GENERAL SURGICAL

INSTRUMENTATION
 Objectives
At the end of this unit you will be able to:
• Identify the use and function of each type of
surgical instrument.
• Define suture and suture materials.
• Identify the different suture materials.
• Mention the types of suturing methods
 Introduction
• Surgical instrumentation is critical to the
surgical procedure.
• The performance of the OR team is enhanced
when team members know each instrument
by name, how each item is safely handled,
and how each is used.
 Classifications of Instruments
• Instruments are classified according to their
function, and most fall into one of four
groups.
1 Cutting group
2 Grasping and Clamping
3 Exposing and Retracting
4 Probing and Dilating
 A. Cutting and Dissecting
• Cutting instruments have sharp edges/points.
• They are used to dissect, incise, separate,
penetrate, or excise tissue.
• These instruments should be kept separate from
other instruments, and the sharp edges should be
protected during cleaning, sterilizing, and storing.
• This group includes: scissors, knives, biopsy
punches, scalpels (blades), saws, osteotomes,
drills, curettes, needles, chisels, etc.
 Cont..
• Scissors may be straight or curved and either
pointed/blunt, pointed/pointed, or
blunt/blunt.
 Cont..
Scalpel blades
• Blades have different sizes;
– #10 is the most commonly used scalpel
blade.
– Blades #11 is pointed and is used in
arthroscopic procedures (stab incisions).
– Blade #12 is hooked and is used to remove
sutures.
 Cont..
– #15 is a smaller version of #10, and is used
in for more delicate incisions.
– Blade #22 and #23 are larger and used
primarily in large tissues.
Bone Saw
drill
Chisels
needles
Curettes (B,C and D) and osteotomes (A)
 B. Grasping and Clamping
• A clamp is an instrument that clasps tissue
between its jaws.
• Clamps are available for use on nearly every
type of body tissue, from delicate eye muscle
to heavy bone.
• The most common clamps are the hemostatic
(artery) clamps, crushing clamps, noncrushing
clamps etc.
Hemostatic forceps
non-crushing clam
Crushing clamp
 Cont..
Grasping instruments are used to hold and
manipulate structures.
• Needle holder, blade holders, tissue forceps,
Alli’s forceps, bone holders, tenaculi
(tenaculm, singular) Babcock etc. are included
in this category.
• Tissue forceps may be toothed or non-toothed
and have different size.
 Cont..
• Blade holders have different sizes (#3, #4, #5
and #7).
• #4 use to handle blade #22 and #23.
• #3, #5 and #7 used to handle Blades #10, #11,
Blade #12, and Blade #15.
Allis
Babcock
Sponge Forceps
Needle holder
tenaculi
bone holders
 C. Exposing and Retracting
• Soft tissues, muscles, and other structures
should be pulled aside for exposure of the
surgical site.
• Exposing and retracting instruments are those
that hold tissue or organs away from the area
where the surgeon is working.
 Cont..
• Retractors are available for use in all parts of
the body.
• They may be very shallow, as for skin
retraction, or very deep, as for the retraction
of abdominal contents.
• Retractors can be handheld or self – retaining.
 Cont..
• Handheld Retractors
– Have a blade (boards) on their handle.
– The blades vary in width and length to correspond
to the size and depth of the incision.
– The blades may be dull or sharp.
– Some retractors have blades at both ends rather
than a handle on one end(roo retractors).
– Are usually used in pairs, and they are held by the
first or second assistant.
 Cont..
• Malleable Retractor
– Is a flat length of low-carbon stainless steel,
silver, or silver-plated copper which may be
bent to the desired angle and depth for
retraction.
 Cont..
• Self-Retaining Retractors
– Holding devices with two or more blades can
be inserted to spread the edges of an incision
and hold them apart.
 D. Probing and Dilating
• A 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.
• Dilators are used to increase/enlarge the
diameter of a lumen, such as the urethra,
uterine cervix, or esophagus.
 Parts of a Clamp
• An instrument has identifiable parts.
• The points of the instrument are its tips.
• The tips should approximate tightly when the
instrument is closed.
• The jaws of instrument hold tissue securely. Most
jaws are serrated.
• The box lock is the hinge joint of the instrument.
 Cont..
• The shank is the area between the box lock
and the finger ring
• The ratchets interlock to keep the instrument
locked shut when the instrument is closed.
These should mesh together smoothly.
 SUTURE MATERIALS AND SUTURES
• The noun suture is used for any strand of
material used for ligating or approximating
tissue; it is also synonymous with stitch.
 Types of Suture Materials
1. Absorbable sutures
• Absorbable suture is eventually absorbed by
the body as a result of the enzymatic action of
body fluids and does not require removal.
• Absorbable sutures come in polyfilament
(braided) and monofilament (unbraided)
sutures.
 Cont..
• The length of time needed by absorption
depends upon the specific type of suture as
well as the condition of the tissue.
• Absorption takes place in from 3 days to 3
months.
