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Surgical instrumentation

Chapter 19

Surgical instrumentation
Chapter outline

Fabrication of Metal Instruments

Classification of Instruments

Handling Instruments

Chapter objectives

After studying this chapter, the learner will be able to:

• Identify the use and function of each type of surgical instrument.

• Demonstrate the appropriate methods for passing each type of instrument.

• Understand the rationale and methods of decontamination of instrumentation.

• Demonstrate the assembly and passing of sharps.

Key terms and definitions

Anodized

Dull blackened surface. The instrument is exposed to conditions that cause an oxide coating that is relatively impenetrable to atmospheric oxygen. Instruments
can be anodized to reduce reflections. Tints and dyes can be added during the process.

Alloy

A mixture of metals or of substances with metallic properties.

Approximating

Bringing together.

Atraumatic

Without injury.

Crushing

Destructive effects of specific instruments. Some procedures require the use of crushing clamps.

Cutting

Separating with a sharp instrument or device.

Debulking

Decrease in mass or volume using an instrument or device.

Dilation
Enlarging an opening in a progressive manner.

Dissection

Process of separating tissues through anatomic planes by using sharp or blunt instrumentation.

Evacuating

Emptying a cavity or space.

Grasping

Holding in a traumatic or atraumatic manner.

Instillation

Fluid is slowly introduced into a cavity or space.

Metallurgy

The study of metals.

Occlusion

Closing a lumen for the purpose of the procedure. The closure can be permanent or temporary.

Percutaneous

Enter directly through the skin; without incision.

Retraction

Stabilizing a tissue layer in a safe position for exposure of a part. A retractor can be manual or self-retaining.

Sharp

Instrument with a cutting edge or pointed tip(s) that is used to cut or dissect tissue. These items include blades, scissors, needles, and other dissection devices.

Traumatic

Causing injury by penetration or crushing.

Trocar

A device used for penetration of tissue layers. It is commonly used for percutaneous endoscopy. It is used as a temporary pathway for gases, fluids, other
instrumentation, or the removal of an organ or substance.

Website

evolve.elsevier.com/berrykohn

• Historical Perspective

• Flashcards

• Self-Assessment Activities

• Glossary

Fabrication of metal instruments

Metallurgy is the study of metals and their properties. This science enhanced the development of surgical instruments over the centuries. Although some
surgical instruments are made of titanium, cobalt-based alloy (Vitallium), or other metals, the vast majority are made of stainless steel. The alloys used must
have specific properties to make them resistant to corrosion when exposed to blood and body fluids, cleaning solutions, sterilization, and the atmosphere. The
manufacturer chooses the alloy for its durability, functional capacity, and ease of fabrication for the intended purpose.

Stainless steel
Stainless steel is an alloy of iron, chromium, and carbon. It may also contain nickel, manganese, silicon, molybdenum, sulfur, and other elements to prevent
corrosion or to add tensile strength. The formulation of the steel plus the heat treatment and finishing processes determine the qualities of the instrument.
Chromium in the steel makes it resistant to corrosion. Carbon is necessary to give steel its hardness, but it also reduces the corrosion-resistant effects of
chromium. Iron alloys in the 400 series (low in chromium and high in carbon) are most commonly used for the fabrication of surgical instruments.
Steel is milled into blanks that are forged, spun, drawn, die cast, molded, or machined into component shapes and sizes. These components are assembled by
hand, then heat-hardened (tempered) and buffed radiograph and/or fluoroscopy techniques are used to detect any defects that may occur as a result of the
forging or machining operations. The stress and tension must be in balance; that is, the instrument must have the flexibility to withstand the stresses of normal
use. The temper of the steel determines this balance.

The instrument is then subjected to processes that protect its surfaces and minimize corrosion. Oxidation of the surface chromium by a process called
passivation forms a hard chromium oxide layer. Nitric acid removes carbon particles and promotes the formation of this surface coating. Polishing creates a
smooth surface for the continuous layer of chromium oxide. Passivation continues to form this layer when the instrument is exposed to the atmosphere and
oxidizing agents in cleaning solutions. The term stainless is a misnomer. Steel does not tarnish, rust, or corrode easily, but some staining and spotting will occur
with normal use and prolonged exposure to corrosive agents.

