Surgical Instrument Lecture OutlineCTVT 1136-1158

1) General Information Cleaning InstructionsCare of Instruments

2) General Surgery Instruments Cutting instrumentsNeedle HoldersForceps

(1) Thumb(2) Tissue(3) Hemostatic(4) Miscellaneous

Towel ClampsRetractorsStaplersSpeculumsCannulasMiscellaneous Small Animal Surgery Equipment

3) Ophthalmic Instruments

4) Basic Orthopedic Equipment

Instruments for independent study purposes can be found in the two drawers labeled “Orthopedic Instruments” and “Surgical Instruments” on the left side of the surgery suite.

There is a list of the color-coding on the cabinet above the instrument drawers.

Anything with a * is something that is included in the Perfect Pack at VTI.

For testing purposes: be able to identify (the complete name based on this guide, spelling within two letters) and describe each instrument (anatomy and purpose).

General Information

The best instruments are made of stainless steelTwo different brands: Pakistan or Germany

Germany is a better product, but more expensive Check engraving on the side of the instrument for the brand

Cleaning of Surgical Instruments

Cleaning= the removal of fluid, tissue, and other organic debris to reduce the number of microorganisms present.All instruments should be cleaned and dried immediately after use; then they are either sterilized or disinfected.

The instruments intended use will decide which method is necessary.o Example: dental prophylaxis instruments are usually disinfected, not

sterilized; suture placement kits may be disinfected for minor wound repair, but would be sterilized for an abdominal surgery

Cleaning process:1. Open box locks/ratchets and scrub in cold water immediately after surgery (soak if you cannot get to them immediately to keep debris moist)

Scrub with a tooth brush or other nylon brush Use either enzymatic instrument cleaner or soapy water (must rinse well when

using dish soap) Touch ALL parts of the instrument-not just the working ends!

2. Place in ultrasonic cleaning machine for better cleaning Machine creates ultrasound waves that create tiny bubbles, which break up

debris on the instrument; more efficient and detailed than manual cleaning Machine makes a high pitched noise must be placed away from animals

o We place in the laundry room at VTI. Place sign on door.STEPS:

o Mix 1 ounce instrument cleaner in 1 gallon of distilled watero Place instruments w/ ratchets fully OPEN into solution and cover with lido Set time for 20 minuteso Remove instruments immediately, drain solution after EVERY use and

wipe the machine clean

3. Inspect instruments for cleanliness, proper alignment, sharpness, the ratchet is working, etc. As a technician, you are responsible for testing the function of instruments-

don’t give a veterinarian a “sprung” instrument (this is a ratcheted instrument that doesn’t close tightly) or a dull scissors

4. Place instruments fully OPEN on dry on a lint free towel

5. Spray with instrument milk Lubes hinges and prevents rust/corrosion Milk comes as a concentrate and must be diluted with tap water; only good for

14 days (this varies with brand)o 1:6 dilution

6. Leave instruments out to dry completely before putting away in proper location

Care of Instruments

Clean properly EVERY time and dry thoroughly Use only for intended purpose- you can dull cutting edges or loosen box locks if used inappropriately

Example: Don’t cut bandages with standard operating scissors!

Avoid dropping/handle carefullySharpen blades as needed

You can sharpen in clinic, send instruments to a professional sharpening company, or have a company come to your clinic

Color coding- instrument tape can be used to identify instruments that are commonly used in the same pack

Example: if your clinic has 4 “Spay Packs”, all of the instruments that makeup one pack can be labeled as red, the second pack can be labeled as yellow, etc.

o This makes it easy when cleaning multiple packs used throughout the day Do not place the instrument tape on the working ends Tape is safe to use in all sterilization methods

General Surgical Instruments

Cutting instruments:

1. Scalpel blades –primary cutting tool of surgeon incisions proven to heal well Scalpel blades can come detached from the handles and individually sterilized in foil

packets or as disposable, pre-sterilized blades (blade and handle all in one) Come in various sizes for small and large animals

#10, #11, #12, #15 (these fit the Bard-Parker no. 3 handle)#20, #21, #22 (these fit the Bard-Parker no. 4 handle)

USES: Incise tissue (#10), lance abscesses (#12), declaws, feline/rat neuter (#15-small precise), lance abscesses, incising vessels (#11), skin scrapes (used and re-sterilized, size depends on sample size)

