Surgical Instruments

Historical Background
As early as 10,000 BC, prehistoric man fashioned tools to cut human flesh for the purpose of either inflicting wounds or repairing them. The Incas of Peru used razor-sharp flint and sharpened animal teeth. The Code of Hammurabi (circa 1900 BC) describes a bronze lancet. The Egyptian Ebers papyrus mentions blades made of flint, reed, and bronze used around 1900 to 1200 BC Hippocrates (460-377 BC) advocated heating the tips of rounded and pointed blades.

 During the pre-Christian era in India, Shusuruta made grasping tools designed for extracting objects such as arrowheads. In the first century AD, Celsus described the use in Rome of scalpel handles with blunt dissecting ends, knives, saws, forceps, and clamps with locking handles, probes, and hooks for retraction. Amroise Par (1510-1590) was the first to grasp blood vessels with a pinching instrument (the predecessor of the hemostat used today).

 In the United States, amputations were the surgical trademark of the Civil War (18611865). Hippocrates wrote that the size, weight, and delicacy of an instrument ought to be well suited for its purpose.

Fabrication of Metal Instruments

Stainless Steel
Is an alloy of iron, chromium, and carbon. It may also contain nickel, manganese, silicon, molybdenum, sulfur, and other elements to prevent corrosion or to add tensile strength.

 Stainless steel instruments are fabricated with one of the three types of finishes before passivation:
Mirror finish is shiny and reflects light. Anodized finish (satin finish), is dull and glareproof. Ebony finish is black, which eliminates glare.

 Titanium
In comparison to stainless steel, the metallurgic properties of titanium are excellent for the manufacture of microsurgical instruments. Nonmagnetic and inert Titanium alloy is harder, stronger, lighter in weight and more resistant to corrosion than is stainless steel A blue anodized finish of titanium oxide reduce glare.

 Vitallium trade name for cobalt, chromium, and molybdenum. This inert alloy has the strength and corrosionresistant properties suitable for some orthopedic devices and maxillofacial implants. Other Metals Some instruments are fabricated from brass, silver or aluminum. Tungsten carbide is an exceptionally hard metal used for laminating some cutting blades or as inerts on the functional tips or jaws of some instruments.

 Plated Instruments
A shiny finish can be put on a basic forging or tooling of an iron alloy. Chromium, nickel, cadmium, silver, and copper are used for coating or flash-plating. When deposited directly on the steel, any of these metals is prone to rupturing, chipping and spontaneous peeling. It is difficult to keep plated instruments from corroding, and rust can form beneath the plating. Plated instruments are used infrequently today.

Classification of Instruments

CUTTING AND DISSECTING

Have sharp edges. Used to dissect, incise, separate, or excise tissues. These instruments should be kept separate from other instruments, and the sharp edges should be protected during cleanin, sterilizing, storing. Proper precautions are necessary to take during the handling or disposing of all sharps, blades, or scalpels.

SCALPELS
The type of scalpel most commonly used has a reusable handle with a disposable blade. Most handles are made of brass; the blades may be made of carbon steel. The blade is attached to the handle by slipping the slit in the blade into the grooves on the handle. A heavy hemostat or Kelly clamp is used to attach and detach the blade. Blades vary by size and shape; handles vary by width and length.

BLADE No. 10 No. 11 No. 12

DESCRIPTION Rounded cutting edge along one side Straight edge that comes to a sharp point Shaped like a hook, with the cutting edge on the inside curvature Smaller and shorter curved cutting edge than No. 10 blade. Same shape as No. 15 blade but is smaller for tiny incisions (for pediatic prcedures) Same shape as No. 10 blade but are larger Curved cutting edge that comes to more of a point than Nos. 20, 21 and 22 blades

HANDLE Nos. 3, 7, and 9 Nos. 3, 7, and 9 Nos. 3, 7 , and 9

No. 15

Nos. 3, 7, and 9

No. 15C

Nos. 20, 21 and 22 No. 23

No. 4 No. 4

KNIVES
Come in various sized and configurations. Usually have a blade at one end, like a kitchen paring knife, and the blade may have one or two cutting edges. Designed for very specific purposes (e.g., cataract knife) Other types of knives have detachable and replaceable blades (e.g., adenotome, dermatome). A knife blade may be incorporated into a multifunctional instrument, such as a gastrointestinal anastomosis (GIA) stapler that cuts and staples tissue.