Stainless steel instruments are fabricated with one of three types of finishes before passivation:

1. A mirror finish is shiny and reflects light. This highly polished finish tends to resist surface corrosion, but the glare can be a distraction for the surgeon or an
obstruction to visibility.

2. An anodized finish, sometimes referred to as a satin finish, is dull and nonreflective. Protective coatings of chromium and nickel are deposited electrolytically
and reduce glare. This type of finish is somewhat more susceptible to surface corrosion than is a highly polished surface, but the corrosion is usually easily
removed.

3. An ebonized finish is black, which eliminates glare. The surface is darkened by a process of chemical oxidation. Instruments with an ebony finish are used in
laser surgery to prevent beam reflection. In other surgical procedures, instruments with an ebony finish may offer the surgeon better color contrast because they
do not reflect the color of tissues.

Titanium
In comparison to stainless steel, the metallurgic properties of titanium are excellent for the manufacture of microsurgical instruments. Titanium is nonmagnetic
and inert. Titanium alloy is harder, stronger, lighter in weight, and more resistant to corrosion than is stainless steel. A blue anodized finish of titanium oxide
reduces glare. Titanium can be used in MRI procedures.2

Vitallium
Vitallium is the trade name for an alloy of cobalt, chromium, and molybdenum. This inert alloy has the strength and corrosion-resistant properties suitable for
some orthopedic devices and maxillofacial implants. Instruments made of Vitallium must be used when these devices are implanted. In an electrolytic
environment such as body tissues, metals of different potentials can cause corrosion if they come into contact with each other. Therefore, an implant of a cobalt-
based alloy is not compatible with instruments that are iron-based alloys (stainless steel) and vice versa.

Other metals
Although most instruments are made of steel alloys, other metals are used. Some instruments are fabricated from brass, silver, or aluminum. Tungsten carbide
is an exceptionally hard metal used for laminating some cutting blades or as inserts on the functional tips or jaws of some instruments.

Plated instruments
A shiny finish can be put on a basic forging or tooling of an iron alloy. Chromium, nickel, cadmium, silver, and copper are used for coating or flash-plating. When
deposited directly on the steel, any of these metals is prone to rupturing, chipping, and spontaneous peeling. It is difficult to keep plated instruments from
corroding, and rust can form beneath the plating. Plated instruments are used infrequently today.

Classification of instruments
Various basic maneuvers are common to all surgical procedures. The surgeon dissects, resects, or alters tissues and/or organs to restore or repair bodily
functions or body parts. Bleeding must be controlled during the process. Surgical instruments are designed to provide the tools the surgeon needs for each
maneuver. Whether they are small or large, short or long, straight or curved, sharp or blunt, all instruments can be classified by their function. Because the
nomenclature is not standardized, the names of specific instruments must be learned in the clinical practice setting. All instruments should be used only for their
intended purpose, and they should not be abused.

Dissecting and cutting instruments

Dissection instruments have sharp edges. They are used to cut, incise, separate, or excise tissues. There are two types of dissecting instruments; sharp and
blunt.

Sharp dissecting instruments should be kept separate from other instruments, and the sharp edges should be protected during cleaning, sterilizing, and storing.
To prevent injury to the handler and damage to the sharp edges, proper precautions are necessary to take during the handling or disposing of all sharps, blades,
or scalpels.

Scalpels
The type of scalpel most commonly used has a reusable handle with a disposable blade. Most handles are made of brass; the blades may be made of carbon
steel. Blades vary by size and shape (Fig. 19-1); handles vary by width and length (Fig. 19-2). Blades with a numeric prefix of “1” as in a “10” series (e.g., 10,
11, 12, and 15) fit handle size number 3 or 7. Blades with a numeric prefix of “2” as in “20” series (e.g., 20, 22, or 25) fit handle size number 4. Disposable
scalpels also are available.
 scalpel # 3

( 10211 12,15) ,

→ scalpel # 4

(20-21)

FIG. 19-1 A, Disposable blades: Ten series for the number 3 scalpel. Blade sizes 10, 11, 12, and 15. B, Twenty series for the number 4 scalpel.
Blade sizes 20, 21, 22, 23, 24, and 25.

