CLEANING, DISINFECTION AND STERILIZATION
These terms do not mean the same thing. The first implies the removal of visible debris and dirt; the second means the reduction of the number of pathogenic organisms except spores. It does not remove all pathogens and certainly does not eliminate spores. Sterilization, however, destroys all pathogens including spores.
- Cleaning is done by (a) washing with detergent (soap) and water or by using (b) the ultrasonic cleaning device which removes dirt even from within tubes and catheters and from the grooves, teeth and serrations of instruments, which cannot be satisfactorily cleaned or may be damaged by (c) the use of a plastic or wire brush.
- Disinfection/sterilization can be done by the methods which are listed below:
- Antiseptic solutions—e.g.
- 70% alcohol (surgical or methylated spirit)
- 0.5% chlorhexidine requiring only 2 minutes of immersion for disinfection,
- Aldehydes (2% Glutaraldehyde—Cidex)—disinfection occurs with 10 minutes of immersion and sterilization takes 10 hours. This solution needs to be freshly prepared and tends to stain the skin. The addition of 1 gm of Sodium Nitrite tablets will prevent rusting of metallic instruments, which are cleaned with water.
- Boiling: This is a cheap, quick and widely used method of disinfection but it does not destroy spores (e.g. clostridia). Instruments are first washed and 3cleaned before boiling for 5 minutes at 100-212°F. However, the temperature reached is dependent on atmospheric pressure and is much less effective at higher altitudes. This method is not suitable for linen.
- Hot Air Oven: This is a thermostatically controlled oven in which instruments are sterilized at 160°C (320°F) for an hour. Obviously this method is unsuitable for perishable items such as rubber, latex and plastic articles.
- Autoclaves: This is the most efficient method of sterilizing instruments, packs and dressings. It is suitable for most materials. The autoclave is basically a pressure cooker (Figs 1.1A and B). In this apparatus higher temperatures (up to 134°C or 273°F) can be reached in a short time by increasing the pressure (up to 30 psi) in the chamber. The air in the sterilizing chamber is removed and replaced with steam, which enters the spaces surrounding the load. As the steam comes into contact with the cooler layers of the load, it leaves a minute quantity of water of condensation. The steam is displaced downwards and the layers of cloth covering the load absorb the latent heat that is given off. The next film of steam that enters then penetrates the outer layer and heats the inner parts of the load. This process continues till the core of the load reaches the same temperature as the outer layer.
The Quick Cycle (flash) in the autoclave heats the water to 134°C for 3.5 minutes under a pressure of 30 psi.
The Slow Cycle is more suitable for plastics and heats water to 120°C under pressure of 15 psi. To sterilize effectively, a vacuum should be created first before letting in steam at the appropriate temperature and pressure. The chamber must be saturated with steam, which should not mix with but displace all the air.
The steam must reach the core and every part of the load. When the desired temperature and pressure are reached, they must be “held” for a critical time called the ‘holding time’. The standard holding time is 15 minutes at 121°C, but may need to be varied according to the nature of the load.
The cycles of operation can be summarized as follows.
Stage I—Pre-vacuum removal: Here the air is removed completely from the chamber by a pump and controlled steam is introduced in a pulsatile fashion. The vacuum achieved should be in the order of 0.5 mm Hg.
Stage II—Sterilization: When all parts of the load have reached the desired temperature (134°C it is maintained for 3.5 minutes.
Stage III—Drying: This is achieved by adequate postvacuum which is checked periodically by a test pack of towels which when removed from the sterilizer, unfolded and allowed to cool are not damp.
Stage IV—Breaking the vacuum-air replacement: This should be completed within 3 minutes through a fiberglass or ceramic filter.
The chamber is then unloaded and the packs marked with the batch number to that particular load.
Double-walled autoclaves are preferred because they can reach a higher pressure and maintain this for a longer time. Also, a horizontal chamber is better because in vertical chamber the lower parts of the load may not reach the desired temperature so their sterility is doubtful. Single-walled chambers cannot take the desired pressure. Also, moisture may not be completely eliminated which is a dangerous situation as far as bacterial growth is concerned. In a double-walled autoclave steam is let into the space between the two 7walls so that moisture does not come directly into contact with the load. Also, sterile air can be let into this space to break the vacuum and for cooling and drying at the end of the process.
Surgical Instruments
Like all equipment, surgical instruments too need to be cleaned and maintained in good condition by means of regular care and attention. Dirt and rust can make instruments less efficient, more dangerous and infective and more difficult to sterilize. Most surgical instruments are made of stainless steel. They have smooth surfaces, which however can become pitted and scarred if not handled properly during washing, cleaning, polishing and lubrication (which is necessary particularly in instruments which have joints). The use of corrosive and abrasive cleaning agents can cause permanent damage on the surface.
Wash with cool, running water and a brush. Hot water will coagulate blood and make subsequent cleaning more difficult. The ultrasonic cleaning device (bath) is ideal for removing organic material and retaining the smoothness and polish. Proper drying is necessary to avoid rusting particularly in the joints. A water-soluble material is ideal for lubrication of joints, which will then function smoothly and last longer. Salt solution should never be used. Ratchets and joints must be kept open while washing and drying. Avoid using wire brushes or steel wool on the working surfaces of instruments. The serrations in some instruments may need to be cleaned with a plastic bristled brush or a soft wire brush 8to remove dirt. Instruments with plastic parts can be sterilized by soaking in antiseptic solutions (see above) or by autoclaving at lower temperatures (121°C at 15 psi for 15 minutes). Surgical blades and needles should NEVER BE REUSED. Wear protective gloves while washing surgical instruments.
Other methods of sterilization are Ultraviolet rays Gamma rays and Ethylene oxide. These methods are used for material, which may be damaged by conventional methods. Gamma radiation is used in situations where the sterilized material is to be kept in its sterile, closed, air-tight pack for a long time and where conventional methods may cause alteration of the chemical composition of the material. Ethylene oxide can be used for small loads. The sterilized material can be used only a number of hours later (overnight) because the gas is toxic.
Electrical Equipment
Most electrical equipment used in the OT operate from a main supply of 110 to 240 Volts AC. When any new equipment is acquired, read its instruction manual thoroughly and ask for a demonstration of its working. Get all doubts clarified before starting to use it. Keep the operator’s manual within easy reach. Get the guarantee card filled and signed right at the time of purchase.
All plugs, fuses and cables, leads, wires should be handled with care and kept dry and clean. They should be checked periodically for damage and this should be reported and rectified immediately. Temporary repair using insulation 9tapes, sticking plaster and other such substandard material IS DANGEROUS and not to be encouraged.
All batteries should be checked for leakage and should be changed before they become weak and dangerous. All fuses should be checked and changed whenever indicated. It is good practice to keep fuses, batteries and bulbs for each piece of equipment within easy reach.
Many pieces of electrical equipment are of life-saving importance, e.g. Cardiac defibrillator. This delivers a high voltage (several thousand volts) of current. It can, therefore, be very dangerous if not handled with caution and maintained in proper condition.
Microchip-based electronic equipment is relatively safe and more hardy. However, these respond badly to fluctuations in temperature, therefore, overheating should be avoided.
Some pieces of electrical equipment use very low voltage current, e.g. Laryngoscopes, Bronchoscopes, Cystoscopes and headlamps. These may use cold light sources (i.e. fibreoptic cables). The voltage in these may range from 1.5 to 10 V. Here, the main’s voltage is suitably stepped down by the use of a built-in or separate transformer. These articles may also work on batteries and not need a transformer.