Cataract Knife

Adenotome

Dermatome

SCISSORS
The blades of scissors may be straight, angled or curved, as well as either pointed or blunt at the tips. The handles may be long or short. Some are used only to cut or dissect tissues; others are used to cut other materials. To maintain sharpness of the blades, scissors should be used only for their intended purpose.

 Tissue/Dissecting Scissors Must have sharp blades. The type and location of tissue to be cut determines which scissors the surgeon will use. Blades needed to cut tough tissues are heavier than those needed to cut fine, delicate structures. Curved/angled blades are needed to reach under or around structures. Handles to reach deep into body cavities are longer than those needed for superficial tissues.

 Suture Scissors Have blunt points to prevent structures close to the suture from being cut. Wire Scissors Have short, heavy blades. Are used instead of suture scissors to cut stainless steel sutures. Heavy wire cutters are used to cut bone fixation wires. Dressing or Bandage Scissors Are used to cut drains and dressings and to open items such as plastic packets.

BONE CUTTERS AND DEBULKING TOOLS

Instruments with cutting edges suitable for cutting into or through bone and cartilage. These instruments incluse: Chisels Osteotomes Gouges Rasps Files

Chisel and Mallet

Osteotome

Rasp
File

OTHER SHARP DISSECTORS

Sharp dissection to cut tissue apart or to separate tissue layers may be accomplished with other types of sharp instruments.

 Biopsy forceps and punches A small piece of tissue for pathologic examination may be removed with a biopsy forceps or punch. These instruments may be used through an endoscope. Curettes Tissue or bone is removed by scraping with the sharp edge of the loop, ring, or scoop on the end of a curette. Snares A loop of wire may be put around a pedicle as it retracts into the instrument. The wire is replaced after use.

Biopsy Punches Biopsy Forceps

Snares

Curettes

 Blunt dissectors
Friable tissues or tissue planes can be separated by blunt dissection. The scalpel handle, the blunt sides of tissue scissor blades, and dissecting sponges may be used for this purpose.

GRASPING AND HOLDING

Tissue Forceps
Are used to pick up or hold soft tissues and vessels.

Smooth Forceps
Also referred to as thumb forceps or pick-ups, smooth forceps resemble tweezers. They are tapered and have serrations (grooves) at the tip. They may be straight or bayonet (angled), short or long, and delicate or heavy. Smooth forceps will not injure delicate structures.

Smooth Forceps

 Toothed Forceps Rather than being serrated, they have a single tooth on one side that fits between two teeth on the opposing side or they have a row of multiple teeth at the tip. Heavy types are sometimes referred to as rat-toothed forceps,. Toothed forceps provide a firm hold on tough tissues, including skin. Finer versions have delicate teeth for holding more delicate tissue. Allis Forceps Has a scissors action. Each jaw curves slightly inward, and there is a row of teeth at the end. The teeth hold tissue gently but securely.

Toothed Forceps

Allis Forceps

 Babcock Forceps
The end of each jaw of a babcock forceps is rounded to a fi around a structure or to grasp tissue without injury. This rounded section is circumferentially fenestrated.

Stone Forceps
Either curved or straight forceps are used to grasp calculi such as kidney stones or gallstones. These forceps have blunt loops or cups at the end of the jaws.

Babcock Forceps

Kidney Stone Forceps

Bladder Stone Forceps

Gallstone Forceps

 Tenaculums The curved or angled points on the ends of the jaws of tenaculums penetrate tissue to grasp firmly, such as when a uterine tenaculum is used to manipulate the uterus. May have a single tooth or multiple teeth, such as a Jacob tenaculum. Some have a built-in uterine cannula or probe elevator tip. The cannula, or probe, can be used during laparoscopy to raise the uterus into the visual field. The cannula is inserted into the cervical os as the tenaculum is clamped on the lip of the cervix. Dye can be instilled through the cannula into the uterine cavity. Bone Holders Grasping forceps, vice-grip pliers and other types of heavy holding forceps stabilize bone.

Bone Holders

CLAMPING AND OCCLUDING

Instruments that clamp and occlude are used to apply pressure.
Hemostatic Forceps
Most clams used for occluding blood vessels have two opposing serrated jaws that are stabilized by a box lock and controlled by ringed handles.

 Hemostats
Are most commonly used surgical instruments and are used primarily to clamp blood vessels. Have either straight or curved slender jaws that taper to a fine point. The serrations go across the jaws.