• Most common absorbable sutures include:
 Cont..
A. Surgical Catgut (biological absorbable
sutures):
• Collagen manufactured from the submucosa
of sheep intestine or serosa of beef intestine.
• Used in tissue that heals rapidly.
• Digested by body enzymes and absorbed by
soft tissues.
 Cont..
• The rate of absorption is influenced by the
following:
– Type of tissue
– Condition of tissue
– General health status of the patient
– Type of surgical catgut
 Cont..
Plain Surgical Catgut
– Lose tensile strength quickly, usually in 5 to 10
days.
– Used to ligate small vessels and to suture
subcutaneous fat.
– Available in sizes 3 to 6-0.
– May be used for epidermal suturing where sutures
are needed for no more than a week.
– These sutures are used only externally on skin, not
internally, particularly for facial cosmetic surgery.
 Cont..
Chromic Surgical Catgut
– Is treated in a chromium salt solution to
resist absorption by tissues.
– It is used for ligation of larger vessels and for
suture of tissues in which nonabsorbable
suture materials are not recommended.
– Available in sizes 3 to 7-0.
– May be dyed blue or black
 Cont..
B. Synthetic Absorbable Sutures
– Are absorbed by a slow hydrolysis process
in the presence of tissue fluids.
– They are used for ligating and suturing.
– They are extremely inert and have great
tensile strength.
– Can be used in nearly all tissues.
 Cont..
– As a disadvantage, it tends to drag through
the tissue rather than passing smoothly.
– The sutures included in this group are:
• Polyglycolic acid (Dexon) suture
• Polyglactin 910 (Vicryl) suture
• Polydioxanone (PDS) Suture
• Polyglicaprone (Monocryl) suture
 2. Non absorbable Suture
• Nonabsorbable suture is removed when
healing is complete, as in skin closure.
• It is used in tissues that heal more slowly than
those requiring any type of absorbable suture.
• Includes:
 Cont..
A. Surgical Silk
– An animal product made from the fiber spun
by silkworm larvae in making their cocoons.
– Widely used non-absorbable suture that is
easy to handle and is both supple and
strong.
– Can be used in a wide variety of tissues,
ranging from ophthalmic to cardiovascular.
 Cont..
B. Surgical Cotton
– Manufactured from the fibers of the cotton
plant
– Supple and easy to handle
– Can be strengthen by dripping it into saline
solution prior to use.
– Its application is nearly identical to that of
silk.
 Cont..
C. Polyester Suture
– The strongest of all sutures except for
surgical steel.
– Used in a wide variety of tissues, including
facial, cardiovascular, and ophthalmic
surgery.
 Cont..
D. Nylon Suture
– Used primarily for skin closure, ophthalmic
procedures, and microsurgery.
– Produces minimal tissue reaction.
– Has high tensile strength,
– The major disadvantages of nylon are its
elasticity and stiffness, which necessitate
the laying of many knots.
 Cont..
E. Polypropylene (Prolene) Suture
– Easier to handle.
– Can be used in the presence of infections.
– The material of choice for many plastic
surgery and cardiovascular procedures
because of its smooth passage through
tissues, as well as its strength and inertness.
– Frequently used for retention sutures.
 Cont..
F. Surgical Steel
– Made of stainless steel and is the most inert
type of suture available.
– Used mainly in the orthopedic surgery to
approximate bone fragments.
– Not widely used because of major
disadvantages:
– Extremely difficult to handle.
– Kinks easily and has a “sawing” effect on tissue.
 Cont..
– Because of its springiness it is easily
contaminated at the field.
– The sharp ends of the strands can easily
puncture a glove, causing contamination
and injury to the person handling it.
 SUTURE SIZES:
• The size of suture material is measured by its
width or diameter and is vital to proper
wound closure.
• Suture as small as 11-0 and as large as number
7 are available.
• As the number increase with the number “0”
the size of needle and the diameter of stichs
decreases.
 Cont..
• As a guide the following are specific areas of
their usage:
– 1,0,1-0 and 2-0: Used for high stress areas
requiring strong retention, i.e. – deep fascia
repair.
– 3-0: Used in areas requiring good retention,
i.e. – scalp and hands.
– 4-0: Used in areas requiring minimal
retention, i.e. – extremities.
 Cont..
– 5-0: Used for areas involving the face,
nose, ears, eyebrows, and eyelids.
– 6-0: Used on areas requiring little or no
retention. Primarily used for cosmetic
effects.
Factors that influence the choice of suture
materials
• Biologic characteristics of the suture material
• Healing characteristics of the tissue
• Location and length of the incision
• Presence or absence of contamination and/or
infection
• Patient problems such as obesity, advanced
age and diseases
• Physical characteristics of the material such as
ease of passing through tissue, knot tying and
other personal preference of the surgeon.
 Surgical Needles
• Surgical needles are needed to safely carry
suture material through tissue with them least
amount of trauma.
