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S URGICAL I NSTRUMENTATION : U SE , C AREH ANDLINGhappening on the surgical field and knowing this progressionwill help the scrub person to anticipate which instrument willbe needed.The next step in the manufacturing process is providingcorrosion resistance. This is accomplished by the removal ofcarbon steel particles through immersion of the instrument intodiluted nitric acid. The final step is to polish the instrument. An incision is made using a cutting instrument, suchas a knife or scissors. Clamps or forceps may be usedto control superficial bleeding at this point.Electrosurgical energy delivered through an activeelectrode may be used to create hemostasis or toextend the excision. Cutting of internal tissue layers is accomplished withscissors. Exposure of the surgical field is made possible byretractors. Suction evacuation is used to eliminate the surgicalsmoke plume created by the electrosurgical unit andto suction fluid or blood from the surgical field.It is easy to see that surgical instruments can be classified intofour main categories:Manufacturers of surgical instruments add one of threefinishes during fabrication: satin (i.e., dull), highly polished,and ebonized. A highly-polished finish, increases resistance tocorrosion, but can affect the ability of the surgeon tosee because of light reflection. A satin finish is less reflective and reduces glare. An ebonized finish is black chromium, isnonreflective, and virtually eliminates glare.For most procedures, either satin or highly-polishedinstruments will be used. Ebonized instruments are typicallyused in laser procedures to prevent laser beam reflection offthe instrument.Instrument Names cutting and dissecting, clamping, grasping or holding, and exposing and retracting.A fifth category exists for other accessory instruments that donot easily fit into these main classifications. These will bediscussed later in this study guide.Surgical nomenclature lacks standardization, but willgenerally follow certain patterns. For example, instrumentsmay be named: by the action that the instrument is designed toperform (e.g., scissors, knife), to recognize the inventor (e.g., Debakey forceps), or a combination of how the instrument is to perform ina particular type of surgery and an inventor’s name(e.g., a Lambotte osteotome, a tool that is designed tocut bone, invented by Lambotte).Names of instruments also vary by the region of the countryin which they are used, the surgeon’s preference for a name,and the facility’s commonly used name.Cutting and Dissecting InstrumentsBasic cutting and dissectinginstruments, sometimesreferred to as “sharps,” doexactly what their nameimplies; they cut anddissect tissue or othermaterials. The useable partof the instrument has asharp or cutting edge. Cutting instruments include knives,scalpels, and scissors of all types and shapes.Because instruments represent a major financial investmentfor a facility, proper care and handling should be a primaryconcern for all personnel who work with instruments. Afterinstruments are received from the supplier, they should becarefully examined, cleaned, decontaminated, and sterilizedaccording to the manufacturer’s instructions before use in thesterile field.Knives and scalpelsThe words knife and scalpel are used interchangeably, butgenerally, a scalpel has a detachable, disposable blade andnondisposable handle, while the term knife refers to singleunit cutting device such as an amputation knife. The handlesize and configuration of scalpel handles varies toaccommodate the area of use. Knife blades may have curvededges or sharp, stabbing points. When using a knife, care mustbe taken to avoid injury to self or others.TYPES OF SURGICAL INSTRUMENTSMany different kinds of surgical instruments and tools havebeen invented over the years. Instruments may be designedfor general surgical use or for use during a specific procedure.Generally, there is a natural progression of instrument useduring a surgical procedure. Paying close attention to what isAND6

S URGICAL I NSTRUMENTATION : U SE , C AREPassing Knives and ScalpelsANDH ANDLINGmeet at the swivel (i.e., the point where the rivet or screwconnects the blades) and the cutting point.The blades of the scissors also must be sharp. Cutting anythingother than what the scissors were designed to cut (i.e., usingtissue scissors to cut suture) will dull the blades and result intheir misalignment. Routinely check to ensure that the bladesare sharp and that the screw joining them together has notloosened. This can be accomplished by holding the scissorshorizontally by one ring handle. If the blades open freely, thescissors need to be tightened. The two basic types of scissorsare: tissue and suture scissors.When required to pass a sharp item to the surgeon, AORN’sGuidance Statement: Sharps Injury Prevention in thePerioperative Setting calls for the use of a “neutral or handsfree technique whenever possible or practical instead ofpassing hand to hand.”2 A neutral zone is a designated area onthe sterile field where the scrub person and the surgeon placeall sharp instruments (including needles). If it is absolutelynecessary to pass a knife hand-to-hand, it should be heldcarefully between thumb and fingers and presented handlefirst to the surgeon with the cutting edge of the blade pointingdown and away from both of you.Tissue ScissorsTissue scissors are used for tissue dissection. Most tissuescissors have curved tapered points. Metzenbaum scissors areused to cut medium to delicate tissue while the sturdier Mayoscissors are used to cutheavy or thicker tissue orstructures such as fascia. AMetzenbaum scissors canbe distinguished from theMayo scissors by its narrowshaft and tips.Caution must be taken when loading or removing blades froma knife handle. Typically, an instrument such as a needleholder or clamp is used to hold the blade during removal.Many health care facilities provide disposable scalpels for useas a way to reduce the risk of injury and exposure to bloodborne pathogens.The curvature on the Metzenbaum and other tissue scissors isdesirable to surgeons because it facilitates the ability to seethe tips of the scissors during dissection and because they canreach around other structures. Small, fine scissors with sharptips (e.g., iris scissors, Castroviejo scissors), are used fordelicate ophthalmic or reconstructive surgery.ScissorsScissors are designed inshort, medium, long, andheavy lengths and may beblunt or sharp with straightor curved tips on theircutting edges. Scissorsconsist of a pair of metal blades connected in such a way thatthe edges of the blades cut materials placed between themwhen the handles are brought together. A conventionalscissors requires one movement to open the jaws and anotherto close them. Some scissors, particularly those used indelicate plastic and eye surgery, have a spring that holds thejaws open. Squeezing the handle together closes the bladesand relaxing of the grip opens them.When preparing for asurgical procedure, it isimportant to check thealignment of the scissorsblades. For scissors to cutsmoothly, the blades mustSuture ScissorsSuture scissors usually have straight blades and blunt points.Straight Mayo scissors are used primarily to cut suture.Angled bandage scissors can be used to cut bandages anddressings. Wire scissors should be used to cut wire and veryheavy sutures.Passing scissorsTo pass any curved instrument, including scissors, hold theinstrument at the joint and place the handle of the instrumentfirmly in the surgeon’s hand, in its position of use. The tips of7

S URGICAL I NSTRUMENTATION : U SE , C AREPowered cutting instrumentsareprecisiondevicesdesigned to make workingwith bone and cartilage easierand quicker than working byhand. They are used mostoften for precision drilling,cutting, shaping, and bevelingbone. There are many interchangeable attachments availablefor powered surgical hand pieces, and they are used in a widevariety of procedures. Some uses include:Other Cutting and Dissecting InstrumentsOther specialized cutting instruments include chisels, curettes,osteotomes, rasps, rongeurs, saws, and trephines. H ANDLINGPowered Cutting Instrumentsthe instrument should always be visible. Curved tips shouldpoint down. Gently snap or flip the wrist when placing theinstrument in the surgeon’s hand so the surgeon knows wherethe instrument is. This eliminates the need for the surgeon tostop and look for the instrument. Release the instrument assoon as the surgeon has a firm grip on it. ANDChisels are used to sculpt bone and have one bevelededge. A mallet is used in conjunction with a chisel.Curettes are used to scrape soft tissue or bone. Theyare manufactured with different size cupped ends andseveral angles and lengths. Uterine curettes are usedto scrape the endometrial lining of the uterus.Osteotomes are bone-cutting instruments used forshaping or marking bone. They have a double, bevelededge and come in several widths and are both curvedand straight in design. They may be used to removeperiosteum from bone. A mallet is used in conjunctionwith an osteotome.Rasps can be used to smooth rough bone surfaces orto evacuate the medullary canal in preparation forinsertion of an orthopedic prosthesis. They may besingle- or double-ended, with curved or taperedblades. Rasps may be forward- or backward- cutting,with fine or coarse teeth.Rongeurs are biting instruments used for cuttingtough tissue or bone. The biting cup comes in varioussizes and angles. When the surgeon squeezes thehandles together, the two sharp, cup-like ends cometogether to bite into the tissue and remove a smallsection. Rongeurs are most commonly used on bonesor heavy ligaments. They may be double- or singleaction.Saws include any notched blade used for cutting bone.Trephines are used to cut bone from the skull. Atrephine has a circular, sharpened edge. Drilling holes for placement of a metal plate to hold afracture together. This requires drill points, screws,and a screwdriver. Removing, reshaping, and reaming of bone at the kneeor hip joint for placement of a total joint prosthesis.This requires saw blades and drill bits of various sizesand shapes. Both forward and reverse speeds arenecessary for some of these