Oculoplastic Instrument Set, 221

https://kat.cr/user/Blink99/ Contents

UNIT ONE: INSTRUMENT PREPARATION 27 Ureteroscopy, 113 FOR SURGERY 28 Nephrectomy, 115 29 Laparoscopic Nephrectomy, 117 1 Care and Handling of Surgical Instruments, 1 30 Pubovaginal Sling/Anterior Repair, 119 2 Sterilization Container Systems, 24 31 Prostatectomy, 122 32 Laparoscopic Prostatectomy, 127 UNIT TWO: GENERAL SURGERY 33 Transurethral Resection of the Prostate, 128 3 Operating Room Suite/Basic Laparotomy, 31 34 Vasectomy, 130 4 Abdominal Self-Retaining Retractors, 39 35 Penile Prosthesis, 133 5 Small Laparotomy Set, 45 6 Minor Laparoscopic Set, 47 UNIT FIVE: ORTHOPEDIC SURGERY 7 Laparoscopy, 49 36 Basic Orthopedic Surgery, 136 8 Laparoscopic Adult MIS Set, 54 37 Power Saws and Drills, Battery Powered, 139 9 Laser Laparoscope, 60 38 Small Joint Arthroscope Set, 144 10 Laparoscopic Cholecystectomy, 61 39 Arthroscopic Carpal Tunnel Instruments, 145 11 Laparoscopic Bowel Resection, 63 40 Small/Minor Joint Replacement, 146 12 Bowel Resection, 69 41 Total Ankle Prosthesis, 148 13 Sigmoidoscopy, 71 42 Arthroscopy of the Knee/Shoulder, 150 14 Laparoscopic Bariatric Surgery, 72 43 Arthroscopic Anterior Cruciate Ligament Reconstruction 15 The da Vinci ® Surgical System and EndoWrist ® Instruments with Patellar Tendon Bone Graft Instruments, 154 (Robotic Instruments), 79 44 Total Knee Replacement, 157 16 Breast Biopsy/Lumpectomy, 84 45 Shoulder Surgery Instruments, 164 17 Mastectomy, 85 46 Hip Fracture, 166 47 Hip Retractors, 169 UNIT THREE: FEMALE REPRODUCTIVE SURGERY 48 Total Hip Replacement, 170 18 Dilatation and Curettage of the Uterus, 88 49 Total Hip Instruments (Zimmer-VerSys), 174 19 Hysteroscopy, 91 50 Spinal Fusion with Rodding, 179 20 Vaginal Laser, 94 51 Long Bone Rodding for Fracture Fixation, 185 21 Abdominal Hysterectomy, 96 52 ASIF Universal Femoral Distractor Set, 187 22 Supracervical Laparoscopic Hysterectomy, 99 53 Synthes Retrograde/Antegrade Femoral Nail, 188 23 Vaginal Hysterectomy, 103 54 Synthes Unreamed Tibial Nail Insertion and Locking 24 Laparoscopic Tubal Occlusion, 105 Instruments, 190 55 External Fixation of Fractures, 191 UNIT FOUR: GENITOURINARY SURGERY 56 ASIF Pelvic Instrument Set, 194 57 Universal Screwdriver/Broken Screw Set, 196 25 Cystoscopy, 108 26 Urethroscopy, 112

https://kat.cr/user/Blink99/ Instrumentation for the OPERATING ROOM A PHOTOGRAPHIC MANUAL

https://kat.cr/user/Blink99/ YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Evolve Student Resources for Tighe: Instrumentation for the Operating Room: A Photographic Manual, Ninth Edition, include the following:

• Additional Images • Review Questions

Activate the complete learning experience that comes with each NEW textbook purchase by registering at http://evolve.elsevier.com/Tighe/instrumentation

You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products.

https://kat.cr/user/Blink99/ NINTH9 EDITION

Instrumentation for the OPERATING ROOM A PHOTOGRAPHIC MANUAL

Shirley M. T ighe, BA, RN, Retired AD in Applied Science in Photography Consultant for the Operating Room Lake Havasu City, Arizona

with over 800 photographs

https://kat.cr/user/Blink99/ 3251 Riverport Lane St. Louis, Missouri 63043

INSTRUMENTATION FOR THE OPERATING ROOM: A PHOTOGRAPHIC MANUAL, NINTH EDITION ISBN: 978-0-323-24315-5

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Brooks Tighe, Shirley M., author. Instrumentation for the operating room : a photographic manual / Shirley M. Tighe. -- Ninth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-24315-5 (alk. paper) I. Title. [DNLM: 1. Surgical Instruments--Atlases. WO 517] RD71 617.9’178--dc23 2014048834

Executive Content Strategist: Tamara Myers Senior Content Development Specialist: Laura Selkirk Publishing Services Manager: Pat Joiner Project Manager: Suzanne C. Fannin Designer: Margaret Reid

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

https://kat.cr/user/Blink99/ Thank you to PeaceHealth Southwest Medical Center and their staff for allowing me to use their faculties for the photographing to update Instrumentation for the Operating Room: A Photographic Manual textbook, ninth edition. It has been a real honor to work with the staff at PeaceHealth Southwest Medical Center in Vancouver, Washington. First, they were very knowledgeable about the work they were doing and were so willing to share it (so many new or improved instrumentation) with my staff who had worked in perioperative nursing. Second, they had their plan of what needed to be updated and were efficient in assisting us in photographing and labeling the instruments. Wendy Weir-Raynor and Denise Reese were definite assets to the entire undertaking of updating the ninth edition of this textbook. They are clinical educators with over 2 decades working in the perioperative services. Wendy is located second from the right in the front row, and Denise is located first on the left in the last row. This photo includes some of the clinical consultants and many technicians who work in the central sterile processing department, where instrumentation processing takes place.

PeaceHealth Southwest Medical Center.

Dedication v https://kat.cr/user/Blink99/ Left to right: Jack Sanders, Glen Tighe, Shirley Tighe, Pauline Vorderstrasse, Gwen Graham, and Beverly Burns, all of whom came out of retirement and assisted Shirley in another edition of her textbook. It has been an honor to work with these friends and many other consultants for over 4 decades on the textbooks. Sharing their expertise of operating room nursing and the time to complete the textbooks, one should really call it “their textbook.” Many thanks to all.

Sincerely, Shirley M. Tighe, BA, RN, Retired, AD in Applied Science in Photography

vi Dedication https://kat.cr/user/Blink99/ CONTRIBUTORS/CONSULTANTS

CLINICAL EDITOR

Denise A. Reese, RN, CNOR Clinical Educator─Perioperative Services PeaceHealth Southwest Medical Center Vancouver, Washington

Wendy M. Weir-Raynor, BSN, RN Clinical Educator─Perioperative Services PeaceHealth Southwest Medical Center Vancouver, Washington

NURSE/CONSULTANTS Marcia Frieze, CEO Case Medical, Inc. South Hackensack, New Jersey

Cynthia C. Spry, MA, MSN, RN, CNOR(E), CBSPDT Independent Consultant, Sterilization, Disinfection, and Related Infection Prevention New York, New York

CLINICAL CONSULTANTS Kathryn Diane Amer, BSN, RN Ambulatory Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

Joan Blackler, RN, CNOR RN Surgical Specialist─Orthopedic Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

M. Tiffany Brenton, BSN, RN RN Surgical Specialist─EENT/Plastics/Robotics Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

Sheryl A. Bundy, RN Pediatric Surgical Coordinator Legacy Emanuel Hospital and Medical Center Portland, Oregon

Robert L. Nyberg, RN RN Surgical Specialist─Cardiovascular Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

Contributors/Consultants vii https://kat.cr/user/Blink99/ Katherine Schneider, RN, CNOR RN Surgical Specialist─Neurosurgery PeaceHealth Southwest Medical Center Vancouver, Washington

Jack Som, RN RN Surgical Specialist─General Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

Shannon Young, RN RN Surgical Specialist─GYN/GU Surgery PeaceHealth Southwest Medical Center Vancouver, Washington

Sandy Zarosinski, RN Open Heart/Vascular Coordinator Legacy Good Samaritan Hospital and Medical Center Portland, Oregon

CONTRIBUTORS/CONSULTANTS Beverly I. Burns, RN, CNOR(E) Clinical Education Specialist, Retired SurgiCount Medical Portland, Oregon

Gwendolyn Graham, MN, RN Associate Professor in AD Nursing Program, Retired Umpqua Community College, Oregon Silverlake, Washington

Kia Holmes Graphic Designer Case Medical, Inc. South Hackensack, New Jersey

Christianne C. Mariano, MA Executive Assistant Case Medical, Inc. South Hackensack, New Jersey

Jack W. Sanders, BA Medical Photography/Videographer Portland, Oregon

Glen E. Tighe Photography and Computer Consultant, Retired Lake Havasu City, Arizona

Pauline E. Vorderstrasse, BSN, RN, Retired Director/Instructor Surgical Technology, Retired Mt. Hood Community College West Linn, Oregon

PeaceHealth Southwest Medical Center Vancouver, Washington viii Contributors/Consultants https://kat.cr/user/Blink99/ Preface

The organization of this edition is the same as in the past editions, starting with the basic and continuing to the advanced, just as you would progress when working in the perioperative area. Knowing the history of the instruments and understanding their care and handling, their classification, and the correct type of sterilization to be used for each instrument will assist you in any perioperative role, whether you work in central sterile processing, ambulatory surgery, or the operating room. In addition, it is important to know the types of sterilization-container systems in which instruments can be sterilized and transported among departments while maintaining their sterility. Instrumentation for 114 surgical procedures is shown in this textbook according to the body systems involved. Each unit begins with a basic set of instruments, or most of the instruments, required to perform that surgery. Most of the basic units begin with a description of how the instruments are used in those procedures and then continue with photographs of the sets of instruments. The sets are photographed in groups, showing instruments that are normally placed in a sterilizing container together. Some instruments are shown individually, with a close-up photograph of their tips if the tips are not visually clear in the group photograph. Once an instrument is shown individually, it will not be shown again as an individual instrument. If you are interested in a specific type of surgery and wish to learn about or review the instruments for that surgery, check the table of contents. If you are searching for an individual instrument, check the index, which provides you with the page on which the individual instrument and the close-up of its tip or tips are found. Most of the clinical consultants are new reviewers to the textbook. They have years of experience in the perioperative area, which has added to the textbook. We deleted some basic sets from the textbook and have them available to you on the Evolve website. If a setup or individual instrument is on Evolve, that information will be located on the front page of that chapter. The information you need to get to Evolve website is available to you on the Evolve page in the beginning of the book. I wish to acknowledge all the valuable assistance I received from Cynthia Spry in her writing of Chapter 1: Care and Handling of Surgical Instruments, and Marcia Frieze, CEO of Case Medical, Inc., for her writing of Chapter 2: Sterilization Container Systems. Three of the very important people who are in the background and who are rarely talked about how valuable they are to the publishing of my textbook are my Elsevier associates: Tamara Myers, Executive Content Strategist; Laura Selkirk, Senior Content Development Specialist; and Suzanne Fannin, Project Manager. You are very much appreciated by this author for all the dedicated work you do to make this textbook available. Thank you very much.

Sincerely, Shirley M. Tighe, BA, RN, Retired, AD in Applied Science in Photography

Preface ix https://kat.cr/user/Blink99/ This page intentionally left blank

https://kat.cr/user/Blink99/ Contents

UNIT ONE: INSTRUMENT PREPARATION FOR SURGERY

1 Care and Handling of Surgical Instruments, 1 2 Sterilization Container Systems, 24

UNIT TWO: GENERAL SURGERY 3 Operating Room Suite/Basic Laparotomy, 31 4 Abdominal Self-Retaining Retractors, 39 5 Small Laparotomy Set, 45 6 Minor Laparoscopic Set, 47 7 Laparoscopy, 49 8 Laparoscopic Adult MIS Set, 54 9 Laser Laparoscope, 60 10 Laparoscopic Cholecystectomy, 61 11 Laparoscopic Bowel Resection, 63 12 Bowel Resection, 69 13 Sigmoidoscopy, 71 14 Laparoscopic Bariatric Surgery, 72 15 The da Vinci® Surgical System and EndoWrist ® Instruments (Robotic Instruments), 79 16 Breast Biopsy/Lumpectomy, 84 17 Mastectomy, 85

UNIT THREE: FEMALE REPRODUCTIVE SURGERY 18 Dilatation and Curettage of the Uterus, 88 19 Hysteroscopy, 91 20 Vaginal Laser, 94 21 Abdominal Hysterectomy, 96 22 Supracervical Laparoscopic Hysterectomy, 99 23 Vaginal Hysterectomy, 103 24 Laparoscopic Tubal Occlusion, 105

UNIT FOUR: GENITOURINARY SURGERY 25 Cystoscopy, 108 26 Urethroscopy, 112 27 Ureteroscopy, 113

Contents xi https://kat.cr/user/Blink99/ 28 Nephrectomy, 115 29 Laparoscopic Nephrectomy, 117 30 Pubovaginal Sling/Anterior Repair, 119 31 Prostatectomy, 122 32 Laparoscopic Prostatectomy, 127 33 Transurethral Resection of the Prostate, 128 34 Vasectomy, 130 35 Penile Prosthesis, 133

UNIT FIVE: ORTHOPEDIC SURGERY 36 Basic Orthopedic Surgery, 136 37 Power Saws and Drills, Battery Powered, 139 38 Small Joint Arthroscope Set, 144 39 Arthroscopic Carpal Tunnel Instruments, 145 40 Small/Minor Joint Replacement, 146 41 Total Ankle Prosthesis, 148 42 Arthroscopy of the Knee/Shoulder, 150 43 Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon Bone Graft Instruments, 154 44 Total Knee Replacement, 157 45 Shoulder Surgery Instruments, 164 46 Hip Fracture, 166 47 Hip Retractors, 169 48 Total Hip Replacement, 170 49 Total Hip Instruments (Zimmer-VerSys), 174 50 Spinal Fusion with Rodding, 179 51 Long Bone Rodding for Fracture Fixation, 185 52 ASIF Universal Femoral Distractor Set, 187 53 Synthes Retrograde/Antegrade Femoral Nail, 188 54 Synthes Unreamed Tibial Nail Insertion and Locking Instruments, 190 55 External Fixation of Fractures, 191 56 ASIF Pelvic Instrument Set, 194 57 Universal Screwdriver/Broken Screw Set, 196

UNIT SIX: EYE, EAR, NOSE, AND THROAT SURGERY 58 Basic Eye Set, 198 59 Clear Corneal Set, 201 60 Corneal Transplant, 205 61 Deep Lamellar Endothelial Keratoplasty, 210 62 Glaucoma, 212 63 Eye Muscle Surgery, 214 64 Retinal Detachment, 217 65 Vitrectomy, 219 66 Oculoplastic Instrument Set, 221

xii Contents https://kat.cr/user/Blink99/ 67 Eye Enucleation, 223 68 Basic Ear Set, 224 69 Tympanoplasty, 225 70 Tonsillectomy and Adenoidectomy, 234 71 Transoral Surgery, 237 72 Tracheotomy, 238 73 Septoplasty and Rhinoplasty, 240 74 Nasal Polyp Instruments, 244 75 Nasal Fracture Reduction, 245 76 Sinus Surgery, 246

UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL SURGERY 77 Facial Fracture Set, 251 78 Orthognathic Surgery, 254 79 Titanium 2.0-mm Microfixation System, 257

UNIT EIGHT: PLASTIC SURGERY 80 Minor Plastic Set, 258 81 Micro Plastic Set, 260 82 Plastic Miscellaneous, 262 83 Skin Graft, 266

UNIT NINE: PERIPHERAL VASCULAR, CARDIOVASCULAR, AND THORACIC SURGERY 84 Endarterectomy, 268 85 Artery Bypass Graft, 269 86 Endovascular Abdominal Aortic Aneurysm Repair, 271 87 Abdominal Vascular Set (Open Procedure), 274 88 Thoracoscopy, 277 89 Thoracic Instruments, 280 90 Cardiac Surgery, 283 91 Open Heart Microinstruments, 287 92 Sternal Saws and Sternum Knife, 289 93 Open Heart Extras, 291 94 Cardiovascular Instruments, 296 95 Open Heart Valve Extras, 299 96 Return Open Heart Set, 301 97 Vein Retrieval Instruments, 304 98 Radial Artery Harvest Set, 306

UNIT TEN: NEUROSURGERY 99 Craniotomy, 307 100 Neurologic Bone Pan Instruments, 314

Contents xiii https://kat.cr/user/Blink99/ 101 Neurologic Retractors, 317 102 Medtronic Midas Rex Electric Drill, 320 103 Rhoton Neurologic Microinstrument Set, 322 104 Ultrasonic Handpieces, 325 105 Neurologic Shunt Instruments, 326 106 MINOP Neuroendoscopy Set, 328 107 Intracranial Pressure Monitoring Tray, 330 108 Yasargil Aneurysm Clips with Appliers, 331 109 Synthes Low-Profile Cranial Plating Set, 332 110 Laminectomy, 334 111 Williams Laminectomy Microretractors, 338 112 Minimally Invasive Spine Surgery, 339 113 Anterior Cervical Fusion, 341 114 ASIF Anterior Cervical Locking Plating Instruments, 344

UNIT ON PEDIATRIC SURGERY (ON EVOLVE WEBSITE)

xiv Contents https://kat.cr/user/Blink99/ UNIT ONE: INSTRUMENT PREPARATION FOR SURGERY CHAPTER 1

Care and Handling of Surgical Instruments*

Although evidence exists that stone knives were used to perform surgery as early as Additional images are available at: 10,000 bc, modern surgical instrumentation began with the introduction of stainless steel evolve.elsevier.com/Tighe/instrumentation in the early 1900s. Approximately 85% of all surgical instrumentation is now made of stainless steel. Although stainless steel continues to compose the bulk of instrumentation used in surgery today, there have been dramatic changes over the past several decades. One has been the addition of new materials. In addition to stainless steel, titanium, Vitallium, and various polymers are also used. The introduction of minimally invasive surgery coupled with the availability of space-age materials have wrought instrumentation once only dreamed of. Cameras, flexible and rigid endoscopes, minimally invasive surgical techniques, and advanced imaging technology now make it possible to explore almost every crevice within the human body without having to perform open surgery and without requiring a hospital stay. Instrument design has focused on enhancing the surgeon’s ability to visualize, maneu- ver, diagnose, and manipulate tissue using minimally invasive surgical techniques. It is possible to repair an aortic aneurysm, perform a coronary artery bypass, and operate on a fetus without making a major incision. Advances in instrumentation design have contributed significantly to improved patient outcomes, early discharge, reduced recuperation time, and less physical trauma and pain. In contrast to the general surgery instruments that have not changed markedly, minimally invasive and interventional procedure instrumentation has become more complex and delicate and requires special care and handling techniques. For example, the working channel of a flexible endoscope can be as small in diameter as 0.1 mm and as long as 2200 mm. The consequence of improved instrument design is higher cost, less inventory of like instrumentation, and greater cleaning, decontamination, and sterilization challenges. When surgical volume increases without a corresponding increase in inventory, instruments will experience increased utilization, handling, and processing. This in turn increases the risk of damage, which can lead to expensive repair costs and possible cancellation of a surgical procedure. In today’s environment of cost consciousness, proper care and handling of surgical instrumentation is more critical than ever. In addition to improvements in instrument design, advances have occurred with regard to cleaning, packaging, and sterilization technologies. Standards, guidelines, and recommended practices related to instrument processing are continually updated to reflect new evidence-based knowledge. As a result, the required knowledge base of the person responsible for the care and handling of instruments has expanded significantly. The person caring for instruments must know the intended uses, functions, and compatibility of instruments with various cleaning, disinfecting, packaging, and sterilizing methods. This person must also have an understanding of the equipment used to clean, decontaminate, package, and sterilize instruments. In recognition of the skill required to process surgical instruments properly, certification of processing personnel is required in many facilities and is a require- ment for employment in at least two states, with other states to soon follow. Although the care and handling of surgical instrumentation is not revenue producing, appropriate and meticulous care and handling can result in lower overall costs for a surgical department by preventing damage and consequently reducing expenditures for repair and replacement.

*This chapter was written by Cynthia C. Spry.

CHAPTER 1 Care and Handling of Surgical Instruments 1 https://kat.cr/user/Blink99/ However, the primary concern should be that the instrument be truly patient ready (i.e., safe for use on a patient in surgery). Instruments must be thoroughly cleaned and decontaminated, and then properly packaged and sterilized in preparation for surgery. Instru- mentation that malfunctions or is not sterile can result in extended surgery time, poor technical results, patient infection, patient injury, and even death. Since the publication of the November 1999 report, “To Err is Human: Building a Safer Health System” issued by the Institute of Medicine in which it is stated that as many as 98,000 injuries to patients occur each year in hospitals, many other reports of patient injury have appeared in professional journals as well as the popular press.1 In a 2014 report from the staff of Senator Barbara Boxer of California it is estimated that between 210,000 and 400,000 patients die each year as a result of medical errors and other preventable harm at hospitals.2 In this same report that lists the most common events that result in patient injury, surgical site infection is number 7. A heightened awareness of the risk of harm to patients and the resulting eco- nomic impact has led to a focus on patient safety and financial initiatives to prevent harm. Several payors such as Medicare, Medicaid, and some private insurance companies will no longer pay a facility for the costs associated with care for a patient who sustains certain adverse events, such as some surgical site infections, that with proper care are preventable.3 There is an ongoing intense focus on patient safety throughout the health care industry. Proper care and handling of surgical instruments are critical components of patient safety (e.g., prevention of surgical site infection). In summary, the proper care and handling of surgical instrumentation is not a simple rote task; it requires specialized knowledge, competence, critical thinking, judgment, and a commitment to excellent patient care.

EVOLUTION OF SURGERY AND SURGICAL INSTRUMENTATION Surgery was practiced long before the development of sophisticated surgical instruments. Stone knives and sharpened flints and animal teeth were the instruments of choice for trephination, circumcision, and bloodletting in prehistoric times. In Corpus Hippocraticum, Hippocrates (460-377 bc) wrote of the use of iron and steel in instrument making; however, there are no existing examples of surgical instruments before the early Roman period. Exca- vations begun in 1771 in the city of Pompeii reveal surgical instruments that bear amaz- ing resemblances to contemporary instrumentation. Among the instruments found were a foreign-body remover, a speculum, retractors, probes, a periosteal elevator, forceps, and hooks. Metal analysis indicates three materials: copper, bronze, and iron. Until the 1790s, surgery was not a strict discipline, and surgeons were not afforded equal status with physicians. Instruments were made by blacksmiths, cutlers, and armorers. How- ever, as surgery evolved into a scientific discipline and achieved a measure of status, the specialty of instrument making also emerged. Surgeons employed coppersmiths, steelwork- ers, silversmiths, wood turners, and other artisans who handcrafted instruments to individual specifications. Instruments often had ornate ivory or carved wooden handles and were cased in velvet. The introduction of anesthesia in the 1840s and the adoption of Lister’s antiseptic technique in the 1880s greatly influenced the making of surgical instruments. The use of anesthesia enabled the surgeon to work more slowly and accurately and to perform longer, more complex procedures. The variety of surgeries performed increased, as did the demand for specialized instruments. The ability to sterilize instruments also had an impact on instrument design. When steam sterilization became a standard process, carved wood or ivory handles were replaced with all-metal instruments made of silver, brass, or steel. Velvet-lined boxes were replaced by trays that could be lowered into steam sterilizers.

MANUFACTURE OF STAINLESS STEEL INSTRUMENTATION The development of stainless steel in the 1900s provided a superior material for the manufacture of surgical instruments. Subsequently, instrument making evolved into a highly skilled occupation. Shortly thereafter, crafters from Germany, France, and England were

2 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ brought to the United States to instruct apprentices in their craft. Even today, many of the delicate, high-quality, stainless steel instruments are manufactured in Europe. Germany is often considered the home of high-quality surgical instruments. Other metals like Vital- lium and titanium are used today, but the bulk of surgical instrumentation is made of stainless steel and is manufactured in the United States. Many surgical instruments are made from plastic polymers as well. Stainless steel is a compound of varying amounts of carbon, chromium, and iron. Small amounts of nickel, magnesium, and silicone may also be incorporated. Varying the amount of these materials produces a variety of qualities, such as flexibility, temper, malleability, and corrosion resistance. There are more than 80 different types of stainless steel. The American Iron and Steel Institute uses three-digit numbers to grade steel based on its various qualities and composition. The most commonly used steel alloys for the manufacture of heat-stable, reusable surgical instruments are stainless steel series 300 and 400, with 400 being the most common. The 300 series is generally used for noncutting surgical instruments requiring high strength, such as speculums and large retractors. The 400 series is used for both cutting and noncutting instruments. Both series resist rust and corrosion, have good tensile strength, and will retain a sharp edge through repeated use. The chromium content in stainless steel provides the stainless quality. Stainless steel is really a misnomer. The degree to which the steel is stainless is also determined by the chemical composition of the metal, the heat treatment, and the final rinsing process. The first step in the manufacture of stainless steel instruments is the conversion of raw steel into sheets that are milled, ground, or lathed into instrument blanks. These blanks are then die-forged into specific pieces and, where appropriate, male and female halves. Excess metal is trimmed away and the pieces are milled and hand-assembled. Jaw serration and ratchet and shank alignment are achieved, after which the instrument is hand-assembled and then ground and buffed. It is then heat-treated to reach its proper size, weight, spring, temper, and balance. Following testing for desired hardness, jaw closure, and ratchet and locking action, a finish is applied. The final two processes are passivation and polishing. Passivation is the immersion of the instrument in a dilute solution of nitric acid that removes carbon steel particles and promotes the formation of a coating of chromium oxide on the surface. Chromium oxide is important because it produces corrosion resistance. When carbon particles are removed, tiny pits are left behind. These are removed by polishing to create a smooth surface upon which a continuous layer of chromium oxide may form. Passivation and polishing effectively close the instrument’s pores and prevent corrosion. There are three types of instrument finishes: highly polished, satin or dull, and ebony. The highly polished finish is the most common, but it does reflect light and can cause glare that may interfere with the surgeon’s vision. The satin finish does not reflect light and eliminates glare. The ebony finish is black and also eliminates glare. The ebony finish is suitable for laser surgery, in which it is critical that the laser not be accidentally reflected, creating the potential for burn or fire.

QUALITY OF STAINLESS STEEL INSTRUMENTS Stainless steel instruments may appear to be of uniform quality when they are new. How- ever, there are various grades of quality, ranging from high quality and premium grade to operating room and floor grade. Some instruments appearing to be stainless steel are of such poor quality that they are sold as single-use instruments. In the United States, there is no agency that sets standards for instrument quality. Quality is determined by the manufacturer. In addition, an instrument labeled Germany may have been forged in Germany but actually assembled in a country where quality standards are minimal or nonexistent. Because instruments represent a substantial portion of the budget of a surgical suite, it is important to be knowledgeable about buying and selecting products with the desired quality. Many factors affect quality. Two major factors are a balanced carbon-chrome ratio and the process of passivation. A balanced carbon-chrome ratio is important for instrument strength and long life. Instruments that are classified as premium have the correct

CHAPTER 1 Care and Handling of Surgical Instruments 3 https://kat.cr/user/Blink99/ balance. The passivation process is important to create a protective coat on the outer layer of an instrument to prevent corrosion and extend its life. Electropolishing is sometimes substituted for passivation. The result is a less expensive instrument but one that will not last as long. When purchasing stainless steel instruments, it is best to deal with a reputable manufacturer who will explain the variation in quality of the products available. It is important to verify that an instrument manufacturer has clearance from the U.S. Food and Drug Administration (FDA) to market its products. Instruments manufactured in some countries outside the United States have been known to enter the American market without this clearance and without providing adequate instructions for use and processing. Another reason to deal with a reputable instrument manufacturer is authenticity. When an instrument that usually sells for $150 is being offered for $50, the buyer should beware and should check for FDA clearance before considering purchase. Instruments manufactured of materials other than stainless steel present an additional set of factors to consider before purchasing. These include their ability to be disassembled, cleaned, and reassembled; their life expectancy; and their compatibility with the existing resources within the sterile processing department (e.g., cleaning chemistries, disinfecting agents, and sterilization modalities) available within the institution.

CARE AND HANDLING OF BASIC SURGICAL INSTRUMENTS: OVERVIEW A well-made, properly cared for instrument can be expected to last 10 years. The most important considerations in extending the life of an instrument are appropriate use, careful handling, and proper cleaning, decontamination, and sterilization. Other considerations are disinfection, packaging, and storage. Every instrument is designed for a specific purpose. Using it for an unintended purpose is a sure method of damaging an instrument. Examples of misuse include securing surgical drapes or bending a wire with an instrument designed to grasp tissue.

RESOURCES Three must-have resources for personnel responsible for instrument processing are the Association for the Advancement of Medical Instrumentation’s (AAMI’s) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, the Asso- ciation of periOperative Registered Nurses (AORN) Recommended Practices for Steriliza- tion, for Care and Cleaning of Surgical Instruments and for Selection and Use of Packaging Systems for Sterilization, and the Centers for Disease Control (CDC) 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities.4,6 The other must-have resources are the instructions for use (IFUs) for all devices. The IFUs are those processes the manufacturer has determined are necessary to obtain outcomes to render a device safe for use. The IFUs should contain explicit instructions for disassembly, cleaning and/or decontamination, inspection, function testing, packaging, high-level disinfection, and sterilization as appropriate to the device. IFUs should be routinely reviewed. Instructions may change when manufacturers make modifications to their devices, when new regulatory requirements become effective, or when new processing technologies come to market. In fact, in a statement relative to ambulatory surgery facilities, the Centers for Medicare and Medicaid Services (CMS) have issued the statement, “If manufacturers’ instructions are not followed, then the outcome of the sterilizer cycle is guesswork, and the Ambulatory Surgical Center’s practices should be cited as a violation of 42 CFR 416.44(b)(5)” (CMS, 2009).7 In addition to IFUs for devices, IFUs for cleaning chemistries, cleaning and sterilization equipment, packaging materials and equipment, and quality monitors should also be reviewed before processing. In instances in which instructions are not compatible with each other, the vendor(s) should be contacted in an attempt to reconcile the incompatibilities. When it is not possible to reconcile instructions, product testing (see Sterilization section later in this chapter) should be performed. Everyone responsible for instrument processing should have ready access to all necessary IFUs and should refer to them routinely. Surveyors, such as those from accrediting

4 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ agencies, have indicated that they will be asking to see IFUs and will be checking to see if personnel are adhering to them. Many facilities contract with a document management system to ensure ready availability and access to current IFUs. When a computerized document management system is in place, staff must be competent to operate the program.

PREPARING INSTRUMENTS FOR PROCESSING

Point of Use The first steps in preparing an instrument to be processed in the sterile processing area should begin at the point of use. During surgery, instruments contaminated by blood or tissue should be wiped, rinsed, or irrigated in the sterile water at the sterile field. This should be accomplished in a manner that prevents splashing and aerosolization and can generally be done by wiping the device with a moistened lap pad and/or syringe. A syringe should be present on the sterile field for the purpose of flushing lumens throughout the procedure as appropriate. Flushing a lumen should be done below the surface of the water to prevent the aerosolization of debris. Saline should not be used for wiping or irrigating instruments. Prolonged exposure to saline can result in corrosion and can eventually lead to pitting of stainless steel. Pitting can cause entrapment of debris, interfere with sterilization, and result in destruction of the instrument. Blood and foreign matter that are not removed or are allowed to dry and harden may become trapped in jaw serrations, between scissor blades, or in box locks, making final cleaning more difficult and the sterilization or disinfection process ineffective. It can cause instruments to become stiff and eventually break. Instruments should be handled carefully and gently, either individually or in small lots, to avoid possible damage caused by their becoming tangled, dented, and misaligned. They should be placed, not tossed, into the basin. In preparation for transport to the decontamination area, all disposable blades and sharps should be removed and placed in a designated sharps container. Heavy instruments should be placed on the bottom of the pan, container, or basin, with the lighter, more delicate and fragile ones on top or protected in another manner. Care should be taken to ensure that instruments are not tangled or piled high. Rigid endoscopes and fiber optic cables should also be placed on top or separated. Fiber optic cables should be loosely coiled, never tightly wound. Instruments that can be disassembled should be disassembled. Ratchets should be opened. Instruments should be returned to their respective containers or baskets to prevent sets from becoming incomplete and should be contained or covered for transport to the decontamination area. The container for transport should be labeled with a biohazard symbol. A red bag or red container may be used instead.8 Delicate instruments, endoscopes, and other specialty instruments may need to be separated and transported to the decontamination area in containers specifically designed to prevent damage. Instruments with cutting edges, pointed tips, or other sharp components should be placed in such a manner that sharp edges are protected and personnel responsible for cleaning and decontamination are not injured when reaching into the container.

CLEANING AND DECONTAMINATION The AAMI defines cleaning as “removal of contamination from an item to the extent necessary for further processing or for the intended use.” AAMI further notes that, “In health care facilities cleaning consists of the removal, usually with detergent and water, of adherent soil (e.g., blood, protein substances, and other debris) from the surfaces, crevices, serrations, joints, and lumens of instruments, devices, and equipment by a manual or mechanical process that prepares the items for safe handling and/or further decontamination.”4 Decontamination is defined by the Occupational Safety and Health Administration (OSHA) as “the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.”8

CHAPTER 1 Care and Handling of Surgical Instruments 5 https://kat.cr/user/Blink99/ Decontamination consists of cleaning and a disinfection process. Mechanical washing machines typically follow the washing phase of the cycle with a thermal or chemical disinfection application that renders a device safe to handle.

AFTER SURGERY: CLEANING Whenever possible, instruments should be taken apart at the point of use. Unless otherwise specified in the device manufacturer’s IFUs, anything that can be disassembled must be disassembled before cleaning. After surgery, instruments are transported in leak-proof containers or trays encased in plastic bags to a designated area for cleaning and decontamination. Instruments should not be transported in basins containing water because the water may spill. Instruments should be cleaned away from patient care areas or areas where clean activities are performed. The decontamination area may be within the operating suite or, more commonly, in the Central Processing Department, also referred to as the Sterile Processing Department. Instruments that can tolerate immersion and cannot be cleaned immediately should be treated with an enzymatic foam or gel to prevent debris from drying and adhering to the device and to prevent formation of biofilm. Another option is to sub- merge the instruments completely in a warm, noncorrosive enzymatic solution and allow to soak until cleaning can be performed. The foam or gel may be applied prior to transport to the dedicated decontamination area. Generally, instruments should be placed horizontally beneath the water; however, some types of lumened instruments may have to be soaked vertically, with the entire shaft submerged. Horizontal soaking of lumens can cause air bubbles to form that can prevent the solution from traveling the length of the inner lumen. All instruments placed in the sterile field for use in a surgical procedure are considered contaminated and should be cleaned whether or not they were actually used. Blood, saline, or debris can be splashed or inadvertently deposited on any of the instruments; therefore, they all require decontamination and processing. There are several methods of decontaminating instruments, but all begin with thorough cleaning. The usual steps in the decontamination process include sorting, soaking, rinsing, washing, rinsing, drying, and lubricating. Cleaning is the removal of visible adherent soil from the surfaces, crevices, serrations, joints, and lumens of instruments. Cleaning may be manual or automated and is accomplished with detergent, water, and friction. Proper use of the detergent is essential. Deter- gents should always be mixed according to the proportions indicated on the label or in the manufacturer’s IFUs. Enzymatic detergents that are over or under concentrated or have been improperly rinsed can interfere with subsequent disinfection and sterilization. Regardless of how heavily soiled instruments appear to be after use, adding more detergent to the water is inappropriate. To ensure proper detergent concentration, it is advisable to obtain an exact measuring device for the detergent and to mark the sink with a piece of tape or a nontoxic, permanent marker to indicate the correct water level. For example, if the instructions call for a mix of 1 oz of detergent to 1 gal of water, a 1-oz container should be obtained and kept next to the detergent bottle or sink. A 1-gal container should be filled with water and poured into the sink in which instruments are washed manually and where the water level is marked. Commercially prepared labels indicating desired water level that may be affixed to the sink are readily available. The presence of the 1-oz container and the mark in the sink should help to ensure the correct preparation of the detergent solution. In addition to concentration requirements, cleaning agents have temperature and contact time requirements. A thermometer and timer should be used to determine temperature and to set contact time. Instructions for rinsing are also important. Some products call for multiple rinses. When a choice is made to switch to an alternative detergent, it is important to ensure that all personnel responsible for instrument processing receive the appropriate notification and information as requirements for use may change. When possible, mechanical cleaning is preferred. However, some instruments cannot tolerate immersion, high temperatures, or pressures of mechanical cleansing units and must be cleaned manually. Instruments that are washed manually should always be completely immersed and allowed to soak in a cleaning agent intended for manual cleaning of

6 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ surgical instruments. Instruments should be disassembled and box locks, hinges, and joints should be opened. Serrations, box locks, crevices, and lumens must be brushed to remove imbedded particles. Scouring pads, stiff brushes, abrasive powders and soaps, and sharp implements should not be used to remove debris because they can destroy the protective coating on surgical instruments. Instruments that are washed manually should always be washed one at a time beneath the surface of the water to prevent the aerosolization and splashing of debris. The final rinse in the cleaning process, whether manual or mechanical, should be with treated water (e.g., distilled, deionized, reverse osmosis). Water quality varies by geographi- cal location and untreated water (tap water) may contain endotoxins. Endotoxins are essentially dead bacteria cells. When found on instruments used in surgery, endotoxins can cause a pyrogenic (fever) reaction in a patient. Some instruments, because of their design, may require manual cleaning followed by mechanical cleaning. Debris and tissue can easily become trapped in complex devices, and mechanical cleaning alone may not be sufficient to remove the debris. Soaking in an enzymatic detergent can help to break down organic soil. Reamers with many crevices tend to trap debris and may have to be soaked and manually brushed before automatic cleaning. Much will depend upon the capability of the mechanical cleaners in the decontamination area. Lumened instruments should be flushed and brushed. Flushing can be achieved by attaching a Luer-Lok syringe filled with an enzymatic detergent solution to one of the ports on the instrument. Brushing must be carried out using a brush that is appropriate to the device (e.g., a brush made of the appropriate bristle material), intended for cleaning surgical instruments, and long enough to exit the distal end of the shaft and wide enough in diameter to cause friction on the walls of the lumen so soil is loosened. Brushes should be either single use disposable or, if reusable, should be cleaned and disinfected at least daily. Mechanical washers and ultrasonic irrigators specifically designed for lumened devices do an excellent job of cleaning and are preferable for cleaning lumened devices. Personnel responsible for cleaning must wear personal protective attire to prevent contact with blood or with fluid that might contain blood and/or other body fluids. Protective attire consists of a fluid resistant face mask and eye protection such as goggles or a full- length face shield, heavy-duty cuffed decontamination gloves, and a liquid-resistant gown with sleeves that cover the scrub suit underneath. Aprons are not acceptable. Masks are recommended when cleaning items that can create aerosols (e.g., lumened devices). Fluid- resistant shoe coverings or waterproof boots are appropriate when fluid may be expected to pool on the floor.4,5,8 Ultrasonic cleaning is another component of instrument cleaning. Ultrasonic cleaners should be used only on devices that can tolerate this process and only after gross debris has been removed. Ultrasonic washers use a process called cavitation to remove fine soil from difficult-to-reach areas of a device that manual cleaning may not remove. High-frequency sound waves are captured and converted into mechanical vibrations in the solution. The sound waves generate microscopic bubbles that form on the surfaces of the instruments. These bubbles expand until they become unstable and collapse or implode (collapse inwardly), creating minute vacuums that rapidly disrupt the bonds that hold debris to instrument surfaces. The tiniest particles are rapidly drawn from every crevice in the instrument. Ultrasonic cleaning is especially effective for box locks and instruments with serrations and interstices that are not easily accessible. Ultrasonic cleaning does not kill pathogens; it only removes them and deposits them in the ultrasonic bath. The energy created in an ultrasonic cleaner is not biocidal, and unless the solution is changed frequently, the bioburden on instruments can actually increase. To prevent this, ultrasonic solutions should be changed between cycles and according to the ultrasonic IFUs. The cover of the ultrasonic cleaner should be closed during operation to prevent the spread of microorganism-containing aerosols that are created during the cleaning process and that may be harmful to personnel. Both the device manufacturer’s IFUs and the ultrasonic IFUs should be reviewed before using ultrasonic cleaning.

CHAPTER 1 Care and Handling of Surgical Instruments 7 https://kat.cr/user/Blink99/ Instruments made of dissimilar metals can be damaged if sonicated together in the ultrasonic cleaner. The electroplating of the more active metal onto the less active metal can result in permanent discoloration of the less active metal (e.g., brass plating on stainless steel turns the steel a golden color) and will eventually weaken the instrument from which the metal is being removed. In addition, some instruments cannot tolerate the energy waves of the ultrasonic cleaning process, and manufacturers of some instruments, such as lensed, in which the sonication process can loosen adhesives, may specifically state not to use ultrasonic methods for cleaning. There are a variety of ultrasonic cleaners on the market and some of them are designed and intended to be used for specific instruments such as robotic instruments. These may include attachments or ports that connect lumens to the cleaner and are especially efficient at removing debris from difficult to access locations on the device. At the completion of the ultrasonic cycle, the instruments are placed in a mechanical washer or rinsed and dried. The performance of ultrasonic cleaners should be tested periodically using monitors specifically designed and intended for this purpose. There is no nationally recognized standard for frequency of testing, however some IFUs may recommend specific testing inter- vals. Weekly or daily testing is common. The most common mechanical cleaning machine in use is the washer-decontaminator/ disinfector. These machines offer a variety of cycles, including cool-water rinse, enzyme soak, wash, sonication (ultrasonic cleaning), hot-water rinse, germicide rinse, and dry. For lumened devices, washers with connection ports that facilitate cleaning lumens should be utilized. Instruments should be placed in a mesh bottom or perforated tray prior to placement within mechanical washing systems. Detergent should be selected according to the type of debris, the tolerance of the instrument, and recommendations from the device and washer manufacturers. The pH of a detergent can be alkaline, neutral, or acidic. A mildly alkaline or neutral detergent is generally preferred. Acidic or heavily alkaline detergents should not be used routinely because they can destroy the passivation layer and promote corrosion. When high-alkaline detergents are used, they must be completely and thoroughly neutral- ized. To accomplish this, some mechanical washers employ a high-alkaline detergent wash followed by an acid rinse. Enzymatic detergents usually consist of a detergent base with a neutral pH in combination with one or more enzymes and a surfactant. Surfactants lower the surface tension of water and allow the detergent to more easily penetrate into crevices and serrations. There are many enzymatic detergents on the market. Some formulations contain only one enzyme; others contain multiple enzymes. There are enzymatic detergent products suitable for ultrasonic cleaners, mechanical washers, and manual cleaning. Some can be used for manual and mechanical cleaning. Some enzymatic cleaners are intended for specialties such as orthopedic or ophthalmic procedures. Some target blood, fat, or organic soil. As a general rule, a low-foaming detergent with a neutral pH is preferable. High-foaming detergents may not be completely rinsed off and can leave spots and stains on instruments. In areas where the water is hard, a water softener should be used to minimize scum and scale formation. Placement of instruments within mechanical washers must be such that cleaning agents and water can make contact with all surfaces of the instrument. Mechanical cleaning equipment should be tested at least weekly, and preferably daily. There are commercially available products that can be used to test the ability of the washer to clean effectively. These should be used according to the manufacturer’s written IFUs. As a final step before inspection and packaging for sterilization, instruments should be lubricated with a nonsilicone, water-soluble lubricant. Mechanical washers often include a lubrication process as part of the cycle. In manual lubrication, instruments are dipped into a milky-white solution or bath. The manufacturer’s instructions for dilution of the lubricant should be followed, and the expiration date after mixing should be noted and indicated on the instrument milk bath.

8 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ SPECIALTY INSTRUMENTS Specialty instruments require exceptional handling. Instruments used in microscopic surgery should be handled separately from those used for general surgery. They easily become tangled or misaligned when the heavier instruments used in general surgery are placed on top of them. Other specialty instruments, such as powered hand pieces and telescopes, will be destroyed if subjected to ultrasonic cleaning or to a washer-decontaminator and should be meticulously cleaned by hand. Other specialty instruments may have instructions that spec- ify steps not common to general surgery instruments (e.g., attachment of accessories, use of special cleaning tools, and use of pressurized water). The device manufacturers provide instructions for cleaning that are determined as necessary to obtain the desired outcome. The manufacturers’ instructions for care and handling of instruments should always be followed.

Eye Instruments Toxic anterior segment syndrome (TASS) is an acute anterior segment inflammation that can lead to impaired vision. TASS has been associated with inadequate cleaning of ophthalmic instruments following cataract and anterior segment surgery.9-14 Detergent residues, viscoelastic solution used in surgery that can quickly harden on instruments, preservatives, and foreign material can induce TASS. Irrigation ports of phacoemulsion hand pieces, tips, small-diameter tubings, and cannulated instruments coupled with viscous solutions used in eye surgery present unique challenges to cleaning eye instruments. Instruments used for cataract surgery are among those that are most commonly subjected to immediate use steam sterilization (IUSS). Although IUSS, if carried out properly, is safe and effective, the resources to process IUSS correctly may be less than ideal (see section on IUSS) and can lead to shortcuts that negatively impact the outcome of the processing. Following surgery, eye instruments should be immediately immersed in sterile water, and lumens should be flushed with sterile water. The aspiration and irrigation ports and tubings on phacoemulsion hand pieces should be flushed prior to being disconnected. Instruments should then be cleaned with a detergent recommended by the instrument manufacturer. Enzymatic detergents should not be used unless indicated in the device manufacturer’s IFUs. Detergent concentration and water quality should also comply with the device manufacturer’s instructions. The final rinse should be done with sterile, distilled, or deionized water. Lumens should be dried with compressed air. Personnel responsible for processing ophthalmic instruments should refer to the AORN Recommended Practice for Cleaning and Care of Surgical Instruments and to the American Society of Cataract and Refractive Surgeons for recommendations specific to cleaning and processing of ophthalmic instruments.5,13

Flexible Endoscopes Flexible endoscopes contain long, narrow lumens and are inherently difficult to clean. A failure to process properly has been reported in a number of studies. Thousands of patients who have undergone gastrointestinal (GI) endoscopy procedures have been sent letters advising them to return to the facility for testing to determine if they were infected from an improperly processed flexible endoscope.14-17 Instructions for cleaning flexible endoscopes are quite detailed and specific and are beyond the scope of this review. In 2003, The Society of Gastroenterology Nurses and Associates released The Multisociety Guideline for Reprocessing Flexible Gastrointestinal Endoscopes,18 which provides detailed cleaning and disinfection protocols for flexible endoscopes and their accessories. The guideline, which was revised in 2011,19 has been endorsed by 11 agencies including the Joint Commission, professional nurse and physician endoscopic societies, and the Association for Practitioners in Infection Control and Epidemiology. In 2005, the American College of Chest Physicians and the American Association for Bronchology published an article entitled Prevention of Bronchoscopy-Associated Infection that provides recommendations for cleaning, disinfecting, and postprocedure processing of flexible bronchoscopes.20

CHAPTER 1 Care and Handling of Surgical Instruments 9 https://kat.cr/user/Blink99/ Adherence to these guidelines is critical to proper processing. The endoscope manufacturers’ guidelines should always be consulted for design features specific to the scope in question. Manufacturers usually provide in-service education in the cleaning and sterilization of these devices. Personnel responsible for cleaning and processing these devices must have thorough knowledge of the process and must have demonstrated competence as well. Competence should be demonstrated for each model and type of scope. Proper cleaning of flexible scopes should begin immediately after their use. The biopsy and suction channel should be flushed with an enzymatic detergent solution and the outside wiped to remove gross soil. Debris must not be allowed to dry within the channel, and the scope should be delivered to the decontamination area as soon as possible after use. Meticulous cleaning must precede exposure to disinfecting or sterilizing agents. The lumens and internal channels should be cleaned using an appropriately sized brush and then rinsed. It is important that endoscope cleaning agents be mixed and used precisely according to the label. Following manual cleaning, the scope may then be processed in an automated endoscope reprocessor (AER) designed specifically for this purpose. The compatibility of the endoscope with the AER, the detergent, and the disinfectant must be determined. In the absence of an automated system, additional meticulous manual cleaning according to the manufacturer’s recommendations is required. Strict adherence to manufacturers’ instructions concerning use of the disinfectant and the AERs is critical to achieve adequate cleaning and disinfection. As a final step, all channels should be flushed with 70% alcohol to facilitate drying. Some AERs include an alcohol flush. Storage in an appropriate drying cabinet that has humidity and temperature control is an additional method to facilitate drying. Pathogenic microorganisms found in rinse water can colonize in a relatively short time (overnight) in an endoscope that has not been adequately dried. In addition, it is possible for a biofilm to form in a lumen that has not been sufficiently dried. A biofilm is an assemblage of microbial cells that forms when bacteria attach to a surface and then exude an extracellular polysaccharide that acts as a glue and a protective layer of slime in which the bacteria proliferate. The extracellular polysaccharide film prevents antibiotic penetration. Biofilms can be removed only by mechanical action. If a biofilm breaks from the surface and enters a patient, the consequences can be deadly because of the especially large number of bacteria in a biofilm. It can require more than 100 times the normal dose of an antibiotic to treat an infection caused by a biofilm. Biofilms have been found to form in moist endoscope lumens as a result of inadequate drying. An alcohol flush can prevent the growth of water-borne microorganisms and biofilms.

