Vascular surgery instruments

Vascular Surgical Instruments
Dr Sandeep mahapatra

Atraumatic vascular
clamp (length 16 cm) by
Ho¨pfner (1908)
(

Lateral views of the tangential occluding
vascular clamps (side
clamps) of Trendelenburg (1908), Meyer
(1931), and Satinsky (ca. 1950).

Raw Material / Steel
Forging Process
Forging Inspection
Machining
Milling
Inspection
Filling
Filling Inspection
Binding and Temper
Snaffling Fitting
Plant or Heat
Treatment
Polishing / Instruments
finish
Ultrasonic Cleaning
Lubrication
Tuck checking
Etching
Cleaning and Checking
Packing
Labeling
Delivery

The Materials Used in Manufacturing
surgical instruments
• Stainless Steel
• Tungsten Carbide
• Titanium
• Aluminum
• Plastics
• Chrome Plating

ANATOMY OF A SURGICAL
INSTRUMENT

The parts of a basic surgical
instrument include:
• Jaws – the working end of the instrument. The jaws make
contact with the patient. The configuration of the jaw
determines its function and helps identify its name.
• Box Lock – (also known as the hinge). There are three parts;
male part, female part and the pin which secures the male
and female parts together. The box lock is the weakest part of
the instrument and the most difficult to clean.
• Shanks – run from the box lock to the finger rings. They
provide the closing force for the instrument. The longer the
shanks the greater the closing force of the jaws.
• Ratchets – located above finger rings on the shanks. The
ratchet locks the instrument.
• Finger rings – Are located at the opposite end of the
instrument from the jaws. Fingers are placed here for control.

Types of surgical instruments
• 1. Cutting and dissecting instruments,
• 2. Grasping instruments,
• 3. Instruments used for hemostasis,
• 4. Retracting instruments

1.Cutting and dissecting instruments
• Their function is to cut or dissect the tissue and
to remove the unnecessary tissues during the
surgery.
• Scalpels or scissors are most frequently used
instruments for these purposes.
• The following instruments also belong to this
category: hemostats used to prepare the tissues,
dissectors, diathermy pencil (mono- or bipolar
diathermy or electrocautry), amputation knife,
saws

Scalpels
• During the tissue dissection scalpels cause
minimum traumatization of the tissue.
• It is used for 1) making an incision on the skin,
2) dissecting the connective tissues, and 3)
preparation of a scarred tissue.

Holding of a scalpel
• In long, straight incisions, the scalpel is held
like a fiddle bow: the handle is gripped
horizontally between the thumb and middle
fingers while the index finger is staying above
the handle. The ring and little fingers are
holding the end of the handle.
• 2. In short or fine incisions, the scalpel is held
like a pencil, and the cutting is made mostly
with the tip

Figure 10. Holding of the scalpel
A. Fiddle bow holding, B. Pencil holding

Scissors subtypes:
• Super-Cut Scissors
• Tungsten Carbide Scissors
• Operating Scissors
• Suture and Wire Cutting Scissors
• Dissecting Scissors
• Bandage Scissors

Correct holding of the scissors and all
ring-ended instruments:
• The thumb and the fourth finger are inserted
into the rings which are located at the handle,
while the index finger is placed distally over
the handle to stabilize the scissors
(1st-4th rule of holding the instrument)

Uses of Scissors
• Scissors are also suitable for blunt dissection
and preparation of the tissues.
• In this case the scissors are introduced into
the tissues with their tips closed.
• Thereafter, we open the scissors and do the
dissection with the lateral blunt edges of the
blades

2.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 minimum requirement for most of them is to
produce as little as possible injury to the tissue or
organ while grasping it.
• Forceps, towel clamps, vascular clamps, needle
holders, organ holders, and sponge holding
forceps belong to this category

Non-locking grasping instruments:
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 electrocautery, to
pack sponges and gauze strips in the case of
bleeding, to soak up the blood, and to extract
foreign bodies.

• Forceps should be held like a pencil. They grip
when compressed between the thumb and
index finger. This makes possible the most
convenient holding, the finest handling and
free movements
• In this way the forceps actually act in a
manner as if our thumb and index finger are
elongated. Any other type of holding is not
acceptable in surgery.

• As a general rule, always use such that kind of
forceps with which you can perform the
desired work with as little as possible injury to
the tissue. The teeth of toothed forceps
prevent tissues from slipping.
• Accordingly, only a small pressure is required
to grasp tissue firmly. Thus, to grip skin and
subcutaneous tissues, the toothed forceps is
used most frequently.

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 Mathieu needle holder has curved shanks with a spring
and a locking mechanism. It should be held in the palm.
• 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 serrated Needle holder

Tungsten carbide (TC), Oslen Hegar
Needle holder

Tungsten carbide (TC), Oslen Hegar Needle holder

Tungsten carbide (TC)serrated Needle holder

Sponge-holding forceps
• In general surgery, it is used to grasp the swabs
for disinfecting the surgical area prior to
operation, or removing the blood and secretions
from surgical territory during operation.
• Swab together with the sponge-holding forceps
are called the handled swab.
• The sponge-holding forceps are also suitable for
creating various subcutaneous tunnels (Figure
29.).

