Introduction
Surgical instruments are the tools of the trade. Just like any in any other trade or manual job, there are a number of surgical instruments that have been designed to perform specific tasks. Surgical instruments have been found dating back to prehistoric times when they were made up of stone or animal bones. The 19th century saw the development of anesthesia and antiseptic techniques, which was the start of modern surgery. The 20th century saw the growth of endoscopic techniques along with ever increasing role of laser and ultrasound devices in the operating room (OR). The majority of the surgical tools are still made from stainless steel, which makes them resistant to corrosion.
Each surgical instrument is designed and built for a specific use. Using it for any other purpose will damage or shorten the life of the instrument. There are some basic rules and etiquettes of handling the instruments in the OR. The surgical technician is there to help you. The technician ensures the instruments are safely held and placed before, during, and after surgery. Instruments should not be tossed or dropped. Heavy items and instruments should not be placed on top of the patient or on other instruments. Careless or mishandlings is not only damaging to the instruments but can hurt others.
Parts of an instrument
The design of the instrument depends on its purpose. Overall, each instrument is constructed around a basic design, which is modified to serve its function. The components of basic design are handles, ratchet, shanks, joints, jaws or blades, and tips .
The handle is where the user holds the instrument; it is connected to the jaw or blade via the shank . The jaw or the blade is the functional part of the instrument. The joint connects the two halves of the instrument and acts as a fulcrum. The ratchets attached to the shanks give the instrument a locking function. The blade and tip shape give the instrument its functionality. The shanks determine size of the instrument while maintaining function ( Fig. 2.1 ).
This chapter reviews basic surgical instruments commonly used in interventional pain procedures. Figures of each instrument are followed by a brief description of the instrument and its uses. The details of how to handle or use the instrument is not included, which is best learned with hands-on experience with a proctor.
List of instruments
Electrosurgical pen ,
Other names
Bovie, bi- or monopolar, cautery
Category
Energy systems
Description
This is a disposable instrument that comes packaged with a blade tip and a holster. It has a high-powered and high-frequency generator that produces a radiofrequency spark between a probe and the surgical site that causes localized heating and damage to the tissue. The current can be activated by a button on the pencil or with a foot pedal ( Fig. 2.2 ).
Use(s)
A surgical device used to incise tissue, destroy tissue through desiccation, and control bleeding by causing coagulation of blood.
Instrument insight
The device was invented by Dr. WT Bovie. He made the device in 1926 when he heard Dr. Cushing inability to operate on tumors that were bloody during dissection. Cushing published his use of electrosurgical technique in a series of 500 cases. The electrosurgical principle is often incorrectly referred as electrocautery. In electrosurgery, the generator sends an alternating current into the body; the current then heats up the tissue. The tip of the instrument never gets heated. Although the electrocautery process involves heating up the device and then transmitting the heat to the tissue, the current never enters the body. The wave form of the current allows the surgeon to either cut or coagulate the tissue. In cut mode, the generator produces continuous low-voltage standard waveform. This high, intense, continuous energy vaporizes the tissue, resulting in a clean cut. In coagulate mode, the generator delivers high-voltage, low-current waves intermittently. This causes desiccation and seals the bleeding vessels. The instrument allows the surgeon to operate efficiently and precisely and with minimal blood loss. Cut mode is less damaging to the tissue than coagulation mode. Excessive use can cause tissue charring and damage blood supply to the tissue, which can both contribute to poor healing, infection, and seroma formation.
The user can operate in monopolar mode or bipolar mode. In monopolar mode, an active electrode concentrates the current to the surgical site, and a dispersive electrode channel (a grounding pad) takes the current away from the patient. The grounding pad should be placed close to the operative site on the ipsilateral side of the surgical field and away from any metallic implant. The pad should completely contact the skin. Uneven contact because of hair, bony prominence, or scar can cause skin damage. In bipolar mode, both the active and return electrodes are located at the surgical site, and there is no need for the grounding pad (returning electrode). The principle of electrosurgery relies on the principle of high-frequency electrical current entering the tissue; therefore, the best results are obtained when electrode tips are kept clean. A scratch pad is provided to remove charred blood or tissue from the electrode tip.
Caution
The tip of the pencil becomes hot after extended use. When not in use, place the pencil in a holster to prevent burning the drapes or the patient.