CONSIDERATIONS FOR INSTRUMENTS CONTAMINATED WITH PRIONS A prion is an infectious proteinaceous particle that is responsible for causing Creutzfeldt- Jakob disease and several other fatal degenerative neurological diseases. Because prions are resistant to routine disinfection and sterilization processes, instruments that have come into contact with prions require treatment according to special processing protocols. Infor- mation about appropriate processing protocols is not always consistent and continues to evolve. In February 2010, the Society for Health care Epidemiology of America (SHEA) published an article entitled Guideline for Disinfection and Sterilization of Prion-Contami- nated Medical Instruments.21 AORN and AAMI also provide recommendations and guidelines related to processing prion-contaminated instruments. These guidelines as well as the most current literature should be consulted when developing a policy and procedure for processing prion-contaminated instruments. Research on best practices related to processing instruments suspected or known to have been exposed to prions is ongoing. In addition, processing protocols are evolving and cleaning chemistries are increasingly being recognized as a critical factor in processing these instruments.22 Institutional policies and procedures for prion-contaminated instruments should be reviewed at least annually and revised accordingly. Processing protocols are based on the presence or suspected presence of a prion disease in a surgical patient, the type of tissue that comes into contact with the instruments used during the surgery, and whether the device is critical. Critical devices are those that enter sterile tissue or the

10 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ vascular system. High-risk patients are those with a known prion disease or those with rapidly progressive dementia consistent with prion disease. High-risk tissue includes brain, spinal cord, posterior eye, and pituitary. Critical instruments used on high-risk patients undergoing surgery on high-risk tissue require special processing protocols. Each health care facility should have policies and procedures for screening patients to determine the presence or possible presence of a prion disease, identifying and tracking the instruments used in these patients, and establishing protocols for processing these instruments.

SPOTTING, STAINING, AND CORROSION Although stainless steel is highly resistant to spotting, staining, rusting, and pitting, these conditions can occur for many reasons. Understanding the cause of the specific problem usually provides an effective solution. Minerals in the water may cause light and dark spots. Instruments processed in health care facilities in which the water supply has a high concentration of minerals may show spotting. When water droplets condense on the instruments and evaporate slowly, mineral deposits in the water can remain and leave spots. Sodium, calcium, and magnesium minerals are particularly problematic. Using treated water (e.g., demineralized, reverse osmosis, and filtered) for rinsing and pure steam for sterilizing may solve the problem. After the sterilization cycle, the door to the autoclave should remain closed until all the steam in the chamber has been allowed to exhaust. This reduces the amount of condensate remaining on the instruments. Vigorous rubbing with a cloth or cleaning with a soft brush may be sufficient to remove mineral-deposit spotting. If spotting remains a problem, the autoclave may need servicing. Leaky or faulty gaskets may be the cause of the problem. A rust-colored film on instruments may be the result of high iron content in the water or foreign material within steam pipes. Yellow-brown to dark-brown spots are sometimes mistaken for rust; the eraser test can be used to determine whether it is rust. If the stain disappears when it is rubbed with a pencil eraser, it is not rust. In some instances, the instal- lation of a steam filter may help prevent this type of stain. Brownish staining can occur when the detergent used for cleaning contains polyphos- phates that dissolve copper elements in the sterilizer. The result is that a layer of copper is deposited on the instruments by electrolytic action. If this happens, a different detergent should be used and the manufacturer’s instructions followed. Brownish-orange stains can be caused by a high pH level in the detergent used to clean the instruments. Black spots are the result of exposure to ammonia, which is found in many cleaning agents. The problem can be resolved by using a different detergent and rinsing thoroughly. Black stains can also be caused by amine deposits that can be traced to the autoclave steam. Amines are used in the boiler to prevent mineral salt deposits on the walls of the boiler and steam pipes. Some of the amines are carried with the steam into the autoclave and by means of electroplating are deposited on the instruments, causing staining to occur. Adding amines to the boiler must be done in a controlled and gradual manner to minimize the risk of concentrations high enough to cause spotting on items to be sterilized. A blue-gray stain can result when cold liquid sterilants are used beyond their recommended time limit. Rusting of stainless steel is unlikely, and what often appears to be rust may actually be organic residue in box locks or mineral deposits baked onto the instrument surface. Unless the cause is remedied, corrosion may occur. Actual corrosion is a physical deterioration of the stainless steel. Pitting is a severe form of corrosion in which small pits form on the surface of the instrument. Corrosion and pitting can occur when instruments are exposed to saline for extended periods of time and when organic debris such as blood and tissue is left in difficult-to-clean areas such as box locks, serrations, and ratchets. Detergents that are either too alkaline or too acidic can also cause corrosion and pitting. Detergents with a chlorine base or an acid pH should be avoided. Exposure to carbolic acid, calcium chloride, ferrous chloride, potassium perman- ganate, and sodium hypochlorite can cause severe pitting. To avoid electrolysis, stainless

CHAPTER 1 Care and Handling of Surgical Instruments 11 https://kat.cr/user/Blink99/ steel instruments should not be mixed with instruments containing aluminum or copper. Improperly cleaned wraps can also create a corrosive environment. The detergent can leach from the wrap during exposure to heat and steam and remain on the instrument. Measures that can be taken to avoid instrument corrosion and pitting include soaking or spraying instruments with an enzymatic foam or spray after use to prevent debris from drying and hardening; scrubbing hard-to-clean areas; using a neutral pH detergent; thoroughly rinsing with treated water; and routinely cleaning the sterilizer according to the sterilizer manufacturer’s IFUs. Water and vinegar can also be used to remove impurities. It is sometimes difficult to identify the cause of stains. Both the instrument manufacturer and the sterilizer manufacturer should be consulted when the cause is unclear. In summary, the following steps should be taken to prevent spotting, staining, and corrosion: 1. Clean as soon as possible after use to prevent debris from drying on instruments. (Cleaning begins at point of use.) 2. Apply enzyme spray or gel designed and intended to prevent debris from hardening on instruments after use in surgery. 3. Clean well; remove all soil. 4. Rinse well. Use treated water for the final rinse. 5. Do not place instruments of dissimilar metal in the ultrasonic cleaner. Remove gross debris prior to placement within the ultrasonic cleaner. 6. Select only detergents and disinfecting solutions that are recommended for instruments. Check with the instrument and washer-decontaminator/disinfector manufacturers. 7. Mix and use detergent solutions exactly as indicated by the manufacturer’s IFUs. 8. Dry instruments before wrapping. Ensure adequate drying following exposure to sterilization. Check autoclaves for proper functioning to ensure drying of packs. 9. Perform sterilizer maintenance according to the sterilizer manufacturer’s IFUs. 10. Periodically have the steam lines and boiler inspected and serviced to prevent boiler additives from being discharged into the steam.

INSPECTION AND TESTING Prior to packaging, instruments should be inspected for cleanliness, proper functioning, and absence of defects. An inadequately cleaned, improperly functioning, or damaged instrument is a source of frustration to the surgeon, can cause critical delays in surgery, and can contribute to patient infection or serious injury. Instruments should be inspected for cleanliness and absence of defects under lighted magnification. Box locks, serrations, crevices, and other hard-to-clean areas should be examined for cleanliness. Deposits left on instruments may prevent sterilization from being achieved and may dislodge in the patient. Box locks should be inspected for minute cracks. Cracks are an indication that breakage is imminent. Other common areas where cracks may appear include hinges, lumens, and the base of needle jaws. Jaw movement, jaw alignment, and ratchet function should be checked on all hinged instruments. Joints should work smoothly, and jaws should be in perfect alignment and not overlap. Ratchets should close easily and hold securely. Joint movement can be tested by opening and closing the instrument several times. The instrument should close and release with ease. Stiff joints can be caused by inadequate cleaning, resulting in minute particles remaining in the joint. Stiffness can also result when water used to clean instruments contains impurities that collect in the joint. Joints that are stiff should be recleaned if necessary and lubricated with a water-soluble lubricant before they are packaged for sterilization. Jaw alignment can be tested by lightly closing the instrument and inspecting the jaws. Any overlap indicates lack of alignment and need for repair. If there are serrations or teeth on the jaws, they should meet and mesh perfectly. This can be tested by closing the instrument and holding it up to the light. Light should not be visible through the jaws. Instruments

12 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ with misaligned jaws can damage tissue and will not effectively occlude bleeders. Misalign- ment of hemostatic clamps is a common problem most commonly caused by improper use of the instrument. Hemostatic clamps should not be used as towel clips, needle holders, or pliers or for purposes other than those for which they are designed and intended. Ratchets may be tested by clamping the instrument on the first ratchet, holding it at the box lock, and lightly tapping the ratchet portion against a solid object. The instrument should remain closed. Instruments that spring open are faulty and require repair. The edges of cutting instruments should be inspected for nicks, burrs, and broken tips. Dull, nicked, or dented cutting edges can cause trauma to tissue. Delicate knives, kera- tomes, needles, and rongeurs can be tested for burrs and rough edges by passing them through kidskin. The sensation of a slight drag is an indication of a burr or a rough edge. Scissors should be tested for cutting ability. Heavy scissors such as Mayo scissors should cut easily through four layers of gauze. The tips of Metzenbaum and other more delicate scissors should cut easily through two layers of gauze. One of the most frequent complaints regarding instruments is that scissors are not sharp. One solution is to create a preventive maintenance schedule for sharpening scissors before edges become dull and problematic. Scissors are most often damaged when used to cut material other than that for which they were designed. One example is the use of Metzenbaum scissors to cut suture material. A needle holder must hold a needle securely without permitting it to slide or slip during suturing. Needle holders can be tested by grasping a needle in the jaws and locking on the second ratchet. If the needle can be turned easily by hand, the instrument should be tagged for repair or replacement. Inappropriate use is a common cause of damage. Needle holders should be selected to match needle size. Using a large needle with a delicate needle holder can spring the jaws of the holder and reduce its holding ability. If the needle holder has tungsten jaws, identified by gold handles, the jaws can be replaced when worn, thus extending the overall life of the instrument. Fiber optic light cords are checked by holding one end up to a light and looking through the other. Broken glass fibers will appear as black dots. The cord should be replaced if more than 20% of the area is affected. Rigid endoscopes, once used only for diagnostic purposes in gynecology, are now used routinely in every surgical specialty. A rigid endoscope is one of the more expensive instruments used in the operating room. It is also easily damaged, and costly repair can be a frequent occurrence. Many operating rooms spend more annually for the repair of rigid endoscopes than for the purchase of new ones. Rigid endoscopes may be damaged in many ways: during surgery, such as during an arthroscopy procedure when the distal tip is nicked by an intraarticular shaver; by placement under heavy instruments that can cause a dent or bend in the shaft and subsequent damage to one or more of the glass rods inside the shaft; by sterilization using an incorrect cycle; and by careless handling of or dropping of the scope. Many companies offer scope repair services. It is important to ensure that only original parts are used during repair. Some third-party repair companies use replacement parts that can cause the endoscope to fail shortly after repair. The best assurance that the original parts will be used for repair is to use the original manufacturer’s repair services. Rigid endoscopes should be checked to ensure that the lens is not cloudy or otherwise occluded. Telescopes are checked by holding the scope up to the light and observing the lens image at the distal end. The image should be clear and easily visualized. The light source used in the operating room should not be used for this test because the high-powered light can cause eye damage. A more precise test of optical resolution is to use a resolution chart. These can be obtained at low cost from an optical imaging company. A resolution chart consists of identical sets of increasingly small bars printed on a circular chart. A set is printed at five locations on the chart: in the center and at the circumference edges to the left, right, top, and bottom of the center. The bar sets are numbered. For example, a set of the largest bars is numbered 75 and a set of the smallest bars is labeled 450. The number represents the number of bars that can be seen if they were lined up across the image. The user should look through the scope and line up the chart so that it fills the field of view. The number in each of the five locations should be recorded. The lower the number is, the poorer the resolution. An optical resolution chart is useful in determining the quality of repair. Measurements should be taken

CHAPTER 1 Care and Handling of Surgical Instruments 13 https://kat.cr/user/Blink99/ when the scope is new (i.e., before the first use), between each use, and after each repair. If the resolution is lower after repair than before damage, the quality of the repair should be questioned. This is one way to hold repair companies accountable. Each time they are processed, insulated instruments (i.e., laparoscopic and robotic) should be inspected for breaks in the insulation and for areas where the insulation has separated from the instrument shaft and appears loose. Both situations are indications that the insulation is not intact. Multiple studies have shown that insulation failures are not always detected with visual inspection.23 In addition to visual inspection, an insulation test device should be used to test insulation integrity. Reusable and single-use insulation testers are available. Testers are also available that may be used from the sterile field in the operating room allowing testing just prior to use rather than only prior to packaging. If either defect is observed, the instrument should be removed from service. Loose or nonintact insulation is a serious defect and can result in an unintended burn inside the patient at the point where the insulation is not intact. Insulated instruments are used in endoscopic surgery where the field of vision is limited by the scope’s distance from the operative site. The site of the burn may not be within the surgeon’s field of vision and can go unnoticed. The patient may even be discharged before a complication is noted. In the case of a burn that causes bowel perforation, the patient can develop peritonitis, which in turn can lead to additional surgery, extended recovery, and even death caused by infection. Microscopic instrumentation should be examined under a microscope to check for burrs or nicks on tips and to check alignment. Some of the teeth on microscopic forceps are very difficult to see with the naked eye, and forceps alignment should be inspected under a microscope.

PREPARATION FOR STERILIZATION OR DISINFECTION

Classification of Surgical Instruments In 1972, Dr. E. Spaulding classified medical devices and instruments into three categories based on the risk of infection involved in their use. The categories are critical, semicritical, and noncritical. This classification was accepted by the Centers for Disease Control and Prevention and is used today to determine the processing strategy for surgical instruments. Critical devices are the devices that penetrate mucous membranes and enter normally sterile areas of the body. Examples of critical devices are instruments used in surgery, needles, and scalpels. Critical devices must be sterile. Semicritical devices contact, but do not penetrate, intact mucous membranes and must be high-level disinfected, at a minimum. Examples of semicritical devices are bronchoscopes, thermometers, and endotracheal tubes. Noncritical items contact intact skin and require low-level disinfection or cleaning with soap and water. Examples of noncritical devices are crutches and blood pressure cuffs. Instruments classified as critical are packaged prior to sterilization. Packaging used for sterilizing instruments includes paper-plastic pouches, Tyvek/mylar, rigid sterilization containers, polypropylene wrap, and nonwoven fabric. All packaging should be used in accordance with the manufacturer’s written IFUs.

Packaging In preparation for sterilization, instruments should be carefully arranged in containers or baskets with wire mesh or perforated bottoms or in other trays that are compatible with the intended sterilization method and that may be wrapped in reusable or single-use wrapping material. Alternatively, instruments can be arranged within rigid instrument containers made of plastic or metal that are compatible with the intended sterilization method. Rigid containers do not require outer wraps. They offer the advantage of greater protection to the instruments during handling and transport and can be stacked for efficient storage after sterilization. Containers should not be stacked within the sterilizer unless indicated in writing by the manufacturer of the container. Stacking can interfere with sterilization and drying. Personnel responsible for packaging should refer to the container manufacturer’s

14 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ written IFUs for instructions for cleaning, inspection, replacement of filters and valves, sterilization methodologies, and sterilization exposure times. The combined weight of an instrument set and its containment device should be no more than 25 lb.4,24,25 Sets weighing more than 25 lb increase the risk of injury to workers who must lift them during processing and increase the risk that a set will retain moisture after sterilization. Whenever practical, contents of instrument sets should be standardized. Standardization reduces the need for inventory, facilitates instrument replacement, and makes it easier to identify and locate sets needed for a surgical procedure.

Placement Instruments should be placed so that joints and hinges are in the open position. Instru- ments with multiple parts should be disassembled. Retractors and other heavy instruments should be placed on the bottom or at one end of the basket, with lighter instruments strung open and placed alongside or on top. Sharp edges should be protected. Delicate, fragile, and lensed instruments should be protected from collision with other instruments in the set. Fingered mats, foam pockets, scope holders, and tip protectors are examples of items that protect instruments. Some instrument sets are supplied in specialized containers, either to secure and protect the instruments, as in the case of fine microsurgical instruments, or to facilitate their location within the set, as with some orthopedic joint replacement sets. Plastic/paper pouches should not be placed within sets. Instruments should not be double pouched unless the pouch manufacturer has validated the plastic pouch for this use. Loading and operating any sterilizer should be carried out in accordance with the sterilizer manufacturer’s written instructions.

Sterilization Steam sterilization is the most commonly used method for sterilizing instruments. Instru- ments that can tolerate repeated exposure to the moisture and high temperature of steam should be steam sterilized. Steam sterilization is an economical and reliable method available in almost every health care facility. Items sensitive to heat and moisture are sterilized using alternative methods, such as ethylene oxide and hydrogen peroxide gas plasma. Cut- ting instruments and other instruments with sharp edges, although they can be processed in steam, will hold their edges longer if sterilized in low-temperature sterilization systems. Instruments, pans, containers, and any packaging material, as well as any padding or protective material used in the pan, must be compatible with the sterilization method. For example, placing a cotton surgical towel in the bottom of a pan or container is useful in steam sterilization to absorb condensate and facilitate drying. However, cotton or other cellulose-containing materials cannot be used in some low-temperature sterilization technologies. Although one sterilization cycle may be appropriate for the majority of instruments, there are instrument sets that require extended exposure time. Sterilization cycles should be selected according to the device, the packaging, and the sterilizer manufacturer’s IFUs. Any discrepancy between the IFUs should be resolved prior to sterilization. In the absence of resolution, product testing may be appropriate. Essentially, product testing consists of placing multiple biological and chemical indicators in the areas within the instrument set that are considered to be the least accessible to the sterilant, exposing the set to the sterilization process, and evaluating the results of the chemical and biological monitors. If monitoring results are negative, the instruments may be washed, packaged in the same manner as they were packaged for product testing, sterilized, and entered into service. Personnel attempt- ing to perform product testing should refer to the AAMI publication ST79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities,4 for a much greater detailed explanation of this process. Because prions, the causative agent of Creutzfeldt-Jakob disease, are resistant to routine sterilization cycles, instruments known or suspected to have contacted prion-contaminated tissue require special procedures and extended sterilization cycles. Extended cycles

CHAPTER 1 Care and Handling of Surgical Instruments 15 https://kat.cr/user/Blink99/ recommended by the Society for Health care Epidemiology of America for prion-contaminated instruments include: • Autoclave (sterilize) at 134°C for 18 minutes in a prevacuum sterilizer. • Autoclave at 132°C for 1 hour in a gravity displacement sterilizer. • Immerse in 1 N NaOH (1 N NaOH is a solution of 40 g NaOH in 1 L water) for 1 hour; remove and rinse in water, then transfer to an open pan and autoclave at 121°C in a gravity displacement sterilizer or 134°C in a prevacuum sterilizer for 1 hour.21 Instruments should be dry prior to sterilization. Processing wet instruments by steam sterilization may cause difficulties in obtaining a dry set. Sterile items that are not completely dry at the end of the cycle are considered contaminated because the moisture inside the package can breach the sterile barrier and create a pathway for microorganisms to enter the package. Lumens should not be moistened prior to sterilization unless the device manufacturer specifies this in the IFUs. Sterilizing wet instruments in ethylene oxide can lead to the formation of ethylene gly- col (antifreeze), a by-product of water and ethylene oxide. This chemical by-product is not removed during the aeration process and can harm patients. Wet instruments processed in hydrogen peroxide gas plasma or vapor will cause the sterilization cycle to cancel.

Immediate Use Steam Sterilization IUSS, formerly known as flash sterilization, is sterilization that does not include a dry time or may include a very minimal dry time. Immediate use is defined as the shortest possible time between the removal of a sterilized item from the sterilizer and its aseptic transfer to the sterile field. Items subject to IUSS may not be stored for future use nor held from one case to another.26 IUSS cycles do not include a dry time or may include a very short dry period. Immediate use is not to be used for purposes of convenience or as a substitute for sufficient inventory.6 Previously, IUSS was carried out in an open pan and cleaning was often done in an area not specifically dedicated for decontamination under less than ideal conditions. Current guidelines call for cleaning to be carried out in a dedicated decontamination area, that the same critical reprocessing steps (such as cleaning, decontaminating, and transport- ing sterilized items) must be followed, and that items are sterilized in a container.26

Disinfection Common liquid chemicals used to disinfect surgical instruments include glutaraldehyde, hydrogen peroxide, peracetic acid, and orthophthalaldehyde. Each has unique characteristics and should be chosen in accordance with department needs and instrument compatibility. Instruments to be disinfected should be cleaned and dried before placement into the disinfectant. Moisture from instruments that are not dry can dilute the disinfectant, causing it to lose its effectiveness. The disinfectant solution should be tested for minimum effective concentration (MEC) according to the manufacturer’s instructions. Testing should be performed before each use. If the MEC falls below the accepted level as indicated by the test strip, the solution should be discarded. The immersion time required for high-level disinfection is indicated on the product’s label and should be strictly adhered to. Follow- ing disinfection, items should be rinsed with copious amounts of water according to the manufacturer’s instructions. Disinfected instruments should be allowed to dry and should be stored in a clean, dry area in a manner that protects the device from contamination. Personnel responsible for carrying out high-level disinfection should refer to the AORN Recommended Practices for High-Level Disinfection.27

IDENTIFICATION SYSTEMS Instrument identification and related instrument-tracking systems are becoming com- monplace in health care facilities. Instrument identification is used for inventory control,

16 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ reordering, and as a deterrent to theft. Color coding and etching are two methods of coding. Color coding may be adapted for a specific instrument set, specialty, department, or surgeon. Most systems use a hard color coating that is permanently fused to the instrument’s ring handle. For example, a set with green ring handles may indicate that the set belongs within a specific specialty. If colored tape is used to mark instruments, it is important to follow the manufacturer’s instructions for proper tape application and to obtain written verification of tape compatibility with the intended sterilization method. It is important to inspect the condition of the tape before packaging the instrument. Tapes may peel or flake over time and harbor microorganisms. Loose, cracked, or flaking tape must be removed, all adhesive removed, and new tape applied. For these reasons, taping is not a preferred method of marking instruments. Another method of instrument identification is etching or engraving the shaft with the desired information. Vibrating mechanical engravers that scratch the surface should not be used because they break down the rust-resistant protective coating of the instrument, potentially allowing corrosion to begin. When a mechanical engraver is used in the area of the box lock, minute fault lines can be created and can result in premature breakage of the lock. Newer acid or laser etching processes are preferred because they do not harm the instruments. It is important to check with the manufacturer of the instrument to ensure that the instrument can withstand the desired coding system. Many instrument companies offer engraving at the time of purchase.

CLASSIFICATION OF INSTRUMENTS The three broad categories of instruments are handheld, nonpowered surgical instruments; powered tools or devices; and endoscopic equipment and instrumentation. Handheld, nonpowered instruments are used for cutting, clamping, grasping, retracting, chiseling, and manipulating tissue and bone. Powered instruments are used for drilling, sawing, or cutting bone and cauterizing tissue. Drills, oscillating and sagittal saws, and wire drivers are examples of powered devices. They may be powered by electricity, compressed gas, or battery. Endoscopic equipment and instruments are used to perform minimally invasive surgery and to examine internal organs through very small incisions. Examples of endoscopic instruments are rigid and flexible endoscopes along with cameras and light cords. Interventional procedures under advanced imaging systems are increasingly being performed in the operating room. Many of the devices that are used in these procedures are single-use disposable and outside the scope of this chapter. These devices should not be reprocessed within health care facilities. The following information describes the general classifications of handheld, nonpowered instruments. Descriptions and examples are included. The names of the instruments may vary with the manufacturer, the geographic location within the country, the surgeon’s preference, and the health care facility in which they are used. The different instrument names are used interchangeably by surgeons and staff. In this textbook, the names given for instruments that appear in the photographs are the manufacturer’s names.

Handheld, Nonpowered General Surgery Instruments Clamps Hemostats are used to control the flow of blood. The jaws of a hemostat contain horizontal serrations designed to close the severed edge of a blood vessel, allowing for minimal tissue damage. There are several sizes of hemostats: for example, mosquito, Crile, Halsted, and Mayo-Péan. The larger hemostats are also used to clamp tissue. Occluding clamps are used to clamp bowel or vessels that will be reanastomosed. The jaws of occluding clamps used on bowel contain vertical serrations. Occluding clamps used on blood vessels contain multiple longitudinal rows of finely meshed teeth. Both are designed to prevent leakage while minimizing trauma to the tissue.

CHAPTER 1 Care and Handling of Surgical Instruments 17 https://kat.cr/user/Blink99/ 1-1 Components of a typical clamping instrument.

Ratchet

Box Lock

Ring Handles Jaws

Tip

Shank

1-2 Scissors. Left to right: Mayo dissecting scissors, straight; Metzen- baum dissecting scissors; iris scissors, straight; and Westcott tenotomy scissors, straight.

Cutting Instruments Knife handles are usually straight handles that hold knife blades of various shapes that are used for incision and dissection. Examples of knife handles are Bard-Parker and Beaver. Other knives, such as Fisher tonsil, Smillie cartilage, and myringotomy knives, incorporate the blade into the structure of the handle. Scissors exist in many different forms; the two basic types are dissection and suture scissors. Dissection scissors are manufactured according to their intended purpose. Small,

18 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ delicate scissors, such as iris or Westcott scissors, are used in ophthalmic, plastic, and microscopic surgery. Metzenbaum scissors are used in intraabdominal and other general surgeries. More sturdy scissors such as Mayo scissors are appropriate for cutting fascia or sutures. Metzenbaum and Mayo scissors are found in most general surgery instrument sets. Curvature, weight, size, and flexibility vary according to intended use.

Retractors Retractors are used to hold back the edges of a wound to permit visualization of the operative site. A handheld retractor consists of a shaft to hold and an end piece for retracting. The end piece may be a hook, a blade, or a rake. Examples of handheld retractors are skin hook, Senn, Army Navy, Parker, and rake. Self-retaining retractors do not require that someone hold them in place. Some self-retaining retractors consist of two blades that are held apart by a ratchet, such as the weitlaner, Jansen, and Gelpi. Larger self-retaining retractors consist of a series of blades that attach to bars that are held in place by a screw or similar device. The bars that hold the blades may be attached to the operating table itself. Examples of larger self-retaining retractors are the O’Sullivan-O’Connor, Thompson, and Balfour.

1-3 Handheld retractors. Top to bottom: Skin hook and double-ended Richardson retractor.

1-4 Self-retaining retractors. Top to bottom: Weitlaner retractor and unassembled O’Sullivan-O’Connor retractor.

CHAPTER 1 Care and Handling of Surgical Instruments 19 https://kat.cr/user/Blink99/ Grasping and Holding Instruments Forceps, also referred to as pickups, are shaped like tweezers and are used to grasp and hold tissue. The tips of forceps vary according to their intended uses. The tips may be smooth or serrated or have single or multiple teeth that interlock.

1-5 Grasping and holding instruments. Top to bottom, left to right: Adson tissue forceps without teeth; Ferris Smith tissue forceps (1 × 2); tissue forceps with teeth (1 × 2). Tips on the right, top to bottom: Fer- ris Smith tissue forceps (1 × 2); tissue forceps with teeth (1 × 2); and Adson tissue forceps without teeth.

Examples of common clamp-shaped grasping instruments include the Ochsner, Kocher, Allis, and Babcock. The Ochsner and Kocher forceps have a heavy tooth at the jaw tip and are used to grasp and hold tissue without concern for trauma. The Allis clamp has multiple noncrushing teeth and is used to grasp tissue without crushing. The Babcock clamp tissue forceps has a curved, fenestrated tip without teeth. It is useful for grasping structures such as the fallopian tube or ureter.

B B

1-6 Grasping instruments. Top to bottom: A, Ochsner forceps and tip; B, Allis tissue forceps and tip.

20 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ A needle holder is a grasping instrument designed to secure a suture needle in its jaws. A needle holder may be a clamp type with a ratchet handle or may be a spring-action type. Size and jaw surface vary and are selected with regard to the procedure and the size of the needle being used. A towel clamp is a holding instrument that is used to secure towels and drapes in place. The tip may be blunt or pointed and designed to penetrate. A sponge holder is a clamplike instrument with rounded jaws that is used to hold a folded 4 × 4 sponge.

1-7 Grasping instruments. Top to bottom: Foerster sponge forceps with sponge in the jaws, and Backhaus towel forceps.

1-8 Accessory instruments. Top to bottom: Frazier suction tube with stylet below; Poole abdominal suction tube with shield below; and Yankauer suction tube with tip off.

Accessory Instruments Suction instruments/tubes vary in length, curvature, and lumen diameter and are selected according to the type of surgery and the amount and depth of fluid to be suctioned. Minor, delicate surgery and surgery on small vessels require small-diameter suction. Two examples of small-diameter suction tubes are Frazier and antrum. Abdominal, deep-joint, and other general surgeries usually require a Yankauer or Poole suction tube. Poole suction tubes are used in areas where the fluid is deep. Yankauer suction tubes are curved, and the suction opening is on the tip. Poole suction tubes are straight and have multiple holes along the length of the shaft.

CHAPTER 1 Care and Handling of Surgical Instruments 21 https://kat.cr/user/Blink99/ REPAIR CONSIDERATIONS Preventive maintenance coupled with careful handling and proper use are the best ways to prevent deterioration and equipment failure and to extend the lives of instruments. Regard- less of the care in handling and use, some instruments will need replacement or repair. The facility may choose to send the item to the original manufacturer or an outside contractor or may utilize the services of an independent service manufacturer that repairs instruments and performs preventive maintenance on site. When selecting a repair facility or service, the following should be considered: • Company reputation • References from other users • Liability and shipping insurance • Cost • Response time • Turnaround time • Loaner program • Repair exchanges: Will your original equipment be returned? • Quality measures: Is quality measured according to ISO 9000? • Replacement parts: Are original manufacturer parts provided? • On-site inspection visits: Are they unrestricted?

INSTRUMENT TRACKING Several companies offer instrument-tracking software that allows the facility to monitor the productivity of processing personnel and track the use, inventory, and location of surgical instrument sets. These programs make it possible to know where any set is within the system at any time. Instruments can be tracked by serial number, where appropriate, according to the patient, surgeon, and procedure. This information would be particularly helpful, for example, in tracking sets used in neurosurgery when the patient is known, or suspected, to have Creutzfeldt-Jakob disease and the set must be quarantined until a definitive diagnosis is made. Bar coding can be used to identify whether a set is complete and what needs to be ordered when a replacement is necessary. Replacement orders can be made via an automated procurement system that interfaces with the tracking program. Data from a tracking system can be used to identify the costs of acquisition and repair. Information about repair rates, reasons for repair, and costs is useful when determining where to focus quality- improvement efforts. Tracking systems also facilitate the optimization of instrument-set inventory based on actual use.

SUMMARY Surgical instruments are a major financial investment in every surgical facility, and processes should be in place to protect this investment. The life of a surgical instrument is dependent upon the way it is used and the care it receives. It is the responsibility of the surgical team and the personnel who process the instruments to handle them carefully, use them for the purpose for which they were designed, and process and maintain them appropriately. The extra time it takes to properly care for instruments is well worth the investment and is always in the patients’ best interests.

REFERENCES 1. Brennan T, et al.: Incidence of adverse events and negligence in hospitalized patients — results of the Harvard Medical Practice Study 1, N Engl J Med I, Feb 9, 1991. 2. Medical Errors: A report by the staff of US Senator Barbara Boxer. 2014,http://www.boxer.senate .gov/en/press/releases/042514.cfm. Accessed May 8, 2014. 3. Agency for Healthcare Research and Quality (AHRQ): Never events, http://psnet.ahrq.gov/prim er.aspx?primerID=3. Accessed May 8, 2014.

22 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ 4. AAMI/ANSI ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013: Comprehensive guide to steam sterilization and sterility assurance in health care facilities, Arlington, Va, 2013, Associa- tion for the Advancement of Medical Instrumentation. 5. AORN: Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN. 6. Rutala WA, Weber DJ, and the Healthcare Infection Control Committee Practices Advisory Com- mittee (HICPAC): Guideline for disinfection and sterilization in healthcare facilities, http://www. cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf, 2008. Accessed May 7, 2014. 7. Centers for Medicare and Medicaid Services (CMS): Flash sterilization clarification-FY 2010 Am- bulatory Surgical Center (ASC) surveys. https://www.cms.gov/Medicare/Provider-Enrollment- and Certification/SurveyCertificationGenInfo/downloads/SCLetter09_55.pdf US. Accessed May 19, 2014. 8. Department of Labor: Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens, CFR 29:1030, 1910, https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_ id=10051&p_table=STANDARDS. Accessed May 10, 2014. 9. Holland SP et al: Update on toxic anterior segment syndrome, http://unboundmedicine.com/ medline/. Accessed May 8, 2014. 10. Mathys KC, et al.: Identification of unknown intraocular material, J Cataract Refract Surg 34: 465–469, 2008. 11. Maier P, et al.: Toxic anterior segment syndrome following penetrating keratoplasty, Arch Oph- thalmol 126(12):1677–1681, 2008. 12. Hellinger WC, et al.: Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave moisture, Infect Control Hosp Epidemiol 27(3):294–298, 2006. 13. American Society of Cataract and Refractive Surgery and American Society of Ophthalmic Reg- istered Nurses Recommended Practices for Cleaning and Sterilizing Intraocular Surgical Instru- ments: Special report, J Cataract Refract Surg 32(2):22–28, 2007. 14. Ofstead CL, et al.: Re-evaluating endoscopy-associated infection risk estimates and their implica- tions, AJIC: Am J Infect Control 41(8):734–736, 2013. 15. Ofstead CL, et al.: Endoscope reprocessing methods: a prospective study on the impact of human factors and automation, Gastroenterol Nurs 33:304–311, 2010. 16. Schaefer MK, et al.: Infection control assessment of ambulatory surgical centers, JAMA 303: 2273–2279, 2010. 17. Langlay AM, et al.: Reported gastrointestinal endoscope reprocessing lapses: the tip of the ice- berg, AJIC: Am J Infect Control 41(8):1188–1194, 2013. 18. Multisociety Guideline on Reprocessing Flexible Gastrointestinal Endoscopes 2011. Ameri- can Society for Gastrointestinal Surgery, https://www.google.com/search?newwindow=1& site=&source=hp&q=multi+society+guideline+for+reprocessing+flexible&oq=Multisocie ty&gs_l=hp.1.0.0i10i30l2.1644.4278.0.5939.13.12.0.1.1.0.259.1845.1j10j1.12.0....0...1c.1.43. hp..2.11.1456.0.cj_1kvZMURc. Accessed May 9, 2014. 19. ASGE and SHEA: Updated Announcement, http://www.shea-online.org/View/ArticleId/82/ASGE- and-SHEA-Issue-Updated-Multisociety-Guideline-on-Reprocessing-Flexible-Gastrointestinal- Endosco.aspx. Accessed May 9, 2014. 20. Moses L, et al.: Prevention of flexible bronchoscopy-associated infection: consensus statement, Chest 128(3):1742–1755, 2005, http://dx.doi.org/10.1378/chest.128.3.1742. 21. Rutala W, Weber D: SHEA guideline: guideline for disinfection and sterilization of prion- contaminated medical instruments, Infect Control Hosp Epidemiol 31(2):107–117, Feb 2010. 22. McDonnell G, et al.: Cleaning, disinfection and sterilization of surface prion contamination, J Hosp Infect 85(4):268–273, 2013. 23. Montero PN, et al.: Insulation failure in laparoscopic instruments, Surg Endosc 24(2):462–465, 2010. 24. AORN: Recommended Practices for Selection and Use of Packaging Systems. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN. 25. AAMI/ANSI ST77: Containment Devices for Reusable Medical Device Sterilization, Arlington, Va, 2013, Association for the Advancement of Medical Instrumentation. 26. AAMI: Immediate-Use Steam Sterilization, https://www.aami.org/publications/standards/ST79_ Immediate_Use_Statement.pdf. Accessed May 10, 2014. 27. AORN: Recommended Practices for High-Level Disinfection. In: Perioperative standards and recommended practices, Denver, Colo, 2014, AORN.

CHAPTER 1 Care and Handling of Surgical Instruments 23 https://kat.cr/user/Blink99/ CHAPTER 2

Sterilization Container Systems*

Additional images are available at: INTRODUCTION evolve.elsevier.com/Tighe/instrumentation Sterilization packaging systems are required to secure instrument sets, provide for sterilant penetration of contents, and withstand multiple handling events during a prolonged period of storage and handling. There are two types of containment devices: rigid reusable sealed containers with filters and valve systems and perforated case trays, which are designed to be wrapped. Rigid reusable container systems provide an efficient, cost-effective way to package and protect surgical devices in order to sterilize the contents, maintain the sterility of the contents until the package is opened at point of use, and to allow for the removal of contents without contamination; some containment devices can be designed to aid in the efficiency of the surgical procedure. They are sealed systems and serve as an alternative to disposable and reusable sterilization wrap. The rigid sides of a sterilization container protect fragile devices within and eliminate the tears associated with sterilization wrap. Some containers are cleared for steam sterilization only, others for low-temperature sterilization. Only one is universal and corrosion resistant, cleared by the FDA for all current sterilization methods from steam to various low-temperature methods. Rigid container systems have been used in the United States for over three decades with the preference for sealed containers instead of wrapped sets increasing in recent years. The rigid sterilization container systems are intended to be used as packaging for medical devices before, during, and after sterilization. Sterilization is required to secure instrument sets, provide for sterilant penetration of contents, and withstand multiple handling events during a prolonged period of storage and handling.

GENERAL DESCRIPTION Containment devices for reusable medical device sterilization include perforated trays, case trays with a lid and base, and sealed container systems. Containers are most typically constructed from anodized aluminum and have a boxlike structure with removable lids, base, filter mechanism, and gasket to secure a tight seal. Sealed containers include tamper-proof locking mechanisms, a location for labeling set name and external indicator/load card, and handles for ease of transport. All sterilization containers have a filter mechanism designed to permit the sterilant to enter and exit as well as to act as a microbial barrier. Filters may be disposable and manufactured from cellulosic, polypropylene, or synthetic materials. Most sealed container systems are designed for terminal sterilization and extended storage, utilizing a disposable filter secured by a filter retention plate with a gasket. Some containers have a filter-less system equipped with a pressure-sensitive or thermostatic valve that opens and closes within the sterilizer. Such devices are cleared for prevacuum steam sterilization only, and a few may be used for sealed flash sterilization, including gravity displacement steam. All sealed container systems require an inner basket or tray to secure the contents of the load. The basket may contain accessories including instrument brackets, partitions, and posts to secure, organize, and protect contents. Some may include stackable trays to

*This chapter was written by Marcia Frieze, CEO of Case Medical Inc., South Hackensack, New Jersey.

24 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ separate contents into levels and protect contents from damage during transport. Peel pouches may not be used within sealed or wrapped container systems as they are not able to stand on their sides for sterilization. Small highly perforated trays or insert boxes to ensure adequate air removal are recommended in lieu of pouches. All perforated trays and case trays may either be wrapped with medical grade wrappers or placed within a sealed container cleared for the intended purpose. Although the wrapper must be both porous for sterilant penetration and intact, it must also be free of rips and tears. The perforated basket should be designed for decontamination, cleaning, and rinsing of contents by means of manual or automated methods.

2-1 SteriTite Container group with MediTray basket inserts. (Courtesy Case Medical Inc., South Hackensack, N.J.)

2-2 SteriTite Container. (Courtesy Case Medical Inc., South Hackensack, N.J.)

CHAPTER 2 Sterilization Container Systems 25 https://kat.cr/user/Blink99/ 2-3 Small, perforated metal case basket inserts.

2-4 SteriTite container with basket designed for Solera instrumentation. (Courtesy Case Medical Inc., South Hackensack, N.J., and Medtronic, Louisville, Colo.)

CARE AND HANDLING Rigid sterilization systems should be cleaned and inspected after each use. The disposable filter should be discarded and the components disassembled for cleaning, including removing the lid from the base and removing the filter retention plate and placing it in a perforated basket. According to AAMI ST79 guidelines, “For all reusable devices, the first and most important step in the decontamination of medical devices is thorough rinsing and cleaning. Cleaning primarily removes rather than kills microorganisms.”1 Valve-type closures must be decontaminated following the manufacturer’s written instructions. Particular attention should be given to the type of detergent used because alkaline cleaners and those followed by acid neutralizers can damage the passive layer of sealed systems, creating the oppor- tunity for corrosion to develop. Validated, pH-neutral cleaners including multienzymatic detergents can be used for both manual and automated cleaning of containment devices. If cleaned manually, a dry, lint-free cloth should be used to wipe off additional moisture. If placed in a cart washer for automated cleaning, ensure that all components are disassembled and placed at an angle to prevent water collection. A chemical disinfectant wipe

26 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ should never be used in lieu of a thorough cleaning and rinsing of the container after each use. Inspection procedures should include verification that gaskets are intact and latches are properly functioning. If the hardware is riveted to the container, such devices may become compromised over time as rivets loosen and create pathways for entry of microorganisms.

2-5 Case Solutions pH neutral cleaning products. (Courtesy Case Medical, Inc., South Hackensack, N.J.)

Aseptic presentation is important with all sterilization packaging systems. To properly remove the inner basket or tray from the container, the sides of the basket must not touch the edge of the container or else the contents will be considered contaminated. Neither the exterior of the container nor the outer wrapping of wrapped trays is sterile. Proper removal and handling at point of use is required. All containers sterilized in an outside contract facility should be double wrapped in plastic bags during transport. Furthermore, the contents of the container system must be dry. Wet packs are considered nonsterile. The contents of the containment device, if wet, must be reprocessed. The only exception to this is for flashed items that are properly cleaned, decontaminated, and sterilized for immediate use only. To manage wet packs, be sure that the contents are dry prior to sterilization. Preheat the load to reduce the formation of condensation during the cycle, evaluate the weight and density of the set, and review the manufacturer’s recommendations for processing, including proper cool-down prior to transport to sterile storage. Plastic containers may require additional drying time as they do not have the thermal conductivity properties of aluminum and other metals. Metal materials used to construct containment devices must be corrosion resistant or treated to improve their corrosion resistance. These materials must not affect the biocompatibility of the device.

STORAGE AND STERILITY MAINTENANCE Sterilized items should be stored in well-ventilated, limited-access areas with controlled temperature and humidity, separated from cleaned items. Sterilized items should not be stored near sinks or any water source from which they can become wet. Although sealed containers may be stacked on top of one another for storage and transport, wrapped pack- ages should not be stacked to avoid tears, crushing, bending, or cramming by other pack- ages. Perforated or wire shelving is commonly used for storage of containment systems to avoid dust accumulation. Wire shelving can contribute to torn wrappers when sterile pack- ages are removed from the shelf. The addition of pull out, perforated shelves can address the environmental as well as ergonomic concerns when removing heavy items from carts and shelving. The shelf life of containment devices may be determined by time or conditions during storage and handling. Event-related sterility maintenance means that if a package is not contaminated during storage and handling, it will remain sterile indefinitely. Shelf life is related to an event that can occur when sterilized items can be compromised or contaminated. Proper packaging, storage, handling, and environmental conditions can affect how

CHAPTER 2 Sterilization Container Systems 27 https://kat.cr/user/Blink99/ long a product will remain sterile. Most facilities have eliminated time dating with expiration dates and have gone to an event-related sterility maintenance program. Items packaged in a sealed container have a longer shelf life than wrapped items. Sealed containers are not as easily compromised by environmental or handling issues, nor is there an opportu- nity for tears in the wrapper.

INSTRUMENT PLACEMENT There are specific guidelines for the placement and organization of surgical instrumentation within sealed containers. Sealed containers must utilize inserts, such as perforated or mesh instrument baskets or trays to secure the contents. Some sealed container systems have been cleared for stacking of multiple levels of inserts to distribute the load. Selecting the correct size container is dependent on the length, height, and volume of the instrumentation within the set to be containerized. AAMI ST79 states, “If a rigid sterilization container is used, the basket(s) placed in the container system should be large enough to allow the metal mass of instruments and devices to be distributed equally in the basket(s). . . Instruments should be positioned to allow the sterilant to come into contact with all surfaces. All jointed instruments should be in the open or unlocked position.” Brackets, posts, partitions, and stringers may be used to secure instruments in place or in an open position. Another important guideline is placing heavy instruments below lighter, delicate instrumentation to avoid damage. The user must refer to the medical device manufacturer’s written instructions regarding set preparation and assembly. Weight and density of the set are integral components to consider during the configu- ration of the instrument set. If a set is too densely packed or heavy, sterilization efficacy, degree of dryness, and proper body mechanics may be adversely affected. ST79 recom- mends that, “The weight of the instrument set should be based on whether personnel can use proper body mechanics in carrying the set, on the design and density of individual instruments comprising the set, on the recommendations of the medical device manufacturer and on the distribution of mass in the set and sterilizer load.” In some cases where the set is too heavy and exceeds the AAMI and AORN recommended total weight of 25 lb, the set should be distributed in more than one sealed container. In other cases, a dense set can be stacked in multiple baskets within the sealed container for better organization and efficiency. The heavier sets should be placed below the delicate instrumentation. Sets should be organized to correlate with the procedure. Items used first should be placed on top or easily accessible.

2-6 Cranial tray with instrumentation. (Courtesy Case Medical Inc., South Hackensack,N.J.)

28 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ 2-7 Spinal tray with instrumentation. (Courtesy Case Medical Inc., South Hackensack, N.J.)

Graphics trays or loaners are offered for specialty sets, primarily for orthopedic procedures. Some containment devices that are designed for specific instrument sets may include graphics to locate and identify placement of devices within the tray system. The specific information may be silk screened, laser etched, or stamped into the tray base. Custom brackets or inserts included in the tray provide instrument protection and a specific location for a device to be placed. In the past, such graphic trays were designed to be wrapped, but recently a number of sets have been placed alternatively in rigid reusable, sealed containers. Some sealed containers meet the size requirements of the German Institute for Standardization (DIN) and have proven to provide seamless integration from wrap to containerization.

SELECTION AND SPECIAL CONSIDERATIONS When selecting a container system, it is important to identify the needs of the facility and to assess what the container system is capable of and for which sterilizers it is compatible. Not all container systems are compatible with low-temperature sterilization or with lumened devices. For example, a container cleared for steam sterilization may not be suitable for use in a different modality. If not provided in the labeling or instructions for use (IFUs), the user should consult the container system manufacturer for testing and validation confirma- tion of the container system for a specific sterilization method. There are numerous factors to consider when selecting a container system. Among these are options such as container size, estimated life of the container system, aseptic presentation of contents, protective accessories for tray customization, ease of use, maximum load, and cost effectiveness. It is important to review any special instructions for decontamination and handling. Although manufacturers are required to validate for efficacy and safety, verification of the packaging within the hospital system is recommended in the guidelines. When verifying containers at health care facilities, biological indicators and integrators (process indicators) must be placed within the containers in areas that will provide the greatest challenge. This may include areas such as the opposing corners of the instrument basket and the underside of the lid away from the perforated area (vent).

MANUFACTURERS’ INSTRUCTIONS FOR USE The written recommendations of the device manufacturer should always be followed. The device manufacturer is responsible for ensuring that the device can be effectively cleaned and sterilized. It is important that all rigid containers be completely disassembled, washed,

CHAPTER 2 Sterilization Container Systems 29 https://kat.cr/user/Blink99/ and dried after each use. Most sterilization container systems are manufactured from anodized aluminum alloy, which requires cleaning with a pH neutral detergent to maintain integrity. Thorough rinsing is essential for the removal of all soil and for removal of cleaning agents. A truly dry container and contents are critical for sterilization. Some low-temperature sterilization systems will abort if the container and its contents are not properly dried. Moisture within containers can create wet packs. An extended reprocessing time may be required when container systems are processed in gravity displacement steam. In addition, the materials of construction and the design of the containment device itself may increase either processing time or drying time. Internal chemical indicators or integrators should be placed in the corner of each inner basket for routine monitoring. Biological indicators should be utilized for verification of an instrument set and for weekly or daily monitoring of the load. In addition, an external indicator and tamper-evident seal, which serves as a security lock, should be assembled to the container prior to sterilization. Such indicators demonstrate that the set has been processed when a color change is confirmed. Containment devices must be placed flat on the sterilizer cart. If wrapped items are included in the sterilizer load, they must be placed on the shelf above the containment device to avoid moisture in the load. To minimize the potential for condensate formation within the sealed container system, a gradual cool down is required. The door of the sterilizer may be cracked after processing for a minimum of 10 to 15 minutes to facilitate a gradual cool down and reduce condensate formation. Wet packs are unac- ceptable for terminal sterilization and storage. Once removed from the sterilizer, the containers should be placed on a rack in a draft-free area until cool enough for handling and then placed in storage or transported to point of use. The only exception is when flash sterilization or immediate use sterilization is required in an emergency. Moisture will most likely occur when items are processed for immediate use without proper drying.

REGULATORY REQUIREMENTS All containment devices, whether sealed containers or wrapped trays, are considered Class II medical devices and must be cleared by the FDA for their intended use. According to the Association of periOperative Registered Nurses (AORN) recommended practices,2 “Pack- aging systems should be evaluated before purchase and use to ensure that items to be packaged can be sterilized by the specific sterilizers and/or sterilization methods to be used and should be compatible with the specific sterilization process for which it is designed.” AAMI ST773 provides guidelines for manufacturers of containment devices for reusable medical devices. Many international standards have been adopted into U.S. documents with the goal of providing minimal labeling, safety, performance, and validation requirements. Manufac- turers are required to validate their containment devices and provide the data to the FDA for clearance. Efficacy testing, material compatibility, sterility maintenance, reuse testing, and whole package microbial testing are examples of the various studies to be presented to the FDA and required before containment devices may be sold to health care facilities. However, health care personnel bear the ultimate responsibility for ensuring that the containment device or sterilization packaging is compatible with, or can be effectively sterilized within, the health care facility.

REFERENCES 1. ANSI/AAMI ST79: 2008/2010 & A12010: Comprehensive Guide to Steam Sterilization and Steril- ity Assurance in Health Care Facilities, Arlington, Va, 2010, Association for the Advancement of Medical Instrumentation. 2. AORN Recommended Practice for Selection and Use of Packaging Systems for Sterilization, Denver, Colo, 2010, AORN. 3. ANSI/AAMI ST77: 2006/2013: Containment Devices for Reusable Medical Device Serilization, Arlington, Va, 2013, Association for the Advancement of Medical Instrumentation.

