Surgery

Tools of the Trade

Tool	Function
Scalpel	Used for cutting through flesh. Has three laser-augmented variants of differing quality, each with a percentage chance to create a bloodless incision instead. Improvised equivalents: PICT system, bayonet, kitchen knife, or glass shard
Incision Management System (IMS)	Used for cutting through flesh, skips bleeder clamping and organ rearranging. Basically acts as a scalpel, hemostat, and retractor in one step during the initial incision. Only functions as a scalpel in steps after the first. (Available in the surgical theatre on Solaris Ridge)
Hemostat	Used to stop bleeding during an operation, or to remove foreign and undesirable objects from a patient's body. Also used to repair the brain by removing chips of bone from grey matter. Improvised equivalents: wirecutters for all of the above uses, a kitchen fork for removing objects and brain repair, or cable coil if you are only trying to clamp bleeders during an operation.
Bone Setter	Used for setting bones back into place. If used on a bone that is not broken then you will break it. Improvised equivalents: wrench or maintenance jack
Bone Gel	Used for repairing broken/shattered bones, both in case of fracture and resealing cut ribcages & skulls. Improvised equivalents: screwdriver
Retractor	Used for widening incisions and re-arranging organs, and moving cut ribcages & skulls. Most scalpels and scalpel substitutes can widen incisions in place of a retractor or one of its substitutes, albeit at a much slower rate. When prying open bones, there is a small chance that the ribcage or skull will suffer a fracture even if this step is performed correctly. Improvised equivalents: crowbar or maintenance jack
Cautery	Used for sealing incisions in a patients skin. Burns skin together. Improvised equivalents: cigarette, lighter, or blowtorch
Fix-O-Vein	Used for repairing veins and arteries, treating internal bleeding in the process. Also used to repair hematoma in the brain, treating severe brain damage. Improvised equivalents: surgical line or cable coil
Circular Saw	Used for cutting through bones, particularly those in the ribcage and skull. Performing a bone cutting step on disarm intent will instantly complete the step at the cost of a guaranteed fracture to that region. Improvised equivalents: bayonet, hatchet , or machete
Advanced Trauma Kit	Used to repair all organs except for the brain and eyes. Improvised equivalents: roll of gauze
Surgical Line	Used to suture damaged flesh together, treating excessive brute damage. It can also be used to close incisions in place of a cautery. Improvised equivalents: Fix-O-Vein or cable coil
Synth-Graft	Used to graft severely burned flesh, treating excessive burn damage. No improvised equivalents.
PICT System	The Precision Incision and Cauterization Tool uses a high-frequency vibrating blade, laser cautery, and suction liquid control system to precisely sever target tissues while preventing all fluid leakage. Despite its troubled development program and horrifying pricetag, outside of complex experimental surgeries it isn't any better than an ordinary twenty-dollar scalpel and can't create a full-length incision bloodlessly. Improvised equivalents: scalpel and all scalpel substitutes (see above)
Surgical Drill	Used to open holes in the thoracic wall to access implant cavities, whether implanting a new object from scratch or removing a deeply-embedded foreign body (such as a monkey cube...) Improvised equivalents: a pen or a metal rod

• Improvised tools perform surgery slower compared to their ideal counterparts and apply a risk of failure mitigated by your surgical skill. The severity of the speed penalty scales on how unsuited the tool is. A bayonet is a much better substitute for a scalpel than a glass shard, for example.
• In addition to the speed penalty, an improvised PICT will spray acidic blood all over you and your patient, dealing burn damage to the patient's body as well as significant organ damage to the heart, lungs, and liver.

Preparing for Surgery

Tools

Before you begin to operate, you should make sure you have all the tools you will need. Occasionally a surgeon will accidentally pocket a tool, or a deploying field surgeon will grab tools out of an operating theatre.

Specifically designed surgical tools are the best, but there are a variety of substitutes; some tools can be used outside of their intended role, and others can be replaced with improvised substitutes.