Straight halstead ,
Other name
Mosquito forceps
Category
Clamping and occluding
Description
It is a small curved or straight clamp with fine tips and horizontal serrations that run the length of the jaws. It is used to occlude bleeding vessels before coagulating them with Bovie or ligating them. Halsted forceps are similar to Hartman forceps in shape and function except that Halsted forceps are lighter and a little bigger in size, ranging from 5.5 to 8.25 inches in length ( Fig. 2.3 ).
Use(s)
Used as a hemostatic agent to compress smaller vessels that regulates blood flow. Also used with suture boots to tag delicate Prolene sutures in vascular procedures.
Instrument insight
The forceps have a 5-inch working length. They are much smaller than a Crile or Kelly forceps.
Crile forceps ,
Other names
Hemostat, snap, clamp, stat
Category
Clamping and occluding
Description
The forceps have horizontal serrations on the entire length of the jaw. The jaws are half the length of the shank. Crile forceps have finger rings and locking ratchets to secure the tissue and vessels ( Fig. 2.4 ).
Use(s)
Atraumatic and nontoothed clamp used to grasp tissue or vessels that will be tied off. It is also used in blunt dissection.
Instrument insight
The curved Crile is the most commonly used clamp forceps. Kelly forceps are a larger size variation of hemostat with similar function.
Kelly forceps ,
Other names
Hemostat, Kelly clamp
Category
Clamping and occluding
Description
Very similar to Crile forceps, but Kelly forceps have a longer jaw for clamping. The jaw is only half serrated. Kelly forceps have finger rings and locking ratchets to secure the tissue and vessels ( Fig. 2.5 ).
Use(s)
Used for occluding bleeders before cauterization or ligation. Also, it is used in blunt dissections.
Rochester-pean forceps ,
Other names
Pean, Mayo, Kelly-Pean forceps, Big Kelly
Category
Camping and occluding
Description
The Rochester-Pean forceps have both straight and curved styles with fully serrated jaws. They have a built-in ratchet mechanism that is able to hold objects firm. It is heavier built and comes in different sizes from 5.5 to 8 inches ( Fig. 2.6 ).
Use(s)
A hemostat used to control bleeding. It is used to occlude larger blood vessels and tissue before ligation. Seen used more in deeper wounds or heavier tissue.
Instrumental insight
Sometimes referred to as the “big hemostat” or “big Kelly”
Carmalt forceps ,
Other names
Carmalt; Rochester-Carmalt Forceps; big, curved forceps; “stars and stripes hemostat”
Category
Clamping and occluding
Description
Carmalt forceps have longitudinal serrations the entire length of the jaw, and the tips are cross-serrated. It comes with either straight or curved jaws. Forceps have ring handles and a ratchet for a secure grip. These are large, crushing hemostatic forceps used for clamping blood vessels and large tissues or ligating pedicles. The textured blades, along with the scissor-like ratchet handles, ensure a strong grip. The size varies from 16 to 20 cm ( Fig. 2.7 ).
Use(s)
A heavy tip and longitudinal serrations provide grip on heavy tissue and stop blood flow of large vessels.
Mixter forceps ,
Other names
Right-angle forceps, Gemini forceps, Lahey forceps, obtuse clamp, ureter clamp
Category
Clamping and occluding
Description
Mixter forceps are available in multiple lengths and have serrations the entire length of the jaw. Forceps have straight shanks, fully serrated jaws, and right-angle tips.
Use(s)
Used for working in obscured surgical sites. They are most frequently used for clamping, dissection, or grasping tissue. Also commonly used to place a tie or vessel loop under and around a vessel or duct. It enables the surgeon to grasp the ligature or loop and pull it up and around the structure to either ligate or retract ( Fig. 2.8 ).
Plain adson tissue forceps ,
Other name
Adson dressing forceps
Category
Grasping and holding
Description
Narrow tips with horizontal serrations ( Fig. 2.9 )
Use(s)
Used for holding and manipulating delicate tissue.
Instrument insight
Tips can have different configurations. All the Adson tissue forceps are the same size and shape. The only difference is the inner tips.
Toothed adson tissue forceps ,
Other names
Adsons with teeth, rat tooth
Category
Grasping and holding
Description
Narrow tips with two small teeth on one side and one small tooth on the other side ( Fig. 2.10 )
Use(s)
Used to align edges of the wound during stapling or when Steri-Strips are placed.
