When should the initial surgical count be performed?

Before the procedure begins, by the surgical tech and circulating nurse together. The initial count is performed BEFORE the procedure begins. The surgical technologist and circulating nurse count together, aloud, and concurrently. This establishes a baseline count of all sponges, sharps, instruments, and miscellaneous items on the sterile field.

A tissue specimen is being sent for frozen section analysis. How should it be handled?

Send it fresh, without fixative, immediately to pathology. Frozen section specimens must be sent FRESH (without fixative) and IMMEDIATELY to the pathology department. Formalin would fix the tissue and prevent the rapid freezing process needed for frozen section analysis. The pathologist freezes, slices, stains, and examines the tissue under a microscope, providing results within 10-20 minutes to guide surgical decision-making.

During the closing count, the sponge count is incorrect — one laparotomy pad is missing. What is the FIRST action?

Notify the surgeon immediately. The surgeon must be notified IMMEDIATELY when a count is incorrect. The wound must remain open while the team searches the field, back table, drapes, floor, kick buckets, and gown folds. If the item is not found, an intraoperative X-ray is performed. Never close a wound with an incorrect count without the surgeon's knowledge.

Kidney stones (calculi) removed during surgery should be placed in:

A dry specimen container. Calculi (stones) should be placed in a DRY specimen container. Formalin and other solutions can dissolve or alter the chemical composition of stones, which must be analyzed to determine their makeup (calcium, uric acid, struvite, etc.) and guide treatment to prevent recurrence.

Key Takeaways

Surgical counts are performed to prevent retained surgical items (RSIs) — a Never Event
Counts include sponges, sharps (needles, blades), instruments, and miscellaneous items (vessel loops, cottonoids)
The initial count is performed before the procedure begins by the surgical technologist and circulating nurse together
Closing counts are performed before closure of a body cavity, before fascia closure, and at skin closure
If a count is incorrect, the surgeon must be notified immediately and an X-ray may be performed
Specimens must be properly identified, labeled, and passed to the circulating nurse for documentation
Formalin (10% formaldehyde) is the standard fixative for tissue specimens sent to pathology
Frozen sections require fresh (unfixed) tissue delivered immediately to pathology for rapid diagnosis

Surgical Counts & Specimen Management

Retained surgical items (RSIs) are classified as Never Events — serious, preventable adverse events. Rigorous counting procedures and specimen management are essential patient safety practices.

Surgical Counts

Items Counted

Sponges: Raytec (4x4), laparotomy pads (lap sponges), cottonoids, peanuts, kitners, tonsil sponges
Sharps: Needles (all sizes), scalpel blades, electrocautery tips, hypodermic needles
Instruments: All instruments placed on the field
Miscellaneous: Vessel loops, umbilical tapes, cottonoid patties, pledgets, bulldogs

When Counts Are Performed

Count Timing	Description
Initial count	Before the procedure begins — surgical tech and circulating nurse count together
Additional items	Any item added to the field during the case is counted and recorded
First closing count	Before closure of a body cavity (e.g., abdomen, thorax)
Second closing count	Before fascia or peritoneum closure
Final count	At skin closure
Relief count	When either the surgical tech or circulating nurse is relieved by another person

Count Procedure

The surgical technologist and circulating nurse count together, aloud, and concurrently
Each item is separated and visualized during the count (no lumping sponges together)
Sponges are counted in groups of 5 (radiopaque sponges are packaged in 5s or 10s)
The circulating nurse records the count on the count sheet or whiteboard
Both individuals must agree the count is correct before closing proceeds

Incorrect Count Protocol

If the count is incorrect at any closing point:

Notify the surgeon immediately — the wound must remain open
Recount the field, back table, Mayo stand, drapes, kick buckets, and floor
Check the gown and drape folds
If the item is still missing, an intraoperative X-ray may be ordered
The incident must be documented in the patient's record
An incident report should be filed per facility policy

Specimen Management

Specimen Handling

Specimen Type	Handling	Container
Routine tissue	Place in formalin (10% formaldehyde)	Labeled specimen container
Frozen section	Fresh tissue (NO formalin) — immediate delivery to pathology	Dry container or moist saline gauze
Culture & sensitivity	Sterile container, no preservative	Culture swab or tube
Calculi (stones)	Dry container, NO formalin	Dry specimen cup
Amputated limb	Per facility policy, may need special handling	Tagged and sent to pathology or morgue
Foreign body (medicolegal)	Dry container, chain of custody	Chain of custody documentation

Key Rules

Never discard tissue without surgeon's permission
Label all specimens with patient name, date, procedure, tissue type, and laterality
Communicate verbally — announce the specimen to the circulating nurse: "This is a gallbladder specimen"
The circulating nurse documents the specimen and completes the pathology requisition
Frozen sections require the surgical technologist to pass the specimen immediately — results are needed within minutes to guide the procedure

CST Certified Surgical Technologist Exam

1Introduction: CST Exam Overview

2Chapter 1: Perioperative Care — Preoperative Preparation

3Chapter 2: Perioperative Care — Intraoperative Procedures

4Chapter 3: Postoperative Procedures & Ancillary Duties

5Chapter 4: Basic Science

6Chapter 5: Exam Strategy & Practice