CST Study Guide — 2026 Edition

This is the heart of the CST role and the heaviest domain on the exam: 68 of the 150 scored questions. The intraoperative phase runs from incision to closure, and the surgical technologist's job is anticipation, sterility, counts, and safe handling of everything that enters or leaves the field.

2.1 Maintaining sterility

Maintain aseptic technique throughout the procedure. When a break in sterile technique occurs — a glove touches a nonsterile surface, a drape shifts — address it immediately: reglove, redrape, or replace the contaminated item. Ignoring a break contaminates the field; acknowledging it protects the patient. Keep the sterile field in view at all times and speak up the moment you see contamination.

2.2 Standard Precautions

Follow Standard Precautions (which incorporate Universal Precautions) with every patient: treat all blood and body fluids as potentially infectious. OSHA requires that "universal precautions shall be observed to prevent contact with blood or other potentially infectious materials"^[1]. Gloves, gowns, masks, and eye protection are used based on the anticipated exposure, not on the patient's diagnosis.

2.3 Anticipation

Anticipate the steps of surgical procedures. Knowing what comes next — the suture the surgeon will ask for, the instrument for the next dissection plane — is what separates a competent scrub from a struggling one. Study the procedure steps, know the preference card, watch the field, and have the next item ready before it is requested.

2.4 Surgical counts

Perform counts with the circulator at appropriate intervals: before the procedure begins (baseline), when new items are added, before closure of a cavity, and at skin closure — plus anytime the team changes or there is concern. Count sponges, sharps, and instruments. AST's standard states that "sponges should be counted on all procedures that present with the possibility that a foreign object could be retained"^[2]. A discrepant count stops closure until it is resolved: recount, search the field, check the drapes and floor, and obtain imaging as policy directs.

2.5 Hemostatic agents

Prepare hemostatic agents as directed — for example, oxidized regenerated cellulose (Surgicel), gelatin-thrombin matrices (Floseal), or starch-based powders (Arista). Oxidized regenerated cellulose is bactericidal: "the cellulosic acid in ORC creates an acidic environment that is bactericidal" ^[3]. Have the agent ready before the bleeding starts, open it onto the field with sterile technique, and hand it in the form the surgeon needs.

2.6 Medications on the sterile field

Verify, receive, mix, and label all medications and solutions on the sterile field. Every container and syringe on the field must be labeled with the drug name and concentration — an unlabeled syringe is never used. Verify the medication with the circulator as it is passed, confirm the dose with the surgeon, and announce when anything is added to the field.

2.7 Assisting the surgeon

Provide intraoperative assistance under the direction of the surgeon. The surgical technologist works within the defined scope: passing, retracting, suctioning, and handling tissue as directed — not making independent surgical decisions. Stay focused on the field, keep your hands in position, and respond to direction promptly.

2.8 Incisions

Identify different types of operative incisions. Know the common ones by name and location: midline and paramedian (abdomen), McBurney (appendix), Kocher (gallbladder), Pfannenstiel (pelvic), and thoracotomy or sternotomy (chest). The incision determines the instruments, drapes, and positioning — recognizing it tells you what the case needs.

2.9 Instruments: classification and identification

Identify instruments by function, application, and classification. The functional families are: cutting and dissecting (scalpels, scissors), grasping and holding (forceps, tenacula), clamping and occluding (hemostats, vascular clamps), retracting and exposing, suturing and stapling, suctioning, and specialty instruments. ACOG's tissue-handling module describes the common patterns: the #10 blade "has a long broad cutting surface" used "to make skin incisions," the #15 blade "is narrower and smaller" for "shorter or angled incisions," and the #11 blade "has an angled, pointed tip" primarily used "to make a stab-type incision"^[4]. Metzenbaum scissors are "primarily used for both blunt and sharp dissection" of delicate tissue, while Mayo scissors "have a broader blade and wider spread" for heavier tissue^[4]. Adson forceps are "small fine forceps, with or without teeth, for handling skin edges or fragile structures"; DeBakey forceps are "longer but still fine forceps without teeth" used "for handling structures such as vessels or nerves"; toothed forceps handle "fascia, muscle, etc."^[4].

2.10 Specialty equipment

Assemble, test, operate, and disassemble specialty equipment: microscopes, ultrasound technology (harmonic scalpel, phacoemulsification), endoscopic technology, power equipment, and robotic and emerging technology. Test before the case: does the harmonic scalpel activate, does the endoscope transmit a clear image, does the power drill run forward and reverse? Know the basic assembly so a malfunction mid-case can be troubleshot quickly.

