INTRODUCTION
A surgical instrument is a designed tool or device used for carrying out desired actions during a surgery, e.g. cutting a biological tissue, holding it or to provide access for viewing a deeper lying structure. Some surgical instruments are designed for general use in surgery, while there are some which are tailor-made for a specific role in a specific procedure, e.g. instruments for nail procedures, implanters in hair transplantation, dermatomes for taking a skin graft, etc. (Table 1.1).
Surgical equipment is as important to the procedure as to the doctor. Faulty and ineffective instruments can do just as much damage as an unqualified doctor could. High quality precision equipment can considerably influence the outcome of any procedure, more so in case of cosmetic procedures involving face and exposed parts of the body. Utmost care must be taken in selecting the correct instrument for a particular step; however, the surgeon must not be obstinate and learn to improvise with instruments like using a chalazion clamp in oral mucosal procedures.
GENERAL INSTRUMENTS
Forceps
This is a handheld, hinged instrument used for grasping and holding objects. The arms of the forceps are used as extensions of thumb and index finger in stabilizing or holding the tissue, sutures or dressings. The free tips of the forceps are modified for various uses. There are two basic type of forceps—the nonlocking type and locking type which are also known as clamps.
Adson's Tissue Forceps |
Description | A type of dissecting forceps with wider blade and better grip. |
Uses | Hold wound edges during exploration and suturing. Removing recipient plugs in hair transplant. |
Remarks | Easy to control as the blades provide better grip. |
Allis Forceps |
Description | A surgical instrument with sharp teeth, used to hold or grasp heavy tissue. Two straight blades with interdigitating teeth at the tip. Handle has a ratchet with 3 catches. |
Uses | Corn enucleation surgery. |
Remarks | Can damage tissues, if used inappropriately, hence it is used to hold the tissue which has to be removed. |
Cheatle Forceps |
Description | Forceps with long handles with complete ring at one end and partial at other. |
Uses | To pick up sterilized articles/gauze pieces from tray. |
Remarks | The tips are kept dipped in antiseptic solution. |
Epilation Forceps |
Description | A kind of small spring forceps, used for removing unwanted hair. |
Uses | In electroepilation to pull out destroyed hair. |
Remarks | Various types are available. For example, Beer epilation forceps, Douglas forceps. |
Dissecting Forceps (Toothed/Plain) |
Description | Forceps with toothed or plain tips and variable types of grip. Plain forceps have horizontal serrations at the tip and toothed ones have two teeth on one jaw and interdigitating tooth on the other. Spring tension at one end holds the grasping ends apart until pressure is applied. This allows one to quickly and easily grasp small objects or tissue to move and release it, or to grasp and hold tissue with easily variable pressure. |
Uses | Plain dissecting forceps are used for holding delicate structures like blood vessels, nerves, etc. Toothed dissecting forceps are used for holding tough tissues like skin, fascia, tendon, etc. |
Remarks | Various types of dissecting forceps have been designed according to the use For example, Plane dressing forceps, Adson forceps, Bonney's forceps, Gillie's forceps, Lane's forceps, Mc'Indoe's forceps, DeBakey's forceps, Gerald's forceps, Bayonet's forceps, etc. |
Sponge Holding Forceps |
Description | Large size hinge forceps with fenestrations/hole at the tip of the blades. The handles are ratcheted as well as looped. Sponge holding forceps can either be curved or they may be straight. Transverse inner surface is serrated to provide better grip. |
Uses | Hold sponges and/or cotton wool swabs in preparing the surgical site. |
Hemostatic Forceps/Artery Forceps |
Description | Forceps with gradually tapering blades towards the tip with serrations at the tip. Commonly referred to as “Artery forceps”. The tip may be either straight or curved. |
Uses | Catch cut end of blood vessels. Blunt dissection in lipoma and sebaceous cyst excision. Crushing pedicles of skin tag and DPN. To hold the free ends of suture in ear lobe repair and nerve biopsy. Three point traction in circumcision. |
Remarks | Medium and small sizes are commonly used in dermatosurgery. |
Iris Forceps |
