sterile equipment and adding Set up sterile trays as close to the time of use as
supplies to a sterile field, take care to avoid possible.
contamination.
Stay organized and complete procedures as soon as
possible.

Place large items on the sterile field using sterile

gloves or sterile transfer forceps.

Sterile objects can become non-sterile by prolonged

exposure to airborne microorganisms.
 6. Any puncture, moisture, or tear that passes
through a sterile barrier must be considered
contaminated.
7. Once a sterile field is set up, the border of one
inch at the edge of the sterile drape is considered
non-sterile.
8. If there is any doubt about the sterility of an
object, it is considered non-sterile.
9. Sterile persons or sterile objects may only
contact sterile areas; non-sterile persons or items
contact only non-sterile areas.
Keep sterile surface dry and replace if wet or torn.
Place all objects inside the sterile field and away
from the one-inch border
Known sterility must be maintained throughout any
procedure.
The front of the sterile gown is sterile between the
shoulders and the waist, and from the sleeves to two
inches below the elbow.

Non-sterile items should not cross over the sterile

field. For example, a non-sterile person should not
reach over a sterile field.

When opening sterile equipment, follow best

practice for adding supplies to a sterile field to
avoid contamination.

Do not place non-sterile items in the sterile field.

10. Movement around and in the sterile field must Do not sneeze, cough, laugh, or talk over the sterile
not compromise or contaminate the sterile field. field.

Maintain a safe space or margin of safety between

sterile and non-sterile objects and areas.

Refrain from reaching over the sterile field.

Keep operating room (OR) traffic to a minimum,

and keep doors closed.

Keep hair tied back.

When pouring sterile solutions, only the lip and

inner cap of the pouring container is considered
sterile.
The pouring container must not touch any part of
the sterile field. Avoid splashes.

SURGICAL TEAM

Surgeon
A surgeon has finished 4 years of medical school and 4 or more years of special training after
medical school. Most surgeons have passed exams for board certification. The American Board of Surgery
is the national group that gives this certification for general surgery in the U.S. Some surgeons also have the
letters FACS after their name. This means they have approval of the Fellows of the American College of
Surgeons (FACS).

Anesthesiologist
An anesthesiologist has finished 4 years of medical school and 4 years of special training in
anesthesia. Anesthesiologists may get additional training in certain surgery specialties. This might be
neurosurgical anesthesia or cardiac anesthesia. The anesthesiologist takes part in all 3 phases of surgery:
before, during, and after.

Certified registered nurse anesthetist (CRNA)

The nurse anesthetist gives you anesthesia care before, during, and after surgery or labor and
delivery. The nurse constantly watches every important function of your body. He or she can change the
anesthesia medicine to make sure you are safe and comfortable. A nurse anesthetist has a bachelor's degree
in nursing and at least one year of experience as a registered nurse in a critical-care setting. He or she also
has at least a master's degree from a nurse anesthetist program. Nurse anesthetists must pass a national
certification exam to become CRNAs.

Operating room nurse or circulating nurse

Registered nurses are registered and licensed by each state to care for patients. Some nurses focus on
a certain field such as surgery. The operating room nurse helps the surgeon during surgery. Operating room
nurses are certified in various areas of surgery. Nurses must pass an exam to be certified.

Surgical tech
Surgical techs assist with the surgery by setting up a sterile operating room. They get supplies and
surgery tools ready. And they hand the surgeon the tools he or she asks for. They must pass an exam to be
certified by the National Board of Surgical Assisting (NBSTA).

Residents or medical students

In many teaching hospitals, resident doctors in training and medical students may be a part of the
surgical team.

Physician assistant
Physician assistants practice medicine under the supervision of a doctor. They may act as an assistant
to the surgeon. Or they may close incisions with stitches (sutures) or staples.

Medical device company representative

Sometimes surgeons will have a representative from a company that makes medical equipment in the
operating room. Such equipment might be artificial joints, spine stabilizers, or pacemakers. The
representative can help the surgeon with sizing and function of the equipment.