Instruments in Surgery, Orthopedics and ENT SR Joharapurkar, SV Golhar
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Instruments in General SurgeryCHAPTER 1

2
 
ARTERY FORCEPS (FIG. 1.1)
Better known as the hemostat, have same basic design as any other articulated instrument.
zoom view
Fig. 1.1: Artery forceps
 
Parts
  • Handle
  • Blade
  • Joint or shanks
  • Finger bows
  • Serrated rack or Ratchet or catch
  • Tip.3
 
Joint
Any of the following three types. This part must be cleaned regularly and deposition of dust or rust must be avoided.
  1. Screw type:
    • Most popular
    • Easy to manufacture as two parts are connected by screw
    • Joint checked periodically
    • Screw tightened as and when required.
  2. Box joint:
    • One arm passes into another through a slot
    • Blades fit accurately
    • Blades do not loosen
    • In delicate version viz. mosquito forceps where accurate approximation of tip is necessary, this type of joint is preferred.
  3. Aseptic or semibox joint: For cleaning and sterilization, two halves can be separated.
Variations in basic designs are based on differences in blades and its parts.
 
Blades
• Shape
– Straight
– Curved
• Length
– Long-standard length 8”
– Small-standard length 5”
– Medium
• Tip
– Fine
– Blunt which will avoid damage to surrounding structures
– Tooth at the tip
– Usual type
4
• Serrations on blades
– Throughout
– Part
• Catch
– Single
– Many
 
Functions and Characters
  • Blunt tip, ‘Avoids damage to surrounding structures'.
  • Conical tapering blade ‘Facilitates slipping of ligature beyond the tip', hence, minimum tissue is caught.
  • Catch or ratchet
    • Firm approximation of blades
    • Crushing
    • Maintained above without relaxation (Human element can relax).
  • There is no gap between the blades
    • To avoid slipping of tissue
    • Optimum crushing.
  • Serrations on blade
    • Crushing
    • Prevents slipping of tissue.
Note: Where they are not present throughout the blade, care must be taken not to catch tissue beyond serrations.
 
Characters of a Good Artery Forceps
  • Tip must oppose accurately.
  • Blades closing firmly on first ratchet.
  • Light should not pass through the blades when handle is fully closed.
Instrument will be spoiled if hard, bulky material is caught with it viz., tapes, abdominal packs, etc.5
 
Sterilization
  • Boiling
  • Autoclaving.
 
How to Use?
  • Insert thumb in one ring
  • Little finger into another which is also steadied by middle and ring finger
  • Pulp of index finger is placed on joint.
 
Primary Use
Hemostat
  • Preventing and arresting bleeding from blood vessles
  • To hold a blood vessel.
  • To catch it
  • To crush it
  • To inflict minimum trauma on surrounding tissue in the process.
By following ways it acts as a hemostat
  • Catch-occlusion of lumen—stasis
  • Catch for few, seconds—occlusion of lumen and intimal damage
  • Catch and crush—intimal damage and stasis.
  • Catch and ligature.
 
Method
  • Visualize the bleeding point
  • Apply at right angle to the direction of blood flow
  • Catch with tip
  • Catch with minimum of surrounding tissue because bulky ligature may—
    • Slip
    • Necrosis of intervening tissue
    • AV fistula6
  • Elevate the handle
  • Slip the knot beyond the tip
  • As knot is tied, gradually release the artery forceps.
 
Other Uses
  • Sinus forceps
  • Appendix crusher
  • To pass a catheter by non-touch technique
  • In closure of peritoneum, series of them are applied to cut edges
  • Blunt dissection, opening of tissue planes and tracks
  • To hold ends of:
    • Ligature
    • Stay sutures
    • Mops (with handle and not with blades)
  • To hold:
    • Fascia
    • Membrane
    • Aponeurosis
  • Long, stout, straight or angled—pedicle clamp
  • Peritoneum is cut open between them
  • To hold the opposite ends of tension sutures together till they are tied
  • In intestinal anastomosis to identify the 1st and 2nd layer (Straight and curved artery forceps are applied as per convention)
  • Dressing forceps
  • Ligature carrier
  • As a needle holder (not advisable)
  • Closure of peritoneum
  • Knot holding
  • For stich removing
  • FB extractor.7
 
Spencer Wells Artery Forceps (Fig. 1.2)
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Fig. 1.2: Spencer wells artery forceps
  • Most popular
  • Developed as torsion forceps
  • In original description (BMJ 1874) large vessels were twisted to produce haemostasis
  • Wells, a gynecologist used this forceps during ovariotomies to secure pedicle before applying ligature to control the bleeding
  • Wells replaced spring catch of earlier forceps with a one step rack that was easier to open and close and was more reliable
  • Grasping ends are roughened by deep transverse cuts so that bleeding vessles could be compressed with sufficient force to stop the bleeding. For smaller vessels, if left for couple of minutes it is sufficient to arrest the bleeding.
 
Kocher's Artery Forceps (Fig. 1.3)
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Fig. 1.3: Kocher's artery forceps
8
  • Designed as an artery forceps
  • Medium and large size
  • Tip has sharp tooth which gives firm hold of the tissue.
This ensures:
  • Firm hold of retractile blood vessels
  • Due to sharp tooth at the tip which is a catching point, minimum of surrounding tissue is included in the grip. This avoids crushing and trauma to surrounding tissue.
 
Uses
  • Originally devised to catch superior thyroid artery and vein
  • Thyroid tissue is slippery and friable. Usual artery forceps will not catch at the time of sectioning of thyroid tissue in subtotal and partial thyroidectomy
  • In section of thyroid tissue, hemi and subtotal thyroidectomy, they are employed circumferentially and thyroid is cut anteriorly.
  • Retractile blood vessels—Intercostal and branches of internal mammary during operation of radical mastectomy.
  • Blood vessels of scalp
  • Mesenteric blood vessels in mass ligation
  • Pile pedicle
  • Appendix crusher
  • Nasal polyp forceps
  • Vessels in tough and fibrous tissue where usual artery forceps will slip viz.
    • Scalp
    • Palm
    • Sole
  • Vessels near periosteum
  • Broad ligament of uterus9
  • Removal of meniscus
  • Sequestrum holding forceps
  • ‘Peanut’ dissection.
 
Mosquito Forceps (Halstead's) (Fig. 1.4)
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Fig. 1.4: Mosquito forceps
 
Characters
  • Delicate, small size, fine tipped, light
  • Straight/curved.
 