Description | A kind of fine spring forceps originally used in ophthalmic surgery to hold iris tissue. But it also finds application in fine surgeries like skin grafting, hair transplant, etc. The tip may be straight/curved or plane/toothed. |
Uses | Miniature punch grafting. Split thickness skin grafting. Blister grafting. |
Remarks | Various designs are available with different names. Common ones used in dermatosurgery are illustrated. |
Iris forceps—Graefe | |
Iris forceps—Stevens | |
Iris forceps—Bishop Harman | |
Iris forceps—Forester | |
Iris forceps—Gill | |
Iris forceps—Mod- Tuebingen |
Jeweler Forceps |
Description | A small thumb forceps with very fine pointed blades, used to grasp tissues in microsurgical procedures. |
Uses | Miniature punch grafting. Punch biopsy. Implantation of follicular units in hair transplantation. |
Remarks | The tip may be straight, bent or curved. |
Scissors
Scissors are cutting instruments with two blades hinged together at a fulcrum. These are available in various sizes and types. Scissors can be classified as having sharp or blunt edges and as straight and curved.
Dressing Scissors/Nurses Scissors |
Description | The lower blade is blunted and the upper blade is sharp. |
Uses | To cut the dressing without injuring the skin. |
Lister Bandage Scissors |
Description | Thick blunt plate at the tip of the lower blade to avoid injury. The blades are curved to an angle for ease of use. |
Uses | To cut the dressing without injuring the skin. |
Mayo Scissors |
Description | A type of surgical scissor with flattened blades. Blades may be straight or curved. |
Uses | Straight: Cutting dressing, Vaseline impregnated gauze, suture materials, dressing pads, etc. Curved: Removal of warts after electrocautery, cutting skin tags, sample taking out the biopsy from tough areas. |
Remarks | Was developed by Mayo Clinic. Most often used to cut fascia in general surgery. |
Metzenbaum Scissors |
Description | Surgical scissors designed for cutting delicate tissue and in blunt dissection. Have a relatively long shank-to-blade ratio. |
Uses | Cutting skin tags. Skin biopsy. Split thickness skin grafting. |
Iris Scissors |
Description | Very small scissors with an extremely sharp and fine tip. The tip may be curved or straight. |
Uses | To cut delicate tissue. Ideal for cutting mucous membranes. Skin biopsy. Enucleation of cyst/lipoma. |
Remarks | Originally designed for the fine detail work of ophthalmic surgery. |
Gradle Scissors |
Description | Short blades with thin pointed ends. May be curved or straight. |
Uses | Cut delicate tissues especially in periorbital area. Cut skin tags. |
O'Brien Scissors |
Description | Small scissors with angled short blades with pointed edges. |
Uses | Cut suture in delicate or tight areas. |
Spencer Scissors |
Description | Small scissors with a small hook shaped tip on one blade. |
Uses | Suture removal. |
Remarks | The small hook shaped tip on one blade slides under sutures to slightly lift them before cutting for removal. This hook also holds the suture, so it does not slip off the blade of the scissors prior to cutting. |
Double S-Shaped Curved Scissors |
Description | Small scissors with two curves which form the alphabet “S”. |
Uses | Useful to operate at a depth. Miniature punch grafting at recipient site. Hair transplantation surgery to cut deeper donor grafts. |
Undermining Scissors |
Description | Small scissors with longer shanks. Distal part is flattened to provide thinner operating edge. |
Uses | In surgeries where considerable undermining is required. |
Remarks | For example, Ragnell dissecting scissors. |
Castroviejo Spring Scissors |
Description | Small scissors with thin short blades and spring action. The tip may be curved or straight. |
Uses | For fine work involving delicate tissue like face. To cut the graft in blister grafting and split thickness skin grafting. |
Remarks | The unique design features allow extremely smooth cutting of fine and coarse tissue with reduced trauma. |
Scalpels
Consists of disposable steel blades which can be fitted on to reusable stainless steel handles. Some handles are designed to fit a specific hand hold. For example, Beaver style handle is shaped like a pen and is suited for close, precise cuts; other handles, such as Bard-Parker style are flatter. A particularly common type of handle, called the No. 3 Bard-Parker style, has a metric ruler to measure precise cuts. Another common type of handle is the rounded Siegel style, designed for curved incisions. The Bard-Parker handle (BP handle) is the commonly used handle in dermatosurgery.