• The equipment on the Almayer is adequate, but sometimes marines will find better tools while deployed. If someone asks if you'd like an Incision Management System, the correct answer is "yes please".

Surgical Surface

The second requirement is a place to work. Some surgeries can be performed on a standing patient, and it doesn't matter where you perform them. Most, however, need a decent surface to work on.

The patient doesn't necessarily need to be buckled - having them on the same tile will do. However the speed modifier is not applied if they aren't buckled. If a surface isn't ideal, the surgery will take longer - and possibly a lot longer.

Locations, namely medical tents, can also provide some benefits to the surgery speed and pain reduction required.

• The ideal surface for surgery is a proper operating table. This is designed for surgery and has a built-in anesthetic system for patients buckled to it. This is the only surface that can be used for extracting xenomorph larvae.

• The next best thing is a portable surgical bed.

• The surfaces that are better than nothing are beds, roller beds, tables, and window frames.

• The worst surfaces are floors and Med-Evac stretchers, which are not designed for surgery, and trying to work with their fittings in their way is as hard as no surface at all.

Surgery Failure Penalties

Improvised tools and poor working conditions contribute to a penalty system that increases the risk of failure, but this penalty is mitigated by your surgical skill.

Tool Suitability	Penalty		Surface Suitability	Penalty		Skill Compensation	Penalty		Penalties	Chance of Failure
Ideal	0		Ideal	0		Novice	0		0	0%
Suboptimal	0		Adequate	0		Trained	-1		1	5%
Subsitute	0		Unsuited	1		Expert	-3		2	25%
Bad Substitue	1		Awful	2		Max	-3		3+	50%
Awful	2

For example, performing internal bleeding surgery, skipping clamp bleeders step, by a corpsman on a roller:

Step	Tool Penalties	Surface Penalties	Skill Mitigation	Total Penalties	Chance of Failure
Knife - Incision (Pre-op)	0 (Subsitute)	- (Lying not required)	0 (Novice)	0	0%
Knife - Expose (Pre-op)	2 (Awful)	- (Lying not required)	0 (Novice)	2	25%
Surgical Line - Fix Vein (IB)	0 (Subsitute)	1 (Unsuited)	0 (Novice)	1	5%
Surgical Line - Suture (Post-op)	0 (Ideal)	- (Lying not required)	0 (Novice)	0	0%

For example, performing internal bleeding surgery, skipping clamp bleeders step, by a surgeon on a roller:

Step	Tool Penalties	Surface Penalties	Skill Mitigation	Total Penalties	Chance of Failure
Shard - Incision (Pre-op)	2 (Awful)	- (Lying not required)	-1 (Trained)	1	5%
Shard - Expose (Pre-op)	2 (Awful)	- (Lying not required)	-1 (Trained)	1	5%
Surgical Line - Fix Vein (IB)	0 (Subsitute)	1 (Unsuited)	-1 (Trained)	0	0%
Surgical Line - Suture (Post-op)	0 (Ideal)	- (Lying not required)	-1 (Trained)	-1	0%

Anesthetic

Surgery is a painful experience, and patients find it difficult to hold still while feeling someone cut into their flesh, which tends to frustrate everyone involved. There are two ways around this: an unconscious (or dead) patient, or powerful painkillers.

Anesthetic (with tank and mask or using the surgery table's integrated anesthesia setup) is a simple and reliable way to render your patient unconscious.

• if the patient's lungs are ruptured, they will occasionally not breath in the anesthetic. Depending on the damage to the lungs, they will either occasionally breath in the anesthetic or it won't work at all. Therefore, you will have to give the patient the anesthetic via Injection, until his lungs are not ruptured anymore.

Operating Table

If you are using an operating table, place your patient on the table (grab your patient, then click the table with your grabbing hand selected). Then buckle them to it to connect the anaesthetic system (click hold and drag the patient to the operating table). After a short delay, your patient will be under general anaesthetic, which will allow you to operate safely.

• The operating table must have an anaesthetic tank attached to be able to put your patient to sleep.

• Click on the surgery table with an anaesthetic tank in hand to insert one.

