Surgical Tools
Let's explore the surgical instruments that you will be using in anatomy lab. These are only some of the tools that you will see in your clinical rotations in the years to come as some instruments have very specialized use in procedures.
Scalpel:
used to cut through skin, subcutaneous tissue, fascia, or other fibrous tissues. Discretion should be used when using a scalpel around delicate structures such as nerves, arteries or veins.
Fine point (sharp/sharp) scissors:
used to dissect through thin areas of subcutaneous tissue, fat, or fascia. Discretion should be used when using sharp scissors around delicate structures such as nerves, arteries or veins. Spreading motions to separate tissue delicately is a common technique with these (see Foundation skills video guides).
Blunt pint scissors:
used to cut or dissect through thick areas of tissue. A blunt end limits the risk of inadvertently puncturing or damaging other tissues while the blade is inserted.
Probe: (blunt or sharp):
usually held with the non-dominant hand and used in conjunction with another tool such as scissors or forceps. Probes are used to push tissues aside tissue or structures that are in the way, but that the surgeon needs to preserve.
Hemostats :
a self-locking type of clamp that can lock onto skin, subcutaneous tissue or fat to pull it to the side to gain adequate exposure to the dissection field. Additionally, hemostats are used to clamp vessel loops when they are used to tag nerves, arteries or veins or when they are used for hemorrhage control. The ends come in a variety of shapes from straight, curved to right angled.
A specific sub-type of hemostat with a curved end is called a Kelly clamp, which is sometimes mistakenly used as the name for the general class of hemostat instrument.
Forceps (ribbed or mouse-toothed):
usually held in the non-dominant hand, forceps are used in conjunction with another tool such as a scalpel or scissors to grasp a structure or body tissue. When handling a delicate structure such as a nerve, artery or vein, ribbed forceps should be used so that the structure is not pierced or damaged. When handling durable tissue such as skin or subcutaneous tissue, mouse-toothed forceps may be used for a firmer grasp. They come in a wide variety of sizes/shapes (and names) specialized to different needs and colloquially known as 'pickups'.
Weitlaner Retractor
:
used to spread and hold open skin and subcutaneous tissue for opening and exposing the dissection field. The self-locking mechanism ratchets open with spring loaded teeth, allows them to be placed and then let go for hands free retraction. The leaver is used to disengage the lock allowing the retractor to be closed (you don't hold the lever when opening, the ratchet takes care of opening locking and the lever is only for unlocking)
Hand saw:
used in a back and forth sawing motion to manually cut through bone. More commonly now the Stryker power tool is used for this task.
Hammer and chisel:
used to split hard bone plates. The sharp edge of the chisel is propped against the bone and the hammer is tapped against the chisel in short, controlled taps until the chisel has gone through the bone to the desired depth.
Finochietto Rib Spreader:
used as a crank to open the chest. The vertical plates are placed into an opening the crank is used to slowly open the chest. Standard thoracic openings are to spread a midline transected sternum or spread the 5th intercostal space (i.s. between ribs 5-6). Once in place, the chest spreader holds open the ribcage for maximum chest exposure for dissection.
Lebsche (Sternal) Knife:
usually used in cardiothoracic procedures that necessitate splitting the sternum. This may be in a midline sternotomy to split down the middle of the sternum or in a resuscitative thoracotomy to split transversely across the sternum. The chisel edge is placed against the sternum with the handle used to control direction while the strike plate is struck with a hammer to generate the force needed to split the bone.
Stryker (power cutter):
A high-speed, oscillatory power saw that can cut efficiently through bone, but is inefficient at cutting soft tissues. This provides soft tissue protection during bond cutting as inadvertent soft tissue contact rarely results in damage.
Needle/Syringe
:
used to inject or extract fluids from various vessels or cavities within the body. Needle-stick injury (impaling yourself with a contaminated needle) is a leading risk for physicians necessitating careful and appropriate needle handling at all times. The standard fitting now is a twist-on/off threaded end called a luer lock, rarely you may encounter the old push on/off which rely upon friction to hold the needle in place.