One should be very careful while using electrical equipment in the vicinity of volatile gaseous anaesthetic agents which (like cyclopropane and ether) are inflammable and may cause explosions and fires. The risk of explosion exists within a 25 cm zone of the point where leakage occurs (Fig. 1.2).
10
All connections must be kept clean and dry. Good contact must be maintained at all plug points. Disconnection must be done only when the equipment is switched off. Pulling on wires, leads and other cables is damaging and dangerous practice. All batteries, which are not in use, must be removed from the equipment and stored in a dry place. Rechargeable11 batteries are long lasting but are expensive. They need to be discharged and recharged regularly to increase their longevity.
The Cardiac Defibrillator allows a high voltage current to be applied to the heart either directly (100 Joules) or through the chest wall (320 Joules). This is done in a heart, which is fibrillating so as to revert it to its normal rhythm. The energy is generally delivered about 40 milliseconds after the peak of the R wave of the cardiac cycle when it is most effective. The shock lasts for 3 milliseconds. This equipment may have a built-in cardiac monitor (ECG machine) so as to deliver the shock accurately and monitor the heart before and after. The operator should ensure that the paddles of the defibrillator are well lubricated and make adequate contact with the patient’s chest wall over the precordium. Take care not to be in contact with any metallic surface or with the patient while delivering the shock.
The Surgical Diathermy (commonly called the cautery machine) (Fig. 1.3). This machine delivers high frequency electrical current through one electrode(the diathermy tip) which is also called the live electrode, through the patient’s body and out through another electrode (the diathermy/cautery plate which is also called the indifferent electrode) which is larger and in the form of a metal plate which is kept lubricated and in close contact with the patient’s skin. In the region of the thigh, buttocks or back. This configuration is what exists in the usually used “unipolar” cautery.
However, in the ‘bipolar” cautery, both electrodes are at the tip of the bipolar forceps or other instrument which is connected to the machine, the high frequency current in both systems, the heat produced at the tip of the live electrode causes coagulation at a small, focused point after which the current is dissipated through the patient’s body and flows out through the larger indifferent electrode (the plate). Since the plate 13is in contact with a very much larger surface area, it does not produce heat enough to cause burns. In the bipolar system, there is no indifferent electrode. The current flows out through the live electrode, through the tissues and back through the other electrode, which is also at the tip of the operating instrument.
The
Surgical Cautery is an instrument, which has a platinum wire in the form of a loop or other shape at its end, which is heated electrically till it is red hot. It then produces the same effect as the above apparatus. However, the voltage used here is much lower. Also, the tip (loop) gets burnt out rather quickly and has to be replaced. This equipment can be used with batteries or by connecting it to the main electrical supply with a transformer to step down the voltage of the current.
Lasers: LASER is the abbreviation of the phrase Light Amplification by Stimulated Emission of Radiation. This equipment produces fine parallel beams of high intensity light, which can be focused on a very small spot (as in microsurgery and endoscopic procedures). The light causes heating, coagulation, and denaturation of proteins and finally vaporization of tissues as the intensity increases. It can thus be used for control of bleeding, removal of lesions, fixation of detached membranes, and lumenisation of hollow viscera (e.g. oesophagus with a malignant stricture). It is also being used in blood vessels and ducts. Since the beam can be very accurately focused, this equipment can also be used to make very precise incisions in tissues (e.g. laser keratotomy). 14Examples of laser are the CO2 laser, NdYag laser (Neodymium Yttrium Aluminum Garnet), the Erbium laser and the Argon laser. These are used for various applications.
Cryosurgery: This is the application of extreme cold to tissues in order to destroy them. There is minimal bleeding and pain. This procedure is applicable in General surgery (haemorrhoidectomy), Gynaecology (cervical erosions), Dermatology (warts, etc), Neurology (tumours) and Urology (bladder polyps). Initially, liquid nitrogen was used to produce temperatures in the range of minus 196°C but this degree of cold is not necessary. Now, nitrous oxide or carbon dioxide is used to produce temperatures in the region of minus 70°C. The system consists of flexible tubing connecting the cylinder of gas to the cryoprobe, which comprises two concentric tubes and a metal tip. Gas is delivered to the tip through one of the concentric tubes and removed by the other. The tip touches the tissue to produce an ice ball. The probe may adhere to the tissue in contact. The gas flow then has to be turned off before removing the tip from contact with the tissue.
Ultrasonic
Operating Equipment—Cavitron Ultrasonic Surgical Aspirator or CUSA: This is used in Neurosurgery for rapid and efficient removal of tumours of the brain and spinal cord. It can also be used for lesions in the liver, kidney, spleen and other solid organs. The equipment is basically an acoustic vibrator (similar to the harmonic scalpel) and consists of:
- The Connecting Body: This mechanically conveys the motion of the transducer to the surgical tip. It also amplifies this motion.
- The Surgical Tip: This completes the amplification and contacts the tissues being operated upon. The tip being long causes its own amplification.
Fluid circulates around the coil so as to prevent heating of the hand piece and making it more comfortable to handle.
Electrical and Pipeline Units: These facilities are an integral part of a modern operating theatre and are used for washing, irrigation, suction, lighting, heating, air conditioning, and a variety of other applications. Suction apparatus (Fig. 1.4) may be connected to a central suction unit (wall mounted outlets), stand alone (independent) electrically operated mobile units which can be taken from one theatre to another or mechanically operated pumps (foot operated). Most modern operation theatres are not only supplied with electricity from the main supply but also have several if not all, electrical outlet points also supplied by a back up generator.
A constant, reliable and safe water supply is very important. Running water is always preferable to stored water for scrubbing and washing. Taps, which are foot operated or at least elbow operated, are ideal. Deep and wide sinks avoid splashing while washing. Dispensers for scrub solutions avoid wastage and the need for another person to pour the scrub from a container.
The use of nylon brushes to scrub fingernails is good practice. The use of a clean waterproof (plastic) apron under the sterile gown will prevent wetting of clothes with body fluids. Closed footwear and the use of shoe covers also prevent wetting of the feet during surgery. Disposable, impervious, sterile gowns are ideal but may be considered expensive. They should gradually become a part of the universal precautions that medical personnel are advised to adopt as a precaution against exposure to diseases like hepatitis and HIV infection. The wearing of double gloves is again a precaution against accidental exposure to infection through punctures in gloves.
ATTRIBUTES OF A GOOD OPERATION THEATRE NURSE
If you wish to be a good OT nurse, it is not enough to want to have the aura of prestige and respect that seems to automatically go with the designation. In any hospital nurses who work in specialized areas such as the Intensive Care Units, Dialysis Units and Emergency Medical Services Units are considered to be in a category above the others. However, the speciality of the OT nurse is that the mystery of the operation theatre surrounds her, giving her a very unique status.
This status has to be earned and to do so takes years of dedicated, backbreaking toil and tension. You should have a genuine love and yearning to work in the operation theatre and not just a fascination for the glamour of the post. Glamour may be there in the eyes of the beholder who knows little or nothing of the long hours of hard work that an OT nurse is expected to put in.
The attributes that a good OT nurse should strive to develop over a period of time are as follows:
- Intelligence of a high order, which means having an enquiring and keen mind which thirsts for knowledge and knows how to satisfy this thirst. Being well prepared in terms of knowledge, skills and readiness well in time even in an emergency situation.