Uses
  • To catch small blood vessels
  • Phimosis
  • Hair lip and soft palate
  • Mesoappendix as it is delicate
  • Minor bleeder
  • Pediatric surgery.
Such forceps should never be misused for holding swabs. catheters, etc.10
Difference between artery forceps and needle holder
Artery forceps
Needle holder
Weight:
Lighter
Heavier for better hold over the needle
Blades:
Longer
Shorter for better hold over the needle
Handle:
Longer for better hold over the needle
Serrations: on blade
Transverse, deep
Criss cross, shallow
Blade:
No groove
Groove, vertically placed
Tip:
Blunt/Fine thin
Blunt/thick
Can be used as a needle holder
Cannot be used as needle holder
Other common types of artery forceps in use, are shown from Figures 1.5 to 1.10.
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Fig. 1.5: Criles artery forceps
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Fig. 1.6: Moynihan's artery forceps
11
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Fig. 1.7: Mayo's artery forceps
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Fig. 1.8: Bainbridge's artery forceps
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Fig. 1.9: Mixter's artery forceps
12
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Fig. 1.10: Kelly's artery forceps
 
LISTER'S SINUS FORCEPS (FIG. 1.11)
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Fig. 1.11: Lister's sinus forceps
13
 
Construction
  • Looks like artery forceps but it has no catch
  • Parts are:
 
Blades
  • Long
  • Slender
  • Tapering
  • Broader at the base, narrower at the tip, so that it can traverse a long and narrow track
  • Can be introduced even through a small incision
  • Transverse serrations at the tip for:
    • Breaking the loculi
    • To introduce either corrugated rubber drain or pack into the cavity.
No catch
  • Without the catch, distance between blades is adjustable. With catch it is always fixed
  • Catch is meant for tight holding and crushing. No crushing is needed
  • Catch leads to self-holding
  • Catch does not permit free movements between blades.
 
Uses
  • Opening an abscess by Hilton's method. This method is employed for the location of a deep seated abscess especially in neck or when it is in relation to a vital structure, e.g. femoral triangle. A small incision is made through skin and fascia. Sinus forceps is pushed deeply and repeatedly in different directions and blades are 14opened and closed until abscess is located. In essence the abscess wall is not opened by knife but is thrust open by sinus forceps. When the skin incision is large, best method to explore the cavity and break the loculi is—use of finger. Finger has a ‘feel’, sinus forceps does not.
  • Exploring or swabing a sinus. Especially to drain the pent up collection
  • To explore the tract of abscess cavity. As blades are withdrawn they are windened for better drainage
  • To introduce—corrugated drain and pack into cavity
  • To remove slough or foreign body especially from the depth
  • To release a hematoma
  • For aural or nasal dressing
  • Can be used as a dressing forceps.
Note: An artery forceps can be used as sinus forceps. But reverse is not true.
 
KNIVES
  • Oldest and the most basic tool
  • Sushruta about 1000 BC, described them.
 
Types
  • Scalpel
  • Bistoury
  • Tenotomy knife
  • Amputation knife.
 
Features
  • Combined handle and blade
  • Handle with interchangeable blade15
  • Blade has a straight back and cutting edge that is shaped for the particular function.
 
Combined Handle and Blade
  • As blade cannot be detached its use is fixed
  • Blade has to be sharpened repeatedly after which it is discarded
  • Sterilization will lead to blunting of edge, hence not commonly used.
 
Detachable Blade (Bard-Parker Type) (Fig. 1.12)
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Fig. 1.12: Detachable blade (Bard-Parker type)
  • Handle and corresponding number of blade
  • Blades can be interchanged with standard handle
  • Blades—different sizes and shapes
  • But principle of attaching them to appropriate handle is standardized.
  • Handle—one aspect of the neck is smooth. On the other there is a slotted ridge at the lower end of which there is an oblique groove. This obliquity of handle must correspond to the obliquity of the blade.
  • Blade has straight back and cutting edge.
  • Shape of the cutting edge decides the function.
  • Large selection of blades of different sizes and shapes are available.16
 
Uses
  • Incision
  • Dissection
  • Sharp instrument of dissection
  • Deliberate cuts in tissue
  • Dividing tissue with minimum trauma
  • Used most commonly:
    • Incising skin
    • Dissecting connective tissue covering area to be displayed
    • Dividing attachment of a structure that is to be mobilized/removed.
 
How to Use?
  • Whole length of blade must be drawn
  • If only point is used, cutting is:
    • Inefficient
    • Uncontrolled
  • For small cut or division of single strand:
    • Tip is used
    • Knief is held like pen
  • Should not be used for cutting:
    • Metal
    • Bone
    • Cartilage
  • If important structure lies in the area of cut a instrument is interposed between it and scalpel:
    • Closed blade of dissecting forceps
    • Grooved dissector
    • Probe.
 
Sterilization
  • Handle:
    • Boiling
    • Autoclaving17
  • Blades:
    • Spare
    • Pre-sterilized
    • Disposable
    • Chemical sterilization
    • Dettol
    • Lysol
    • Carbolic acid and washed with distilled water to remove excess before use
    • Sterilization by boiling will blunt the cutting edge.
 
Methods of Holding Scalpel
  • Primarily depends on the purpose:
    1. Dinner knife position—
      • Making an incision to avoid tailing
      • Separating soft tissue from bone.
    2. Writing position—
      • Delicate dissection specially in the area of important structures, damage to which is to be avoided
      • Control over the knife is to be exercised.
    3. Fiddle bow position
    4. Grasping position—
      • Mainly used in amputations. Cutting edge is towards the surgeon.
 
Bistouries (Figs 1.13A and B)
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Fig. 1.13A:
18
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Figs 1.13A and B: Bistouries
 
General
  • Under certain situations knife cannot be used for division, especially when structure to be divided is narrow or it has important structures as its relation, or is in depth
  • Long, narrow thin blade of uniform width. It stops little away from tip
  • Tip is blunt
  • Straight shape pointed for end cutting
  • Curved probe pointed for side cutting.
 
Uses
  • Division of:
    • Constricting band
    • Obstructed hernia
    • Ligaments
  • Amputation of:
    • Fingers
    • Toes
  • Laying open:
    • Sinuses
    • Fistulae
  • When small incision is required.
 
Hernia Bistoury (Fig. 1.14)
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Fig. 1.14: Hernia bistoury
19
  • Probe pointed
  • Cutting edge is reduced for division with precision and to avoid division of adjacent structures
  • Cutting edge stops little away from the tip which is blunt
  • Always used in association with hernia director
  • Along with the director it is introduced between constricting band and soft tissue. Bistoury is then rotated till cutting edge is against the constricting band. Then it is divided
  • Also used to divide lacunar ligament in femoral hernia
  • Not essential. Ordinary knife serves the purpose.
 
Fistula Bistoury (Fig. 1.15)
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Fig 1.15: Fistula bistoury
  • Blunt end
  • Longer cutting edge than hernia bistoury
  • Used along with a fistula director or a probe which guides the bistoury
  • Tract is laid open by the cutting edge, e.g. fistula-in-ano.
 
Other Bistouries
– Small incision
– Tonsillar
– Avoids damage to surroundings.
– Pharyngeal
– Incision and drainage of peritonsillar and retropharyngeal abscess.
20
 
Amputation Knife (Fig. 1.16)
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Fig. 1.16: Amputation knife
  • Undetachable blade
• Handle
Plane
Grooved for grip.
  • Length of blade varies from 10-28 cm (4” – 11”).
 
How to Use?
  • Held between palm and fingers with blade pointing upwards and cutting edge facing surgeon
  • All tissue down to bone are divided in one sweep
  • In some cases one flap is cut by transfixion
  • Knife is plunged through the limb close to the bone and flap is cut from within outward
  • Instrument has gone into disuse. Scalpel has replaced it
  • It is now only used to divide bulky muscles as it gives clean section
  • It can be used in emergency amputation—in guillotine amputation, e.g. gas gangrene.
 
