CHAPTER II

INTRAOPERATIVE CARE

Objectives:
At the end of the chapter, the students should be able to:
1. Discuss the role of the members of the operating room team.
2. Describe correct handling of sterile supplies.
3. Describe essential nursing interventions required for patient prior to surgery.
4. Identify/perform the duties of the scrub nurse before, during and after surgery.
5. Define draping and explain the purpose, techniques and responsibility.
6. Perform correct draping technique using laparotomy sheet.
7. Describe the layers of tissues.
8. State the types and locations of incisions using anatomical drawing.
9. Identify basic surgical instruments required for a particular operatio n.
Activities:
Circulating Nurse
1. Opening Sterile packs following sterile technique.
2. Set up a sterile field in the operating room.
3. Observe an OR nurse prepare a sterile table and submit a written reaction based from your
observation.

Scrub Nurse
1. Assist in the surgical procedure as member of the operating team, either as circulating nurse or
scrub nurse.

ROLES OF THE OPERATING ROOM TEAM MEMBERS

Surgeon
Although the surgeon’s most obvious responsibility is to perform the operative procedure safely and
correctly, there are other responsibilities to the patient both before and after surgery. Like all members of the
operating room team, the surgeon must be properly attired. The surgeon will visit the patient prior to induction
of anesthesia and, if needed, assist with positioning of the patient. A proper scrub with the approved drying,
gowning and gloving techniques must also be done.
The surgeon may assist with draping the patient and will check or assist with placement of suction,
cautery, Mayo stand, etc. The surgeon is responsible for being certain that all team members are aware of
what is needed during the procedure and that all necessary equipment and instruments are available. If the
surgeon is to give the anesthetic (local, nerve, block or regional) it will be given either prior to scrubbing or
after the patient has been draped.
At completion of the operation, the surgeon secures the dressings in place. After the anesthesiologist
gives permission, the surgeon should assist in moving the patient to the post anesthesia recovery stretcher.
The surgeon may then accompany the patient to the postanesthesia recovery room or may go directly to
write the postoperative orders.

Anesthesiologist or Anesthetist
 The anesthesiologist or anesthetist is the person who administers the anesthetic to the patient. The
anesthesiologist must be properly attired before entering the operating room, although a scrub is not done.
This person is responsible for being certain that all equipment and supplies necessary for the induction of
anesthesia are available and then checks the patient and the chart for any last minute changes, such as
special requests from the patient or additional laboratory tests. A blood pressure cuff and other monitoring
devices are then placed on the patients as needed.
At the proper time, the anesthesiologist administers the anesthetic to the patient and determines
when the surgeon or circulating nurse may proceed with positioning and preparing the operative site. The
anesthesiologist often helps to position the patient properly.

The surgeon generally checks with the anesthesiologists before the incision is made. During the
procedure, the anesthesiologist monitors the patient’s vital signs and is responsible for keeping the surgeon
aware of the patient’s condition. The anesthesiologist gives fluids and blood transfusion needed during the
surgery, and if tourniquets are used, he is responsible for informing the circulating nurse of the time for the
next patient to be premedicated.
The anesthesiologist determines when the patient may be moved to the postanesthesia recovery
stretcher after the surgical procedure has been completed. This person usually checks the patient’s airways
and vital signs before taking the patient to the postanesthesia recovery room. Postanesthesia recovery room
personnel are given all necessary information, such as a report on the patient’s condition both at present and
during the operation, and the type of surgery performed.

Assistant Surgeon
The primary responsibility of the assistant surgeon is to help the surgeon in any way requested. The
assistant must be properly attired. After performing a hand scrub, including proper drying, gowning and
gloving procedures, the assistant may help with draping the patient and with the final placement of equipment
and supplies. During the procedure, this team member gives any assistance as requested by the surgeon.
At the completion of the procedure, the assistant may close the incision and help with the placement of
dressings. After the anesthesiologist gives permission, the assistant helps to move the patient to the
postanesthesia recovery stretcher and may accompany the patient to the postanesthesia recovery room and
write the postoperative orders.

Circulating Nurse
Although the circulating nurse does not scrub, a good handwashing technique must be carried out
and proper operating room attire must be worn. The circulator is responsible for the overall running of the
operating room before, during and after the operative procedure. One of the most important duties is to
assure that sterility is maintained at all times. In addition, the circulating nurse is responsible for preparing
the operating room, assisting the scrub nurse, caring for the patient before and after he is taken into the
operating room, assisting the anesthesiologist, positioning the patient and preparing the operative site,
assisting the scrub team before and during surgery, caring for the patient immediately after surgery, and
cleaning up the operating room after the procedure has been completed.

