introduction to surgical instrumentation

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Introduction to Surgical INSTRUMENTATION

ST230Concorde Career College

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Objectives

• Discuss the relationship between instrumentation, equipment, and supplies and quality patient care in the OR

• Identify basic instruments by type, function, classification, and name

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Manufacturing

• Most are stainless steel

– Carbon, chromium, iron, alloys

• High carbon makes instruments harder and less likely to wear

• Chromium increases resistance to corrosion

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Manufacturing

• Three types of finishing– Highly polished = increased resistance to

corrosion, but increases glare from OR lights

– Satin (dull) = less reflective, reduces glare

– Ebonized = non-reflective, eliminates glare• Used for laser procedures because it prevents

reflection of laser beam

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CLASSIFICATIONS

• CUTTING/DISSECTING• GRASPING/HOLDING• CLAMPING/OCCLUDING• RETRACTING/VIEWING• PROBING• DILATING• SUTURING• SUCTIONING• ACCESSARY INSTRUMENTS

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CUTTING/DISSECTING

• One or more sharp edges– Used for incision, sharp dissection, or excision of

tissue– Include knives, scalpels, scissors, and bone cutting

instruments – osteotomes, curettes, chisels, gouges, and rongeurs

– May be classified as cutting instruments – saws, drills, biopsy punches, adenotomes, and dermatomes

– -tome – refers to a cutting instrument

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CUTTING/DISSECTING

• The term knife and scalpel are interchangeable although typically scalpels have a detachable disposable blade and non-disposable handle and knives refers to non-disposable handle and blade such as an amputation knife

• Scalpels handles sizes include #3, #4, #7, and #9; Beaver blade handle

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CUTTING/DISSECTING

• Disposable blades are made from carbon steel• Blades should be loaded and removed with an

instrument such as a needle holder• #10, #11, #12, #12B, #15, #15C, #20, #21, #22,

#23, #25• Blades fit specific handles - #10, #11, #12,

#12B, #15, #15C blades fit #3, #7, #9 handles

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CUTTING/DISSECTING

• #20, #21, #22, #23, #25 blades fit on a #4 knife handle• Any size Beaver blade will fit on a Beaver blade handle• #10 blades are the most frequently used blades and

should be loaded on a #3 knife handle; do not load #10’s on a #7 knife handle

• #11, #12, #15 blades are loaded on a #7 knife handle, although a #15 blade is used on a #3 knife handle for small skin incisions

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CUTTING/DISSECTING

• Blades become dull very quickly. 2 or 3 cuts usually dulls the blade

• The blades have to be changed as needed

• For safety reasons, if the blade has been changed, the surgeon should be informed that it is a new blade when passing it

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CUTTING/DISSECTING

• Scissors– Tissue scissors, suture scissors, wire scissors, or

bandage scissors– Tissue scissors should only be used to cut tissue

because others materials will dull them; an exception would be CV surgeons, they use Metz to cut the small sutures

– Wire scissors are used to cut wire– Bandage and straight mayo scissors can be used

on dressings

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Cutting and Dissecting

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CUTTING/DISSECTING

• In addition to cutting tissue (sharp dissection), scissors are also used to spread and open tissue planes (dull dissection)

• Curved mayo scissors are used on heavy tissue• Metz are used on medium to fine tissue• Iris, tenotomy, and Potts-smith scissors are

used on delicate tissues

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CUTTING/DISSECTING

• Examples of specialized scissors– Potts-smith – ducts, veins, or arteries– Cushing - dura– Jorgenson – hysterectomy– Strabismus, Iris, corneal scissors – eyes

• Scissors have straight and curved blades and sharp or dull tips

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GRASPING/HOLDING

• Used to grasp or hold tissue for counter traction or manipulation• Forceps – aka pickups or thumb forceps• Forceps are usually used in the non-dominate hand• Forceps have either teeth, serrations or smooth; Vary in length• Adson – smooth, with teeth, or Brown tips; primarily used for skin

closure• Ferris-Smith – used for heavy tissue• Brown, Russian, Gerald, Cushing, bayonet, rat tooth• Allis, Babcock, Kocher - clamps• Bone-holding clamps – ex; Lane, Kern, Lowen, Lewin