3.Hemostats used for tissue preparation
• Instruments listed here are suitable for tissue
preparation (dissecting instruments), grasping
(grasping instruments), as well as haemostasis.
• They are used for blunt dissection and
preparation of the tissues. In this case they are
introduced into the tissues with their tips closed.
Thereafter, we open them and do the dissection
with the lateral blunt edges of the instrument.
• There are rings at the proximal end of the
handle. A little bit below the rings you can find
the locks, which are used to close the handle.

(Correct holding of the ring-ended
instruments with right and left hands)

Halsted’s mosquito haemostatic
forceps

Mixter’s Right angled forceps

Long-handled, ring-ended
instrument, which is bended
90° at its distal part.
It may or may not
have the interlocking teeth.
We use them to dissect and
prepare the tissues
atraumatically .

Traumatic hemostatic
forceps
A. Kocher, B. Lumnitzer
clamps

Reratcting instruments
• Retarctors are used to hold tissues and organs aside in
order to improve the exposure and hence the visibility and
accessibility of the surgical field.
• Hand-held retractors (e.g. skin hook, rake, Roux,
Langenbeck, visceral and abdominal wall retarctors) are
held by assistant. They cause minimal tissue damage
because the assistant maintains tension on tissues only as
long as necessary.
• When applied properly, self-retaining retractors
(e.g.Weitlaner self-retaining retractor, Gosset self-retaining
retractor) are of great help, but care should be taken not to
damage the tissues when they are placed and removed

VASCULAR
SURGERY FINE
INSTRUMENTS

1. Fine Cutting Vascular Instruments

• Potts and Diethrich vascular scissors are very delicate and
very sharp, and are used on delicate soft tissues, such as
blood vessels.
• The scissors’ tips are available in angles varying from 25 to
135 degrees.
• Some versions have a spring mechanism, and others are
held with rings. Those with a spring mechanism allow the
scissors to have a very fine cutting motion and a delicate,
quick grip.
• The tension of spring-loaded instruments is an important
concern. If the tension is too weak, it will be difficult to
secure the tool between the surgeon’s fingertips without
closing it excessively or dropping it from the hand grip.

Lawrie Vs Potts-Smith Scissors

2. Fine grasping vascular
instruments, Needle holders &
Retractors

Forceps
• Vascular forceps are atraumatic, and most have a
DeBakey pattern. Some have a tying platform (a
slightly-elevated surface near the tip of the
forceps) that is used to assist with suturing by
catching the suture to help make a knot.
• A needle pulling forceps enables suturing
procedures because the surgeon is able to pull
the suture needle out of the tissue quickly and
easily with the same thumb forceps used to
manipulate the incision edges.

DeBakey
Diethrich
tissue
forceps

Needle Holders
• Castroviejo and Jacobson needle holders are used for
passing 5/0 to 7/0 swedgedon sutures. They are spring-
loaded, and the jaw pattern may be smooth or serrated
with straight or curved tips.
• Some surgeons prefer needle holders with locks, and
others choose to grasp the needle without a lock.
When closed, the jaws should close in a parallel
fashion, so the needle will be securely grasped.
• Needle holders should be opened by releasing their
distal (farthest) latch to allow thorough cleaning.

Why Castroviejo?
• The conventional needle holder can only be comfortably
rotated through about 180’ without replacing it in the
hand, and clamping and unclamping the needle causes
momentary loss of control of the needle.
• In most general surgical procedures this is of little
importance, but in the anastomosis of small vessels in
situations with difficult exposure and in many’plastic
procedures these handicaps can assume major proportions.
The needle is engaged by spring-loaded pressure, and is
released by squeezing the handles
• The holder can be held in several positions and it can be
easily rotated through the entire curvature of the needle
engaged.

Advantages of Castroviejo needle
holder
• The clamping tension is adequate to hold the needle in all
normal suturing operations, and will only disengage when
subjected to unusual stress that would distort or break the
needle. This, therefore, constitutes a safety feature.
• The narrow handle is less in the way in a crowded operative
field and, because of the configuration of the hand while
holding it, allows better visualization of the site being
sutured.
• Another advantage is that the instrument has no right or
left and may be as easily used in the right or left hand
without learning of any special technique for engaging or
disengaging the needle. As with all new instruments, a little
period of practice is necessary to become comfortable with
it.