The sizes of surgical blades which fit into various sizes of BP handle is given in Table 1.2. Various sizes and shapes of blades available are listed in Figure 1.1. Commonly used blades in dermatology and their uses are enumerated in Table 1.3.
|
Bard-Parker Handle |
Description | Flat blade holders of various sizes. Different sizes are suited for particular blade sizes. Handle #3 has a metric ruler to measure the size of the incision. |
Uses | For handling the surgical blade safely and precisely during procedures like skin biopsy, enucleation/excision of cyst, etc. |
Remarks | The flat design is helpful to have a better grip of the knife. Longer handles are denoted by the letter L after the size of the handle. For example, 3L, 4L, etc. |
Siegel Handle |
Description | Round bodied blade handle designed to hold standard surgical blades. The distal end has a prominence similar to that of Bard-Parker handle. Also referred to as handle #7. |
Uses | To hold the knife like a pen. |
Remarks | The round design is helpful in holding the knife like a pen and in performing precise cuts in difficult areas. |
|
Beaver Handle |
Description | Round bodied blade handle shaped like a pen. The distal end has a slit into which the blade can be placed and fixed. Specific set of blades referred to as “Beaver mini blades” are available for use with this type of handle. |
Uses | To hold the knife like a pen. For close and precise cuts. |
Remarks | The round design is helpful in holding the knife like a pen and in performing precise cuts in difficult areas. |
Needle Holder
It is a surgical instrument used for grasping the needle during suturing. Most needle holders have a clamp mechanism to lock the needle in place. The size of the needle holder to be used should be determined by the size of the needle and the anatomical site of the surgery. The jaws of a needle holder are textured and short to maintain a firm grip on the needle.7
Mayo-Hegar Needle Holder |
Description | Larger size needle holder with long shanks. Serrated tips with central longitudinal depression. |
Uses | For holding larger size needles—3.0 and 2.0 suture needles. For performing sutures involving larger areas like trunk, limbs, etc. |
Remarks | The cross serrations help to provide better hold on the needle used. |
Crile-Wood Needle Holder |
Description | Smaller size needle holder than Mayo-Hegar with long shanks. Serrated tips with transverse groove to accommodate the needle. |
Uses | For holding larger size needles. For performing sutures involving larger areas like trunk, limbs, etc. |
Remarks | The transverse groove helps in achieving a good perpendicular grip of the needle. |
Ryder Needle Holder |
Description | Smaller size needle holder with long shanks. Tips are thinner with cross-serrations. |
Uses | For holding smaller size needles—4.0 and 5.0 suture needles. For performing sutures involving delicate skin like face, earlobe, periorbital area, etc. |
Remarks | The thin short blades help to provide better grip to small sized needles. |
Castroviejo's Needle Holder |
Description | Small size needle holder with spring action. Very thin tips for fine work. |
Uses | For holding smaller size needles—4.0 and 5.0 suture needles. For performing sutures involving delicate skin like periorbital area. Used in delicate cosmetic surgeries. |
Remarks | The thin short blades help to provide better grip to small sized needles. |
Skin Hooks and Retractors
Skin hooks are a commonly used equipment in dermatology where the use of a forceps is better avoided. It can reduce undue damage to skin edges as they are less traumatic. Skin hooks are available with one, two or multiple teeth.