• Click on the table with an empty hand when no patient is buckled to it to remove an existing one.

• If the tank runs out, simply replace it with a new one.

Anesthetic Tank and Medical Mask

If there is no available operating table then you can make the patient wear an anesthetic tank and medical mask and turn on its internals. Encourage your patient to don and activate the tank and mask themselves, as this is much faster than doing it yourself.

• It is advisable to remove the anesthetic tank and medical mask during the cauterizing step for maximum efficiency; the anesthetic takes a few seconds to wear off.

Painkillers

If you don't have anesthetic equipment or you just want to save time, you can give your patients Oxycodone for quick surgeries without anesthetic (15-20U recommended). You will need to work quickly, though, as it wears off.

Different surgeries cause different amounts of pain. If Oxycodone isn't available, some painkillers are much better than none; a mixture of Tramadol, Inaprovaline or Paracetamol (Paracetamol and Tramadol are toxic when mixed - do not give them simultaneously) will make them less likely to flinch.

• Use your medical scanner to monitor your patient's painkiller levels and re-dose as necessary. Using painkillers instead of anesthetics can cause distress in the patient (screaming over the radio about getting operated on without anesthetics, standing up and trying to leave or fight back).

Now that the preparations are done, you can begin with the actual surgery.

Surgeries

Surgeries are simple processes with a series of steps. Once these steps are memorized it should become effortless and routine to perform. Keep in mind that once you have mastery over the basics, it's a good idea to aim to be as fast and efficient as possible due to the importance of recycling casualties back into the fight, or even preventing them from dying in the case of Foreign Object/Alien Embryo Removal.

To perform surgery on someone, you must Toggle the Surgery Mode to be On. This can be bound to a hotkey in preferences. This will toggle the Help-Intent Safety preference, if you didn't have it already, preventing you from accidentally hurting people with objects when on help intent. You will be forced on to Help intent (top left, 1) , which allows you to perform any surgeries.

• The patient must not be wearing any armor.

• Only one surgery can be performed on a given aim-location at a time.

• Once you complete a step in a surgery, you must finish the surgery before you can begin a different one.

• Failing or cancelling the first attempted step doesn't injure the patient unless done deliberately.

• Some steps can be skipped, if the conditions are right, sometimes including the first step.

• If you are in a rush, attempting surgery steps on

Disarm intent (top right, 2) deliberately fails the step. For a handful of specific steps, this will quickly and violently complete the step at the expense of your patient's health. Useful when you need to do a critical surgery very quickly, or to save time if you're certain you know what you're doing. It isn't necessary to switch back to Help intent afterwards - that happens automatically. (You can use disarm intent to skip the widening incision with Scalpel or break the rib with Circular Saw)

Standing Patients and Self-Surgery

Some surgeries can be performed on a patient who's standing up. These surgeries aren't affected by the surface under the patient. These are marked as (STANDING).

Some surgeries can be performed on yourself. As you need to be able to hold tools while you work, this means they have to be able to be performed on a standing patient, since people who're lying down can't handle objects. These are marked as (SELF).

• If you're trying to work on a standing patient and can't begin a surgery that you know you should be able to, make sure that it doesn't need them to be lying down.

• Since it's difficult and awkward to work on your own body, self-surgery takes longer to do.

• You can't perform surgery on the same arm you're holding the tool with.

• Self-surgery requires you to use painkillers rather than anesthesia, since it's hard to work when unconscious.

Required Skills

Your character's training affects how quickly they can work and mitigates risk of failure due to improvised tool or unsuitable working condition penalties.

Some surgeries can be performed by anyone with any surgical training, but others need a more thorough education.

Medics, nurses, and pilot officers all have basic surgical training and can perform simple level 1 surgeries.

Doctors, chief medical officers, and synthetic units have more skills and can perform level 1 and level 2 surgeries.