2.11 Retractors

Assemble and maintain retractors. Know the families: handheld (Richardson, Army-Navy, Deaver), self-retaining (Balfour, Bookwalter), and specialty (malleable, vein). Assemble self-retaining frames correctly, keep blades matched to the wound, and protect tissue from excessive retraction pressure. A retractor left pressing on tissue too long causes injury.

2.12 The second scrub role

Perform the second scrub role when assigned: hold retractors or scopes during the case, assist with exposure, and support the primary scrub. The second scrub stays sterile, follows the same technique rules, and anticipates alongside the primary — two coordinated pairs of hands, not two people doing separate jobs.

2.13 Passing technique

Pass instruments and supplies firmly and safely. Place the instrument into the surgeon's hand so it is ready to use — handles first for most instruments, with the working end oriented correctly. Pass sharps with explicit communication ("sharps back") and use a neutral zone or tray when policy requires. Never toss, never reach across the incision, and keep counts current as sharps move.

2.14 Sutures and needles

Identify appropriate usage of sutures, needles, and stapling devices. Absorbable sutures "such as catgut and polyglycolic acid (PGA) are mostly used in internal tissues," while non-absorbable sutures like nylon and silk are used where tissue needs stabilization for longer periods^[5]. Cutting needles (with cutting edges) pass through tough tissue like skin; taper needles (round-bodied) pass through delicate tissue like bowel or vessels without cutting. Match suture size to tissue: finer suture for delicate structures, heavier for fascia.

2.15 Suture handling

Prepare, pass, and cut suture material as directed. Keep suture organized by type and size, pass the needle loaded correctly on the holder (about one-third back from the tip for most work), and cut tails to the length the surgeon requests. Tie or hand ties as directed; keep the field clear of loose strands that could contaminate.

2.16 Stapling devices

Provide assistance with stapling devices: linear staplers, circular (EEA) staplers, and skin staplers. Know how each loads, fires, and releases; keep the correct staple loads available; and confirm the device is the right size for the tissue. Announce firing and confirm the staple line as directed.

2.17 Methods of hemostasis

Differentiate among the methods and applications of hemostasis: mechanical (pressure, clamps, ligatures, staples), thermal (electrosurgery, ultrasonic devices), and chemical (topical hemostatic agents). Mechanical methods physically occlude vessels; thermal methods use energy to coagulate; chemical methods accelerate clotting at the tissue surface. Choose per the surgeon's direction and the tissue at hand.

2.18 Irrigation, suction, sponging

Irrigate, suction, and sponge the operative site as directed. Use the solution the surgeon orders (commonly warmed sterile saline or an antibiotic irrigation per protocol), keep suction tips clear and within reach, and sponge with counted sponges only. Announce irrigation amounts so intake is tracked, and never leave a sponge in the wound.

2.19 Monitoring medications and solutions

Monitor medication and solution use throughout the case. Track how much of each labeled medication has been used, watch for the maximum-dose limits the surgeon observes, and report amounts to the circulator for the record. If a medication looks wrong — wrong label, wrong color, unexpected precipitate — stop and verify before it reaches the patient.

2.20 Implants

Verify with the surgeon the correct type and size of specialty-specific implantable items before they are opened: joint prosthesis components, mesh, plates, screws, lenses. Check the labels aloud with the circulator, confirm expiration and package integrity, and open implants only when the surgeon confirms. An opened wrong-size implant is wasted money and a delay.

2.21 Grafts

Prepare bone and tissue grafts: allograft (donor tissue), autograft (the patient's own tissue), and synthetic substitutes. Handle grafts with atraumatic technique, keep them moist and uncontaminated, and prepare them to the size and shape the surgeon specifies. Confirm identification and documentation for allograft material per policy.

2.22 Specimen handling

Verify, prepare, and label specimens. Confirm the specimen identity with the surgeon, place it in the correct container and preservative, and label the container completely. AST's standard directs: "The label should be placed on the side of the container and not the lid to avoid loss of the label when the lid is removed in the pathology or laboratory department" ^[6]. AST says "the use of a preservative should be confirmed by the CST and circulator with the surgeon"^[7]; special studies (frozen section, cultures, cytogenetics) need fresh, moist, or specially handled specimens — confirm before adding fixative, because fixative ruins some tests. Never let a specimen sit unlabeled.

2.23 Drains, catheters, tubing

Prepare drains, catheters, and tubing for insertion: Jackson-Pratt and Hemovac closed-suction drains, Foley catheters, chest tubes, and irrigation tubing. Check integrity, confirm the correct size, and have them ready before the surgeon needs them. For urinary catheters, insertion uses "aseptic technique and sterile equipment"^[8].