Tenotomy Knives (Figs 1.17A and B)
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Fig. 1.17A:
21
zoom view
Figs 1.17A and B: Tenotomy knives
  • Straight/curved
  • Sharp/probe pointed
  • Single edged/double edged
  • Long slender handle
 
Used for Subcutaneous Tenotomy
  • Blind procedure
  • Small skin incision
  • Knife is introduced between skin and structure to be divided
  • Rotated till blade can cut through it, e.g. sternomastoid in congenital torticolis, tendo-Achilles in congenital TEV.
Can be used to open the pelvis of the kidney for the extraction of stones.
 
Syme's Abscess Knife (Fig. 1.18)
zoom view
Fig. 1.18: Syme's abscess knife
  • Opening an abscess by transfixion
  • Blade 3” in length, thick back
  • Ordinary knives can be used.22
 
NEEDLES (FIG. 1.19)
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Fig. 1.19: Needles
A needle has three parts:
  • Point
  • Shaft
  • Eye
Each has been developed to suit the need and type of tissue, it is suppose to stitch or penetrate.
 
Classification
  1. According to shape:
    • Straight
    • Curved
    • Half circle
    • 5/8 circle
    • 3/8 circle
    • Full circle23
  2. According to edge:
    • Non-cutting/round body
    • Cutting
    • Hagedron
  3. According to eye:
    • Traumatic—needle with eye
    • Atraumatic—eyeless
  4. According to tip
    • Triangular
    • Rounded
  5. According to cross-section
    • Round
    • Triangular
    • Hagedron
  6. According to use:
    • General
    • Special—Gallic's needle (Fig. 1.20)
    • Liver suture needle
    • Macewen's hernia needle (See Fig. 2.30)
    • Cleft palate needle
    • Aneurysm needle
    • Pedicle needle of Galabin
    • Boomrang needle.
  7. All shapes are made into fine, coarse sizes and small and large in length.
 
Advantages of Curved Needle
  • Traverses tissue less because of their circular movements and are safe for working in depth and in confined space
  • Because of curvature, tip is always visible
  • Tip will be always directed away from the structures in the vicinity except through which it is passed
  • 5/8 circle needle will turn in a space that of its own width and is used for working in deep cavities24
  • Straight needless whether cutting or round bodied are used for surface suturing. Sometimes they are used for passing splints, e.g. vaso-vasostomy.
 
Types of Curvature
  • 3/8
  • 1/2
  • 5/8
Half circle needle with an eye, arm elongated like a fish hook are especially useful while placing sutures in confined space where there is danger of damaging adjoining structures, i.e. repair of femoral and inguinal hernia.
 
Cutting Edge
  • Depends on nature of the tissue through which it is passed
  • Tough structures will require a cutting edge
  • Delicate structures will require smooth cutting edge to reduce trauma to minimum
  • Round body needle will split the fibers rather than tear them.
 
Types of Edge
  • Round body
  • Flat from side to side (Hagedorn),
  • Triangular cutting needle:
    • Regular cutting with two cutting edges in horizontal plane and one cutting edge along inner curvature of the shaft
    • Reverse cutting with two cutting edges in horizontal plane and one cutting edge along the outer curvature of the shaft to allow easier initial penetration of tough tissue, i.e. skin.25
  • Cutting needle may be—
    • Triangular cutting
    • Trocar
    • Hagedorn
    • Spear pointed.
  • Hagedorn needle is flattened from side-to-side in opposite plane to that of curve and has spearshaped point. Hagedorn needles are comfortable to fingers but cannot be held in ordinary needle holder. For this a reverse Hagedorn needle is available, in which half of the needle towards the eye is flattened in the opposite plane from rest. Because of their spear point, equally suitable for skin.
 
Uses According to Cutting Edge
  • Cutting for skin/fascia as edges have cutting action which enables the needle to slip through more easily.
  • Round bodied
    • Peritoneum.
    • Muscles
    • Viscera.
 
Eye of the Needle
  • Eyeless
    Suture material is fitted to their base by a process of swaging.
  • Catgut fills the puncture made by the needle making it atraumatic.
  • Suture material passed is single stranded (in needles with an eye, it is double stranded) and single strand gets much less resistance to pass through the tissue and inflict less trauma.26
  • Disposable and hence sharpness is never blunted.
  • Needles have a channel set into the end of the needle to take and grip the suture so that bulk of material passing through the tissue is reduced from double to single strand.
  • Especially used for:
    • Eye
    • Face
    • Blood vessles.
 
Needle with Eye
  • Ordinary
  • Spring eye
    • Intestinal surgery
    • Neurosurgery.
 
Spring Eye (French or Split)
Has slit above. Suture material is to be pressed from the top and it will go in the eye. This allow easy insertion of suture material and saves much time during speed surgery.
 
Disadvantages
Thick suture material may get frayed during insertion and may break through. Only thin suture material silk/linen should be used. Catgut is too large for the eye of the needle.
 
Paterson's
  • Have an eye that grips the thread firmly so that it does not slip.27
 
Tip of the Needle
  • Triangular tip needles:
    • Tough tissue to overcome the initial resistance
    • Easy passage through firm tissue
    • Skin
    • Aponeurosis.
  • Round tip:
    • Delicate tissue
    • Is tapered to slide through soft thin tissue that either offer little resistance to the needle or are delicate and might tear, e.g. peritoneum.
  • Probe pointed:
    • For soft, friable tissue like liver.
 
Weakest Point of the Needle
  • Near its eye
  • As shaft approaches the eye, it is gradually flattened to give better mechanical advantage to the needle holder to hold it (not allowing a chance to slip). If jaws of the needle holder grasp the needle near this region it will break.
 
Where to Hold the Needle?
  • At the junction of posterior 1/3 rd and anterior 2/3 rd of the needle in the shaft.
  • This also depends on where and which structures are to be sutured.
 
Sterilization
  • Not boiled or autoclaved otherwise sharpness is lost.
  • Dipped in concentrated antiseptic solution for 24 hours.
  • Blunt needle-boiling for 1/2 hours.28
    Sharp cutting edge of—needles, scalpels, gauge, chisel, scissors can be used greater number of times without resharpening by sterilizing in strong non-corrosive antiseptics like pure lysol, dettol or 1:10 solution of one of these disinfectants in alcohol.
  • Minimum time for immersion—30 minutes.
  • These fluids are soapy and injurious to skin hence instrument should be rinsed in hot sterile water and dried before use.
  • To avoid direct contact of sharp edge with receptacle, they are placed over a lint in a receptacle.
 
Gallie's Needle (Fig. 1.20)
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Fig. 1.20: Gallie's needle
  • Thick, curved, strong, broad, short, sharp pointed
  • Flattened anteroposteriorly
  • Large eye to permit broad strip of fascia lata
    • Autogenous material is threaded through eye and fixed by suture with catgut or silk
    • Structure is not approximated. Darning is done to bridge the gap29
    • Fascia is passed through the eye, folded on itself and tied into knot, which is reinforced further by a stitch of catgut/thread
    • It is very large and traumatising especially to inguinal ligament. It can take away or separate a strip of inguinal ligament.
 
