BASIC SURGICAL INSTRUMENTS

Surgical instruments are specially designed tools or device that assist health care professionals carry out specific actions or carrying out desired effects during a surgery or operation.

Most instruments crafted from the early 19th century on are made from durable stainless steel. Some are designed for general use, and others for specific procedures.

The majority of surgical instruments are made of high-quality stainless steel. Stainless steel is an alloy of iron, chromium & carbon. Carbon component of the stainless steel gives the hardness. Chromium makes the stainless-steel resistant to corrosion. It also contains nickel or manganese to add tensile strength & also to prevent corrosion. Some instruments are made of titanium or vitallium---a cobalt base alloy.

Among our many responsibilities in the OR setting, handing instruments to the surgeon and keeping sterile field sterile are primary. So, we must know the instruments’ names and aliases and understand their purpose and function to be proficient in our role.

INSTRUMENT ANATOMY

1. Finger Rings - controls the jaws of the instruments by finger of the health care personnel.

2. Ratchets - interlocking parts between the finger rings of surgical instruments which lock to keep the instruments closed.

3. Shank - runs from the joint to the finger ring.

4. Box-lock - the hinge point of many surgical instruments.

5. Blades or Jaws - The working end of an instrument.

6. Teeth - prongs at the tips of surgical instruments which allow firm grasping.

7. Serrations - grooves that allow for firm holding of tissue, may be horizontal, longitudinal, or cross-hatched.

INSTRUMENT CLASSIFICATION

Depending on their function, basic surgical instruments can be categorized into six groups. These six groups are as follows:

1. Cutting and dissecting instruments
2. Grasping instruments
3. Retracting instruments
4. Tissue unifying instruments and materials
5. Miscellaneous Instruments

CUTTING AND DISSECTING INSTRUMENTS

• These instruments usually have sharp edges or tips to cut through skin, tissue and suture material. So, they are also called sharp instruments. These instruments have single or double razor-sharp edges or blades and are used for incising or dissecting tissues. These instruments are kept separated from the other instruments and regularly inspect these instruments before using, for re-sharpening or replacement.
• These instruments never boiled or autoclave for sterilization to protect their sharpness because heat, especially moist heat destroy their sharpness & make them blunt.
• These instruments are sterilized by chemical method-keeping them submerged in chemical solutions for a prescribed period.
• Nurses and OR personnel need to be very careful while handling to prevent accidental cuts or injuries during use
• The most common instruments in this category are - Bard parker (BP) handle & blade, Knife, Scalpel and Scissors.

Bard parker handle or scalpel - It is a handle to hold blades at the distal end. Its proximal end is flat & round. It has a shaft. Part of the shaft is serrated to have a better grip. Its distal end is narrow which has got a slant dent in which the blade is fixed. B.P handles vary in size.

Bard parker Blades - BP blades also vary in size & shapes. The blades usually have curved cutting edges. Blades with numeric prefix of “1” (e.g., 10, 11, 12, 15) fit #3 or #7 handles. Blades with the numeric prefix “2” (e.g., 20, 21, 22, 23, 24) fit #4 handles. #10 are used for large skin incisions. #11 are used for initial skin puncture of tiny deep incisions. #15 are used for short shallow incisions.

Surgical knife - It is like a kitchen knife with usually a brass handle. Its edge runs along one side till the tip. The tip is pointed or blunt. Knives are used for cutting or dissecting skin or tissues.

Skin grafting knife - There is special knife which is called Humby's or Blair’s knife. This knife is specially designed for obtaining a skin graft. Made of stainless steel. It consists of a handle and stem, on which is mounted and adjustable roller. It is used for taking split skin grafts used for coverage of raw surface composed of healthy vascularized or clean granulations to obtain healing and limit deformity and disability.

Scissors - Scissors are most often used to dissect and cut tissues. Threads and bandages are also cut with scissors. Scissors can be of different sizes. Their blade can be straight, curved or angular. The tips of the blades can be blunt-blunt, blunt-sharp or sharp-sharp. The cutting is usually made by portion of the blade which is close to its tip.

