SURGICAL INSTRUMENTS Claudia Gherman, ăCiocan, Ovidiu Fabian Learning objectives What you should know The main types of surgical instruments The main instruments used for cutting tissues The main instruments used for tissue manipulation The main instruments used for exposure (retractors) The main instruments used for suturing The functioning principle of electrocautery devices The main laparoscopic instruments What you should do Recognize the main surgical instruments Attach a scalpel blade to a handle/remove it from the handle Hand a scalpel to another person correctly Perform an incision Handle scissors (hold them correctly, cut under visual control, hand scissors to another person) Handle a self-retaining forceps (hold it correctly, grip the tissue, close and open the forceps, hand it to another person) Hold a retractor correctly Hold, close/open and hand over a needle holder correctly Recognize a suturing needle; recognize a sharp needle and an intestinal needle; find on the needle and suture package the main information about the needle Classification In order to perform surgery, the surgical team needs a number of surgical instruments. Each of the thousands of instruments used is designed for a specific function. They can be classified depending on use as follows: Cutting instruments Instruments for tissue grasping and manipulation Instruments for tissue exposure Suturing instruments Hybrid instruments Endoscopic instruments Cutting instruments Scalpels: consist of a handle and a blade; the handle is made of metal (reusable) or plastic (disposable); blades are disposable, of various shapes and sizes. The top of the scalpel handle has a special part, with a groove that allows its sliding into the blade slot and securing of the blade in position. The scalpel blade has a slot - larger at its base and narrower at its top. The larger part is fitted to the groove of the handle, and the narrower part secures the blade into the groove. Figure 1. Handle of a scalpel Figure 2. Scalpel blades The attachment of a scalpel blade is illustrated below: Figure 3. Attachment of a scalpel blade: the larger part of the blade slot is placed in the handle groove, then the blade is moved so that the narrower part of the slot slides and snaps into the groove The removal of a scalpel blade is presented below: Figure 4. Removal of a scalpel blade: the blade is lifted over the securing device and then slided out of the handle groove A scalpel must be handed from one person to another so as to completely eliminate any risk of injury. The scalpel is held by the upper part of the handle, with the completely visible blade pointing upwards; the recipient takes the scalpel by grasping the lower part of the handle. Figure 5. Handing over During its use, the scalpel can be a scalpel Held as a knife, as a pencil or as a dagger (see the figure below). Figure 6. Use of scalpels – as a knife, as a pencil, as a dagger Scissors are used to cut tissues, suture threads, dressings, as well as for blunt dissection (the closed scissors are introduced between the planes to be separated, and are opened Figure 7. Metzenbaum before they are extracted). scissors Scissors exist in a variety of sizes and shapes. They can be straight, curved or angular. They can have a sharp or blunt tip. A. B. C. D. Figure 8. Different types of scissors: A. Mayo scissors; B. Potts scissors (used in biliary and vascular surgery); C. Castroviejo scissors (used in microsurgery, ophthalmology, neurosurgery); D. Scissors for cutting dressings During usage, scissors are held as follows: The fourth finger is inserted through the ring of the lower arm of the scissors The third finger supports the lower arm of the scissors The second finger is extended along the arms of the scissors, ensuring the precision of movement The thumb (about half of the first phalanx) is inserted through the ring of the upper arm of the scissors Figure 9. The correct way to hold scissors It is important that cutting with scissors should be performed under visual control; the tip and the entire length of the blades must be observed in order to avoid damaging other tissues than those concerned. To cut the threads after tying a knot, the following are performed: The open blades are placed around the threads The scissors are lowered to the proximity of the knot, they are rotated Figure 10. Cutting a so as to make the knot clearly visible thread under visual control The threads are cut to the desired length This allows to avoid o Leaving too long or too short thread ends o Cutting the knot Scissors should be handed from one person to another as follows: The first person holds the tip of the scissors The second person opens the Figure 11. Handing over scissors Palm of the hand to receive the instrument The first person places the handle of the scissors in the palm of the recipient Other cutting instruments