2.24 Monitoring the patient

Observe the patient's intraoperative status: monitor the color of blood (bright red arterial vs. dark venous), estimate blood loss, and watch patient position for shifts that threaten nerves or skin. Report changes to the team promptly — the scrubbed technologist's eyes on the field are part of patient surveillance.

2.25 Emergencies

Perform appropriate actions during an emergency: cardiac arrest, malignant hyperthermia, hemorrhage, or fire. Know your role in the code — bring the crash cart supplies, keep the field sterile if the emergency is at the field, and follow the team's direction. For operating room fire, remove the ignition source and burning material, extinguish per protocol, and protect the airway. Preparation for emergencies happens before they occur.

2.26 Prevention

Initiate preventative actions in potentially harmful situations. The fire triangle needs an oxidizer (oxygen, nitrous oxide), a heat or ignition source (electrosurgery, lasers, drills and burrs, fiber-optic light sources) and a fuel (alcohol preps, drapes, gauze, body hair, ointments) ^[9]; prevent fires by managing oxygen near ignition sources, keeping alcohol-based preps from pooling, and moistening sponges near energy devices. Prevent retained items with disciplined counts; prevent burns with correct dispersive-pad placement; prevent wrong-site surgery with the Time Out.

2.27 Drain activation

Connect and activate drains to suction apparatus. For closed-suction drains, compress the reservoir to establish suction, secure the connections, and confirm the system holds vacuum. Connect chest tubes to the drainage system as directed and confirm tidaling or drainage per the surgeon's parameters.

2.28 Dressings

Prepare dressings and the wound site. Have the dressing materials ready before closure finishes: gauze, abdominal pads, transparent films, or specialty dressings per the surgeon's preference. Clean the wound edges as directed, apply dressings with sterile technique, and secure without excessive tension.

2.29 Casts, splints, braces

Assist in the application of casts, splints, braces, and similar devices. Have materials ready (plaster or fiberglass, padding, water at the right temperature), assist with positioning the limb, and support the limb while the material sets. Protect skin with adequate padding and confirm circulation after application.

Chapter 2 Quiz

Chapter 2 quiz — 25 questions

Answer each question, then check the key that follows.

1. A surgeon wants a porcine gelatin sponge packed around a nerve root in a tight foraminal space. What concern should the CST raise?

• A. It can swell and compress nerves
• B. Saline inactivates it
• C. It is not absorbable
• D. It works only on arteries

2. Bleeding from exposed cancellous bone is controlled with bone wax. How does bone wax work?

• A. It is absorbed in 48 hours
• B. It forms a physical barrier
• C. It cauterizes the bone
• D. It triggers clotting chemically

3. For a lower-limb procedure under pneumatic tourniquet, when should the tourniquet be inflated?

• A. After exsanguination and prep
• B. After the incision
• C. Before the patient arrives
• D. Before the skin prep

4. A tourniquet has been up for a long time. What safe time limit does the tourniquet review describe?

• A. 15 to 30 minutes
• B. 1 to 3 hours
• C. 6 to 8 hours
• D. No limit at low pressure

5. The circulator hands off a medication to the sterile field. How should it be verified?

• A. Visually by the CST alone
• B. By the surgeon at the end of the case
• C. Verbally by the circulator alone
• D. Verbally and visually, by two people

6. During a case, the CST finds an unlabeled syringe of clear fluid on the back table. What should be done?

• A. Ask the surgeon what it is
• B. Discard it at once
• C. Label it as saline
• D. Set it aside for later

7. When labeling a syringe on the field, what must the CST avoid?

• A. Writing the drug's strength
• B. Labeling it before the drug is drawn up
• C. Covering the syringe's volume markings
• D. Using the drug's full name

8. Two strengths of epinephrine are on the field for a middle-ear procedure. What final safety check does the CST provide?

• A. Passing what the surgeon points to
• B. Mixing them to one strength
• C. Naming drug and strength aloud
• D. Keeping both unlabeled

9. Who is responsible for administering medications at the surgical site?

• A. The CST
• B. The circulator
• C. The surgeon
• D. The pharmacist

10. Which OR control does AST's sharps guideline recommend when feasible?

• A. Recapping by hand
• B. Loading needles by hand
• C. Hand-to-hand passing
• D. Blunt suture needles

11. In what order does a typical intraoperative sponge count proceed?

• A. Any order, if all are counted
• B. Back table, field, buckets, Mayo
• C. Buckets, back table, Mayo, field
• D. Field, Mayo, back table, buckets

12. When should the binding strip on a package of sponges be broken?

• A. At the final count
• B. When the pack is opened
• C. After the first count
• D. When they are counted and used

13. A bag of counted sponges is full. When may it be taken out of the room?

• A. After all counts are verified
• B. At the first closing count
• C. When the circulator has counted it once
• D. As soon as it is full, to save space