Straight blunt-blunt scissors	Straight blunt-sharp scissors	Straight sharp-sharp scissors
Curved blunt-blunt scissors,	Curved blunt-sharp scissors	Curved sharp-sharp scissors

Different types of scissors are mentioned below:

• Fine scissors are used to cut delicate tissues.
• Heavy scissors are used to cut tough tissues.
• Short shaft scissors are used for cutting superficial structures or tissues.
• Long shaft scissors are used to reach & cut inner or under structures.
• Sutures scissors have blunt tips to prevent cut or injury on the body structures near suture. These are used to cut suture or ligament after stitching or ligating.
• Dressing or bandage scissor are used to cut gauze pieces, dressing, drains or plastic packets.

Mayo straight or curved tip scissor - Mayo’s straight or curved scissors are smooth at the tips & are used for cutting tissues & internal organs.
Metzenbaum scissor - Metzenbaum scissors are surgical scissors designed for cutting delicate tissue. The scissors come in variable lengths and have a relatively long. They are constructed of tungsten carbide blades can be curved or straight. The blade tips are blunt.
Lister scissor - scissors designed for the cutting of bandages that are in place on the patient. The blades take a 45° angle at the pivot so that they can be inserted under the bandage and leave the knuckles of the cutting hand clear of the patient. The lower blade has a rounded, blunt end to facilitate entry under the bandage without catching the blade.
Nelson scissor - blunt-pointed, curved or straight-bladed, long-handled scissors designed for surgery.

Amputating knife, saws, raspatories - Amputating knives of different sizes are manufactured with one- or two-sided cutting edge for limb amputations. Various types of saws are suitable for cutting the bones. One side of the raspatory is smooth while its other side is rolled up. The semi-circle end of it is a little sharp. Use: blunt separation of the periosteum and connective tissue from the surface of the bone.

GRASPING INSTRUMENTS

• These instruments are used to grasp, pick up, and hold the tissues or organs during the operation for the purpose of having a better retraction, a more precise incision and a more effective movement. The most common instruments in this category are - Forceps, Towel clamps, Vascular clamps, Needle holders, Organ holders, and Sponge holding forceps.
  

  Forceps - Forceps are the non-locking grasping instruments and also known as thumb forceps. These are the simplest grasping tools. Forceps are made of different sizes, with straight, curved or angled blades. They can have blunt (smooth forceps), sharp (splinter forceps), or ring tips. Forceps are used to hold the tissues during cutting and suturing, to retract tissues for exposure, to grasp vessels for electro cautery, to pack sponges and gauze strips in the case of bleeding, to soak up the blood, and to extract foreign bodies.

  Smooth forceps,	Toothed forceps	Splinter forceps,
  Ring forceps (brain tissue forceps),	Dental forceps

  Towel-holding clamps - These serve to fix the draping towels to the ether screen, to one another, and to the skin of the patient. These locking grasping instruments serve to fix the grasped object. In the case of the Schaedel towel clip the springiness of the distal part, while in relation to the Backhaus towel clip the ratchet lock of its proximal portion serves to fix the grasped draping towel.

  Backhaus towel clamps	Schaedel towel clamps

  Artery forceps or Haemostatic forceps (haemostats) - These instruments are the main means of establishing hemostasis during an operation. They are used to stop bleeding by grasping and clamping the ends of the cut vessels or for preventive hemostasis by applying them before cutting the vessel. Forceps are hinged instruments used to hold an object that’s difficult to grasp in place. There are hundreds of types of forceps used in medicine, from surgery to obstetrics to dentistry. These forceps are used for various purpose. It has a catch lock to bring the blade together which when locked prevents the blades from slipping on objects. The inner surface of the blades is serrated. It is of various size & shape. It can be straight & curved & used for holding or clamping purpose. Its tips is round or blunt.

  Mosquito artery forceps	Dunhill artery forceps	Robert artery forceps
  Kelly’s haemostat forceps	Kocher’s artery forceps	Spencer well’s haemostat forceps
  Curved tip right angle artery forceps	Lehey artery forceps	Oschner artery forceps

  Needle holders - In modern surgery suturing is performed almost exclusively with curved needles that are held with needle holders designed for the grasping and guiding of needles. The needle holders grip the needle between the jaws, specially developed for this purpose; they usually have a ratchet lock.