Handled Needle/Aneurysm Needle (Fig. 1.21)
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Fig. 1.21: Handled needle/aneurysm needle
 
Parts are Blade and Handle
Blade:
  • Curved in one plane only to give mechanical advantage. Flattened and completely blunt at the tip so that when it is passed it will not injure the structures
  • Eye at the tip for ligature
  • Groove that leads to an eye:
    • It guides and accommodates ligature into the eye
    • As ligature is brought along the groove on to the handle, it prevents tip and ligature from passing through different tissue planes.30
  • Tip is curved:
    • Gives mechanical advantage
    • Working in the depth
    • Tip always remains under vision.
Handle
How to Use it?
  • Ligature is threaded through the eye. Tip is passed behind the structure to be tied. The ligature is grasped with forceps on other side and pulled around the structure and needle retraces its path.
  • It is passed in the direction which will ensure that its tip will be directed away from adjoining vital structures.
Uses
  • Handled needles or aneurysm needles are required when usual needles are impracticable or dangerous to use
  • Ligating the aneurysm when that was the only treatment available and instrument derives its name from this
  • To ligate the pedicle. Consisting of important and large sized vessels:
    • Renal pedicle
    • Splenic pedicle in mass ligation
  • Superior thyroid pedicle is ligated by passing aneurysm needle along grooved thyroid dissector
  • To ligate a vessel around its sheath in continuity
  • To ligate cystic duct in cholecystectomy
  • Mesentric vessels during resection
  • To ligate vascular adhesions, bands and cut them in between
  • The commonest use—venesection.31
 
Pedicle Needle (Fig. 1.22)
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Fig. 1.22: Pedicle needle
 
Boomerang Needle (Fig. 1.23)
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Fig. 1.23: Boomerang needle
 
NEEDLE HOLDER
 
Construction
  • Designed on the line of artery forceps
  • Short blade and long handle for firm and better grip and control over the needle
  • Heavier than artery forceps for better grip and control
  • Blades have criss-cross serrations for:
    • Better grip
    • To prevent rotation or slipping of needle.
  • Designed to be rotated in it's long axis.
  • Blades are either:
    • Slightly hollowed.
    • Split
    • Have a central groove.
      1. To minimise crushing effect on needle.
      2. To prevent straightening out of a curved needle.32
      3. To use it as a Boomrang needle if one is not available.
Within the above mentioned basic farmework, wide variations are available and selection is a matter of choice for the surgeon.
Choice of needle holder will also depend on:
  • Depth at which to work.
    • Straight and short—superficial
    • Curved and long—in depth.
  • Types of tissue to be sutured.
    zoom view
 
Usual Mayo's (Fig. 1.24)
zoom view
Fig. 1.24: Usual Mayo's
  • Types of needle
    • Gallie's
    • Hagedorn
 
Types Available
  • Pressure of the surgeon's hand on the handle maintaining the needle. No catch.
    • Mace wen's
    • Gillie's33
  • Ratchet maintaining the needle:
    • Ratchet attached to the ends of the handle where it is released either by further tightening of surgeon's grip. McPhali's
    • Or by pressure from little finger.
    • Crushing (Halstead's)
    • Ratchet may be fixed to shanks where it is released by pressure from hand that unlocks teeth of the ratchet.
      1. Blalock's
      2. Kilner's
 
Gillie's Needle Holder (Fig. 1.25)
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Fig. 1.25: Gillie's needle holder
  • Designed for ‘Forceps tie’ method of suturing. A pair of scissors is incorporated. Jaws are used for holding needle and tying suture.
  • Blades for cutting stitches.
  • Especially useful where large number of skin stitches are to be given.34
 
Naunton Morgon Needle Holder
  • Working in:
    • Depth
    • Confined space.
  • Have two joints and their double action requires minimum space during its use.
 
How to Use the Needle Holder?
  • Most needles are flattened towards the eye, so that needle holder holds them firmly and prevents slipping or turning.
  • Needle should not be grasped too close to the eye which is the weakest area of the needle.
  • Correct place to hold the needle is 1/3 to 1/2 distance along the shaft from the eye. But it also depends on where exactly the needle is being used.
  • The needle should be held little away from the tip of the needle holder, but also not too much proximally.
 
SCISSORS
 
Basic Design
  • Two blades.
  • Each blade has a chisel edge with a bevel.
  • Bevel varies according to the function and structure it has to cut.
  • Its function decides subsequent construction and modification.
 
General Classification
  • Tip
    • Blunt
    • Sharp35
  • Blades
    • Straight—surface use
    • Curved on flat—used in depth
    • Angled on edge
  • Length
    • Variable
  • Shape
    • Variable
  • Scissors for depth and fine dissection:
    • Long handle and short blade for better control
    • Blunt tip
    • Curve on flat blade so that vision and tip is not obstructed.
 
Uses
  • Cutting:
    • Ligature
  • Dissection—with the blades closed, rounded nose can be employed for blunt dissection (Vide infra)
  • Dressing, cutting
  • Stitch cutting scissors.
 
Tissue Scissors—Mayo's Scissors (Fig. 1.26)
zoom view
Fig. 1.26: Tissue scissors—Mayo's scissors
36
  • Most popular
  • Straight or curved on flat blades.
  • Various sizes 12-30 cm (5-12”)
  • Tapered but not sharp points. Hence can be used for blunt dissection.
 
Uses
  • Cutting
  • Dissection. Because of blunt ends they are much safer than scalpel for dissection. Moreover, as only tip is used for dissection it is safer than scalpal where wider area is needed for operation.
 
McIndoe's Scissors (Fig. 1.27)
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Fig. 1.27: McIndoe's scissors
zoom view
 
Uses
  • As above
  • Dissection in depth
 
Dressing Scissors
  • Heavy
  • Straight
  • Blunt tip
  • Used by
    • Doctors
    • Nurses37
 
Lister's Bandage Scissors (Fig. 1.28)
zoom view
Fig. 1.28: Lister's bandage scissors
  • Has flattend slightly convex and blunt end on one blade that slides under the bandage and will not damage the skin.
 
Stitch Scissors (Fig. 1.29)
zoom view
Fig. 1.29: Stitch scissors
  • Sharp and pointed tip so that only small part of blade will have to be inserted between skin and stitch.
  • Straight or curved on flat, blade.
 
Littaure's Stitch Scissors (Fig. 1.30)
zoom view
Fig. 1.30: Littaure's stitch scissors
38
  • Has hook on one blade to hold the suture while it is cut
  • One of the blades has serration on its lateral aspect. Stitches are hooked on to these serrations by passing the blade beneath the stitches.
 
RETRACTORS
 
Why Retractors are Used?
  • To have adequate exposure of the anatomical site without an unduely long incision
  • Adequate exposure of the surrounding organs and tissues
  • Proper planning and execution of operation
  • Decreases:
    • Bleeding
    • Unnecessary tissue handling and damage.
  • Smaller retractors are referred as muscle retractors and they are used to hold apart edges of the wound
  • Large retractors (abdominal retractors) are employed to hold aside organs (e.g. small intestine) while access is obtained to deeper structures.
 