- Thorough knowledge of the steps of most of the common procedures performed routinely. Reading about a procedure or asking the surgeon what exactly it will entail will help greatly to acquire this knowledge and to be prepared.
- Constant alertness, awareness and observation of the operation throughout the procedure. The above three attributes make for the ability to anticipate moves and be prepared for every step of an operation.
- Stamina to stand and work under tension for long periods of time even without taking a break for a meal or refreshment. You should be prepared to assist in the operation and not just hand over instruments, etc. If you have read about the procedure and know its steps, you can be a very valuable assistant indeed. This means you need to be physically fit and mentally prepared for a long and hard day every day.
- A calm and unruffled temperament. This comes with experience and knowledge. This is a quality, which will enable you to stand head and shoulders above the common or garden OT nurse and to be a valuable and indispensable asset to an operating team even in a crisis.
- A sense of responsibility. Remember that you are an integral and vital part of the operating team and you are as responsible as the first assistant to see that the operation goes off without mishap. Every operation is teamwork and the success of it is due not only to the chief surgeon but also to the assistant and the OT nurse as well as the Anaesthesiologist. Learn to take responsibility for your actions and their consequences.
- Good communication and leadership skills. These can be translated into good rapport with the other members of the team and the ability to make yourself understood without ambiguity. Also, this means the ability19 to record events and observations precisely and promptly, and report incidents to ones superior in a similar manner. You should also be able and interested in guiding, teaching and training your subordinates without being overbearing. Every day offers an opportunity to teach a junior person something useful and valuable.
- Neatness and cleanliness reflect good organization, competence and efficiency. These qualities will earn you the respect of your subordinates, your peers and even your superiors. It is gratifying to be a role model whom ones juniors would love to emulate.
- Finally, you are as much of a professional as any doctor so, as in any profession which depends on special knowledge, skills, experience and ability, you should be proud to be an OT nurse in a reputed institution and be staunchly dedicated to your work.
To prepare for an Elective Operation
- Know in which department’s OT you are going to be posted the next day.
- Find out what the OT list is and the order in which cases will be operated upon.
- Know which surgeon will be operating on which patient (it is good to know and be prepared for the quirks, preferences and idiosyncracies of senior surgeons).
- Read on the previous evening about the operations in which you are going to assist. If you have no time to read, then ask the surgeon concerned or the Resident in his unit.
- If something is not available, tell the surgeon in advance so that he will have the time to prepare an alternative strategy.
- Have an adequate breakfast and arrive in the OT well in advance of the surgical team to see that all things are in readiness.
- Be prepared for a modification of the order of the list. This means that you may have to be ready to assist at some other operation other than the one which is posted first on the list. In general, surgeons will not trouble you too much with these changes unless there is no choice because they themselves are not too keen on changing the order in their lists without compelling reasons.
- Scrub before the surgeon and get your trolley and other equipment ready quickly.
- Ensure that the OT Technician is always available to carry out orders during the operation.
- Anticipate the need for an assistant for yourself well in advance and make sure that such a person (student nurse for example) is also prepared adequately and well in advance to play her part (Fig. 1.5). This is particularly essential in long operations and in operations in which more than one team may be operating at the same time.
To prepare for an Emergency Operation
- Be aware of the days on which you are on emergency/night duty and do not have any other engagements or appointments on these days.
- Be easily available in the OT or in its vicinity or in your Duty Room. If you are going out for any reason (e.g. meals, etc.), ensure that your whereabouts are known to someone responsible in the OT and that you are on the hospital premises and easily contactable.
- Have your meals when time permits, otherwise you may miss your meals totally.
- Find out about the likely emergencies from the duty doctors in the operating departments and the emergency room (Casualty). This will give you some idea about how busy you are likely to be and whether it may become necessary to call for extra hands to help.
- In a large, tertiary referral general hospital, it is difficult to predict the nature or the number of emergency operations that may be performed on any given day. So it is not possible for one to be fully geared up for all contingencies. However, if you are equipped to handle (mentally, physically and technically) the more common emergencies such as Caesarean Sections, Laparotomy (adult and paediatric) for peritonitis (perforation/intestinal obstruction), Trauma (Neurosurgery, Orthopaedics, Plastic and Vascular Surgery), you will be quite adequately prepared. Cardiac, Ophthalmic, ENT and other emergencies are fortunately uncommon.
- When you are on emergency duty, see that equipment that is necessary for the above-mentioned surgeries is easily available.
- Make sure that the OT Technician is also well prepared to take his responsibilities.
In both elective and emergency operations, while handing over charge to another nurse in the middle of an operation ensure that you have the surgeon’s permission to do so. Make sure that the nurse who is replacing you is fully prepared and informed about everything that she should know about the operation. Take particular care to see that the counts of sponges, gauze pieces, and instruments are correct and 23accounted for before leaving the OT. It would be good practice to do this along with the first assistant (Resident/Intern) and to put it in writing with your signature and the signature of one of your superiors affixed.
Report all damage and loss promptly and to the right person. If you wish to share a responsibility, prefer to share it with a person who is senior to you. Similarly, to solve problems, consult a senior and not a junior or a person on the same level as yourself.
THE OPERATION THEATRE TABLE (Figs 1.6A and B)
The modern Operation Theatre table is a mechanical device, which is capable of adjustments to give a variety of positions for the convenience of the patient and the surgeon during operations.
The table can have a variety of attachments (accessories) so as to make it possible to perform a variety of operations including Neurosurgery, Plastic surgery, Urology, Gynaecological and Orthopaedic procedures using the same basic table.
More sophisticated tables are available which may incorporate radiolucent tops for peroperative X-rays, electrically operated remote control device to change positions and configurations, removable tabletop to make transfer of patients on and off easier and safer.
The Basic Parts of a Table
- The base which incorporates the wheels or castors, the hydraulic mechanism to elevate and lower the table top, the brake which prevents the table from moving during surgery and the electrical mechanism for remote control attachments.
- The tabletop. This rests on the pedestal which may be at its centre or closer to the head end or foot end so as to facilitate the use of a C Arm X-ray device (Fig. 1.7) in which case the tabletop is radiolucent.26The top may be removable so that it can sit on a trolley and be used for transport of patients. The top may consist of two, three or four sections. In the 2 section top, the shorter section is movable and is hinged at the head end so that it can be tilted upwards or downwards to raise or lower the patient’s head alone. The longer section in this configuration is the part on which the patient’s body rests. In the three-section table there is another short section at the foot end, which can be adjusted in a similar manner. It can be removed to facilitate putting the patient in a lithotomy position for surgery on the genito-perineal. Both these sections can be removed to shorten the table for use for a child or short adult. In the four-section table the “body” of the tabletop can be “broken” in the centre so as to flex the patient’s body in the lateral position for surgery on the flank. This section may incorporate a separate small horizontal plate, which can be independently raised or lowered mechanically by a ratchet mechanism so as to flex the body in the lateral position in order to widen the space between the costal margin and the iliac crest (costo-cristal distance). This section is called the kidney bridge. As the name implies, it is used for operations on the kidney. The tabletop is covered by sections of foam mattress, which are fixed so as to prevent the patient from slipping even when the tabletop is tilted or “broken”. In every configuration, it is possible to obtain a head low (Trendelenburg) or a head high (reversed Trendelenburg) position by tilting the tabletop suitably. The tabletop can be tilted laterally also.