• The best surgical needles are made of high-
quality tempered steel that is:
– Strong enough so that it does not break easily
– Rigid enough to prevent excessive bending,
yet flexible enough to prevent breaking after
bending
 Cont..
– Sharp enough to penetrate tissue with minimal
resistance
– Approximately the same diameter as the suture
material it carries to minimize trauma in passage
through tissue.
– Appropriate in shape and size for the type,
condition, and accessibility of the tissue to be
sutured
– Free from corrosion and burrs to prevent infection
and tissue trauma.
 Needle parts
Point of the Needle
• Points of surgical needles are honed to the
configuration and sharpness desired for
specific types of tissue.
• The basic shapes are cutting, tapered or
blunt.
 Cont..
Body of the Needle
• The body, or shaft, varies in length, shape, and
gauge.
• The nature and location of tissue to be sutured
influences the selection of needles with these
variable features.
• The shape may be ¼ circle, 1/8 circle, 1/2 circle,
5/8 circle,1/2 curve, straight and compound
curve.
 Cont..
Eye of the Needle
• The eye is the segment of the needle where the
suture strand is attached.
• Surgical needles are classified as eyed, or eyeless.
• Eyed needles need to be thread with stichs
before use and tends to unthread easily and
more traumatic.
• An eyeless needle is a continuous unit with the
suture strand and also known as swaged or
atraumatic.
 Placement of the Needle in the Needle
holder
• Needle holders have specially designed jaws
to securely grasp surgical needles without
damage if they are used correctly.
• The scrub nurse should observe the following
principles in handling needles and needle
holders:
– Select a needleholder with appropriate-size jaws
for the size of the needle to be used.
– Select an appropriate-length needleholder for the
area of tissue to be sutured.
 Cont..
– Clamp the body of the needle in an area one
fourth to one half of the distance from the eye
to the point.
– Never clamp the needleholder over the
swaged area since this area is the weakest area
of an eyeless needle.
– Place the needle securely in the tip of the
needleholder jaws and close the needleholder
in the first or second ratchet.
 Cont..
– Pass the needleholder with the needle point
up and directed toward the surgeon’s thumb
when grasped.
– Hold the free end of the suture in one hand
while passing the needleholder with the other
hand.
 Methods of Suturing
1. Simple continuous (running).
– This suture can be used to close multiple
layers with one suture. The suture is not cut
until the full length is incorporated into the
tissue.
 Cont..
2. Simple interrupted.
– Each individual stitch is placed, tied, and cut in
succession from one suture
 Cont..
3. Horizontal mattress.
– Stitches are placed parallel to wound edges.
– Each single bite takes the place of two
interrupted stitches.
 Cont..
4. Vertical mattress.
– This suture uses deep and superficial bites,
with each stitch crossing the wound at right
angles.
– It works well for deep wounds. Edges
approximate well.
 Cont..
5. Inverting sutures.
– These sutures are commonly used for two-
layer anastomosis of hollow internal organs,
such as the bowel and stomach.
– Placing two layers prevents passing suture
through the lumen of the organ and creating
a path for infection.
– These stitches can be either interrupted or
continuous.
 Knot Placement
• Each suture placed in tissue usually requires
the placement of a knot to secure the ends.
• Interrupted stitches require individual knots,
and therefore placement of each knot can
influence how well the wound heals and the
cosmetic result.
• Principles concerning knots and knot tying
include the following.
 Cont..
1. The knot should be tied away from:
– Vital structures, such as the eye
– Source of contamination, such as the mouth
– Potential irritants, such as the nares
– Potential sources of increased
inflammation, such as the incision line
 Cont..
2. The knot should be tied toward:
– The better blood supply
– The area that provides the best security of
the knot
– If possible, where the mark would be less
noticeable
 Special Suturing Techniques
The Retention Suture
– The retention suture is used on the abdomen
to give added support to the closure.
– For this purpose, heavy suture materials
usually 2 or 3 nylon or silk are used.
– Bolster (bumpers) are used to protect the
skin and to distribute the tension evenly.
– Bumpers are made from rubbers or plastics
to be inserted over the retention suture to
prevent it from cutting into the skin.
 Cont..
The Suture ligature
– The suture ligature (sometimes called a
“stick tie”) is used to ligate very large
vessels.
– The suture is passed through the walls of
the vessel and surrounding tissue. In this
way, the ligature cannot slip off the end of
the vessel.
 Cont..
Purse-String Suture
– A purse-string suture is used to
approximate the end of a lumen, such as a
hernia sac or appendicle stump. The suture
is passed around the lumen and tied in
purse-string fashion.
 Non suture products
• Materials other than suture are available for
wound closure and ligation of vessels. They
include:
– Sterile tapes
– Wound clips
– Ligation clips, and
– Stapling instruments
 Quiz
• Explain the four types of surgical instruments
and give an examples for each

• Differentiate absorbable and non-absorbable

101