A retractor is used to actively separate the edges of a surgical incision or to hold back underlying organs/structures (e.g. blood vessels, nerves, deeper cysts, etc.), so as to avoid accidental injury to them.
Guthrie Skin Hook |
Description | Small skin hook with two, three or four prongs. The tip is flattened. The prongs may be sharp or blunt. |
Uses | To retract skin while performing deep procedures like nerve biopsy, tendon repair, etc. |
Remarks | Skin hooks are useful in avoiding use of forceps on delicate tissue which is more traumatic than the hooks. |
Joseph's Double Skin Hook |
Description | Small skin hook with two prongs. The tip is “U” shaped. The tip is not flattened when compared to Freer skin hook. |
Uses | To retract skin while performing deep procedures like nerve biopsy, tendon repair, etc. Provides better field of vision when compared to Freer skin hook. |
Remarks | Skin hooks are useful in avoiding use of forceps on delicate tissue which is more traumatic than the hooks. Another hook with similar structure but a different curvature angulation is the Cottle's hook. |
Frazier Skin Hook |
Description | Small skin hook with single prong. Also called Frazier Dura hook. |
Uses | To hold tongue, lips and cheeks away from the surgical area. |
Remarks | Provide better visualization and easy accessibility of the surgical site. |
Senn Retractor |
Description | Handheld, double-ended retractor used to retract primarily surface tissue. It has one angled, blunt end and, at the opposite end, facing the opposite direction has a three prong, rake tip. The prongs may be sharp or blunt. |
Uses | Retract skin in deep procedures like nerve biopsy and tendon surgeries. |
Remarks | Provide better visualization and easy accessibility of the surgical site. |
Haber Spreader |
Description | A set of straight handles connected to a set of curved front arms, and culminating in a set of jaws with four sharp staggered prongs. |
Uses | It is used separate a superficial incision along a natural tissue dissection plane. |
Other General Instruments
Curette |
Description | Sharpened scrapping instrument. Loop shaped cutting edge at both edges. |
Uses | Curettage of various benign and malignant cutaneous growth. |
Remarks | Different types are in use. |
Fox Dermal curette | |
Piffard Dermal curette | |
Rein Round curette |
Volkmann Double Ended Scoop |
Description | A modification of curette. Stout handle with spoon shaped extension at the ends. Extensions maybe round or oval with sharp edges. |
Uses | Scooping abscess cavities. Nail surgeries. Corn enucleation. Ulcer debridement. Application of pellet in cell based vitiligo surgeries. |
Maneksha's Manual Dermabrader |
Description | It has a handle with thumb rest and a rectangular plate at the distal end. The plate has horizontal and vertical sharp teeth. Various sizes of 3 to 25 mm are available. |
Uses | Recipient area preparation in STSG, SBEG, and NCES. Dermabrasion of acne scars. Tattoo removal. Debridement of wound/ulcer. |
Comedone Extractor |
Description | Central handle with two perforated cups at the ends. |
Uses | Expression of comedones. |
Remarks | Used keeping the convexity of the cup held against the comedones. For example, Saalfield comedone extractor, Schaumberg comedone extractor. |
Chalazion Clamp |
Description | It has a forceps-like handle with one distal tip with a flat solid oval plate and another distal tip with a ring-like aperture. The shaft has a thumbscrew. |
Uses | Oral mucosal biopsy. Deroofing of mucocele. Minor salivary gland biopsy. Ear lobe repair. Scrotal surgery. Nasal lesions on ala nasi. |
Remarks | Various types are available. For example, Braid chalazion clamp, Desmarres Chalazion clamp, Weis Chalazion clamp, etc. |
Instruments for Specific Procedures
Vitiligo Surgery
The following transplantation procedures are employed for hypopigmentation disorders.