30 UNIT 1 Instrument Preparation for Surgery https://kat.cr/user/Blink99/ UNIT TWO: GENERAL SURGERY CHAPTER 3

Operating Room Suite/Basic Laparotomy

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

3-1 Operating room equipment: 1, ring stand; 2, back table; 3, Mayo stand; 4, surgical step lifts; 5, sponge bucket; 6, sponge count bags; 7, garbage; 8, timeout briefing/ debriefing poster; 9, nurses’ station/ desk; 10, integration/video equipment (i.e., printer); 11, stop/start clock; 10 12, nitrogen regulator. 9 11 8 12 6 3

1 4 5

3-2 Basic back table setup.

CHAPTER 3 Operating Room Suite/Basic Laparotomy 31 https://kat.cr/user/Blink99/ 3-3 Two basic Mayo stand setups for starting a procedure. The same instruments and equipment are on the stands, just arranged differently. The arrangement is determined by the individual scrub personnel.

A laparotomy is an incision into the abdominal cavity for the purpose of exploration or the performance of an operative procedure on organs or structures within. To start the procedure, a dissection set is placed on the Mayo stand. Possible instruments needed include: 1. A Bard-Parker scalpel handle #4 with a #20 blade, used for the skin incision. 2. A Bard-Parker scalpel handle #3 with a #10 blade, used for the abdominal layers. 3. 2 Ferris Smith tissue forceps, used for grasping the abdominal layers. 4. A curved Mayo dissecting scissors, used for the dissection. 5. A straight Mayo dissecting scissors, used for cutting the suture. 6. 6 straight Crile hemostatic forceps, used for clamping the bleeders. 7. 6 curved Crile hemostatic forceps, used for clamping bleeders in the deeper abdomen. 8. 2 Army Navy retractors, used for retracting the abdominal layers. 9. 2 small Richardson retractors, used for retracting the abdominal layers. During the exploration, longer and heavier instruments may be needed. Add the following instruments to the Mayo stand: 1. A Bard-Parker scalpel handle #7 with a #10 blade, used for the deeper dissection. 2. A Bard-Parker scalpel handle long #3 with a #10 blade, used for the deeper dissection. 3. A Mayo-Péan hemostatic forceps, used for clamping the deeper bleeders. 4. A Babcock clamp tissue forceps, used for “running the bowel” and retracting structures without injury to tissue. 5. A tonsil hemostatic forceps, used for clamping the deeper bleeders. If heavy graspers are needed, add the following instruments: Kocher clamps, regular and long, used for grasping structures that may be removed; Ochsner hemostatic forceps; and Allis tissue forceps, regular and long. For deeper retraction, add the following instruments: a large Richardson retractor; medium and wide Deaver retractors; Ochsner malleable retractors (ribbons); and a self- retaining retractor such as a Balfour, O’Sullivan-O’Connor, Harrington, or Thompson. After the exploration has been completed, remove the instruments from the sterile field, and bring up the following incision-closing instruments: 1. 4 curved Crile hemostatic forceps, used to grasp the peritoneum. 2. An Army Navy retractor, used to retract the abdominal layers. 3. A Ferris Smith tissue forceps, used to hold the layer being closed. 4. A 7-inch Mayo needle holder with suture and needle, used for suturing the tissue. 5. Straight Mayo dissecting scissors, used for cutting suture. To close the skin, possible instruments include Adson tissue forceps with teeth used to grasp the tissue and a skin stapler.

32 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 3-4 Left to right: 2 Mayo-Hegar needle holders, 7 inch; 2 Ayers needle holders, 8 inch; 3 Foerster sponge forceps; 2 Mixter hemostatic forceps, long, fine-point; 2 Babcock clamp tissue forceps, long; 2 Allis tissue forceps, long; 6 Ochsner hemostatic forceps, long, straight; 4 Mayo-Péan hemostatic forceps, long, curved; 6 tonsil hemostatic forceps; 2 Westphal hemostatic forceps; 4 Babcock clamp tissue forceps, short; 4 Allis tissue forceps, short; 8 Crile hemostatic forceps, curved, 6½ inch; 1 Halsted mosquito hemostatic forceps, straight; 6 paper drape clips.

3-5 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #7; 1 Bard-Parker knife handle #3, long; 1 Mayo dissecting scissors, curved; 2 Mayo dissecting scissors, straight; 1 Metzenbaum dissecting scissors, 7 inch; 1 Snowden-Pencer dissecting scissors, curved; 1 Snowden-Pencer dissecting scissors, straight.

CHAPTER 3 Operating Room Suite/Basic Laparotomy 33 https://kat.cr/user/Blink99/ 3-6 Left to right: 2 Adson tissue for ceps with teeth (1 × 2 teeth); 2 Ferris Smith tissue forceps; 2 Russian tissue forceps, medium; 2 DeBakey vascular atraugrip tissue forceps, medium; 2 DeBakey vascular atraugrip tissue forceps, long; 2 Russian tissue forceps, long.

3-7 Left to right: 2 Goelet retractors; 2 Army Navy retractors; 1 Richard- son retractor, medium; 1 Richardson retractor, large; 1 Yankauer suction tube and tip; 1 Poole abdominal shield and suction tube.

34 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 3-8 Left to right: Deaver retractors, small, medium, and large; Ochsner malleable retractors, narrow, medium, and wide.

AB CD

A B C D

3-9 Left to right: A, Adson tissue forceps and tip; B, Ferris Smith tissue forceps and tip; C, Russian tissue forceps and tip; D, DeBakey vascular atraugrip tissue forceps and tip.

CHAPTER 3 Operating Room Suite/Basic Laparotomy 35 https://kat.cr/user/Blink99/ 3-10 Left to right: A, Paper drape clip and tip; B, Halsted mosquito hemostat- ABC ic forceps, straight, and tip; C, Halsted hemostatic forceps and tip.

A B C

3-11 Left to right: A, Crile hemostatic forceps and tip; B, Allis tissue forceps A B C and tip; C, Babcock clamp tissue forceps and tip.

A B C

36 UNIT 2 General Surgery https://kat.cr/user/Blink99/ A B C

A B C D

3-12 Left to right: A, Tonsil hemostatic forceps and tip; B, Westphal hemostatic forceps and tip; C, Mayo-Péan hemostatic forceps, curved, and tip; D, Mixter hemostatic forceps, fine-point tip.

CHAPTER 3 Operating Room Suite/Basic Laparotomy 37 https://kat.cr/user/Blink99/ 3-13 Left to right: A, Ochsner hemostatic forceps and tip; A B C B, Foerster sponge forceps and tip; C, Mayo-Hegar needle holder and tip.

A B C

3-14 Basic Mayo stand setup for closing the skin. After the sponge count is completed and correct, have a few instruments, sponges, suture and needles, or skin stapler available to complete the skin closure.

38 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 4

Abdominal Self-Retaining Retractors

Abdominal self-retaining retractors are retractors that do not require a person to hold Additional images are available at: them in the proper position. Once the surgeon places the retractor and sets the racket, evolve.elsevier.com/Tighe/instrumentation nut, or universal joint, the retractor stays open until released.

4-1 Top to bottom: Bookwalter retractor table post; Bookwalter retractor horizontal bar; Bookwalter retractor horizontal flex bar.

4-2 Top to bottom: Bookwalter retractor oval ring, medium; Bookwalter retractor: Balfour blades, second blade, side view.

CHAPTER 4 Abdominal Self-Retaining Retractors 39 https://kat.cr/user/Blink99/ 4-3 Top to bottom: Bookwalter retractor: segmented parts (2 segmented half-circles, medium; 2 segmented straight extensions) placed together with 4 locking screws; 1 vertical extension bar; 1 Kelly retractor blade with ratchet mechanism attached; 2 post couplings.

4-4 Left to right: 1 Harrington retractor blade; 1 Kelly retractor blade (2 × 6 inch); 1 Kelly retractor blade (2 × 4 inch); 1 Kelly retractor blade (2 × 3 inch); 2 Kelly retractor blades (2 × 2½ inch); 6 ratchet mechanisms; 2 malleable retractor blades (2 × 6 inch); 2 malleable retractor blades (3 × 6 inch).

40 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 4-5 O’Sullivan-O’Connor retractor with 3 blades.

4-6 Top to bottom, left to right: Balfour abdominal retractor: retractor frame with 2 detachable shallow fenestrated blades; 1 shallow center blade; 2 deep fenestrated blades; 1 deep center blade.

CHAPTER 4 Abdominal Self-Retaining Retractors 41 https://kat.cr/user/Blink99/ 4-7 Top to bottom, left to right: Upper hand retractor: 2 Balfour abdominal blades, deep and shallow; 1 Deaver blade, side view; 1 Weinberg blade (modified Joe’s Hoe); 1 malleable blade.

4-8 Thompson bariatric posts and bars.

42 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 4-9 Thompson bariatric retractor blades and clamps.

4-10 Left to right: Thompson retractor rotatable blades: 1 Deaver, medium, side view; 1 Harrington, side view; 1 Deaver, medium (2½ × 5 inch), side view; 1 Deaver, large, front view.

4-11 Left to right: Thompson retractor rotatable blades: 1 finger malleable; 2 Balfour, side view and back view; 1 rake Murphy, sharp, 3 prong; 1 Balfour-Mayo center (2¾ × 5 inch), side view.

CHAPTER 4 Abdominal Self-Retaining Retractors 43 https://kat.cr/user/Blink99/ 4-12 Left to right: Thompson retractor rotatable blades: 1 Weinberg (3¼ × 5¼ inch), side view; 1 Richardson (2 × 5 inch), side view; 1 Kelly (2½ × 3 inch), side view; 1 Kelly (2 × 2½ inch), front view; 2 Richardson carotid (1 × ¼ inch and ¾ × 1 inch), side view.

4-13 Top to bottom, left to right: Thompson retractor joints: 1 extension arm, angular, 12 inch; 1 wrench, universal; 1 adapter blade, universal; 2 universal (½ × ¼ inch); 2 universal split (½ × ¼ inch); 2 universal (½ × ½ inch); 2 universal (½ × ½ inch), large.

44 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 5

Small Laparotomy Set

A smaller number of instruments may be used for less involved procedures, such as an Additional images are available at: appendectomy or an inguinal herniorrhaphy. An appendectomy is the removal of the ver- evolve.elsevier.com/Tighe/instrumentation miform appendix of the bowel. An inguinal herniorrhaphy is the repair of an outpouching through an abnormal opening in the abdominal muscle wall in the lower right or left quad- rant of the abdomen. These procedures may also be done through a laparoscope. A brief description of the instruments follows: 1. Adson tissue forceps without teeth, used for the handling of delicate tissue. 2. Adson tissue forceps with teeth, used for grasping the skin edges. 3. Halsted mosquito hemostatic forceps, used for clamping the bleeders. 4. Babcock clamp tissue forceps, used for handling the appendix or hernia sac. 5. Short Allis forceps, used for grasping the tissue when closing the incision. 6. Weitlaner self-retaining retractor, used for the retraction of the abdominal layers. 7. Farr spring retractors, used for retracting the skin edges.

5-1 Top, left to right: 1 Brown-Adson tissue forceps (9 × 9 teeth); 2 Adson tissue forceps with teeth (1 × 2). Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Cushing forceps with teeth (1 × 2); 1 Ferris Smith tissue forceps (1 × 2); 2 DeBakey vascular atraugrip tissue forceps, medium; 4 paper drape clips; 6 Halsted mosquito hemostatic forceps, curved; 1 Halsted mosquito hemostatic forceps, straight; 8 Crile hemostatic forceps, curved, 5½ inch; 1 Halsted hemostatic forceps, straight; 6 Crile hemostatic forceps, curved,6½ inch; 4 Allis tissue forceps, short; 4 Babcock clamp tissue forceps, short; 4 Ochsner hemostatic forceps, short; 1 Westphal hemostatic forceps; 2 tonsil hemostatic forceps; 1 Foerster sponge forceps; 2 Mayo-Hegar needle holders, 6 inch; 1 Crile-Wood needle holder, 6 inch.

CHAPTER 5 Small Laparotomy Set 45 https://kat.cr/user/Blink99/ 5-2 Top pairs, left to right: 2 Army Navy retractors, front view and side view; 2 Miller-Senn retractors, side view and front view. Bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum dissecting scissors, 7 inch; 1 Metzenbaum dissecting scissors, 5 inch; 2 Goelet retractors, front view and side view; 2 Richardson retractors, small, side view and front view.

5-3 Left, top to bottom: 1 Metal medicine cup; 1 weitlaner retractor, medium. Right, top to bottom: 1 Yankauer suction tube with tip; 1 Poole abdominal suction tube with shield; 1 Ochsner malleable retractor, medium; 1 Ochsner malleable retractor, narrow; 1 Deaver retractor, medium.

46 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 6

Minor Laparoscopic Set

A minor laparoscopic set is used for the placement of the trocars and a laparoscope in Additional images are available at: preparation for the examination of the abdominal cavity. evolve.elsevier.com/Tighe/instrumentation

6-1 Left to right: 4 Crile hemostatic forceps, 6½ inch; 2 Péan artery clamps, 7¼ inch; 1 Péan artery clamp, 8 inch; 2 Allis clamps, 5 × 6 teeth, 6 inch; 2 Kocher clamps, 1 × 2 teeth, 6½ inch; 1 right angle Gemini, fine curved, 8 inch; 1 Randall kidney stone forceps, quarter curved; 1 Schroeder Braun 1 uterine tenaculum, 9 ⁄2 inch; 1 Foerster sponge stick, straight; 1 Mayo-Hegar needle holder, 8 inch; 1 Crile-Wood needle holder, 6¼ inch; 2 needle 1 holders, 5 ⁄2 inch; 1 Baumgartner serrated tungsten carbide needle holder, 5 inch; 2 Backhaus towel forceps.

CHAPTER 6 Minor Laparoscopic Set 47 https://kat.cr/user/Blink99/ 6-2 Top to bottom, left to right: 1 Knife handle, #3; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum scissors, curved, 7 inch; 2 Adson tissue forceps, 1 × 2 teeth, 4¾ inch; 1 tissue forceps, 1 × 2 teeth, 6¾ inch; 1 Bonney tissue forceps, 1 × 2 teeth, 6¾ inch; 1 DeBakey-Diethrich coronary artery tissue forceps, 6 inch; 1 Russian tissue forceps, 6 inch; 2 Senn retractors, sharp, 6¾ inch; 2 Army Navy retractors, double-ended; 2 Richardson retractors, 9½ inch. Bottom, left to right: 1 Suture passer pistol grip; 1 blue clip; 1 fascia closure inlet trumpet.

48 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 7

Laparoscopy

Laparoscopy is visualization within the abdominal cavity. The structures have to be moved Additional images are available at: away from the abdominal wall so the scope can be inserted safely. Pneumoperitoneum is evolve.elsevier.com/Tighe/instrumentation accomplished by insufflation of carbon dioxide. Laparoscopes, like arthroscopes, cystoscopes, hysteroscopes, nephroscopes, sigmoido- scopes, sinuscopes, thoracoscopes, and urethroscopes, are types of endoscopes. Endoscopy is the introduction of a small tube to visualize inside a body cavity or structure. The tube (endoscope) has a lens and a light source for vision. The lens angle determines the area that will be seen inside the patient. The most common lens angles are 0 degrees, 30 degrees, and 70 degrees. Many of the endoscopic instruments can be used interchangeably within the various endoscopic specialties. Interchangeable terms include obturator/trocar and cannula/port or sleeve. The addition of instruments, either through attachments to the scope or through another port into the cavity or structure, allows the surgeon to perform operative procedures. The light source is usually a fiber optic cable, or cold light, that prevents injury to internal structures. Minimally invasive surgery (MIS) incorporates all the fields of endoscopic surgery (orthopedic; genitourinary; gynecological; and ear, nose, and throat) using small incisions or no incisions, such as when using an endoscope rather than using traditional open methods. The advantages of MIS include: (1) decreased size of the incision sites, (2) decreased postoperative pain, (3) decreased recovery period, and (4) quicker return to work and fam- ily. Almost all surgical specialties now perform MIS procedures on most anatomical areas. In laparoscopy, the Mayo stand is set up to include a Bard-Parker scalpel handle #3 with a #11 blade; 2 Backhaus towel forceps; a Verres needle for insufflation; insufflation tubing; trocars with sleeves; a laparoscope; and a fiber optic light cable. A brief description of the laparoscopic procedure follows: 1. The abdominal wall is elevated with 2 Backhaus towel clips. 2. A stab wound is made near the umbilicus with a Bard-Parker scalpel. 3. The Verres needle is inserted at a 45-degree angle. 4. The insufflation tubing is attached to the needle and the CO2 is insufflated to create the pneumoperitoneum. At 12 to 15 mm Hg pressure, the needle is removed. 5. A trocar with sleeve is introduced. 6. The trocar is removed and the laparoscope is inserted. 7. The fiber optic cable is attached.

CHAPTER 7 Laparoscopy 49 https://kat.cr/user/Blink99/ 7-1 Top to bottom: Nondisposable laparoscopic lens: 0-degree, 5 mm; 25-degree, 5 mm; 50-degree, 5 mm; 25-degree, 10 mm; 50-degree, 10 mm.

7-2 Left to right: Camera and light cord.

50 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 7-3 Olympus EndoEye rigid 5-mm 0-degree laparoscope.

7-4 Olympus EndoEye flexible 3D HD 10-mm laparoscope.

CHAPTER 7 Laparoscopy 51 https://kat.cr/user/Blink99/ 7-5 Kronner laparoscopic scope holder.

7-6 Left to right: 1 Port and 1 trocar, 5 mm × 100 mm, separated, then together; port and trocar together and then separated, 11 mm × 100 mm; 1 12 mm Hasson trocar, 12 mm. 5 mm × 100 mm Hasson 11 mm × 100 mm trocar 11 mm × 100 mm

52 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 7-7 Left to right: 1 Verres needle, disposable; 3 dilating-tipped trocars, disposable, 5 mm, 10/11 mm, and 12 mm; 1 optical trocar, disposable, 10 mm; 1 blunt-tipped trocar (Hasson type), disposable, 10 mm.

7-8 Left to right: Insufflation tubing and insufflation tubing with battery- operated suction/irrigator system.

CHAPTER 7 Laparoscopy 53 https://kat.cr/user/Blink99/ CHAPTER 8

Laparoscopic Adult MIS Set

Additional images are available at: A minimally invasive laparoscopic instrument set is used for the placement of trocars, laparoscope, and camera. Laparoscopic instruments are used to examine the abdominal evolve.elsevier.com/Tighe/instrumentation cavity to diagnose, remove, or repair structures with small multiple incisions. Examples of laparoscopic procedures include bowel resections, cholecystectomies, and hernia repairs.

8-1 Left to right: Nondisposable cautery cord; instrument pan with 1 applied obturator 5 mm ×100 mm; 3 applied cannulas, 5 mm; 1 Verres needle stylet; 1 Verres needle, medium; 1 Nezhat dorsal plug; 1 applied obturator 10 mm × 100 mm; 3 applied cannulas, 10 mm. Bottom, in pan: 2 Red port caps; 5 gray port caps; 1 red cap with pinhole; 1 gray cap with 3-mm hole; 1 male Luer-Lok adapter.

54 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 8-2 Top, left to right: 5 Gray port caps; 1 male Luer-Lok adapter. Bottom, left to right: 1 Gray rubber cap with 3-mm hole; 2 red port caps; 1 red rubber cap with pinhole.

8-3 Top to bottom, left to right: 1 Double-action fenestrated grasper with handle, closed; 1 double-action aggressive grasper with handle, open; 1 single-site surgery triport sleeve; 1 guide to introduce triport into abdomen; 1 active cord.

CHAPTER 8 Laparoscopic Adult MIS Set 55 https://kat.cr/user/Blink99/ 8-4 First rack with laparoscopic instruments that fit inside a sterilization container.

F G

A B C D E F G H

8-5 Top to bottom: A, Nezhat-Dorsey L-shaped cautery with sheath below, tip (note A below has protective cover); B, needle-tip suction, tip; C, spatula cautery, tip; D, spatula suction, tip; E, L-hook cautery, tip; F, Marlow knot pusher, tip; G, Ranfac knot pusher, tip; H, 10-mm and 5-mm Nezhat-Dorsey suction, tips. (Tips shown below are enlarged.)

56 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 8-6 1 Disposable ligating and dividing clip applier.

8-7 Top to bottom: 1 Maryland bipolar dissector with handle; 1 Mini-Metzen- baum scissors with handle; 1 active cord; 1 J-hook cautery electrode; 1 Endoweave grasper with handle; 1 fenestrated single action grasper with handle; 1 Wave grasper with handle.

CHAPTER 8 Laparoscopic Adult MIS Set 57 https://kat.cr/user/Blink99/ 8-8 Second rack with laparoscopic instruments that fit inside a sterilization container.

8-9 Tips of most of the instruments in A B C D E the above rack: A, 10-mm Cup forceps; B, 5-mm grasper with teeth; C, 10-mm grasper with teeth; D, Olsen clamp; E, double-action grasper; F, Hook scissors; G, 5-mm Apple needle holder with left curve; H, 5-mm Babcock clamp grasping forceps; I, monopolar scissors, 5 mm × 32 mm; J, Maryland bipolar dissector.

F G H I J

58 UNIT 2 General Surgery https://kat.cr/user/Blink99/ ANESTHESIA CAMERA HOLDER OPTIONAL ASSISTANT ASSISTANT

VIDEO __10 __5 SURGEON (alternate2 position)* __5 TABLE BACK SCRUB

VIDEO

2 VIDEO1

Can be variable if staples = 12 mm.

* Change per physician preference 8-10 Position for laparoscopic appendectomy and herniorrhaphy.

CHAPTER 8 Laparoscopic Adult MIS Set 59 https://kat.cr/user/Blink99/ CHAPTER 9

Laser Laparoscope

Additional images are available at: Laser laparoscope is using a laser beam as a precision tool for cutting, coagulating, vapor- izing, and welding tissue during the surgical intervention. It is very important that basic evolve.elsevier.com/Tighe/instrumentation education on the written laser policies and procedures for all personnel in the surgical environment are mandatory within the health care facility. Policy and procedure topics should include the following: eye protection, controlled access, fire safety, smoke (plume) evacuation, documentation, laser team responsibilities, skin tissue protection, electrical safety, education/training, and credentialing.

9-1 Top to bottom: 1 Suction tip; 1 medicine cup, metal. Bottom: 1 Bard-Parker knife handle #3; 1 Adson tissue forceps with teeth (1 × 2); 2 Allis tissue forceps; 1 Crile- Wood needle holder, 7 inch; 1 Mayo dissecting scissors, straight; 2 Crile hemostatic forceps, curved; 2 Kocher clamps; 1 Backhaus towel clip; 2 paper drape clips; 2 Senn retractors; 1 News tracheal hook.

9-2 Top to bottom: Laser laparoscope; 3 disposable ports, 2 with adapter on side. Bottom: 1 Applied cannula, 10 mm; disposable trocar; 1 applied cannula, 5 mm; 1 obturator, 5 mm; 1 applied cannula, 5 mm; 1 Verres needle stylet.

60 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 10

Laparoscopic Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder by means of a laparoscope or an Additional images are available at: abdominal incision. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a minor laparoscopic set, a laparoscope set, and an adult minimally invasive surgery set. A brief description of the procedure through a laparoscope, after the abdomen has been insufflated, follows: 1. 3 or 4 trocars with sheaths are needed. There is one port for the laparoscope with camera attached; one port for the retraction instruments; one port for dissection; and one port for ligation. 2. Claw forceps are used to stabilize the gallbladder. 3. An Olsen clamp is used to stabilize the cystic duct during cholangiograms. 4. Metzenbaum scissors are used for dissection. 5. Ligaclip appliers are used for hemostasis. 6. An Apple needle holder is used for suture ligation. 7. A Marlow knot pusher is used for suture tightening. 8. Ligature scissors are used for cutting suture. 9. An Endo catch retriever is used for removing the specimen. If electrosurgery is to be used, the equipment needed for the procedure includes: 1. A spatula electrode, used for hemostasis. 2. A monopolar Metzenbaum scissors, used for dissection. 3. A Maryland bipolar dissector, used for soft tissue dissection and to remove the specimen.

10-1 A, Endo catch retriever with the A tip closed; B, Endo catch retriever with the tip expanded.

CHAPTER 10 Laparoscopic Cholecystectomy 61 https://kat.cr/user/Blink99/ 10-2 Position for laparoscopic cholecystectomy. ANESTHESIA VIDEO 2 VIDEO2* ELECTRO- CAUTERY SURGEON __

5 5 ASSISTANT 5

__10 CAMERA HOLDER SCRUB

BACK TABLE

LASER OR ELECTROCAUTERY USED

*Video position change per physician preference

62 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 11

Laparoscopic Bowel Resection

A bowel resection is the excision of a portion of the small or large intestine and the reanas- Additional images are available at: tomosis of it through a laparoscope or through an abdominal incision. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a minor laparoscopic set, laparoscope, laparoscopic camera, fiber optic light cord, and trocars. A brief description of the procedure through a laparoscope, after the abdomen is insufflated, follows: 1. An Endoflex retractor is used for visualization. 2. A Hunter (Glassman) bowel grasper is used for handling the bowel. 3. A Maryland bipolar dissector is used for freeing up the bowel. 4. A Nezhat suction/irrigator is used for lubrication and removal of fluid. 5. A linear stapling device is used for transecting the bowel. 6. A Ligaclip applier is used for hemostasis. 7. A needlepoint suture passer is used in suturing. 8. A Marlow knot pusher is used for suture tightening. 9. A linear stapling device is used for reanastomosis of the bowel.

11-1 Applied Medical Alexis protractor 5 to 9 cm.

11-2 Top to bottom: 1 Endoflex protective cover; 1 Endoflex retractor, triangle, 5 mm, 80-mm length; 1 biopsy forceps, 5 mm, and tip.

CHAPTER 11 Laparoscopic Bowel Resection 63 https://kat.cr/user/Blink99/ 11-3 FastClamp with Endoflex snake retractor. Top to bottom: 1 Table bar; 1 table attachment; 1 Endoflex snake retractor (in coiled position); 1 supporting arm (attached to snake retractor).

11-4 Top to bottom: 1 EEA anvil grasper and 1 esophageal retractor.

11-5 Top to bottom: These are extra long instruments; 1 Hunter (Glassman) bowel grasper, 5 mm, 45-cm length; 1 Nezhat suction/irrigator, 5 mm, 45-cm length; 1 Maryland bipolar dissector, monopolar, 5 mm, 45-cm length.

64 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 11-6 Left to right: Tips: A, Hunter AB C (Glassman) bowel grasper, 5 mm, 45-cm length; B, Nezhat suction/irrigator, 5 mm, 45-cm length; C, Maryland bipolar dissector, 5 mm, 45-cm length.

11-7 1 Laparoscopic ligating and dividing disposable clip applier.

11-8 1 Linear cutter with reloadable head.

11-9 A, 1 Ethicon SecureStrap A laparoscopic tacker. B, SecureStrap tack.

CHAPTER 11 Laparoscopic Bowel Resection 65 https://kat.cr/user/Blink99/ 11-10 A, Ethicon Echelon Flex A 60 Endo GIA power stapler. B, Endo GIA power stapler tip.

11-11 Top to bottom: 1 Contour curved cutter; 1 proximate linear stapler, 60 mm; 1 proximate linear stapler, 90 mm.

66 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 11-12 1 Ethicon endoscopic curved intraluminal stapler ECS33.

11-13 Top to bottom: 1 Covidien Endoscopic 60 Endo GIA tri-stapler, power and 1 radial attachment.

11-14 Endo GIA stapler with universal handle and tip with staples.

CHAPTER 11 Laparoscopic Bowel Resection 67 https://kat.cr/user/Blink99/ 11-15 A, Top to bottom: 1 Ethicon AB Laparoscopic Enseal, 5 mm 35 cm; 1 Ethicon Laparoscopic Harmonic scalpel, 5 mm 23 cm. B, Enlarged tip: Ethicon Laparoscopic Enseal, 5 mm.

11-16 A, Top to bottom: 1 Covidien AB Sonicision cordless ultrasonic dissection, 5 mm, 39 cm with tightening key. B, Enlarged tip: Covidien Sonicision cordless ultrasonic dissection.

11-17 Position for laparoscopic ANESTHESIA bowel resection. ASSISTANT HOLDER CAMERA

__5__5 __5 __10 SURGEON

5, 10, or 12 mm VARIABLE; DEPENDS SCRUB ON SURGERY

VIDEO

1 VIDEO2*

BACK TABLE

* Video position change per physician preference

REVERSE FOR RIGHT SIDE PATIENT IN LOW ALLEN STIRRUPS

68 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 12

Bowel Resection

Possible equipment needed for a bowel resection includes a basic laparotomy set and a Additional images are available at: self-retaining retractor. evolve.elsevier.com/Tighe/instrumentation A brief description of the procedure, doing the surgery through an abdominal incision, includes: 1. A self-retaining retractor is used for visualization after the abdomen is opened. 2. A Doyen intestinal forceps is used for atraumatic bowel clamping. 3. A Carmalt hemostatic forceps is used for hemostasis and blunt dissection. 4. A long Babcock clamp tissue forceps is used for handling the bowel. 5. An Ethicon linear cutter is used for dissection of the bowel. 6. An Ethicon linear stapler is used for reanastomosis of the bowel. Resection of the sigmoid colon may need a special stapling device (EEA) that also cuts the tissue.

12-1 Left to right: 2 DeBakey vascular atraugrip tissue forceps, short; 2 Doyen intestinal forceps, straight; 2 Doyen intestinal forceps, curved; 12 Halsted mosquito hemostatic forceps, curved; 4 Carmalt hemostatic forceps, long, curved; 6 Carmalt hemostatic forceps, long, straight.

CHAPTER 12 Bowel Resection 69 https://kat.cr/user/Blink99/ 12-2 Left to right: Tips: A, Doyen A B intestinal forceps, straight and curved; B, Carmalt hemostatic forceps, long, curved, and straight.

12-3 Top to bottom: 1 Ethicon stapler PPH (utilized for prolapse rectal hemorrhoid tissue) and attachment; 1 Covidien purse string, disposable.

70 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 13

Sigmoidoscopy

A sigmoidoscopy is the visualization within the sigmoid and descending colon with the aid Additional images are available at: of a scope and a light source. Also used is a laparoscopic sigmoid colectomy to check the evolve.elsevier.com/Tighe/instrumentation anastomosis after stapling. A brief description of the procedure follows: 1. The scope is inserted with the obturator in place. 2. The obturator is removed. 3. The air hose and bulb are attached to the scope. 4. The colon is inflated. 5. The light source is attached to the scope.

13-1 Welch Allyn operative sigmoidoscope. Left to right: 1 Fiber optic cord; 1 light handle; 1 obturator; 1 disposable sigmoidoscope; 1 colonic insufflator.

CHAPTER 13 Sigmoidoscopy 71 https://kat.cr/user/Blink99/ CHAPTER 14

Laparoscopic Bariatric Surgery

Additional images are available at: Bariatrics is the field of medicine that deals with obesity and weight-related conditions. Laparoscopic surgery decreases the surgical incision on individuals that may be obese and evolve.elsevier.com/Tighe/instrumentation have impaired healing. Bariatric instruments are the same as basic laparoscopic instruments except they are longer and may be wider to accommodate a patient’s larger size. Possible equipment needed for laparoscopic bariatric surgery includes laparoscopic instrumentation, trocars, and obturators that are longer in length. A brief description of the procedure follows: 1. The laparoscope is inserted in the usual manner. 2. The Nathanson retractor is positioned to retract the liver. 3. Depending on the scheduled surgery, various types of instrumentation may be used. 4. To assist closure, a fascia closure device may be used.

14-1 Left to right: 1 Bard-Parker knife handle #3; 2 Adson tissue forceps with teeth (1 × 2); 2 thumb tissue forceps without teeth, short; 1 Mayo dissecting scissors, curved; 1 Metzenbaum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, straight; 2 Mayo- Péan hemostatic forceps, curved; 2 Kocher clamps; 1 Crile-Wood needle holder, 7 inch; 1 Crile-Wood needle holder, 5 inch; 6 Crile hemostatic forceps, curved, 6½ inch; 4 Backhaus towel clips; 8 paper drape clips; 3 noninsulated rotating handles.

72 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 14-2 Two baby Deaver retractors.

14-3 Left to right: 2 Sets of trocars and obturators, 1 set 5 mm × 100 mm (standard), 1 set 5 mm × 150 mm (bariatric); 2 sets of trocars and obturators, 1 set 11 mm × 150 mm (bariatric), 1 set 12 mm × 150 mm (bariatric); 1 set Hasson trocar and obturator, 12 mm.

CHAPTER 14 Laparoscopic Bariatric Surgery 73 https://kat.cr/user/Blink99/ 14-4 Left to right: Disposable high- flow insufflation tube and InsuFlow heater hydrator insufflation tubing.

14-5 Top to bottom: 1 Bariatric telescope, 10 mm, 30 degrees; 3 telescopes, 45, 30, and 0 degrees; 1 telescope, 5 mm, 30 degrees.

74 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 14-6 Nathanson retractor with laparoscopic Thompson retractor holder.

14-7 Top: 2 Apple needle holders with locks, 5 mm, right and left curves. Bottom, left to right: 1 Inlet fascia closure device; 1 cone, long; 2 medicine cups, metal, side view and top view; 1 Nathanson liver retractor.

CHAPTER 14 Laparoscopic Bariatric Surgery 75 https://kat.cr/user/Blink99/ 14-8 A, Top to bottom: 1 Harmonic A scalpel 5 mm, 23 cm; 1 Harmonic cord and 1 tightening key. B, Enlarged tip: Harmonic scalpel 5 mm with curved shears.

14-9 Rack with laparoscopic instruments that fits inside a sterilization container.

76 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 14-10 Top to bottom: 1 Switchblade scissors, bariatric; 1 switchblade scissors, regular; 1 bariatric spatula; 1 Nezhat-Dorsey irrigator.

14-11 Top and bottom instruments work together: bottom: fenestrated bowel grasper that slides inside the noninsulated sheath at the top; both connect to the noninsulated metal handle; middle: DeBakey tissue forceps, 10 mm, curved.

14-12 Three Hunter (Glassman) bowel graspers.

CHAPTER 14 Laparoscopic Bariatric Surgery 77 https://kat.cr/user/Blink99/ 14-13 Tips of Hunter (Glassman) bowel AB grasper, 5 mm: A, Closed; B, open.

14-14 A, 3 Apple needle holders, 2 A left curved, 1 right curved. B, 5-mm Apple needle holder with left curve.

78 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 15

The da Vinci ® Surgical System and EndoWrist ® Instruments (Robotic Instruments)

EndoWrist instruments are manufactured by Intuitive Surgical, Inc. specifically for use with Additional images are available at: the da Vinci Surgical System. The EndoWrist instruments provide surgeons with natural evolve.elsevier.com/Tighe/instrumentation dexterity and a full range of motion for more precise operation through tiny incisions. Simi- lar to the human wrist, an EndoWrist instrument allows for rapid and precise suturing, dissection, and tissue manipulation. The EndoWrist instrument line features a variety of specialized tip designs, including forceps, needle drivers, and scissors; monopolar and bipolar electrocautery instruments; scalpels, and more. TheEndoWrist instruments are available in 5-mm and 8-mm diameters to meet surgeons’ requirements. After anEndoWrist instrument is installed on the da Vinci System, the interface is designed to recognize the type and function of the instrument and to display the number of uses available. This interface allows the da Vinci System to detect when an instrument needs replacement. Because of the delicate nature of these instruments, all handling, cleaning, and sterilization must be performed in strict accordance with the manufacturer’s guidelines. Intuitive Surgical, Inc. has training courses available to assist with education.

15-1 Snap-fit scalpel instruments, AB shown with Snap-fit: A, 15-Degree blue blade; B, paddle blade. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-2 Scissors: A, Potts scissors; A B C B, round tip scissors; C, curved scissors. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

CHAPTER 15 The da Vinci ® Surgical System and EndoWrist ® Instruments (Robotic Instruments) 79 https://kat.cr/user/Blink99/ A B C D

EFGH

IJK L

15-3 Forceps/graspers: A, DeBakey forceps; B, Cadiere forceps; C, Resano forceps; D, double-fenestrated grasper; E, Cobra grasper; F, long tip forceps; G, ProGrasp forceps; H, tenaculum forceps; I, thoracic grasper; J, fine tissue forceps; K, Graptor (grasping retractor); L, black diamond microforceps. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-4 EndoWrist monopolar cautery A B C instruments: A, Hot Shears, also called monopolar curved scissors; B, permanent cautery hook; C, permanent cautery spatula. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

80 UNIT 2 General Surgery https://kat.cr/user/Blink99/ A B C 15-5 EndoWrist bipolar instruments: A, PreCise bipolar forceps; B, Mary- land bipolar forceps; C, fenestrated bipolar forceps; D, PK® dissecting forceps; E, microbipolar forceps. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-6 Harmonic® curved shears. (Courtesy of Intuitive Surgical, Inc., Sunnyvale, Calif.)

A B 15-7 EndoWrist needle drivers: A, Large needle driver; B, large SutureCut needle driver; C, Mega needle driver; D, Mega SutureCut needle driver. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

CHAPTER 15 The da Vinci ® Surgical System and EndoWrist ® Instruments (Robotic Instruments) 81 https://kat.cr/user/Blink99/ 15-8 Specialty instruments: A, Atrial ABC retractor; B, atrial retractor short right; C, dual blade retractor; D, EndoPass delivery instrument; E, cardiac probe grasper; F, valve hook; G, pericardial dissector. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

DE F

15-9 EndoWrist clip appliers: A, AB Small clip applier; B, large Hem- o-lok® clip applier. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-10 EndoWrist 5-mm instruments AB (graspers): A, Schertel grasper, 5 mm; B, bowel grasper, 5 mm. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

15-11 EndoWrist stabilizer shown with tubing. (Courtesy Intuitive Surgi- cal, Inc., Sunnyvale, Calif.)

82 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 15-12 da Vinci Si HD Surgical Systems. Left to right: Two surgeons’ consoles (power cables do not show on this photo); nurse at the operating table by Mayo stand in surgical attire and in front of patient cart, with a vision cart to her right. During an operation, you would see an assistant to the surgeon at the patient’s cart with the scrub nurse (photographed on the right), an anesthesiologist at his or her machine, a circulating nurse, and the surgeon or surgeons in an anteroom next to the operating room where the patient is being operated upon. In most situations the da Vinci Si HD Surgical Systems are located within the operating room, and the surgeons are wearing proper operating room attire, including head covers and masks. (Courtesy Intuitive Surgical, Inc., Sunnyvale, Calif.)

CHAPTER 15 The da Vinci ® Surgical System and EndoWrist ® Instruments (Robotic Instruments) 83 https://kat.cr/user/Blink99/ CHAPTER 16

Breast Biopsy/Lumpectomy

Additional images are available at: A breast biopsy is the removal of suspicious breast tissue for the purpose of microscopic examination. evolve.elsevier.com/Tighe/instrumentation A brief description of the procedure follows: 1. A Halsted mosquito forceps is used for hemostasis. 2. A DeBakey tissue forceps is used for atraumatic handling of breast tissue. 3. A Lahey thyroid tenaculum is used for grasping the pathology. 4. A Senn retractor is used for deeper retraction. 5. Joseph hooks are used for skin retraction.

16-1 Top, left to right: 1 Medicine cup, metal; 2 Army Navy retractors, front view and side view. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Adson tissue forceps (1 × 2); 1 Brown-Adson tissue forceps (9 × 9); 2 DeBakey vascular atraugrip tissue forceps, short (front view and side view); 2 paper drape clips; 4 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps, 5½ inch; 2 Allis tissue forceps; 2 Lahey goiter vulsellum forceps; 1 Crile-Wood needle holder, 6 inch; 2 Mayo dissecting scissors, straight and curved; 1 Metzenbaum dissecting scissors, 5 inch; 2 Joseph skin hooks, double; 2 Miller-Senn retractors, side view and front view.

84 UNIT 2 General Surgery https://kat.cr/user/Blink99/ CHAPTER 17

Mastectomy

A mastectomy is the removal of a breast (mammary gland). Additional images are available at: A brief description of the procedure follows: evolve.elsevier.com/Tighe/instrumentation 1. Lahey traction forceps are used for grasping skin edges. 2. Prince-Metzenbaum scissors are used for dissecting. 3. Hayes Martin tissue forceps are used to help with dissection. 4. Volkmann (rake) retractors (sharp and dull) are used for visualization. 5. A Poole suction tip with tubing is used to improve visualization. 6. Adair breast clamps are used for grasping breast tissue. 7. Curved Crile hemostatic forceps are used for hemostasis and blunt dissection. 8. A skin stapler is used for skin closure. For the axillary node dissection, a brief description of the procedure follows: 1. A Green retractor is used for visualization. 2. A Cushing vein retractor is used for retracting small structures. 3. A Yankauer suction tube and tip are used for visualization.

17-1 Top to bottom: Yankauer suction tube and tip; Poole abdominal suction tube and shield. Bottom, left to right: First instrument stringer: 6 paper drape clips; 2 Backhaus towel forceps; 8 Halsted mosquito hemostatic forceps, curved; 12 Crile hemostatic forceps, 5½ inch; 8 Crile hemostatic forceps, 6½ inch; 2 Mayo-Péan hemostatic forceps, long; 2 Halsey needle holders, serrated, 5 inch; 2 Crile-Wood needle holders, 7 inch. Second instrument stringer: 12 Allis tissue forceps; 4 Babcock tissue forceps; 4 Ochsner hemostatic forceps, straight, short; 8 Adair breast clamps, short; 4 tonsil hemostatic forceps; 4 Westphal hemostatic forceps; 4 Lahey traction forceps.

CHAPTER 17 Mastectomy 85 https://kat.cr/user/Blink99/ 17-2 Top, left to right: 2 Bard-Parker knife handles #3; 1 Hoen nerve hook; 1 Bard-Parker knife handle #4. Bottom, left to right: 2 Metzenbaum dissecting scissors, 5 inch and 6 inch; 1 Prince- Metzenbaum dissecting scissors; Mayo dissecting scissors: 2 straight and 1 curved.

17-3 Left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Brown-Adson tissue forceps (9 × 9), front view and side view; 1 Adson tissue forceps without teeth, front view; 2 DeBakey vascular atraugrip tissue forceps, short, front view and side view; 2 Hayes Martin tissue forceps, short, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, medium, front view and side view.

17-4 Left to right: 2 Richardson retractors, small and medium; 2 Volkmann retractors, 6 prong, sharp, front view and side view; 2 Volkmann retractors, 6 prong, dull, front view and side view; 2 Volkmann retractors, 4 prong, dull, front view and side view; 2 Volkmann retractors, 4 prong, sharp, front view and side view.

86 UNIT 2 General Surgery https://kat.cr/user/Blink99/ 17-5 Left to right: 2 Army Navy retractors, side view and front view; 2 Langenbeck retractors, side view and front view; 2 Green goiter retractors, side view and front view; 2 Cushing vein retractors, side view and front view; 2 Miller-Senn retractors, side view and front view.

A B C D

17-6 Left to right: A, Halsey needle holder, serrated, 5 inch, and tip; B, Crile-Wood needle holder, 7 inch, and tip; C, Adair breast clamp and tip; D, Lahey traction forceps and tip.

CHAPTER 17 Mastectomy 87 https://kat.cr/user/Blink99/ CHAPTER 18 UNIT THREE: FEMALE REPRODUCTIVE SURGERY

Dilatation and Curettage of the Uterus

Additional images are available at: A dilation and curettage of the uterus (D and C) is performed to treat illness or to obtain a specimen for microscopic evaluation. evolve.elsevier.com/Tighe/instrumentation A description of the procedure follows: 1. An Auvard speculum is placed to open the posterior wall of the vagina. 2. A Heaney right-angle retractor is placed to elevate the anterior wall of the vagina. 3. A Schroeder tenaculum is placed on the cervix to stabilize the uterus. 4. A Sims uterine sound is inserted to determine the depth of the uterus. 5. Hegar dilators are inserted to dilate the cervix (from the smallest to the largest). 6. A Sims uterine curette is inserted to scrape tissue from the uterus. 7. A Thomas dull curette is used to remove any remaining tissue.

18-1 Left to right: 1 Bard-Parker knife handle #7; 1 Ferris Smith tissue forceps; 1 dressing forceps, long; 1 Mayo dissecting scissors, curved; 4 paper drape clips; 2 Backhaus towel forceps; 4 Crile hemostatic forceps, 5½ inch; 2 Allis tissue forceps; 1 Randall stone forceps, ¼ curved; 1 Bozeman uterine forceps, S-shaped; 2 Schroeder uterine tenaculum forceps, single tooth; 1 Foerster sponge forceps; 1 Crile-Wood needle holder, 7 inch.

88 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ 18-2 Top, left to right: 1 Graves vaginal speculum; 1 Auvard weighted vaginal speculum, medium lip. Bottom, left to right: 1 Heaney retractor; 1 set of Hegar dilators, sizes 3 to 13½ (including half sizes).

18-3 Left to right: 1 Sims uterine sound; 1 Heaney uterine biopsy curette, sharp, serrated, 5-mm wide; 1 Thomas uterine curette, semirigid, dull, small, 0.6-mm wide loop; 1 Sims uterine curette, semirigid, sharp, medium, 2.8-mm loop; 1 Kevorkian- Younge endocervical biopsy curette, 2-mm loop.

CHAPTER 18 Dilatation and Curettage of the Uterus 89 https://kat.cr/user/Blink99/ 18-4 Left to right: Tips: A, Sims uter- A B C ine sound; B, Heaney uterine biopsy curette, sharp, serrated, 5-mm wide; C, Thomas uterine curette, semirigid, dull, small, 0.6-mm wide loop; D, Sims uterine curette, semirigid, sharp, medium, 2.8-mm loop; E, Kevorkian- Younge endocervical biopsy curette, 2-mm loop; F, Bozeman uterine forceps, S-shaped.

D E F

90 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ CHAPTER 19

Hysteroscopy

Hysteroscopy is an endoscopic visualization of the uterine cavity and is usually performed Additional images are available at: to aid in the diagnosis and treatment of intrauterine diseases. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a hysteroscope, dilatation and curettage instruments, and possibly if the surgeon wishes to examine inside the abdomen, a laparoscope, insufflation tubing, fiber optic light cord, and camera (see Chapter 7: Laparoscopy).

19-1 VersaPoint hysteroscopic resectoscope unassembled.

19-2 VersaPoint resectoscope assembled. Top to bottom: 1 Resecto- scope assembled with cautery cord; 1 sheath with obturator; 1 multitooth, semirigid grasping forceps, 5 Fr.

CHAPTER 19 Hysteroscopy 91 https://kat.cr/user/Blink99/ 19-3 Top to bottom: Enlarged tips of multitoothed semirigid grasping forceps, 5 Fr; semirigid Metzenbaum scissors; semirigid cup biopsy forceps.

19-4 Top to bottom: 1 Versascope; 1 Versascope sheath.

92 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ 19-5 Top to bottom: 2 TruClear hysteroscopy systems, top is 9.0 system and bottom is 5.0 system with each system containing 1 obturator, 1 telescope with working channel, and 1 sheath.

19-6 TruClear hand piece.

CHAPTER 19 Hysteroscopy 93 https://kat.cr/user/Blink99/ CHAPTER 20

Vaginal Laser

Additional images are available at: The term laser stands for Light Amplification by Stimulated Emission of Radiation. Ordi- nary light, such as that from a light bulb, has many wavelengths and spreads in all direc- evolve.elsevier.com/Tighe/instrumentation tions. Laser light, on the other hand, has a specific wavelength. It is focused in a narrow beam and creates a very high intensity light. This light can burn the patient or cause blind- ness to health care workers if special glasses or other precautions are not taken. Because lasers can focus very accurately on tiny areas, they can also be used for very precise surgical work or for cutting through tissue. Vaginal instruments have a special coating called ebon- ization, so they do not reflect the laser beam onto unintended tissues. The coating is one example of a precaution taken by trained laser staff to protect patients and staff. Examples of surgical procedures that lasers may be used on are vaginal warts, tumors, or small lesions.

20-1 Left to right: 1 Hook, 10 inch; 1 Schroeder uterine tenaculum forceps, 9½ inch; 1 tonsil forceps; 2 Heaney retractors (lateral vaginal retractors); 1 Auvard weighted vaginal speculum; 1 Graves vaginal speculum with smoke evacuation attachment.

94 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ 20-2 Left to right: 1 Graves bivalve speculum, full view, purple; 1 Graves bivalve speculum, wide view, purple; 1 lateral vaginal retractor, purple.

CHAPTER 20 Vaginal Laser 95 https://kat.cr/user/Blink99/ CHAPTER 21

Abdominal Hysterectomy

Additional images are available at: Abdominal hysterectomy is the removal of the uterus through an abdominal incision. Additional structures that may be removed through the same incision and at the same time evolve.elsevier.com/Tighe/instrumentation are the ovaries (oophorectomy) and fallopian tubes (salpingectomy). Instruments needed for the procedure include a basic laparotomy set, an O’Sullivan- O’Connor retractor, and Z clamps. A brief description of the procedure follows: 1. An abdominal incision is made and dissection occurs. 2. A Schroeder uterine tenaculum forceps is used for grasping and manipulating the uterus. 3. Heaney forceps, Heaney-Ballantine forceps, or Z clamps are used for clamping uterine ligaments and vessels. 4. A Jorgenson dissecting scissors is used for dissection. 5. A Heaney needle holder is used for suture ligation.

21-1 Top, right: 1 O’Sullivan-O’Connor retractor body. Bottom, left to right: 1 Mayo dissecting scissors, curved, 9 inch; 1 Jorgenson dissecting scissors, curved, 9 inch; 4 Ochsner hemostatic forceps, 8 inch; 2 Heaney hysterectomy forceps, single tooth; 2 Heaney-Ballantine hysterectomy forceps, single tooth; 4 Ochsner hemostatic forceps, 8 inch; 1 Schroeder uterine tenaculum forceps, single tooth; 1 Schroeder uterine vulsellum forceps, double tooth; 2 Jarit hysterectomy forceps, straight, 8½ inch; 2 Jarit hysterectomy forceps, curved, 8½ inch; 2 Heaney needle holders; 2 medium blades for O’Sullivan- O’Connor retractor, side view; 1 large blade, front view.