- 27 Attachments that are commonly used are: (1) Metal runners on either side to attach brackets to fix self-retaining retractors or L Angles, IV poles or stirrups (for lithotomy position), (2) Arm boards to rest the abducted arms during surgery, (3) Neurosurgical head frame—this is a horseshoe shaped padded metal frame, which stabilizes the patient’s head, (4) An arm sling to support the unused arm and prevent it from falling off the table, (5) A hand table for hand surgery, (6) Orthopaedic attachments to abduct the hips and support the legs for surgery on the hip, (7) Sand bags, head rings or doughnuts and pillows can be used for support and immobilization during surgery. Some tables have electrically operated “ripple” mattresses (alpha bed), which is ideal for the prevention of deep vein thrombosis during time-consuming operations. A metal plate at right angles to the plane of the tabletop can be attached at the foot end of the table to support the patient when a steep head up position is used.
POSITIONS OF THE PATIENT FOR SURGERY
The position of the patient is not the same for all operations. It depends upon the region of the body on which the procedure is going to be performed and has to be comfortable and safe for the patient, ideal for the surgeon to have the best possible approach to and exposure of the region being operated and most suitable for the anaesthetist to administer anaesthesia (See Fig. 1.2) and monitor the patient’s vital parameters adequately.
The commonest position used for most operations is known as the dorsal recumbent or supine position. In this, the patient lies on his back with the legs extended and straight and the arms outstretched on arm boards or kept securely by the sides of his body. This is the position that is used for operations in the region of the head, face, eyes, neck, abdomen, the pelvis, the groin and the upper thighs. This position is also used for surgery on the breast and anterior chest wall. In the former case, the arm on the side being operated is abducted so as to facilitate surgery on the axilla. Some surgeons even hyperabduct this arm, flex it at the elbow and place the hand under the patient’s head. In this position, the patient can be placed in the Trendelenburg position (see above) (for the Trendelenburg operation and for operations in the pelvis and lower abdomen where upward displacement of the intestines in this position would aid the surgeon) or the reversed Trendelenburg position (for thyroid and other head and neck procedures) in which case the head ring and sand bag (between the scapulae) may be used to support the head and provide extension of the neck. This position would displace the intestines downwards and provide better access to the upper abdominal viscera.
In this position a sand bag or rolled sheet placed behind the back would elevate that side of the abdomen and make it easier to approach the gallbladder and liver on the right and the spleen on the left side. Some tables may incorporate a back elevator for this purpose.
The lithotomy position is one in which the supine patient’s knees and hips are flexed acutely and the legs are 29supported on stirrups attached to the tabletop on each side. The hips are also abducted. The pelvis may be elevated on a sand bag and the tabletop tilted into the Trendelenburg position (the Trendelenburg lithotomy position) to make it easier to operate on the perineum and genital region. The foot section of the table is removed or hinged downwards at right angles to the tabletop. The buttocks rest at the lower end of the tabletop. For operations in this position, the surgeon is seated on a stool.
In the lateral position the patient’s body is turned to one side so that the side to be operated upon is uppermost. The leg that is in contact with the table is flexed at the hip and knee so as to provide a broader base. The other leg is kept extended. A pillow may be placed between the legs. The kidney bridge may be elevated in order to flex the spine laterally and increase the space available between the costal margin and the iliac crest. The patient is naturally rather unstable in this position and needs to be strapped to the table with two broad straps over the hip and the shoulder. The arm that is uppermost can be supported in a slide or sling and used for administering IV fluids and for the BP cuff. This position is used for surgery on the kidney and other retroperitoneal structures as well as for the lumbar spine.
The prone cranial position is one in which the patient lies face down on the table with the shoulders and chest supported on pillows and the body secured by straps. A slight reverse Trendelenburg tilt may be used. This position is used for operations on the posterior cranial fossa (e.g. cerebellar operations).
30If in the above position, the tabletop is broken in the center so as to flex the patient’s body and the hips are slightly abducted the position is called the prone jackknife position. This position is used for operations in the sacrococcygeal region and lower back (e.g. for pilonidal sinus and for the posterior sagittal approach to the rectum).
Sometimes, in the prone position, the patient may be placed with the hips and knees fully flexed so as to arch the back. This (knee chest position) increases the space between the vertebrae in the thoraco-lumbar region and is used for laminectomy.
Sitting cranial position. The patient sits with the hands on his laps and the head, the arms and the torso suitably supported to make him stable. This position is used for surgery on the posterior cranial fossa.
Other
“accessories” that are necessary in the operation theatre are:
- Upholstered swivel chairs whose seats can be raised and lowered—for long procedures performed with the surgeon seated
- Stools whose tops can also be raised and lowered—for shorter procedures in the sitting position
- Foot stools for the benefit of shorter personnel!
- Mayo’s stands
- Basins and basin stands, buckets and bins for various uses.
- Bed cradles covered with sterile waterproof sheets (mackintosh) to be placed over the patient’s legs so as to: (i) keep the weight of the drapes off the body, (ii) to prevent wetting the limbs and causing hypothermia 31particularly during prolonged procedures and (iii) to avoid sterile instruments, etc. placed over the lower half of the patient’s body from coming in contact with unsterile, unprepared parts of the body through wet drapes.
- Arm boards which can be firmly fixed to the tabletop without going under the mattress and causing pressure and discomfort to the patient’s back.
- X-ray viewing box
- Stand with hooks to hang used sponges and gauze pieces.
- A black/white board with suitable writing device and duster/wiping cloth
- A clock
- A telephone instrument so as to avoid personnel from moving in and out many times to deliver or receive messages and to facilitate contact with laboratory, blood bank and other areas of the hospital when necessary.
- OTs should preferably be air-conditioned. Laminar flow is ideal. This is not only for comfort but also more importantly in order to provide a frequent change of air to prevent infection. Fans are not advocated because they tend to raise dust and make drapes fly.
- An adequate number of pillows, sand bags, head rings and other OT table accessories mentioned above should be readily available in each OT.
- A room heater may become necessary under certain circumstances.
- Soft music helps to ease the tension in an operating room. However, this may be disturbing at times and should, therefore, be used with discretion.
32It is the responsibility of the senior nurse in overall charge of the OT to inspect each operating room/suite regularly and see that all these are made available at all times in every operating room. It is the duty of the staff nurses assigned to particular operating rooms to ensure that any deficiency, damage, malfunction or loss is reported and rectified promptly.
OPERATION THEATRE PROTOCOL
General Instructions
- If you have any infection, e.g. skin and upper respiratory infection DO NOT ENTER THE OT.
- Keep fingernails short and clean and DO NOT APPLY NAIL POLISH.
- Jewellery is NOT to be worn on the hands and forearms in the OT.
- Keep the hair well tied back so that it can be covered completely by the cap.
- On entering the OT remove street footwear and put on the prescribed OT footwear (preferably closed and waterproof).
- Wear the prescribed OT uniform, cap and mask and shoe covers. See that the cap completely covers the hair. The mask should cover the mouth and nose and should be tied securely behind the head.
- Discard shoe covers when you go to the toilet. Wear fresh shoe covers thereafter.
- Do not go out of the OT in your OT uniform and footwear.
- Avoid loud noise and unnecessary talk during surgery.
- Smoking, eating and drinking in the vicinity of an operating room are prohibited.
Preparing to Assist in an Operation
- Before you scrub, wear a waterproof apron over your OT uniform. If an intra-operative X-ray is likely to be taken, wear the protective lead apron also.