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Grasping/holding

• Designed to manipulate tissue to facilitate dissection or suturing or to reduce and stabilize fractured bone during internal fixation

• Lowman – Turkey claw• Lane

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CLAMPING/OCCLUDING

• Designed to occlude or restrict tissue• Have ringed handles with interlocking ratchets• Straight or curved, long or short, pointed or round• Vascular clamps have atraumatic serrations that are

vertical• Bulldog clamps are small spring loaded for temporary

occlusion – vascular • Hemostats are used to occlude bleeders until they can

be ligated

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Clamping and Occluding

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RETRACTING/VIEWING

• Designed for the exposure of the operative site• May be hand-held or self-retaining• Many sizes and designs; sharp or dull tips• Some retractors are malleable • Many hand-held are double-ended with a variation on

each end and usually are mostly used two at a time

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RETRACTING/VIEWING

• Most commonly used hand-held retractors – – small wounds - Richardson, Army/Navy, Senn, Ragnell,

• A variety of rakes, skin hooks; – large wounds – Deaver, Ribbon (malleable), Harrington

• Most common self-retaining retractors – small wounds – Gelpie, Weitlaner– large wounds – Balfour, Bookwalter, O’Sullivan-O’Conner

• Many have a variety of attachments

• Some large self-retaining retractors are attached to the OR table for stabilization

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RETRACTING/VIEWING

• Viewing instruments are more specialized • Ear speculum; nasal speculum; vaginal

weighted speculum– vaginal retractors

• Endoscopes are also considered viewing instruments

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PROBING

• Malleable, wire-like instruments that are used for exploration of tubular structures– Fistula probes, lacrimal duct probes, biliary probe,

rectal probes

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DILATING

• Used to gradually dilate a duct or an orifice to allow introduction of a larger instrument or open a stricture

• Used from the smallest to largest– May require lubrication

• Can be single or double ended – CBD, lacrimal duct, tracheal, urethral, cervical

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SUTURING

• Used to hold a curved needle – needle holders, needle drivers

• Choosing an appropriately-sized needle holder depends on the size of the needle– the length depends on the depth– can be curved for deep tissue

• Vary by specialty– General, ophthalmic, plastic, GYN, vascular,

microscopic

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Suctioning

Poole Suction

Yankauer Suction

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SUCTIONING

• For the removal of blood and bodily fluids• Disposable and non-disposable• Vary by specialty

– Abdominal, ear, neurosurgery, nasal, rectal

• Some suction devices have the ability to coagulate • Many different lengths for trachea, esophageal, larynx

– these are not typically used in sterile fashion

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MICROINSTRUMENTATION

• Used for working under the microscope• Small and delicate• Must be handled with extra care and precision

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Introduction to Surgical INSTRUMENTATION

ST230Concorde Career College

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Objectives

• Describe different types of specialty sets

• Describe types of instruments included in the sets

• Describe procedures performed using specialty sets

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Instrument Sets

• Assembled into sets for specific specialties• Assembled for specific procedures– Laparotomy– Craniotomy– Cardiovascular

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Specialty Sets

• May contain a count sheet

• Names of instruments may vary by manufacturer, locality, facility, or surgeon

• Many procedures require more than one set

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Laparotomy Sets

• Abdominal procedures

• May need additional sets for certain procedures (gallbladder, rectal, etc)

• Can be major or minor

Major Laparotomy Set

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OB/Gyn

• D&C• Abdominal hysterectomy• Vaginal hysterectomy• Laparoscopic procedures• C-section

Abdominal Hysterectomy Set

D&C Set

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ENT• Myringotomy

• Tympanoplasty

• Tonsils

• Tracheotomy

• Sinuses

ENT Instruments

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Plastics

• Lipo

• Minor plastic

• Major plastic

• Breast Augmentation

Plastic Instrument Tray

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GU

• Kidney procedures may need a major set, basic vascular set, kidney set, long instrument set and a thoracotomy set

• Prostate procedures may require several sets as well

What are these used for?