FIG. 19-2 Most common scalpels. 4, 3, and 7.

The blade is attached to the handle by slipping the slit in the blade into the grooves on the handle. An instrument, never the fingers, is used to attach and detach
the blade; this instrument, usually a heavy hemostat or Kelly clamp, should not touch the cutting edge. Needle holders are not designed to load scalpel blades
and the jaws can become misaligned by excess torque. The following are descriptions of blade and scalpel combinations:

ROUNDED
• Number 10 blades are rounded toward the tip and are often used to open the skin.

linear
• Number 11 blades have a linear edge with a sharp tip. Can be used to make the initial skin puncture for tiny deep incisions.
curved
• Number 12 blades have a curved cutting surface like a hook. Commonly used for tonsillectomy.
SNORT ROUNDED
• Number 15 blades have a short rounded edge for shallow short controlled incisions.

1=0
• Number 20 blades are shaped similar to number 10 blades but larger.

• An assortment of blades with angulations and configurations for specific uses, such as a Beaver blade, also are used (Fig. 19-3). These blades insert into a
special universal handle that secures by turning a screw-in collar (Fig. 19-4).

FIG. 19-3 Beaver scalpel blades.

FIG. 19-4 Beaver scalpel handle.

Knives
Knives come in various sizes and configurations. Like a kitchen paring knife, they usually have a blade at one end that may have one or two cutting edges. The
knives are designed for very specific purposes (e.g., cataract knife). Other types of knives have detachable and replaceable blades (e.g., dermatome). A knife
blade may be incorporated into a multifunctional instrument, such as a gastrointestinal anastomosis (GIA) or end-to-end anastomosis (EEA) stapler that cuts
and staples tissue simultaneously.

Scissors
The blades of scissors may be straight, angled, or curved, as well as either wedge-shaped, sharp, blunt, or combined sharp-blunt tips (Fig. 19-5). The handles
may be long or short. Some scissors are used only to cut or dissect tissues; others are used to cut other materials. To maintain sharpness of the cutting edges
and proper alignment of the blades, scissors should be used only for their intended purpose:

tissue
scissors
-

OR feral
Directing

scissors
-
suture
 scissors
- wire suture

Scissors
-
Joseph Nasal

scissors
-

Potts Aviated

Bandar
lister
-

forges

- Tenotomy
Jason legally )
 FIG. 19-5 Surgical scissors. A, Tissue scissors. Blades may be straight or curved and either tip can be sharp or blunt. B, Suture scissors. C, Wire
suture scissors. D, Joseph nasal scissors. E, Potts angled scissors. F, Lister bandage scissors. G, Tenotomy scissors.

• Tissue/dissecting scissors have sharp or blunt tips. The type and location of tissue to be cut determine which scissors the surgeon will use. Blades needed to
cut tough tissues are heavier than those needed to cut fine, delicate structures. Curved or angled blades are needed to reach under or around structures.

Tissue scissors with blunt tips can be used to bluntly dissect between individual planes before sharply dissecting. Handles to reach deep into body cavities are
longer than those needed for superficial tissues (Fig. 19-5, A).

• Suture scissors have sharp-blunt points to prevent structures close to the suture from being cut. The scrub person may use scissors to cut sutures during
preparation if needed (Fig. 19-5, B).

• Wire scissors have short, heavy serrated blades. Wire scissors are used instead of suture scissors to cut stainless steel sutures. (Fig. 19-5, C). Heavy wire
cutters are used to cut bone fixation wires.

• Short jaw sharp-tipped scissors are used for deep, confined areas such as the nasal cavity (Fig. 19-5, D).

• Sharp-tipped angled scissors with short jaws are used for vascular surgery (Fig. 19-5, E).