- When you scrub before an operation, see that the sleeves of your uniform are well above the elbows.
- Scrub for at least 2 minutes and up to at least an inch above the elbows.
- Use a brush to scrub the fingernails but not for the skin.
- Repeat the procedure again for another 2 minutes.
- Do not touch the tap or the lotion dispenser with your hands after scrubbing for the first time. Use your elbows or ask for someone’s assistance to do this.
- Use plenty of running water to wash off the lotion.
- See that all the soap is washed off and that the water runs down from the hands to the elbows. This means that the hands should be kept raised.
- Shut off the tap with the elbow and not with the scrubbed hands.
- Do not touch anything that is likely to be unsterile after you have scrubbed.
- To don the gown, open it fully with both hands and insert both hands simultaneously into the arms of the gown. (Single use disposable gowns are ideal but expensive.)
- Know your glove size and ask for the correct size of gloves.
- Wear the left glove first with the fingers of the right hand touching only the inside of its folded cuff. Then, wear the right glove using the fingers of the already gloved left hand inserted into the fold of the cuff. Then unfold both cuffs to cover the cuffs of the gown fully all round. Wear a second pair of gloves of the next larger size over the first pair.
- Now, all your outer attire is sterile. See that you do not come into contact with anything unsterile including personnel and articles, furniture and walls.
- Inspect the instruments and other articles on your trolley and make sure that all the necessary things are there.
- Count sponges and gauze pieces meticulously and twice along with the circulating nurse. Note the number of these articles on the blackboard and in the record/chart if this is provided. Inform the surgeon about this. Do the same for instruments also.
- Find out from the operating surgeon if any special materials are required (e.g. special retractors and other accessories, instruments, sutures, drains, catheters, haemostatic agents, radiopaque contrast, other medication like scolicidal agents (hypertonic saline, Chlorhexidine), povidone iodine (Wokadine/Betadine), local anaesthetic, sterile saline and distilled water, syringes, 35needles, etc.) so that you may arrange to have these supplied well in time. Do this before the operation even if you have done it already the previous day.
- See that the required number and types of drapes are available and are in good condition (i.e. dry and undamaged).
- See that the OT table accessories that are required for that particular operation are readily available.
- Position your trolley, Mayo’s stand, basin stand, etc. within easy reach and in such a way as to avoid coming into contact with personnel who have not scrubbed for the case.
During Surgery
- Be neat, careful and practical in arranging your trolley, Mayo’s stand, suction and diathermy connection, etc.
- Be alert and observant throughout the procedure and follow the steps carefully.
- Be aware of the number of instruments, sponges and gauze pieces in use or discarded during the procedure. Keep track of all extra materials taken during the course of the operation (e.g. sponges, gauze pieces, instruments, etc). Keep the circulating nurse informed about this repeatedly.
- Handle all instruments with care so as to avoid injury to yourself and others and damage to instruments. While handing over sharp edged or tipped instruments in particular see that the handle is towards the surgeon’s hand. Better still; hand over such instruments in a 36container such as a kidney tray. While receiving instruments also, the same procedure is safer.
- Do not keep instruments and other sterile articles over areas that are unprepared and, therefore, unsterile e.g. between the patient’s legs during a laparotomy. It would be a good idea to cover the patient completely with sterile waterproof material (mackintosh) so that even if you inadvertently place something over these areas they would not come into contact with unsterile parts.
- After the surgeon has painted the area to be operated, see that drapes are firmly fixed with towel clips so that only the area to be operated upon is adequately exposed. It is a good idea to fix a sterile screen to separate the anaesthetist’s territory from the surgical field.
- Take unsatisfactory instruments away and see that they do not come into circulation again.
- Change gloves immediately if they become punctured or torn. Change drapes if they become wet.
- Keep separate containers to discard sponges, gauze pieces, blunt things and sharp things.
- If you are handing over to another nurse in the middle of an operation, inform the surgeon well in time. Inform your substitute about what has been done till then. Especially, inform her about the sponges, gauze pieces and instruments used and discarded. Check the counts of all these and see that all are accounted for before leaving. It would be good to stay for a while before your reliever gets into the tempo of the procedure. If you want the surgeon to stop till you hand over satisfactorily do not hesitate to ask him to do so. It is safer for all concerned.
- Avoid distractions. Keep conversation down to the necessary bare minimum. If and when you do need to converse let it be in a language that is understood by the team.
- During an operation the scrub nurse may stand to the right of the surgeon, which makes it easier to take instruments from the Mayo’s stand with the right hand and hand them over to the surgeon with the left hand. The scrub nurse may also stand on the opposite side of the table so as to face the surgeon. In this position it is easier to read eye and hand signals and the question of turning the back to the surgeon does not arise.
After the Operation
- At the end of the procedure, check counts of all sponges, gauze pieces, instruments, etc. and make sure that everything is accounted for before letting the surgeon close the operating field. Take the help of the circulating nurse for this and note this in the record/chart.
- See that all things such as the suction tube, diathermy, etc. have been switched off and disconnected before shifting the patient. Be extremely careful with drains, tubes, catheters and urine bags. These may still be attached/tied to the table. See that they are not attached to the table in any way before shifting the patient.
- Consult the anaesthetist and obtain his permission before turning or shifting the patient.
- Make sure that the details of sponges, gauze pieces and other materials used and the fact that these were counted and found to be correct are noted in your record and in the patient’s chart.
- See that all electrical gadgets (lights, suction, diathermy, light sources, X-ray viewing box, monitors, etc.) are switched before leaving the theatre.
- Report to the Sr. In Charge at the end of every operation. Any untoward incidents, injury, loss, breakage, damage and malfunction should be reported and recorded in the appropriate register immediately.
- See that all used materials are removed safely. It is vital to remember at all times that blood and body fluids are all potentially infective. Safe disposal of all articles that have come into contact with these is imperative.
- Universal precautions are a must while handling and cleaning reusable articles that have been in contact with potentially infective material.
- Gloves, syringes, catheters, needles and scalpel blades are meant for single use and must be discarded safely after use. Unused materials should be returned and accounted for.
- See that the operating room is cleaned properly by the helper and kept ready quickly for the next case.
- Prepare the charge sheet in consultation with the surgeon and the Sr. In Charge.
- 39If you have doubts and questions, have them cleared and answered by the surgeon at the end of the procedure. You will then be better prepared the next time the same procedure is performed.(Note: an interested, dedicated, intelligent, cheerful, and hard working OT nurse can be the best possible surgical assistant.)(Note: the OT technicians are there to help you. Behave In a manner that will earn their respect and willingness to assist you in your work. If you are knowledgeable, confident and conscientious this will follow automatically.)
NEEDLES AND SUTURE MATERIALS
Surgical needles are most often made of stainless steel. Depending on their shape they may be either straight or curved. Depending on whether they have an eye through which a thread has to be passed or whether the thread is fused (suaged) to the back of the needle they are called eyed or eyeless (atraumatic) needles. Atraumatic needles are so called because here, the needle and thread form a smooth junction and therefore there is no difference in width unlike in the eyed needle where the eye section of the needle is naturally broader than its body and a double thickness of thread is obtained when the thread is passed through the eye and out. Because of these reasons this kind of needle is more traumatizing and, therefore, is not ideal for use in soft and delicate structures such as intestines, etc.
Curved needles are further classified into the following types:
- Round bodied—here, in cross section, the body of the needle is round and it tapers uniformly to a point
- Cutting needle—here, in cross section the body of the needle is triangular with the apex of the triangle facing the convex surface and its base facing the concave surface.