96 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ AB CD

A B C D

21-2 Left to right: A, Heaney hysterectomy forceps, single tooth, and tip; B, Heaney-Ballantine hysterectomy forceps, single tooth, and tip; C, Schroeder uterine tenaculum forceps, straight, with single-tooth tip, and Schroeder uterine vulsellum forceps, with double-tooth tip; D, Z clamp, in tips, straight and curved.

CHAPTER 21 Abdominal Hysterectomy 97 https://kat.cr/user/Blink99/ A BC

A B C D E

1 1 21-3 Left to right: A and B, Jarit hysterectomy forceps: A, Straight, 8 ⁄2 inch, and tip; B, curved, 8 ⁄2 inch, 1 and tip. C, Heaney needle holder, curved, 8 ⁄2 inch, and tip. D and E, Jorgenson dissecting scissors: D, Front view; E, side view.

98 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ CHAPTER 22

Supracervical Laparoscopic Hysterectomy

Supracervical laparoscopic hysterectomy is the removal of the uterus without the cervix Additional images are available at: through a laparoscope. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a laparoscope, laparoscopic instrumentation, a Harmonic scalpel, an electrosurgical unit, and a morcellator or minor laparotomy instrumentation. A brief description of the procedure follows: 1. A Graves bivalve speculum is inserted into the vagina. A Schroeder uterine tenaculum forceps grasps the cervix and a Cohen cannula is inserted into the cervix to establish uterine manipulation, or disposable uterine manipulators may be used. 2. The laparoscope is inserted in the usual manner. 3. A laparoscopic tenaculum is used to grasp the uterus. 4. A Harmonic scalpel and a LigaSure sealer/divider is used to dissect and cauterize the uterine ligaments and vessels and to transect and cauterize the uterus above the cervix. 5. If used, a morcellator is inserted through another port. The morcellator is used to shave the uterus into pieces so it may be removed. A heavy grasper is inserted through the morcellator to remove the uterine tissue fragments. 6. If a morcellator is not used, a mini laparotomy is performed to remove the uterus.

22-1 Left to right: 1 Uterine manipulation probe; 1 Cohen cannula; 2 black Cohen cones; 1 uterine sound; 1 Schroeder uterine tenaculum forceps, single tooth; 1 Graves bivalve speculum.

CHAPTER 22 Supracervical Laparoscopic Hysterectomy 99 https://kat.cr/user/Blink99/ 22-2 Disposable uterine manipulators.

22-3 Top to bottom: 1 Harmonic scalpel, 5 mm, 23 cm; 1 Harmonic cord; 1 tightening key.

100 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ 22-4 Top to bottom: 1 LigaSure impact sealer/divider, curved, 18 cm; 1 LigaSure sealer/divider, 19 cm; 1 LigaSure laparoscopic sealer/divider, 5 mm, 37 cm.

22-5 Tips: A, LigaSure impact sealer/ AB divider; B, LigaSure laparoscopic sealer/divider.

CHAPTER 22 Supracervical Laparoscopic Hysterectomy 101 https://kat.cr/user/Blink99/ 22-6 Suction/irrigator with pump.

22-7 Position for hysteroscopic ANESTHESIA procedures. ASSISTANT HOLDER CAMERA

__10 __5 __5 SURGEON

Patient in stirrups

SCRUB

VIDEO

1 VIDEO2*

BACK TABLE * Video position change per physician preference REVERSE FOR RIGHT SIDE PATIENT IN LOW ALLEN STIRRUPS

102 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ CHAPTER 23

Vaginal Hysterectomy

A vaginal hysterectomy is the removal of the uterus through a vaginal incision. Possible Additional images are available at: equipment needed for this procedure are Z clamps. evolve.elsevier.com/Tighe/instrumentation A brief description of the procedure follows: 1. An Auvard speculum and Heaney retractor are placed to visualize the cervix. 2. A Schroeder vulsellum forceps is used to grasp the cervix. 3. A Bard-Parker long scalpel handle #3 with a #10 blade is used to incise into the peritoneum. 4. Heaney forceps and Z clamps are used for clamping uterine ligaments and vessels. 5. A long curved Mayo scissors is used to bisect the ligaments and vessels. 6. A curved Heaney needle holder is used to ligate the ligaments and vessels with the use of Russian tissue forceps. 7. Foerster forceps with 4 × 4 sponges are used for hemostasis and visualization. 8. Allis-Adair forceps are used to approximate the peritoneum edges. 9. A long Crile-Wood needle holder is used to suture the peritoneum edges.

23-1 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #4, long; 1 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, 7 inch; 1 Mayo dissecting scissors, curved; 1 Mayo dissecting scissors, long, curved; 2 Ferris Smith tissue forceps; 2 Russian tissue forceps; 1 tissue forceps without teeth, long.

CHAPTER 23 Vaginal Hysterectomy 103 https://kat.cr/user/Blink99/ 23-2 Top to bottom: 1 Uterine sound; 1 Yankauer suction tube with tip. Bottom, left to right: 4 Paper drape clips; 2 Backhaus towel clips; 8 Crile hemostatic forceps, 6½ inch; 4 Halsted hemostatic forceps; 12 Allis tissue forceps; 6 Allis-Adair tissue forceps; 4 tonsil hemostatic forceps; 2 Heaney needle holders; 2 Crile-Wood needle holders, 8 inch; 2 Heaney hysterectomy forceps, single tooth, curved; 2 Heaney-Ballantine hysterectomy forceps, single tooth, curved; 2 Och- sner hemostatic forceps, 8 inch; 2 Allis tissue forceps, long; 2 Babcock clamp tissue forceps, medium; 2 Schroeder uterine tenaculum forceps, single tooth; 1 Schroeder uterine vulsellum forceps, double tooth, straight; 2 Foerster sponge forceps.

23-3 Top, left to right: 1 Graves vaginal speculum; 1 Auvard weighted vaginal speculum, medium lip. Bottom, left to right: 2 Heaney retractors; 1 Auvard weighted vaginal speculum, long lip; 2 Deaver retractors, narrow.

A B C D E F

23-4 Left to right: Tips: A, Allis tissue forceps; B, Allis-Adair tissue forceps; C, Heaney hysterectomy forceps, single tooth, curved; D, Heaney-Ballantine hysterectomy forceps, single tooth, curved; E, Schroeder uterine tenaculum forceps, single tooth; F, Schroeder uterine vulsellum forceps, double tooth, straight.

104 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ CHAPTER 24

Laparoscopic Tubal Occlusion

Tubal occlusion is the interruption of the fallopian tubes for the purpose of permanent Additional images are available at: sterilization. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes laparoscopic instrumentation and the method of tubal occlusion. There are various options: Falope rings and applier, Filshie clips and applier, or bipolar and electrosurgical generator. A brief description of the procedure follows: 1. A Cohen cannula is inserted into the cervix vaginally to elevate the uterus (see Figure 21-2). 2. The laparoscope is inserted in the usual manner. 3. A manipulation probe is used to expose the fallopian tube. 4. The Endoflex retractor is used to retract the structures away from the tube. 5. Babcock tissue forceps are used to stabilize the tube. 6. A Falope ring applier with silastic band, a Filshie clip applier with clip, or a bipolar forceps is introduced. 7. The ring is placed over a loop of the fallopian tube or a clip is placed over a segment of the fallopian tube. If the bipolar forceps are used, a segment of the fallopian tube is cauterized.

24-1 Top to bottom, left to right: 1 Wolf bipolar outer sheath; 2 bipolar internal graspers; 1 handle; 1 cord.

CHAPTER 24 Laparoscopic Tubal Occlusion 105 https://kat.cr/user/Blink99/ 24-2 Top to bottom: 1 Fallopian ring applicator, extended; 1 fallopian ring separate and 1 in package; 1 fallopian applicator tip; 1 fallopian ring pusher; 1 Filshie clip applicator with clip; 1 Filshie clip separate with blue disposable handle.

24-3 Left to right, top to bottom: 1 Fallopian applicator tip; 1 fallopian ring; 1 Filshie clip with blue handle; 1 Filshie clip.

106 UNIT 3 Female Reproductive Surgery https://kat.cr/user/Blink99/ ANESTHESIA 24-4 Position for tubal occlusion. ASSISTANT HOLDER CAMERA

__5 __5 SURGEON

Patient in stirrups

SCRUB

VIDEO

1 VIDEO2*

BACK TABLE * Video position change per physician preference

REVERSE FOR RIGHT SIDE PATIENT IN LOW ALLEN STIRRUPS

CHAPTER 24 Laparoscopic Tubal Occlusion 107 https://kat.cr/user/Blink99/ CHAPTER 25 UNIT FOUR: GENITOURINARY SURGERY

Cystoscopy

Additional images are available at: Cystoscopy is the visualization of the urinary bladder, urethra, bladder neck, and ureteral orifices via a cystoscope. Males will also have their ejaculatory duct and the lobes of the evolve.elsevier.com/Tighe/instrumentation prostate examined. Possible procedures include cystograms, retrograde pyelograms, ful- guration of the bladder, bladder biopsies, stone removal, transurethral resections of the prostate (TURPs), transurethral resections of bladder tumors (TURBTs), and urethrotomy. If the urethra is constricted for any reason, possible equipment needed for the procedure includes passing graduated sized Van Buren dilators for men and Walther dilators for women and a urethrotome with blades. A brief description of the procedure follows: 1. A sheath and obturator are lubricated and inserted into the urethra. 2. An obturator is removed, the bladder is drained, and the cystoscope 30-degree telescope is inserted into the sheath. 3. Irrigation tubing and the fiber optic light cord are attached and the bladder is filled with solution for visualization. 4. A visual obturator may be used if there is difficulty placing the sheath and obturator. 5. If ureteral catheterization is necessary, an Albarran deflector is used to help guide the catheter into the ureter. If a stone presents within the bladder, a stone breaker may be utilized. This is a handheld intracorporeal contact lithotripter. It is nonelectric, powered by high-pressure carbon dioxide gas. This device is used most commonly via a passage through a cystoscope to destroy a bladder stone, sometimes a distal ureteral stone, and percutaneously via a nephroscope to break up a large kidney stone.

108 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 25-1 Top to bottom: 1 Olympus cystoscope high-definition urology camera; 1 light cord.

25-2 Basic cystoscope. Top to bottom, left to right: 1 Grasping forceps, 7 Fr, flexible; 1 stopcock, 3 mm; 2 silicon seal caps (1 on side); 1 cystoscope obturator; 1 cystocope sheath, 21 Fr; 1 cystoscope lens, 70-degree; 1 cystoscope lens, 30-degree; 1 catheter deflector; 1 single bridge channel adapter; 1 double bridge channel adapter.

CHAPTER 25 Cystoscopy 109 https://kat.cr/user/Blink99/ 25-3 Left to right: Double-action stent grasper; biopsy forceps, straight; biopsy forceps, angled.

25-4 Left to right: Tip: A, Double- A action stent grasper; B, biopsy B forceps, straight and angled.

25-5 Top to bottom: 1 Bugbee electrode; 1 Bugbee cord.

110 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 25-6 Left to right, top to bottom: 1 Olympus flexible cystoscope; 1 irrigation plug adapter; 1 light cord; 1 flexible tooth grasping forceps, alligator open.

25-7 Top to bottom, left to right: 1 single-use probe; 1 CO2 cartridge; 1 sterilization cap; 1 exhaust cap; 1 stone breaker pneumatic lithotripter with attached CO2 exhaust line.

CHAPTER 25 Cystoscopy 111 https://kat.cr/user/Blink99/ CHAPTER 26

Urethroscopy

Additional images are available at: Urethroscopies are usually done in addition to a cystoscopy and, as such, have very little additional instrumentation besides the cystoscope set. A common reason for doing a ure- evolve.elsevier.com/Tighe/instrumentation throscopy is to treat a urethral stricture in which an internal urethrotomy is done with a urethrotome. A brief description of the procedure follows: 1. A sheath and obturator are lubricated and inserted into the urethra. 2. The obturator is removed, and a telescope adapting bridge and telescope are inserted.

26-1 Left to right: 1 Wolf optical urethrotome obturator, hollow 20.5 Fr; 1 Wolf optical urethrotome sheath; 1 cystoscope lens, 0 degree; 1 scalpel rigid stricture; 1 scalpel rigid stricture, ½ moon. Top to bottom: 1 Working element (handle) urethrotome; 1 single bridge channel adapter.

112 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 27

Ureteroscopy

Ureteroscopies are procedures in which small scopes are inserted into the bladder and the Additional images are available at: ureters to diagnose and treat a variety of problems. Usually this procedure is performed evolve.elsevier.com/Tighe/instrumentation so that the urologist can locate ureteral stones and then pass a tiny wire basket up into the ureter to grab the stones and remove them. Sometimes it is difficult to basket a stone due to the location or the size of the stone, and other equipment is necessary to treat the stone and decrease its size. This is usually done internally with either a holmium laser or externally with extracorporeal shock wave lithotripsy. Many times after these additional treatments no basketing is necessary and the stones will pass out of the urinary tract on their own. Sometimes a ureteral stent may be placed to help facilitate the passage of stones out of the urinary tract.

27-1 Olympus flexible ureteroscope.

CHAPTER 27 Ureteroscopy 113 https://kat.cr/user/Blink99/ 27-2 Top to bottom: 2 Sealing caps (1 on side), 3 mm; 1 rigid ureteroscope, dual lumen; 1 rigid ureteroscope, single lumen.

27-3 Left to right: 1 Disposable stone extractor, partially open; 2 channel adapters.

27-4 1 Holmium laser fiber.

114 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 28

Nephrectomy

A nephrectomy is the removal of a kidney. This can be done with a subcostal, transthoracic, Additional images are available at: transabdominal, or a laparoscopic approach. Instrumentation needed for an open proce- evolve.elsevier.com/Tighe/instrumentation dure includes a basic laparotomy set and a self-retaining retractor. A brief description of the nephrectomy procedure follows: 1. A Thompson retractor is used to expose the kidney area. 2. Metzenbaum dissecting scissors are used to incise Gerota’s capsule. 3. Adson tissue forceps are used for blunt dissection and hemostasis. 4. Curved Mayo dissecting scissors are used for sharp dissection. 5. Mixter hemostatic forceps are used to double-clamp the ureter. 6. Long Metzenbaum dissecting scissors are used to cut the ureter. 7. A Guyon-Péan vessel clamp or Herrick kidney clamps are used to double-clamp the kidney pedicle.

28-1 Left to right: 1 Lincoln- Metzenbaum scissors, narrow dissecting tip; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 1 probe dilator; 1 grooved director; 2 Hoen nerve hooks; 2 Love nerve retractors, straight, front view, 90-degree angle, side view; 2 Little retractors, medium; 4 Gil-Vernet retractors, assorted sizes.

CHAPTER 28 Nephrectomy 115 https://kat.cr/user/Blink99/ 28-2 Left to right: 4 Westphal hemostatic forceps; 6 tonsil hemostatic forceps; 2 Adson hemostatic forceps, fine, curved; 1 Guyon-Péan vessel kidney clamp; 2 Herrick kidney clamps; 2 Satinsky (vena cava) clamps; 6 tonsil hemostatic forceps, 9½ inch; 2 tonsil hemostatic forceps, 10½ inch; 2 Babcock tissue forceps, extra long; 4 Mixter hemostatic forceps, 10½ inch, fine tip; 2 Ayers needle holders, extra long; 2 Heaney needle holders, long; 4 Randall stone forceps: full curve, ¾ curve, ½ curve, and ¼ curve.

A BCD

A B CDE

28-3 Left to right: A, Adson hemostatic forceps, fine curve, and tip; B, Herrick kidney clamp and tip; C, Satinsky (vena cava) clamp, medium, 4 cm, 9½ inch, and tip; D, Mixter hemostatic forceps, fine tip, 10½ inch, and tip; E, tip of Guyon-Péan vessel clamp, 9½ inch.

116 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 29

Laparoscopic Nephrectomy

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

29-1 Top to bottom: 3 Endoscopic Hem-O-Lok appliers with clips, 1 large, 1 small, and 1 medium; 1 Endoscopic Hem-O-Lok remover.

29-2 Hem-O-Lok, tip.

CHAPTER 29 Laparoscopic Nephrectomy 117 https://kat.cr/user/Blink99/ 29-3 Top to bottom: 1 Laparoscopic Satinsky atraumatic clamp, short, 5 mm; 1 monopolar handle with ratchet; 1 laparoscopic Satinsky atraumatic clamp, long, 5 mm.

29-4 Percutaneous nephroscope with graspers. Top to bottom, left to right: 1 Stone grasping forceps; 1 tooth forceps, 3 prong, 42 cm; 1 red operating channel seal; 1 green scope cap on operating telescope, 30 degree, 4-mm channel; 1 outer sheath, 25 Fr (on telescope), continuous flow; 1 attachment with stopcock.

118 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 30

Pubovaginal Sling/Anterior Repair

Anterior and/or posterior repair procedures are used to repair prolapses of the vaginal wall Additional images are available at: or bulging that occurs when the bladder or urethra sink into the vagina. Pubovaginal slings evolve.elsevier.com/Tighe/instrumentation are done to help control urinary stress incontinence by closing the urethra and bladder neck. Pubovaginal slings are done surgically with various materials and methods. Tension- free vaginal tape (TVT) and transobturator tape (TOT) procedures are just a few of the methods that are used. The surgeon places a band of synthetic material around the urethra to lift the bladder and urethra with the right amount of support (like a hammock) via incisions in the groin, lower abdomen, and vagina. The tape is held in place by friction between the tape and the surrounding tissue.

30-1 Left to right: 4 Halsted mosquito clamps, curved, 5 inch; 2 Crile forceps, straight, 6¼ inch; 2 Crile forceps, curved, 6¼ inch; 1 Péan artery forceps, 6½ inch; 2 Ochsner-Kocher artery forceps, 1 × 2 teeth, 6½ inch; 4 Allis tissue forceps, 5 × 6 teeth, 6 inch; 2 Adair tissue forceps, 6¼ inch; 1 right-angle forceps, 7 inch; 4 Boettcher tonsil artery forceps, curved, 7½ inch; 2 Wikstroem dissecting forceps, right angle, 8 inch; 1 Foerster sponge stick; 1 Crile-Wood needle holder, 6¼ inch; 1 Mayo-Hegar needle holder, 8 inch; 1 Heaney needle holder, curved, serrated, 8 inch; 1 Hegar uterine dilator, 7-8 mm.

CHAPTER 30 Pubovaginal Sling/Anterior Repair 119 https://kat.cr/user/Blink99/ 30-2 Left to right: 1 Knife handle, #3; 1 Mayo dissecting scissor, curved, 6¾ inch; 1 Metzenbaum dissecting scissor, curved, blunt, 7 inch; 1 Mayo scissor, straight, 6¾ inch; 1 Forester scissor, curved, fine, blunt, 9 inch; 1 1 tissue forceps, 1 × 2 teeth, 6 ⁄4 inch; 1 tissue forceps, 1 × 2 teeth, 7½ inch; 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 1 DeBakey vascular tissue forceps, 7¾ inch; 1 Russian tissue forceps, 10 inch.

30-3 Left to right: 2 Volkmann rake retractors, sharp, 4 prong, 8¾ inch; 2 Army Navy retractors; 1 Richardson- Eastman retractor, double-ended; 3 1 Deaver retractor blade 1 × 12 ⁄8 inch; 1 Heaney-Simon vaginal retractor, 1 × 4½ inch; 1 Garrigue weighted vaginal speculum, short blade; 1 Garrigue weighted vaginal speculum, long blade.

120 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 30-4 Left to right: 1 Cystoscope, 4 mm, 12-degree lens; 1 cystoscope, 4 mm, 70-degree lens. Top to bottom: 2 Red nipples 1-2 mm (1 on side); 1 single port bridge; 1 light cord; 1 stopcock; 1 Albarrán bridge; 1 cystoscope obturator, 21 Fr.

CHAPTER 30 Pubovaginal Sling/Anterior Repair 121 https://kat.cr/user/Blink99/ CHAPTER 31

Prostatectomy

Additional images are available at: A prostatectomy is a surgical procedure that removes either all or a portion of the prostate for treatment of prostate cancer or benign prostatic hyperplasia. There are many ways to evolve.elsevier.com/Tighe/instrumentation remove the complete prostate including incisions via a retropubic, suprapubic, or perineum incision, and/or a laparoscopic or robotic approach. A partial prostatectomy is most commonly done for benign prostatic hypertrophy via a transurethral approach. Instruments needed for a suprapubic approach include an electrosurgical unit, additional retractors, and a disposable skin stapler. A brief description of the procedure follows: 1. After the abdomen is opened, a Balfour retractor with blades may be placed for visualization. 2. A Harrington retractor may be needed to retract the abdominal structures superiorly. 3. Long Allis forceps may be used to stabilize the bladder. 4. A Bard-Parker long scalpel handle #3 with a #10 blade may be used to incise into the bladder. 5. Long, curved Metzenbaum dissecting scissors may be used to extend the incision. 6. A small Richardson retractor may be used to hold the bladder walls open. 7. The prostate gland is enucleated manually. 8. Horizon clip appliers and clips may be used for hemostasis. 9. A long, fine-needle holder and a long DeBakey vascular atraugrip tissue forceps may be used to close the bladder. 10. After closing the abdominal layers, the skin may be closed with staples with the aid of Adson tissue forceps.

31-1 Top: 1 Poole abdominal suction tube and shield. Left to right: 2 Yankauer suction tubes and tips; 6 paper drape clips; 4 Halsted mosquito hemostatic forceps, curved; 4 Halsted mosquito hemostatic forceps, straight; 1 Halsted hemostatic forceps; 6 Crile hemostatic forceps, 6½ inch; 4 tonsil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, curved; 2 Allis tissue forceps, medium; 1 Babcock tissue forceps, medium; 4 Ochsner hemostatic forceps, straight, long jaw; 6 Mixter hemostatic forceps, 9 inch; 6 tonsil hemostatic forceps, long; 4 Allis tissue forceps, extra long, curved; 4 Mixter hemostatic forceps, extra long; 3 Foerster sponge forceps; 2 Crile-Wood needle holders, 7 inch; 2 Crile-Wood needle holders, 8 inch; 2 Mayo-Hegar needle holders, 12 inch.

122 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 31-2 Left to right: 2 Bard-Parker knife handles #4; 1 Bard-Parker knife handle #3, long; 2 Mayo dissecting scissors, curved and straight; 2 Metzenbaum dissecting scissors, 7 inch and extra long; 2 Snowden-Pencer scissors, straight and curved; 1 Jorgenson dissecting scissors; 1 Mayo dissecting scissors, long, curved.

31-3 Left to right: 2 Adson tissue forceps (1 × 2), front view and side view; 2 Ferris Smith tissue forceps (1 × 2), front view and side view; 2 Russian tissue forceps, front view and side view; 2 thumb tissue forceps with teeth (1 × 2), long, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, extra long, front view and side view.

CHAPTER 31 Prostatectomy 123 https://kat.cr/user/Blink99/ 31-4 Left to right: Hemoclip-applying forceps, 2 medium, 2 large.

31-5 Left to right: 1 Gil-Vernet retractor; 2 Goelet retractors, front view and side view; 2 Gelpi retractors.

124 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 31-6 Left to right: 2 Greenwald suture guides, 24 Fr and 28 Fr; 3 Deaver retractors: narrow, side view; medium, front view; wide, side view; 2 Har- rington splanchnic retractors, small and large, side view.

31-7 Top: 2 Balfour abdominal retractor fenestrated blades, large. Left to right: 1 Balfour abdominal retractor frame; 2 Balfour abdominal retractor fenestrated blades, small; 2 Balfour abdominal retractor center blades, large and small; 2 Richardson retractors, medium and large; 3 Ochsner malleable retractors, narrow (side view), medium, and large.

CHAPTER 31 Prostatectomy 125 https://kat.cr/user/Blink99/ 31-8 Left to right: 1 Lone Star steel retractor, hinged; 1 Lone Star retractor hook, disposable; 1 Lone Star wrench, hex round, knurled handle.

126 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 32

Laparoscopic Prostatectomy Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

32-1 Laparoscopic Bull Dog Set. Right top, top to bottom: 1 Vascular bulldog, 45 mm, straight; 1 vascular bulldog, 45 mm, curved; 1 vascular bulldog, 25 mm, curved; 1 vascular bulldog, 25 mm, straight, (loaded into clip applier); 1 laparoscopic clip applier/remover, angled, 12.5-340 mm; 1 laparoscopic clip applier/remover, straight, 12.5-340 mm.

CHAPTER 32 Laparoscopic Prostatectomy 127 https://kat.cr/user/Blink99/ CHAPTER 33

Transurethral Resection of the Prostate

Additional images are available at: Transurethral resection of the prostate (TURP) is the removal of the enlarged portion of the prostate gland with a resectoscope. Possible equipment needed for the procedure includes evolve.elsevier.com/Tighe/instrumentation an electrosurgical unit, volumes of irrigating solution, a light source, and an Ellik evacuator. Today most TURPs are performed with bipolar energy. A brief description of the procedure follows: 1. A Van Buren dilator is inserted to enlarge the urethra. 2. The resectoscope sheath with obturator is passed into the bladder. 3. Irrigating tubing is attached and the bladder is filled with solution. 4. A fiber optic cord and electrosurgery cord are connected. 5. The obturator is removed and the working element is inserted. 6. A cutting electrode is inserted to remove prostate tissue. 7. A ball electrode is used to cauterize bleeders. 8. An Ellik evacuator is used to retrieve the specimen that has floated into the bladder. 9. A spoon is used for prostate tissue that is drained from the bladder and collects on the screen of the drape.

33-1 Left to right: 1 Telescope 30-degree, 4 mm; 1 dual valve sheath, 22.5 Fr; 1 standard obturator; 1 visual obturator; 1 continuous flow resectoscope inner sheath, 24 Fr; 1 deflecting obturator; 1 continuous flow resectoscope outer sheath, 27 Fr with 2 vertical stopcocks; 1 high-frequency bipolar cable 4 mm; 1 working element, passive.

128 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 33-2 Left to right, top to bottom: 8 Van Buren sounds; 1 spoon; 1 Ellik evacuator; 1 light cord.

A B C A B C

33-3 Left to right: A, Cutting electrode with pointed end and tip; B, coagulating electrode with ball end and tip; C, cutting electrode with round wire and tip.

CHAPTER 33 Transurethral Resection of the Prostate 129 https://kat.cr/user/Blink99/ CHAPTER 34

Vasectomy

Additional images are available at: A vasectomy is the transection of both vas deferens in the scrotum for the purpose of per- evolve.elsevier.com/Tighe/instrumentation manent sterilization. A brief description of an open procedure follows: 1. A Beaver knife is used to make an incision over the vas. 2. Providence Hospital hemostatic forceps are used for clamping bleeders. 3. Westcott tenotomy scissors are used for blunt dissection of the vas. 4. Jeweler’s forceps are used to grasp the vas. 5. Providence Hospital hemostatic forceps are used for clamping the vas. 6. A Beaver knife is used to bisect the vas. 7. DeBakey tissue forceps are used to assist in closing the incision. 8. A Barraquer needle holder is used to suture the incision.

34-1 Top to bottom, left to right: 1 Beaver knife handle, knurled, with tip; 1 Jeweler’s forceps; 2 DeBakey vascular atraugrip tissue forceps, short. Bottom, left to right: 1 Iris scissors, straight, sharp; 1 Stevens tenotomy scissors; 4 Providence Hospital hemostatic forceps; 2 Backhaus towel forceps.

130 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 34-2 Left to right: 1 Vannas capsulotomy scissors; 1 Westcott tenotomy scissors; 3 Henle probes, assorted sizes; 1 lacrimal probe, 0-00; 1 titanium microneedle holder, nonlocking; 1 Bar- raquer needle holder, extra delicate, tapered, curved, with lock; 1 Troutman tier needle holder with lock.

34-3 Top, left to right: 2 Chamber maintainers; 1 Silber vasovasostomy clamp; 1 Strauch vasovasostomy approximator, hinged, small; 1 vasovasostomy approximator, hinged, large. Bottom, left to right: 2 McPherson tying forceps, angled, front view and side view; 1 Castroviejo suturing forceps, 0.12 mm, front view; 3 Jeweler’s forceps #3, side view, front view, and side view; 2 Jeweler’s forceps #4, front view and side view; 1 Jeweler’s forceps #5, front view; 1 Snowden-Pencer dissecting forceps; 1 Snowden-Pencer fixation forceps.

CHAPTER 34 Vasectomy 131 https://kat.cr/user/Blink99/ 34-4 Left to right: 1 Snowden-Pencer dissecting forceps; 1 Snowden-Pencer fixation forceps.

132 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ CHAPTER 35

Penile Prosthesis

A penile prosthesis is a surgical treatment for erectile dysfunction. Erectile dysfunction can Additional images are available at: either be of an organic nature or a common cause from nerve damage due to a radical pros- evolve.elsevier.com/Tighe/instrumentation tatectomy. Penile prostheses can be either bendable or inflatable. The bendable prosthesis is comprised of rods implanted into the erection chambers of the penis. These rods can be bent and positioned to the individual’s preference depending on their activity. An inflatable prosthesis enables the man to have an erection whenever he chooses and can be disguised more easily.

35-1 Left to right: 1 Joseph scissors, curved, 5 inch; 1 Mayo TC scissors, curved, 6½ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Vital Mayo dissecting scissors, beveled blades, straight, 6¾ inch; 2 Vital Mayo-Hegar TC needle holders, 6¼ inch; 1 Crile-Wood TC needle holder, 6 inch; 2 Babcock tissue forceps; 4 Allis forceps, 5 × 6 teeth, 6 inch; 1 Kantrowitz right angle forceps, serrated, 8 inch; 2 Schnidt forceps, 7½ inch; 6 Crile forceps, curved, 6¼ inch; 6 Halsted mosquito forceps, straight, 5 inch; 22 Halsted mosquito forceps, curved, 5 inch.

CHAPTER 35 Penile Prosthesis 133 https://kat.cr/user/Blink99/ 35-2 Left to right: 2 Knife handles, #3; 1 tissue forceps, 1 × 2 teeth, 6 inch; 1 Adson forceps, delicate, 1 × 2 teeth with serrations, 4¾ inch; 2 Adson forceps, 1 × 2 teeth, 6 inch; 2 DeBakey vascular atraugrip tissue forceps, 7¾ inch; 1 Hegar uterine dilator, 7-8 mm, 8 inch; 1 Hegar uterine dilator, 9-10 mm, 8 inch; 1 Hegar uterine dilator, 11-12 mm, 8 inch; 1 Hegar uterine dilator, 13- 14 mm, 8 inch; 1 Hegar uterine dilator, 15-16 mm, 8 inch; 1 steel ruler, graduated in millimeters and inches, 6 inch.

35-3 Left to right: 1 Richardson retractor, double-ended, large; 1 3 Deaver retractor, ⁄8 inch blade width, 8 inch; 2 Army Navy retractors, 8 inch; 2 S-retractors; 1 Davis brain spatula, 3 ⁄8 inch; 1 Davis brain spatula, ¼ inch; 2 Senn retractors, sharp, 6¾ inch; 2 Ragnell-Davis retractors; 2 Volkmann rake retractors, medium.

134 UNIT 4 Genitourinary Surgery https://kat.cr/user/Blink99/ 35-4 Left to right: 1 Killian nasal speculum, 5-inch blade, 85 × 8.5 mm wide; 1 Furlow insertion tool; 1 Furlow insertion tool obturator; 1 cavernotome, 6 mm; 1 cavernotome, 7 mm; 1 cavernotome, 9 mm; 1 cavernotome, 11 mm; 1 cavernotome, 13 mm; 1 AMS closing tool; 1 AMS Quick Connect assembly tool; 1 tubing passer, curved.

CHAPTER 35 Penile Prosthesis 135 https://kat.cr/user/Blink99/ CHAPTER 36 UNIT FIVE: ORTHOPEDIC SURGERY

Basic Orthopedic Surgery

Additional images are available at: Orthopedics is surgery on the skeletal system. The variety of procedures that may be performed are too numerous to be included in this book. evolve.elsevier.com/Tighe/instrumentation In most surgeries, a small soft-tissue dissection set is needed to expose the bony structures. The general instrumentation and a description of possible equipment needed for orthopedic procedures include the following: 1. Chisels are used to shape bone. They come in several widths and require the use of a mallet. Hoke and Hibbs chisels are two that are commonly used. 2. Periosteal elevators are used for removing periosteum. They, too, require the use of a mallet. Key and Langenbeck elevators are commonly used. 3. Bone curettes are used to scrape and shape bone. They are available in several cup sizes. Spratt and Cobb curettes are commonly used. 4. Rongeurs, used to shape bone, include Luer, Kerrison, Adson, and Smith-Petersen rongeurs. 5. Bone cutters are used to cut bone for removal. They include Ruskin-Liston bone cutters. 6. Bone clamps are used to stabilize the long bones during fixation. They include Low- man and Kern clamps. 7. Retractors are used for visualization and sometimes for supporting structures during surgery. There are, among others, Hibbs, Taylor, Doane, and Bennett retractors. 8. Rasps are used to smooth the bone or to ream the shaft of a long bone for implanta- tion. They include Putti, Aufricht, Wiener, and Lewis rasps. 9. Gouges are used for removing large pieces of bone. They are used with a mallet and include such names as Smith-Petersen, Hibbs, and Cobb. 10. Bone hooks are used to stabilize bone. 11. Bone forceps such as the Joplin forceps are used to hold bone. 12. Mallets are used with chisels, periosteal elevators, gouges, impactors, and osteotomes. Some mallets are the Lucae, Mead, Heath, and Kirk mallets. 13. Osteotomes are used to shape bone and are used with a mallet. Cottle and Converse are the names of two osteotomes.

136 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 36-1 Top, left to right: 1 Metal medicine cup, 2 oz; 1 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, 5 inch. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 plastic scissors, straight, sharp; 1 plastic scissors, curved, sharp; 2 thumb tissue forceps with teeth (1 × 2), front view and side view; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Brown-Adson tissue forceps with teeth (9 × 9), front view and side view; 2 paper drape clips; 2 Backhaus towel forceps; 6 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps, curved, 5½ inch; 2 Allis tissue forceps; 2 Ochsner hemostatic forceps; 2 Crile-Wood needle holders, 6 inch; 1 Crile-Wood needle holder, 7 inch.

36-2 Top: 2 Adson suction tubes with finger valve controls and stylets, 9 Fr and 11 Fr. Bottom, left to right: 2 Joseph skin hooks, double prong, front view and side view; 2 Miller-Senn retractors, side view and front view; 2 Hohmann retractors, mini, front view and side view; 1 Freer elevator; 5 Hoke chisels, assorted sizes; 3 front view, 4th side view, and 5th front view; 1 Key periosteal elevator, ¼ inch; 1 Key periosteal elevator, ½ inch.

CHAPTER 36 Basic Orthopedic Surgery 137 https://kat.cr/user/Blink99/ 36-3 Top, left to right: 1 Weitlaner retractor, baby, curved; 1 metal ruler, 6 inch. Bottom, left to right: 1 Lucae mallet; 1 Ruskin rongeur, double-action; 1 Ruskin-Liston bone-cutting forceps; 2 Volkmann retractors, 2 prong, sharp; 2 Army Navy retractors, front view and side view.

138 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 37

Power Saws and Drills, Battery Powered

Power saws and power drills are commonly used equipment. Power saws are used to remove Additional images are available at: or shape bone. The blades of an oscillating saw move back and forth in a swinging motion, evolve.elsevier.com/Tighe/instrumentation whereas the blades of a reciprocating saw move back and forth in a straight line. The power source may be a battery pack, compressed nitrogen, or electricity. When setting up the saw, it is important to attach the power cord to the saw before attaching it to the power source. Power drills are used to make holes for the insertion of wires or screws or for reaming long bones. Some drill bits are attached by a chuck that requires a key, whereas others may be tightened with a keyless chuck. Drill bits may be cannulated so wires can be used as guides for the drill. Power drills include the Stryker system 5 battery drills, Synthes small battery system, Stryker Mini Driver, and Stryker REM B.

37-1 Stryker System 5 in case: drills, batteries, and most of the attachments are shown in the top right of the case. Far right, top: Pin collet.

CHAPTER 37 Power Saws and Drills, Battery Powered 139 https://kat.cr/user/Blink99/ 37-2 Top to bottom: Oscillating saw and battery.

37-3 Left, top to bottom: ¼ inch Key- less drill attachment; drill; ¼ inch drill; chuck key. Right, top to bottom: Dual- trigger rotary hand piece; battery.

140 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 37-4 Top: 1 Synthes Small Battery Drive II hand piece. Bottom, left to right: 1 Synthes Small Battery Drive casing; 1 Synthes battery insertion shield; 1 Synthes 14.4-volt battery.

37-5 Synthes Small Battery attachments. Top, left to right: 3 Synthes AO quick coupling chucks: 1 ream attachment, up to 7.3 mm; 1 chuck drill attachment, up to 7.3 mm; 1 chuck drill attachment, up to 4.0 mm; 1 chuck key; 1 Synthes quick coupling for K wires; 1 saw blade; 1 Synthes sagittal saw attachment. Bottom, left to right: 1 Synthes mini quick coupling; 1 burr attachment; 1 screw attachment; 1 Hudson quick coupling; 1 AO quick coupling.

CHAPTER 37 Power Saws and Drills, Battery Powered 141 https://kat.cr/user/Blink99/ 37-6 Stryker Mini 4200 Driver in case.

37-7 Left, top to bottom: Dual-trigger rotary hand piece; battery. Middle: Pin collet. Right, top to bottom: Jacobs chuck attachment; chuck key; oscillating saw attachment; Synthes chuck.

142 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 37-8 Top, left to right: 1 Stryker REM B cord; 1 hand piece; 1 wire collet; 1 pin collet. Bottom, left to right: 1 Chuck 5 key; 1 Jacobs chuck, ⁄32 inch; 1 Jacobs drill, ¼ inch; 1 drill adapter; 1 micro drill long; 1 micro drill and hand switch; 1 sagittal saw and hand switch.

CHAPTER 37 Power Saws and Drills, Battery Powered 143 https://kat.cr/user/Blink99/ CHAPTER 38

Small Joint Arthroscope Set

Additional images are available at: Arthroscopy is the visualization of a joint via a scope. The diameter and length of the scope evolve.elsevier.com/Tighe/instrumentation vary according to the size of the joint. Possible equipment needed for the procedure includes 1 Bard-Parker knife handle #3; 1 Adson tissue forceps with teeth (1 × 2); 1 Mayo dissecting scissors, straight; 1 Halsted mosquito hemostatic forceps, curved; and 1 Webster needle holder.

38-1 Left to right: 1 Trocar sleeve, 2.7 mm; 1 pyramidal trocar; 1 blunt obturator; 1 probe; 1 telescope lens, 25-degree.

38-2 In case, left: 1 Blunt probe; 1 hook probe; 1 straight rasp; 1 angled- down rasp; 1 angled-up rasp; 1 lateral- release knife; 1 retrograde knife; 1 serrated banana knife; 1 meniscectomy knife, right; 1 meniscectomy knife, left; 1 handle. In case, right top: 1 Blunt obturator; 1 pyramidal trocar. Right bottom: 2 Trocar sleeves; telescope lens, 30-degree. Right, top to bottom, not in case: 1 Cup forceps; 1 scissors; 1 grasper.

144 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 39

Arthroscopic Carpal Tunnel Instruments

Carpal tunnel syndrome is the narrowing of the space where the median nerve enters the Additional images are available at: hand from the wrist. An arthroscope is used for the arthroscopic carpal tunnel release pro- evolve.elsevier.com/Tighe/instrumentation cedure. Lactated Ringer’s solution or saline is often used to distend the joint for visualization. Possible carpal tunnel instruments needed for the procedure include a small joint arthroscope set, 1 Bard-Parker knife handle #3; 1 Mayo dissecting scissors, straight; 1 Adson tissue forceps with teeth (1 × 2); and 1 Crile-Wood needle holder. A brief description of the arthroscopic carpal tunnel release procedure follows: 1. A small arthroscope is inserted with the usual attachments into the carpal tunnel. 2. A retrograde knife incises the flexor reticulum with the aid of the arthroscope. A brief description of the open carpal tunnel release procedure follows: 1. A Bard-Parker scalpel handle #3 with a #10 blade is used to make a small incision in the palm of the hand. 2. A probe is inserted along the carpal tunnel narrowing. 3. A #3 Hegar dilator may be inserted to open the space. 4. A blunt dissector may be used to release the stricture.

39-1 Left to right: 1 Ridged obturator; 1 straight blunt dissector; 1 curved blunt dissector; 1 right-angle probe; 3 Hegar dilators (3, 4, and 5). Right, top to bottom: 1 Carpal tunnel video endoscope, 30 degrees; 1 slotted cannula; 2 gold handles for disposable carpal tunnel blades.

CHAPTER 39 Arthroscopic Carpal Tunnel Instruments 145 https://kat.cr/user/Blink99/ CHAPTER 40

Small/Minor Joint Replacement

Additional images are available at: Small joints are replaced with Silastic prosthetics to relieve pain and improve function. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a small bone set; a prosthesis; and a mini drill with bits and burrs. A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #3 with a #15 blade is used to make an incision on the dorsal side of the joint. 2. A weitlaner retractor is placed to expose the joint. 3. A Ruskin-Liston bone cutter is used to cut the distal and proximal ends of the bones of the joint. 4. An Adson rongeur is used to round the bone ends. 5. The mini drill is used to ream both bone canals. 6. The caliper is used to measure the length of the bone for sizing the prosthesis. 7. The Silastic prosthesis is inserted. 8. The ligaments and tendons are reattached as needed. 9. The incision is closed.

40-1 Top to bottom, left to right: 1 Metzenbaum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, straight; 1 bandage scissors, 8 inch; 1 Mayo dissecting scissors, curved. Bottom, left to right: 2 Bard-Parker knife handles #3; 1 Bard-Parker knife handle #4; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Ferris Smith tissue forceps, front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), 8 inch, front view and side view; 6 paper drape clips; 2 Backhaus towel forceps; 6 Crile hemostatic forceps, 5½ inch; 2 tonsil hemostatic forceps; 2 Ochsner hemostatic forceps, long; 2 Allis tissue forceps, long; 2 Crile-Wood needle holders, 7 inch.

146 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 40-2 Top, left to right: 2 Adson suction tubes with finger valve controls: 1 straight, 1 curved, with stylets; 1 metal ruler, 6 inch; 1 caliper, inside/outside. Bottom, left to right: 2 Weitlaner retractors, sharp, medium; 2 Volkmann retractors, 2 prong, sharp; 2 Volkmann retractors, 2 prong, dull; 2 Army Navy retractors, side view and front view.

40-3 Top, left to right: 1 Heath mallet; 1 pliers. Bottom, left to right: 3 Spratt curettes: long curved, 2-0, and 3-0; bone hook; 1 Ruskin-Liston bone-cutting forceps, double-action; 1 Adson rongeur, double-action; 1 Luer bone rongeur.

CHAPTER 40 Small/Minor Joint Replacement 147 https://kat.cr/user/Blink99/ CHAPTER 41

Total Ankle Prosthesis

Additional images are available at: The most frequent cause of debilitating ankle pain is arthritis. Three of the most common causes of joint damage are (1) osteoarthritis, (2) rheumatoid arthritis, and (3) trauma- evolve.elsevier.com/Tighe/instrumentation related arthritis.

41-1 Preoperative: post-traumatic left ankle arthritis.

148 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 41-2 Postoperative: left Agility LP total ankle arthroplasty.

41-3 Postoperative: left Agility total ankle arthroplasty with custom stem talar component and subtalar joint fusion.

CHAPTER 41 Total Ankle Prosthesis 149 https://kat.cr/user/Blink99/ CHAPTER 42

Arthroscopy of the Knee/Shoulder

Additional images are available at: Possible equipment needed to perform surgery through an arthroscope includes: 1. Joint arthroscopic instrumentation. evolve.elsevier.com/Tighe/instrumentation 2. Arthroscopic linear punch used to grasp tough tissue, such as periosteum or cartilage. 3. Arthroscopic biters and baskets to remove tissue and cartilage. 4. Arthroscopic shaver and shaver tips. 5. A specialty suture passer may be used to secure a repair.

42-1 Top, right: Large bandage scissors. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 self-locking trocar sleeve, 4 mm; 1 blunt obturator, 4 mm; 1 LUMINA telescope, 25 degrees, 4 mm; 1 egress cannula, 4.5 mm; 1 pyramidal trocar, 3.7 mm; 1 conical obturator, 3.7 mm; 2 probes; 1 Adson tissue forceps with teeth (1 × 2); 1 Crile-Wood needle holder, 6 inch; 1 Mayo dissecting scissors, straight.

150 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 42-2 Left to right: Tips: 1 Acufex duckbill biter, right; 1 Acufex duckbill biter, left. 1 Acufex duckbill biter, upbite; 1 Acufex duckbill biter, straight bite. Tips: 4 Acufex duckling bill biters: right; upbite; straight; left.

42-3 Acufex biter tip.

CHAPTER 42 Arthroscopy of the Knee/Shoulder 151 https://kat.cr/user/Blink99/ 42-4 Left to right: 1 Grasper. Tips: 1 Acufex upbiting linear punch, 1.3 mm; 1 Acufex upbiting linear punch, 1.5 mm; 1 Acufex basket, 90 degrees, 2.2 mm, left; 1 Acufex basket, 90 degrees, 2.2 mm, right.

42-5 Left to right: Stryker arthroscopy shaver; 1 sheath; 1 shaver; 1 sheath; 1 shaver.

152 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 42-6 Arthrex scorpion suture passer, 16 mm.

42-7 Scorpion suture passer: A B A, Closed; B, open with needle.

CHAPTER 42 Arthroscopy of the Knee/Shoulder 153 https://kat.cr/user/Blink99/ CHAPTER 43

Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon Bone Graft Instruments

Additional images are available at: In addition to arthroscopic joint instrumentation, possible equipment needed for the procedure includes: evolve.elsevier.com/Tighe/instrumentation 1. Acorn cannulated drill bits used for femoral drilling. 2. Acufex cannulated drill bits used for tibial drilling. 3. Rasps used to smooth bone. 4. Arthrex tips used as graft pushers to push the tendon into position; a femoral tunnel notcher for graft attachment; and a femoral positioning drill guide for placing guidewires. 5. An Isotac screwdriver used with suture to secure the graft.

43-1 Top, left to right: 1 Tonsil hemostatic forceps, straight; 1 Webster needle holder, 5 inch; 1 small sharp scissors. Middle: 1 Jacobs chuck. Bot- tom, left to right: 7 Acufex graft sizers, 6-12 mm; 3 Acufex isometric centering guides, 7-8 mm, 9-10 mm, 11 mm; 1 parallel drill guide, 5 mm; 1 isometric positioner; 6 acorn cannulated drill bits for femoral drilling; 6 Acufex cannulated drill bits for tibial drilling.

154 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 43-2 A, Left to right: 1 Arthrex graft A pusher; 1 Arthrex femoral tunnel notcher; 1 Arthrex over-the-top femoral positioning drill guide, 6 mm; 1 Arthrex over-the-top femoral positioning drill guide, 7 mm; 1 osteotome, thin, ¼ inch; 1 Isotac screwdriver with suture and Isotac in place; 3 chamfering rasps, convex, concave, half-round; 2 gouges, ¼ inch, straight and curved; 1 osteotome, ¼ inch, curved. B, Left to right: 4 Arthrex tips: graft pusher; femoral tunnel notcher; over-the-top femoral positioning drill guide, 6 mm; over-the-top femoral positioning drill guide, 7 mm; osteotome, ¼ inch, thin; Isotac screwdriver with suture and Isotac in place. C, Left to right: 3 Rasp tips: convex, concave, and half-round; 2 gouges, ¼ inch; tips: curved and B straight; 1 osteotome, ¼ inch, curved.

CHAPTER 43 Arthroscopic Anterior Cruciate Ligament Reconstruction 155 https://kat.cr/user/Blink99/ 43-3 Top to bottom: 2 Hyperflex guidewires; 2 Beath passing pins; 1 Kirschner wire (K-wire); 1 drill bit, 1 ⁄16 inch. Bottom, left to right and top to bottom: 3 Templates: 8 and 9, side view; 10, front view; 1 Beyer rongeur, curved; 1 Ferris Smith rongeur, cup jaw (Martin); 1 pituitary rongeur.

43-4 Left to right: 2 Tibial aiming hooks, right and left, for Arthrex tibial aiming guide; 1 Kirschner wire (K-wire) sleeve for Concept precise tibial aiming guide; 1 K-wire sleeve for Arthrex tibial aiming guide; 1 notchplasty gouge. Right, top to bottom: 1 Concept precise tibial aiming guide; 1 Arthrex tibial aiming guide.

156 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 44

Total Knee Replacement

A total knee replacement is the removal of the distal end of the femur and the proximal end Additional images are available at: of the tibia. A prosthesis is used to reestablish the joint. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a total joint replacement set and battery powered drills. A brief description of the procedure follows: 1. A positioning device may be used. The De Mayo knee positioner assists in the stabilization of the patient’s leg during surgery. The spring loaded lever allows for control of flexion, extension, tilt, and rotation. 2. A Doane retractor is used to protect the medial collateral ligament. 3. An alignment guide is placed lateral to the tibial tubercle. 4. A power saw is used to resect the proximal end of the tibia. 5. Spacer/alignment blocks are used to check for valgus alignment. 6. The AP cutting guide is used to determine where to cut the femur. 7. The saw is used to resect the distal end of the femur. 8. Tibial and femoral ends are checked for size. 9. The trial components are placed and secured. 10. The joint is evaluated and the trials are removed. 11. A prosthesis is chosen and placed. Both a femoral impactor and a tibial impactor are needed. A mallet is used to seat each component.

44-1 Sigma total knee, base femur and tibia pan #1.