Preparation of the operating room. Before preparing the operating room, the circulating nurse
must know the operating room schedule and must be familiar with the type of procedure to be done, since
the choice and placement of the table and equipment will depend on the type of operation to be performed.
For example, the plain operating table top is used for a hysterectomy, whereas a special top is needed if x-
ray equipment is to be used. For head and neck surgery, the head of the table should be placed away from
the entrances so that less air current is near the operative area. For lower extremity surgery, the foot of the
table should be farthest from the entrance. If the operating room department has laminar airflow of the Friesen
concept, the placement of the table will vary according to the location of filters or positive air currents. (The
operative site should be toward the filters or positive air currents.)
If electrocautery is to be used, it must be arranged in the room and plugged in, with the ground plate
available to be placed on the patient.
The circulating nurse is responsible for the selection and arrangement of both sterile and nonsterile
supplies. Supplies should be arranged for maximum efficiency; it would be to the department’s advantage to
have basic set-ups so that all nursing personnel know where the various supplies are located.
When preparing the operating room, the circulating nurse should test all lights and x-ray viewers.
Suctions must be tested to be sure that they are ready for later use. The diameter and intensity of spotlights
should be checked also.
All surfaces that may come into direct or indirect contact with the operative site, such as spotlight,
intravenous stands, and autoclave equipment, should be damp dusted with disinfectant before any sterile
supplies are opened. The nurse also checks the autoclave. The master steam valve should be turned on, if
required.

Fig. 2-1 Opening Linen-wrapped supplies.

A. Unwrap first fold away from the nurse.
B. Hold unto first flaphand holding article, unwrap side, then esp. side allow to hang .

A. B.

E.
C. D.

C. Unwrap fold towel toward nurse last.

D. Gather loose ends of wrapper approximately 31 cm (12 inches) from sterile supplies.
E. Front view with all loose ends of linen wrapper held tightly to arm holding sterile supplies.
 Handling sterile supplies. The Circulating nurse is responsible for opening the outer wrapper of
sterile supplies that will be used during the operative procedure. In doing so, the nurse must adhere strictly
to the principles of aseptic technique.
1. The unsterile nurse should not reach over a sterile surface of sterile field. For example, when
opening a sterile article that is wrapped in a double thickness of linen with the four corners folded in. The
corner farthest from the nurse should be opened first and the corner nearest the nurse opened last. As
another example, if a solution must be poured into a sterile pitcher that is on a sterile table, the circulating
nurse should wait until the scrub nurse can either hold the pitcher away from the table or set the pitcher on
the corner of a waterproof-draped table. In either case, the unsterile nurse avoids reaching over a sterile
surface.
2. The unsterile nurse must not touch sterile supplies or equipment. A distance of 12 inches (30
cm) should be maintained between the circulating nurse and all sterile equipment. Although this is not always
feasible, the nurse must be very careful when walking around sterile areas to avoid contaminating. The
circulator avoids walking between two sterile areas.

3. Only the tops of sterile tables are considered sterile. If a table must be moved, the circulating
nurse holds it 12 inches (30 cm) below the top. Also, anything that falls over the edge of a sterile table is
considered unsterile.
4. Splashing can be avoided when pouring solutions by tilting the bottle so that air can get into the
bottle at the same time the solution is poured out.
5. Because the circulating nurse is unsterile, special precautions must be taken to avoid
contamination when removing lids or caps from sterile supplies. As an example, once a bottle of saline
solutions has been opened, the lid or cap should not be replaced.
6. Irrigating solutions must be tested for sterility (each department has its own methods):
7. Special care must be exercised when transfer forceps are used. In inexperienced hands, they can
be a source of contamination. Wet forceps must never touch a sterile field unless it is waterproof. The tips
are kept down so that any solution will not run down to the unsterile handles. Only the tips are used to handle
sterile supplies.

