Silent hand signals in obstetric and gynecologic surgery. Okay, so I'm going to do anything right now? No. All right, good. Despite advancements in surgical instrumentation, basic manual function is still required during obstetric and gynecologic surgery. The use of more personnel and equipment in the operating room has increased noise levels that may distract scrub team members at the surgical field and evoke anxiety in awake patients. Efficient surgical care depends on clear, accurate, and timely communication among surgeons, nurses, and other ancillary staff. A reliable method to achieve the necessary care and coordination in the operating room is the use of visual signals. The purpose of this video is to demonstrate a coordinated system of silent hand signals that augment nonverbal communication during surgery and to serve as a training reference for operating room learners. The potential for nonverbal communication via hand signals has been long recognized by various industries, each employing their own standards. To communicate their intentions to other drivers and vehicles, cyclists employ a standardized set of hand signals. The use of these signals is critical for the safety of cyclists and of those around them. The field of surgery is not a newcomer to the use of hand signals. There are well-established signals utilized by the surgeon in requesting specific instruments from the scrub nurse. These have been used in operating rooms for decades. There is still potential for not only expanding the variety of silent hand signals used in the operating room, but also for catering their use to specific scenarios, such as navigating language barriers among surgical staff and operating on the awake patient. The use of silent hand signals when operating on the awake patient reduces noise levels in the operating room, enhances communication among surgical staff, and minimizes the spread of contaminants through talking. From the patient's perspective, the absence of audible surgical jargon also reduces the degree of evoked anxiety in the operating room. Straight mayo scissors can be requested by performing a scissoring motion with the index and middle fingers. Curved mayo scissors can be specified by keeping these fingers slightly bent during motion. Vicral suture is specified by repeated supination of the wrist with the index and middle fingers mimicking the letter V. To signal for PDS suture instead, the fingers are used to display the American Sign Language sign for the letter P. A pop-off suture is specified by changing from a closed fist to an open hand. If instead the suture is desired to be swaged on, the fist remains closed. O suture is specified by approximating the index finger and thumb while the other fingers are held in equal mid-flexion. The general signal for pickups is repeated approximation of the index finger and thumb. Russian pickups are specified by a thumbs-up with flexion of the forearm, much like taking a hypothetical shot of water. Smooth pickups are specified by moving the flat hand in a circular motion to mimic touching a smooth surface. Rat-tooth pickups are specified by partially flexing the index and middle fingers and then performing repeated downward flexion of the wrist. This is to mimic teeth chomping down. A clamp can be requested by crossing the index and middle fingers together. An alice is specified by extending only the index and middle fingers and then simultaneously performing downward flexion of the wrist with extension of the elbow. This is in reference to the hopping of a rabbit that Alice follows into Wonderland. A coker is signaled by forming a closed fist with the thumb sandwiched between the index and middle fingers and then fully extending the thumb. This is to mimic popping off the cap of a Coke bottle. A haney is signaled by forming a closed fist with an extended thumb pointed to the side and the wrist flexed, followed by pronation of the wrist. This digging motion is a reference to Seamus Haney's famous poem, Digging. A bozeman is specified by extending only the middle three fingers in a downward direction. This mimics the letter M in reference to Montana, home to the city of Bozeman. In general, a retractor is signaled by performing a raking motion. An army-navy is specified by subsequently adding a mid-chest salute. A Richardson is signaled by rubbing the thumb against the index and middle fingers repeatedly, a common symbol for wealth or riches. The size of the Richardson can then be further specified using the index finger and thumb. Size correlates to the amount of empty space between the fingers. A scalpel can be requested by performing a chopping motion with the forearm. A ring forcep is signaled by tapping the ring finger of one hand with the index finger of the other hand. Bovie electrosurgery is requested by extending only the index and small finger in an upward direction. This is to mimic the horns of a bovine animal. The need for suction is indicated by performing a corkscrew motion with an extended index finger pointed downwards. Requesting an injection, for example a local anesthetic, involves mimicking the motion of depressing a syringe. The need for a sponge is signaled by moving a flat hand in a circular motion, as if wiping a surface. The surgeon can request a speculum be inserted by approximating the thumb to the index and middle fingers and then spreading these fingers apart. This mimics the opening action of a speculum. A charge nurse can be called by performing a cross-chest salute using the middle three fingers. These symbolize rank by resembling military stripes. Time can be indicated by first pointing to an imaginary watch on the wrist, then specifying a number using held-up fingers, and finally designating minutes or hours using relative approximation of the index finger and thumb. The surgeon can request a faster work pace by mimicking the arm movements typically seen while running. The surgeon can ask their assistant to wipe the surgical field by dabbing using one hand. To request irrigation of the wound, the surgeon can make it rain. All silent hand signals should be performed in a steady cadence so that the scrub nurse can visualize them clearly. Despite this, visual signals can have certain limitations. Their reliability is reduced when the surgeon's hands are not readily visible, for example, during abdominal surgery. Without mastery of a given set of hand signals by surgical team members, their use during high-acuity events may delay necessary interventions. The signals demonstrated in this video are basic and specific to our needs. We encourage surgical teams to develop additional signals based on their specific needs. In conclusion, silent hand signals serve to inform assistants and the scrub nurse of anticipated needs for the surgeon's most common request in the operating room. The only limitation to this form of communication is the surgeon's initiative and imagination.

silent hand signals

obstetric and gynecologic surgery

communication enhancement

noise reduction

operating room