You may occasionally see Professor DUMMY, the medical mannequin. This is a sophisticated training tool designed to realistically simulate any wound. Real patients are more difficult to perform surgery on - a medic may be able to set Professor DUMMY's broken ribs, but that doesn't mean they can do it on a real patient in the field. (You can create an ahelp to ask admins to spawn you in a Professor DUMMY)

Level 1 Surgeries

() (optional)

Surgery:	Description:
Suture Wound (Everywhere except mouth/eyes.) (STANDING - SELF)	Suture and tend a wound that has brute or burn damage on it. This will heal 10 brute on the targeted area when a surgical line is used, and will heal 10 burn if a synth graft is used. This will loop until half of all damage on the area has been fixed. Tend to the damaged brute wound. Tend to the damaged burn wound.
Foreign Object (Everywhere except mouth/eyes.)	Removal of unknown objects, such as shrapnel or implants from the body. Incision Management System. OR Open the incision. (->->) Fish out the foreign objects until they are all removed. () Close the incision ()
Sealing a Stump (Severed Arms and Legs)	Sealing a stump where the patient's arm or leg should have been. Seal the stump. (-> ->)
Autopsy (Only on Permanently Dead)	Helps find out how the person died. Displays wounds, possible causes, and detected chemicals in the body. This surgery is of minimal priority and should only be done if you have literally nothing better to do. This is a combat operation, not a funeral parlor. Aim for the affected area on the deceased using the Hud-target Cut the skin open () (the chest may require two cuts). Use the autopsy scanner to scan the area. () Repeat scalpel and scan procedure for all affected areas. (->) Right click the autopsy scanner to print out autopsy data. () Close the incision
Internal Bleeding Surgery (Everywhere except mouth/eyes.)	This surgery mends the torn/ripped arteries and veins within the body to stop internal bleeding. Incision Management System. OR Open the incision. (->->) Mend the artery. () Close the incision. ()

Level 2 Surgeries

Surgery:	Description:
Alien Embryo Removal	Removal of an alien embryo from the body. This must be performed on an operating table. Alien embryos will always be in the chest behind the ribcage. Time is of the essence when removing them, and you must complete this surgery as quickly as possible; your patient will die instantly when it finishes gestating, resulting in the birth of an alien larva. Make haste in removing any embryos. Incision Management System. OR Open the incision. (->->) Open the skull or ribcage if necessary. (->) Cut away the larva's pseudoroots.() OR use () (very much not recommended, as it deals burn damage to yourself and the patient). Pull out the alien embryo. () OR use your hands (not recommended). Close the ribcage.(->). Close the incision ()
Bone Repair Surgery (Everywhere except mouth/eyes.)	This surgery is used for mending broken bones and fractures. Note that a repaired bone will rebreak if your patient has more than 50 brute damage. Incision Management System. OR Open the incision. (->->) Repair the bone. (->) (Use the Health Analyzer to double check) Close the incision. ()
Internal Organs Surgery (Groin, Chest.)	Mending broken internal organs such as the heart or appendix. Note that this surgery excludes the eyes and brain as they have their own surgeries respectively. Peridaxon does not heal organ damage. This is the only way to heal organs in the chest and groin. Incision Management System. OR Open the incision. (->->) Open the ribcage if necessary. (->) Repair the biological organ with a Trauma Kit, or the robotic organ with Nanopaste. It loops fixing each damaged organ until none remain.(/) Close the ribcage if necessary. (->) Close the incision. ()
Monkey Cube Removal (Chest.)	Removing a monkey cube post-ingestion. This surgery is one of the few that require a surgical drill. The embedded monkey will cause continual organ damage and may even result in the host heartbreaking. Time is of the essence. Incision Management System. OR Open the incision. (->->) Open the ribcage. (->) Extract the malformed monkey with a hemostat. (). If this doesn't work, continue with the other steps. Drill open the thoracic cavity wall. () Extract the malformed monkey with a hemostat. () Close the hole with a cautery. () Check for organ damage by using an advanced trauma kit or nanopaste if the organ is robotic.(/) Close the ribcage. (->) Close the incision. ()
Eye Surgery (Eyes.)	Mending the eyes to cure blindness and eye damage. Using imidazoline is usually faster than this surgery. Mend the eyes. (->->->).
Brain Damage Surgery (Head.)	Fixing up the brain. Using alkysine is usually faster than this surgery. Incision Management System. OR Open the incision. (->->) Open the skull.(->) Repair severe brain damage, if any. () Extract embedded bone chips until they are all removed. () (Use Health Analyzer to double check) Close the skull. (->) Close the incision. ()
Facial Reconstruction Surgery (Mouth.)	This surgery fixes facial deformities caused by severe damage to the head. I.E. "Unknown as (name)" when speaking. This surgery is of minimal priority and should only be done if you have literally nothing better to do. This is a combat operation, cosmetic surgery can wait. Fix the facial deformities. (->->) Close the incision. ()
Amputation (Limbs: Legs, Arms, Hands, Feet.)	Removal of a limb. Incision Management System. OR Open the incision. (->->) Use the Incision Management System to sever the muscles. OR Sever the muscles using the scalpel. () (Optional) Cancel the amputation with Fixoven () or a surgical line () Saw through the limb. ()
Limb Replacement Surgery (Limbs: Legs, Arms, Hands, Feet.)	The replacement of missing limbs with robotic ones. Robot arms and legs are used to replace hands and feet; there is no need to further amputate if that's all the patient has lost. If they've lost an organic Limb. Seal the stump. (-> -> ) (Fix-o-vein and surgical line are substitutes for each other) If they've lost a robotic limb Saw off the remaining clamps holding the broken prosthetic to the body. () Use your hand to take broken prosthetic out Attach the robotic limb. (Robotic Limb) Tighten the new robotic limb. () OR Use your hand (Click on them with help intent) Calibrate the new robotic limb with your hand. (Click on them with help intent) Inform the patient that the robotic limb can be repaired with Blowtorch (brute) and Cable coils(burn).
Synthetic Head Re-Attachment Surgery (Head.)	Re-attaching a decapitated synthetic head. Mend the torn silicone tissue. () Attach the synthetic head. Reconstruct the tissue (->). Use a Defibrillator on the synthetic. Note: There isn't a timer on defibbing a synthetic.