Care of the patient prior to surgery. Before the patient is brought into the operating room the
circulating nurse should identify the patient and check his chart. The patient is asked to state his name, and
the identification band is checked. If the patient has no ID band, a nurse from the ward must identify the
patient and place a band on him. (The patient will feel much more at ease if the nurse does not wear a mask
at this time because he will see a face, not just a pair of eyes.) Although the nurse should be alert to any
cues from the patient concerning his need for reassurance, this is not a time for idle chatter. The preoperative
medication must be given a chance to work.
Fig.2-2.Circulating nurse flipping a sterile suture packet from Fig.2-3.Circulating nurse opening sterile drape pack. Nurse lifts wrapper
overwrap into a basin on the scrub nurse’s sterile back keeping hands on the outside. Hands are in folded cuff to avoid
instrument table. contaminating contents of pack. The area touched falls below unsterile
table level & sterile inside of wrapper (now table cover)
remains sterile.

Fig.2-4. Scrub nurse taking contents from suture packet opened Fig.2-5.Circulating nurse removing sterile suture from packet and held by
circulating nurse. The scrub nurse avoids touching the with sterile forceps. unsterile outer
wrapper.

When checking the patient’s chart, the circulating nurse should ascertain the following:
1. Has the operative permit been signed correctly according to hospital policy?
2. Are laboratory reports complete? The anesthesiologist should be told of any abnormalities in
the patient’s report, because the reports may have been placed in the chart after the
anesthesiologist visited the patient.
3. Have the surgeon’s orders been carried out?
4. Were the preoperative medications given as ordered?
5. Has the patient been prepared properly?
a. Has any prosthesis been removed and stored properly?
b. Have dentures or hearing aids been removed or left in place as required.
c. Has the operative site been prepared properly?

After the preliminary check the circulating nurse brings the patient into the operating room after
checking with the scrub nurse (whether more supplies are needed) and the anesthesiologist. The scrub nurse
should have the majority of instruments arranged on the back table so that noise is minimized. The circulator
should inform the patient when something is to be done so that there will be no surprises. The circulator
should know how to handle a stretcher. When the patient is being moved onto the operating table, it is very
important to hold the stretcher in place against the table. The patient should be told that there is a small
distance from the stretcher to table. If the patient is instructed to put his outstretched arms across the
operating table and move over, he can center himself fairly easily on the table. Some patients will need more
assistance and an orderly or nurse’s aid may be needed to help. Children or infants may be anesthetized in
their bed, depending on the wishes of the anesthesiologist. Check with the anesthesiologist before moving a
sleepy child into the operating table.

Once the patient is on the table, it is essential that the circulating nurse stay right beside the patient
until the anesthesiologist gives permission to go ahead with other duties or until a thigh belt is placed 4 inches
(10 cm) above the patient’s knees. (An infant or small child must never be left alone while on patient’s knees.
(An infant or small child must not be left alone while on the operating room table.) If an adult is capable of
following directions (remember, the patient is medicated and may not be able to do what is asked) and is
strapped onto the table, the circulating nurse can attend to other duties, however, the nurse is still responsible
for the patient’s care. The circulator must keep a close aye and ear on the patient when doing other duties in
the room.

As soon as the stretcher is moved out of the room, the operating room door should be closed and
kept closed as much as feasible. The patient’s modesty must be protected as much as possible.

Fig. 2-6. Circulating nurse assists anesthesiologist during induction of anesthesia.

Assisting the Anesthesiologist. When the anesthesiologist is ready to give the anesthetic,
the circulator must have the suction available and turned on. The circulating nurse must stay beside the
patient and be available to assist as requested. It is important at this time to let the anesthesiologist do all
the talking to the patient. Too many individuals talking to the patient will only confuse him. The circulating
nurse must stay with the patient until the anesthesiologist gives permission to leave. The anesthesiologist
may need assistance immediately, not minutes or even seconds later. Although complications can occur, all
the anesthesiologist usually needs is assistance in placing and holding the patient in position for a regional
block or in holding a piece of equipment. The most important duty of the circulating nurse is to be available
and to reassure the patient by placing a reassuring hand on the patient’s arms or shoulder. Many patients
will hold the circulating nurse’s hand during this time as a way of communicating their fear; it is important that
the nurse reassure them.
 Fig.2-7 Circulating nurse assists the anesthesiologist with positioning the patient for a regional block (Spinal Anesthesia)

Positioning the patient for surgery. This is done only after the anesthesiologist states that the
patient can be positioned. Either the circulator or the anesthesiologist will assist the surgeon in positioning
the patient depending on the type of surgery and the team member’s responsibilities. If the surgeon is
planning to use electrocautery, the ground plate or pad should be placed on or under the patient’s thigh after
positioning is completed.