Hemostats

 Crushing Clamps
Many variations of hemostatic forceps are used to crush tissues or clamp blood vessels. Jaws may be straight, curved, or angle, and the serrations may be horizontal, diagonal, or longitudinal. The tip may be pointed or rounded or have a tooth. Many forceps are named for the surgeon who designed the style, such as the Kocher and the Ochsner forceps. Some are designed to be used on specific organs, such as Pean intestinal forceps or kidney forceps. Fine points are needed for small vessels and structures. Longer and sturdier jaws are needed for larger vessels, dense structures, and thick tissue. Longer handles are needed to reach structures deep in body cavities.

Kocher Clamp

Ochsner Clamp

Pean Intestinal Forceps

 Noncrushing Vascular Clamps

Are used to occlude peripheral or major blood vessels temporarily, which minimizes tissue trauma. The jaws of these types of clamps have opposing rows of finely serrated teeth. The jaws may be straight, curved, angled or S-shaped.

Vascular Clamp

EXPOSING AND RETRACTING

Soft tissues, muscles and other structures should be pulled aside for exposure of the surgical site.

 Handheld Retractors Most retractors have a blade on a handles. The blades vary in width and length to correspond to the size and depth of the incision. The curved or angled blade may be solid or pronged like a rake. These blades are usually dull, but some are sharp. Some retractors have blades at both ends rather than a handle on one end. Other retractors have traction groves for slippery surfaces such as the tongue. Handheld retractors are usually used in pairs, and they are held by the first or second assistant.

 Malleable Retractors Is a flat length of low-carbon stainless steel, silver, or silver-plated copper that may be bent to the desired angle and depth for retraction. Hooks Single, double, or multiple very fine hooks with sharp points are used to retract delicate structures. Are commonly used to retract skin edges during a wide-flap dissection such as a face-lift or mastectomy. Some styles of hooks have ball tips, which cause less trauma to tissues.

Hooks

Malleable Retractors

 Self-Retaining Retractors Holding devices with two or more blades can be inserted to spread the edges of an incision and hold them apart. For example, a rib spreader holds the chest open during a thoracic or cardiac procedure. May have shallow or deep blades. Some have ratchets or spring locks to keep the device open; others have wing nuts to secure the blades. Some have changeable blades of different sizes. Some ban be attached to the operating bed for stability.

Bookwalter Retractor

SUTURING OR STAPLING
Needle Holders
A needle holder is used to grasp and hold curved surgical needles. Most needle holders resemble hemostatic forceps; the basic difference is the jaws. Has short, sturdy jaws for grasping a needle without damaging it or the suture material. Jaws are usually straight, but they may be curved or angled; the inside surfaces of the jaws may also differ.

Tungsten Carbide Jaws Tungsten carbide is a hard metal. Jaws with an insert of solid tungsten carbide with diamond-cut precision teeth are designed specifically to eliminate the twisting and turning of the needle in the needle holder. Can be identified by the gold plating on the handles. Crosshatched Serrations The serrations on the inside surface of the jaws are crosshatched rather than grooved, as in a hemostat. Crosshatching provides a smoother surface and prevents damage to the needle. Smooth Jaws Some surgeons prefer needle holders that have jaws without serrations. These needle holders are used with small needles, such as those used for plastic surgery

Tungsten Carbide Jaws

Crosshatched Serrations

Smooth Jaws

 Staplers Whether reusable or disposable, all surgical staplers are bulky, heavy instruments. Reusable staplers have many moving parts and are disassembled for cleaning and assembled at the sterile field before use. Sterile, single-use, disposable staplers that are completely assembled eliminate the many problems associated with reusable instruments. The staples are usually made of titanium, stainless steel, or absorbable material.

 Clip Appliers Individual staples can be placed with loaded or single clip applier. Used to occlude vessels Terminal End Staplers Designed for closing the end of a hollow organ (bowel, stomach) with a double staggered line of staples. The stapler is L-shaped and is positioned across the end of the hollow organ to be closed or the tissue to be amputated. Internal Anastomosis Staplers Are designed to connect hollow organ segments to fashion a larger pouch or reservoir. End-to-End Circular Staplers Are designed to staple two hollow, tubelike organs end to end to create a continuous circuit. Are commonly used for bowel anastomosis after resection.

Terminal End Stapler Clip Applier

Internal Anastomosis Stapler

End-to-End Circular Stapler

VIEWING
Speculums
The hinged, blunt blades of a speculum enlarge and hold open a canal or a cavity.