Tissue Grafts
- Thin and ultra-thin split-thickness skin grafts (STSG)
- Mini-punch grafts (MPG)
- Hair follicular grafts (HFG)
Cellular Grafts
- Noncultured epidermal cell suspension (NCES)
- Cultured “pure” melanocytes (CM)
- Cultured epithelial grafts (CE)
Apart from the general instruments, various special instruments are also required to perform many of these procedures.
Razor Blade Holder |
Description | Stainless steel holder which can fit in standard razor blades. The blade is fixed by thumbscrew. |
Uses | To obtain split thickness skin grafts from the donor site. |
Remarks | Ideal for harvesting small grafts. Both the sides of the blade are exposed and can be used conveniently. |
Silver Knife |
Description | Stainless steel knife which can fit regular razor blades. It has screws for adjusting the thickness of the graft to be harvested. |
Uses | To obtain split thickness skin grafts from the donor site. |
Remarks | Ideal for harvesting small intricate grafts from areas which would not be accessible with the larger standard knives, such as the ear, dorsa of the hands or scalp. |
Humby Knife |
Description | A long knife (12 inch long) with disposable blade (6¼ inch long). It has a handle and a plate where the blade is attached. The design of the plate is slightly different in different modifications of the knife available. These knives have an in-built adjustable guard which can limit the maximal thickness of the graft harvested. A thumbscrew is used to adjust the thickness of the graft. |
Uses | To obtain split thickness skin grafts from the donor site. |
Remarks | Watson modification is the most commonly used modification of Humby knife. |
Braithwaite modification (1955 Fenton Braithwaite) | |
First modification of Humby knife which can be sterilized without dismantling. The guard oscillates and rotates when the knife is used. | |
Watson modification (1960 John Watson) | |
Modified Braithwaite design with a fine, smooth guard with no movement. The guard passes eccentrically through the bushes at both ends enabling control of thickness of graft with adjustment of a single knob. It eliminates “play” of the guard but can cause considerable “drag” on the skin as the guard is fixed. | |
Cobbett modification (1968 J Cobbett) | |
Another modified Braithwaite design with oscillating guard to eliminate “drag”. The guard is fixed to a “D” shaped hole to avoid rolling up of the graft harvested on to the guard. | |
Powered Dermatomes | |
Description | These are mechanical dermatomes which use either compressed air/water, DC current or AC current. Different types are available. |
Uses | To obtain split thickness skin grafts from the donor site. Rapidly remove long strips of skin. |
Remarks | Operation is simple. Procedure can be performed with least number of assistants. |
Brown's dermatome | |
Zimmer dermatome | First mechanical dermatome to be introduced. Works with compressed air/water. |
Davol Dermatome | |
Cordless, battery operated dermatome. Ideal for harvesting small grafts. | |
Padgett Dermatome | |
AC current operated dermatome. |
Nail Surgery
Nail Splitter |
Description | Also referred to as English anvil pattern nail splitter. Has sharp triangular shaped anvil opposed by a sharp and flat edge at the distal end and double spring at the handle. |
Uses | To cut longitudinal strip of nail plate in partial nail avulsion. |
Remarks | The nail plate is split from the distal to the proximal end. |
Nail Spatula |
Description | Rod shaped/ flattened equipment with flat edges. The tip of the flat edges may be modified into different shapes. |
Uses | Proximal and lateral nail fold separation in nail avulsion, nail matrix biopsy, etc. |
Remarks | Spatula is inserted between the proximal/lateral nail fold and nail plate and gently separated by lateral movements. |
Freer Septum Elevator |
Description | Rod shaped equipment with thin curved blades. |
Uses | To loosen distal nail plate from hyponychium, proximal nail fold and lateral nail folds. |
Skin Biopsy
Punches |