Preparation of the operative site. The circulating nurse should turn on spotlights when getting
ready to prep the operative site so that the site may be observed closely.

Assisting the scrub team. The circulating nurse helps the surgeon or surgeons into their gowns by
pulling the gowns over their shoulders (and therefore the cuffs over their hands) and tying the back ties. The
circulator should also be available to help if the scrub nurse needs more drapes or other supplies. The
circulator positions and connects the electrocautery, connects suctions, and assists the scrub nurse in
arranging the back table or other equipment. Before surgery the circulator and the scrub nurse complete the
first of three sponge counts.

Duties during surgery. During surgery the circulating nurse has many specific duties but must
always be alert to the needs of the scrub team and anesthesiologist. The circulator’s primary responsibility,
as previously stated, is to be certain that aseptic technique is maintained throughout the procedure. The
circulating nurse is to remain in the operating room at all times unless leaving is absolutely necessary. Then
the scrub nurse and the anesthesiologist must be informed.
The duties of the circulating nurse may vary somewhat, depending on the type of procedure and the
preferences of the scrub team, but during any procedure the circulating nurse must:
1. Be aware of emergency procedures.
2. Anticipate the needs of the scrub team and have all equipment and supplies ready, including
sterile saline solution (if needed), dressings etc.
3. Keep the operating room neat. This will provide a safe environment for the scrub team & the
patient.
4. Complete specimen cards and labels. Complete the required records because these record are
permanent, they must be legible.
5. Inform the head nurse of the progress of the operation so that the next patient can be prepped
and given premedication at the proper time.
 6. Observe the scrub team for perspiration and wipe team member’s forehead as necessary.
7. Give any medication as requested by the surgeon.
8. Get supplies as they are requested during an operation.
9. Count sponges (see below) and have them available so the anesthesiolologist can see them and
estimate the blood loss.

Figure 2-8. Most frequently used sponges. Top: Lap sponge with radiopaque tag. Bottom, left to right: X-ray or 4 x 4; pill (five
on pin); neurosurgical sponges – all with radiopaque threads; dental and weck, or spear, sponges for eye, ear, nose and throat
surgery.

Counting Sponges. Sponges are counted at least three times- before surgery, as the cavity is being closed
and when the skin is being closed. The circulating nurse and the scrub nurse have this very important
responsibility. A miscount could be fatal if a sponge is inadvertently left in the wound.
Because there are so many kinds and sizes of sponges, two persons are needed to complete the
count, each acting as a double-check for the other. There can be no mistakes.
When counting used sponges the circulating nurse should wear gloves to minimize the spread of
bacteria. Although some authorities suggest using instruments to handle the sponges, adequate inspection
of each sponge is possible only when done manually. However, repeated handling of the sponges should be
avoided to lessen the possibility of contaminating the air in the operating room.

Duties after surgery. At the end of the procedure the circulating nurse assist with dressings as needed.
After surgery has been completed the circulator is responsible for assisting the scrub team in taking off their
gowns and for bringing the post-anesthesia recovery stretcher into the room. The circulating nurse also
makes sure that there is sufficient help to move the patient safely, but the anesthesiologist decides when the
patient is to be moved. The circulator checks to see that any catheters, suctions, intravenous poles, etc., are
moved with the patient.
The circulator should be available to assist the anesthesiologist to move the patient to the post-
anesthesia recovery room if necessary.
After the patient has been taken to the recovery room, the scrub nurse and the circulating clean up
the operating room (this may vary depending on the hospital policy). The linen on the operating room table
should be removed and the table washed with disinfectant solution. Refuse from the waste baskets and kick
buckets are removed, and any non-disposable laparatomy sponges are put in the laundry. Any equipment
such as suctions or electrocautery must be cleaned and ready for the next procedure. The floor should be
damped mopped with disinfectant ( a clean mop for each room) and the linen removed.
The circulating nurse is also responsible for double-checking the specimen labels and cards before
they are taken to the laboratory. All paperwork must be completed and placed in the appropriate area.
 If possible, all supplies that were contaminated by the patient are placed on a table and removed
together. Meanwhile, if possible, the room is wet, vacuumed and prepared for the next procedure. Otherwise,
it is damp mopped with disinfectant. Wash hands between cases.