CHAPTER 44 Total Knee Replacement 157 https://kat.cr/user/Blink99/ 44-2 Sigma total knee, base femur and tibia pan #2.

44-3 Sigma total knee, fixed REF femur prep pan #1.

44-4 Sigma total knee, fixed REF femur prep pan #2.

158 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 44-5 Sigma total knee, patella insertion pan #1.

44-6 Sigma total knee, patella insertion pan #2.

44-7 Sigma total knee, femoral trials pan.

CHAPTER 44 Total Knee Replacement 159 https://kat.cr/user/Blink99/ 44-8 Sigma total knee, FB tibia prep pan.

44-9 Sigma total knee, spacer blocks pan #1.

44-10 Sigma total knee, spacer blocks pan #2.

160 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 44-11 Sigma total knee, MBT prep pan.

44-12 De Mayo knee positioner: Top : Base. Bottom, left to right : Universal distractor, single lever clamp, and foot holder.

CHAPTER 44 Total Knee Replacement 161 https://kat.cr/user/Blink99/ 44-13 Stryker cement gun.

44-14 Left to right: 1 Depuy cement mixer. Right, top to bottom: 1 Cement gun; 1 cement restrictor; 1 nozzle; 1 spatula; 2 cement scrapers.

162 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 44-15 Left to right: 1 Impactor; 2 Doane retractors, side view and front view.

44-16 NexGen system. Left to right: 1 Patella button; 1 femoral component; 1 articulating surface; 1 stem–tibial base plate.

CHAPTER 44 Total Knee Replacement 163 https://kat.cr/user/Blink99/ CHAPTER 45

Shoulder Surgery Instruments

Additional images are available at: Possible equipment needed for a shoulder procedure includes specialized retractors, files, punches, and forceps. evolve.elsevier.com/Tighe/instrumentation A brief description of the open surgical procedure follows: 1. Retractors are placed to help visualize the joint and hold structures out of the operative field. These include the humeral head retractor, the glenoid self-retaining retractor, the Bankart shoulder retractor, and the Bateman glenoid retractor. 2. A bone file is used to shape the bone. 3. A glenoid punch is used to grasp the cartilage. 4. Joplin bone forceps are used to grasp and stabilize bone.

45-1 Left to right: 2 Humeral head retractors, side view and front view; 2 Richardson retractors, small, side view and front view; 2 Richardson retractors, medium, side view and front view; 2 Hibbs laminectomy retractors, side view and front view.

164 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 45-2 Left to right: 1 Glenoid self- retaining retractor with 4 blades: 2 short, 2 long, front view and side view; 1 glenoid (Bateman) retractor, narrow; 1 glenoid (Bateman) retractor, medium; 1 shoulder retractor, angled, short; 1 Bankart shoulder retractor; 1 shoulder retractor, angled, long.

45-3 Left to right: 1 Shoulder ligature carrier; 2 bone hooks; 1 double-ended blunt elevator; 1 Foman rasp, double- ended; 1 glenoid punch; 1 Joplin bone forceps.

CHAPTER 45 Shoulder Surgery Instruments 165 https://kat.cr/user/Blink99/ CHAPTER 46

Hip Fracture

Additional images are available at: A hip fracture is usually a break in the neck of the femur. The fracture may be pinned with a nail, a screw, or a screw and plate. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes hip retractors. A brief description of the hip-pinning procedure follows: 1. An Israel retractor is used for muscle retraction. 2. A Hibbs retractor is used for visualization of the hip joint. 3. A Bennett elevator is used to raise the femur into position. 4. A Scott-McCracken elevator is used to remove periosteum. 5. A Hohmann retractor is used to hold soft tissue back from the operative site. 6. An Adson suction tip with tubing is used for visualization. 7. A drill guide is used to show the angle of drilling. 8. A drill is used to make a hole for the nail or the screw. 9. A depth gauge is used to determine the length of the dynamic hip screw (DHS). 10. A nail is inserted. 11. If a plate is needed, it is chosen to fit the femur. A drill is used to start the screw holes; a depth gauge is used to determine the screw length; and a screwdriver is used to tighten the screws.

46-1 Top to bottom: 1 Yankauer suction tube with tip; 2 Adson suction tubes with finger valve controls and stylets, large. Bottom, left to right: 1 Metal ruler, 6 inch; 1 pliers; 6 paper drape clips; 2 Backhaus towel forceps; 6 Crile hemostatic forceps, 6½ inch; 2 tonsil hemostatic forceps; 4 Ochsner hemostatic forceps, 8 inch; 2 Crile- Wood needle holders, 8 inch.

166 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 46-2 Top, left to right: 2 Mayo dissecting scissors, straight; 1 Metzen- baum dissecting scissors, 7 inch; 1 Mayo dissecting scissors, curved. Bottom, left to right: 2 Bard-Parker knife handles #4; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 thumb tissue forceps with teeth (1 × 2), front view and side view; 2 thumb tissue forceps with multiteeth (4 × 5), front view and side view; 2 Ferris Smith tissue forceps, front view and side view.

46-3 Left to right: 2 Bone hooks; 2 Army Navy retractors, front view and side view; 2 Volkmann retractors, 2 prong, sharp; 2 Volkmann retractors, 6 prong, sharp, front view and side view; 2 Israel retractors, front view and side view.

46-4 Left to right: 2 Weitlaner retractors, medium, sharp; 2 Bennett bone elevators and retractors, side view and front view; 2 Hibbs laminectomy retractors, medium, side view and front view.

CHAPTER 46 Hip Fracture 167 https://kat.cr/user/Blink99/ 46-5 Left to right: 1 Scott-McCracken elevator; 1 Key periosteal elevator, ¾ inch; 1 Heath mallet; 1 Luer bone rongeur; 2 Lowman bone-holding clamps, front view.

168 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 47

Hip Retractors

Hip retractors are made to be used in the various angles of the hip joint. Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

47-1 Left to right: 1 Antler retractor, front view; 1 double Cobra retractor, side view; 2 blunt Cobra retractors, side view; 1 Hohmann retractor, front view; 1 bone hook.

47-2 Top: 1 Flexible depth gauge. Bottom, left to right: 2 Anterior retractors, left and right; 1 superior retractor; 3 Hohmann retractors, narrow, 1 side view and 2 front views; 1 posterior/ inferior retractor; 1 femoral retractor.

CHAPTER 47 Hip Retractors 169 https://kat.cr/user/Blink99/ CHAPTER 48

Total Hip Replacement

Additional images are available at: A total hip replacement is the removal of the acetabulum and the head of the femur, which are replaced with prosthetic implants. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes power saws and blades; power drill, bits, and reamers; a hip prosthesis; total hip instruments; and hip retractors. A brief description of the procedure follows: 1. Bennett and Hibbs retractors are used for visualization and stabilization of the hip joint. 2. A power saw is used to remove the head of the femur. 3. A power drill is used to ream the shaft of the femur. 4. An acetabular reamer set is used to prepare the acetabulum. 5. The sizer sets are used to determine the size of the acetabular component. 6. A trochanter reamer set is used to prepare the proximal femur. 7. A reamer tray with drill is used to prepare the femoral shaft. 8. A rasp tray with a mallet is used to prepare the femur for the femoral component. 9. The complete set of hip prostheses is used to select the correct size of the prosthetic to be used.

48-1 Top: 2 Volkmann retractors, 2 prong, sharp. Bottom, left to right: 2 Bard-Parker knife handles #4; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 1 thumb tissue forceps with teeth (1 × 2); 2 Ferris Smith tissue forceps, front view and side view; 1 Mayo dissecting scissors, curved; 1 Mayo dissecting scissors, straight; 4 paper drape clips; 2 Back- haus towel forceps; 2 Crile hemostatic forceps, 6½ inch; 2 tonsil hemostatic forceps; 1 Mayo-Péan hemostatic forceps; 2 Ochsner hemostatic forceps; 1 Foerster sponge forceps; 2 Crile- Wood needle holders, 8 inch.

170 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 48-2 Top, left to right: 2 Yankauer suction tubes with tips; 2 Volkmann retractors, 6 prong, sharp. Bottom, left to right: 1 Bard-Parker knife handle #4, long; 1 Russian tissue forceps, long; 1 Mayo dissecting scissors, curved, long; 1 bandage scissors, large; 1 Spratt curette, straight, short; 1 Spratt curette, angled, long; 2 weitlaner retractors, medium.

48-3 Top left: 1 Metal mallet. Right, top to bottom: 1 Metal ruler, 12 inch; 1 Townley femur caliper; 2 Steinmann 9 pins, ⁄64 inch. Bottom, left to right: 3 Cobb spinal elevators: small, medium, and large; 1 Key periosteal elevator, 1 inch; 1 bone hook; 1 pliers; 1 Smith- Petersen laminectomy rongeur, double-action; 1 Luer bone rongeur.

CHAPTER 48 Total Hip Replacement 171 https://kat.cr/user/Blink99/ 48-4 Top right: 1 Prosthesis driver. Bottom, left to right: 3 Richards bone curettes, long, assorted sizes; 1 tapered T-handle femoral shaft reamer; 1 Buck cement restrictor inserter; 1 Stryker cement restrictor inserter; 1 Murphy bone lever or skid; 1 impactor; 1 cork- screw femoral head remover.

48-5 Initial incision retractor with two blades: long and short.

172 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 48-6 Top: 1 Hohmann retractor, large. Bottom, left to right: 1 Hohmann retractor, small; 1 Cobra retractor, straight, front view; 1 Cobra retractor, angled, side view; 1 Cobra retractor, slightly angled, side view; 1 Taylor spinal retractor, black finish, short; 1 Taylor spinal retractor, black finish, long; 3 Hibbs laminectomy retractors: small, medium, and large.

CHAPTER 48 Total Hip Replacement 173 https://kat.cr/user/Blink99/ CHAPTER 49

Total Hip Instruments (Zimmer-VerSys)

Additional images are available at: Possible equipment needed for the total hip replacement procedure includes a basic total evolve.elsevier.com/Tighe/instrumentation hip set, hip retractors, and total hip prosthesis.

49-1 Instruments (Trilogy acetabular).

49-2 Hall surgical acetabular reamer set.

174 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 49-3 Shell provisionals and acetabular instruments.

49-4 Shell provisionals and acetabulars.

49-5 Linear provisionals.

CHAPTER 49 Total Hip Instruments (Zimmer-VerSys) 175 https://kat.cr/user/Blink99/ 49-6 General instruments: stem.

49-7 General instruments: femoral.

49-8 Rasp tray.

176 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 49-9 Reamer tray 2A.

49-10 Top, left to right: V-Lign instrument tray; intramedullary taper reamers. Bottom, left to right: Stabilizer; 1 Crile template.

CHAPTER 49 Total Hip Instruments (Zimmer-VerSys) 177 https://kat.cr/user/Blink99/ 49-11 Cone provisionals. A, Size options. B, Porous and enhanced taper. C, Left, Cemented. Right, Cemented extended offset. A

49-12 Left to right: 1 Acetabular prosthesis; 1 femoral head prosthesis; 1 femoral stem prosthesis, plain; 1 femoral stem prosthesis, cemented.

49-13 Left to right: Prosthesis: Midcoat porous stem; prosthesis: fully porous stem.

178 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 50

Spinal Fusion with Rodding

A spinal fusion with rod attachment is performed to correct curvature of the spine. The Additional images are available at: fusion may use bone from the iliac crest or bone from a bone bank. The soft tissue around evolve.elsevier.com/Tighe/instrumentation the vertebra is removed and the bone graft is placed for the fusion. Possible instrumentation and equipment needed for this procedure includes basic spine instruments including retractor systems, fluoroscopy to verify placement of pedicle screws, a high-speed drill with burring attachments, dural repair microinstruments, and a microscope. There are a wide variety of spinal systems. Texas Scottish Rite Hospital (TSRH) is a system using crosslinks to stabilize rods and is presented in this chapter. A brief description of how a spinal construct could be inserted is as follows: 1. Decompression of the spine and cleaning out of the disc space for a graft. 2. Shaving, sizing, and trialing for an interbody disc spacer made of allograft, poly-ether ether ketone (PEEK) plastic, or titanium. 3. Measuring and tapping for titanium pedicle screws on one side of the spine or bilaterally. 4. Sizing and insertion of a titanium rod between the screws. 5. Placing locking caps on the screw heads of the screws to hold the rod in place. 6. Distracting the screw rod construct to reduce the amount of kyphosis, lordosis, or sco- liosis present in the spine. 7. Optional placement of cross-connectors between the rods to provide additional stability.

50-1 TSRH implant tray (labeled).

CHAPTER 50 Spinal Fusion with Rodding 179 https://kat.cr/user/Blink99/ 50-2 TSRH top tightening implant tray (labeled).

50-3 TSRH bending tray (labeled).

50-4 TSRH rod tray (labeled).

180 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 50-5 TSRH pediatric instrument, bottom tray (labeled).

50-6 TSRH pediatric instrument, top tray (labeled).

50-7 TSRH hook trials (labeled).

CHAPTER 50 Spinal Fusion with Rodding 181 https://kat.cr/user/Blink99/ 50-8 TSRH cross-link tray (labeled).

50-9 TSRH wrench tray (labeled).

50-10 Left, top to bottom: Holt probe set: curved probe, T-handle probe, round/straight probe. Bottom, left to right: 1 T-handle wrench; 2 probes (DePuy AcroMed); 1 anterior awl, straight.

182 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 50-11 Left to right: 2 Mini–hook holders with attachments; 3 hook holders without pegs; 2 hook holders with rod movers, front view and side view; 1 hook inserter.

50-12 Left to right: 1 Harrington outrigger (3 pieces), assembled; 1 Harrington outrigger nut, pin, wrench; 1 large compressor; 1 curved spreader (Sofamor); 1 large distractor.

50-13 Rod cutter.

CHAPTER 50 Spinal Fusion with Rodding 183 https://kat.cr/user/Blink99/ 50-14 Postoperative. Postposterior fusion at L4-L5 with normal alignment.

184 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 51

Long Bone Rodding for Fracture Fixation

Possible equipment needed for the procedure includes an Association for the Study of Additional images are available at: Internal Fixation (ASIF) basic set. evolve.elsevier.com/Tighe/instrumentation A brief outline of the procedure follows: 1. A small dissection set is needed to make a small incision on the proximal end of the bone to be reduced. 2. A cannulated drill bit is placed through a drill sleeve with the aid of fluoroscopy. 3. A calibrated guidewire is placed down the shaft across the fracture site. 4. The size and length of the rod (nail) is determined. 5. A slide hammer is attached to the rod. 6. A mallet drives the rod down the shaft. 7. Screws may be placed on either end of the rod for stabilization.

51-1 Top: Tray that includes reamer heads, flexible shafts and reamer, ram, and cannulated guide rod. Middle: Wrench. Bottom: 1 Awl and 3 hand reamers.

CHAPTER 51 Long Bone Rodding for Fracture Fixation 185 https://kat.cr/user/Blink99/ 51-2 Top: 2 Plastic medullary tubes. Bottom, left to right: 1 Diameter gauge; 1 awl; 1 socket wrench for conical bolts. Middle, top to bottom: 3 Threaded conical bolts; 1 guide handle for nails; 1 quick-coupling adapter; 4 reamer heads, assorted sizes; 1 holder for reaming rod and guide shaft. Right, top to bottom: 1 Tissue protector; 1 curved driver (2 pieces).

186 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 52

ASIF Universal Femoral Distractor Set

The distractor is applied directly to the bone allowing for reduction of the fracture and aid- Additional images are available at: ing in stabilization prior to the final fixation of the fracture site. This can also be used for evolve.elsevier.com/Tighe/instrumentation fractures involving the tibial plateau and pelvic fractures.

52-1 Top, left to right: Universal T-handle and shank pin; 1 drill bit; 3 drill guides; 1 pin wrench. Bottom, left: Stationary pin bar on distractor bar; traveling pin bar on right.

CHAPTER 52 ASIF Universal Femoral Distractor Set 187 https://kat.cr/user/Blink99/ CHAPTER 53

Synthes Retrograde/Antegrade Femoral Nail

Additional images are available at: Femoral nails are placed to align and stabilize a femoral long bone fracture. The type of nail (antegrade vs. retrograde, reamed vs. unreamed) is dependent on the type of fracture, loca- evolve.elsevier.com/Tighe/instrumentation tion, accessibility of the fracture, and physician’s preference.

53-1 Synthes retrograde/antegrade femoral nail pan #1.

53-2 Synthes retrograde/antegrade femoral nail pan #2.

188 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 53-3 Synthes retrograde/antegrade femoral nail pan #3.

CHAPTER 53 Synthes Retrograde/Antegrade Femoral Nail 189 https://kat.cr/user/Blink99/ CHAPTER 54

Synthes Unreamed Tibial Nail Insertion and Locking Instruments

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

54-1 Synthes unreamed tibial nail insertion and locking set (labeled). Bottom: 5 Sizes of locking bolts.

54-2 Synthes unreamed tibial nail set, assorted sizes.

190 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ CHAPTER 55

External Fixation of Fractures

External fixation is the attachment of a framework outside the body to stabilize complex Additional images are available at: fractures. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes an Association for the Study of Internal Fixation (ASIF) basic set. A brief description of the procedure follows: 1. A small incision is made at each insertion and each exit of the pins. 2. A periosteal elevator is used for blunt dissection to the bone. 3. The drill sleeve is placed to protect the soft tissue. 4. Pins are drilled through the bone above and below the fracture or fractures. 5. This process is repeated for every bone fragment that must be stabilized. 6. Universal joints are placed over the ends of each pin. 7. The frame is placed. 8. A wrench is used to tighten the frame. 9. A pin cutter is used to cut the pins as needed.

55-1 The Evolution Tray has the instruments to put together the Taylor Spatial framework. (The Evolution Tray was prepared by Dr. Douglas N. Beaman.)

CHAPTER 55 External Fixation of Fractures 191 https://kat.cr/user/Blink99/ 55-2 Left to right: Pin cutter; wire; tensioner; wrench; box wrench; drill. (The Evolution Tray was prepared by Dr. Douglas N. Beaman.)

55-3 Left, top to bottom: Taylor Spa- tial rings with struts in place; Taylor Spatial foot plate. Right, top to bottom: 2 Struts; 1 Taylor Spatial ring.

192 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 55-4 Taylor Spatial frame on patient. (Courtesy Lynn Scott, Gaston, Ore.)

55-5 ASIF external fixator miniset.

CHAPTER 55 External Fixation of Fractures 193 https://kat.cr/user/Blink99/ CHAPTER 56

ASIF Pelvic Instrument Set

Additional images are available at: Pelvic stabilization is needed due to the traumatic nature of pelvic fractures. This may include acetabular restructure or stabilization of the iliac, ischium, and pubic bones. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes a soft tissue set, basic orthopedic instrumentation, and pelvic fixation.

56-1 Left to right: 1 Plate bender; 2 pelvic plate-bending templates, long; 1 small hexagonal screwdriver; 1 drill guide, long, 2.5 mm; 1 drill guide, long, 3.5 mm; 1 small hexagonal screwdriver, long, large handle; 1 small hexagonal screwdriver, regular; 1 depth gauge; 4 drill bits, 2.5 × 180 mm; 4 drill bits, 3.5 × 170 mm; 2 taps, 3.5 × 180 mm.

56-2 ASIF pelvic implant set.

194 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 56-3 Pelvic external fixator.Top to bottom: 3 Straight black carbon tubes with attaching clamps on each side; 1 curved black carbon tube with Schanz pins attached on each side.

CHAPTER 56 ASIF Pelvic Instrument Set 195 https://kat.cr/user/Blink99/ CHAPTER 57

Universal Screwdriver/Broken Screw Set

Additional images are available at: The universal screw set allows you to have multiple types and sizes of screwdrivers available when you may not know what type of hardware was previously implanted, whereas the evolve.elsevier.com/Tighe/instrumentation broken screw set allows you to extract stripped or broken screws.

57-1 Shukla Universal Screwdriver Set. 1 Cannulated silicone ratcheting screwdriver with various sized screwdriver attachments including flexible and solid hex drivers, torx drivers, flat-tip drivers, and Phillips-tip drivers.

196 UNIT 5 Orthopedic Surgery https://kat.cr/user/Blink99/ 57-2 Top, left to right: 1 Broken screw caddy and 1 stripped screw caddy. Bottom, left to right: 1 Extension driver, 8 inch; 1 extension driver, 6 inch; 1 stripped screw extractor breaker bar with cannulated ratcheting T-handle; 1 extension driver, 4 inch; 1 power drill adapter.

CHAPTER 57 Universal Screwdriver/Broken Screw Set 197 https://kat.cr/user/Blink99/ CHAPTER 58 UNIT SIX: EYE, EAR, NOSE, AND THROAT SURGERY

Basic Eye Set

Additional images are available at: The basic eye set is used for the initial preparation of the eye. Examples include placement of the Lancaster speculum, Beaver knife handles with blades, and iris scissors. In this chap- evolve.elsevier.com/Tighe/instrumentation ter we have also included a chalazion set and a pterygium set, both of which include basic eye instrumentation that is seen throughout this unit. The chalazion set is used for the excision of a chalazion, a lipogranuloma of either the meibomian or Zeiss gland. A brief description of the procedure follows: 1. An appropriate size chalazion clamp is applied to evert the lid and to control bleeding. 2. A #11 knife blade on a #9 Bard-Parker knife handle is used to make a 2- to 3-mm incision. 3. An appropriate size chalazion curette is used to remove contents including any cyst lining. 4. Pressure is applied for a few minutes to achieve hemostasis. 5. Occasionally, a Castroviejo needle holder is used to place stitches. 6. McPherson forceps, straight and curved, are used to tie the suture. The pterygium set is used for excision of pterygium with autograft or amniotic membrane placement. Pterygium is a noncancerous growth on the conjunctiva. Possible equipment needed for the procedure includes an ophthalmic microscope.

58-1 Top, left to right: 1 Plastic scissors, straight, sharp, 5½ inch; 1 Lancaster speculum; 4 Edwards holding clips. Bottom, left to right: 1 Bard-Parker knife handle #9; 2 Beaver knife handles, knurled, one insert above; 1 iris scissors, straight, 4½ inch; 1 Stevens tenotomy scissors; 4 Halsted mosquito hemostatic forceps, curved; 2 Halsted mosquito hemostatic forceps, straight.

198 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 58-2 Chalazion set. Top, left to right: 2 Blue clips; 1 Jeweler’s bipolar forceps; 1 Desmarres chalazion forceps; 1 Francis chalazion forceps; 1 Baird chalazion forceps; 1 Lambert chalazion forceps; 1 Hunt chalazion forceps; 1 Vital Mayo dissecting scissors. Bottom, left to right: 1 Bard-Parker knife handle, #9; 1 Beaver blade handle; 1 Meyerhoeffer chalazion curette, 1.5-mm cup; 1 Castroviejo needle holder, locking, curved, 11 mm; 1 Westcott tenotomy scissors, curved, blunt tip; 1 Stevens tenotomy scissors, straight; 1 Castroviejo suturing forceps, 0.12 mm; 1 Castroviejo suturing forceps, 0.3 mm; 1 McPherson tying forceps, straight; 1 McPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.9 mm; 1 Halsted mosquito forceps, curved; 1 Skeele curette, 2.0-mm cup; 1 Meyerhoeffer chalazion curette, 2.5-mm cup; 1 chalazion curette, 3.0-mm cup.

58-3 Curette tips. Left to right: 1 Meyerhoeffer curette, 1.5 mm; 1 Skeele curette, 2.0 mm; 1 chalazion curette, 2.5 mm; 1 chalazion curette, 3.0 mm.

CHAPTER 58 Basic Eye Set 199 https://kat.cr/user/Blink99/ 58-4 Pterygium set. Top, left to right: 2 Blue chips; 2 Halsted mosquito forceps, straight, smooth; 1 Halsted mosquito forceps, curved, smooth; 1 Mayo dissecting scissors, straight; 1 Castroviejo caliper; 1 Lieberman eye speculum; 1 Kratz-Berraquer wire eyelid speculum. Bottom, left to right: 1 Beaver knife handle; 1 Castroviejo suturing forceps, 0.9 mm; 1 Fechtner micro ring forceps; 1 Harms-Tubingen tying forceps, straight; 1 MacPherson tying forceps, straight; 1 MacPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.12 mm; 1 Stevens tenotomy scissors, straight, 3½ inch. 1 Vannas capsulotomy scissors, 1 straight, 3 ⁄8 inch; 1 Westcott tenotomy scissors, curved; 1 Barraquer needle holder, locking, curved, 9 mm; 1 Barraquer needle holder, nonlocking, curved; 1 Castroviejo needle holder, locking, straight, 12 mm; 1 Castroviejo needle holder, locking, curved, 11 mm; 1 Jeweler’s bipolar forceps.

200 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 59

Clear Corneal Set

The clear corneal cataract procedure is performed with the use of topical anesthetics, fold- Additional images are available at: able intraocular lenses (IOLs), and diamond or disposable knives. This allows the surgeon evolve.elsevier.com/Tighe/instrumentation to make microincisions that are self-healing and may not need stitches. Possible instruments and equipment needed for the procedure include an ophthalmic operating microscope and a phacoemulsifier. For this procedure to be performed, it is imperative that the patient can hear and is able to follow specific directions. A brief description of the procedure follows: 1. A Lieberman speculum is placed to retract the eyelids. 2. A fine Thornton fixation ring or a 0.12 Castroviejo suturing forceps is used to stabilize the cornea. 3. A disposable 1-mm sideport blade is used to make paracentesis. 4. After local anesthesia and viscoelastic are placed in the anterior chamber, Utrata forceps is used to make a capsulorrhexis. 5. Balanced salt solution (BSS) in a 3-cc syringe with a 27-gauge disposable cannula is used to hydrodisect the lens nucleus. 6. The phacoemulsifier is used to remove the nucleus with a nucleus manipulator or IOL hooks of surgeon’s choice. 7. A 1/A tip and hand piece are used to remove lens cortex. 8. After filling a capsule with viscoelastic, the IOL is inserted with an Alcon Monarch III IOL injector and disposable cartridge. 9. The Lester IOL manipulator is used to position the IOL accurately. 10. A 1/A tip and hand piece is used to remove the viscoelastic. 11. BSS in a 3-cc syringe with a 27-gauge disposable cannula is used to hydroseal the incision.

59-1 Top, left to right: 1 Lieberman speculum; 4 needle cannulas, 1 30-gauge, 1 27-gauge, 1 Chang, and 1 27-gauge. Bottom, left to right: 1 Halsted mosquito hemostatic forceps, fine tip; 3 Edwards holding clips; 1 paper drape clip.

CHAPTER 59 Clear Corneal Set 201 https://kat.cr/user/Blink99/ 59-2 Left to right: 1 Gaskin fragment forceps, angled; 1 Kelman-McPherson tying forceps, angled; 1 Castroviejo suturing forceps, 0.12 mm; 1 Utrata forceps; 1 iris scissors, straight.

59-3 Left to right: Enlarged tips: AB A, Gaskin fragment forceps, angled; B, Kelman-McPherson suture-tying forceps, angled; C, Castroviejo suturing forceps, 0.12 mm; D, Utrata forceps, angled.

202 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 59-4 Left to right: 1 Fine Thornton swivel fixation ring, 13 mm; 1 Graether collar button; 1 Bechert nucleus rotator; 1 Nagahara Phaco chopper; 1 Seibel nucleus chopper; 1 Hirschman iris hook, titanium; 1 Lester IOL manipulator; 1 Kuglen iris hook manipulator, angled round; 1 Sinsky lens hook, straight; 1 Castroviejo cyclodialysis spatula, double-ended; 1 iris spatula. Top to bottom, going across: 1 Disposable 27-gauge cannula; 1 Jensen capsule polisher; 1 Connor anesthesia cannula; 1 Jensen capsule polisher; 1 disposable cannula, 19-gauge.

A BCD

EF GH

59-5 Enlarged tips: A, Bechert nucleus rotator; B, Nagahara Phaco chopper; C, Seibel nucleus chopper; D, Hirschman iris hook; E, Lester IOL manipulator; F, Kuglen iris hook manipulator; G, Sinsky lens hook; H, iris spatula.

CHAPTER 59 Clear Corneal Set 203 https://kat.cr/user/Blink99/ 59-6 Left to right, top to bottom: 1 Alcon Monarch III IOL injector; 1 0.9-mm MicroSmooth l/A sleeve; 1 wrench; 1 0.3-mm 45-degree bend l/A tip; 1 0.3-mm small bore l/A tip (attached to hand piece); 1 Alcon l/A UltraFlow SP hand piece, threaded; 1 Intrepid 0.3-mm bend l/A tip; 1 testing chamber; 1 wrench; 1 Phaco tip (attached); 1 Alcon OZil torsional hand piece; 1 0.9-mm MicroSmooth Phaco sleeve.

59-7 Left to right: 1 Duckworth & Kent cionni toric reference marker; 1 Gimbel Mendez fixation and guide ring (handle mounted at 90 degrees); 1 Bores two-ray corneal meridian marker.

204 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 60

Corneal Transplant

Corneal transplant is the replacement of a damaged cornea with a cornea from a human Additional images are available at: donor’s eye. evolve.elsevier.com/Tighe/instrumentation Possible equipment and instruments needed for the procedure include an operating microscope, a disposable trephine, a Teflon block, and a basic eye set. A brief description of the procedure follows: 1. The Schott eye speculum is placed to retract the eyelids. 2. The Flieringa fixation ring is placed to stabilize the eyeball. 3. A disposable trephine is used to cut a button from the cornea of the donor’s eye. 4. The trephine is used to cut a slightly smaller button from the recipient’s eye. 5. The Polack forceps is used to place the donor’s button in the space in the recipient’s cornea. 6. The Troutman-Barraquer needle holder with suture and Sinskey tying forceps are used to secure the cornea in place. 7. Irrigating cannulas are used to lubricate the eye with solution as needed.

60-1 Top, left to right: 2 Barraquer wire speculums; 1 Flieringa fixation ring (double ring); 1 McNeil-Goldman scleral ring (with wings); 2 single-wire Flieringa fixation rings; 1 Lancaster speculum. Bottom, left to right: 1 Schott eye speculum; 1 Castroviejo caliper.

CHAPTER 60 Corneal Transplant 205 https://kat.cr/user/Blink99/ 60-2 Left to right: 1 Jeweler’s forceps, straight; 1 Elschnig fixation forceps; 1 Lester fixation forceps; 1 serrated forceps, fine; 1 Castroviejo suturing forceps, 0.5 mm; 1 Castroviejo suturing forceps, 0.12 mm; 1 McPherson tying forceps, angled; 1 Troutman-Barraquer forceps (Colibri type); 1 Polack double- tipped, corneal forceps (Colibri type); 1 Maumenee corneal forceps; 1 Clay- man lens-holding forceps.

60-3 Left to right: Enlarged tips: A, Jeweler’s forceps, straight; ABC B, Elschnig fixation forceps; C, Lester fixation forceps.

60-4 Left to right: Enlarged tips: A B C A, Castroviejo suturing forceps, 0.5 mm; B, Troutman-Barraquer forceps (Colibri type); C, Polack double- tipped corneal forceps (Colibri type).

206 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 60-5 Left to right: Enlarged tips: A, Clayman lens-holding forceps; A B B, Maumenee corneal forceps, side view.

60-6 Top, left to right: 1 Sheets irrigating vectis, 27-gauge; 2 irrigating cannulas, 23- and 27-gauge. Bottom, left to right: 1 Beaver knife handle, knurled, with insert; 1 corneal scleral marker; 1 Shepard iris hook; 1 Bechert nucleus rotator, Y-shaped tip; 1 Sinskey iris and IOL hook; 1 Culler iris spatula; 1 Jameson muscle hook; 1 lens loop; 1 Paton spatula, double- ended; 1 Castroviejo needle holder with lock, curved; 1 titanium needle holder with stop, no lock, curved; 1 Sinskey tying forceps, straight; 1 Troutman-Barraquer microneedle holder, curved.

CHAPTER 60 Corneal Transplant 207 https://kat.cr/user/Blink99/ 60-7 Left to right: Enlarged tips: A B C A, Corneal scleral marker; B, Shepard iris hook; C, Bechert nucleus rotator, Y-shaped tip; D, Sinskey iris and IOL hook; E, Culler iris spatula.

60-8 Left to right: Enlarged tips: A, Jameson muscle hook; B, lens loop; ABC C, Paton spatula, double-ended.

208 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 60-9 Left to right: Enlarged tips: AB CDA, Titanium needle holder with stop, no lock, curved; B, Castroviejo needle holder with lock, curved; C, Troutman- Barraquer microneedle holder, curved; D, Sinskey tying forceps, straight.

60-10 Left to right: 2 Halsted mosquito hemostatic forceps; 2 blunt scissors, straight; 2 Castroviejo corneal section scissors, left and right; 1 Van- nas capsulotomy scissors, straight; 2 transplant microscissors, right and left; 1 Westcott tenotomy scissors.

60-11 Left to right: Enlarged tips: A, Castroviejo corneal section scissors, ABCD left; B, Castroviejo corneal section scissors, right; C, Westcott tenotomy scissors; D, Vannas capsulotomy scissors, straight.

CHAPTER 60 Corneal Transplant 209 https://kat.cr/user/Blink99/ CHAPTER 61

Deep Lamellar Endothelial Keratoplasty

Additional images are available at: Deep lamellar endothelial keratoplasty (DLEK) is a split-thickness (lamellar transplant) form of corneal transplantation. When this procedure is performed, a smaller incision is evolve.elsevier.com/Tighe/instrumentation used, and only the diseased tissue is removed. The remainder of the patient’s cornea remains intact. This procedure involves the replacement of the back layers of the cornea rather than the front layers. It is performed through a small pocket incision, which avoids any changes in the front surface of the cornea. In the DLEK procedure, one to three tiny sutures are placed, rather than the 16 regular sutures or one to two long looping sutures in a circle that are used in penetrating keratoplasty (PK). In the DLEK procedure, the cornea has a smoother surface and a clearer transplant, which allows many of the patients to see better in a matter of weeks instead of the months or years in a standard full-thickness corneal transplant. Possible instruments needed for the procedure include a cataract removal set. Today there are disposable kits available for both the donor and the recipient.

61-1 Left to right: 1 8-mm Corneal marker; 1 Charlie insertion forceps; 2 Devers dissectors, curved; 1 Cindy scissors; 1 Cindy 2 scissors; 1 reverse Sinskey hook; 1 Nick pick; and 1 Terry scraper.

210 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 61-2 Left to right: Enlarged tips: A B C A, 8-mm Corneal marker; B, Charlie insertion forceps; C, Terry scraper, Nick pick, and reverse Sinskey hook; D, Devers dissectors; E, Cindy scissors and Cindy 2 scissors.

D E

CHAPTER 61 Deep Lamellar Endothelial Keratoplasty 211 https://kat.cr/user/Blink99/ CHAPTER 62

Glaucoma

Additional images are available at: Glaucoma is a condition of increased intraocular pressure because of obstructed aqueous humor outflow. evolve.elsevier.com/Tighe/instrumentation Possible instruments and equipment needed for the procedure include a basic eye set, an operating microscope, and a shunt. A brief description of the procedure follows: 1. A Lancaster speculum is placed to retract the eyelids. 2. A Beaver knife handle with blade is used to incise the conjunctiva. 3. A Jameson muscle hook is used to isolate the rectus muscles. 4. The device plate is sutured to the sclera using the Barraquer needle holder and Kelman-McPherson tying forceps. 5. A Kelly Descemet membrane punch is used to create a tunnel into the anterior chamber. 6. The device tube is inserted into the anterior chamber and anchored with suture. 7. The conjunctiva is closed.

62-1 Left to right: 1 Kelman- McPherson tying forceps, straight, front view; 1 Kelman-McPherson tying forceps, angled, side view; 2 Mc- Cullough utility forceps, front view and side view; 1 McPherson tying forceps, straight; 1 McPherson tying forceps, curved; 1 Chandler (Gills) forceps; 2 Hoskins forceps, straight and curved.

212 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 62-2 Top right: 1 Irrigation cannula, 19-gauge. Bottom, left to right: 2 Vannas scissors, straight and curved; 1 Westcott corneal miniscis- sors, sharp; 1 Westcott tenotomy scissors, blunt; 1 Kelley Descemet membrane punch; 1 Elschnig cyclodialysis spatula; 2 Halsted mosquito hemostatic forceps, curved.

CHAPTER 62 Glaucoma 213 https://kat.cr/user/Blink99/ CHAPTER 63

Eye Muscle Surgery

Additional images are available at: Eye muscles are released and tucked to treat the condition called strabismus or “cross-eyes.” evolve.elsevier.com/Tighe/instrumentation Possible instruments needed for the procedure include a basic eye set. A brief description of the procedure to loosen the inferior oblique muscle follows: 1. A Cook speculum is used to retract the lids. 2. Westcott tenotomy scissors are used for incision into the tenon capsule. 3. A Jameson or Green muscle hook is used to isolate and lift the muscle. 4. A Beaver knife handle with blade is used to bisect the muscle. 5. Jameson recession forceps are used to grasp the ends of the muscle. 6. A cautery is used for hemostasis. 7. A Castroviejo caliper is used to measure how much to relax the muscle. A brief description of the procedure to tuck the superior rectus muscle follows: 1. Follow steps 1 through 3 above. 2. A Castroviejo caliper is used to measure how big a tuck to make. 3. Jameson recession forceps are used to grasp the muscle. 4. A Von Graefe strabismus hook is used to elevate the tendon to be doubled into a loop. 5. A Troutman-Barraquer needle holder is used for attaching the loop to the sclera. 6. A titanium needle holder is used for closing the conjunctiva. 7. Kelman-McPherson tying forceps are used to tie the suture.

63-1 Left to right: 2 Jameson muscle recession forceps, right, front view and side view; 2 Castroviejo tying forceps, wide handles, without tying platforms, 0.5-mm teeth (1 × 2), front view and side view; 2 McCullough utility forceps, cross-serrated; 1 Jameson muscle hook; 1 Von Graefe strabismus hook; 1 Stevens tenotomy hook; 1 Desmarres lid retractor.

214 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 63-2 2 Green muscle hooks, 7 mm wide.

63-3 Left to right: Enlarged tips: A B C A, Jameson muscle recession forceps, right; B, McCullough utility forceps, cross-serrated; C, Jameson muscle hook; D, Stevens tenotomy hook; E, Desmarres lid retractor; F, Green muscle hook.

DE F

CHAPTER 63 Eye Muscle Surgery 215 https://kat.cr/user/Blink99/ 63-4 Top, left to right: 1 Castroviejo caliper; 1 Cook eye speculum, child- sized; 1 Lancaster speculum. Bottom, left to right: 4 Serrephines; 1 strabismus scissors, straight; 1 Westcott tenotomy scissors, curved; 1 Stevens tenotomy scissors, curved; 1 Castro- viejo needle holder with lock, curved; 1 Castroviejo needle holder with lock, straight; 1 Erhardt chalazion clamp; 1 metal ruler, small.

216 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 64

Retinal Detachment

A retinal detachment is the separation of the retina from the internal wall of the eye. Additional images are available at: Possible instruments needed for repair of a detachment include a basic eye set. evolve.elsevier.com/Tighe/instrumentation A brief description of the possible methods of repairing a detached retina follows: 1. Scleral buckling. In this procedure a silicone band, sponge, or other device is placed against the outside of the eye at the area of the detachment. This presses the wall of the eye into the retina to encourage reattachment. 2. Pneumatic retinopexy. This procedure uses gas, which is injected into the posterior chamber. By positioning the patient, the gas bubble is forced against the wall of the eye where the detachment is. The gas used will expand and later diffuse in 7 to 10 or 30 to 50 days, depending on which gas is used. 3. Laser photocoagulation. This procedure uses a laser beam to treat the retinal hole. The laser may be used in conjunction with scleral buckling or pneumatic retinopexy.

64-1 Left to right: 4 Castroviejo suturing forceps, wide handles, with tying platforms: 0.3-mm front view, 0.5-mm side view, 0.12-mm front view, 0.12-mm side view; 1 Bonn suture forceps; 1 Wills Hospital utility forceps, straight; 1 Elschnig fixation forceps; 1 Harms tying forceps; 2 McCullough utility forceps, front view and side view; 1 Watzke sleeve-spreader forceps.

CHAPTER 64 Retinal Detachment 217 https://kat.cr/user/Blink99/ 64-2 Left to right: Enlarged tips: A B C A, Bonn suture forceps; B, Wills Hospital utility forceps, straight; C, Elschnig fixation forceps;D, Harms tying forceps, straight; E, Watzke sleeve-spreading forceps.

D E

64-3 Left to right: 1 Stevens tenotomy scissors; 1 Westcott tenotomy scissors; 1 Green needle holder and forceps; 1 Castroviejo needle holder, straight, without lock; 2 Castroviejo needle holders, straight, with locks; 1 Thorpe calipers; 1 Castroviejo calipers.

64-4 Top, left to right: 2 Barraquer wire speculums; 5 Mira diathermy tips, assorted. Bottom, left to right: 4 Serre- phines; 1 Beaver knife handle, knurled, with insert above; 1 Schepens orbital retractor; 1 Jameson muscle hook; 1 Von Graefe strabismus hook; 1 Gass retinal detachment hook.

218 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 65

Vitrectomy

Vitrectomy is the removal of the vitreous humor in the posterior chamber of the eye. This Additional images are available at: may be done when there is a retinal detachment to gain better access to the posterior por- evolve.elsevier.com/Tighe/instrumentation tion of the eye. Vitrectomy may also be done if blood in the vitreous humor (hemorrhage) does not clear on its own. This generally occurs from trauma to the eye.

65-1 Left to right: 1 Barraquer wire speculum; 1 iris scissors, straight; 1 Castroviejo suturing forceps, 0.12 mm; 1 Westcott tenotomy scissors; 1 Paton forceps; 1 Troutman-Barraquer needle holder, with lock; 1 Castroviejo needle holder, with lock; 1 Vannas capsulotomy scissors.

65-2 Top, left to right: 1 19-Gauge irrigating cannula; white sponge; 1 27-gauge Bishop-Harmon irrigating cannula; 1 20-gauge and 1 19-gauge cannula. Bottom, left to right: 1 Cas- troviejo caliper; 2 scleral plug forceps; 1 flat Machemer irrigating lens with attached silicone tubing; 1 Minus irrigating lens with attached silicone tubing; 1 Schocket scleral depressor, doubled-ended; 1 Von Graefe strabismus hook; 2 Castroviejo needle holders, curved, straight.

CHAPTER 65 Vitrectomy 219 https://kat.cr/user/Blink99/ 65-3 Left to right: Tips: Minus and Machemer irrigating lens.

65-4 Left to right: Tips: Scleral plug forceps, side view and front view.

220 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 66

Oculoplastic Instrument Set

Oculoplastic means plastic surgery on or about the eye. Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

66-1 Top, left to right: 1 Lancaster speculum; 2 Edwards holding clips. Bottom, left to right: 1 Castroviejo caliper; 1 Bard-Parker knife handle #3; 1 Mayo dissecting scissors, straight, 6 inch; 1 Westcott tenotomy scissors; 1 Stevens tenotomy scissors; 1 Adson tissue forceps with teeth (1 × 2); 2 Halsted mosquito hemostatic forceps, curved and straight.

66-2 Left to right: Westcott scissors, sharp and dull.

CHAPTER 66 Oculoplastic Instrument Set 221 https://kat.cr/user/Blink99/ 66-3 Left to right: 1 Mueller clamp; 1 lacrimal sac retractor, 4 prong, blunt; 1 double fixation hook, 2 prong; 1 iris scissors, sharp; 2 Bishop-Harmon tissue forceps, 0.5 mm; 2 Paufique suture forceps with teeth (1 × 2); 1 Desmarres lid retractor; 2 Castroviejo needle holders with locks, straight and curved.

66-4 Left to right: Enlarged tips: AB A, 2 Bishop-Harmon tissue forceps, with teeth 1 × 2 and smooth; B, Paufique suture forceps with teeth 1 × 2.

66-5 3 Serrephines.

222 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 67

Eye Enucleation

Enucleation is the removal of the eyeball. Additional images are available at: Possible instruments needed for the procedure include a basic eye set. evolve.elsevier.com/Tighe/instrumentation

67-1 Top: 2 Serrephines. Bottom, left to right: 1 Enucleation scissors, sharp, curved; 1 Stevens tenotomy scissors; 1 Castroviejo suturing forceps with tying platforms, 0.5-mm teeth (1 × 2); 1 Wells enucleation spoon; 2 tonsil hemostatic forceps; 1 Westphal hemostatic forceps.

CHAPTER 67 Eye Enucleation 223 https://kat.cr/user/Blink99/ CHAPTER 68

Basic Ear Set

Additional images are available at: The basic ear set is used for the preparation of the ear, the initial incision if needed, and placement of a retractor (handheld or self-retaining) to perform the surgery. evolve.elsevier.com/Tighe/instrumentation

68-1 Top, left to right: 2 Paper drape clips; 2 Backhaus towel forceps, small. Bottom, left to right: 1 Bard- Parker knife handle #3; 1 Adson tissue forceps, without teeth; 1 Adson tissue forceps, with teeth (1 × 2); 1 Brown- Adson tissue forceps with teeth (7 × 7); 1 Sheehy ossicle-holding forceps; 1 strabismus scissors, curved; 2 Halsted mosquito hemostatic forceps, curved; 2 Crile hemostatic forceps; 1 Mayo dissecting scissors, straight; 1 Johnson needle holder, 7 inch.

68-2 Upper left, top to bottom: 1 Weitlaner retractor, dull prongs, angled; 3 Baron ear suction tubes with finger valve control: 3, 5, and 7 Fr; 2 stylets. Upper right, top to bottom: 9 Richards ear speculums, assorted sizes, 4-8 mm, one side view. Bottom, left to right: 1 Cottle elevator, double-ended; 1 Lempert elevator (converse periosteal); 2 Johnson skin hooks; 2 Senn-Kanavel retractors, side view and front view; 1 House Teflon block; 1 House Gelfoam press or Sheehy fascia press; 2 metal medicine cups, 2 oz.

224 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 69

Tympanoplasty

A tympanoplasty is the repair of the tympanic membrane (eardrum). Additional images are available at: Possible equipment and instruments needed for the procedure include an operating evolve.elsevier.com/Tighe/instrumentation microscope for visualization, an ototome (Saber drill) with microbits and microburrs, and a basic ear set. A Skeeter drill (a finer microdrill) may be used if performing procedure farther into the middle ear (i.e., stapedectomy). A brief description of the procedure follows: 1. A Richards speculum of appropriate size is placed in the ear canal. 2. A Crabtree wax curette is used to remove wax from the canal. 3. A Jordan oval knife may be used to incise the tympanomeatal junction. 4. A Rosen needle is used to elevate the skin of the canal. 5. Richards cup forceps are used to clean all epithelium from the eardrum perforation. 6. An ototome drill with microburrs may be needed if the perforation is not clearly visible. 7. A House pick is used to explore the middle ear for ossicle mobility. 8. Richards alligator forceps are used to remove any epithelium in the middle ear. To harvest a graft from the temporalis muscle, a Lempert elevator may be used to separate fascia from the temporalis muscle. A strabismus scissors is used to cut the fascia, and a Sheehy fascia press is used to thin the fascia before placement. 9. Richards alligator forceps are used to place the graft over the perforation. 10. A Rosen needle is used to position the graft securely. An ossicular reconstruction may be performed; a brief description of the procedure follows: 1. A Bellucci scissors is used to cut soft tissue. 2. A Mueller malleus nipper is used to loosen the bones. 3. A House sickle knife is used to free the incus from the stapes. 4. Richards alligator forceps are used to remove the bones or fragments. 5. A partial ossicular replacement prosthesis (PORP) is needed to replace several bones. 6. A total ossicular replacement prosthesis (TORP) is needed when all middle-ear bones are removed.

CHAPTER 69 Tympanoplasty 225 https://kat.cr/user/Blink99/ 69-1 A, Rack No. 1 of delicate ear instruments with labels. B, Left to A right: Tips of delicate ear instruments: House sickle knife; Austin sickle knife; House tympanoplasty knife. C, Left to right: Tips of delicate ear instruments: Jordan oval knife; House joint knife; drum elevator; angled pick #6; angled pick #7; straight needle; House-Rosen needle.

226 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 69-2 A, Rack No. 2 of delicate ear A instruments with labels. B, Left to right: Tips of delicate ear instruments: curved needle, large curve; curved needle, small curve. C, Left to right: Tips of delicate ear instruments: straight needle; Austin 25-degree pick; House pick, 1 mm; House pick, 3 mm; oval window pick; whirleybird pick, left; whirleybird pick, right.

CHAPTER 69 Tympanoplasty 227 https://kat.cr/user/Blink99/ 69-3 A, Rack No. 3 of delicate ear instruments with labels. B, Left to right: A Tips of delicate ear instruments: small double-end curette #3; House double- end curette #1; House double-end curette; Black double-end J curette; House double-end J curette. C, Left to right: Tips of delicate ear instruments: Crabtree; ring curette; wax curette #1; wax curette #2.

228 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 69-4 A, Rack No. 4 of delicate ear A instruments with labels. B, Left to right: Tips of delicate ear instruments: measuring rod; House measuring rod, 4 mm; House measuring rod, 4.5 mm; House measuring rod. C, Left to right: Tips of delicate ear instruments: measuring rod; Derlacki; angled pick. D, Left to right: Tips of delicate ear instruments: delicate hook #14; Buckingham footplate hand drill; Rosen knife.

CHAPTER 69 Tympanoplasty 229 https://kat.cr/user/Blink99/ A

B C

69-5 A, Tray No. 1 of delicate ear forceps with labels. B, Delicate ear forceps out of tray. C, Left to right: Tips of delicate ear forceps: small alligator, serrated; Bellucci scissors; left-cup forceps. D, Left to right: Tips of delicate ear forceps: straight-cup forceps; right-cup forceps; large-cup forceps.

230 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 69-6 A, Tray No. 2 of delicate ear A forceps with labels. B, Left to right: Tips of delicate ear forceps: large crimper; small crimper; malleus nipper.