• Dressing/bandage scissors are used to cut drains and dressings and to open items such as plastic packets (Fig. 19-5, F). The protective tip prevents cutting
into concealed structures.

• Small scissors with specially wedge-shaped tips such as tenotomy scissors (Fig. 19-5, G)

Bone cutters and saws

Many types of instruments have cutting edges suitable for cutting into or through bone and cartilage. Some have moving parts, such as rib cutters. Others, such
as drills, saws, and reamers, are powered by air or electricity.

Blunt dissectors
Friable tissues or tissue planes can be separated by blunt dissection. The scalpel handle, the blunt sides of tissue scissors blades, and dissecting sponges may
be used for this purpose (Fig 19-6). Elevators, strippers, and dissectors can be used to remove adherent tissue such as periosteum from bone or dura from the
inner aspect of the skull.
 FIG. 19-6 Blunt dissectors. A, Penfield blunt dissectors and tamps. B, Periosteal elevators.

Debulking instruments
Debulking instruments include chisels, osteotomes, gouges, rasps, and files (Fig. 19-7). The purpose of these instruments is to decrease the bulk of firm tissue
and not necessarily cut along defined tissue planes.

FIG. 19-7 A, Osteotomes. B, Rasps.

• Biopsy forceps and punches. A small piece of tissue for pathologic examination may be removed with a biopsy forceps or punch. These instruments may be
used through an endoscope (Fig. 19-8).
 FIG. 19-8 Punch biopsy instrument.

• Curettes. Soft tissue or bone is removed by scraping with the sharp edge of the loop, ring, or scoop on the end of a curette (Fig. 19-9).

FIG. 19-9 Tissue curettes. A, Soft and compact tissue curettes. B, Uterine curettes.

• Snares. A loop of wire may be put around a pedicle to dissect tissue such as a tonsil or a polyp. The wire cuts the pedicle as it retracts into the instrument. The
wire is discarded and replaced with a new one after use (Fig. 19-10).
 FIG. 19-10 Tonsil snare.

Grasping and holding instruments

Tissues should be grasped atraumatically and held in position so the surgeon can perform the desired maneuver, such as dissecting or suturing
(approximating), without injuring the surrounding subcutaneous tissues or perforating the skin (Fig. 19-11). Forceps without ring handles are commonly referred
to as pick-ups.

FIG. 19-11 Tissue forceps. A, Bishop eye or forceps. B, Adson forceps. C, Bayonet forceps. D, Smooth forceps. E, Forceps with teeth.

Delicate forceps
Fine tissues such as eye tissue are held with delicate forceps (Fig. 19-11, A). They can be toothed or smooth; straight or angled.

Adson forceps
Forceps are used to pick up or hold soft tissues in approximation during closure (Fig. 19-11, B). They can be toothed or smooth.

Bayonet forceps
Forceps are angled like a bayonet to prevent the user’s hand from occluding vision in a small space (Fig. 19-11, C). They can be toothed or smooth.
Smooth tissue forceps
Also referred to as thumb forceps or pick-ups, smooth forceps resemble tweezers. They are tapered and have serrations (grooves) at the tip. They may be
straight or bayonet (angled), short or long, and delicate or heavy. Smooth forceps are atraumatic and will not injure delicate structures (Fig. 19-11, D).

Toothed tissue forceps

Toothed forceps differ from smooth forceps at the tip. Rather than being serrated, they have a single tooth on one side that fits between two teeth on the
opposing side or they have a row of multiple teeth at the tip. Heavy types are sometimes referred to as rat-toothed forceps. Toothed forceps provide a firm hold
on tough tissues, including skin. Finer versions have delicate teeth for holding more delicate tissue (Fig. 19-11, E).

Allis forceps -

curved , scissors action

Allis forceps have ringed handles and lock with ratchets. Each jaw curves slightly inward, and there is a row of teeth at the end. The teeth grasp tissue edges
securely (Fig. 19-12, A). Allis forceps can be short or long. Some of the long forceps have a slight curve, such as those used with a hemorrhoid band ligator.

FIG. 19-12 Ring-handled forceps used for grasping. A, Allis forceps. B, Babcock forceps. C, Lahey forceps.