Scrub Nurse
As a member of the scrub team, the scrub nurse must be properly attired, scrubbed, gowned and
gloved. However, before scrubbing, the nurse assists the circulator in the preparation of the operating room
if necessary. The scrub nurse must be familiar with the procedure to be done and with the supplies and
equipment needed.
After completing the proper scrubbing, gowning and gloving procedures, the scrub nurse set up the
back table, Mayo tray and prep stands. Sponges, needles, instruments, etc., are counted as required by
hospital policy. All instruments and supplies must be checked against the surgeon’s card to be sure that
everything is available.

Scrub nurse sets up table in preparation for operation.

Fig. 2-9. Basic prep set before the circulating nurse pours Fig 2-10. Contents of Mayo stand in preparation for
operation: solution. Prepared prep sets are also in the market. (1) scalpels (2) st. & curved scissors (3) smooth & toothed
tissue forceps (4) retractors, (5) st. hemostats, (6)Kelly
clamps, (7) Allis’ forceps, (8) sponges, (9) suture towel &
needleholders.

Fig. 2-11. Starting to drape the Mayo stand. Scrub nurse’s hands Fig. 2.12 Completing the draping of the Mayo stand. The
are protected in cuff of the drape. Folds of drape are supported nurse’s hands are protected in cuffs.
on arms, in bend of elbows to prevent their falling below waist
level. Nurse may place foot on base to stabilize it.
Fig 2.13. Putting scalpel blade on a knife handle. To avoid Fig. 2.14 Passing an instrument. Tip is visible; hand is free.
injury, always use an instrument, never use your hand. Handle is placed directly into waiting hand.
Holding it down and away from your eyes with a strong
needle holder (not a hemostat), grasp blade at its widest,
strongest part and slip blade into the groove on the handle.
The needle holder must not touch the cutting edge.

The scrub nurse then assists the surgeon and assistant to the surgeon into their gowns and gloves.
After the patient is brought into the operating room, anesthetized and positioned and the operative site is
prepped, the scrub nurse drapes the operative site.

Fig. 2-15. Basic Mayo tray set-up. Top, L-R: Spotlight handles (reminds team to put them in place before starting operation), reels of suture,
retractors, sponges, suture scissors. Bottom L-R: Clamps: dissecting, scissors, thumb forceps, scalpels
Fig.2-16. Basic back table set-up for laparotomy. Top, L-R: Drapes; Balfour retractor; long dissecting scissors; extra thumb forceps;
retractors:Deavers, ribbons, Richardsons, Army, Goelet, Bottom, L-R: Surgeon’s gown, x-ray sponges; extra instruments : sponge sticks (ring
forceps), long and short Lauer, straight & curved long Criles, long Allis, long Kocher, tonsil clamps, long Kelly, clamps, long & short Babcock,
short Allis, curved Kelly clamps, straight Halstead clamps, towel clips, straight mosquito clamp; sterile paper bag for suture wrappers, etc., extra
scalpel; needle holder & suction tips.

Fig. 2-17. L-R:P Back table, Mayo tray & ring stand. Scrub nurse’s area.

The nurse assists the surgeon throughout the procedure as required. Many times the surgeon’s
need can be anticipated; for example: when the surgeon is using a scalpel or scissors, the use of clamps
should be anticipated. When clamps are used, suture on a reel, a stick tie, or electrocautery should be ready.
When the suture is used, suture scissors will be needed. The nurse should listen carefully to what the surgeon
is saying an instrument that was not anticipated may be needed and it could be sent for and ready for use.
Sutures and other supplies must be available as needed. Dressings should be available at the time of surgical
closure.
The operative field must be in good order. Unused instruments should be picked up and soiled
sponges replaced with clean ones.
 At the completion of the surgery, the scrub nurse and the instruments must remain sterile. It is
to the patient’s advantage if the scrub nurse keeps the Mayo tray partially set up (with scalpel, clamps,
retractors and scissors) in case they are needed before the patient leaves the operating room. The scrub
nurse is responsible for cleaning up the back table and preparing for between surgery clean-up. As the patient
leaves the room, the scrub nurse gets all of the instruments ready for terminal cleaning. The gown and gloves
can then be removed as the nurse prepares the room for between-surgery clean-up. (The gown is removed
first so that fewer bacteria will be on the nurse’s hands.)

Notes
 LAYERS OF TISSUE/ COMMON ABDOMINAL INCISION

Fig. 2.18. five main layers of body (abdominal) tissue.