Principles of Retraction
  • Retractors are not substitutes for button-hole incision. In fact forcible retraction will cause:
    • Soft tissue injuries
    • Hematoma—infection
      1. Postoperative pain.
    • Injury to:
      1. Vein—thrombosis.
      2. Artery—spasm
      3. Nerve—neuropraxia39
  • Delicate structures to be retracted must be protected by intervening sponge.
  • Direction of retraction should be such that it will give adequate exposure without instrument obstructing the vision of the surgeon and assistant—usually it is upward and laterally.
  • Retractors should be placed at correct site and angles.
  • Optimum force is applied and maintained throughout operation.
Selection and construction depends on:
  • Site of operation
  • Depth of operation
  • Thickness of the tissue to be retracted.
  • Tissue/organ to be retracted e.g. artery, nerve, etc.
 
Types
  • Required to be held by an assistant.
    • Pull can relax at critical moment.
  • Self retaining.
    • Assistant is free
    • Wound edges may be over stretched and damaged.
 
Basic Parts
  • Handle
  • Shaft—long for retraction from a distance without obstruction to vision.
  • Blade
  • Lip/tip—gives better hold of retracted tissues.
 
Basic Design
  • Notches
  • Serrations for firm grip of handle.40
  • Fenestration—to reduce the weight so that assistant is not tired easily. Fenestration also allows the soft tissues to prolapse out. This minimises crushing.
  • Smaller retractors are used for superficial retraction.
  • Larger and heavy retractors are used for operations in depth.
 
Double Hooked Retractors (Fig. 1.31A)
  • Two rounded hooks instead of blade.
  • This allows retraction of tissue on either side of a vessel or nerve.
  • Used to retract vessels and nerves.
zoom view
Figs 1.31A and B: (A) Double hooked retractors; (B) Self-retaining retractors
41
 
Self-retaining Retractors (Fig. 1.31B)
  • This is achieved by racks or ratchet.
    • Two blades held apart with locking
    • A frame on which two blades can be adjusted or fixed by
    • Screw
    • Friction
    • Pinions
  • Advantages
    • Assistant is spared.
    • Human failure
      1. Relaxation at critical moment and tiredness at critical moment is avoided.
    • Uniform and correctly judged pressure can be applied continuously.
    • Can be used for long time without human error resulting from exhaustion.
  • Disadvantages: Cannot be moved, or manipulated as and when required to suit the steps of operation.
 
Nerve Hook/Retractor (Fig. 1.32)
zoom view
Fig. 1.32: Nerve hook/retractor
  • Delicate instrument
  • Sharp hook at its distal end
  • To retract, lift nerve during dissection.
 
Morris's Right Angled Abdominal Retractor (Fig. 1.33)
zoom view
Fig. 1.33: Morris's right angled abdominal retractor
42
  • Single blade
  • Double blade
  • Large and strong retractor
  • Serrated/grooved handle for better grip
  • Fenestrated handle to reduce weight
  • Slightly concave blade to give wider space for work
  • Lip retracts retracted tissue firmly and prevents them from slipping.
 
Uses
  • To retract strong abdominal wall
  • Hollow viscera-coils of intestine
  • Kidney.
 
Deaver's Curved Abdominal Retractor (Fig. 1.34)
zoom view
Fig. 1.34: Deaver's curved abdominal retractor
  • Large
  • Curved, flat blade in the convacity of which the structures to be retracted are accommodated
  • Long handle ending like a hook for firm grip
  • Blade describes a curve which lies flush with anterior abdominal wall, so that instrument does not come in the way
  • Various sizes.43
 
Uses
  • To retract solid intraperitoneal organs, i.e. liver/spleen
  • Organs to be retracted must be protected by a sponge
  • Small bladed for intravesical retraction
  • It is one of the very commonly used retractor in abdominal surgery.
 
Doyen's Retractor
  • Heavy duty type similar to Deaver's
  • With slight modification in its handle and by attaching a lead weight to it, it can be converted into self-retaining type.
 
Use
  • Mainly in pelvic surgery.
 
Single Hook Retractor
  • Single, solid sharp hook.
  • Resembles aneurysm needle but without an eye.
 
Use
  • To retract skin while subcutaneous stitches are given.
 
Volkmann's Catspaw Retractor (Fig. 1.35)
zoom view
Fig. 1.35: Volkmann's catspaw retractor
44
  • Blade is in the form of many sharp hooks
  • To retract tough structures
    • Fascia of palm and sole
    • Scalp
    • Investing layer of deep fascia in tracheostomy.
 
Langenbeck's Retractor (Fig. 1.36)
zoom view
Fig. 1.36: Langenbeck's retractor
  • Standard design
 
Uses
  • To retract skin and subcutaneous tissue
  • To retract vessels/nerves.
 
Czerny's Retractor (Fig. 1.37)
zoom view
Fig. 1.37: Czerny's retractor
  • Fenestrated shaft—to reduce the weight
  • Solid blade on one side
  • Double hook blade on other side, pointing in opposite direction. This permits use of the most desirable type of blade (with its advantages) without changing direction of hand.45
 
Uses
  • Superificial retraction
  • Solid blade for retracting margins of incision
  • Hooked blades to retract ends of incision during closure of laparotomy.
 
Allison's Lung Retractor (Fig. 1.38)
zoom view
Fig. 1.38: Allison's lung retractor
  • Special blade made of wires in die form of net
  • Long curved handle for firm grip
  • Blade attached to handle at an angle.
 
Uses
  • To retract lung
  • Blade prevents any damage to lung
  • Angulation between blades and handle
    • Vision is not obstructed
    • Instrument does not come in the way.
 
Mollison's Self-retaining Mastoid Retractor (Fig. 1.39)
zoom view
Fig. 1.39: Mollison's self-retaining mastoid retractor
46
  • Blade has many hooks which gives firm retraction of tough tissue, i.e. skin, muscles and fascia:
    • Mastoid surgery
    • Scalp
    • Laminectomy
    • Minor
      1. Operations—gland biopsy.
      2. Removal of—sebaceous cyst.
      3. Dermoid cyst.
 
TISSUE FORCEPS
 
Construction
Two principal aims in construction are:
  1. Firm grip provided by
    • Jaws or teeth of the blades
    • Catch or ratchet
    • Area of blade in contact with tissue
    • Interlocking teeth
    • Sharp hooked blades
    • Combination of above
  2. Should inflict minimum trauma.
To achieve above
  • It should hold tissue by apposition or interlocking arrangement at the tip of the blades only
  • There should be space between blades:
    • To accommodate ‘amount’ of tissue
    • To accommodate bulky tissue
    • With minimum crushing action
  • Blades should not be serrated because serrated blade will crush the tissue.47
 
Principal Uses
  • Designed to take firm but non-crushing grip over the tissue for:
    – Retraction
    During
    i. Insicion
    – Apposition
    ii. Dissection
    – Dissection
    iii. Excision
    – Traction for
    i. Dissection
    ii. Apposition
    iii. Retraction
As jaws have crushing action it should not be applied to skin.
 