Babcock forceps -

ROUNDED
Babcock forceps have ringed handles and lock with ratchets. The end of each jaw of a Babcock forceps is rounded to fit around a tubular structure (i.e.,
fallopian tube) or to grasp tissue without injury. This rounded section is circumferentially fenestrated (Fig. 19-12, B). Babcock forceps are straight and can be
short or long; they are not occlusive or crushing.

Lahey forceps
Lahey forceps have ringed handles and lock with ratchets. The jaws of the Lahey forceps have sharp apposing points for grasping tough organs or tumors
during excision (Fig. 19-12, C). They are not occlusive or crushing.
Stone forceps
Either curved or straight forceps are used to grasp polyps or calculi such as kidney stones or gallstones. Stone forceps have blunt loops or cups at the end of
the jaws and do not have ratchets.

Tenaculums
Tenaculums have ringed handles and lock with ratchets and may have a single tooth or multiple teeth, such as a Jacob tenaculum (Fig. 19-13). The curved or
angled points on the ends of the jaws of tenaculums penetrate tissue to grasp firmly, such as when a uterine tenaculum is attached to the cervix and used to
manipulate the uterus during laparoscopy.

FIG. 19-13 Uterine cervix graspers. A, Single-tooth uterine tenaculum. B, Jacob multitooth uterine tenaculum.

Some uterine tenaculums have a built-in uterine cannula or probe elevator tip, such as a Hulka tenaculum (Fig. 19-14). A uterine cannula, or probe, can be used
during laparoscopy to raise the uterus into the visual field (Fig. 19-15). The cannula tip is inserted into the cervical os as the tenaculum is clamped on the
anterior aspect of the cervix. Dye or contrast media can be instilled through the cannula into the uterine cavity to visualize tubal patency or the inner
configuration of the uterine cavity. Some styles have a tenaculum stabilizer attached.

FIG. 19-14 Hulka uterine elevator and tenaculum.

 FIG. 19-15 Kahn uterine cannula and manipulator.

Bone holders
Grasping forceps, Vice-Grip pliers, and other types of heavy holding forceps stabilize bone (Fig. 19-16). Some styles have ring handles and locking ratchets.
Others have compression grips and do not lock.

FIG. 19-16 Lambotte bone holding forceps.

Clamping and occluding instruments

Instruments that clamp and occlude are used to apply pressure. Some clamps are designed to crush the structure as the instrument is applied and are
considered traumatic. Other clamps are noncrushing (atraumatic) and are used to occlude or secure tissue, which is restored to patency.

Hemostatic clamps
Most clamps used for occluding blood vessels have two opposing jaws (with or without serrations or teeth), ringed handles, and lock with ratchets. Most ring-
handled clamps have a common design (Fig. 19-17). The length and shape of the shanks or jaws may vary according to the intended function of the instrument.

FIG. 19-17 Anatomy of a ring-handled clamp.

Hemostats
Hemostats are the most commonly used surgical instruments and are used primarily to clamp blood vessels. They have a crushing action. Hemostats have
either straight or curved slender jaws that taper to a fine point. The serrations are longitudinal or horizontal inside the jaws (Fig. 19-18).
 FIG. 19-18 Crushing clamps. Jaws may be straight or curved. Tips may be pointed or rounded. Serrations may be horizontal or longitudinal. Jaws
and handles may be long or short.

Crushing clamps
Many variations of hemostatic forceps are used to crush tissues or clamp blood vessels. The jaws may be straight, curved, or angled, and the serrations may be
horizontal, diagonal, or longitudinal. The tip may be pointed or rounded or have a tooth along the jaw such as on a Heaney or hysterectomy clamps (Fig. 19-19).
The length of the jaws and handles varies. Many forceps are named for the surgeon who designed the style, such as the Kocher and the Ochsner clamps (Fig.
19-20).

FIG. 19-19 Hemostatic uterine clamps. A, Heaney clamp with teeth along crosshatched jaw. B, Hysterectomy clamp with longitudinal jaw and
crosshatched tips.

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