The Autodoc System

The Autodoc system is located in the middle of the treatment center and is only usable by the medical staff (and Squad Medics during WO). Note that while the autodoc is an extremely useful machine in medical, it cannot conduct larva removal surgery. The autodoc used to be able to fix bone damage and organ damage, but this has been removed.

Operating Mode:

Manual:

Manual mode will fix everything of the selected surgery type, but autodoc can no longer fix broken bones or organ damage. Manual Surgery List: Trauma Surgeries Shrapnel Removal Surgery: Removes all instances of shrapnel from the patient. Hematology Treatments Blood Transfer: Transfers blood into the patient. The autodoc has an internal reservoir of O- blood that it refills as needed. Dialysis: Purges chemicals from the patient's blood stream; use with toxin damage chelation to treat poisoning and overdoses. Toxin Damage Chelation (Kelation): Removes toxin damage. Special Surgeries Close Open Incision: Closes all open surgical incisions on the patient. Facial Surgery: Treats and repairs facial deformities (typically from physical damage) so the patient can be clearly identified and doesn't look like an unga. Limb Replacement Surgery: Replaces any missing limbs the patient has with robotic prosthetics.

Combining Surgeries

Very often people will come in with multiple problems at once. For instance, you might have a patient who has a fractured skull, brain damage, and shrapnel in their head. Performing three separate surgeries is very time consuming when other marines may be waiting. It is possible to condense the surgery down to one in such a manner:

• Broken skull, brain damage, and head shrapnel removal surgery

1. Use the Incision Management System. OR (->->) to make an incision.
2. Cut through the skull
3. Open up the skull
4. Here it gets a bit tricky, use a hemostat repeatedly to pull out bone chips and shrapnel until you get a message that nothing more can be found in the brain. Both types of removal can take several rounds or attempts.
5. Use the FixOVein and Trauma Kit to repair hematomas and damage to the brain and eyes if necessary
6. Use the Health Analyzer to check that the patient does not have brain damage! If the patient still has brain damage go back and use the hemostat and FixOVein more until the Analyzer shows no brain damage.
7. Close the skull back up
8. Use bone gel on the damaged bones in the skull
9. Piece together the broken or fractured skull
10. Add bone gel once more
11. Seal up the incision
12. Use the Health Analyzer again to see if the patient needs antibiotics or anti-toxins and administer them as needed

What about an infected marine with a broken chest, internal bleeding, and a ruptured lung? Here you'll want to use medication from the vendors in medbay in order to tackle the problems at hand.

• Alien embryo removal, ruptured lung, and broken chest surgery (with a side of internal bleeding)

1. First use one Dexalin Plus injector to halt suffocation damage from the ruptured lung. While you can stop internal bleeding surgically, Keep a couple of Dex+ injector on hand to keep the patient from dying from the ruptured lung.
2. Make an incision quickly
3. Ignore bleeders and rearrange organs. Removing the larva ASAP is the top priority right now
4. Cut open the rib cage
5. Separate the rib cage
6. Begin cutting out the alien embryo
7. Begin pulling out the alien embryo
8. Repair the ruptured lungs and any other damaged organs, note that a mechanical heart requires to fix
9. Now stem the bleeders with the hemostat
10. Close up the rib cage
11. One application of bone gel for the cut rib cage. Cut rib cages and skulls require one application of bone gel after they've been pushed back together.
12. Set the broken bones in the chest
13. An application for the set bones. In general remember that fixing a broken bone requires two application of bone gel before the setting it.
14. Cauterize the incision, your patient should be recovering nicely now
15. Again, use the Health Analyzer to double-check your work and to dispense dylovene as needed

Tips

• Patients can often tell you where they need surgery if an advance scanner is not available.
• The hemostat step can be saved for later in the surgery or skipped entirely at the cost of your patient losing blood volume.
• Be sure to stand in a spot where you won't be pushed around. Any movement will violently fail the surgery step you are currently performing. It is recommended for field surgeons to bring a folding chair for this exact reason.
• The most common type of surgery that a person would need is Bone Repair Surgery and Internal Organs Surgery. Be sure to be familiar with the steps. (Using Bone Gel twice is a good habit while fixing Fracs)
• Note that only the Sealing a Stump surgery and Alien Embryo Removal surgery require a high level of anesthetic/painkilling, like what Oxycodone ( PNK 8) or the surgical table provides when hooked up to the patient (provided they have functional lungs).
• Tramadol has enough painkilling ( PNK 5) to perform all other surgeries besides Sealing a Stump surgery and Alien Embryo Removal. Tramadol also lasts longer than Oxycodone, leading to less time wasted injecting and more time for performing surgery. Ideal for several broken bone surgeries in a row.
• Be sure to check if any Tramadol is already in the system when performing the initial scan, as it is often used as a painkiller.
• If you see a broken red heart next to the patient, that means they have heartbreak. The broken heart indicates that the patient's heart has suffered too much trauma for revival attempts. When scanned the message will say: "Patient's general condition does not allow reviving." To fix this, a doctor (or person able to do surgery level 2 or higher) must repair their heart in time before any further revival attempts are under taken. If a doctor (or someone applicable) is not immediately available, perform CPR on the corpse to extend their defib timer until a doctor can perform surgery to repair the heart.
• Shrapnel is never good as it gives organ damage when received, and deals brute damage (which can also cause further organ damage) when moving with it still inside the body. The most common way to remove shrapnel is to way remove with a knife or other sufficiently sharp object. To do this, activate/click yourself/patient on help intent with knife in hand. Yanking out the object is another option (only if object is externally embedded). To do this, right click the person with shrapnel and click Yank out object. The last option is surgery (only if object is deeply embedded or small to remove).
• Refer to Guide to Medicine, Chemistry, or the Researcher page for further information.