Allis' Tissue Forceps (Fig. 1.40)
zoom view
Fig. 1.40: Allis' tissue forceps
  • Most commnonly used
  • Light
  • Blades are straight
  • Tip is slightly curved or angulated for better grip
  • Tip is provided with interlocking teeth. They are 3-4 in number, fine and sharp and they interlock. They do not crush or damage the tissue in their grasp (minimum damage). As they inflict minimum trauma, they can be used to hold blowel and hence sometimes called as ‘anastomosis forceps’.48
  • Two type:
    • General—for general use—provided with long teeth.
    • Fine—for delicate structures—short, fine teeth.
 
Uses
• Retraction
• Dissection
– Skin
• Apposition
– Fascia and aponeurosis
• Traction
– Fibrous capsule
• Bladder neck for wedge resection.
• Fine one can be applied to the bowel but cannot be applied to bulky tissue as there is little space between blades.
 
Babcock's Tissue Forceps (Fig. 1.41)
zoom view
Fig. 1.41: Babcock's tissue forceps
  • Extra light to minimise crushing action.
  • Curved, fenestrated blades which can grip or enclose delicate structures like:
    • Ureter
    • Appendix
    • Intestine
    • Fallopian tube
    • Spermatic cord.
  • As tip is transversely serrated, it gives light but firm grip and as they do not have teeth, very little trauma is inflcted.49
  • Fenestrated blades make the instrument:
    • Light
    • Minimises crushing action over the tissue enclosed in blades.
    • Allows the tissue to bulge through.
  • Applied to delicate structures like:
    • Intestine
    • Ureter
    • Fallopian tube
  • Occasionally can be used as hemostatic forceps when bleeder is difficult to pin-point. In such cases whole chunk of tissue is caught and temporary hemostasis is achieved. Then bleeder is carefully searched.
 
Duval's Forceps
(See Chapter 6—Thorax, Page No. 164)
 
Moynihan's Tissue Forceps
  • Longer than other tissue forceps
  • Blades are thinner and curved
  • Tip has interlocking teeth.
 
Lane's Tissue Forceps (Fig. 1.42)
zoom view
Fig. 1.42: Lane's tissue forceps
50
  • Designed on the line of artery forceps
  • Blades are curved and fenestrated to:
    • Minimise crushing effect
    • Permit bulky tissue to be accommodated and allow them to bulge. This again minimise crushing action
  • Sharp, interlocking teeth at the tip that gives firm grip
  • Catch for self-holding
  • This forcep is heavier, shorter and bulkier than Allis's and Babcock's tissue forceps.
 
Uses
  • Originally devised to remove mesenteric gland for biopsy, not used as it crushes and breaks the gland
  • Bulky and/or slippery tissue:
    • Subcutaneous tissue of obese patients
    • Breast, pectoralis major and minor muscles as they are elevated from chest wall during radical mastectomy
    • To breast during simple mastectomy.
  • Can replace Morrant Baker's forceps where tip is applied to mesoappendix and appendix is accommodated between blades
  • As a cord holding forceps
  • For skin apposition especially scrotal skin
  • For lymph node biopsy when used, must grip capsule only
  • To hold together fractured
    • Patella
    • Olecranon.
  • In emergency as
    • Towel clip.
51
 
Poirier's Tissue or Peritoneum Forceps (Fig. 1.43)
zoom view
Fig. 1.43: Poirier's tissue or peritoneum forceps
  • Similar to Allis's tissue forceps. They have one and two teeth at the ends of the blades. Used for applying to:
    • Peritoneum
    • Hollow viscera
    • Other uses are same as for Allis's tissue forceps.
 
Dissecting Forceps (Figs 1.44 to 1.49)
zoom view
Fig. 1.44:
zoom view
Fig. 1.45:
zoom view
Fig. 1.46:
52
zoom view
Fig. 1.47:
zoom view
Fig. 1.48:
zoom view
Figs 1.44 to 1.49: Dissecting forceps
  • Originated in Egypt around 3300 BC
  • Since then their pattern has changed a little
  • Standard pattern is
    • Simple.
    • Springed
    • Two armed instrument
  • Variations are based on following points.
  • Length
    • Long—working in depth
    • Medium and short—surface working.
  • Thickness of the arm depends on structures desired to be held.
  • Tip
    • Toothed
    • Non-toothed.
    • Non-toothed-Delicate
    • Inflicts minimum damage53
      – Applied to delicate or friable structures like
      • Artery
      • Vein
      • Nerve
      • Peritoneum
      • Viscera
      Toothed
      – Has teeth at the tip
      – Gives firm hold
      – Inflicts trauma
      – Applied to:
      • Bulky tissue
      • Slippery tissue
      • Heavy and tough tissue from skin down to fascia.
      • Holding and retracting skin flaps.
    • Outer surface is made rough by grooves, ridges or serrations for firm grip
    • Inner aspect of the blade near the tip has serrations which gives firm hold over the tissue and gives firm grip over the needle during suturing
    • Blades have spring like action, and on pressing their limbs tips appose and do not slip
    • Some have guard between blades. It will prevent overapproximation of blades which can reduce pliability and elasticity of blades.
 
Uses
  • To hold the structures
  • To steady the structure during incision and dissection
  • Dissection in depth
  • Swabing in the depth
  • Packing of tonsillar bed and any other cavity.54
 
Test for Good Forceps
  • On gently pressing the blades tips must appose each other and should not override
  • Special types used in:
    • Plastic surgery.
    • Ophthalmology
    • Vascular
    • Their lengths, breadth of the blades, pattern of the blade and tipes are modified for the need of the situation.
 
SPECIAL FORCEPS
 
Sponge Holding Forceps (Rampley's) (Fig. 1.50)
zoom view
Fig. 1.50: Sponge holding forceps (Rampley's)
  • Length-about 9-10”
  • Long blades and handle-permits:
    • Non-touch technique.
    • Working in depth
  • Ratchet
  • Finger rings
  • Blades are serrated and fenestrated
  • Long handle permits cleaning of operative field without touching it or adjoining areas.55
 
Uses
  • Although it has retained its old name of ‘Sponge’, it is used to hold small guaze swabs.
  • To prepare the field for operation by soaking the swabs in antiseptics
  • Other uses:
    • Swabing a cavity—vaginal cavity
    • Packing forceps.
    • Pressure haemostasis especially in the depth
    • Deep but blunt dissection with the help of swab
    • Pile holding forceps
    • Tongue holding forceps
    • To mop or pack tonsillar bed or any other small cavity in the depth
    • Holding fundus of gallbladder during cholecystectomy.
    • Rarely
      1. As ovum holding forceps
      2. To hold cervix of a pregnant uterus.
    • Prolapsing the pile masses in haemorrhoidectomy by putting a fairly large swab inside the anal canal and pulling it out.
Note: Swab should be correctly applied.
  • It should not be too loose or too tight.
  • Usually it should be 3/4 in the jaws and 1/4 out of it.
 