LAYERS OF TISSUE

The nurses who assist in surgery must know the basic tissue layers of the body. Circulating nurses
must also know that they can gauge the progress of the operation and call for the next patient or count
sponges at the correct time. The scrub nurse must know the layers of tissue to have the correct instruments
and types of suture at hand.
The five main layers of abdominal tissue from the outer most are:
1. Skin
2. Subcutaneous
3. Fascia
4. Muscle
5. Peritoneum

TYPES AND LOCATIONS OF INCISIONS

When discussing incisions and their locations, it is important to refer to the median and horizontal
planes so that the nurse will know where the basic landmarks are located when terms such as upper, lower,
right and left are used. In Fig.2-19 shows parts of organs commonly operated on Fig. 2-20 illustrates some
of the common incisions that are used for the parts listed in Fig. 2-19.

Fig. 2.19. parts of organs commonly operated on

 Fig. 2.20. Common abdominal inscisions. 1. Upper
abdominal midline; 2. lower abdominal midline; 3. left
lower transverse; 4. right lower paramedian;
5. McBurney; 6. right horizontal flank or right flank;
7. right upper oblique, right subcostal, or right Kocher;
8. left upper paramedian; 9. left lower oblique or left
inguinal (shown by dotted line but is one continuous
incision); 10. Pfannesteil, modified lower midline
abdominal transverse, or bikini.

SURGICAL NEEDLES

Classification:
1. By the shaft
a. Straight – used generally on the skin
b. ½ circle – mostly internal to skin
c. 3/8 circle – skin, plastic surgery

2. By the eye
a. Eye present – will require threading
b. Lack of eye – the needle and suture are one unit [Atralox (double arm-two needles),
atraumatic or swaged-on]

3. By the point
a. Cutting – spear or trocar
b. Round

Fig. 2-21. Eyes of needles: (1) oblong eyes (2) French eyes Fig. 2-22. To thread French eye needle, pull strand taut across
(3) Eyeless (swayed) center of V-shaped area and draw down through the
slit into the eye
 Figure 2-23. Needle Points. Needle Shafts. Needle Eyes

Common suture needles and uses

Name Body Eye Point Common usage

Keith Straight Both Spear Skin
King 3/8 circle Both Spear Retention sutures
Fistula ½ circle (heavy) Eye Spear Back and thigh muscles
Trocar ½ circle Both Trocar Cervix
Scalp ½ circle Eye Trocar Scalp
Reverse cutting 3/8 circle Both Spear Skin, plastic surgery
Ferguson ½ circle (medium size) Both Round Subcutaneous, fascia, peritoneum, abdominal
muscle
Mayo
Gastrointestinal ½ circle (heavy) Both Round Uterine muscles
Cardiovascular ½ circle (thin) Both Round Gastrointestinal
½ circle (double arm- 2 Atraumatic Round Cardiovascular
needles)

Placement of the needle on the holder

Fig. 2-24. Correct position of a curved needle In a needle holder, about one-third down from swage or eye.
 Fig.. 2-25. Minor instrument set (left to right): No. 4 knife handle, small Metzenbaum scissors, regular
Metzenbaum scissors, straight mayo scissors, curved mosquito clamps, straight mosquito clamps, curved Kelly clamps, straight
Kelly clamps, two Allis clamps. Two Bobcock clamps, two Pean clamps, two straight Kocher clamps, short needle holder, long
needle holder, Foerster sponge forceps, Senn retractor. U.S. Army-navy retractor, rake retractor. Top. Two towel clamps, Adson
tissue forceps, tissue forceps without teeth and tissue forceps with teeth. Retractors would be used in pairs.

Fig. 2-26 Major laparotomy set (left to right): Deaver, malleable, U.s Army, rake Richardson double-ended
retractor, Mayo-hegar needle holder, Foerster sponge forceps, straight Kocher clamp, long and short; Mixter Adson hemostatic
forceps; pean, Babcock, allis, curved Crile, straight Kelly, and mosquito clamps, towel clips; curve Mayo, Metzenbaun, and straight
Mayo scissors; Nos. 3 and 4 knife handles. Top right. Tissue forceps, Adson forceps with teeth, and Russian, long and short plain
forceps and long and short forceps with teeth.
Fig. 2.27 Major Instruments Sets

Mixter Right angled forceps

Thorek- Feldman scissors (for gallbladder surgery)

Harrington retractors

Straight Glassman non-crushing intestinal clamp

 Kocher intestinal forceps: straight and curved.