Balfour Retractor
:
a large retractor used in abdominal surgery to hold open large incisions in the abdominal wall. These most commonly come with a self-retaining mechanism and frequently with a detachable third arm equipped with a bladder blade retractor arm.
Army-Navy Retractor
:
The army-navy retractor is a very common manual retractor having a long hock end and a short hock end with a split in the middle of the center span. Either end can be used to retract tissues depending on the depth/size of tissue to be retracted with the large/small end of the instrument.
Doyen Retractor
:
(image, left side) a large
curved retractor with a handle used to hold soft or sensitive organs out
of the ways. The wide contact area holds organs with limited tension on
any individual point (in contrast to the army-navy retractor which has a
smaller contact area).
The Doyen retractor shape is nearly identical to the bladder blade of
the Balfour retractor (image, right side), thus the bladder blade in
isolation can be used as a Doyen retractor.
Emesis (kidney) basin
:
A shallow basin with sloping walls to receive medical waste or other materials. The kidney shape of the dish allows it to be held more readily against a patient's body to catch any falling fluids or debris.
Organ (aka 'Brain') Knife
:
These are larger pathology knives ranging from 6" (for organs) to 15" (for brain) commonly used to prepare surgical biopsy samples for pathology preparation. Pathology sample preparation is termed 'grossing' samples.
Operating room instruments are the basic tools that are used in surgery. Examples are:
In this article, we’ll look into the design, handling and uses of some of these instruments in the operating room.
There are three different types of needles available; the 1/2 circle needle, the 3/8 circle needle and the straight needle. Needles are used for different purposes in a surgical operation. Some of which are:
There is a 10-blade with a curved cutting edge, an 11-blade that is triangularly pin-pointed, a 12-blade (stitch cutter) and a 15-blade. The blade is used to make an incision in the skin.
Gauze is used as a surgical dressing to keep a wound clean and protected. It can also be used to absorb blood and other fluids from the wound.
Diathermy is used to cut through tissue.
Retractors are sharp and round retractors. The sharp retractors have six prongs. They are commonly used for retracting and simultaneously lifting the skin and subcutaneous tissue.
Different scissors are used, either straight or curved. Scissors are basically used for cutting. To cut sutures, bandages, gauze, tape, cotton or cloth.
There are anatomical forceps and surgical forceps. The surgical forceps have teeth at the tip. Surgical forceps are used for grasping and holding various objects during surgical procedures. These tools include hand forceps, needle holders, clamping forceps, and others.
There are many types of clamps with their common denominator being the cremaillere that allows permanent closure. There are many uses of clamps in surgical operations. They can be used to hold tissues together, to stop bleeding, and to secure instruments or other materials in place. Plastic clamps are available for the insertion of blood vessels in order to feed blood from the site of surgery. Other plastic surgical clamps are used for the placement of implants, to tie ligaments, or for other various procedures.
This is one of the most basic instruments used during surgery. It is a knife with a short blade (about 1 to 3 cm) that makes cuts in the skin or other tissues. The blade is very small and this helps make clean cuts.
There are different types of needle holders. They include straight, curved-left, curved-right, and self-righting needle holders. They are used to hold suturing needles during surgical procedures.
The curette is used to scrape away tissue.
Instrument handling is a critical part of surgical procedures. Proper technique can minimize the risk of injury to the worker and damage to the instrument. Here are some tips for safe handling of Operating room instruments:
Good knowledge of different angles will allow operating team members to optimize how they use instruments. These include:
this is the angle formed between two instruments converging at the operative field. An effective manipulation angle is around 60° (45-75°).
This is the angle formed by the shaft of an instrument in relation to the horizontal axis of the patient. The ideal elevation angle is 30-60°.
This is the angle formed between the laparoscope shaft and an instrument. It should ideally be equal for all instruments.
Limberg flap angleBasic instruments like needles, blades and forceps also have safe handling procedures.
The removal of the blade should not be done with fingers but with a blade remover or forceps. The blade is placed with a clamp or needle driver on a scalpel holder and multiple grips are possible according to the desired type of incision.