69-7 Blunt needles attached to tubing for suction tips, assorted sizes, 15- to 24-gauge.

CHAPTER 69 Tympanoplasty 231 https://kat.cr/user/Blink99/ 69-8 Left to right: 6 House suction/ irrigators with finger valve control and 1 stylet; 1 metal suction connector; 6 Baron ear suction tubes with finger valve control and 1 stylet.

69-9 Left, top to bottom: 2 Irrigation clips; 1 straight attachment; 1 angled attachment. Right: 1 Saber drill.

232 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 69-10 Left to right: 1 Medtronic Skeeter Ultra-Lite oto tool and 1 ruler.

CHAPTER 69 Tympanoplasty 233 https://kat.cr/user/Blink99/ CHAPTER 70

Tonsillectomy and Adenoidectomy

Additional images are available at: Tonsillectomy is the removal of the palatine tonsils in the oropharynx. Adenoidectomy is the removal of the lymph tissue on the posterior wall of the nasopharynx (pharyngeal evolve.elsevier.com/Tighe/instrumentation tonsils). Possible equipment and instruments needed for the procedure include an electro surgical unit and a tonsil snare. A brief description of a tonsillectomy follows: 1. A McIvor mouth gag with blade is placed in the mouth for visualization. 2. A Wieder tongue depressor is placed and held on the tongue to expose the tonsils. 3. An Andrews-Pynchon suction tip with tubing is used for removing secretions and blood. 4. A long curved Allis tissue forceps is used to grasp the tonsil. 5. A Bard-Parker scalpel handle #7 with a #11 blade is used to incise the tonsil capsule. 6. A Fisher knife may be used to extend the incision. 7. A Hurd spoon (tonsil dissector) is used to bluntly dissect the tonsil. 8. Tonsil hemostatic forceps are used to clamp the main blood supply. 9. Metzenbaum dissecting scissors are used to excise the tonsil. 10. A Ballenger sponge forceps with tonsil sponge is placed in the tonsil fossa to apply pressure for hemostasis. 11. A Hurd tonsil dissector and pillar retractor may be used to check for bleeding. 12. Electrocautery may be used for hemostasis. A brief description of an adenoidectomy follows: 1. A Lothrop uvula retractor is placed at the back of the throat for exposure of the adenoids. 2. A LaForce adenotome is inserted and cuts out the adenoid. 3. A Meltzer adenoid punch may be needed to remove any adenoid tags.

234 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 70-1 Left to right: 1 Bard-Parker knife handle #7; 1 Metzenbaum dissecting scissors, 7 inch; 2 paper drape clips; 2 Crile hemostatic forceps, 6½ inch; 1 Westphal hemostatic forceps; 4 tonsil hemostatic forceps; 1 Allis tissue forceps, long, curved; 3 Allis tissue forceps, long; 3 Ballenger sponge forceps, curved; 1 Crile-Wood needle holder, 8 inch.

70-2 Top to bottom: 1 Andrews- Pynchon suction tube with tip; 1 adenoid suction tube, tip connected. Bottom, left to right: 2 Weder tongue depressors; 1 Hurd tonsil dissector and pillar retractor; 1 Fisher tonsil knife and dissector; 1 LaForce adenotome, small, front view; 1 LaForce adenotome, large, side view. Right, top to bottom: 1 Lothrop uvula retractor; 1 Meltzer adenoid punch, round, with basket.

CHAPTER 70 Tonsillectomy and Adenoidectomy 235 https://kat.cr/user/Blink99/ 70-3 Mouth set. Top to bottom: 1 Andrews-Pynchon suction tube with tip; 2 bite blocks: child and adult. Left to right: 1 McIvor blade, long; 1 McIvor mouth gag frame with blade; 1 McIvor blade, medium; 3 Weder tongue depressors, 2 side views and 1 front view; 1 side mouth gag.

236 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 71

Transoral Surgery

The FK retractor is mainly used for transoral robotic surgery (TORS). This retractor may Additional images are available at: also be used in general transoral surgeries to provide the most versatility for achieving ideal evolve.elsevier.com/Tighe/instrumentation exposure of the hypopharynx, larynx, and base of the tongue. The Bruening injection set is utilized to inject the vocal cords.

71-1 Top, left to right: 1 FK retractor custom frame L-shaped; 1 FK frame adapter, 45 degrees; 1 FK-WO TORS basic frame; 1 smoke suction tube; 1 light clip with lateral cable connection. Bottom, left to right: 1 Mandible blade, 11 cm; 2 cheek retractors, curved; 1 tongue blade, curved; 1 TORS blade, right, small; 1 tongue blade, curved, left side open (posterior view); 1 tongue blade, curved, right side open (posterior view); 1 TORS blade, right, large; 1 TORS blade, left, large; 1 TORS blade, left, small; 1 laryngeal blade, concave, 17 cm.

71-2 Top to bottom, left to right: 1 Ar- nold needle, 20.5 cm/18-gauge tip with wire pusher inserted; 1 wire pusher; 1 Arnold needle, 20.5 cm/19-gauge tip; 1 Bruening syringe extension; 1 Bruening syringe with syringe plunger attached; 1 Bruening wrench.

CHAPTER 71 Transoral Surgery 237 https://kat.cr/user/Blink99/ CHAPTER 72

Tracheotomy

Additional images are available at: A tracheotomy is an incision into the trachea below the cricoid cartilage in the anterior neck. evolve.elsevier.com/Tighe/instrumentation A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #3 with a #15 blade is used to make a small incision above the suprasternal notch. 2. Halsted mosquito hemostatic forceps are used to clamp bleeders. 3. A Senn retractor is placed to hold the skin edges. 4. A short curved Metzenbaum dissecting scissors is used to extend the incision to the trachea. 5. A baby weitlaner retractor is placed for exposure. 6. A Bard-Parker scalpel handle with a #11 blade is used to incise between the cartilaginous rings of the trachea. 7. A Jackson tracheal tenaculum holds the trachea. 8. A Trousseau-Jackson tracheal dilator is inserted to enlarge the opening for placement of the tracheostomy tube.

72-1 Top left: 1 Blue clip. Left to right: 1 Bard-Parker knife handle, #3; 2 Adson tissue forceps with teeth (1 × 2), 4¾ inch; 1 tissue forceps with teeth (2 × 3), 6 inch; 2 DeBakey vascular atraugrip tissue forceps, 7¾ inch. On stringer: 4 Halsted mosquito forceps, curved, 5 inch; 4 Crile forceps, curved, 5½ inch; 2 Allis forceps (5 × 6), 6 inch; 2 right-angle forceps, 7 inch; 1 Crile-Wood needle holder, 6¼ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum dissecting scissors, 5¾ inch; 1 Joseph scissors, curved, 6¼ inch; 2 Backhaus towel forceps.

238 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 72-2 Top left: 1 Medicine cup, 2 oz. Left to right: 2 Senn retractors; 2 Army Navy retractors, front view and side view; 1 Jackson tracheal tenaculum, 5¼ inch; 1 skin hook, single; 1 baby weitlaner retractor, dull; 1 Trousseau-Jackson tracheal 3 dilator, 5 ⁄8 inch; 1 Frazier suction tube; 1 Andrews suction tube, 3-mm tip, 9½ inch; 1 Andrews-Pynchon suction tube, 9½ inch.

72-3 Left to right: Tips: A, Tracheal ABC hook; B, sharp tip of Senn retractor, double-ended; C, Trousseau-Jackson tracheal dilator, adult.

CHAPTER 72 Tracheotomy 239 https://kat.cr/user/Blink99/ CHAPTER 73

Septoplasty and Rhinoplasty

Additional images are available at: In a septoplasty, a submucous resection (SMR) is performed to correct a deviated septum of the nose. A rhinoplasty is the reconstruction of the bony and cartilaginous parts of the nose. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedures includes a power drill with burrs and an electrosurgical unit. A brief description of the septoplasty procedure follows: 1. A Vienna nasal speculum is inserted into the naris for visualization. 2. A Bard-Parker scalpel handle #7 with a #15 blade is used to incise into the septum. 3. A Freer elevator is used for blunt dissection to separate and elevate tissue layers. 4. A Freer knife is used to incise the cartilage. 5. A Cottle septum elevator is used to elevate the mucous membrane. 6. A Becker scissors may be used to trim the deviated cartilage. 7. A Kerrison rongeur is used to remove any bony, thickened structures. 8. A Converse guarded osteotome with mallet is used to trim bony spurs. 9. Frazier suction tips of various sizes with tubing are used to remove drainage to aid in visualization. A brief description of the rhinoplasty procedure follows: 1. A Bard-Parker scalpel handle #3 with a #15 blade may be used to make an incision in the tip of the nose. 2. Joseph hooks are placed to retract the skin. 3. A McKenty elevator may be used to elevate the skin from underlying structures. 4. A Cottle septum elevator is used to free up the periosteum and perichondrium. 5. A Ballenger chisel with a mallet is used to break the nasal bones. 6. A curved Metzenbaum dissecting scissors may be used to trim the upper lateral cartilage. 7. A Converse osteotome with a mallet may be used to shape the bony dorsal hump. 8. An Aufricht rasp may be used to smooth the hump. 9. A Cottle dorsal angular scissors may be used to remove a cartilaginous hump. 10. A Becker septum scissors may be used to remove the septal cartilage. 11. A Cottle osteotome with a mallet is used to remove bony spurs.

240 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 73-1 Top: 5 Ludwig wire applicators. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard-Parker knife handle #7; 1 Cottle columella forceps; 1 Brown-Adson tissue forceps with teeth (7 × 7); 1 Beasley-Babcock tissue forceps; 1 Jansen thumb forceps, bayonet shaft, serrated tips; 1 Joseph button-end knife, curved; 1 Freer septum knife; 1 Cottle nasal knife; 1 McKenty elevator; 1 Cottle septum elevator; 1 Freer elevator; 2 Joseph skin hooks; 1 Cottle knife guide and retractor.

73-2 Left to right: 1 Bauer rocking chisel; 1 Lewis rasp; 1 Maltz rasp; 1 Aufricht rasp, large; 1 Aufricht rasp, small; 1 Wiener antrum rasp; 2 Ballenger swivel knives; 1 Ballenger chisel, 4 mm; 2 Converse guarded osteotomes; 1 Cottle osteotome, round corners, curved, 6 mm; 4 Cottle osteotomes, straight: 4, 7, 9, and 12 mm; 1 mallet, lead-filled head.

73-3 Left to right: Tips: 1 Cottle columella forceps; 1 Freer septum knife; 1 Joseph button-end knife; 1 Aufricht rasp, small, front view; 1 Aufricht rasp, large, side view; 1 Cottle knife guide and retractor, side view; 2 Ballenger swivel knives, side view and front view.

CHAPTER 73 Septoplasty and Rhinoplasty 241 https://kat.cr/user/Blink99/ 73-4 Top, left to right: 1 Fomon lower lateral scissors; 1 Metzenbaum dissecting scissors. Bottom, left to right: 1 Metzenbaum dissecting scissors, 4 inch, straight; 1 Metzenbaum dissecting scissors, 4 inch, curved; 1 Mayo dissecting scissors, straight; 1 Cottle spring scissors; 1 Cottle dorsal angular scissors; 1 Becker septum scissors.

73-5 Top: 1 Andrews-Pynchon suction tube with tip. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard- Parker knife handle #7; 1 Beasley- Babcock tissue forceps; 1 Brown- Adson tissue forceps with teeth (7 × 7); 2 Frazier suction tubes with stylets, 7 Fr; 2 Frazier suction tubes with stylets, 12 Fr; 2 Backhaus towel forceps, small; 2 paper drape clips; 12 Halsted mosquito hemostatic forceps, curved; 2 Allis tissue forceps; 2 tonsil hemostatic forceps; 1 Johnson needle holder (hidden).

242 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 73-6 Top, left to right: 1 Ferris Smith fragment forceps; 1 mastoid articu- lated retractor; 1 Cottle bone crusher, closed; 1 Aufricht retractor. Bottom, left to right: 1 Kerrison rongeur, upbite; 1 Killian nasal speculum, 2 inch, front view; 1 Killian nasal speculum, 3 inch, side view; 1 Vienna nasal speculum, 1⅜ inch, front view; 1 Vienna nasal 1 speculum, 1 ⁄8 inch, side view; 1 Asch septal forceps; 2 Army Navy retractors, side view and front view.

CHAPTER 73 Septoplasty and Rhinoplasty 243 https://kat.cr/user/Blink99/ CHAPTER 74

Nasal Polyp Instruments

Additional images are available at: Nasal polyps are small, rounded, elongated growths that project from the mucous mem- evolve.elsevier.com/Tighe/instrumentation brane surface in the nose.

74-1 Left to right: 1 Killian nasal speculum, 3 inch; 1 Druck-Levine antrum retractor with blade (2 parts); 6 Coakley antrum curettes, assorted sizes, #1 to #6; 1 Bruening nasal snare, bayonet (disposable wire).

74-2 Left to right: A, Tips: Coakley antrum curettes, 7.5 × 9.5 mm; A oval tip #1, 30-degree angle; oval tip #2, 60-degree angle; oval tip #3, 100-degree angle. B, Coakley antrum curettes, 6 × 7.5 mm, oval tip #4, 30-degree angle; oval tip #5, 60-degree angle; Coakley antrum curette, #6, 6 × 6 mm, triangular tip, 30-degree angle.

244 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ CHAPTER 75

Nasal Fracture Reduction

Nasal fracture reduction is a correction of a traumatic injury to the nose. Additional images are available at: A brief description of the procedure follows: evolve.elsevier.com/Tighe/instrumentation 1. A Gillies elevator is inserted to align the bones and cartilage. 2. Asch forceps may be inserted to maintain alignment during packing insertion.

75-1 Left to right: 1 Gillies elevator; 3 Asch forceps; assorted angles.

CHAPTER 75 Nasal Fracture Reduction 245 https://kat.cr/user/Blink99/ CHAPTER 76

Sinus Surgery

Additional images are available at: The paranasal sinuses may need drainage improved or may need diseased membranes removed. evolve.elsevier.com/Tighe/instrumentation The endoscopy approach may be used. The instruments are introduced alongside the scope. Possible equipment and instruments needed for the procedure include a light source and a nasal set. For irrigation, cysto tubing, a bag of normal saline, and suction tubing may be used. A brief description of the procedure follows: 1. A Vienna speculum may be needed to dilate the nares. 2. The scope is inserted through the nose. 3. An axial suction/irrigator is used for secretions and for visualization. 4. Blakesley-Weil ethmoid forceps are used to enlarge the maxillary sinus ostium. 5. A Coakley antrum curette may also be used to enlarge the maxillary sinus opening. 6. Gruenwald nasal forceps are used to grasp polyps. 7. Struycken nasal forceps are used to cut the polyps. 8. A Stammberger antrum punch may be used to remove diseased tissue.

76-1 A, Left to right: Pediatric and small nasal Blakesley-Weil forceps: A 1 pediatric straight; 1 pediatric 45 degrees; 1 45-degree small; and 1 90-degree small. B, Left to right: Tips: Pediatric and small Blakesley-Weil nasal forceps: 1 pediatric straight; 1 pediatric 45 degrees, 1 45-degree small; 1 90-degree small.

246 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 76-2 A, Top, left to right: 1 Stamm- A berger antrum punch (backbiter); 1 axial suction/irrigation handle. Bottom, left to right: 1 Sickle knife, sharp; 1 sickle knife, blunt; 1 sheath for 0 and 25 degrees, 4-mm lens; 1 maxillary sinus seeker; 1 Von Eicken antrum wash tube, 11 Fr; 2 antrum curettes, sizes 2 and 1. B, Left to right: Tips: Sickle knife, sharp; sickle knife, blunt; maxillary sinus seeker; 2 antrum curettes, sizes 2 and 1; Stammberger antrum punch (backbiter).

76-3 A, Left to right: 1 Gruenwald nasal A forceps, size 2, 1 straight, cutting; 1 Struycken nasal forceps, 1 straight, cutting; 1 90-degree upward-bent nasal forceps; 1 45-degree upward-bent nasal forceps. B, Left to right: 1 Gruenwald nasal forceps tip; 1 Struycken nasal forceps tip; 1 90-degree upward-bent nasal forceps tip; 1 45-degree upward-bent nasal forceps tip.

CHAPTER 76 Sinus Surgery 247 https://kat.cr/user/Blink99/ 76-4 A, Left to right: Blakesley-Weil nasal forceps: 1 straight, size 0; A 1 straight, size 1; 1 straight, size 2. B, Left to right: Blakesley-Weil nasal forceps, tips: 1 straight, size 0; 1 straight, size 1; 1 straight, size 2.

76-5 A, Left to right: 1 Kuhn-Bolger giraffe forceps, 90 degrees (frontal A sinus punch); 1 Kuhn-Bolger giraffe forceps, 110 degrees (frontal sinus punch); 1 Stammberger antrum punch, left; 1 Stammberger antrum punch, right. B, Left to right: Tips: 1 Kuhn- Bolger giraffe forceps, 90 degrees; 1 Kuhn-Bolger giraffe forceps, 110 degrees; 1 Stammberger antrum punch, left; 1 Stammberger antrum punch, right.

248 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ 76-6 A, Left to right: 1 Frontal sinus A curette, 90 degrees; 1 Coakley antrum curette, straight with triangle tip; variety of Coakley antrum curettes with various angles and sizes, 1 to 6. B, Left to right: Tips: Frontal sinus curette and a variety of Coakley antrum curettes with various angles, sizes 1 to 6.

76-7 Left to right: 1 Beaded measuring probe; 1 maxillary sinus ostium seeker; 1 frontal ostium seeker; 1 Ostrom-Terrier ostium forceps, retrograde.

CHAPTER 76 Sinus Surgery 249 https://kat.cr/user/Blink99/ 76-8 Left to right: 1 Small nasal scissors, straight; tips: small nasal scissors, curved left; small nasal scissors, curved right.

76-9 Top to bottom: 3 Telescope lenses, 4 mm: 0 degrees, 25 degrees, 70 degrees.

250 UNIT 6 Eye, Ear, Nose, and Throat Surgery https://kat.cr/user/Blink99/ UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL SURGERY CHAPTER 77

Facial Fracture Set

Facial fracture is a traumatic injury in which the continuity of the bone tissue of one or Additional images are available at: more facial bones is broken. evolve.elsevier.com/Tighe/instrumentation

77-1 Top, left to right: 1 Stevens tenotomy scissors, curved; 1 plastic scissors, straight, sharp; 3 wire- cutting scissors; 1 Mayo dissecting scissors, straight. Bottom, left to right: 1 Bard-Parker knife handle #3; 1 Bard-Parker knife handle #7; 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Adson tissue forceps without teeth, front view and side view; 1 Brown-Adson tissue forceps with teeth (9 × 9), front view; 1 bayonet dressing forceps, 7½ inch; 1 Mayo dissecting scissors, curved; 1 Metzenbaum dissecting scissors; 2 paper drape clips; 2 Backhaus towel forceps, small; 2 Backhaus towel forceps; 6 Halsted mosquito hemostatic forceps, curved; 2 Halsted mosquito hemostatic forceps, straight; 2 Providence Hospital hemostatic forceps, curved; 2 Halsted hemostatic forceps, straight; 4 Crile hemostatic forceps, curved; 2 Allis tissue forceps; 2 Webster needle holders, 4 inch; 2 Crile-Wood needle holders, 6 inch; 2 Johnson needle holders, 6 inch.

CHAPTER 77 Facial Fracture Set 251 https://kat.cr/user/Blink99/ 77-2 Top, left to right: 2 Frazier suction tubes with 1 stylet; 1 Yankauer suction tube with tip; 2 zygomatic arch awls. Bottom, left to right: 2 Joseph skin hooks, single; 2 Joseph skin hooks, double; 1 Kerrison rongeur, 90-degree upbite; 1 Lucas curette #0, short; 2 mandibular awls; 1 Cottle osteotome, curved; 1 Cottle osteotome, straight; 1 Crane mallet.

77-3 Left to right: 1 Weder tongue retractor, large, side view; 1 Weder tongue retractor, small, front view; 2 University of Minnesota cheek retractors, front view and side view; 3 ribbon retractors, assorted sizes; 2 Senn- Kanavel retractors, side view and front view.

252 UNIT 7 Oral, Maxillary, and Facial Surgery https://kat.cr/user/Blink99/ 77-4 Left to right: 1 Cottle nasal speculum #1, side view; 1 Cottle nasal speculum #2, front view; 1 Cottle nasal speculum #3, side view; 1 Friedman rongeur, single action; 1 Asch forceps; 2 Rowe disimpaction forceps, left and right.

77-5 Top, left to right: 3 Dingman bone-holding forceps; 1 Dingman zygoma elevator; 1 Gillies malar elevator; 1 Freer elevator; 2 Langenbeck elevators; 1 Langenbeck periosteal elevator, straight; 1 Langenbeck periosteal elevator, angled. Bottom left: Tip of Dingman bone-holding forceps.

CHAPTER 77 Facial Fracture Set 253 https://kat.cr/user/Blink99/ CHAPTER 78

Orthognathic Surgery

Additional images are available at: Orthognathic surgery is bony reconstruction of the mandible and/or the maxilla. The procedure can be classified as Le Fort I, Le Fort II, or Le Fort III. Le Fort I is a fracture through evolve.elsevier.com/Tighe/instrumentation the maxilla. Le Fort II is a fracture through the zygomatic arches. Le Fort III is a fracture through the bony orbits of the eye. Possible instruments and equipment needed for the procedure include small bone instruments, drills and saws, and a mini-fracture fixation system. If arch bars and stainless steel wires are used, a wire cutter will be needed. A brief description of the procedure follows: 1. A Petri pterygoid retractor is used to retract the cheek and stabilize the jaw. 2. A weitlaner retractor is used to retract the mucous membrane over the jaw. 3. A Bauer retractor is used to elevate the mandible and stabilize it. 4. A pterygomasseteric stripper is used to remove soft tissue from mandible. 5. Mini screws and plates are used to maintain the placement of the bones. 6. Arch bars with wires are applied to prevent movement of the jaw during healing. The arch bars will be removed at a later time.

78-1 Top right: 1 Burton retractor, double. Left to right: 2 Bauer retractors, left and right; 1 Joseph coronoid self-retaining retractor; 1 Petri pterygoid retractor; 1 channel retractor; 2 general-purpose retractors; 1 Kent- Wood adjustable retractor.

254 UNIT 7 Oral, Maxillary, and Facial Surgery https://kat.cr/user/Blink99/ 78-2 Left to right: 1 Piriform rim retractor; 2 Langenbeck retractors, front view and side view; 2 Langenbeck retractors, up-curved tip, front view and side view; 1 pterygomasseteric sling stripper, small; 1 pterygomasseteric sling stripper, medium; 1 Gillies malar elevator; 1 weitlaner retractor, 5 inch, blunt prong.

78-3 Left to right: 2 Roller compres- sions with metal trocar points, above: small and large; 1 trocar cannula (with trocar); 1 trocar with handle; 1 holding forceps; 2 dental mirrors #5; 2 cheek retractors; 1 mandibular reduction forceps.

78-4 Left to right: 1 Drill guide; 1 ball-end nasal osteotome; 3 osteotomes, straight: 4, 6, and 8 mm; 1 osteotome, angled, 6 mm; 1 osteotome, curved, 8 mm; 1 Parkes osteotome; 1 sagittal splitting osteotome; 1 Crile- Wood needle holder, curved, 6 inch; 1 coronoid match retractor.

CHAPTER 78 Orthognathic Surgery 255 https://kat.cr/user/Blink99/ 78-5 Top: 2 Trocar cannulas. Bottom, left to right: 1 Caliper; 1 condylar stripper; 1 Byrd screw; 2 zygomatic arch awls; 1 Freer elevator, double-ended; 1 periosteal elevator; 1 chisel.

78-6 Top to bottom, left to right: 1 MMF set lid; 2.0 × 8 mm MMF self- drilling screws and 2.0 × 12 mm MMF self-drilling screws (in set); ligature wire, blunt 22-gauge and 24-gauge (in set); 1 twist drill, 1.6 × 58 mm; 1 screwdriver ratchet handle with screwdriver blade and grasping sleeve; 1 2.0 × 8 mm MMF self-drilling screw.

256 UNIT 7 Oral, Maxillary, and Facial Surgery https://kat.cr/user/Blink99/ CHAPTER 79

Titanium 2.0-mm Microfixation System

The titanium 2.0-mm microfixation system is used for fixation of facial bones. Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

79-1 Titanium 2.0-mm microfixation system instrumentation, trays 1 and 2 of 3 (labeled).

79-2 Titanium 2.0-mm microfixation system instrumentation, tray 3 of 3 (labeled).

CHAPTER 79 Titanium 2.0-mm Microfixation System 257 https://kat.cr/user/Blink99/ CHAPTER 80 UNIT EIGHT: PLASTIC SURGERY

Minor Plastic Set

Plastic surgery is performed to mold, alter, and restore visible parts of the body.

80-1 Top, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 1 Brown-Adson tissue forceps with teeth (9 × 9), front view. Bottom, left to right: 2 Bard-Parker knife handles #3; 2 DeBakey vascular atraugrip tissue forceps, short; 2 Cushing tissue forceps with teeth (1 × 2); 4 paper drape clips; 6 Halsted mosquito hemostatic forceps, curved; 1 Halsted mosquito hemostatic forceps, straight; 8 Crile hemostatic forceps, curved, 5½ inch; 1 Halsted hemostatic forceps, straight; 6 Crile hemostatic forceps, curved, 6½ inch; 4 Allis tissue forceps; 4 Babcock clamp tissue forceps; 4 Ochsner hemostatic forceps, straight; 1 Westphal hemostatic forceps; 2 tonsil hemostatic forceps; 1 Foerster sponge forceps; 1 Johnson needle holder, 6 inch; 2 Crile-Wood needle holders, 6 inch.

80-2 Top, left to right: 2 Army Navy retractors, front view and side view; 2 Miller-Senn retractors, side view and front view. Bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzen- baum scissors, 7 inch; 1 Metzenbaum scissors, 5 inch; 2 Goelet retractors, front view and side view; 2 Richardson retractors, small, side view and front view.

258 UNIT 8 Plastic Surgery https://kat.cr/user/Blink99/ 80-3 Left, top to bottom: 1 Metal medicine cup, 2 oz; 1 weitlaner retractor, small. Right, top to bottom: 1 Yankauer suction tube with tip; 1 Poole abdominal suction tube with shield; 1 Ochsner malleable retractor, medium; 1 Ochsner malleable retractor, narrow; 1 Deaver retractor, medium.

CHAPTER 80 Minor Plasic Set 259 https://kat.cr/user/Blink99/ CHAPTER 81

Micro Plastic Set

A Micro Plastic Set is used in microvascular surgery. Possible equipment includes a surgical microscope and micro plastic instrumentation.

81-1 Left to right, top to bottom: 1 Bard-Parker knife handle, #3; 1 Bard- Parker knife handle, #7; 1 strabismus scissors, curved, 4½ inch; 1 tenotomy 1 scissors, curved, 4 ⁄8 inch; 1 plastic scissors, sharp, straight, 4¾ inch; 1 Weck scissors; 1 Stevens tenotomy scissors, straight; 1 round handle scissors, straight, 18 cm; 1 round handle dissecting scissors, curved, 15 cm; 1 round handle scissors, curved, 18 cm; 1 Potts scissors, angled 25 degrees; 1 Freer elevator, double ended; 2 Cottle hooks, single, small, deep.

81-2 Left to right: 2 Bishop-Harmon tissue forceps, straight, with teeth 1 × 2, front and side view; 2 dilator forceps, tip 3 angled 10 degrees, 4 ⁄8 inch, front and side view; 1 Adson micro forceps, 4¾ inch; 1 micro tying forceps, straight, 12 cm; 2 Gerald-DeBakey tissue forceps, 7¼ inch, 1-mm tip; 2 Delicate Touch Gerald-DeBakey tissue forceps, straight, titanium, 7 inch; 1 Delicate Touch micro forceps, round handle, titanium, 7¼ inch, 1-mm ring tips; 1 Delicate Touch Dennis micro forceps, round handle, titanium, 1-mm ring tips; 2 Mills proximal ring forceps, micro diamond jaw, round handle, 8¼ inch; 2 Delicate Touch micro 1 forceps, straight, 7 ⁄8 inch; 1 Jeweler’s forceps, straight, flat handle, 7 inch.

260 UNIT 8 Plastic Surgery https://kat.cr/user/Blink99/ 81-3 Enlarged tips: 2 Ring forceps.

81-4 Top right corner, left to right: 1 Approximator vein clamp, double, 0.4-1.0 mm; 1 COAMPS vein clamp, single 0.4-1.0 mm; 1 approximator vein clamp, double, 0.6-1.5 mm; 2 vein clamps, single, 0.6-1.5 mm. Bottom, left to right: 2 Harmon mosquito forceps, curved, 4 inch; 1 Delicate Touch micro needle holder, titanium, locking, 7 inch; 1 Castroviejo eye needle holder, locking, straight, 5½ inch; 1 Barraquer micro needle holder, curved; 2 Rizzutti clip appliers.

CHAPTER 81 Micro Plasic Set 261 https://kat.cr/user/Blink99/ CHAPTER 82

Plastic Miscellaneous

Lighted breast retractors are used for breast cases such as breast augmentation, mastecto- mies, and breast reconstructions. These provide better visualization and smoke evacuation. The Coleman Infiltration Set is used for fat transplantation, whereas the Byron liposuction, liposcution tulip cannula, and bucket handle are used for liposuction. Depending on the location and extent of treatment, different liposuction cannulas may be used.

82-1 Left to right: 1 Tebbetts fiber optic retractor, 9 × 24 cm blade; 1 Luxtec fiber optic light cable; 1 Tebbetts fiber optic retractor, 15 × 36 cm blade.

262 UNIT 8 Plastic Surgery https://kat.cr/user/Blink99/ 82-2 Left to right: 1 Cushing insulated bipolar forceps; 1 Maxwell flap retrac- 7 tor, 4 × ⁄8 inch; 1 Maxwell flap retractor, 4 × 1½ inch; 1 Gorney-Freeman SuperCut scissors.

82-3 Left to right, top to bottom: 1 Coleman mini cannula, 19-gauge; 1 V-dissector, 7 cm; 1 Coleman mini stylet, 19-gauge; 1 Coleman infiltration cannula, 7 cm; 1 Coleman infiltration cannula, concave curve, 9 cm; 1 Coleman cannula, 9 cm; 1 Coleman aspiration cannula, 1 × 15 cm; 1 Lamis infiltration needle, 16-gauge ×15 cm; 1 Luer-Lok to Luer-Lok, 12-gauge; 1 Blue rack with collection tube.

CHAPTER 82 Plastic Miscellaneous 263 https://kat.cr/user/Blink99/ 82-4 Enlarged Coleman infiltration tips, four variations.

82-5 Top to bottom: Byron liposuction cannulas: 14 mm × 26 cm; 15 mm × 32 cm; 14 mm × 32 cm; 13 mm × 30 cm; 12 mm × 15 cm.

82-6 Enlarged Byron tip.

264 UNIT 8 Plastic Surgery https://kat.cr/user/Blink99/ 82-7 Top to bottom: 1 Tulip cannula; 2 liposuction handles, bucket handle, 5-mm and 10-mm tips.

82-8 Left to right: 2 Bucket cannula tips.

CHAPTER 82 Plastic Miscellaneous 265 https://kat.cr/user/Blink99/ CHAPTER 83

Skin Graft

A skin graft is performed when the full thickness of skin has been lost. Possible instruments needed for the procedure include a minor plastic set. A brief description of the procedure follows: 1. An electric dermatome is used to harvest skin. 2. Disposable dermatome blades are used in various widths, depending on the size of the graft needed. 3. A Dermamesher graft expander is used to enlarge the piece of skin so it will cover a larger area.

83-1 Padgett dermatome. Top to bottom, left to right: Screwdriver to tighten screws for guards; calibration tool; Padgett dermatome hand piece; electric power cord; three guards.

83-2 Head of Padgett dermatome, adjustable depth level for skin procurement.

266 UNIT 8 Plastic Surgery https://kat.cr/user/Blink99/ 83-3 Guards for Padgett dermatome. Top to bottom: 4-inch, 3-inch, and 2-inch.

83-4 Bioplasty Dermamesher, 1:1 ratio. This does not require a carrier for the meshing of the skin. Also comes in 1:2, 1:3, and 1:4 ratios.

CHAPTER 83 Skin Graft 267 https://kat.cr/user/Blink99/ UNIT NINE: PERIPHERAL VASCULAR, CHAPTER 84 CARDIOVASCULAR, AND THORACIC SURGERY

Endarterectomy

Additional images are available at: Endarterectomy is the surgical removal of the intimal lining of the artery. This procedure is performed to clear a major artery that may be blocked by plaque accumulation. The most evolve.elsevier.com/Tighe/instrumentation common arteries needing endarterectomy are the carotid (neck) and the femoral (groin). Possible equipment needed for the procedure includes femoral-to-popliteal artery bypass instruments, DeBakey tunnelers, 2 Cooley coarctation clamps, 1 Hollman tunneling forceps, and possibly a synthetic graft.

84-1 Endarterectomy instruments in the sterilization container. (Courtesy Case Medical, Inc., South Hacken- sack, N.J.)

A B

84-2 A, Femoral artery shows blockage in the main artery and deep femoral artery in the groin. B, Following endarterectomy of both arteries, the contrast shows arteries with increased blood supply.

268 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 85

Artery Bypass Graft

Possible equipment needed for the procedure includes a DeBakey tunneler, 2 Cooley coarc- Additional images are available at: tation clamps, 1 Hollman tunneling forceps, and a synthetic graft. evolve.elsevier.com/Tighe/instrumentation A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #3 with a #11 blade is used to incise into the popliteal artery. 2. Potts-Smith scissors (45 degrees) are used to extend the incision in the artery. 3. DeBakey vascular forceps are used to clamp the popliteal artery. 4. A DeBakey tunneler is used to make a passage beneath the sartorius muscle for the graft from the popliteal artery to the femoral artery. 5. A Bard-Parker scalpel handle #7 with a #11 blade is used to make a small incision into the femoral artery. 6. Potts-Smith scissors are used to extend the incision. 7. A Cooley coarctation clamp is used to occlude the femoral artery. 8. Hollman tunneling forceps are used to pull the graft into position. 9. An Ayers needle holder is used for the suturing of the graft. 10. DeBakey tissue forceps are used to help with the suturing.

85-1 Top to bottom: 2 Yankauer suction tubes with tips; 1 Frazier suction tube with stylet. Bottom, left to right: 6 Paper drape clips; 10 Halsted mosquito hemostatic forceps, curved; 6 Crile hemostatic forceps, curved, 5½ inch; 6 Providence Hospital hemostatic forceps (delicate tip), curved, 5½ inch; 4 Crile hemostatic forceps, curved, 6½ inch; 4 Allis tissue forceps; 4 Westphal hemostatic forceps; 6 tonsil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, long, curved; 2 Carmalt hemostatic forceps, long; 2 Adson hemostatic forceps, long; 2 Mixter hemostatic forceps, long, fine and heavy tips; 2 Foerster sponge forceps; 2 Crile-Wood needle holders, 7 inch; 2 Ayers needle holders, 7 inch, fine tips.

CHAPTER 85 Artery Bypass Graft 269 https://kat.cr/user/Blink99/ 85-2 Top, left to right: 2 Bard-Parker knife handles #7; 2 Miller-Senn retractors. Bottom, left to right: 2 Bard-Parker knife handles #3; 2 Adson tissue forceps with teeth (1 × 2), side view and front view; 2 DeBakey vascular atraugrip tissue forceps, short, side view and front view; 2 Ferris Smith tissue forceps, side view and front view; 2 DeBakey vascular atraugrip tissue forceps, medium, side view and front view; 1 eyed obturator (stylet) for Rumel tourniquet.

85-3 Left to right: 1 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum scissors, 5 inch; 1 Metzenbaum scissors, 7 inch; 1 Lincoln-Metzenbaum scissors; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 1 Strully scissors, probe tip.

85-4 Top: 2 Army Navy retractors, side view and front view. Bottom, left to right: 2 weitlaner retractors, sharp, medium; 2 vein retractors, side view and front view; 2 Richardson retractors, small, side view and front view; 2 Richardson retractors, medium, side view and front view; 1 Deaver retractor, small, side view.

270 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 86

Endovascular Abdominal Aortic Aneurysm Repair

An aneurysm is the abnormal bulging of an artery. Additional images are available at: Possible equipment and instruments needed for the procedure include an angiocath for evolve.elsevier.com/Tighe/instrumentation an arteriogram, an endoluminal synthetic graft, a small dissection set, 2 Rumel tourniquets, and a skin stapler. A brief description of the procedure follows: 1. A Bard-Parker scalpel handle #7 with a #11 blade is used to make small incisions over both femoral arteries in the groins. 2. Femoral cutdown instrumentation may be needed for additional exposure. 3. Halsted mosquito hemostatic forceps are placed for hemostasis and blunt dissection. 4. A snare is introduced through the left femoral artery up through the descending aorta to above the aneurysm. 5. A pull wire is introduced through the right femoral artery and right iliac artery to the descending aorta. 6. The pull wire is snared and pulled into the left iliac artery to the femoral artery. 7. The endoluminal graft is introduced through the right femoral artery above the bifurcation. 8. The graft is inflated, which secures it to the walls of the descending aorta and the iliac arteries. 9. The small incisions are closed with staples with the aid of Adson tissue forceps with teeth.

86-1 Graphic diagram of a descending aortic aneurysm. (Courtesy VAS Communications, Phoenix, Ariz.)

CHAPTER 86 Endovascular Abdominal Aortic Aneurysm Repair 271 https://kat.cr/user/Blink99/ 86-2 Graphic diagram of an endoluminal graft postoperatively. (Courtesy VAS Communications, Phoenix, Ariz.)

86-3 Top, left to right: 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 1 Dennis forceps, 8½ inch; 1 DeBakey tissue forceps, 2-mm tip, 7¾ inch; 1 tissue forceps, 1 × 2 teeth, 6¾ inch. Bottom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 1 Metzenbaum dissecting scissors, curved, 7 inch; 1 Metzenbaum, curved, sharp, 7 inch; 1 Diethrich scissors, 25-degree angle; 1 Potts scissors, reversed. On stringer: 6 Halsted mosquito clamps, curved, 5 inch; 6 Crile forceps, curved, 5½ inch; 2 right-angle clamps, fine, 7 inch; 2 Mayo-Hegar needle holders, 7¼ inch; 2 Crile-Wood needle holders, 6 inch; 2 Fogarty stealth clamps, straight, 6½ inch; 2 Fogarty stealth clamps, angled, 6 inch; 1 Gregory Profunda vascu- 1 lar clamp, medium; 2 Gregory Profunda vascular clamps, small; 2 DeBakey clamps, short, 40 degrees; 1 titanium micro clamp, 4 ⁄8 inch (blue).

272 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 86-4 Enlarged tip: Potts scissors, reversed.

86-5 Left to right: 2 Weitlaner retractors, blunt, 3 × 4, 6½ inch; 1 Army Navy retractor; 1 Richardson-Eastman retractor, double-ended, 10 inch; 1 Richardson retractor, narrow, 9½ inch; 1 Andrews suction tube; 1 heparin needle, short; 1 heparin needle, medium, angled; 1 eyed obturator for 1 Rumel tourniquet, 11 ⁄8 inch; 1 hemoclip applier, medium; 1 petri dish; 1 hemoclip applier, small.

CHAPTER 86 Endovascular Abdominal Aortic Aneurysm Repair 273 https://kat.cr/user/Blink99/ CHAPTER 87

Abdominal Vascular Set (Open Procedure)

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

87-1 Top, left to right: 2 Backhaus towel forceps; 6 paper drape clips. Bottom, first stringer, left to right: 2 Ochsner hemostatic forceps, straight, long; 2 Mayo-Péan hemostatic forceps, long; 4 tonsil hemostatic forceps; 1 Westphal hemostatic forceps; 4 Providence Hospital hemostatic forceps (delicate tip), 5½ inch, curved; 4 Crile hemostatic forceps, 5½ inch, curved; 4 Halsted mosquito hemostatic forceps, curved. Second stringer, left to right: 4 Halsted mosquito hemostatic forceps, curved; 6 Crile hemostatic forceps, 5½ inch, curved; 1 Westphal hemostatic forceps; 4 tonsil hemostatic forceps; 4 Carmalt hemostatic forceps, long; 2 Adson hemostatic forceps, long; 2 Allis tissue forceps, long; 4 Ochsner hemostatic forceps, long, straight; 3 Mixter hemostatic forceps, long, heavy tip; 2 Mixter hemostatic forceps, long, fine tip; 4 Foerster sponge forceps; 2 Ayers needle holders, 8 inch; 2 Crile-Wood needle holders, 8 inch.

87-2 Top to bottom: 2 Bard-Parker needle holders #4; 2 Bard-Parker needle holders #7. Bottom, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Hayes Martin tissue forceps with multiteeth, short, front view and side view; 2 Ferris Smith tissue forceps, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, medium, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 Russian tissue forceps, long, front view and side view.

274 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 87-3 Top, left to right: 1 Metzen- baum scissors, 5 inch; 1 Lincoln- Metzenbaum scissors; 1 Metzenbaum scissors, 7 inch. Bottom, left to right: 1 Strully scissors, probe tip; 1 Potts-Smith cardiovascular scissors, 45-degree angle; 2 Mayo dissecting scissors, straight; 1 Metzenbaum scissors, long, sharp; 1 Snowden-Pencer scissors, curved; 1 Snowden-Pencer scissors, straight.

87-4 Top to bottom: 2 Vein retractors; 1 metal ruler. Bottom, left to right: 1 Eyed obturator (stylet) for Rumel tourniquet; 2 weitlaner retractors, sharp, medium; 2 Army Navy retractors, side view and front view; 1 Poole abdominal suction tube with shield; 2 Yankauer suction tubes with tips.

CHAPTER 87 Abdominal Vascular Set (Open Procedure) 275 https://kat.cr/user/Blink99/ 87-5 Top: 2 Ochsner malleable retractors: large and small. Bottom, left to right: 1 Richardson retractor, small; 1 Richardson retractor, medium; 2 Richardson retractors, large, side view and front view; 3 Deaver retractors: small, medium, and large.

87-6 Left to right: Tips: A, Adson ABCD hemostatic forceps, curved, 8½ inch; B, Mixter forceps, delicate, longitudinal serrations, 10¾ inch; C, Mixter forceps, full curve, heavy, 10½ inch; D, comparison of the three tips of the above instruments.

276 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 88

Thoracoscopy

A thoracoscopy visualizes inside the chest cavity via a laparoscope. Additional images are available at: Possible instruments needed for the procedure include a laparoscope, a minimally evolve.elsevier.com/Tighe/instrumentation invasive surgery (MIS) adult set, and a minor instrument set. A brief description of the procedure follows: 1. Thoracoports, including obturators and cannulas are used for scope insertion. 2. A fan retractor is used for visualization. 3. Roticulating Babcock tissue forceps are used to gently handle tissue. 4. A Duval lung clamp is used to stabilize tissue that is being removed. 5. Roticulating Metzenbaum dissecting scissors are used to excise the tissue.

88-1 Top to bottom: 1 Articulating lung grasper, 10 mm; 1 roticulating Metzenbaum scissors, 5 mm × 33 cm, angled shaft; 1 roticulating Babcock tissue forceps, 5 mm × 33 cm, angled shaft.

88-2 Left to right: Tips: A, Roticulating A B C Metzenbaum scissors, 5 mm, 33-cm length, angled shaft; B and C, roticulating Babcock tissue forceps, 5 mm, 33-cm length, angled shaft; B, closed; C, open.

CHAPTER 88 Thoracoscopy 277 https://kat.cr/user/Blink99/ 88-3 Top to bottom: Duval clamp, 10 mm, open; Duval clamp, 10 mm, closed; fan retractor, 10 mm (two parts, together).

88-4 A, Tip of Duval clamp, 10 mm, A B closed; B, tip of Duval clamp, 10 mm, open.

88-5 Top: 2 5-mm Thoracoports, includes 1 blunt obturator, 1 cannula. Middle: 2 10-mm Thoracoports, includes 1 blunt obturator, 1 cannula. Bottom: 1 12-mm Thoracoport, includes 1 blunt obturator, 1 cannula; 1 15-mm Thoraco- port, includes 1 blunt obturator, 1 cannula.

278 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ THORACOSCOPY (LEFT) 88-6 Position for thoracoscopy.

ANESTHESIA VIDEO 2* VIDEO1 SURGEON

__10 _5 _5 ASSISTANT CAMERA HOLDER SCRUB

5, 10, or 12 Variable; depends on surgery BACK TABLE

*Video position change per physician preference

CHAPTER 88 Thoracoscopy 279 https://kat.cr/user/Blink99/ CHAPTER 89

Thoracic Instruments

Additional images are available at: A thoracotomy is an incision into the chest cavity. Possible instruments needed for the procedure include an abdominal vascular set and evolve.elsevier.com/Tighe/instrumentation cardiovascular instruments. A brief description of the procedure follows: 1. A Matson rib stripper is used to remove muscle and periosteum from ribs. 2. A Giertz rib cutter is used to resect a rib. 3. A Semb rongeur is used to trim bone ends. 4. A Burford retractor is placed to retract the ribs. 5. A Semb retractor is used to expose the lung. 6. A Duval lung clamp is placed for gentle maneuvering of the lobes of the lungs. 7. A Sarot clamp is used for clamping the bronchus. 8. A Bailey rib contractor is used during chest closure.

89-1 Top, left to right: 1 Malleable T retractor; 1 Giertz (first rib) (rib guil- lotine) rongeur; 1 Matson rib stripper and elevator. Bottom left: Burford rib spreader with shallow blade attached; 1 shallow blade; 2 deep blades.

280 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 89-2 Top to bottom: Bethune (rib) rongeur; 1 Sauerbruch (rib) rongeur, double-action.

89-3 Left to right: 2 Doyen rib elevators and raspatories, left and right; 1 Alexander rib raspatory (periosteo- tome), double-ended; 1 Semb lung retractor; 1 Semb gouging rongeur, double-action; 1 Bailey rib contractor.

CHAPTER 89 Thoracic Instruments 281 https://kat.cr/user/Blink99/ 89-4 Top: 2 Crile-Wood needle holders, 11 inch. Bottom, left to right: 1 Sarot bronchus clamp, angled; 1 Lee bronchus clamp, angular; 4 Allis tissue forceps, long; 3 Duval lung forceps, 2 front views and 1 side view.

89-5 Left to right: Tips: A, Sarot bron- A B chus clamp, angled; B, Lee bronchus clamp, angled; C, Duval lung forceps; D, Semb lung retractor.

C D

282 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 90

Cardiac Surgery

Cardiac surgery relates to surgery of the heart. Some heart surgeries include a coronary Additional images are available at: artery bypass graft (CABG); replacement of the heart valves (valvular annuloplasty); or evolve.elsevier.com/Tighe/instrumentation repair of the wall between the chambers of the heart (septal repair). Specialty instrumentation needed for open cardiac procedures include sternal saws, microinstruments, and cardiac specific clamps. A brief description of the procedure follows: 1. A sternal knife or saw is used to open the chest. 2. A sternal retractor is used to expose the pericardial sac. 3. Stay sutures are used to hold the pericardium open and expose the heart. 4. The necessary procedure is performed. 5. The pericardium, sternum, soft tissue, and skin are then closed.

90-1 Left to right: 1 Vital Metzenbaum scissors; 1 Mayo dissecting scissors, curved, 6¾ inch; 1 Metzenbaum scissors, fine, curved, blunt, 9 inch; 1 Metzenbaum scissors, fine, 8 inch (hidden); 2 DeBakey needle holders, serrated, 9 inch; 6 Julian needle holders, serrated, 8 inch; 6 Mayo- Hegar needle holders, 7 inch; 3 wire twisting forceps; 6 Crile forceps, curved, 5½ inch (1 hidden); 2 Boettcher tonsil clamps, 7½ inch; 1 Mayo-Péan hemostatic forceps, 8 inch; 2 Kocher clamps, 1 × 2 teeth, 8 inch; 1 Foerster sponge stick, straight; 1 DeBakey tangential occlusion vascular forceps, 7¾ inch; 1 Cooley forceps, curved, 8 inch; 1 Semb ligature-carrying forceps, fully curved, 9 inch; 1 Lambert-Kay aortic clamp, 8 inch; 1 Fogarty Hydragrip clamp, angled, 8½ inch; 1 Fogarty Hydragrip clamp, angled, curved shank, 9¼ inch; 1 Stealth aortic cross clamp, angled, 9 inch.

CHAPTER 90 Cardiac Surgery 283 https://kat.cr/user/Blink99/ 90-2 Enlarged tips: A, DeBakey AB C tangential occlusion vascular forceps. B, Cooley forceps. C, Semb ligature- carrying forceps, fully curved tip. D, Semb ligature-carrying forceps, top of tip. E, Lambert-Kay aortic clamp. F, Left to right: Fogarty Hydragrip clamps, angled without inserts and with inserts.

D EF

90-3 Top, left to right: 16 Kocher clamps, 1 × 2 teeth, 6¼ inch. Bot- tom, left to right: 1 Vital Metzenbaum scissors; 6 Halsted mosquito clamps, curved, 5 inch; 8 Crile forceps, curved, 5½ inch; 2 Boettcher tonsil clamps, 7½ inch; 1 Kantrowitz forceps, 8 inch; 1 Carmalt hemostatic forceps, right angle, heavy duty, 9 inch; 1 Mayo-Péan hemostatic forceps, 8 inch; 4 tubing clamps (for tubing with 5 OD, ⁄8 inch), 7½ inch; 1 Fogarty stealth applicator forceps; 2 hemoclip appliers, small; 2 hemoclip appliers, medium; 2 Mayo dissecting scissors, 6¾ inch.

284 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 90-4 Enlarged tip: Fogarty stealth applicator forceps.