Gland Holding Forceps (Cummin's) (Fig. 1.51)
zoom view
Fig. 1.51: Gland holding forceps (Cummin's)
56
  • Ringed blades.
  • Surface of the blade is smooth for obvious reason
  • This differentiates it from:
    • Sponge holding forceps
    • Pile holding forceps
    • Tongue holding forceps to which it resembles.
  • Ringed blades have relatively sharp edges, which secures a firm hold and can be applied to softened gland without risk of rupture.
  • Catch. But even if it is fully on, some space is left between blades to minimise crushing.
  • Finger rings.
 
Uses
  • Removal of:
    • Lymph node
    • Benign growths
    • Cyst
  • Used with caution in:
    • Tubercular lymph node
    • Malignant lymph node.
Note: Morant Baker's forceps can be used in it's place.
  • Non-toothed tissue forceps is best.
  • Not commonly used because if the gland size is small it tends to slip out and if the size is large the instrument tends to crush the gland. For accurate histological interpretation it is necessary that the lymph node is handled carefully and minimally.57
 
Pile Holding Forceps (Fig. 1.52)
zoom view
Fig. 1.52: Pile holding forceps
  • Blades may be oval or triangular ring like and centrally fenestrated.
  • Ringed blade is centrally grooved for grasping pile mass.
  • Handle has:
    • Ratchet for self-holding.
    • Finger rings.
 
Uses
Used forgrasping pile mass prior to dissection and ligation. Replaced by artery forceps. Morever we do not follow mass ligation method. The disadvantages are: it is short and hinders the vision. The large blades tends to flatten the pile mass and obscures the pedicle.
Note- Easily confused with:
  • Spong holding forceps
  • Tongue holding forceps
  • Gland holding forceps
but none of them have groove on inner aspect of the blade.58
 
Pile Forceps (Fig. 1.53)
zoom view
Fig. 1.53: Pile forceps
  • Used for clamping base or pedicle of the pile, prior to ligation or overstitching.
  • Blades are serrated longitudinally. This give firmer grip and clamp slips out more easily when running sutures are in position.
 
Tongue Holding Forceps (Thompson's) (Fig. 1.54)
zoom view
Fig. 1.54: Tongue holding forceps (Thompson's)
  • Triangular, fenestrated blades
  • Blades are serrated but there is no groove
  • Catch
  • Rings59
 
Uses
  • To hold the tongue during operation:
    • Oral cavity
    • On tongue
  • To pull the tongue out to prevent its falling back.
  • To perform minor operations, i.e. removal of a papilloma
  • Rarely to stop bleeeding from tongue.
 
Disadvantages
  • Discarded because:
    • Crushing effect
    • Pain due to trauma
    • Pressure necrosis
    • If applied lightly-tongue slips
It is substituted by:
  • Towel clip
  • Tongue stitch - stay suture
  • Metal air-way
  • Holding tongue between two guaze pieces
 
Guy's Tongue Holding Forceps (Fig. 1.55)
zoom view
Fig. 1.55: Guy's tongue holding forceps
  • One blade is pointed
  • This causes trauma to tongue at one point only.60
 
Towel Clips (Backhaus's Towel Clip) (Fig. 1.56)
zoom view
Fig. 1.56: Towel clips (Backhaus's towel clip)
  • Most popular
  • Designed on the line of artery forceps
  • 4-5” in length
  • Strong but light in weight
  • Blades are sharply pointed for firm hold. They are so curved that whole thickness of the drape is held easily and they lie flush with it without protruding and interfering in operative field. Catch and finger rings.
 
Uses
Primary—to isolate the field of operation and to protect the tissue and organs exposed during operation.
 
Other Uses
  • As a tongue holding forceps. It is applied over a guaze piece little away from the tip (otherwise it will get detached) over the median raphae (least vascular area). As area of injury is pin-pointed it is preferred to tongue holding forceps.
  • To fix the suction tubing to the draping61
  • As a cord holding forceps
  • Applied to scrotum to clean its under surface
  • In flail chest to elevate the depressed segment if three or less ribs-are fractured
  • To retain the corrugated drain in position (especially scrotum) at its site till main incision is closed and drain is fixed to the site by anchoring stitch (Otherwise in the intervening period it will come out)
  • To elevate fractured segments of:
    • Clavicle
    • Mandible
    • Sternoclavicular dislocation
    • Recurrent dislocation of shoulder
  • To make holes for suturing:
    • Patella
    • Olecranon
  • To give traction in fractures of small long bones.
 
Gray's Towel Clip (Fig. 1.57)
zoom view
Fig. 1.57: Gray's towel clip
  • Short (3”) and convenient to use
  • Due to spring action it is self-retaining
  • Does not obstruct the field.62
 
Mayo's Towel Clips (Fig. 1.58)
zoom view
Fig. 1.58: Mayo's towel clips
  • Towel clips must be differented from towel holding forceps. Later are used to fasten towels to the skin edges after incision has been given. They are so designed as to lie under the towel and are out of sight. They do not interfere in operative field
  • They protect exposed tissue in the wound from bacteria released from the patient's skin during operation. When infective focus is present, wound edges are prevented from contamination from it.
 
Moynihan's Towel Clips or Tetraforceps (Fig. 1.59)
zoom view
Fig. 1.59: Moynihan's towel clips or tetraforceps
  • Each tip has two sharp teeth. That is why it is called tetraforceps
  • Criss-cross in action. Designed like No. 8, When handle is pressed, blades open and approximates on release of pressure63
  • Blades are gently curved. So that they lie flush with skin and anterior abdominal wall and do not protrude and interfere in operations (They are mainly used during intra-abdominal operations).
 
Doyen's Towel Cups (Fig. 1.60)
zoom view
Fig. 1.60: Doyen's towel cups
  • Gently curved blades ending in sharp teeth
  • Criss-cross in action. On pressing the handle tips open and approximates on release of pressure
  • Because of gentle curve, will lie flush with anterior abdominal wall and will not interfere in operating field.
 
Sterilization
  • Boiling
  • Autoclaving
 
PROBE, DIRECTOR, DISSECTOR, SCOOP
 
Probe
Requisite of a good probe?
  • Malleable (Silver is the best).
  • Blunt, preferably olive tipped.
  • Tip may have an eye, eye was used previously for threading a antiseptic soaked gauze into cavity and pulling it out.
Probes come in various forms depending on and varying in:
  • Length
  • Width64
  • Tip
  • Firm/malleable
  • Straight/curved
  • Handle.
 
Uses
  • To explore sinus or fistula to know its:
    • Length
    • Depth
    • Direction
    • Contents–– foreign body
    • Sequestrum
  • To cauterise stump of appendix
  • To know depth and direction of wound
  • Acts as a guide during the excision of the tract of sinus or fistula.
Note: Probing in clinical examination of sinuses or fistulas without anaesthesia is a painful procedure. Sinography and fistulography is much better and more informative.
 
Directors
 
Construction
  • Narrow, blunt pointed.
  • Has a groove along which knife or bistoury can be “Directed”. This in turn will facilitate control of length and direction of the incision.
 