activities.The first powered surgical instruments were powered byelectricity, air, or nitrogen under pressure stored in largeportable tanks. The electrically powered instruments weredifficult to maintain because the electrical cords deterioratedrapidly due to processing. For pneumatic instruments, apressure gauge controls the flow at a specified pounds persquare inch (PSI) pressure. Alternatively, compressed gas canbe piped directly into the operating suite. In this type ofsystem, a wall unit acts as the pressure gauge and controls theflow of gas, delivering a specific PSI. Special high-powerhoses connect the gas source to the handpiece of theinstrument. Surgeons found these pneumatic hoses unwieldywhich promoted the development of battery-operated surgicalinstruments, that have now become commonplace. After use,the battery pack is recharged and is sterilized immediatelybefore the powered instrument is used.3Clamping and Occluding InstrumentsSurgical clamps can be used to either compress or grasp astructure. They can be either occluding or nonoccluding (alsoreferred to as crushing or non-crushing). The types of clampsneeded for a particular procedure will depend on the kind oftissue to be held (i.e., delicate or tough) and the depth of thesurgical procedure (i.e., near the surface or deep). Hemostatsand occluding clamps should never be used to attach items tothe surgical drapes because this could bend their tips and strainthe box lock, making the instrument unsafe to use on tissue.8

S URGICAL I NSTRUMENTATION : U SE , C AREHemostatsANDH ANDLINGAllis clamps also allow grasping and holding withoutcrushing. They have multiple, tiny, fine teeth thatcurve slightly inward. Allis clamps will hold slightlyheavier tissue than Babcock clamps because they haveserrations along their edges. Kocher clamps are easily identified by the transverseserrations and the large teeth at the tips. This enablesthe surgeon to grasp and tightly hold heavy, tough, orslippery tissue such as fascia, bone, and cartilage. TheKocher is also known as an Ochsner clamp.Other types of clamps include hemostatic clips that may beloaded singly onto an applier or may come as a preloaded,disposable unit. These clips come in multiple sizes and theclip appliers are available in long and short lengths. These willbe covered in more detail under “Suturing and StaplingInstruments.” Hemostats are the mostcommon of all clampinginstruments. They are usedto grasp bleeding vesselsand prevent blood loss withminimal tissue damage.Hemostats range in sizefrom short to long and fromdelicate to heavier in design. They can be straight or curved.Examples of hemostats are the mosquito, Kelly, and Crile.Mosquito clamps are used to control surface bleedersand handle delicate tissue (e.g., plastic surgery handsurgery); Kelly clamps are used to control bleeders in muscletissue, to pass drains, and to hold Kitner or peanutsponges; and, Crile clamps are used to control bleeders insubcutaneous tissue.Perhaps the most important design feature of a hemostat is thejaw portion between the box lock and the tip. Some hemostatsare very slender and tapered to a fine point; others are thicker,with more blunt tips. The inside surfaces have deep groovesor serrations, which may go from side to side or runlongitudinally in the same direction as the jaws. Theseserrations allow bleeding vessels to be compressed withsufficient force to stop bleeding. The serrations must becleanly cut and perfectly meshed to prevent the tissue fromslipping free from the ends of the clamp. A general rule of thumb for selecting a clamp is to use delicateclamps for delicate tissue, heavy clamps for heavier or toughertissue. This concept can also be applied to the depth of thesurgical procedure; shorter clamps for superficial areas, longerclamps when working deep within a cavity. Another conceptto note is that finer clamps should be used on smaller vesselsand heavier clamps on thicker structures.Anatomy of a clampOccluding clampsOccluding clamps are usedto occlude or constricttissue and to clamp or graspbowel, ducts, and otherstructures with lumens.These instruments are usedto apply pressure. Theytypically have vertical serrations or special jaws with finelymeshed, multiple rows of longitudinally arranged teeth. Theyfunction to prevent leakage and minimize trauma to vesselsthat are to be reanastomosed. Examples of occluding clampsare Babcock, Allis, and Kocher clamps. Babcock clamps have curved fenestrated tips withoutteeth. They are used to grip or enclose delicatestructure such as bowel, appendix, ureters, or fallopiantubes. The smooth edges and bowed shape allowgrasping without penetrating, crushing, ortraumatizing tissue.The two parts of a clamp fit together at a box lock which,when closed or clamped together, remains locked until theratchets are released.The easily identifiable parts of a clamp are: 9The point of the tip which, when closed, should fittightly together unless it is designed to only partiallycompress tissue.The jaws of the instrument are either smooth or areserrated to hold tissue securely.The box lock is the hinge point of the instrument tipand handle.