90-5 Left to right, top to bottom: 1 Bard-Parker knife handle, #4; Bard- Parker knife handle, #7; 2 Adson forceps, 1 × 2 teeth, 4¾ inch; 2 fixation forceps, 7 × 8 teeth, 6 inch; 1 Baker tissue forceps, 1 × 2 teeth, serrated, 7½ inch; 1 DeBakey-Diethrich coronary artery forceps, 1.0-mm tip, 9½ inch; 1 DeBakey tissue forceps, 2-mm tip, 9½ inch; 1 Russian forceps, 10 inch; 1 DeBakey vascular forceps, angled, 9½ inch; 1 Backhaus towel forceps, small; 1 Backhaus towel forceps, large; 1 Lorna towel forceps, nonperforating, 5¼ inch.

90-6 Left to right: 1 Bandage scissor; 1 Pemco suction tip; 1 Yankauer suction tip; 1 Codman wire cutter; 2 Greene retractors, 8½ inch; 2 eyed obturators (stylet) for Rumel tourniquets, 11½ inch; 1 Penfield dissector, #4; 1 myocardial dilator, 5¾ inch; and 1 Finochietto rib spreader, pediatric.

CHAPTER 90 Cardiac Surgery 285 https://kat.cr/user/Blink99/ 90-7 Enlarged tip: Eyed obturator (stylet) for Rumel tourniquet.

286 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 91

Open Heart Microinstruments

Open heart microinstrumentation is used for coronary artery bypass grafting. These deli- Additional images are available at: cate instruments allow the surgeon to handle very fine needles and work in very small areas evolve.elsevier.com/Tighe/instrumentation of the heart.

91-1 Top, left to right: 1 Frazier suction, 7 Fr, 7½ inch; 1 Frazier suction stylet; 2 Parsonnet epicardial retractors, 2 inch, 1½ inch, 1¼ inch. Bottom, left to right: 1 Beaver knife handle, round, 6 inch; 1 Prince-Metzenbaum scissors; 1 Strully scissors, 8 inch; 1 microvascular scissors, angled, 120 degrees, 7 inch; 1 microvascular scissors, angled, 25 degrees, 7 inch; 1 Weary nerve hook, fine; 3 coronary artery probes, 1.0 mm, 1.5 mm, 2.0 mm; 1 micro forceps, titanium 0.5 mm tip, 8½ inch; 1 micro forceps, titanium-toothed, 0.5-mm tip, 8¼ inch; 1 Castroviejo micro needle holder, titanium, 8¼ inch; 1 Castroviejo micro needle holder, titanium, 7¼ inch; 1 Jacobson needle holder, titanium, fine, 8½ inch.

CHAPTER 91 Open Heart Microinstruments 287 https://kat.cr/user/Blink99/ 91-2 Enlarged tips: A, Microvascular ABC scissors, angled, 120 degrees, 7 inch; B, microvascular scissors, angled, 25 degrees, 7 inch; C, 3 coronary artery probes (Garrett dilators), 1.0 mm, 1.5 mm, 2.0 mm; D, Parsonnet epicardial retractor, 3 × 3 sharp prongs, 1½ inch; E, Strully scissors.

D E

288 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 92

Sternal Saws and Sternum Knife

The sternal knife and sternal saws are used to expose the pericardium and the heart. The Additional images are available at: incision is made through the skin, subcutaneous tissue, and muscle to expose the sternum. evolve.elsevier.com/Tighe/instrumentation A sternotomy is then performed.

92-1 Left to right: 1 Stryker hand piece with battery separate; 1 blade; 1 Stryker sternal saw attachment with safety guard.

CHAPTER 92 Sternal Saws and Sternum Knife 289 https://kat.cr/user/Blink99/ 92-2 Left to right: Power cord; Hall sternal saw. Right, top to bottom: 1 Saw blade; 1 saw guide; 1 wrench.

92-3 Surgeons’ preference instead of sternal saw. Top to bottom: Lebsche sternum knife and mallet.

290 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 93

Open Heart Extras

Open heart extras include internal defibrillator paddles, sternal plating systems, and beating Additional images are available at: heart retractors and stabilizers. Internal defibrillator paddles are used to reverse fibrillation evolve.elsevier.com/Tighe/instrumentation and initiate cardiac contractions. Sternal plating systems are used to reapproximate and fix- ate the sternum after a sternotomy. Beating heart retractors attach to the sternal retractor proximally, and the stabilizers attach to the heart to immobilize the coronary artery to be grafted. The stabilizer will compress or use suction on the tissue around the arteriotomy to immobilize the anastomosis site.

93-1 Left to right: 1 Ankeney sternal retractor; 1 Himmelstein sternal retractor.

CHAPTER 93 Open Heart Extras 291 https://kat.cr/user/Blink99/ 93-2 Morse sternal retractor.

A B

93-3 Left to right: A, Horizon clip appliers, 2 small, 2 medium; B, enlarged tips of Horizon clip appliers, small, medium.

292 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 93-4 Internal defibrillator paddles and handles with cable.

93-5 Octopus retractor with disposable tissue stabilizers.

CHAPTER 93 Open Heart Extras 293 https://kat.cr/user/Blink99/ 93-6 Top, left to right: 1 Sternal crimper; 1 tensioning handle. Bottom, left to right: 1 Crimp passer; 3 sternal cables with needles attached and 3 crimpers in the middle; cable cutter.

93-7 Top, left to right: 2 SternaLock power driver units (cords not included); 1 bone reduction forceps; plate and wire cutter. Bottom, left to right: 1 Tray containing plates, screws, and blades; 1 Beuse plate-holding forceps; 1 SternaLock screw sizer; 1 plate- holding wand, 2.4 mm; 1 ratcheting screwdriver with SternaLock blade attached; 1 ratcheting screwdriver; 1 SternaLock blade; 1 double-action rongeur, small.

294 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 93-8 Pericardial window. Top, left to right: 1 Bandage scissors; 1 double- action ronguer, small; 1 Richardson retractor, narrow; 1 Army Navy retractor. Bottom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 2 Adson forceps, 1 × 2 teeth; 1 fixation forceps, 7 × 8, 6 inch; 1 Baker tissue forceps, 1 × 2, serrated 7½ inch; 1 Russian forceps, 10 inch; 1 atraugrip forceps, 9½ inch. On stringer: 4 Halsted mosquito clamps, curved, 5 inch; 4 Crile hemostatic forceps, curved, 6½ inch (1 hidden); 2 Boettcher tonsil clamps, curved, 7½ inch; 2 Allis clamps; 2 Ochsner-Kocher, 8 inch (1 hidden); 1 sponge forceps; 1 Mayo- Péan hemostatic forceps; 2 Mayo- Hegar needle holders, 7¼ inch; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 Vital Metzenbaum scissors; 1 Nelson scissors, curved, 9 inch; 1 4-prong rake, sharp, 8½ inch.

CHAPTER 93 Open Heart Extras 295 https://kat.cr/user/Blink99/ CHAPTER 94

Cardiovascular Instruments

Additional images are available at: Cardiovascular instruments are used on the vessels because, when clamped on them, the evolve.elsevier.com/Tighe/instrumentation instrument tips do not damage the vessels. These instruments needed for the procedure are often found within open heart sets.

94-1 Left to right: A, Cooley clamp, angled jaw, straight shank, 5¼ inch, front view and tip; B, DeBakey bulldog clamp, ring handle, 45-degree angle, 4¾ inch, front view and tip; C, DeBakey peripheral vascular clamp, angular, 7 inch, front view and tip.

A B C

296 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 94-2 Left to right: A, Fogarty clamp- applying forceps, angled, front view and tip; B, Fogarty clamp-applying forceps, straight, front view, and tip; C, renal artery clamp, 7¼ inch, front view and tip.

A B C

94-3 Left to right: A, Potts-Smith tissue forceps, Carb-Bite tip, front view and tip; B, Lee bronchus clamp, 9¼ inch, front view and tip; C, Cooley coarctation clamp, straight handle, 8¾ inch, front view and tip.

A B C

CHAPTER 94 Cardiovascular Instruments 297 https://kat.cr/user/Blink99/ 94-4 Left to right: 1 DeBakey aortic exclusion clamp, acute S-shape, medium, 7¼ inch; 1 DeBakey aortic exclusion clamp, acute S-shape, long; 1 DeBakey multipurpose vascular clamp, obtuse angle, 60 degrees, 8¼ inch; 1 Semb ligature-carrying forceps, 9 inch.

94-5 Top: 1 Andrews-Pynchon suction tube. Bottom, left to right: 1 Metal ruler, 6 inch; 1 Freer double-ended elevator; 1 Penfield dissector, single- ended, #4; 1 Hoen nerve hook; 1 Adson hemostatic forceps, angled, fine tip; 2 Ryder needle holders, 7 inch, fine tip.

94-6 Left to right: Tips: A, DeBakey A B aortic exclusion clamp, S-shape; B, Hoen nerve hook, straight.

298 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 95

Open Heart Valve Extras

Instrumentation needed for a heart valve repair or replacement includes a basic open heart Additional images are available at: set and a valve instrument set. evolve.elsevier.com/Tighe/instrumentation

95-1 Left to right: 6 Backhaus towel forceps, small; 1 Providence Hospital hemostatic forceps; 2 Ayers needle holders, 11 inch; 2 Heaney needle holders; 2 tonsil hemostatic forceps; 2 tonsil hemostatic forceps, long; 2 Allis tissue forceps, long; 1 Allis tissue forceps, long, curved. Right, top to bottom: 1 Pituitary rongeur, straight bite, 7 inch; 1 pituitary rongeur, upbite, 7 inch; 1 pituitary rongeur, downbite, 7 inch.

95-2 Left to right: 3 Pituitary rongeur tips: straight bite, downbite, upbite.

CHAPTER 95 Open Heart Valve Extras 299 https://kat.cr/user/Blink99/ 95-3 Left to right: 1 Bard-Parker knife handle #3, long; 1 Cushing-Brown tissue forceps with teeth (9 × 9); 1 Cushing tissue forceps with teeth (1 × 2); 2 Teflon Bardic plugs; 3 leaflet retractors, 2 side view and 1 front view; 1 grafting suction tube.

95-4 Enlarged tips: A, Leaflet retractor; A B B, Cushing-Brown tissue forceps with teeth (9 × 9); C, Heaney needle holder; D, Allis tissue forceps, curved.

C D

300 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ CHAPTER 96

Return Open Heart Set

A return open heart set is used when an unexpected complication (e.g., hemorrhage) occurs Additional images are available at: following an open heart procedure. Possible equipment needed for the procedure includes evolve.elsevier.com/Tighe/instrumentation open heart instrumentation including retractors and a re-open sternal saw or sternal plating removal instrumentation.

96-1 Top left: 3 Bard-Parker knife handles: #7, #4, and #3. Bottom, left to right: 2 Hayes Martin tissue forceps with multiteeth, front view and side view; 1 Ferris Smith tissue forceps; 1 Cushing tissue forceps with teeth (1 × 2), 7 inch; 2 Reul dressing forceps, front view and side view; 2 DeBakey vascular atraugrip tissue forceps, long, front view and side view; 2 Russian tissue forceps, long, front view and side view.

96-2 Left to right: 8 Paper drape clips; 6 Crile hemostatic forceps, 6½ inch; 12 Ochsner hemostatic forceps, medium jaw; 2 Ochsner hemostatic forceps, long jaw; 2 Westphal hemostatic forceps, short; 4 tonsil hemostatic forceps; 2 Mayo-Péan hemostatic forceps, long, curved; 1 Adson hemostatic forceps, long; 1 Foerster sponge forceps; 1 Crile-Wood needle holder, 7 inch; 2 Jarit sternal needle holders, 7 inch; 2 Crile-Wood needle holders, 8 inch; 1 Ayers needle holder, 8 inch; 2 Yankauer suction tubes with tips.

CHAPTER 96 Return Open Heart Set 301 https://kat.cr/user/Blink99/ 96-3 Left to right: 2 Volkmann retractors, 4 prong, dull, front view and side view; 1 Richardson retractor, small; 1 Ochsner malleable retractor, medium; 2 Army Navy retractors, front view and side view; 1 wire cutter, heavy.

96-4 Top, left to right: 1 Wire cutter, small; 1 hemoclip cartridge base. Bottom, left to right: 2 Mayo dissecting scissors, straight; 1 Mayo dissecting scissors, curved; 1 Metzenbaum scissors, 7 inch; 2 Weck EZ Load hemoclip appliers (the new version is the Weck Horizon hemoclip).

302 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 96-5 Left to right: 1 Lambert-Kay aortic clamp; 1 DeBakey multipurpose vascular clamp, obtuse angle, 60 degrees; 1 Beck aorta clamp; 1 Jarit microsurgical needle holder with lock, 7 inch; 2 eyed obturators (stylets) for Rumel tourniquet.

CHAPTER 96 Return Open Heart Set 303 https://kat.cr/user/Blink99/ CHAPTER 97

Vein Retrieval Instruments

Additional images are available at: Vein retrieval instruments are used when veins are taken from one part of the body (usually evolve.elsevier.com/Tighe/instrumentation the legs or arms) and used for a bypass procedure on the heart. Leg procedures for harvesting the greater saphenous vein can be performed as an open procedure or as a minimally invasive procedure. A vein harvest kit can be used for the minimally invasive procedure.

97-1 Top, left to right: 2 DeBakey tissue forceps, 6 inch; 2 Adson forceps, 1 × 2, 4¾ inch; 1 weitlaner retractor, 3 × 4 inch, sharp, 6½ inch; 1 Bard-Parker knife handle, #3. Bottom, left to right, on stringer: 2 Metzenbaum scissors, curved, 5½ inch; 1 Vital Metzenbaum scissors; 1 Mayo dissecting scissors, straight, 6¾ inch; 1 tenotomy scissors, 6 inch (hidden); 2 Mayo-Hegar needle holders, 7¼ inch; 2 tubing clamps (for 5 tubing with OD, ⁄8 inch); 1 Boettcher tonsil clamp, curved, 7½ inch; 1 Lahey gall duct forceps, 7½ inch; 6 Halsted mosquito clamps, curved, 5 inch; 10 mosquito clamps, fine, (1 hidden); 1 Backhaus towel forceps, 3½ inch; 1 Senn retractor, sharp, 6¾ inch; 1 Army Navy retractor; 1 Richardson retractor, 1 × ¾ inch; 1 Castroviejo delicate touch micro needle holder, straight, locking, 5 7 ⁄8 inch; 1 hemoclip applier, small; 1 hemoclip applier, medium.

304 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ 97-2 Top to bottom: 1 Bipolar cord; 1 VasoView harvesting cannula; 1 BiSector bipolar ligating forceps (connects to bipolar cord); 1 Olympus 5-mm 0-degree lens; 1 short port, blunt tip; 1 sealing balloon; 1 20-cc syringe; 1 dissection tip (connects on harvesting cannula).

97-3 Top to bottom: Olympus 1 chip camera and light cord.

CHAPTER 97 Vein Retrieval Instruments 305 https://kat.cr/user/Blink99/ CHAPTER 98

Radial Artery Harvest Set

Additional images are available at: Radial artery harvest instrumentation is used when the radial artery is harvested from the evolve.elsevier.com/Tighe/instrumentation arm and used for a coronary artery bypass graft procedure.

98-1 Left to right: 1 Andrews- Pynchon suction tube; 1 Bard-Parker knife handle #3; 2 DeBakey vascular atraugrip tissue forceps, medium. Top: 2 Brawley scleral wound retractors. Bottom: 1 Weitlaner retractor; 1 cerebellar retractor, small. On instrument stringer: 4 Halsted microline artery forceps; 2 Adson hemostatic forceps, fine, right-angle; 2 Horizon clip appliers, small; 2 Metzenbaum dissecting scissors, 7 inch, 5 inch; 1 Crile-Wood needle holder, 5 inch (hidden).

306 UNIT 9 Peripheral Vascular, Cardiovascular, and Thoracic Surgery https://kat.cr/user/Blink99/ UNIT TEN: NEUROSURGERY CHAPTER 99

Craniotomy

Craniotomy is an incision made in the head through the skull that allows the performance Additional images are available at: of surgery on the brain for tumor resection, vascular defect repair, or traumatic injury. evolve.elsevier.com/Tighe/instrumentation Possible equipment needed for the procedure includes: 1. Midas Rex drill with craniotome blades, used to open the skull. 2. A Cavitron ultrasonic surgical aspirator (CUSA), used for tumor removal. 3. An operating microscope, used for visualization. 4. An electrosurgical unit, used for hemostasis. 5. A neuroplating set of screws and plates, used to repair fractures and to replace the bone flap. 6. Burr-hole covers, used to cover the burr holes. A brief description of the procedure follows: 1. Local injection at incision. 2. Incision of skin and galea with skin blade and hemostasis with cautery. 3. Remove scalp from the periosteum with either cautery or a periosteal elevator. 4. Burr holes are created using a high-speed drill with a perforator attachment. 5. Hemostasis of the burr holes use bone wax, followed by separation of the dura using a Penfield dissector. 6. To create a bone flap, the burr holes are connected with a craniotome attachment to the high-speed drill. The bone flap is removed using a Penfield dissector. 7. The dura is preserved by cutting with dura or Metzenbaum scissors and tacking up the dura with sutures to the skull. 8. Hemostasis of brain tissue is achieved using bipolar forceps or irrigating bipolar forceps. Hemostatic agents such as Thrombin and Gelfoam may be used. 9. Exposure to deep brain tissue is achieved by using a Leyla or Greenberg retractor. Superficial work on the surface or skull may be limited to weitlaner retractors or skin hooks attached to the drape. 10. Tumor resection or dissection of brain tissue may involve microsurgical instruments such as micro Penfield dissectors, scissors, and Rhoton dissectors. An ultrasonic irrigator/aspirator may be used in larger tumors. All of these instruments will be utilized under a microscope. 11. Craniotomies for aneurysms or arteriovenous malformations utilize specialized clips with appliers to prevent the aneurysm from rupturing. 12. Following hemostasis, the dura is closed and the skull flap replaced using titanium screws and plates to secure the bone flap in place. If swelling of brain tissue is too great to replace the bone flap, the patient’s bone flap is cryopreserved until brain swelling subsides. If the skull flap is not intact, methyl methacrylate can be used in conjunction with titanium mesh for a skull flap substitute, or an artificial skull flap using a poly-ether ether ketone (PEEK) plastic can be constructed and applied in a separate cranioplasty procedure.

CHAPTER 99 Craniotomy 307 https://kat.cr/user/Blink99/ 99-1 Top to bottom, left to right: 2 Bard-Parker knife handles #7; 2 Bard- Parker knife handles #3; 1 Cushing bipolar cautery forceps, microtip, insulated bayonet shaft; 1 Adson hypophyseal forceps, bayonet shaft, round-cup tip; 1 Gerald dressing forceps, bayonet shaft, narrow tips, serrated; 1 Adson dressing forceps, bayonet shaft. Bottom, left to right: 2 Adson tissue forceps with teeth (1 × 2), front view and side view; 2 Gillies tissue forceps with teeth (1 × 2), front view and side view; 2 DeBakey vascular atraugrip tissue forceps, medium, front view and side view; 2 Gerald tissue forceps with teeth (1 × 2), front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), front view and side view; 2 Cushing tissue forceps with teeth (1 × 2), Gutsch handle, front view and side view.

99-2 Left to right: Enlarged tips: A B C A, Gillies tissue forceps with teeth (1 × 2); B, Gerald tissue forceps with teeth (1 × 2); C, Adson dressing forceps, bayonet shaft; D, Gerald dressing forceps, bayonet shaft, narrow tips, serrated; E, Adson hypophyseal forceps, bayonet shaft, round-cup tip; F, Cushing bipolar cautery forceps, microtip, insulated bayonet shaft.

D EF

308 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 99-3 Top to bottom, left to right: 1 Mayo dissecting scissors, straight; 1 Metzenbaum dissecting scissors, 7 inch; 1 Metzenbaum dissecting scissors, 5 inch; 1 Strully scissors, 8 inch; 1 Adson ganglion scissors, straight, 6¼ inch. Bottom, left to right: 2 Raney scalp clip appliers; 3 paper drape clips; 2 Ligaclip appliers, small/short; 4 Backhaus towel forceps; 6 Back- haus towel forceps, small; 6 Cairns hemostatic forceps; 6 Crile hemostatic forceps, curved; 2 Allis tissue forceps; 2 Ochsner tissue forceps; 2 Ligaclip appliers, medium/medium; 1 Westphal hemostatic forceps; 1 Adson hemostatic forceps, fine tip; 2 DeBakey needle holders, 7 inch; 2 Webster needle holders, 6 inch; 2 Crile-Wood needle holders, 7 inch.

99-4 Left to right: Tips: A, Strully B A C D scissors; B, Adson ganglion scissors, straight; C, Samii scissors (tip); D, dura scissor (tip).

99-5 Top to bottom, left to right: 1 Dura scissors, 1 Samii scissors, 3 micro suctions.

CHAPTER 99 Craniotomy 309 https://kat.cr/user/Blink99/ 99-6 Top, left to right: 6 Frazier suction tubes, sizes 6 to 12. Bottom, left to right: 5 Silicone spatula retractors, 6, 9, 13, 16, and 22 mm; 1 metal ruler; 5 Davis brain spatulas, various widths.

99-7 Top to bottom, left to right: 5 Ventricular needles with stylets, 3½ inch, 12, 14, 16, 18, and 20 gauge; 1 10-cc glass syringe (2 parts). Bottom, left to right: 2 Jarit crossing-action retractors, 4 inch, blunt prongs; 2 Raney scalp clip appliers, side view; 2 vein retractors, side view and front view.

310 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 99-8 Left to right: 1 Acra scalp clip applier, unloaded; 1 scalp clip cartridge; 1 scalp clip; 1 Acra scalp clip applier, loaded.

99-9 Left to right: 1 Dura hook; 1 Woodson dura separator and packer, 7 inch; 1 Brun oval-cup curette, angled, 3-0; 3 Penfield dissectors, #1, #2, and #3, 7¼ inch; 1 Penfield dissector, #4, 8 inch; 1 Adson dura hook, sharp; 1 nerve hook, dull, flat; 1 Freer elevator; 1 Kistner probe; 1 Adson periosteal elevator (joker), curved, blunt, 6¾ inch; 1 Hoen periosteal elevator, narrow; 1 Hoen periosteal elevator, wide.

CHAPTER 99 Craniotomy 311 https://kat.cr/user/Blink99/ ABC D

E F

G H I J

K L M

99-10 Left to right: Enlarged tips: A, Frazier dura hook, 5 inch; B and C, Woodson dura separator and packer, double-ended, 7 inch; B, packer end; C, separator end; D, Brun oval-cup curette, angled, 3-0; E and F, Penfield dissectors, #1, #2, and #3;E, side view, dissector end; F, front view, spoon and wax-packer end; G and H, Penfield dissector #4, 8 inch; G, side view; H, front view; I, Adson dura hook, sharp, 8 inch; J and K, Freer double-ended elevator, 7¾ inch; J, side view; K, front view; L and M, Adson periosteal elevator (joker), curved, blunt, 6¾ inch; L, side view; M, front view.

312 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 99-11 Top to bottom: 1 Gigli blade with attached saw handles; 1 passer.

CHAPTER 99 Craniotomy 313 https://kat.cr/user/Blink99/ CHAPTER 100

Neurologic Bone Pan Instruments

Additional images are available at: Bone instrumentation consists of instrumentation to be used on bone and tougher tissues. evolve.elsevier.com/Tighe/instrumentation It may also consist of handheld and self-retaining retractors.

100-1 Top, left to right: 1 Adson rongeur; 1 cup rongeur, 6 mm. Bottom, left to right: 1 Ruskin double-action rongeur, small, straight; 1 Ruskin double-action rongeur, small, curved; 1 Leksell rongeur, side-curved; 1 Leksell rongeur, curved; 1 Smith- Petersen laminectomy rongeur.

314 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 100-2 A, Top: 1 Kerrison rongeur, A 45-degree, 1 mm. Bottom, left to right: 4 Kerrison rongeurs, 45-degree: 2, 3, 4, and 5 mm. B, Left to right: Tips: 5 Kerrison rongeurs, 45-degree, 1, 2, 3, 4, and 5 mm.

100-3 Left to right: 2 Senn retractors, side view and front view; 2 Army Navy retractors, side view and front view; 2 Green goiter retractors, side view and front view; 1 metal mallet. Top to bottom, left to right: 2 weitlaner retractors, baby, angled; 2 weitlaner retractors, small, angled.

CHAPTER 100 Neurologic Bone Pan Instruments 315 https://kat.cr/user/Blink99/ 100-4 Left to right: 2 Weitlaner retractors, small; 2 weitlaner retractors, medium; 2 Adson retractors, sharp, medium, angled.

316 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ CHAPTER 101

Neurologic Retractors

Neurologic retractors generally are flexible and have numerous attachments in various sizes Additional images are available at: allowing the retractor to be positioned to gain the best exposure. evolve.elsevier.com/Tighe/instrumentation

101-1 Left to right: 1 Leyla holding arm, angled; 1 Leyla ball and socket joint clamp; 1 Leyla holding arm, straight. (Flexible Lone Star retractor hooks in Figure 31-8 may be attached to Leyla retractor for retraction.)

CHAPTER 101 Neurologic Retractors 317 https://kat.cr/user/Blink99/ 101-2 Tapered malleable brain retractors that are often used with the Leyla retractor.

101-3 Top to bottom, left to right: Greenberg Universal retractor: hand rest with flexible bar to clamp; 2 primary bars; 1 long retractor arm. Right side: 4 Secondary bars.

318 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 101-4 Greenberg Universal retractor, continued: 2 flexible retractor bars, long. Middle, top to bottom: 8 Metal brain spatulas, various widths; 10 plastic-coated blades, various widths. Right: 2 Flexible retractor bars, short.

CHAPTER 101 Neurologic Retractors 319 https://kat.cr/user/Blink99/ CHAPTER 102

Medtronic Midas Rex Electric Drill

Additional images are available at: The Midas Rex drill has numerous attachments to cut and drill bone as needed. evolve.elsevier.com/Tighe/instrumentation

102-1 Top: Midas Rex cord and hand piece. Bottom, left to right: Midas Rex hand piece attachments: 1 perforator; 8 B small bone attachment; 9 M large bone attachment; AM-14 large bone attachment; F1 B5 footed attachment; TT 12 telescoping attachment; AT 10 telescoping attachment.

320 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 102-2 3 Midas tips.

102-3 1 Midas perforator tip.

CHAPTER 102 Medtronic Midas Rex Electric Drill 321 https://kat.cr/user/Blink99/ CHAPTER 103

Rhoton Neurologic Microinstrument Set

Additional images are available at: Rhoton microinstruments are dissection instruments used in aneurysms, tumors, and evolve.elsevier.com/Tighe/instrumentation acoustic neuroma resections. Each instrument is made of light-weight titanium for balance and durability. These instruments are often referred to by number.

103-1 A, Left to right: 2 Beaver A blade handles with insert, knurled; 1 microscissors, straight; 1 microscissors, curved; 1 microneedle holder, straight; 1 microneedle holder, curved; 1 micrograsping forceps. B, Left to right: Tips: Microscissors, straight; microscissors, curved; microneedle holder, straight; microneedle holder, curved; micrograsping forceps.

322 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 103-2 Rhoton dissectors #1 to #19 in numbered rack for identification.

103-3 Tips: 3 Round microdissectors: 1, 2, and 3 mm; 2 general-purpose microelevators: curved and angled; 3 spatula microdissectors: small, medium, and large; 2 microhooks, 90-degree: semisharp and blunt.

103-4 Tips: Microhook, 45-degree, semisharp; microneedle point, straight; 2 microcurettes: straight and angled; 4 ball microdissectors: straight; 40-degree, 4 mm; 90-degree, 5 mm; 40-degree, 8 mm; 1 arachnoid microknife.

CHAPTER 103 Rhoton Neurologic Microinstrument Set 323 https://kat.cr/user/Blink99/ 103-5 Left to right: Enlarged tips: 3 Round microdissectors: 1, 2, and 3 mm; 1 general-purpose microeleva- tor, angled.

103-6 Left to right: Enlarged tips: 4 Spatula microdissectors: large, small, medium, and medium straight.

103-7 Left to right: Enlarged tips: 2 Microhooks, 90 degrees: Semisharp and blunt; 1 general purpose microel- evator, curved; 1 microneedle point, straight.

103-8 Left to right: Enlarged tips: 2 Microcurettes: straight and angled; 1 ball microdissector, 90-degree angle tip.

324 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ CHAPTER 104

Ultrasonic Handpieces

Ultrasonic aspirators use ultrasound technology to dissect and aspirate targeted tissues with Additional images are available at: minimal transmitted movement to adjacent normal neural structures and with minimal evolve.elsevier.com/Tighe/instrumentation blood loss.

104-1 Top to bottom, left to right: 1 Selector 24 KHz flue; 1 Selector metal extension, angled; 1 Selector black plastic shroud, angled; 1 Selector hand piece with cord; 1 hand piece support with wrench.

CHAPTER 104 Ultrasonic Handpieces 325 https://kat.cr/user/Blink99/ CHAPTER 105

Neurologic Shunt Instruments

Additional images are available at: A shunt is a tube or device implanted in the body to redirect body fluid from one cavity or evolve.elsevier.com/Tighe/instrumentation vessel to another. Generally, a neurological shunt redirects cerebrospinal fluid from the ven- tricles in the brain to another cavity, often the abdomen. A valve and catheter combination is placed. The neurosurgeon will place the valve and catheters, and a general surgeon may assist with placement of a catheter into the abdomen laparoscopically.

105-1 Top, left to right: 1 Frazier suction, angled 10 Fr; 1 Green bipolar bayonet forceps, 1.5 mm × 8.5 inch; 1 Kerrison ronguer, 2 mm, 7 inch. Bot- tom, left to right: 1 Bard-Parker knife handle, #3; 1 Bard-Parker knife handle, #7; 1 DeBakey vascular tissue forceps, 7¾ inch; 1 bayonet forceps, Gutsch handle, 7¾ inch; 1 Crile forceps, curved, 6¼ inch; 1 Heiss skin retractor, blunt, 4 × 4 prongs; 1 weitlaner retractor, sharp; 1 Penfield dissector, #1; 1 curette, straight, 3-0; 1 Penfield dissector, #4; 1 Codman cranial perforator; 1 Midas Rex perforator driver; 1 Péan clamp, curved, 10 inch.

326 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 105-2 Shunt passer.

CHAPTER 105 Neurologic Shunt Instruments 327 https://kat.cr/user/Blink99/ CHAPTER 106

MINOP Neuroendoscopy Set

Additional images are available at: MINOP is a neuroendoscopy system used primarily for intraventricular indications, although it can be used for endoscope-assisted neurosurgery. It consists of endoscopes, evolve.elsevier.com/Tighe/instrumentation trocars, instruments, and electrodes for diagnostic and therapeutic purposes.

106-1 Top to bottom: 2 Guidewires; 1 endoscope lens, 0 degrees × 2.7 mm; 1 endoscope lens, 30 degrees × 2.7 mm; 1 sheath, 6 mm; 1 sheath, 4.6 mm; 1 trocar, 4.6 mm; 1 trocar, 6 mm; 1 sheath (no working channel), 3.2 mm; 1 trocar, 3.2 mm.

328 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 106-2 Top to bottom in rack: 2 Micro- scissors, B/B, S/S; 1 biopsy forceps; 1 fixation and dissecting forceps; 1 surgical microforceps; 2 suction tips.

106-3 Left to right: 1 Monopolar cord; 1 hook electrode; 1 needle electrode; 3 hook electrodes; 1 blunt electrode. Top to bottom: 1 Silastic tubing; in center of tubing: 2 Light cord adaptors; 1 bipolar cord. Right: 1 Bipolar fork electrode.

CHAPTER 106 MINOP Neuroendoscopy Set 329 https://kat.cr/user/Blink99/ CHAPTER 107

Intracranial Pressure Monitoring Tray

Additional images are available at: An Intracranial Pressure (ICP) monitoring tray contains equipment used to monitor intra- evolve.elsevier.com/Tighe/instrumentation cranial pressure. The monitoring device may be a fiber optic catheter or a bolt-shaped sensor that connects to a machine that measures ICP. A disposable cranial access kit is generally used to place the monitor, as this procedure is most frequently performed at the bedside or in the emergency department.

107-1 All contents of the Codman cranial access kit are disposable. Top, left to right: 1 Codman cranial hand crank drill; 2 medicine cups; 1 drill bit with stop, 2.7 mm; 1 Allen wrench; 1 drill bit with stop, 5.8 mm. Tray contents: 2 25-gauge Needles; 1 18-gauge needle; 1 spinal needle; 1 ventricular needle; 1 culture tube with screw cap; 1 razor; 2 syringes, 12 cc. Bottom, left to right: 1 #15 Scalpel; 1 #11 scalpel; 1 ruler; 1 skin marker; 1 suture scissors, sharp; 1 Adson forceps with teeth; 1 Adson forceps, smooth; 1 Heiss skin retractor, blunt, 4 × 4 prongs; 2 mosquito forceps, curved; 1 needle holder.

330 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ CHAPTER 108

Yasargil Aneurysm Clips with Appliers

Yasargil aneurysm clips are used on either side of an aneurysm, which is a localized dilation Additional images are available at: of the wall of a blood vessel. evolve.elsevier.com/Tighe/instrumentation

108-1 Aneurysm clip trays and 2 nonlocking aneurysm clip appliers.

CHAPTER 108 Yasargil Aneurysm Clips with Appliers 331 https://kat.cr/user/Blink99/ CHAPTER 109

Synthes Low-Profile Cranial Plating Set

Additional images are available at: At closure, the skull flap is replaced using titanium screws and plates to secure the bone flap in place. If swelling of brain tissue is too great to replace the bone flap, the patient’s bone evolve.elsevier.com/Tighe/instrumentation flap is cryopreserved until brain swelling subsides. If the skull flap is not intact, methyl methacrylate can be used in conjunction with titanium mesh for a skull flap substitute, or an artificial skull flap using a poly-ether ether ketone (PEEK) plastic can be constructed and applied in a separate cranioplasty procedure. Both of these are secured with titanium screws and plates.

109-1 Synthes low-profile cranial plating set. Left side: 2 Screwdriver handles and a variety of drill bits, 4 mm, 6 mm. Right side: 1.5-mm Screws.

332 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 109-2 Variety of Synthes low-profile implant cranial plates. Right side: 2 Burr hole covers, 12 mm, 17 mm.

CHAPTER 109 Synthes Low-Profile Cranial Plating Set 333 https://kat.cr/user/Blink99/ CHAPTER 110

Laminectomy

Additional images are available at: A laminectomy is an incision in the back to remove the lamina so as to expose the spinal evolve.elsevier.com/Tighe/instrumentation column. Possible instruments and equipment needed for the procedure include a neurologic soft tissue set; an operating microscope for visualization; an electrosurgical unit; and an electric drill, bits, and burrs. A brief description of the procedure follows: 1. A Beckman-Adson retractor is used to expose the vertebrae. 2. A Hibbs retractor is used if deeper retraction is needed. 3. A Cobb elevator is used to remove periosteum from the laminae. 4. A Smith-Petersen rongeur is used to remove the spinous processes. 5. Cushing bayonet forceps with teeth are used to grasp the ligamentum flava. 6. A Bard-Parker scalpel handle #7 with a #15 blade is used to incise close to the mid- line. 7. A Mellon curette is used to remove lateral gutter ligaments. 8. A Brun curette is used to define the laminae edges. 9. A Leksell rongeur is used to remove the laminae and expose the spinal cord. 10. An Adson blunt nerve hook is used to explore nerve roots and extradural space. 11. A Love retractor is used to protect nerves from injury. 12. A Cushing disk rongeur is used to remove disk material.

110-1 Top, left to right: 4 Cushing intervertebral disk rongeurs, 2 mm: straight, 6 inch; upbiting, 6 inch; narrow, straight, 7 inch; straight, 7 inch. Bottom, left to right: 1 Cushing intervertebral disk rongeur, 3 mm, 7 inch, upbiting; 1 Ferris Smith pituitary rongeur, 6 mm, 7 inch; 1 Cushing intervertebral disk rongeur, 4 mm, 7 inch.

334 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 110-2 Middle, top to bottom: 4 Frazier suction tubes: 12, 10, 8, and 6 Fr. Bot- tom, left to right: 1 D’Errico nerve root retractor; 1 Love nerve root retractor, straight; 1 Love nerve root retractor, 90-degree angle; 1 Scoville nerve root retractor, angular.

110-3 Left to right: Tips: A, D’Errico A B nerve root retractor; Love nerve root retractor, straight; B, Love nerve root retractor, 90-degree angle; Scoville nerve root retractor, angular.

CHAPTER 110 Laminectomy 335 https://kat.cr/user/Blink99/ 110-4 A, Left to right: 4 Spurling- A Kerrison rongeurs, 40 degrees: 2, 3, 4, and 5 mm. B, Left to right: Tips: 4 Spurling-Kerrison rongeurs, 40 degrees: 2, 3, 4, and 5 mm.

110-5 Top: 2 Adson cerebellar retractors, medium. Bottom, left to right: 2 Weitlaner retractors, straight, long; 2 Taylor spinal retractors: short, front view; long, side view; 2 Hibbs laminectomy retractors: narrow, front view; wide, side view.

336 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 110-6 A, Top: 1 Mellon curette, long, A large. Bottom, left to right: 3 Curettes, size 4-0: reverse-angled, angled, and straight; 3 curettes, size 2-0: reverse-angled, angled, and straight; 3 curettes, size 3-0: reverse-angled, angled, and straight; 3 curettes, size 0: reverse-angled, angled, and straight; 1 Cobb spinal elevator, narrow; 1 Cobb spinal elevator, wide. B, Left to right: Curette tips: 1 size 4-0, straight; 3 size 2-0: reverse-angled, angled, and straight; 3 size 3-0: reverse-angled, angled, and straight; 2 size 0: reverse- angled and straight.

110-7 Left to right: 1 Backward-angled curette; 1 forward-angled curette.

CHAPTER 110 Laminectomy 337 https://kat.cr/user/Blink99/ CHAPTER 111

Williams Laminectomy Microretractors

Additional images are available at: Williams laminectomy microretractors are utilized to retract tissue away from a bony sur- evolve.elsevier.com/Tighe/instrumentation face. The pointed hook side is placed aside bone while the blade retracts tissue.

111-1 Left to right: Williams laminectomy microretractors: short blade, right-handed, back view; long blade, right-handed, front view; long blade, left-handed, front view.

338 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ CHAPTER 112

Minimally Invasive Spine Surgery

Minimally invasive spine surgery is spine surgery through a small incision utilizing a retrac- Additional images are available at: tor system that allows visualization of the anatomy. Specially designed instrumentation is evolve.elsevier.com/Tighe/instrumentation utilized to enhance this visualization. A brief description of the procedure follows: 1. Local injection is placed at the skin incision site. 2. K-wire is inserted at the intended level of the spine and verified under fluoroscopy. 3. A small stab skin incision is made and a dilator is placed over the K-wire. 4. A succession of increasing-in-size dilators is placed over one another while under fluoroscopy. The dilators split the muscle and fascia versus dissection with cautery or Cobb elevators. The last dilator is short with an attachment to a retractor arm to the side of the surgical bed. Verification of the correct spinal level occurs after final adjustment of the retractor tube, removal of dilators, and before work on the lamina begins with either a high-powered drill with specialized minimally invasive attachments or Kerrison rongeurs.

112-1 Left to right: 1 Boss titanium bed rail clamp; 1 guidewire; 9 Boss titanium-colored dilating tubes; 3 Boss titanium tubular retractors; 1 Boss flex- arm retractor.

CHAPTER 112 Minimally Invasive Spine Surgery 339 https://kat.cr/user/Blink99/ 112-2 Top to bottom, left to right: 1 Kerrison rongeur, bayonet, 2 mm; 1 Kerrison rongeur, bayonet, 3 mm; 1 suction nerve root retractor; 1 knife handle, bayonet, #11; 1 MIS bone curette, bayonet, straight, 6-0; 1 MIS bone curette, bayonet, forward angle, 6-0; 1 MIS bone curette, bayonet, reverse angle, 6-0; 1 MIS bone curette, bayonet reverse angle, 3-0; 1 MIS bone curette, bayonet, forward angle, 3-0; 1 Penelope, bayonet; 1 nerve hook, bayonet; 1 Penfield dissector, bayonet, #4; 1 micro Penfield dissector, bayonet, #4; 1 Woodson elevator, bayonet.

340 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ CHAPTER 113

Anterior Cervical Fusion

An anterior cervical fusion is performed to relieve pain and stabilize the neck by fusing the Additional images are available at: cervical vertebrae. The patient is placed in the supine position. Bone from the iliac crest or evolve.elsevier.com/Tighe/instrumentation from a bone bank may be used for the fusion. Possible instruments needed for the procedure include a neurologic soft tissue set. A brief description of the anterior cervical fusion procedure follows: 1. A Cloward cervical retractor with one long and one short blade is used to separate the carotid sheath, trachea, and esophagus. 2. A Ferris Smith pituitary rongeur is used to remove the disk. 3. A Cloward vertebra spreader is used to widen the space. 4. A Cloward double-ended impactor is used to seat the bone graft between the vertebrae. 5. Plates and screws are used to stabilize the fusion.

113-1 Left to right: 1 Twist drill; 1 screwdriver with 14-mm disposable distraction screw; 1 Teflon mallet; 1 vertebral body distractor, right; 1 Cloward blade retractor with lip, 17 mm; 1 Cloward blade retractor without lip, 13 mm; 1 Cloward blade retractor, 20 mm.

CHAPTER 113 Anterior Cervical Fusion 341 https://kat.cr/user/Blink99/ 113-2 Top, left to right: 6 Sets of blunt cervical retractor blades, small to large. Middle, left to right: 1 Cloward cervical retractor handle, small; 1 Cloward cervical retractor handle, large. Bottom, left to right: 6 Sets of 4-pronged cervical retractor blades, small to large.

113-3 Shadow ACF retractor blades of various lengths, widths, and tip ends; 2 retractor handles; 1 color depth gauge.

342 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 113-4 Top: 1 Shadow ACF transverse retractor with blades attached; 1 Shadow ACF longitudinal retractor with blades attached. Bottom: Tray containing long and short teeth retractor blades.

CHAPTER 113 Anterior Cervical Fusion 343 https://kat.cr/user/Blink99/ CHAPTER 114

ASIF Anterior Cervical Locking Plating Instruments

Additional images are available at: evolve.elsevier.com/Tighe/instrumentation

114-1 ASIF anterior cervical locking plating instruments in tray, with names marked.

344 UNIT 10 Neurosurgery https://kat.cr/user/Blink99/ 114-2 Drill guide with axillary bin with names marked.

114-3 Top, left to right: 3 Sizes of cervical plates taken out of trays. Bottom, left to right: 3 Marked trays: 1 of screws and 2 of various sizes of cervical plates.