Uses
  • To lay open tract of:
    • Fistula
    • Sinus
  • To divide ring of obstructed hernia
65
 
Brodie's Probe Pointed Fistula Director with Frenum Slit (Fig. 1.61)
zoom view
Fig. 1.61: Brodie's probe pointed fistula director with frenum slit
Two separate parts used entirely for different purposes:
  • Probe pointed director
  • Frenum slit
Probe pointed director:
  • Olive tipped
  • Upper surface has a tunnel which starts little away from the tip
  • The other end expands in to frenum slit.
 
Uses
  • Can be used as a:
    • Probe
    • Director
  • In fistula or sinus to know its:
    • Depth
    • Length
    • Direction
    • No. of side communications
    • Contents-Foreign body (X-ray is better)
    • Sequestrum
    • In case content is liquid it flows along the tunnel and will be available for pathological examination.
Mainly used in fistula-in-ano.
Note: Examination must be done preferably under anesthesia.66
  • Must be done gently
  • Unreliable
  • Painful without anesthesia
  • In wheelhouse's operation to divide the stricture urethra after urethra is slit open (Wheelhouse's staff is also available)
  • In circumcision probe must be passed between prepuce and glance or is freed from glans to ensure that prepuce is free from glans or is freed from glans (Small curved artery forceps can be used).
 
Frenum Slit
  • Wing shaped proximal part is used for division of tongue tie
  • This is passed under the tip of the tongue. In the slit, frenum of tongue is held and the tongue is lifted up from the floor of the mouth. This instrument stretches the frenum and also retracts the tongue.
 
HERNIA DIRECTOR
  • Construction is same as other directors
  • It guides the knife or bistury (which is always used with it) along the groove to the constricting band in obstructed or strangulated hernia
  • It also protects the bowel or omentum during division
  • They are broader (to protect the underlying structure) and have a shallow groove
  • It should be always passed between sac and constricting ring superolaterally in inguinal hernia, (outside the sac). If passed in the sac, peritoneal tear at the neck may extend inside the peritoneal cavity making it difficult to close.67
This instrument can also be used in other obstructed hernias (Femoral, umblical, etc.) but anatomical knowledge of structures related to the neck of hernia is absolutely essential, as this decides the size and the direction in which the director should be used.
 
Types
 
Key's Hernia Director (Fig. 1.62)
zoom view
Fig. 1.62: Key's hernia director
  • General characters are on usual lines
  • Shallow groove which stops just away from the tip
  • Handle has serrations for firm grip.
 
Childe's Hernia Director (Fig. 1.63)
zoom view
Fig. 1.63: Childe's hernia director
  • Winged blade
  • Wing protects the intestine as it rolls over the edges during the division of constricting band.
Note: This instrument is not essential in operations of strangulated or obstructed hernia. Careful use of ordinary knife and artery forceps is enough.68
 
DISSECTOR
  • Used to separate the tissue covering a structure to which access is desired.
  • They are blunt pointed to avoid injury to vessels or nerves.
 
Watson Cheyne's Probe and Dissector (Fig. 1.64)
zoom view
Fig. 1.64: Watson Cheyne's probe and dissector
  • For blunt tissue dissection
    • Dissection of nerves specially during cervical and lumbar sympathectomy.
    • In retrograde appendicectomy it is passed between appendix and caecum where it protects the latter. Then base of the appendix is divided between clamps.
  • To clear the surface of pelvis of the kidney from surrounding fat.
  • Its use is especially applicable in:
    • Cholecystectomy to clear junction of cystic duct and common bile duct
    • In collar stud abscess, with the probe end to seek the opening which leads to underlying gland after superficial abscess is evacuated
    • To clear the upper pole of the thyroid from surrounding structures.
69
 
Trocar and Cannula (Fig. 1.65)
zoom view
Fig. 1.65: Trocar and cannula
  • A cannula is a hollow tube used for aspirating and removing fluid from:
    • An organ
    • Body cavities
    • Tissue spaces
  • A trocar is a sharp pointed stylet which fits closely into cannula with a sharp projecting tip projecting beyond the cannula. This permits thursting of cannula
  • It is withdrawn as soon as instrument is entered in and reinserted again before removal to:
    • Empty the cannula
    • To prevent entry of anything else into cannula.
  • Under certain circumstances where we want to drain the fluid away, it is achieved by:
    • Side tubing which is connected to receptacle.
    • Trocar is not completely detachable from cannula. It is only withdrawn, e.g.70
    • Gallbladder trocar and cannula
    • Ascites trocar and cannula
    • Urinary bladder trocar and cannula
    • Overian cyst trocar and cannula
  • Sites where used:
    • Hydrocele
    • Gallbladder
    • Ovarian cyst—to reduce the size before removal
    • Ascites
    • Suprapubic drainage of bladder
    • Empyema, hydrothorax, hemothorax
    • For laparoscopic examination and peritoneal lavage
    • Antral puncture.
 
Gallbladder Trocar and Cannula (Ochsner's) (Fig. 1.66)
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Fig. 1.66: Gallbladder trocar and cannula (Ochsner's)
  • 6” long, 1/4” internal diameter so that even thick bile can be aspirated.
  • Trocar is not detachable from cannula and as trocar is withdrawn leakage is prevented from proximal end.
  • Cannula has a side tube to which via a rubber tubing suction is applied. This ensures that irritant/infected fluid (bile) is drained away without spill over into surrounding, i.e. as soon as instrument is in, trocar is withdrawn (but not removed) and suction is applied.71
 
Uses
  • Cholecystostomy
  • Cholecystectomy: Gallbladder is emptied before removal as distended gallbladder may interfere with dissection.
Note: It was necessary in preantibiotic era. Not in use nowadays. Large aspiration needle and packing of the surrounding area serves the purpose.
 
Hydrocele, Trocar and Cannula (Fig. 1.67)
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Fig. 1.67: Hydrocele, trocar and cannula
  • Cannula—hollow and open at both ends.
  • Base is little greater in diameter.
  • Trocar
    • Obliterates cannula
    • Solid metal rod, flat base and sharp tapering tip.
  • After puncture, trocar is removed by its handle and hollow cannula is left in situ for drainage.
 
Uses
  • Hydrocele
    • Tapping
    • In hydrocele operation after separation of its layers, sac is delivered and before tunica is opened for eversion/excision, it is emptied by trocar and Cannula passed anterior and parallel to testis, position of which is known by preoperative transil-lumination.
  • Abdomen
    • To drain ascites
    • To puncture abdominal wall for laparoscopic examination.72
  • Suprapubic drainage of bladder
  • Empyema, hydrothorax, hemothorax
  • Originally devised for drainage of liver abscess.
 
Suprapubic Trocar and Cannula (Cantue's) (Fig. 1.68)
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Fig. 1.68: Suprapubic trocar and cannula (Cantue's)
  • Cannula has external diameter of 10-12 mm (English catheter gauge 18-22).
  • Passed through bladder wall in a distended bladder.
  • Blind method—hence all the disadvantages of blind procedure.
    • Trauma to surrounding structure, e.g. intestine.
    • Bleeding—if it is passed through a large vein on the bladder wall.
 
Abdominal Trocar and Cannula (Spencer Wells's) (Fig. 1.69)
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Fig. 1.69: Abdominal trocar and cannula (Spencer wells's)
Note: Most commonly and constantly used even now.
  • For hydrocele
  • For antral puncture.