- The Reversed Cutting needle—here also, in cross section the body of the needle is triangular but the configuration of the triangle is opposite to the above needle—that is—the apex of the triangle faces the concave aspect while the base faces the convex aspect of the needle.
- The Taper Cut needle—here, the body of the needle is round in section but only the tip is of the cutting needle configuration.
- The Dolphin Nose needle is one whose tip is like a duck’s bill or a dolphin’s nose. Because of this it is less traumatizing and so can be used to suture soft solid viscera like the liver and spleen.
- The Spatulate needle—here, the tip is shaped like a spade. This needle is used in Ophthalmology.
Curved needles can also be described according to their curvature. A curved needle is basically the arc of a circle (i.e., a part of the circumference of a circle). Depending on how much of the circumference the needle forms it may be called a 5/8-circle needle (5/8th of the circumference), a ½ circle needle (half of the circumference) or 3/8-circle needle. The 5/8th circle needle is most curved while the 3/8th circle needle is least curved. The length of the needle in millimeters from 41its tip to its base is also mentioned on the packet of suture material. It is important to know all this information from the packet of atraumatic sterile suture material before opening it in order to avoid opening the wrong packet.
All curved needles are used with the help of a needle holder while straight needles are held directly in the hand for suturing. Fine needle holders are held between the index finger and thumb while handling very thin and delicate curved needles (e.g. for microsurgery and vascular surgery). Some needles may be coloured black (e.g. JB Visiblack needle) to make them more easily visible.
Some suture materials are manufactured with needles at both ends. These are called Double Armed sutures. They are used in vascular surgery.
Needles vary in their thickness also. The thinner a needle is, the more likely it is to bend and break.
Suture Materials
Suture materials are basically classified as follows.
- Obtained from a natural source: Like Silk (silk worm), Catgut (submucosa of the small intestine of sheep), Linen (flax plant fibre), and Cotton (cotton plant fibre). Catgut is further classified as Chromic (it is treated with dichromate so as to increase its life span and it is, therefore, tanned brownish in colour) and Plain Catgut, which is untreated and is, therefore, golden yellow in colour. Of these, catgut is absorbable—chromic catgut generally in 21 days while plain catgut lasts for about 7 to 8 days in the body. The other materials are non-absorbable. 42Depending on whether the material consists of a single strand of thread or many skeins wound together (like knitting wool) they are called monofilament (like catgut) of braided (like a plait) (silk).
- Synthetic: These again may be absorbable (e.g. vicryl-polyglactin—completely absorbed in 90 days, dexon-polyglycolic acid—completely absorbed in 90 days and maxon-polyglyconate—completely absorbed in about 180 days). Vicryl rapide is a type of vicryl that has a life span, which is a little more than that of chromic catgut. Non-absorbable synthetic sutures are, e.g. prolene (polypropylene), nylon, polyethylene, stainless steel, tantalum alloy and silver. Some suture materials are dyed so as to make them last a little longer and to make them more visible in the body. Dyed vicryl is violet and dexon and maxon are green. Prolene is blue while nylon is black in colour.
Some suture materials can be straightened out into long threads while others coil back into the configuration in which they were when packed (e.g. prolene). This property of retaining its coiled configuration is called the “memory” of the material. Prolene and nylon are smooth and so knots tied with these are more likely to become loose. Also, because of an excellent memory these materials tend to get entangled and knotted while in use. Therefore, the scrub nurse or assistant needs to follow the suture very carefully to prevent this.
Suture materials are available in various sizes according to their thickness ranging from No. 2 to ten zero. The greater 43the number of zeroes, the thinner is the material. Generally, for intestinal anastomosis, etc No. 2-0 or 3-0 is used while for ophthalmic surgery 10 zero is necessary. Cotton, however, is numbered as 20, 30, 40, etc. No 40 cotton is the size that is usually used. Most suture materials come sealed in sterile packs containing a small quantity of fluid, which prevents them from becoming dry. The details of the type, length, thickness, type and size of needle and whether double armed or single armed are mentioned on each pack. The date of manufacture and expiry are also mentioned. All these details have to be read and understood before opening a packet. Packets must always be opened with sterile gloved hands.
Alternatives to Sutures
- Staples made of silver or tantalum (used for skin or bowel)
- Clips which maybe absorbable or non-absorbable (Michel clips and Kifa clips)
- Adhesive tapes (Ethistrips)
- Fibrin glue
- Isobutyl cyanacrylate glue—Nectacryl (for skin wounds)
The Common Methods of Suturing Skin
- Simple sutures
- Mattress sutures
- Half mattress sutures
- Subcuticular sutures
- Tension sutures of thick nylon or prolene (number 1) are sometimes used over rubber or PVC (plastic) tube bolsters to close the abdomen.
The Common Methods of Suturing Bowel
- Lembert suture
- Connell suture
- Gambee suture
All these can be used for anastomosis or for closure of the end of transected bowel (e.g. duodenal stump closure after Billroth II Gastrectomy). A Purse String suture is a continuous encircling suture applied around a stump or a tube in order to bury it (e.g. appendicular stump or jejunostomy/gastrostomy tube).
Sutures may be continuous or interrupted. These names are self-explanatory. A continuous suture maybe of the interlocking type where each suture is locked with a loop of thread so as to make it more secure and more haemostatic.
For organs lined by mucosa, it is preferable to bury (invert) the mucosa while suturing. Sutures such as the Connell and Gambee suture achieve this. Bowel is usually sutured in two layers—the first (inner) being the through and through layer which takes bites through all layers of the wall and is of absorbable material and the second (outer) which takes only the seromuscular layer and is of non-absorbable material. In some situations in the gastrointestinal tract, 45however, a single layered closure or anastomosis may be done, e.g. the oesophagus, which does not have a serosal coat. The use of continuous or interrupted suture in a given case depends on the surgeon’s preference and local conditions in the particular viscus.
Staples can also be used for bowel (anastomosis or closure) as well as for skin.
DRAINS AND TUBES
Drains are usually used when there is some body fluid, which needs to be prevented from collecting. Fluid may accumulate as a result of various pathologies including ascites, peritonitis, abscess formation, anastomotic dehiscence (leak), hematoma, etc. to give a few examples. The common types of drains used are:
- Glove drain or Penrose drain (flat strip of latex rubber)—used in superficial sites e.g. surgical incisions and superficial abscesses.
- Corrugated rubber drain—also used in deeper abscess cavities (e.g. gluteal abscess, breast abscess, etc).
- Tube suction drain (usually small caliber—Romovac, Variodrain, etc.) connected to vacuum container (intraabdominal collections, after thyroidectomy, mastectomy, etc).
- Wider bore tube drains are used to drain bowel (e.g. formal duodenal fistula, caecostomy, gastrostomy, cholecystostomy, oesophagostomy) or the peritoneal or pleural cavity (e.g. Intercostal tube, Malecot catheter).
- Salem tube drain—Used as an alternative to the Ryle’s tube for nasogastric drainage and feeding
- Ryle’s tube—Used for nasogastric aspiration and feeding and for gastric juice analysis.
- T Tube (Kehr)—This is a T-shaped tube which is used to drain the Common Bile Duct after it has been opened and explored during surgery on the biliary tree.
- The infant feeding tube or small caliber Ryle’s tube—used as a transanastomotic jejunal feeding tube. It is passed across a gastrojejunostomy into the efferent loop of the jejunum so as to enable enteral feeding post-operatively.