  The Hegar needle holder resembles a hemostatic forceps, but the shanks are longer and the relatively short jaws are made of a hard metal. The serrations are designed to grip needles. During suturing in deep layers, needle holders with long shanks should be used

  

  Mayo-Hegar needle holder.

  Tissue-grasping forceps - These are special instruments used for delicate grasping and holding of the organs.

  Klammer intestinal clamp,	Allis clamp (used to grasp and hold the lung),
  Gall bladder forceps, and	Babcock forceps (used to hold the Fallopian tube),

  Sponge-holding forceps - It is known as a sponge holder. It is a heavy instrument which is approximately 24-72 cm long. Its shaft is long blades & are fenestrated at the tips. The inner sides’ blades are serrated so as to provide a firm grip on an object & prevent from slipping. It has a catch lock. It is used for holding sponge & cleaning the site of the operation or for deep mopping to clean or swab blood in the cavity. It is also used for packing body cavities such as vagina. It is used for separating tissues also. It is again used to catch soft organs like ovary, cervix etc.

  

  Sponge Holder

  
  

RERATCTING INSTRUMENTS

• These instruments are used to retract the wound edges & expose the cavity. These are again of various types:
• Manual retractor
• Self-retaining retractors

Manual Retractors

These retractors are to be held by hands & are of different types:

Lagenback retractors: it has got a handle &a long flat shaft which has a blade bent at right angle at the tip of the shaft.
Hook retractor- It has got a handle & a shaft. The shaft has hook at the tip. It can be single or double hook retractor.
Morris double ended retractor - It has got a shaft angle. The both ends of the shaft have blades at the right angle. This is used to hold back edges of the wound or cavity to facility exposure or retract strong structures like abdominal walls.
Deaver’s deep retractor - It has broad & curved blade at one end of the shaft. It used for deep retraction.
Czerny's retractor- It has fenestrated shaft. There is a blade at right angle at one tip. The other tip has double hook bent at right angle on the opposite side.
Abdominal retractor - Abdominal retractor is a surgical instrument by which a surgeon can either actively separate the edges of a surgical incision or wound, or can hold back underlying organs and tissues, so that body parts under the incision may be accessed

Self-Retaining retractors

Balfour’s self-retaining retractor - This is known as Belfour’s self-retaining retractor. It has special fittings for self-retaining. It is used for retracting abdominal cavity during laparotomy. Two small retracting blades are attached to the ends of both the metal clips. The rods are curved at the tip to give space. It can be locked & adjustable.

Balfour’s self-retaining retractor

Weitlaner self-retaining retractor		Gosset self- retaining retractor

MISCELLANEOUS INSTRUMENTS

Suctioning and Aspiration - These instruments remove body fluid, irrigation fluid, and blood from the surgical area, which enables the surgeon to see the area.

Yank Auer suction

Poole suction

Frazier suction

Viewing Instruments - Used to observe body cavities or structures.

Rectal speculum (Proctoscope)

Vaginal speculum

Nasal speculum

Ear speculum

Endoscopes

Laparoscopes

Others - Those instruments which are not used routinely during surgical interventions belong to this group.

Aneurysm needle: It has a handle & a hook at the tip. The tip of the hook is blunt & has a eye. The eye hold is used to carry the ligatures to separate a blood vessels & ligate.

Probe: It is a long instrument. There is an eye hold at the proximal end. The distal end is smooth & round. It is used to introduce into the depth of a cavity.

Trocars & cannula: Canula is a hollow instrument with a sharp trocar which fits into the lumen of the canula. It is used for abdominal paracentesis. The trocar & canula is introduced together. The sharp pointed tip of a trocar punctures the site. Then the trocar is removed. The canula is retained through which the fluid is drained out.

Volkmann curette: They have various sizes. The edges of the distal spoon-shaped part of this instrument are sharp which make possible to remove the tissues. The main application areas: skin tags (e.g. condyloma, wart) removal, to clean the base of the infected wound, and to remove the infected bone in the case of osteomyelitis.