Instrument insight
Tips can have different configurations. All the Adson tissue forceps are the same size and shape. The only difference is the inner tips.
Brown adson tissue forceps ,
Other name
Brown forceps
Category
Grasping and holding
Description
Narrow tips with two rows of multiple teeth on each side. The teeth interlock when closed ( Fig. 2.11 ).
Use(s)
Used for grasping superficial delicate tissue.
Instrument insight
Tips can have different configurations. All the Adson tissue forceps are the same size and shape. The only difference is the inner tips.
Straight mayo scissors ,
Other name
Suture scissors
Category
Cutting and dissecting
Description
Heavy scissors with straight blades, made from stainless steel or titanium material. It comes in standard size (6 inches) or as extra. The tips are rounder than Metzenbaum and look blunter ( Fig. 2.12 ).
Use(s)
Designed for cutting body tissues near the surface of a wound and are also used for cutting sutures.
Instrument insight
When cutting sutures, use the tips of the scissors.
Caution
The blades of scissors should be inspected for dents or nicks that will not allow for smooth cutting. It is important to also check the screw to ensure it is fully tightened to prevent it from dropping into the wound.
Curved mayo scissors ,
Other name
Heavy tissue scissors
Category
Cutting and dissecting
Description
Heavy scissors with curved blades
Use(s)
Used to cut thick tissues and to dissect or undermine heavy fibrous tissue
Instrument insight
Mayo scissors used for dissection are placed in tissue with the tips closed. The scissors are then opened so that the tips open and spread out the tissue during the dissection process ( Fig. 2.13 ).
Metzenbaum scissors ,
Other names
Metz scissors, tissue scissors
Category
Cutting and dissecting
Description
Lighter scissors. Have a longer handle to blade distance. Can have blunt or sharp tips ( Fig. 2.14 ).
Use(s)
Used for cutting delicate tissue and for blunt dissection.
Instrument insight
It should only be used to cut heavy or thick tissue. It is meant for delicate tissue dissection or finding tissue plans. If used to cut sutures, the blades can become dull and not function properly.
Lister bandage scissors ,
Other name
Bandage scissors
Category
Cutting and dissecting
Description
Jaws of scissors are angled with the lower blade being slightly longer. Ring handles can be equal in size or with one ring larger ( Fig. 2.15 ).
Use(s)
Scissors are used for sizing dressings and removing circumferential bandages. The tip of the lower blade features a flattened blunt nodule that is intended to slide between bandages and skin without harming the skin.
Instrument insight
Can be used in cesarean section to open the uterus without causing inadvertent injury to the baby
Wire scissors ,
Other name
Wire cutters
Category
Cutting and dissecting
Description
Curved scissors. Blades with fine serrations. Has a circular notch in the inner jaws for cutting wires ( Fig. 2.16 ).
Use(s)
Cut small gauge wires and sutures.
Instrument insight
The serrations are intended to facilitate grasping the item being cut. When the wire is placed inside the notch, it gives the scissors the ability to exert additional pressure to cut heavier gauge wire.
No. 3 knife handle ,
Other names
No. 3 scalpel handle, no. 3 handle
Category
Cutting and dissecting
Description
A no. 3 handle holds blades 10, 11, 12, and 15. It has grooves to assist in a better grip and to avoid slippage. Its long handle is used to help make deep cuts within a wound ( Fig. 2.17 ).
Use(s)
Knife handles hold various blades to make a scalpel. When a handle is attached to blades, it is used to make straight, long cuts.
Instrument insight
Because skin is not sterile, after skin incision is made, the scalpel should be removed from Mayo stand, because it is unsterile. It is only to be reused to incise the skin.
Caution
Never retrieve a scalpel from the surgeon’s hands. Wait until the surgeon places it in the neutral zone before picking it up. Never use your fingers to unload or load a knife blade from the handle. A needle holder should be used when manipulating the blade.
No. 7 knife handle ,
Other names
No. 7 scalpel handle, no. 7 handle
Category
Cutting and dissecting
Description
A no. 7 knife handle holds blades 10, 11, 12, and 15. It is more rounded in shape and contains a thin neck toward the top, similar to a writing pen ( Fig. 2.18 ).