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Ortho

• Internal fixation sets• External fixation sets• Minor ortho• Major ortho• Total joints• IM rods• Hands

Synthes ORIF Instruments

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Cardiac sets

• CABG- vein harvesting instrumentation, cannulization for bypass, diethrich scissors, sternal saw, IMA retractors, surgeon specific instrumentation

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Thoracic sets

• Used for procedures of the thorax• Includes instruments to shear and remove ribs• Thoracoscopy sets differ from thoracotomy

sets

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Peripheral vascular

• Instruments for exposure and repair of vessels

• Aneurysms, Fem-pops, A-V fistulas

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Neuro

• Exposure and repair of the brain, spinal cord, and peripheral nerves

• Crani sets, lami sets, thrasphenoidal hypophysectomy sets

• Cloward retractors

Craniotomy Instruments

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Introduction to Surgical INSTRUMENTATION

ST230Concorde Career College

Objectives

• Discuss the various uses for basic surgical instrumentation

• Identify some commonly-used instruments

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Farris Smith

• VERY traumatic• Uses- closure of fascia• Nickname- Big Ugly,

Mother-in-Law

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DEBAKEY

• Atraumatic• Uses- DELICATE

TISSUE such as BOWEL• MOST COMMONLY

USED FORCEP IN GENERAL SURGERY

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HARRINGTON RET

• Blunt edges• Uses- retracting the

liver

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GREEN RET

• Uses – thyroid ret

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LAHEY RET

• Uses – thyroid ret

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SENN RAKE RET

• Mostly used x 2• Sharp and dull• Uses- small incisions

such as hands

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POTTS-SMITH SCISSORS

• Vascular• Billary tract

explorations• Extending incisions

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FREER ELEVATOR

• Uses – removing periosteum from bone

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METZENBAUM SCISSORS

• Uses – for fine or delicate dissection

• The most commonly used scissors

• DO NOT USE OR PASS FOR CUTTING SUTURE

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FRAZIER SUCTION TIP

• Uses – suctioning in small places

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POOLE SUCTION

• Uses – suctioning irrigation

• Changed on and off for laparotomies

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DEAVER RETRACTOR

• DEEP ABDONMINAL

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RICHARDSON

• OPENING AND CLOSING INCISIONS

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STRIAGHT MAYO SCISSORS

• Uses- cutting suture• Called “Suture

scissors”

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CURVED MAYO SCISSORS

• Uses- cutting heavy tissue such as muscle, fascia, uterus

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OSHNER/KOCHER

• Traumatic • Uses- heavy tissue

such as fascia or uterus

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Hemostats

• Crile - Big bites of tissue such as mesentery

• Kelly – Clamping of superficial vessels

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BABCOCK

• Atraumatic• Uses – clamping

delicate tissue such as bowel, uterine tubes

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ALLIS

• Uses – medium tough tissue such as skin, mucusmembranous tissue

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Adson Tissue Forceps

• Uses – skin, specialty surgery

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BODY-WALL RET

• Uses – retracting the abdominal wall

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LAHEY CLAMP

• Very traumatic• UTERUS• THYROID

Passing Instruments

Passing the scalpel

Passing Instruments

Passing the scissors

Passing Instruments

Passing the tissue forceps

Passing Instruments

Passing the hemostat

Passing Instruments

Hand signal for suture

Passing Instruments

Passing the suture

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Instrument Care

• Handled with great care during all phases– Prevents injury – Extends the life of the instrument– Allows instrument to perform correctly

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Instrument Sets

• Assembled into sets for specific specialties• Assembled into sets for physician

preference (ie: Dr. Smith tubal set)• Assembled for specific procedures– Laparotomy– Craniotomy– Cardiovascular

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Instrument Sets

• Names vary from one facility to another– Major tray versus laparotomy tray– Laparoscopy tray versus Pelviscopy tray– Ortho tray versus Bone tray

Instrumentation

Instrument List/Count Sheet

Instrumentation

Preference Card

Instrumentation

Instrument Care and Handling

• The Instrument Cycle– Preoperative Phase– Intraoperative Phase– Postoperative Phase