are chisels, osteotomes, saws (used for cutting bones), curettes (used for scraping tissues), dermatomes (used for collecting free skin). Tissue manipulation instruments Hemostats are used to grasp, handle and retract tissues. In certain situations, spaces are too narrow for the ’hands, so that hemostats can apply force, pressure or can expose certain anatomical structures. There are two types of hemostats: self- retaining and non-self-retaining. Surgical hemostats are traumatic hemostats (equipped with teeth allowing to grasp tissue firmly). They are used for handling hard tissues (skin, fascias). Anatomical hemostats are atraumatic (without teeth). They are used for handling sensitive, friable tissues. A. B. Figure 12. A. Surgical hemostat. B. Anatomical hemostat An anatomical or Surgical hemostat should be held with the thumb on one A. side and with the B. second and third Figure 13. Holding an anatomical/surgical hemostat: A. fingers on the other Correct B. Incorrect Side, towards the volar part of the hand – similarly to a pencil. Holding A hemostat with its handle in the palm should be avoided; this position is uncomfortable and does not allow precision. An anatomical or surgical hemostat should be passed from one person to another by placing the instrument with its handle (not its tip) in Figure 14. Handing over an the ’hand. anatomical/surgical hemostat Self-retaining forceps are used for grasping tissues and they have a locking (rack and pinion) mechanism that keeps them closed, allowing them to hold the tissue Figure 15. Self-retaining forceps Between their arms. They are similar in shape to scissors, the locking mechanism being situated near the rings. They can be straight or curved. The most widely used self-retaining forceps are: P‚an’ forceps – without teeth Kocher’forceps – with teeth A. B. Figure 16. A. P‚an’forceps. B. Kocher’forceps Other forceps, similar to the two above, are Mosquito forceps – a fine, small size Pean’ forceps Overholt forceps – a fine, curved P‚an’ forceps, used for dissection or hemostasis A. B. Figure 17. A. Mosquito forceps. B. Overholt forceps To secure drapes that cover the patient during surgery, special self-retaining forceps are used1: Backhaus forceps (with a rack and pinion mechanism) Doyen forceps (with a spring mechanism) A. B. Figure 18. Forceps for securing surgical drapes: A. Backhaus forceps B. Doyen forceps Handling of self-retaining forceps: Forceps should be held similarly to scissors: the fourth finger is inserted through the lower ring, the middle finger supports the forceps, Figure 19. Holding a self-retaining forceps The index finger is extended along the arms of the forceps to ensure precision of movement, and the thumb (the proximal half of the first phalanx) is inserted through the upper ring A self-retaining forceps is closed by moving its arms so as to allow engagement of the teeth of the locking mechanism The forceps is opened by pushing the rings (arms) apart so as to disengage the teeth of the rack and pinion mechanism Figure 20. Opening a self-retaining forceps by pushing apart the teeth of the locking mechanism 1 Known as “”due to their arms similar to the claws of crayfish A self-retaining forceps should be handed from one person to another similarly to scissors: the handing person holds the tip of the instrument and places the Figure 21. Handing over a self- handle (rings) of the forceps retaining forceps In the ’open palm. Instruments for exposure (retractors) They are used to hold back tissues/organs in order to expose only those organs/tissues that are being operated on; they ensure visibility of the surgical site. Retractors come in different shapes and sizes, depending on anatomical location. To minimize trauma to the retracted organs and tissues, the position of retractors must be frequently changed during surgery. Below are some examples of retractors: A. B. C. Figure 22. Retractors: A. Farabeuf retractor; B. Doyen retractor; C. Self- retaining (Weitlaner) retractor Handling retractors is difficult and fastidious, but exposure provided by them is important because it ensures visibility of the surgical site. Traction on retractors is generally Figure 23. Handling the Farabeuf exerted in two directions: retractor Laterally and downwards; consequently, the most effective way to hold a mobile retractor is using the thumb and the third- fifth fingers (ensuring lateral traction), while the second (index) finger is extended along the instrument and ensures downward pressure. Suturing instruments Needle holders are special self-retaining forceps used to maneuver the needle during suturing (they hold and guide the suturing needle). X-shaped striations allow a secure grip of the needle between the arms. There are 2 main types of needle holders, the others being variations of these: the Mathieu needle holder and the Hegar needle holder.