Description | Circular blade ranging in size from 1 to 8 mm which is attached to a pencil-like handle. May be provided with corresponding size plungers. |
Uses | Skin biopsy involving delicate areas, cosmetically important areas, etc. Proximal and distal nail matrix biopsies, nail bed biopsy. Mini punch grafting in vitiligo surgery. |
Remarks | The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4 mm punch. |
Reusable metallic punches with plungers | |
Disposable punches | |
Disposable punches with stainless steel blades of sizes varying from 1 to 8 mm. Punches with or without and inbuilt plungers are available. | |
Disposable elliptical punches | |
Disposable elliptical punches with fixed and moveable blades are available. Used for better closure of the wound and for better comsetic results especially on the face and exposed parts. |
Dermablade/BiopBlade |
Description | Small, flexible, sterile blade with plastic side grips. |
Uses | Shave biopsy. |
Remarks | Can also be used for harvesting small STSG in vitiligo surgery. |
Hair Transplantation
Implanters |
Description | An attempt to automate and quicken the process of implantation of hair. |
Uses | In hair implantation of scalp, eyebrow and other parts of body. |
Remarks | In a single move a slit is created and without removing the implanter the graft can be placed. |
Choi implanter (Korea) | |
Originated at the Kyungpook National University (KNU) in Korea | |
Atlanta implanter (USA) | |
SAVA Implanter (India) | |
Conceived by Dr Sajeev Vasa of Ahmedabad, Gujarat. An inexpensive, high quality disposable implanter. Minimises the graft trauma, but also reduces the overall cost of the surgery. | |
Lion Implanter (Spain) | |
The device uses a clip, which is not found in previously used hair transplanters. This clip reduces the procedural time and makes the replacement of the needle easier. |
Circumcision Instruments
Plastibell Clamp |
Description | It is a plastic device designed for circumcising infant males. |
Uses | Circumcision. |
Remarks | Other popular available clamps include Gomco clamp and the Mogen clamp. |
Acne Scar Surgeries
Nokor Needle |
Description | It is a 1.5 inch, 18-gauge needle with a flat pointed end. |
Uses | Subcision. |
Remarks | For treatment in boxcar acne scars. |
Sterilization of Instruments
Defined as a process that destroys or eliminates all forms of microbial life including bacterial endospores.
Sterilization Methods |
Method | Suitable for | Remarks |
---|---|---|
Hot air sterilization | Glass instruments, forceps, scissors, scalpels, swabs, dusting powder | 1 hour at 160°C ½ hour at 180°C 10 min at 200°C |
Steam autoclaving (Gravity displacement) | Wrapped instruments/utensils | Most widely used method 30 min at 121°C or 15 min at 132°C and drying time of 15–30 min. |
Textile packs | 30 min at 121°C or 25 min at 132°C and drying time of 15 min. | |
Steam autoclaving (Dynamic air removal) | Wrapped instruments/utensils | 4 min at 132°C and 20–30 min of drying time |
Textile packs | 4 min at 132°C and 20 min of drying time | |
Cold sterilization or Chemical sterilization | Sharp metallic instruments | 2% Glutaraldehyde, 70% Alcohol, Carbolic acid, Lysol, etc. can be used Instrument immersed for at least 30 min |
Gas sterilization | Glass, Rubber articles Fumigating OTs, hand pieces of hand machine. | Ethylene dioxide, Formaldehyde used |
Sterilization of Dermatological Equipment |
Skin grafting for vitiligo | Stainless punches | Autoclaving |
Disposable punches | Not to be reused | |
Artery forceps | ETO sterilization | |
Blades, forceps, scissors | Autoclaving | |
Hair transplant | Needles, Forceps, Cutting boards, Blades, BP handle, Artery forceps, Adson's forceps, Needle holder | Autoclaving |
Plastic blade holders, Plastic bottles for spraying saline | ETO sterilization or prolonged exposure to chemical disinfectant like Glutaraldehyde | |
Chemical peels | Brushes to apply chemicals on face | ETO sterilization |
Laser | Metal spacers, Interchangeable metal hand pieces | Autoclaving |
Interchangeable plastic hand pieces, Goggles | ETO sterilization or prolonged exposure to chemical disinfectant like Glutaraldehyde |