Retractors
• Hand held
• Self retaining

Retractors
• Self-retaining retractors, like Gelpi with
single-point tips and Wietlaner with blunt or
sharp rake-style tips, are used to retract
shallow incisions

3. Vascular Surgical instruments for
Hemostasis

HISTORY
• Atraumatic clamps (those that did not cause damage or
injury) were developed by Friedrich Trendelenburg
(1844–1924), and his invention was later improved
upon by renowned surgeons like DeBakey, Cooley,
Satinsky, and others.
• Arterial homografts (artery transplants) were
introduced, followed by the development of synthetic
vascular suture materials and surgery-specific
instruments. The introduction of devices, such as
embolectomy catheters used for the surgical removal
of emboli (clots or other material that travel through
the bloodstream and lodge in and block a blood
vessel), have progressed at an exponential rate

Clamps
• Vessel clamps are used to temporarily interrupt
blood flow. Common vascular clamps have fine
widthwise or longitudinal serrations. Special
vascular clamps and forceps used for cardiac and
vascular surgery are non-traumatic (also referred
to as atraumatic), and have two types of jaw
patterns:
• • DeBakey-type jaws have two rows of finely-
serrated teeth on one blade and one row on the
opposing blade to provide a triangular grip.
• • Cooley-type jaws have a double row of finely-
serrated teeth arranged in opposing rows.

Contd...
• Vascular surgery clamps have angled jaws of various sizes.
• Because the clamps remain on the blood vessel for a
specified time during the surgery, they should be selected
for size to fit the operative site.
• Each size and angle is designed to clamp at a different
region and to allow as wide an operative access as possible.
• Vascular clamp jaws require careful cleaning and
inspection to avoid the accumulation of debris.
• A Fogarty clamp has rubber-shod serrated blades to
provide an atraumatic grip on tissues and blood vessels.
• The rubber-shod is disposable and should be replaced after
each patient use

Contd...
• Clamps used to shut off small arteries.
• They open when squeezed, and the serrated-face clamp
blades shut when squeeze pressure is relaxed.
• These clamps vary in sizes, curves, and angles, and the force
that is applied by each type is measured in grams applied to
the artery.
• These clamps present a reprocessing challenge because it is
difficult to keep them open, and repeated openings decrease
the strength of the spring and alter the force that is
subsequently applied on the blood vessel.
• Gentle manual cleaning is most effective to provide and
maintain a clean and properly functioning clamp.
• Tubing clamps are used during open heart surgery to clamp
off and control the heart bypass machine tubes.

Uses of cooley’s clamp
• Clamping of right atrial appendage for purse
string
• Clamping of LA appendage for occlusion
• BT shunt at aortic end
• Aortic canulation
• Proximal graft anastomosis in CABG
• Partial clamping in Glen shunting
• PDA clamping
• Cross clamping as used for DeBakey clamps

Lambert Kay Aorta partial occlusion clamp

Gregory classic& Non Serrated Diethrich Bulldog clamp

Glover and
Jacobson
Bulldog
clamp

Valvulotomes
• The Expandable LeMaitre Valvulotome is designed to be used
with a less invasive in situ bypass technique.
• It cuts valves in the saphenous vein, a vein that runs from the
groin to the knee.
• When used with a semi-closed technique, it helps to prevent
wound complications.
• Valvulotomy can be performed without the need for
angioscopy and without changing cutting heads during valve
lysis.
• Teflon sheath for smooth advancement Saline injections via
built-in irrigation port

Valvulotomes
• Instrument Specifications
Maximum Hoop Diameter 9.0 mm
Maximum Blade Diameter 6.0 mm
Blade Housing Diameter 1.8 mm
Outer Diameter of Protective Sheath 1.5 mm
Usable Length 98 cm
Benefits of the Expandable LeMaitre Valvulotome:
Wide blade range: a smaller diameter of 1.8 mm and a
blade range of 1.8 to 6.0 mm allows for effective valve
cutting without changing blades or instruments
• Blade range of 1.8-6.0 mm in a single instrument
• Four recessed blades for cutting valve cusps
• Hoop design helps keep device centered in the vein .
• Adjusts to vein diameter automatically

Vascular Dilators
• Vascular dilators assist the dilation of vessels for
coronary and vascular surgery. Their tip size
typically ranges from 0.5 mm to 5.0 mm.
• Dilators are malleable (capable of being shaped
or bent) and tend to bend. While it is possible to
smooth the dilators somewhat, if the instrument
is too twisted it may not be suitable for use, and
the surgical team may assist in this decision.
• When a question about instrument usability
arises, it is always best to obtain surgical input
before processing begins

Fogarty occlusionCatheter
Small balloon occlusion catheters are effective in gaining
temporary occlusion of blood flow in the following
applications:
1.Small diameter vessels such as those in the distal periphery.
2.Operative occlusion of blood supply to specific organs such as
the kidneys.
3.Vascular-neuro surgery procedures, such as carotid-
cavernous sinus fistulas.
Large balloon occlusion catheters are ideally suited for:
• Aortic or cardiac hemorrhage.
• Internal jugular vein hemorrhage near the base of the skull.
• Operation on the lower part of the abdominal aorta and renal
arteries to eliminate the need for extensive dissection.
• Thrombectomy procedure utilizing the Fogarty graft

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