In laparoscopic suturing, the suture is grasped so that the needle can 'flop' when introduced through a port. If the needle is directly grasped instead, there is likely going to be a tear in the lining of the cannula and, potentially, the abdominal wall tissues and internal structures.
The needle is usually held near its midpoint in a perpendicular manner in the tip of the jaws. A needle can be placed in a needle holder in different ways based on the desired way of stitching.
More force can be applied when the forceps is held at its tip.
The thumb and either ring finger or middle finger are placed in the holes. It is important to have sufficient pressure on the blades by putting the correct force on both finger rings.
In laparoscopic surgery, the principle of triangulation is utilized. This is when the viewing trocar and laparoscope are placed in the centre with working ports placed equidistant at either side to form a triangle. This arrangement allows the surgeon to have a central view of the target structure, optimal instrument manipulation angles, helps the depth perception, camera orientation and surgical ergonomics.
Like triangulation, sectorization is another way of organizing an operative field. It involves placing the working trocars to one side of the viewing trocar.
Laparoscopic Surgery: triangulationSurgical instruments must be kept clean and sterile by all members of the surgical team to prevent the spread of infection and to avoid contamination. This is ensured by proper preparation/handling of sterile items and sterilization of surgical instruments. Here’s a breakdown of how to maintain sterility:
The setting up of table setting and preparation of instruments should be done in a sterile preparation room that has a laminar down-flow ventilation system that directs ambient air away from the site, carrying contaminant dust particles along. A back table and Mayo stand are used to set up the sterile field upon which the sterile instruments and materials can be placed. In a situation where there is no dedicated sterile preparation, the sterile field can be set up in the Operating room with an OR furniture (back table, Mayo stand and Operating room trolley) but must be far away from the door to prevent contamination. Table setting furniture and equipment should be placed, at least 1m from the walls and the person passing materials from the unsterile area to the sterile field should stand 50cm away from it.
All sterile items/instrument sets required are ensured to be in the OR. The content and size of these packs depend on the procedure and local protocol for performing the procedure. The local protocol will dictate that chemical indicator, packaging material and expiry date should all be checked.
Surgical instruments must be maintained and sterilized in order to prevent the spread of infection. To ensure that the instruments are clean, used tools must be cleaned and disinfected. The use of disposable instruments like gauze swabs and sutures is very effective in preventing the spread of infection. Some surgical instruments have a built-in sterilisation feature or may be purchased with a sterilisation system.
A very important item to note is that metal instruments should never be immersed in ethylene oxide (ETO) as they are made from stainless steel, which can cause pitting or rusting of the metal. Another method of sterilisation is by using autoclaving. The items are placed in a water bath and subject to steam for 5 minutes at around 121°C. The autoclave is then turned off, and the water bath is removed. The items are then left for a further 5 minutes at room temperature in an environment which will not induce condensation on the surface of the items.
Without proper understanding of instrument handling and maintenance of sterility, there are a number of common complications associated with the use of these surgical instruments. One of the most common complications is infection. Infection can occur when the instruments are not properly cleaned and disinfected before use.
In order to prevent an infection, both personnel and processes should be guided by hospital policyAnother common complication is damage to surrounding tissues. This can occur when the instruments are not properly used or when they are not properly sterilized. The type of instruments used and the type of procedure performed will also affect the rate of complications. For example, the use of scalpels is associated with more severe complications than the use of forceps and other types of cutting instruments.
Surgeons and other surgical team members must have a clear understanding of how to properly handle basic operating room instruments in order to optimize their usage during surgery. By using the correct techniques, surgeons can minimize the risk of injury to themselves and their patients. Improper handling of surgical instruments can lead to a number of problems, including accidental puncture wounds, lacerations, and infection.
Incision Nurse(s) are scrub nurses and nurse anesthetists creating courses for the Academy. The content we create is always checked by perioperative team members from client hospitals. By understanding their needs, we design what we believe to be the best solution to help healthcare professionals perform their daily tasks. The videos are intended to provide quick and concise overviews of the skills and concepts, relevant to the practice of scrub nurses and nurse anesthetists.