Fig.2-28. Suture set (L-R): No. 4 knife handle; No. 3 knife handle; small Metzenbaum scissors; regular Metzenbaum scissors;
straight Mayo scissors; straight Kelly clamp; curved Crile, Pean, Kocher, Allis and Babcock clamps; Webster needle holder; Senn
retractor. TOP: two towel clamps, Adson tissue forceps, plain tissue forceps without teeth and tissue forceps with teeth; Senn
retractors are used in pairs. This minor suture set could be used for small procedures and instruments could be added for specific
and size of patient.

Notes
 SCISSORS

Fig. 2-29 L-R. Suture scissors, straight Mayo scissors, Fig 2-30. L-R. Stitch scissors. Steven tenotomy scissors,
Metzenbaum scissors, curved Mayo scissors, long Metzen- Steven iris scissors, left and right neal scissors and
baum scissors and long Mayo scissors. Wescott scissors.

Fig. 2-31. L- Mayo curved scissors, Fig. 2-32. L-Regular Metzenbaum scissors
R-Mayo straight scissors R- Short Metzenbaum scissors.

Fig. 2-33 A. Common Dissecting Scissors: L-R: Curved Mayo; B. Tips: L-R: Sharp-tipped curved Metzenbaum (Prince):
blunt curved Metzenbaum; sharp-tipped Metzenbaum (Prince) blunt curved Metzenbaum; curved Mayo.
C. L-R: Comparison of curved and straight D. Handling curved scissors to surgeon. Curve of instruments goes with the
Mayo scissor tips. curve of the surgeon’s palm. Nurse holds instrument by the hinge, allowing
the nurse to view the tip of the instrument and the surgeon to have full use
of the handles.

Fig. 2-34. Hemoclip appliers

(L-R) long, short, medium.
Top: Hemoclip holder with hemoclips

Needle Holders

Fig. 2-35. Webster needle holder Fig 2-36. L-R: Plastic, medium length to large.
Fig.2-37. L-R: Tips- comparison of needle holder to Halstead clamp Fig. 2-38. Handing needle holder, needle and suture to
surgeon. Nurse holds hinge of instruments, handle is free
for surgeon; needle point is pointing up and suture end
of instrument is held by other hand-free from handle

Cutting Instruments, Scalpel Handles and Blades

Fig. 2-39. Scalpel handles L-R: No.4 long, No. 4 regular, No.3 long,
No. 3 regular, No. 7 & No. 3 angled Beaver chuck handle for Beaver
blades. Disposable blades (T-B): No. 64 Beaver, No. 12, No. 11,
No.15, No. 10 and No. 20

Fig.2-40. A.Basic Scalpel handles, numbers marked on base

of handle. L-R: Nos. 3,4,7 & 31. (no 3 long). B. Basic scalpel
blades, number marked on base of blade, number marked on
base of blade.
L-R: Nos. 11,15,10 & 20.

Fig. 2-41. Handling scalpel to surgeon. Nurse holds above and just
behind cutting edge of blade. Surgeon has complete use of handle.
 Tissue Forceps
Fig. 2-42

Tissue forceps without teeth, long and regular.

Tissue forceps with teeth, long and regular.

Russian tissue forceps, long and regular.

Fig. 2-43. L-R: Tissue forceps, TIPS Adson-without teeth, Fig. 2-44. L-R: Tissue forceps con’t. Russian, Multiple
Adson –with teeth, Plain or without teeth and single tooth. Teeth and Ferris- Smith
Fig.2-45. Two ways of handing tissue forceps to surgeons. In both photographs, the nurse’s hands is shown at the left.

Grasping Instruments

Fig. 2-46. Bobcock clamp (with inset) Fig. 2-47. Kocker (Ochsner) clamp.
(inset courtesy of Baxter Healthcare Corporation.)

Fig. 2-48. Allis clamp (with inset) Fig. 2-49. Foerster sponge forceps.
Fig. 2-50. Backhaus towel clamps. Large and small

Clamping Instruments

Fig. 2-51. Mosquito (Halsted) clamp

Fig. 2-52. Kelly clamps; curved and straight. (with inset) Fig. 2-53. Curved Crile clamp. (with inset)

Fig. 2.54. Handing a straight clamp to a surgeon versus a curved Fig. 2.55. Handing a curved clamp. Curve of instrument goes with
clamp. Holding at hinge, therefore allowing nurse to view the the curve of the surgeon’s palm.
Instrument being handed.
 Retractors

Fig.2-56. U.S. Army-Navy retractors Fig. 2-57. Deaver retractors

Fig. 2-58. Ribbon (malleable) retractors. Fig. 2-59. Richardson retractor

Fig. 60. Weitlaner retractor Fig. 2-61. Gelpi retractor

Fig. 2-62. Beckman retractor

Fig. 2-63. Balfour abdominal retractor, one

blade, four wire side blades.