14. The surgeon wants to pack the wound with counted lap sponges for the patient to leave with. What does AST recommend?

• A. Use a cut lap sponge
• B. Use non-counted packing
• C. Use them if the surgeon agrees
• D. Use counted sponges; note it

15. A bullet is removed from a gunshot patient. How should it be handled?

• A. Sent to pathology
• B. Kept as legal evidence
• C. Given to the family
• D. As medical waste

16. The fire risk assessment is high. According to the fire-prevention guidance, what oxygen change reduces the risk?

• A. Lower the concentration to 30%
• B. Raise the concentration to 100%
• C. Switch to nitrous oxide
• D. Leave oxygen as it is

17. Before the electrosurgical unit is used near the airway, what does the fire guidance say about oxygen flow?

• A. Stop it 1 minute before activation
• B. Stop it only if a fire starts
• C. Increase it to protect the patient
• D. Stop it 10 minutes after activation

18. A high-speed burr is being used on bone. What does the fire guidance suggest to reduce sparking?

• A. Run the burr at top speed
• B. Turn up the oxygen
• C. Dry the field with lap sponges
• D. Irrigate the burr with saline

19. A laser is in use during a case but the surgeon is not firing it at the moment. What mode should it be in?

• A. Standby
• B. Low power
• C. Unplugged
• D. Ready

20. A pregnant CST wears a dosimeter during fluoroscopic cases. Where should it be worn?

• A. Under the apron at the waist
• B. In a pocket in the locker room
• C. On the collar outside the apron
• D. On the back of the apron

21. A robotic case must be converted to open because of sudden bleeding. What must the CST be ready to do?

• A. Leave the room so the team has space
• B. Leave the arms docked and open the abdomen around them
• C. Remove the scope and instruments to the back table
• D. Wait for the robot to restart

22. At the end of a robotic procedure, what is removed first?

• A. The instruments, then the endoscope
• B. The patient cart, with everything attached
• C. The trocars, then the instruments
• D. The endoscope, then the instruments

23. Bleeding must be controlled in a small space next to the spinal cord. Which hemostat type does the review favor there?

• A. A dry gelatin sponge
• B. A flowable hemostat
• C. A retained lap sponge
• D. A collagen sheet

24. A patient under arrest arrives for surgery. What should happen to the patient's clothes?

• A. Leave them under the OR table
• B. Hand them to any visitor
• C. Discard them with the linen
• D. Secured as police evidence

25. Why is exposed cancellous bone often a target for mechanical or active hemostats?

• A. They stop arterial bleeding
• B. They sterilize bone
• C. They replace suction
• D. Less blood loss from bone

Answer key & explanations

1. A. The review says porcine gelatin absorbs blood and expands up to 200%, so it should not be used in small spaces because of the risk of injury to neighboring structures, and it should be removed once hemostasis is achieved. It is absorbable (4 to 6 weeks) and may be combined with saline or thrombin.^{[3, 10]}

Sources cited in this excerpt

1. 29 CFR 1910.1030 Bloodborne Pathogens. OSHA / govinfo. https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol6/pdf/CFR-2024-title29-vol6-sec1910-1030.pdf
2. AST Standard: Surgical Counts. Association of Surgical Technologists. https://www.ast.org/uploadedfiles/main_site/content/about_us/standard%20counts.pdf
3. Topical Hemostatic Agents: Review (PMC10090851). PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC10090851/
4. Tissue Handling and Dissection Module (Halsted Principles). ACOG. https://www.acog.org/education-and-events/simulations/tissue-handling-and-dissection/module
5. Suture Materials: Review (PMC9275112). PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC9275112/
6. AST Standard: Handling and Care of Surgical Specimens. Association of Surgical Technologists. https://WWW.AST.ORG/uploadedFiles/Main_Site/Content/About_Us/Standard_Handling_Care_Surgical_Specimens.pdf
7. AST Standards of Practice for Handling and Care of Surgical Specimens. https://WWW.AST.ORG/uploadedFiles/Main_Site/Content/About_Us/Standard_Handling_Care_Surgical_Specimens.pdf
8. CAUTI Core and Supplemental Prevention Measures. Nevada DPBH (CDC HICPAC-derived). https://www.dpbh.nv.gov/siteassets/programs/hai/dta/publications/CAUTIPreventionMeasures_Remediated.pdf
9. FDA Preventing Surgical Fires Initiative, "Practical Advice for Preventing Surgical Fires" (2012).
10. Peer-reviewed review of topical hemostatic agents (PMC10090851). https://pmc.ncbi.nlm.nih.gov/articles/PMC10090851/