Endoscopes
The round or oval sheath of an endoscope is inserted into a body orifice or through a small skin incision.

Hollow Endoscopes
The rigid hollow sheath permits viewing in a forward direction through the endoscope.

Lensed Endoscopes
Have either rigid or flexible sheaths, and they have an eyepiece with a telescopic lens system for viewing in several directions.

Vaginal Speculum

Endoscope

Ear Speculum

SUCTIONING AND ASPIRATING Suction

Involves the application of pressure (less than atmospheric pressure) to withdraw blood or fluids, usually for visibility at the surgical site.

 Poole Abdominal Tip

Is a straight hollow tube with a perforated outer filter shield. Used during abdominal laparotomy or within any cavity in which copious amounts of fluid or pus are encountered.

Frazier Tip
Is a right angle tube with a small diameter. Used when encountering little or no fluid except capillary bleeding and irrigating fluid, such as in brain, spinal, plastic, or orthopedic procedures. Keeps the field dry without the need for sponging.

Yankauer Tip
Is a hollow tube that has an angle for use in the mouth or throat. Large quantities of blood and fluid can be suctioned quickly with a Yankauer tip, which is useful for visualization during ruptured aneurysms.

Autotransfusion
A double-lumen suction tip is used to remove blood for autotransfusion.

Frazier Tip

Yankauer Tip

Poole Abdominal Tip

 Aspiration
Blood, body fluid, or tissue may be aspirated manually to obtain a specimen for laboratory examination or to obtain bone marrow for transplantation. Suction is performed with a needle and syringe.

 Trocar
May be needed to cut through tissues for access to fluid or a body cavity. Has sharp edges at the end of a hollow tube. A cannula with a blunt end fits inside the trocar to keep fluid or gas from escaping until the cannula is removed. Endoscopic instruments may be manipulated through special trocars that have valves for insufflation, irrigation and aspiration.

Cannula
A cannula with a blunt end and perforations around the tip may be used to aspirate fluid without cutting into tissue. Cannulas are also used to open blocked vessels or ducts for drainage or to shunt blood from the surgical site.

Trocar

Cannula

DILATING AND PROBING

Dilator
Is used to enlarge orifices and ducts, such as dilation of the uterine cervix.

Probe
Is used to explore a structure or to locate an obstruction. Probes are used to explore the depth of a wound or to trace the path of a fistula.

Hegar Uterine Dilator

Probes

MEASURING
Rulers, depth, gauges, and trial sizers are used to measure parts of the patients body. Some of these devices are used to determine the precise size needed for an implant, such as a joint or breast prosthesis.

Ruler

Depth Gauge

ACCESSORY INSTRUMENTS
Mallet
Needed to drive a cutting instrument into a bone.

Screwdrivers
Used to affix screws into bone.

MICROINSTRUMENTATION
The instruments are extremely fine, delicate, and miniature enough to handle in the very small working area. Primary uses:
Cutting (knives, scissors, saws) Exposure (spatulas, retractors) Gross and fine fixation (forceps, clamps) Suture and needle manipulation (needle holders)

Microsurgical Scissors
Microsurgical Knife

Microsurgical Retractors

Microsurgical Forceps

Microsurgical Needle Holder

Powered Surgical Instruments

Air-Powered Instruments
Suction tubes

Electrically Powered Instruments

Saws, drills

Battery Power
shavers

Alternating Current Sonic Energy

HANDLING INSTRUMENTS
Setting Up the Instrument Table
Standardized basic sets of sterile instruments are selected for each specific surgical procedure. A set is a group of instruments that may include all appropriate classifications of instruments or the instruments needed for a specific part of the procedure. Instruments are usually prepared, wrapped, and sterilized several hours before the surgical procedure so they are dry and cool for safe handling. When removed from the sterilizer, the instruments are hot. Condensate must not contaminate the sterile table cover. The scrub person counts all instruments, sponges and sharps with the circulator before setting up the Mayo stand and instrument table.

Key point in handling instruments before the surgical procedure include:

Handle loose instruments separately to prevent interlocking or crushing.
Instruments are never piled one on top of another on an instrument table; they are laid side by side. Close the box locks on the instrument to avoid entanglement. Microsurgical, ophthalmic, and other delicate instruments are vulnerable to damage through rough handling. Tip protectors are removed during setup. Metal-to-metal contact should be avoided or minimized. Scalpel blades should not be set in a metal basin. The edges can become dull, and small chips of metal can become dislodged and inadvertently transferred to the patient during irrigation.