- Foley catheter—To drain the urinary bladder it is passed per urethra. It can also be used for a formal duodenal fistula, a cholecystostomy and a caecostomy. The Foley and Malecot catheters are “self-retaining catheters”. This means that they do not need to be fixed by means of sutures to prevent them from coming out. The Foley catheter is made of latex rubber and has a balloon near its tip, which can be filled with sterile distilled water after it has been inserted. The inflated balloon prevents the catheter from slipping out. This catheter may have a second channel through which the bladder may be irrigated. The Malecot catheter has a “flower like” segment of rubber strips near its tip, which prevent it from slipping out.
- The red rubber catheter is a tube, which looks like the flatus tube but is of a much smaller caliber. It was originally meant for drainage of the bladder, but it is now put to a number of uses including for irrigation of cavities, administration of nasal oxygen, suction, etc.
- The suction catheter—This is transparent PVC tube, which comes in a sterile pack and is used by the anaesthetist for suction of the mouth, the pharynx and the trachea.
- Fogarty catheter—This is a stiff, thin catheter, which has a small latex balloon at its tip, which can be inflated with a very small volume of saline. This catheter is inserted through a small incision in the wall of an artery to extract emboli. The usual sizes used are 3, 4 or 5 French. It can also be called an embolectomy catheter.
Most tubes come in different sizes according to the French (Charriere) scale. In this scale 1 millimeter = 3 French. This is the outer diameter of the tube. Thus, 3 F = 1 mm, 18F = 6 mm.
Other tubes that may be encountered are:
- Tracheostomy tube—Metal/portex with cuff
- Endotracheal tubes—Portex with or without cuff—for naso- or oro-endotracheal intubation to administer general anaesthesia or to facilitate artificial ventilation. Double lumen endotracheal tubes are used to ventilate one lung alone and collapse the other one during 48thoracic surgical procedures. Armoured endotracheal tubes are also available which are more rigid. These are used during thyroid surgery and in neurosurgical procedures done in the prone position (e.g. posterior cranial fossa operations).
- Mousseau Barbin tube—PVC tube with a funnelshaped upper end and a conical lower end to which is fused a “nasogastric” like PVC tube for passage into the oesophagus through the mouth. This tube is used for traction intubation of the oesophagus to palliate dysphagia in an unresectable oesophageal cancer.
The common sizes of handles used are 4 and 7. The former is for the larger blades and the latter has a longer handle and is meant for the smaller blades. The blades themselves are numbered 10, 10A, 11, 12 and 15 (small blades), and 20, 21, 22, 22A, 23, 24 and 25 (larger).
SURGICAL INSTRUMENTS
Surgical instruments can be simply classified as follows (Fig. 1.9):
- Sharp cutting instruments
- Dissecting forceps
- Hemostats (artery forceps)
- Iissue forceps
- Gastric and intestinal clamps
-
Fig. 1.9: Some surgical instruments. (1) Needle holder—Kilner, (2) Right-angled dissecting forceps—Mixter, (3) Sinus forceps—Hilton, (4) Tissue holding forceps—Allis, (5) Intestinal occlusion clamp-straight—Doyen or Kocher, (6) Medium sized hemostat—Spencer-Wells, (7) Tissue holding forces—Babcock, (8) Curved clamp with teeth—Kocher, (9) Sponge holder, (10) Towel clip—Backhaus, (11) Non-toothed dissecting forceps, (12) Small, curved haemostat—“Mosquito”—Halstead
- Suture materials
- Tubes, catheters and drains
- Retractors
- Dilators and probes
- Special instruments
- Diagnostic instruments
Sharp Instruments
Examples of sharp cutting instruments are as follows:
Scalpels (see above), amputation knives, bone cutting instruments—saws (amputation saw and Gigli saw), osteotomes, chisels, gouges, ronguers, rougines and rib cutters which are also called costotomes), skin graft knives (Humby, Blair, Braithwaite and Padgett) which are also called dermatomes.
Scissors are of various configurations (Figs 1.10A to C). The common ones are Mayo’s straight and curved, McIndoe’s curved, Nelson curved, Metzenbaum (baby, small and large), Lloyd-Davies (straight), Abel (straight), Pott’s (vascular), DeBakey (vascular) and microvascular. A special scissors called the Lister’s bandage cutting or dressing scissors is not truly a surgical instrument as the name implies.
Other sharp instruments are trocars with cannulae which come in several sizes and are used for various purposes such as insertion of intercostals tubes, suprapubic cystostomy, drainage of the gallbladder, etc. trephines which are used to make holes in the cranial bones—the commonest example of this is the Hudson’s brace and burr with which the burr hole is made. Other trephines are the Rowbotham and the Buchanan trephines.
Examples of Dissecting Forceps (also called thumb forceps)
Canadian, Mitchell’s, Lane’s, Adson’s. These instruments come with and without teeth (smooth) and are used to dissect tough and delicate structures respectively.
The smooth dissecting forceps are also used to hold cut bleeding vessels for coagulation with diathermy. These forceps may be insulated and connected to the bipolar diathermy machine (see above).
Examples of Haemostats (which may be straight, curved on the flat or curved on the straight)
The mosquito or Halstead haemostat which is a small and delicate instrument which is ideally suited for fine dissection, the medium sized haemostats—Spencer Wells, Dunhill (curved on the straight and used in Neurosurgery for scalp 54vessels), Kelly’s, Moynihan, Rochester-Oschner and Kocher. The last two have teeth and are ideal for large vascular pedicles.
Examples of Tissue Forceps (meant for grasping without traumatizing)
Allis (has teeth and is, therefore, meant for tougher tissues), Lane’s which have curved, ladle-shaped fenestrated blades, Babcock’s whose fenestrated blades form a small cylinder when approximated, Littlewood’s which look like Lane’s but without fenestrations, Stille’s which look like the Allis but are more delicate and thin, Duval and DeBakey, both of which have triangular fenestrated blades. In all these instruments, some configuration is present to prevent crushing tissue—like curvature of blades and fenestrations in the blades.
Gastric and Intestinal Clamps
These are of the crushing or the non-crushing (occlusion) type. Examples of the former are: Payr’s, Kocher’s, and Zachary Cope clamps. Examples of the latter are the Moynihan, Doyen, Lane, Lane twin anastomotic clamp, Lloyd-Davies rectal occlusion clamp, Lang-Stevenson clamp, Parker-Kerr clamp, Leyland-Jones clamp and Pean’s clamp. Crushing clamps are more traumatic. They not only occlude the lumen of the bowel but also crush and devitalize the tissues between their blades. Therefore, such clamps are only applied on bowel, which is to be resected. Occlusion clamps on the other hand do not devitalize tissues but only occlude the lumen and close 55blood vessels. They can, therefore, be safely applied on bowel, which is going to be retained in the body.
Needle Holders
As the name suggests these instruments are used to hold curved needles while suturing. Examples are: Mayo and Mayo-Hegar which are the most commonly used ones, Kilner—whose handle is bent on the flat, Naunton-Morgan double jointed long needle holder, Gillies needle holder which incorporates scissors also and the microvascular needle holder.
For suture materials, needles, drains, tubes and
catheters see above.
Retractors
These are also of various configurations, lengths and strengths for use in various situations and applications. Some of the common ones are as follows (Figs 1.11A to D).