S URGICAL I NSTRUMENTATION : U SE , C ARE Sponge forceps have ring-shaped jaws and are usedto hold gauze sponges which are then used forretraction, blunt dissection, or to absorb blood fromthe surgical field. Sponge forceps may be straight orcurved. Examples of these are Fletcher sponge forcepsand sponge sticks. Towel forceps are typically used to attach and securedraping material but also may be used to hold cartilageor scar tissue or to apply traction. They are availablein perforating and nonperforating varieties. Tenacula have sharp points that are used to penetrateand grasp tissue firmly. An example is a uterinetenaculum that is used to manipulate the cervix of theuterus.1 Tenacula may be single- or multitoothed.Other grasping and holding instruments include stone forcepswhich are used to grasp calculi (e.g., kidney or gallstones).Passing clampsRefer to the preceding section on Passing Scissors. Ensure thatthe clamp is closed and locked (if applicable). The tips andcurve of the instrument should always be visible.GRASPING AND HOLDING INSTRUMENTSGrasping or holding instruments allow the surgeon to dissectand suture tissue without causing injury. Forceps and somevarieties of clamps are referred to as grasping instrumentsbecause of how they perform.Forceps, or pickups as they aresometimes called, are two-bladed,tweezer-like instruments that aredesigned to pick up, grasp, andhold tissue to facilitate dissectionor suturing. There are manyvarieties of tips available onforceps. The selection of forceps depends on the intended use. H ANDLING The shank is the area between the box lock and thefinger rings.The ratchet is part of the finger ring handle andinterlocks to keep the clamp shut when the instrumentis closed. ANDPassing forcepsThe scrub person should grasp the top of the instrument wherethe two arms meet, and with the points down, pass it to thesurgeon allowing the surgeon access to the full length of theinstrument to adjust his or her grasp. Clamp-type forcepsshould be passed as stated above under Passing ClampsEXPOSING AND RETRACTING INSTRUMENTSSmooth forceps have simple serrations andsmooth, tapered points for use on delicate tissue.Examples of smooth forceps include Adsonforceps and Cushing or bayonet forceps.These instruments are used for two major purposes: to hold open the incision to provide exposure of thesurgical site, and for holding back surrounding organs and tissue tofacilitate the surgeon’s ability to see during theprocedure.Retractors come in many different sizes and shapes. Retractorsare referred to as either hand-held or self-retaining. Smallertypes can be held by the fingers or hands to retract skin andsubcutaneous tissue in shallow surgical areas while larger,heavier types may be self-retaining and are used to retractmuscle tissue and organs in deeper surgical sites.Toothed forceps may be either single-toothed orhave multiple teeth that interlock. These areused on dense structures such as tough skin,fascia o

the instrument. Instrument Names Surgical nomenclature lacks standardization, but will generally follow certain patterns. For example, instruments may be named: by the action that the instrument is designed to perform (e.g., scissors, knife)