Fig. 2-64. Spring wire retractors. Fig. 2-65. Vein retractor.

2.67. Crile retractors. Bottom: Children’s

Fig. 2-66. Mayo abdominal retractor Fig. hospital retractors

Fig. 2-68. Harrington retractor

Fig. 2-69. Non- self retaining retactors.

L-R: Single skin hook; double- skin hook;
Senn.

Fig. 2-70. Non-self-retaining retractors. Fig.2-71. Side view of Parker; Goelet; U.S. Navy
L-R: Parker; Goelet; U.S. Army.
Fig. 2-72. Non-self-retaining retractors L-R. Israel, 6 prong Fig. 2-73. Non-self-retaining retractors. L-R. Narrow, medium
Dull rake; 4 prong dull rake; 3 prong dull rake; 2 prong dull and wide Deaver, TIPS: narrow, medium and wide Deaver.
Side view: Israel and 4 prong dull rake; TIPS: 6 prong dull
and sharp rake; TIPS, side view of 4 prong dull rake and 4
prong sharp rake.

Accessory Instruments

Fig. 2-74. Frazier suction tips Fig. 2.75. Buie probe, Fig. 2.76. Suction tips. L-R: Frazier tip guide, Frazier suction;
groove director tonsil suction with tip off, abdominal suction shield., Frazier
suction with guide in place; tonsil suction with tip;
abdominal suction with shield.
 Instruments for Dilatation and Curettage

Fig. 2-77. Auvard vaginal speculum Fig 2-78. Jackson vaginal retractors

Fig 2-79. Schroeder-Braun uterine tenaculum Fig.2-80. Schroeder uterine tenaculum

Fig.2-81. Straight Museux uterine vulsellum forceps. Fig. 2-80. Goodell uterine dilator
 Fig.2-81. Sims uterine sound. Fig. 2-82. Curtis tissue forceps

Fig.2-83. Bozeman uterine packing forceps Fig. 2-84. Foerster sponge forceps

Fig. 2-85. Fletcher-Van Doren uterine polyp forceps. Fig. 2-86. Hank uterine dilators.
 Fig. 2-87. Hegar uterine dilators Fig. 2-88. Pratt uterine dilators

Fig. 2-89. Sim sharp curette Fig 2-90. Heancy uterine curette

Fig 2-91. Thomas dull uterine curettes Fig 2-92. Kevorkian-Younge endocervical curette.
 Instruments for Minor Orthopedic Surgery

L-R: Skin hooks. Seen retractors and rake (Volkmann) Meyerding finger retractors with assorted blades.
retractors

Inge lamina spreader Heiss retractor Freer elevator

Key periosteal elevators L-R: Brun (Spratt) curette Caroll tendon passing
Size 3-0; Mouse curette
(double ended) and
Maltz-lip sett nasal rasp
 Kern bone-holders Hike osteotomes Zimmer Stainless steel mallet

ZA Zimmer bone cutting forceps

(double action)

Kleiner-Kutz bone ronguer

(double action)

Instruments for Major Orthopedic Surgery

Sofield retractors Hibbs retractors Meyerding retractors

Bennet bone elevator retractors Israel rake retractor

 L-R: Leksell bone rongeur, Jansen-Zaufel
bone rongeur and Echhn bone rongeur
Lowman bone holding clamps Bone hook

Key periosteal elevators Crego periosteal elevators Brun bone curettes; straight & angled

Ferris Smith tissue forceps

Hohmann retractors

Smith-Peterson osteotomes
curved and straight

Bone chisel
 Zimmer bone mallet Zuelzer awl Kiene bone tomp Left: Maltz nasal rasp
Right: Universal file

Kerrison cervical rongeurs Cushing pituitary rongeurs; straight and curved

Zimmer drill bits

Hand drill with Jacobs chuck key Sadle-nosed pliers

Standard pliers Traction bow

 Vise-grip pliers

L-R: T-wrench, Philips screwdriver L: Lane bone holding forceps

And straight screwdriver R: Bishop bone

Wire Cutter Solid Gigli saw handles with Gigli saw blade

Stille-Mosley bone cutting forceps

Multiaction pin cutter