Kilner—also called the cat’s paw, which is used for skin and superficial tissues, skin hooks (Gillies and McIndoe), Alms self-retaining skin retractor which is somewhat like a light mastoid retractor. These are used for skin and superficial tissues.
Self-retaining retractors (Figs 1.12A and B) are—Joll’s thyroid retractor, Traver’s (mastoid) retractor, Norfolk (a deeper version of the mastoid retractor), Balfour (three bladed) abdominal retractor, Turner-Warwick ring abdominal retractor, sternocostal extension retractor, Allison lung retractor. Sydenham’s and Boyle-Davis mouth gag. Rib spreader and rib retractor. These are examples of selfretaining retractors, which leave the assistant’s hands free to perform other tasks.
Figs 1.11A to D: Retractors. (A) Deaver, (B) Volkman’s retractor (Catspaw), (C) Morris retractor and (D) Langenbeck retractor
Figs 1.12A and B: Self-retaining retractors. (A) Mastoid retractors—Left: Adson, Right: Beckmann-Adson and (B) Joll-thyroidectomy
retractor
There is also an instrument called the rib approximator, which is used to bring ribs together to facilitate the closure of a thoracotomy.
Non-self retaining superficial retractors are the Langenbeck and the Ollier which are single hook retractors and the Czerny which is a double hook retractor which has a forked hook on one side. Cheek retractor
Deeper retractors are Morris, Deaver, Lloyd-Davies (pelvic), Kelly (pelvic) and the Doyen.
Probes and Dilators
These usually come in sets containing instruments of varying diameters and curvatures.
Examples are Lister’s, Clutton’s and Turner-Warwick bougies for urethral dilatation, Hegar’s dilators for cervical dilatation, Bake’s bile duct dilators and Chevalier Jackson, Gum elastic, Eder Puestow, Canny Ryall and Neoplex oesophageal bougies (which may or may not be used in an operation theatre).
Special Instruments
Stone
extractors (calculus removing forceps): Desjardin’s/Turner-Warwick calculus forceps—these come in sets which contain several instruments of different curvatures and fenestrated blades. They have no ratchets and are used to extract stones from the bile ducts and the renal calyces.
Vascular instruments—Satinski clamp—used to partially occlude the lumen of a major vessel (e.g. vena cava). DeBakey clamp—used for cross clamping (completely occluding) major vessels like the aorta. Bulldog clamps are small spring-loaded vascular clamps, which come in various sizes and configurations (curvatures) and are meant for smaller vessels. All these instruments are non-traumatizing.
Myer’s vein stripper is a length of monofilament steel cable or braided steel wire with an olivary tip at one end and an acorn tip at the other, both of which are detachable. This instrument is used to strip a varicose (dilated) vein.
INSTRUMENTS USED AS DIAGNOSTIC AIDS (Figs 1.13A to D)
For biopsy—Sim’s uterine curette—for endometrial biopsy. Vim-Silverman needle, Menghini needle, Turkell Trucut needle—for percutaneous or intraoperative core biopsy of the liver/kidney. Abram’s punch—for pleural biopsy. Volkman’s scoop for curetting walls of abscess cavities for biopsy. Yeoman’s biopsy forceps—for sigmoidoscopic biopsy, cervical punch biopsy forceps.
For examination and procedures within tubular hollow viscera—Sim’s vaginal speculum (also used for examination of the anal canal and lower rectum. Cusco’s bivalve speculum—used as the above instrument, Proctoscope/anal speculum—used to examine the anal canal and take a biopsy and also for sclero/cryotherapy and banding of haemorrhoids. This instrument may have the facility for illumination. Rigid and flexible sigmoidoscope, Mediastinoscope, rigid and fibreoptic bronchoscope, cystoscope/resectoscope which can be used for a variety of diagnostic procedures as well as therapeutic procedures such as transurethral prostatectomy and resection of tumours of the urinary bladder. The uretero-renoscope/nephroscope is a newer instrument which permits examination and procedures in the renal pelvis, and ureters. The upper gastrointestinal tract can be studied, biopsies obtained from their mucosa and therapeutic and palliative procedures performed with the use of the fibreoptic oesophago-gastro-duodenoscope. The rigid oesophagoscope has now given way to the fibreoptic instrument, which is safer.
Figs 1.13A to D: Instruments for anal and rectal examination. (A) Graeme Anderson rectal speculum, (B) Gabriel rectal speculum, (C) Sims rectal speculum and (D) Kelly proctoscope
All fibreoptic instruments are thinner and flexible. They also permit the incorporation of other channels for the purpose of irrigation, suction, biopsy and the passage of other tubes and catheters, stents, etc through the scope. Most flexible/fibreoptic scopes are now videoscopes by means of which a clear image can be obtained on a TV monitor screen. This provides good magnification and permits many people to see the procedure including assistants, students and trainees. The laryngoscope is a hand held, battery61 operated, foldable instrument, which comes in two parts. It is used for direct examination of the pharynx and the larynx up to the vocal cords and is most commonly used as an aid to oro-endotracheal intubation to administer gaseous general anaesthetic agents or to facilitate assisted ventilation. A flexible choledochoscope is also available to examine the inside of the biliary tree and perform procedures such as removal of calculi, etc.
The laparoscope/thoracoscope and its accessories are a whole array of instruments used for a variety of laparoscopic and thoracoscopic procedures including diagnostic laparoscopy, laparoscopic cholecystectomy, diagnostic thoracoscopy and thoracoscopic assisted operations. Basically it consists of a rigid telescope with a microchip TV camera and fibreoptic light source in order to visualize a magnified image of the abdominal organs on a TV monitor, an insufflator which instills carbon dioxide into the peritoneal cavity in order to distend it and permit better visualization in a more spacious area without organs and viscera obstructing the view. This attachment also permits suction and irrigation of the body cavity in which the procedure is being performed. There are many instruments, which are specifically meant, for use in laparoscopic/thoracoscopic surgery and newer innovations are being produced every day. New indications for laparoscopic/thoracoscopy are also being described.
MISCELLANEOUS INSTRUMENTS
These may not be surgical instruments in strictest sense of the term.
- Rampley’s sponge holding forceps
- Cheetle’s forceps or lifter
- Diathermy tip—unipolar/bipolar
- Towel clip (two types—spring loaded or with ratchet, the latter is called the Backhaus towel clip)
- Malleable copper retractor
- Mallet—used like a hammer in Orthopaedic surgery
- Hilton’s sinus forceps—looks like a haemostat but has no ratchet. The blades are thin and have serrations only at the last 1 cm or so. Used to probe sinuses and for the drainage of abscesses, e.g. breast abscess, etc.
Haemostatic Agents
These are materials, which are placed in areas where diffuse oozing haemorrhage is taking place following surgery (e.g. the gallbladder bed after cholecystectomy). Examples of commonly used haemostatic agents are: Gelfoam (looks like thermacol), Surgicel, Spongostat that are available as sheets, which can be placed over the site of oozing. Spongostat is also available in the form of a hollow tube (called Spongostat anal), which can be inserted after anal surgical procedures. These materials are inert and do not act as foreign bodies or cause any harm. Botropase is a liquid haemostatic agent in which the above materials can be dipped to produce additional haemostatic effect. Botropase can be used by itself also. Horsley’s bone wax is another type of haemostatic material, which is used to stop bleeding from bones (e.g. from the end of a bone after amputation).
This list does not include every possible instrument in every speciality because the objective of these notes is to kindle an interest in further reading.