 Inspect instruments such as scissors and forceps for alignment, imperfections, cleanliness, and working condition. Remove any malfunctioning instrument from the set. It should be labeled and sent for repair. Replace it in the set with a correctly functioning instrument before processing. If the procedure is in process, the circulator can obtain a sterile replacement and remove the broken instrument from the room. Be sure to reconcile the count sheet.
Scalpel blades should be properly set in handles using a heavy instrument, not fingers. Teeth and serrations should align exactly. Tips should be straight in alignment. Scissors should be snug and sharp in action. Cannulas should be clear and without obstruction. Stylets should be removed.

 Sort instruments neatly by classifications. Keep ring-handled instruments together with the curvatures and angles pointed in the same direction.
Hang ring handles over a rolled towel or over the edge of the instrument tray or container. Remove instrument stringers or holders if used to keep box locks open during processing. Close box locks on the first ratchet.

Leave retractors and other heavy instruments in a tray or container, or lay them out on a flat surface of the table.

 Protect sharp blades, edges, and tips. They should not touch anything. Take care not to perforate the sterile table cover.
Sets of instruments, such as osteotomes or micro-surgical instruments, may be in sterilization racks so that the blades and tips are suspended. These instruments can remain in racks during the initial table setup and until they are needed during the surgical procedure. Tip-protecting covers or instrument-protecting plastic sleeves should be removed and discarded before the instruments are used on the patient. Most covers and sleeves are not radiopaque and could become a retained foreign body. If they are not in a rack, handles should be supported on a rolled towel or gauze sponge. This keeps the blades and tips of microinstruments suspended in midfair for easy visualizations.

Handling Instruments during the Surgical Procedure

Know the name and appropriate use of each instrument. Using fine instruments for heavy tissue damages the instrument. Handle instruments individually. Tangled instruments are hard to separate in an emergency. Hand the surgeon or assistant the correct instrument for each particular task. Remember the following principle: Use for the intended purpose only. Pass instruments decisively and firmly. When the surgeon extends his or her hand, the instrument should be slapped or placed firmly into his or her palm in the proper position for use. In general, when passing a curved instrument, the curve of the instrument aligns with the direction of the curve of the surgeons hand. Watch the sterile field for loose instruments. After use, remove them promptly to the Mayo stand or instrument table. The weight of instruments can injure the patient or cause postoperative discomfort. Keeping instruments off the field also decreases the possibility of their falling to the floor.

 With a moist sponge, wipe blood and organic debris from instruments promptly after each use. Flush the suction tip and tubing with sterile distilled water periodically to keep the lumens patent. Use only a few milliliters of solution if using irrigating fluids from the surgical field. Keep a tally of the amount used to clear the suction line, and deduct this amount from the total used to irrigate the surgical sire. Accurate accounting of the solutions used for patient irrigation is necessary when determining the amount of blood lost during the surgical procedure. Remove debris from electrosurgical tips to ensure electrical contact. Avoid using a scalpel blade to clean electrosurgical tips, because the debris may become airborne and contaminate the surgical field. Place used instruments that will not be needed (except sharp, cutting, delicate or powered instruments) into a tray or basin during or at the end of the surgical procedure.

Dismantling the Instrument Table

Check drapes, towels, and table covers to be sure that instruments do not go to the laundry or into the trash. A final quick count is a safeguard. Collect instruments from the Mayo stand and any other small tables, and collect those that may have been dropped or passed off the sterile field. Separate the delicate, small instruments and those with sharp or semisharp edges for special handling. Disassemble all instruments with removal parts to expose all surfaces for cleaning.

 Open all hinged instruments to expose block locks and serrations. Separate instruments of dissimilar metals. Instruments of each type of metal should be cleaned separately to prevent electrolyte deposition of other metals. Flush cold, distilled water through hollow instruments or channels, such as suction tips or endoscopes, to prevent organic debris from drying. Rinse off blood and debris with demineralized distilled water or an enzymatic detergent solution.

 Follow the procedures for preparing each instrument for decontamination or terminal sterilization. Procedures vary depending on the type of instrument and its components and on the equipment available to its location. Wrap the instrument for sterilization. Sterilize the instrument in steam unless contraindicated by the manufacturer.