CHAPTER 114 ASIF Anterior Cervical Locking Plating Instruments 345 https://kat.cr/user/Blink99/ This page intentionally left blank

https://kat.cr/user/Blink99/ Index

A Apple needle holder (tip), 58f, 78f Baker tissue forceps, 285f Applied Medical Alexis protractor, 63f Balfour abdominal blade, 42f–43f AAMI. See Association for the Advancement Army Navy retractor, 19, 32, 34f, 46f, 87f Balfour abdominal retractor, 125F, 41f of Medical Instrumentation (AAMI) Arnold needle, 237f Balfour blade, 39f Abdomen, aortic aneurysm in, 271–273 Artery Balfour-Mayo blade, 43f Abdominal vascular set, 274–276 aorta, repair of, 271–273 Balfour retractor, 19, 32 Acetabular prosthesis, 178f bypass graft of, 269–270 Ballenger knife, 241f Acra scalp clip applier, 311f femoral, blockage of, 268f Ballenger knife (tip), 241f Acufex basket, 152f radial, 306 Banana knife, 144f Acufex duckbill biter, 151f Arthrex femoral tunnel notcher, 155f Bandage scissors, 285f Acufex duckbill biter (tip), 151f Arthrex femoral tunnel notcher (tip), 155f Bankart shoulder retractor, 165f Acufex upbiting linear punch, 152f Arthrex graft pusher, 155f Bard-Parker knife handle, 86f Adair breast clamp, 87f Arthrex graft pusher (tip), 155f Bard-Parker scalpel handle, 32, 33f, 49 Adair breast clamp (tip), 87f Arthrex over-the-top femoral positioning Bard-Parker scalpel handle, 32, 33f Adenoidectomy, 234–236 drill guide, 155f Bard-Parker scalpel handle, 32, 33f Adson cerebellar retractor, 336f Arthrex over-the-top femoral positioning Bariatric spatula, 77f Adson dura hook, 311f drill guide (tip), 155f Bariatric surgery, laparoscopic, 72–78 Adson dura hook (tip), 312f Arthrex scorpion suture passer, 153f Bariatric telescope, 74f Adson ganglion scissors, 309f Arthrex scorpion suture passer (tip), 153f Bariatrics, 72 Adson ganglion scissors (tip), 309f Arthrex tibial aiming guide, 156f Baron ear suction tube, 224f, 232f Adson hemostatic forceps, 116f Arthritis, ankle, 148 Barraquer needle holder, 131f Adson hemostatic forceps (tip), 116f, 276f Arthroplasty, ankle, 149f Barraquer wire speculum, 205f Adson hypophyseal forceps, 308f Arthroscopy Basket insert, container tray, 26f Adson hypophyseal forceps (tip), 308f anterior cruciate ligament, 154–156 Bateman retractor, 165f Adson periosteal elevator, 311f carpal tunnel, 145 Bauer retractor, 254f Adson periosteal elevator (tip), 312f definition of, 144 Bauer rocking chisel, 241f Adson rongeur, 147f instrument set for, 144 Beasley-Babcock tissue forceps, 241f Adson suction tube, 137f knee, 150–153 Beath passing pin, 156f Adson tissue forceps, 20f, 34f–35f, 45 shoulder, 150–153 Beaver knife handle, 130f Adson tissue forceps (tip), 20f, 35f Articulating lung grasper, 277f Bechert nucleus rotator, 203f, 207f AER. See Automated endoscope reprocessor Asch forceps, 245f Bechert nucleus rotator (tip), 203f, 208f (AER) Asch septal forceps, 243f Beck aorta clamp, 303f Agility LP total ankle arthroplasty, 149f ASIF anterior cervical locking plating Becker septum scissors, 242f Albarrán bridge, 121f instruments, 344–345 Bellucci scissors (tip), 230f Alcohol, instrument cleaning with, 10 ASIF external fixator miniset, 193f Bennett bone elevator, 167f Alcon I/A UltraFlow SP hand piece, 204f ASIF pelvic instrument set, 194–195 Bethune rongeur, 281f Alcon Monarch III IOL injector, 204f ASIF universal femoral distractor set, 187 Beuse plate-holding forceps, 294f Alcon OZil torsional hand piece, 204f Association for the Advancement of Medical Biofilm, 6, 10 Alexander rib raspatory, 281f Instrumentation (AAMI), 4–5 Bioplasty Dermamesher, 267f Alligator forceps, 230f Association of periOperative Registered Biopsy forceps, 63f, 110f Allis-Adair tissue forceps (tip), 104f Nurses (AORN), 4 Biopsy forceps (tip), 63f, 110f Allis clamp, 20 sterilization container system maintenance Bipolar forceps (tip), 81f Allis tissue forceps, 20, 20f, 32, 36f, 45 and, 30 BiSector bipolar ligating forceps, 305f Allis tissue forceps (tip), 20f, 36f, 104f Atrial retractor (tip), 82f Bishop-Harmon irrigating cannula, 219f American Iron and Steel Institute, 3 Aufricht rasp, 241f Bishop-Harmon tissue forceps, 222f Amines, instrument staining from, 11 Aufricht rasp (tip), 241f Bishop-Harmon tissue forceps (tip), 222f Ammonia, instrument spotting from, 11 Austin pick (tip), 227f Black double-end J curette (tip), 228f AMS Quick Connect assembly tool, 135f Austin sickle knife, 226f Blakesley-Weil nasal forceps, 246f Andrews-Pynchon suction tube, 235f Automated endoscope reprocessor (AER), 10 Blakesley-Weil nasal forceps (tip), 246f, 248f Andrews suction tube, 239f Auvard weighted vaginal speculum, 89f, 94f, Blunt elevator, 165f Anesthesia, introduction of, 2 104f Blunt probe, 144f Aneurysm clip tray, 331f Boettcher tonsil clamp, 304f Ankeney sternal retractor, 291f B Bone hook, 165f Ankle prosthesis, 148–149 Bone instruments, 314–316 Anterior cervical fusion, 341–343 Babcock clamp, 20 Bonn suture forceps, 217f Anterior cruciate ligament reconstruction, Babcock clamp grasping forceps (tip), 58f Bonn suture forceps (tip), 218f 154–156 Babcock forceps, 20 Bonney tissue forceps, 48f Antler retractor, 169f Babcock tissue forceps, 32, 36f, 45 Bookwalter retractor, 39f–40f AORN. See Association of periOperative Babcock tissue forceps (tip), 36f, 277f Bookwalter retractor horizontal bar, 39f Registered Nurses (AORN) Back table, setup for, 31f Bookwalter retractor horizontal flex bar, 39f Aortic aneurysm, repair of, 271–273 Backhaus towel forceps, 21f, 224f Bookwalter retractor oval ring, 39f Appendectomy, position for, 59f Bailey rib contractor, 281f Bookwalter retractor table post, 39f Apple needle holder, 75f, 78f Baird chalazion forceps, 199f Bores two-ray corneal meridian marker, 204f

Index 347 https://kat.cr/user/Blink99/ Boss flex-arm retractor, 339f Cholecystectomy Crabtree wax currette, 225 Boss titanium bed rail clamp, 339f definition of, 61 Crane mallet, 252f Boss titanium tubular retractor, 339f laparoscopic, 61–62 Cranial tray, 28f Bowel grasper, fenestrated, 77f position for, 62f Craniotomy, 307–313 Bowel grasper (tip), 82f Chromium oxide, 3 Creutzfeldt-Jakob disease, 10, 15–16, 22 Bowel resection, 69–70 Cindy scissors, 210f Crile clamp, 17 laparoscopic, 63–68 Cindy scissors (tip), 211f Crile hemostatic forceps, 32, 36f position for, 68f Clamp, 18f Crile hemostatic forceps (tip), 36f Box lock occluding, 17 Crile template, 177f example of, 18f types of, 17–18 Crile-Wood needle holder, 87f inspection of, 12 Clayman lens-holding forceps, 206f Crile-Wood needle holder (tip), 87f Bozeman uterine forceps, 88f Clayman lens-holding forceps (tip), 207f Critical instruments, 14 Bozeman uterine forceps (tip), 90f Cleaning Culler iris spatula, 207f Brain retractor, 318f instrument, 5 Culler iris spatula (tip), 208f Breast biopsy, 84 manual, 6–7 Cup forceps (tip), 58f Bridge channel adapter, 109f mechanical, 6–8 Cushing bipolar cautery forceps, 308f Broken screw set, 196–197 ultrasonic, 7 Cushing bipolar cautery forceps (tip), 308f Bronchoscope, cleaning of, 9 Clear corneal instrument set, 201–204 Cushing-Brown tissue forceps, 300f Brown-Adson tissue forceps, 86f Clip applier, 57f, 65f Cushing-Brown tissue forceps (tip), 300f Bruening nasal snare, 244f Cloward blade retractor, 341f Cushing insulated bipolar forceps, 263f Bruening syringe, 237f Coagulating electrode, 129f Cushing intervertebral disk rongeur, 334f Bruening wrench, 237f Coagulating electrode (tip), 129f Cushing vein retractor, 87f Brun oval-cup curette, 311f Coakley antrum curette, 244f Cutting electrode, 129f Brun oval-cup curette (tip), 312f Coakley antrum curette (tip), 244f Cutting electrode (tip), 129f Buck cement restrictor inserter, 172f Cobb spinal elevator, 171f Cutting instruments, 13, 18–19 Bucket cannula (tip), 265f Cobra grasper (tip), 80f Cystoscope, 108, 109f, 121f Buckingham footplate hand drill, 229f Cobra retractor, 169f Cystoscope lens, 109f Bugbee cord, 110f Codman cranial access kit, 330f Cystoscope obturator, 109f, 121f Bugbee electrode, 110f Codman cranial hand crank drill, 330f Cystoscopy, 108–111 Burford rib spreader, 280f Codman wire cutter, 285f Burton retractor, 254f Cohen cannula, 99f D Byron liposuction cannula, 264f Cohen cone, 99f Byron liposuction cannula (tip), 264f Coleman cannula, 263f Da Vinci Surgical System, 79–83 Coleman cannula (tip), 264f surgeon console for, 83f C Colonic insufflator, 71f Davis brain spatula, 134f, 309f Comprehensive Guide to Steam Sterilization De Mayo knee positioner, 161f Cadiere forceps (tip), 80f and Sterility Assurance in Health Care Deaver blade, 42f–43f Cairns hemostatic forceps, 309f Facilities, 4, 15 Deaver retractor, 32, 35f, 46f, 73f, 104f Camera, laparoscopic, 50f Cone provisionals, 178f Deaver retractor blade, 120f Cannula, for laser laparoscope, 60f Connor anesthesia cannula, 203f DeBakey aortic exclusion clamp, 298f Carbon-chrome ratio, 3–4 Container system. See Sterilization container DeBakey aortic exclusion clamp (tip), 298f Cardiac probe grasper (tip), 82f system DeBakey bulldog clamp, 296f Cardiac surgery, 283–286 Contour curved cutter, 66f DeBakey bulldog clamp (tip), 296f Cardiovascular instruments, 296–298 Cook eye speculum, 216f DeBakey-Diethrich coronary artery forceps, Carmalt hemostatic forceps, 69f Cooley clamp, 296f 48f, 285f Carmalt hemostatic forceps (tip), 70f Cooley clamp (tip), 296f DeBakey multipurpose vascular clamp, 298f Carpal tunnel instruments, 145 Cooley coarctation clamp, 297f DeBakey peripheral vascular clamp, 296f Carpal tunnel syndrome, 145 Cooley coarctation clamp (tip), 297f DeBakey peripheral vascular clamp (tip), 296f Castroviejo caliper, 205f Cooley forceps (tip), 284f DeBakey tangential occlusion vascular Castroviejo corneal section scissors, 209f Copper, instrument staining from, 11 forceps (tip), 284f Castroviejo corneal section scissors (tip), 209f Cornea, transplant of, 210 DeBakey tissue forceps, 77f Castroviejo cyclodialysis spatula, 203f Corneal instrument set, 201–204 DeBakey tissue forceps (tip), 80f Castroviejo needle holder, 199f Corneal marker, 210f DeBakey vascular Atraugrip tissue forceps, Castroviejo needle holder (tip), 209f Corneal marker (tip), 211f 34f–35f Castroviejo suturing forceps, 131f Corneal scleral marker (tip), 208f DeBakey vascular Atraugrip tissue forceps Castroviejo suturing forceps (tip), 202f, 206f Corneal transplant instrument set, 205–209 (tip), 35f Cataract surgery, 9 Corpus Hippocraticum, 2 Decontamination, instrument, 1–2, 5–6 Cautery cord, nondisposable, 54f Corrosion Deep lamellar endothelial keratoplasty Cautery hook (tip), 80f avoidance of, 12 (DLEK), 210–211 Cautery spatula (tip), 80f of instruments, 11–12 Defibrillator, internal, 293f Cavernotome, 135f Cottle bone crusher, 243f Delicate Touch micro forceps, 260f Cavitation, ultrasonic cleaning and, 7 Cottle columella forceps (tip), 241f Delicate Touch micro needle holder, 261f Centers for Disease Control and Prevention Cottle dorsal angular scissors, 242f Depth gauge, 169f (CDC), 4, 14 Cottle elevator, 224f DePuy AcroMed probe, 182f Cervical retractor, 342f Cottle nasal knife, 241f DePuy cement mixer, 162f Cervical vertebra, fusion of, 341–343 Cottle nasal speculum, 253f D’Errico nerve root retractor, 335f Chalazion set, 198, 199f Cottle osteotome, 241f D’Errico nerve root retractor (tip), 335f Chamber maintainer, 131f Covidien Endoscopic Endo GIA tri-stapler, Desmarres chalazion forceps, 199f Chamfering rasp, 155f 67f Desmarres lid retractor, 214f Chamfering rasp (tip), 155f Covidien purse string, 70f Desmarres lid retractor (tip), 215f Chandler (Gills) forceps, 212f Covidien Sonicision cordless ultrasonic Detergent Channel retractor, 254f dissection, 68f corrosion and pitting caused by, 11–12 Charlie insertion forceps, 210f Covidien Sonicision cordless ultrasonic enzymatic, 8 Charlie insertion forceps (tip), 211f dissection (tip), 68f instrument cleaning with, 6

348 Index https://kat.cr/user/Blink99/ Detergent (Continued) EndoWrist stabilizer (tip), 82f Freer double-ended elevator (tip), 312f for mechanical cleaning, 8 Enucleation scissors, 223f Freer elevator, 137f for sterilization container systems, 26–27 Enzymatic detergent, 6, 8 Freer septum knife, 241f Devers dissector, 210f instrument cleaning with, 6 Freer septum knife (tip), 241f Devers dissector (tip), 211f Erhardt chalazion clamp, 216f Friedman rongeur, 253f Deviated septum, repair of, 240 Esophageal retractor, 64f Furlow insertion tool, 135f Diameter gauge, 186f Ethicon Echelon Flex Endo GIA power Dilatation and curettage, 88–90 stapler, 66f G Dingman bone-holding forceps, 253f Ethicon Echelon Flex Endo GIA power Dingman zygoma elevator, 253f stapler (tip), 66f Garrigue weighted vaginal speculum, 120f Disinfectant, instrument cleaning with, 10 Ethicon endoscopic curved intraluminal Gaskin fragment forceps, 202f Disinfection, 14–16 stapler, 67f Gaskin fragment forceps (tip), 202f Dissection scissors, 18–19 Ethicon Laparoscopic Enseal, 68f Gass retinal detachment hook, 218f Distractor, 183f Ethicon Laparoscopic Enseal (tip), 68f Gelpi retractor, 19, 124f DLEK. See Deep lamellar endothelial Ethicon Laparoscopic Harmonic scalpel, 68f Gerald dressing forceps, 308f keratoplasty (DLEK) Ethicon SecureStrap laparoscopic tacker, 65f Gerald dressing forceps (tip), 308f Doane retractor, 163f Ethicon stapler PPH, 70f Gerald tissue forceps, 308f Double fixation hook, 222f Ethylene oxide, 16 Gerald tissue forceps (tip), 308f Doyen intestinal forceps, 69f Evolution Tray, 191f Giertz rongeur, 280f Doyen intestinal forceps (tip), 70f Eye enucleation, 223 Gigli blade, 313f Doyen rib elevator, 281f Eye instruments, 198–200 Gil-Vernet retractor, 115f, 124f Drill cleaning of, 9 Gilles elevator, 245f Jacobs, 143f Eye muscle, surgery for, 214–216 Gillies malar elevator, 253f keyless, 140f Eyed obturator (tip), 286f Gillies tissue forceps, 308f power, 139–143 Gillies tissue forceps (tip), 308f Druck-Levine antrum retractor, 244f F Gimbel Mendez fixation and guide ring, 204f Drum elevator (tip), 226f Glaucoma, 212–213 Duckworth & Kent cionni toric reference Facial fracture instrument set, 251–253 Glenoid punch, 165f marker, 204f Fallopian ring applicator, 106f Glenoid (Bateman) retractor, 165f Dura hook, 311f Fallopian ring applicator (tip), 106f Glenoid self-retaining retractor, 165f Dura scissors, 309f Farr spring retractor, 45 Glutaraldehyde, disinfection with, 16 Dura scissors (tip), 309f FDA. See Food and Drug Administration Goelet retractor, 34f, 46f, 124f Duval clamp, 278f (FDA) Gomey-Freemen SuperCut scissors, 263f Duval clamp (tip), 278f Femoral artery, blockage of, 268f Graether collar button, 203f Duval lung forceps, 282f Femoral head prosthesis, 178f Graptor retractor (tip), 80f Duval lung forceps (tip), 282f Femoral nail, 188–189 Grasper Ferris Smith fragment forceps, 243f in da Vinci Surgical System, 80f E Ferris Smith pituitary rongeur, 334f double-action, 55f Ferris Smith rongeur, 156f double-action (tip), 58f Ear, basic instrument set for, 224 Ferris Smith tissue forceps, 32, 34f–35f double-fenestrated (tip), 80f Ear forceps, 230f–231f Ferris Smith tissue forceps (tip), 20f, 35f single action, 57f Eardrum, repair of, 225–233 Fiber optic cord, 71f Grasper (tip), 58f Edwards holding clip, 198f Fiber optic light cable, 49 Grasping forceps (tip), 92f EEA anvil grasper, 64f Fiber optic light cord, 13, 50f Graves bivalve speculum, 95f Electrode Filshie clip, 106f Graves vaginal speculum, 89f, 94f, 104f coagulating, 129f Filshie clip applicator, 106f Green bipolar bayonet forceps, 326f cutting, 129f Fine tissue forceps (tip), 80f Green goiter retractor, 87f Ellik cystoscope evacuator, 129f Finochietto rib spreader, 285f Green muscle hook (tip), 215f Elschnig cyclodialysis spatula, 213f Fisher tonsil knife, 235f Green strabismus hook, 215f Elschnig fixation forceps, 206f FK retractor, 237f Greenberg Universal retractor, 318f Elschnig fixation forceps (tip), 206f, 218f Flash sterilization. See Immediate use steam Greenwald suture guide, 125f, 125f Endarterectomy, 268 sterilization (IUSS) Gruenwald nasal forceps, 247f Endo catch retriever, 61f Flexible endoscope, cleaning of, 9–10 Gruenwald nasal forceps (tip), 247f Endo GIA stapler, 67f Flieringa fixation ring, 205f Guideline for Disinfection and Sterilization in Endo power stapler, 66f Foerster sponge forceps, 21f, 38f, 88f Healthcare Facilities, 4 Endo power stapler (tip), 66f Foerster sponge forceps (tip), 38f Guideline for Disinfection and Sterilization Endoflex protective cover, 63f Fogarty clamp-applying forceps (tip), 297f of Prion-Contaminated Medical Endoflex retractor, 63f Fogarty Hydragrip clamp (tip), 284f Instruments, 10 Endoflex snake retractor, 64f Fogarty stealth applicator forceps (tip), 285f Guyon-Péan vessel clamp (tip), 116f EndoPass delivery instrument (tip), 82f Foman rasp, 165f Endoscope Fomon lower lateral scissors, 242f H carpal tunnel video, 145f Food and Drug Administration (FDA), 4 cleaning of, 9–10 regulation of sterilization container Hall sternal saw, 290f inspection of, 13 systems by, 24, 30 Hall surgical acetabular reamer set, 174f Endoscopy, definition of, 49 Forceps Halsey needle holder, 87f Endovascular aortic aneurysm repair, in da Vinci Surgical System, 80f Halsey needle holder (tip), 87f 271–273 description of, 20 Halsted clamp, 17 Endoweave grasper, 57f Fracture fixation Halsted hemostatic forceps, 36f EndoWrist bipolar instruments, 81f external, 191–193 Halsted hemostatic forceps (tip), 36f EndoWrist clip applier (tip), 82f long bone, 185–186 Halsted mosquito hemostatic forceps, 36f, EndoWrist instruments, 79–83 Francis chalazion forceps, 199f 45, 213f EndoWrist monopolar cautery instruments, Frazier dura hook (tip), 312f Halsted mosquito hemostatic forceps (tip), 80f Frazier suction tube, 21f 36f EndoWrist needle driver, 81f Freer double-ended elevator, 298f Harmonic cord, 76f, 100f

Index 349 https://kat.cr/user/Blink99/ Harmonic curved shears (tip), 81f House teflon block, 224f Instruments (Continued) Harmonic scalpel, 76f, 100f Hudson quick coupling, 141f stainless steel, 2–4 Harmonic scalpel (tip), 76f Humeral head retractor, 164f sterilization of, 15–16, 24–30 Harms tying forceps, 217f Hunt chalazion forceps, 199f testing of, 12–14 Harms tying forceps (tip), 218f Hunter (Glassman) bowel grasper, 64f, 77f thoracic, 280–282 Harrington blade, 43f Hunter (Glassman) bowel grasper (tip), 65f, 78f tracking of, 22 Harrington outrigger, 183f Hurd tonsil dissector, 235f vein retrieval, 304–305 Harrington retractor, 32 Hydrogen peroxide, disinfection with, 16 Insufflation tubing, 53f, 74f Harrington retractor blade, 40f Hydrogen peroxide gas plasma, 16 InsuFlow heater hydrator insufflation tubing, Harrington splanchnic retractor, 125f Hyperflex guidewire, 156f 74f Hasson obturator, 73f Hysterectomy Insulated instruments, 14 Hasson trocar, 52f, 73f abdominal, 96–98 Insulation, inspection of, 14 Hayes Martin tissue forceps, 86f position for, 102f Intracranial pressure monitoring tray, 330 Heaney-Ballantine hysterectomy forceps, supracervical laparoscopic, 99–102 Intramedullary taper reamer, 177f 96f–97f vaginal, 103–104 Intrepid I/A tip, 204f Heaney-Ballantine hysterectomy forceps (tip), Hysteroscopy, 91–93 Intuitive Surgical, Inc., 79 97f, 104f Iris scissors, 18f, 130f Heaney hysterectomy forceps, 96f–97f I Iris spatula (tip), 203f Heaney hysterectomy forceps (tip), 97f, 104f Iron, instrument staining from, 11 Heaney needle holder, 98f ICP monitoring tray, 330 Irrigation cannula, 213f Heaney needle holder (tip), 98f, 300f Identification systems, 16–17 Isotac screwdriver, 155f Heaney retractor, 89f, 104f IFU. See Instructions for use IUSS. See Immediate use steam sterilization Heaney-Simon vaginal retractor, 120f Immediate use steam sterilization (IUSS), (IUSS) Heaney uterine biopsy curette, 89f 9, 16 Heaney uterine biopsy curette (tip), 90f Impactor, 163f J Heart surgery, 283–286 Incision retractor, 172f open, 287–288, 291–295 Inlet fascia closure device, 75f J-hook cautery electrode, 57f Heart valve, repair of, 299–300 Instructions for use, 4 Jackson tracheal tenaculum, 239f Heath mallet, 147f for sterilization container systems, 29–30 Jacobs chuck, 143f Hegar dilator, 89f Instrument pan, 54f Jacobs chuck attachment, 142f Hegar uterine dilator, 134f Instrument rack Jacobs drill, 143f Hem-O-Lok clip applier, 117f laparoscopic, 76f Jameson muscle hook, 207f Hem-O-Lok clip applier (tip), 82f, 117f for tympanoplasty, 226f–228f, 230f Jameson muscle hook (tip), 208f, 215f Hem-O-Lok remover, 117f Instrument-tracking software, 22 Jameson muscle recession forceps, 214f Hemoclip-applying forceps, 124f Instruments. See also Microinstruments Jameson muscle recession forceps (tip), 215f Hemostat, types of, 17 accessory, 21 Jansen retractor, 19 Hemostatic clamp, 12–13, 17 ASIF anterior cervical, 344–345 Jansen thumb forceps, 241f Henle probe, 131f cardiac surgery, 283–286 Jarit hysterectomy forceps, 98f Heparin needle, 273f cardiovascular, 296–298 Jarit hysterectomy forceps (tip), 98f Herniorrhaphy, position for, 59f care and handling, 1–23 Jarit microsurgical needle holder, 303f Herrick kidney clamp, 116f resources for, 4–5 Jaw, example of, 18f Herrick kidney clamp (tip), 116f classification of, 14, 17–21 Jaw alignment, inspection of, 12–13 Hibbs laminectomy retractor, 164f cleaning of, 5–8 Jensen capsule polisher, 203f Himmelstein sternal retractor, 291f corrosion of, 11–12 Jeweler’s forceps, 131f, 206f Hinge, inspection of, 12 craniotomy, 307–313 Jeweler’s forceps (tip), 206f Hip cutting, 18–19 Johnson needle holder, 224f fracture of, 166–168 decontamination of, 5–6 Johnson skin hook, 224f total replacement of, 170–173 design of, 1 Joint, inspection of, 12 instruments for, 174–178 evolution of, 2 Joint replacement, small, 146–147 Hip retractor, 169 eye, cleaning of, 9 Joplin bone forceps, 165f Hippocrates, 2 finish of, 3 Jordan oval knife (tip), 226f Hirschman iris hook, 203f grasping, 20–21 Jorgenson dissecting scissors, 96f, 122–126 Hirschman iris hook (tip), 203f handheld, 17–21 Jorgenson dissecting scissors (tip), 98f Hoen nerve hook, 86f, 115f history of, 1 Joseph button-end knife, 241f Hoen nerve hook (tip), 298f holding, 20–21 Joseph button-end knife (tip), 241f Hoen periosteal elevator, 311f identification systems for, 16–17 Joseph coronoid self-retaining retractor, 254f Hohmann retractor, 169f inspection of, 12–14 Joseph skin hook, 84 Hoke chisel, 137f insulated, 14 Holmium laser fiber, 114f microscopic, 14 K Holt probe set, 182f neurologic bone pan, 314–316 Hook holder, 183f neurologic shunt, 326–327 K-wire, 156f Hook scissors, 58f nonpowered, 17–21 Kelley Descemet membrane punch, 213f Horizon clip applier, 292f packaging of, 14–15 Kelly retractor blade, 40f, 44f Horizon clip applier (tip), 292f point of use, 5 Kelman-McPherson tying forceps, 202f Hoskins forceps, 212f powered, 17 Kent-Wood adjustable retractor, 254f Hot Shears (tip), 80f preparation of, for processing, 5 Keratome, inspection of, 13 House double-end curette (tip), 228f prion contamination of, 10–11 Keratoplasty, deep lamellar endothelial, House Gelfoam press, 224f quality of, 3–4 210–211 House joint knife (tip), 226f radial artery harvest, 306 Kerrison rongeur, 243f House measuring rod (tip), 229f repair of, 22 Kerrison rongeur (tip), 315f House pick (tip), 227f return open heart, 301–303 Kevorkian-Younge endocervical biopsy House-Rosen needle (tip), 226f specialty, cleaning of, 9–10 curette, 89f House sickle knife, 226f spotting of, 11–12 Kevorkian-Younge endocervical biopsy House suction/irrigator, 232f staining of, 11–12 curette (tip), 90f

350 Index https://kat.cr/user/Blink99/ Key periosteal elevator, 137f, 168f Lee bronchus clamp (tip), 282f, 297f Mayo-Hegar needle holder, 38f Kidney, nephrectomy of, 115 Leksell rongeur, 314f Mayo-Hegar needle holder (tip), 38f Killian nasal speculum, 135f Lempert elevator, 224f Mayo needle holder, 32 Kirschner wire (K-wire), 156f Lens loop, 207f Mayo-Péan clamp, 17 Kistner probe, 311f Lens loop (tip), 208f Mayo-Péan hemostatic forceps, 32, 37f Knee Lester fixation forceps, 206f Mayo-Péan hemostatic forceps (tip), 37f arthroscopy for, 150–153 Lester fixation forceps (tip), 206f Mayo scissors, 18–19, 18f total replacement, 157–163 Lester IOL manipulator, 203f inspection of, 13 Knife Lester IOL manipulator (tip), 203f Mayo stand, setup for, 32f, 38f inspection of, 13 Lewis rasp, 241f McCullough utility forceps, 212f sternal, 289–290 Leyla ball and socket joint clamp, 317f McCullough utility forceps (tip), 215f Knife handle, 18 Leyla holding arm, 317f McIvor blade, 236f Kocher clamp, 32 Lieberman eye speculum, 200f–201f McKenty elevator, 241f Kocher forceps, 20 Ligament, anterior cruciate, 154–156 McNeil-Goldman scleral ring, 205f Kratz-Berraquer wire eyelid speculum, 200f LigaSure impact sealer/divider, 101f McPherson tying forceps, 131f Kronner laparoscopic scope holder, 52f LigaSure impact sealer/divider (tip), 101f McPherson tying forceps (tip), 202f Kuglen iris hook manipulator, 203f LigaSure laparoscopic sealer/divider, 101f MEC. See Minimum effective concentration Kuglen iris hook manipulator (tip), 203f LigaSure laparoscopic sealer/divider (tip), (MEC) Kuhn-Bolger giraffe forceps, 248f 101f Mechanical cleaning, 6–8 Lincoln-Metzenbaum scissors, 115f Mechanical washer, 8 L Linear cutter, 65f Medicine cup, 46f Linear provisionals, 175f MediTray basket insert, 25f L-hook cautery, 56f Linear stapler, 66f Medtronic Midas Rex electric drill, 320–321 L-hook cautery (tip), 56f Lister’s antiseptic technique, 2 Medtronic Skeeter Ultra-Lite oto tool, 233f Lacrimal probe, 131f Lithotripter, stone breaker pneumatic, 111f Mega needle driver (tip), 81f Lacrimal sac retractor, 222f Little retractor, 115f Mega SutureCut needle driver (tip), 81f LaForce adenotome, 235f Lone Star steel retractor, 126f Mellon curette, 337f Lahey gall duct forceps, 304f Long tip forceps (tip), 80f Mellon curette (tip), 337f Lahey goiter vulsellum forceps, 84f Lorna towel forceps, 285f Meltzer adenoid punch, 235f Lahey thyroid tenaculum, 84 Lothrop uvula retractor, 235f Meniscectomy knife, 144f Lahey traction forceps, 87f Love nerve retractor, 115f Metzenbaum dissecting scissors, 18–19, 18f, Lahey traction forceps (tip), 87f Love nerve root retractor, 335f 33f, 46f Lambert chalazion forceps, 199f Love nerve root retractor (tip), 335f Metzenbaum scissors Lambert-Kay aortic clamp, 303f Lowman bone-holding clamp, 168f inspection of, 13 Lambert-Kay aortic clamp (tip), 284f Lubrication, of mechanical washer, 8 roticulating, 277f Laminectomy, 334–337 Lucae mallet, 138f Meyerhoeffer chalazion curette, 199f Laminectomy, Williams microretractor, 338 Ludwig wire applicator, 241f Meyerhoeffer chalazion curette (tip), 199f Lamis infiltration needle, 263f Luer bone rongeur, 147f Micro Plastic Set, 260–261 Lancaster speculum, 198f, 205f Luer-Lok adapter, 55f Microbipolar forceps (tip), 81f Langenbeck elevator, 253f Lumen Microcurette, 323f Langenbeck periosteal elevator, 253f cleaning, 5, 7 Microcurette (tip), 324f Langenbeck retractor, 87f inspection of, 12 Microdissector (tip), 324f Laparoscope, 49 LUMINA telesope, 150f Microfixation system, 257 laser, 60 Lumpectomy, 84 Microforceps (tip), 80f lens for, 50f Lung grasper, 277f Microhook, 323f Olympus EndoEye, 51f Luxtec fiber optic light cable, 262f Microhook (tip), 324f Laparoscopic clip applier/remover, 127f Microinstruments. See also Instruments Laparoscopic ligating and dividing clip M open heart, 287–288 applier, 65f Rhoton neurologic, 322–324 Laparoscopic set Machemer irrigating lens, 219f Microneedle holder, 131f, 322f adult MIS, 54–59 Machemer irrigating lens (tip), 220f Microscissors, 322f minor, 47–48 Malleable retractor blade, 40f, 42f MicroSmooth I/A sleeve, 204f Laparoscopy, 49–53 Malleable T retractor, 280f MicroSmooth Phaco sleeve, 204f bariatric surgery, 72–78 Mallet Microvascular scissors (tip), 288f bowel resection, 63–68 Crane, 252f Midas Rex electric drill, 320–321 cholecystectomy, 61–62 Heath, 147f Midas Rex electric drill (tip), 321f definition of, 49 Lebsche, 290f Miller-Senn retractor, 46f, 87f instrument rack for, 56f, 58f Lucae, 138f Minerals, instrument spotting caused by, 11 for nephrectomy, 117–118 Malleus nipper, 231f Mini-hook holder, 183f position for, 59f Maltz rasp, 241f Mini-Metzenbaum scissors, 57f for prostatectomy, 127 Manual cleaning, 6–7 Minimally invasive spine surgery, 339–340 tubal occlusion, 105–107 Marlow knot pusher, 56f Minimally invasive surgery (MIS), 1, 49 Laparotomy Marlow knot pusher (tip), 56f Minimum effective concentration (MEC), 16 definition of, 32 Maryland bipolar dissector, 57f, 64f MINOP neuroendoscopy set, 328–329 setup for, 31–38 Maryland bipolar dissector (tip), 58f, 65f Minus irrigating lens, 219f Laparotomy set, small, 45–46 Maryland bipolar forceps (tip), 81f Minus irrigating lens (tip), 220f Laser, vaginal, 94–95 Mastectomy, 85–87 Mira diathermy tip, 218f Laser laparoscope, 60 Matson rib stripper, 280f MIS. See Minimally invasive surgery (MIS) Lateral vaginal retractor, 95f Maumenee corneal forceps, 206f MIS bone curette, 340f Le Fort fracture, 254 Maumenee corneal forceps (tip), 207f Mixter hemostatic forceps, 37f, 116f Leaflet retractor, 300f Maxwell flap retractor, 263f Mixter hemostatic forceps (tip), 37f, 116f Lebsche mallet, 290f Mayo dissecting scissors, 33f, 46f MMF self-drilling screw set, 256f Lebsche sternum knife, 290f curved, 32, 33f, 46f Monopolar scissors, 58f Lee bronchus clamp, 282f, 297f straight, 32, 33f, 46f Morse sternal retractor, 292f

Index 351 https://kat.cr/user/Blink99/ Mosquito clamp, 17 Ostium seeker, 249f Prostate Mueller clamp, 222f Ostrum-Terrier ostium forceps, 249f procedure for, 122–126 Multisociety Guidelines for Reprocessing O’Sullivan-O’Connor retractor, 19, 19f, 32, transurethral resection of, 128–129 Flexible Gastrointestinal Endoscopes, 9 41f, 96f Prostatectomy, 122–126 Murphy blade, 43f blades for, 41f laparoscopic, 127 Murphy bone lever, 172f Ototome, 225 Prosthesis Oval window pick (tip), 227f acetabular, 178f N femoral head, 178f P penile, 133–135 Nagahara Phaco chopper, 203f porous stem, 178f Nagahara Phaco chopper (tip), 203f Paddle blade, 79f Prosthesis driver, 172f Nasal fracture reduction, 245 Padgett dermatome, 266f Providence Hospital hemostatic forceps, 130f Nasal polyp, instruments for, 244 guards, 267f Pterygium set, 200f Nasal scissors, 250f head, 266f Pterygomasseteric sling stripper, 255f Nathanson liver retractor, 75f Paper drape clip, 36f, 224f Pubovaginal sling/anterior repair, 119–121 Nathanson retractor, 75f Paper drape clip (tip), 36f Pyramidal trocar, 144f Neck, cervical fusion for, 341–343 Parker retractor, 19 Needle, inspection of, 13 Parkes osteotome, 255f R Needle driver (tip), 81f Parsonnet epicardial retractor, 287f Needle holder, 21 Parsonnet epicardial retractor (tip), 288f Ragnell-Davis retractor, 134f inspection of, 13 Passivation, instrument manufacture and, Raney scalp clip applier, 309f Needle-tip suction, 56f 3–4 Ranfac knot pusher, 56f Nephrectomy, 115–116 Patient safety, 1–2 Ranfac knot pusher (tip), 56f laparoscopic, 117–118 Paton spatula, 207f Rasp (tip), 155f Neuroendoscopy set, MINOP, 328–329 Paton spatula (tip), 208f Rasp tray, 176f Neurologic bone pan instruments, 314–316 Paufique suture forceps, 222f Ratchet Neurologic retractor, 317–319 Paufique suture forceps (tip), 222f example of, 18f Neurologic shunt instruments, 326–327 Pelvic external fixator, 195f inspection of, 12–13 NexGen system, 163f Pemco suction tip, 285f Reamer tray, 177f Nezhat dorsal plug, 54f Penfield dissector, 285f Recommended Practices for Sterilization, Nezhat-Dorsey cautery, 56f Penfield dissector (tip), 312f for Care and Cleaning of Surgical Nezhat-Dorsey cautery (tip), 56f Penile prosthesis, 133–135 Instruments and for Selection and Nezhat-Dorsey irrigator, 77f Peracetic acid, disinfection with, 16 Use of Packaging Systems, 4 Nezhat-Dorsey suction, 56f Perforated tray, 24 Regulation, of sterilization container systems, 30 Nezhat-Dorsey suction (tip), 56f Pericardial dissector (tip), 82f Renal artery clamp, 297f Nezhat suction/irrigator, 64f Personal protective attire, instrument Renal artery clamp (tip), 297f Nezhat suction/irrigator (tip), 65f cleaning and, 7 Resano forceps (tip), 80f Nick pick, 210f Petri pterygoid retracor, 254f Resectoscope, 128f Nick pick (tip), 211f Phaco tip, 204f Resolution chart, 13–14 Noncritical instruments, 14 Pin collet, 142f Retinal detachment, 217–218 Notchplasty gouge, 156f Pin cutter, 192f Retractor, 19–20 Piriform rim retractor, 255f abdominal self-retaining, 39–44 O Pitting brain, 318f avoidance of, 12 neurologic, 317–319 Obturator, 71f instruments affected by, 11–12 self-retaining, 19f, 39–44 examples of, 73f Pituitary rongeur, 156f upper hand, 42f eyed (tip), 286f Pituitary rongeur (tip), 299f Retractor blade Occluding clamp, 17 PK dissecting forceps (tip), 81f fenestrated, 41f Occupational Safety and Health Plastic surgery, minor, 258–259 malleable, 40f, 42f Administration (OSHA), 5 Plate bender, 194f Rheumatoid arthritis, ankle, 148 Ochsner forceps, 20, 20f Polack double-tipped corneal forceps, 206f Rhinoplasty, 240–243 Ochsner forceps (tip), 20f Polack double-tipped corneal forceps (tip), Rhoton dissector, 323f Ochsner hemostatic forceps, 32, 38f 206f Rhoton neurologic microinstrument set, Ochsner hemostatic forceps (tip), 38f Polishing, instrument manufacture and, 3 322–324 Ochsner malleable retractor, 32, 35f, 46f Polymers, instruments made from, 1 Ribbon retractor, 252f Octopus retractor, 293f Poole abdominal suction tube, 21f, 34f, 46f Richards alligator forceps, 225 Oculoplastic instrument set, 221–222 Poole suction tube, 21 Richards bone curette, 172f Olsen clamp (tip), 58f Port, laparoscopic, 52f Richards ear speculum, 224f Olympus 1 chip camera, 305f Port cap, 55f Richardson-Eastman retractor, 120f Olympus EndoEye laparoscope, 51f Potts scissors, 79f Richardson retractor, 19f, 32, 34f, 46f Olympus flexible cystoscope, 111f Potts scissors (tip), 273f double-ended, 134f Olympus flexible ureteroscope, 113f Potts-Smith cardiovascular scissors, 115f Richardson retractor blade, 44f Open heart microinstruments, 287–288 Potts-Smith tissue forceps, 297f Ridged obturator, 145f Open heart surgery, 291–295, 299–303 Potts-Smith tissue forceps (tip), 297f Rigid endoscope, inspection of, 13 Operating room, setup for, 31–38 Power drill, 139–143 Ring forceps (tip), 261f Orthognathic surgery, 254–256 Power saw, 139–143 Rizzutti clip applier, 261f Orthopedic surgery, 136–138 PreCise bipolar forceps (tip), 81f Robotic instruments, 79–83 Orthophthalaldehyde, disinfection with, 16 Prince-Metzenbaum dissecting scissors, 86f Rod Oscillating saw, 140f Prions for long bone fracture, 185–186 OSHA. See Occupational Safety and Health description of, 10 spinal fusion with, 179–184 Administration (OSHA) instrument contaminated with, 10–11 Rod cutter, 183f Osteoarthritis, ankle, 148 sterilization and, 15–16 Rongeur, inspection of, 13 Osteotome, 155f Probe dilator, 115f Rosen knife (tip), 229f Osteotome (tip), 155f ProGrasp forceps (tip), 80f Rotary hand piece, 142f

352 Index https://kat.cr/user/Blink99/ Rowe disimpaction forceps, 253f Shunt passer, 327f Sterilization container system (Continued) Ruskin double-action rongeur, 314f Sickle knife, 247f regulation of, 30 Ruskin-Liston bone-cutting forceps, 147f Sickle knife (tip), 247f selection of, 29 Ruskin ronguer, 138f Sigma total knee FB tibial prep pan, 160f shelf life of, 27–28 Rusking-Liston bone-cutting forceps, 138f Sigma total knee femoral trials pan, 159f storage and sterility maintenance for, Russian tissue forceps, 34f–35f Sigma total knee fixed REF femur prep pan, 27–28 Russian tissue forceps (tip), 35f 158f SteriTite Container, 25f–26f Rust, instrument staining from, 11 Sigma total knee MBT prep pan, 161f Sternal crimper, 294f Ryder needle holder, 298f Sigma total knee pan, 157f Sternal knife, 289–290 Sigma total knee patella insertion pan, 159f Sternal saw, 289–290 S Sigma total knee spacer blocks pan, 160f SternaLock blade, 294f Sigmoidoscope, 71f SternaLock power driver unit, 294f Saber drill, 225 Sigmoidoscopy, 71 Stevens tenotomy hook, 214f Safety, patient, 1–2 Silber vasovasostomy clamp, 131f Stevens tenotomy hook (tip), 215f Sagittal splitting osteotome, 255f Sims uterine curette (tip), 90f Stevens tenotomy scissors, 130f Samii scissors, 309f Sims uterine sound, 89f Stone breaker pneumatic lithotripter, 111f Samii scissors (tip), 309f Sims uterine sound (tip), 90f Stone extractor, 114f Sarot bronchus clamp, 282f Sinskey iris and IOL hook, 207f Stone grasping forceps, 118f Sarot bronchus clamp (tip), 282f Sinskey iris and IOL hook (tip), 208f Strabismus scissors, 216f Satinsky atraumatic clamp, 118f Sinskey lens hook, 203f Strully scissors, 275f Satinsky (vena cava) clamp, 116f Sinskey lens hook (tip), 203f Strully scissors (tip), 288f Satinsky (vena cava) clamp (tip), 116f Sinskey tying forceps (tip), 209f Struycken nasal cutting forceps, 247f Sauerbruch rongeur, 281f Sinus surgery, 246–250 Struycken nasal cutting forceps (tip), 247f Saw Skeele curette, 199f Stryker arthroscopy shaver, 152f Hall sternal, 290f Skeele curette (tip), 199f Stryker cement gun, 162f oscillating, 140f Skeeter drill, 225 Stryker REM B cord, 143f power, 139–143 Skin graft, 266–267 Stryker sternal saw, 289f Stryker sternal, 289f Skin hook retractor, 19, 19f Stryker System 5, 139f Scalpel rigid stricture, 112f Smith-Petersen laminectomy rongeur, 171f Suction/irrigator system, 53f, 102f Schepens orbital retractor, 218f Snap-fit scalpel instruments, 79f Suction tube, 21 Schertel grasper (tip), 82f Snowden-Pencer dissecting forceps, 132f Supracervical laparoscopic hysterectomy, Schocket scleral depressor, 219f Snowden-Pencer dissecting scissors, 33f 99–102 Schott eye speculum, 205f Snowden-Pencer fixation forceps, 132f Surgery Schroeder uterine tenaculum forceps, 88f, Snowden-Pencer scissors, 275f cardiac, 283–286 94f, 97f, 99f Society of Gastroenterology Nurses and evolution of, 2 Schroeder uterine tenaculum forceps (tip), Associates, 9 eye muscle, 214–216 97f, 104f Sofamor spreader, 183f history of, 2 Scissors Spacer block, knee, 160f instrument cleaning after, 6–8 in da Vinci Surgical System, 79f Spatula cautery, 56f minimally invasive. See Minimally invasive description of, 18–19 Spatula cautery (tip), 56f surgery (MIS) examples of, 18f Spatula microdissector (tip), 324f open heart, 287–288, 291–295, 299–303 inspection of, 13 Spinal column, laminectomy for, 334–337 orthognathic, 254–256 Scleral plug forceps, 219f Spinal fusion, 179–184 orthopedic, 136–138 Scleral plug forceps (tip), 220f postoperative radiograph of, 184f sinus, 246–250 Scott-McCracken elevator, 168f Spinal tray, 29f spinal, 339–340 Scoville nerve root retractor, 335f Spine, minimally invasive surgery for, transoral, 237 Scoville nerve root retractor (tip), 335f 339–340 Surgical instruments. See Instruments SecureStrap tack, 65f Sponge holder, 21 SutureCut needle driver (tip), 81f Seibel nucleus chopper, 203f Spotting, of instruments, 11–12 Switchblade scissors, 77f Seibel nucleus chopper (tip), 203f Spratt curette, 147f Synthes AO quick coupling chuck, 141f Selector hand piece, 325f Spurling-Kerrison rongeur, 336f Synthes low-profile cranial plating set, Semb gouging rongeur, 281f Spurling-Kerrison rongeur (tip), 336f 332–333 Semb ligature-carrying forceps (tip), 284f Staining, of instruments, 11–12 Synthes Mini 4200 Driver, 142f Semb lung retractor, 281f Stainless steel Synthes mini quick coupling, 141f Semb lung retractor (tip), 282f composition of, 3 Synthes retrograde/antegrade femoral nail, Semicritical instruments, 14 corrosion of, 11–12 188–189 Senn-Kanavel retractor, 224f grades of, 3 Synthes sagittal saw attachment, 141f Senn retractor, 19 instruments made from, 1–3 Synthes Small Battery Drive II, 141f Senn retractor (tip), 239f quality of, 3–4 Synthes unreamed tibial nail insertion and Septoplasty, 240–243 Stammberger antrum punch, 247f locking instruments, 190 Serrephines, 218f, 222f–223f Stammberger antrum punch (tip), 247f Shadow ACF retractor blade, 342f Steinmann pin, 171f T Shadow ACF transverse retractor, 343f Stent grasper, 110f Shank, example of, 18f Stent grasper (tip), 110f T-handle probe, 182f Sheehy fascia press, 224f Sterilization, 15–16 T-handle wrench, 182f Sheehy ossicle-holding forceps, 224f immediate use steam, 16 TASS. See Toxic anterior segment syndrome Sheets irrigating vectis, 207f instrument packaging for, 14–15 (TASS) Shell acetabular instruments, 175f of instruments, 1–2 Taylor Spatial framework, 191f Shepard iris hook, 207f preparation for, 14–16 Taylor Spatial ring, 192f Shepard iris hook (tip), 208f steam, 15 Taylor spinal retractor, 173f Shoulder, arthroscopy for, 150–153 Sterilization container system, 24–30 Tebbetts fiber optic retractor, 262f Shoulder ligature carrier, 165f care and handling of, 26–27 Telescope Shoulder surgery, instruments for, 164–165 instructions for use, 29–30 bariatric, 74f Shukla Universal Screwdriver Set, 196f instrument placement in, 28–29 inspection of, 13

Index 353 https://kat.cr/user/Blink99/ Tenaculum forceps (tip), 80f Trocar sleeve, 144f Verres needle, 49, 53f Tendon, patellar, 154–156 Trousseau-Jackson tracheal dilator, 239f Verres needle stylet, 60f Tensioner, 192f Trousseau-Jackson tracheal dilator (tip), 239f VersaPoint hysteroscopic resectascope, 91f Terry scraper, 210f Troutman-Barraquer forceps, 206f sheath for, 92f Terry scraper (tip), 211f Troutman-Barraquer forceps (tip), 206f Vienna nasal speculum, 243f Texas Scottish Rite Hospital (TSRH), 179 Troutman-Barraquer microneedle holder, 207f Vital Metzembaum scissors, 304f bending tray, 180f Troutman-Barraquer microneedle holder Vitallium, instruments made from, 1 crosslink tray, 182f (tip), 209f Vitrectomy, 219–220 hook trials, 181f Troutman tier needle holder, 131f Volkmann rake retractor, 120f implant tray, 179f TruClear hand piece, 93f Volkmann retractor, 86f pediatric instrument tray, 181f TruClear hysteroscopy system, 93f Von Eicken antrum wash tube, 247f rod tray, 180f TSRH. See Texas Scottish Rite Hospital Von Graefe strabismus hook, 214f spinal system, 179 (TSRH) top tightening implant tray, 180f Tubal occlusion W wrench tray, 182f laparoscopic, 105–107 Thomas uterine curette, 89f position for, 107f Washer-decontaminator/disinfector, 8 Thomas uterine curette (tip), 90f Tubing passer, 135f Watzke sleeve-spreader forceps, 217f Thompson bariatric post and bar, 42f Tulip cannula, 265f Watzke sleeve-spreader forceps (tip), 218f Thompson retractor, 19, 32, 43f TURP. See Transurethral resection of the Wave grasper, 57f blades for, 43f prostate (TURP) Wax curette (tip), 228f joints for, 44f Tympanoplasty, 225–233 Weary nerve hook, 287f rotational blades for, 43f–44f Webster needle holder, 154f Thompson retractor holder, 75f U Weck EZ Load hemoclip applier, 302f Thoracic grasper (tip), 80f Weck Horizon hemoclip, 302f Thoracic instruments, 280–282 Ultrasonic cleaning, 7 Weck scissors, 260f Thoracoport, 278f Ultrasonic handpiece, 325 Weder tongue depressor, 235f Thoracoscopy, 277–279 Universal screwdriver/broken screw set, Weinberg blade, 42f position for, 279f 196–197 Weinberg retractor blade, 44f Thorpe calipers, 218f University of Minnesota cheek retractor, 252f Weitlaner retractor, 19, 19f, 46f, 138f Thorton fixation ring, 203f Upper hand retractor, 42f Weitlaner self-retaining retractor, 45 Tibial aiming hook, 156f Ureteroscope, rigid, 114f Welch Allyn operative sigmoidoscope, 71f Tibial nail insertion and locking instruments, Ureteroscopy, 113–114 Wells enucleation spoon, 223f 190 Urethra, cystoscopy of, 108 Westcott tenotomy scissors, 18–19, 18f Tissue forceps (tip), 20f Urethroscopy, 112 Westcott tenotomy scissors (tip), 209f, 221f Titanium, instruments made from, 1 Urinary bladder, cystoscopy of, 108 Westphal hemostatic forceps, 37f Titanium 2.0-mm microfixation system, 257 U.S. Food and Drug Administration. See Westphal hemostatic forceps (tip), 37f Titanium needle holder (tip), 209f Food and Drug Administration (FDA) Whirleybird pick (tip), 227f To Err is Human: Building a Safer Health Uterine manipulation probe, 99f Wiener antrum rasp, 241f System, 1–2 Uterine manipulator, disposable, 100f Williams laminectomy microretractor, 338 Tonsil hemostatic forceps, 32, 37f Uterine sound, 99f Wills Hospital utility forceps, 217f Tonsil hemostatic forceps (tip), 37f Uterus, dilatation and curettage of, 88–90 Wills Hospital utility forceps (tip), 218f Tonsillectomy, 234–236 Utrata forceps, 202f Wire collet, 143f Tooth forceps, 118f Utrata forceps (tip), 202f Wolf bipolar grasper, 105f TORS. See Transoral robotic surgery (TORS) Wolf optical urethrotome obturator, 112f TORS blade, 237f V Woodson dura separator and packer, 311f Total hip replacement, 170–178 Woodson dura separator and packer (tip), Total knee replacement, 157–163 V-Lign instrument tray, 177f 312f Towel clamp, 21 Vagina, repair of, 119–121 Woodson elevator, 340f Townley femur caliper, 171f Vaginal hysterectomy, 103–104 Toxic anterior segment syndrome (TASS), 9 Vaginal laser, 94–95 Y Tracheal hook (tip), 239f Valve hook, 82f Tracheotomy, 238–239 Van Buren sound, 129f Yankauer suction tube, 21, 21f, 34f, 46f Transoral robotic surgery (TORS), 237 Vannas capsulotomy scissors, 131f, 209f Yankauer suction tube (tip), 34f Transoral surgery, 237 Vannas capsulotomy scissors (tip), 209f Yasargil aneurysm clip, 331 Transplant microscissors, 209f Vas deferens, 130 Transurethral resection of the prostate Vascular bulldog, 127f Z (TURP), 128–129 Vasectomy, 130–132 Trilogy acetabular instruments, 174f Vasovasostomy approximator, 131f Z clamp, 97f Trocar VasoView harvesting cannula, 305f Z clamp (tip), 97f examples of, 73f Vein retractor, 275f Zimmer-VerSys instruments, 174–178 laparoscopic, 52f–53f Vein retrieval instruments, 304–305 Zygomatic arch awl, 252f

354 Index https://kat.cr/user/Blink99/ Contents—cont’d

UNIT SIX: EYE, EAR, NOSE, AND UNIT NINE: PERIPHERAL VASCULAR, THROAT SURGERY CARDIOVASCULAR, AND THORACIC SURGERY

58 Basic Eye Set, 198 84 Endarterectomy, 268 59 Clear Corneal Set, 201 85 Artery Bypass Graft, 269 60 Corneal Transplant, 205 86 Endovascular Abdominal Aortic Aneurysm Repair, 271 61 Deep Lamellar Endothelial Keratoplasty, 210 87 Abdominal Vascular Set (Open Procedure), 274 62 Glaucoma, 212 88 Thoracoscopy, 277 63 Eye Muscle Surgery, 214 89 Thoracic Instruments, 280 64 Retinal Detachment, 217 90 Cardiac Surgery, 283 65 Vitrectomy, 219 91 Open Heart Microinstruments, 287 66 Oculoplastic Instrument Set, 221 92 Sternal Saws and Sternum Knife, 289 67 Eye Enucleation, 223 93 Open Heart Extras, 291 68 Basic Ear Set, 224 94 Cardiovascular Instruments, 296 69 Tympanoplasty, 225 95 Open Heart Valve Extras, 299 70 Tonsillectomy and Adenoidectomy, 234 96 Return Open Heart Set, 301 71 Transoral Surgery, 237 97 Vein Retrieval Instruments, 304 72 Tracheotomy, 238 98 Radial Artery Harvest Set, 306 73 Septoplasty and Rhinoplasty, 240 74 Nasal Polyp Instruments, 244 UNIT TEN: NEUROSURGERY 75 Nasal Fracture Reduction, 245 99 Craniotomy, 307 76 Sinus Surgery, 246 100 Neurologic Bone Pan Instruments, 314 101 Neurologic Retractors, 317 UNIT SEVEN: ORAL, MAXILLARY, AND FACIAL 102 Medtronic Midas Rex Electric Drill, 320 SURGERY 103 Rhoton Neurologic Microinstrument Set, 322 77 Facial Fracture Set, 251 104 Ultrasonic Handpieces, 325 78 Orthognathic Surgery, 254 105 Neurologic Shunt Instruments, 326 79 Titanium 2.0-mm Microfixation System, 257 106 MINOP Neuroendoscopy Set, 328 107 Intracranial Pressure Monitoring Tray, 330 UNIT EIGHT: PLASTIC SURGERY 108 Yasargil Aneurysm Clips with Appliers, 331 109 Synthes Low-Profile Cranial Plating Set, 332 80 Minor Plastic Set, 258 110 Laminectomy, 334 81 Micro Plastic Set, 260 111 Williams Laminectomy Microretractors, 338 82 Plastic Miscellaneous, 262 112 Minimally Invasive Spine Surgery, 339 83 Skin Graft, 266 113 Anterior Cervical Fusion, 341 114 ASIF Anterior Cervical Locking Plating Instruments, 344

UNIT ON PEDIATRIC SURGERY (ON EVOLVE WEBSITE)

https://kat.cr/user/Blink99/