2. *Scalpel handles – used to hold scalpel blade to safely cut tissues Two common sizes Can be plastic or stainless steel

Bard Parker no. 3 – fit blades #10, #11, #12, #15Bard Parker no. 4 – fit blades #20, #21, #22 (large animal surgeons)

HOLD: Scalpel blade is held with thumb, middle and ring finer; index finger is placed on upper edge and used as a guide*Should never be used in a stabbing motion – only long, gentle strokes

3. Electrocautery – allows surgeon to cut, or cut while simultaneously providing coagulation minimizes bleeding

Electrical current passes through a hand piece to the tissue and is grounded to the ground plate under the patient.

o Ground plate - keeps patient from being burned (gel or towel) Required for MONOPOLAR cautery Not required for BIPOLOR cautery

With bipolar cautery, current passes out one tip, through patient, and then travels back into the other tip

o Hand piece is controlled by surgeon via a foot pedal This item must be sterilized!

o Tips- come in many different shapes and sizes These must be sterilized as they will be secured onto the hand piece by

the surgeon.o Machine operation: Power level and switching from cautery to

cautery/coagulation is adjusted by tech, or non-sterile assistant

4. Scissors – one of the most common surgical instruments used

available in MANY widths, lengths, and shapes Classified by: shape of tips and character of their points

o Shape = curved or straighto Character = blunt-blunt, sharp-sharp, or blunt-sharp

May ONLY be used for their intended purpose

PARTS: points, two blades, two handles, pivot/box lock and finger rings

USES: Incising tissue, transecting tissue, separating tissue (ex. Fascia from muscle), cutting suture, drape, bandages…HOLD: thumb and ring finger are inserted into the rings; index and middle fingers are used as guidesTYPES:

A. *Standard operating scissors- used to cut drape and suture material Full name depends on shape and character Example: Curved sharp/sharp standard operating scissors

B. *Mayo dissecting scissors – sturdy; cut ligaments and tendons

C. *Metzenbaum dissecting scissors – cutting delicate tissues (fat, muscle, organs) Very long shanks; short blades

D. Littauer suture removal scissors - removing suture from patient Lower blade has a hook-shaped point Wide, round blades Not used to cut wire suture

E. Spencer suture removal scissors – removing suture from patient Lower blade has a hook-shaped point Thin blades Not used to cut wire suture

F. Wire cutting scissors – used to cut wire (ex. stainless steel suture, cerclage wire, OR small diameter IM pins)

G. Bandage cutting scissors – used to remove or fit bandage material flat, blunt nodule on the lower tip

prevents cutting the patient’s skin

TYPES:1. Utility scissors- heavy duty; angled blades with serrations

o Large plastic handles

2. Lister bandage scissors – stainless steel; angled blades

3. Knowles bandage scissors – stainless steel; straight blades

5. *Needle Holders – also known as “needle drivers”; may OR may not cut

USE: to grasp needle and pass suture material through tissue; tying knots

PARTS: rounded tips, jaws w/ longitudinal groove in the center, box lock, shank, finger rings and RACHET

Optional: carbide jaw inserts to extend life of instrument (GOLD in color)TYPES:

A. Mayo-Hegar – no scissors; can only hold suture needle Remember: “you can’t cut mayo”

B. Olsen-Hegar – jaws are flat and finely serrated Has suture scissors below the jaws = efficient suturing

o Downside- may cut suture accidentally Remember: “TWO functions, like the Olsen twins”

Grasping/Holding Instruments:

1. Thumb Forceps- form a V-shape; work by spring action with a joint at the end of two handles

PARTS: tines/tips, jaws, handles, spring hinge Are opposed by manually compressing the two handles together Come in varied sizes and grasping surfaces The more intermeshed teeth = more gentle

o ex. Bed of nails vs. 1 nail

USES: manipulation of delicate tissues (usually in non-dominant hand)Example: hold the skin around an incision you are suturing

HOLD: like a pencil; hand sits under the instrument (not over the instrument)

TYPES:A. Adson thumb forceps – One jaw has two teeth, interlock with the one tooth

on the other jaw; bowed handlesa. The “Adson” handle is specific to any Adson instrument

B. Adson dressing forceps – flat jaws; no teeth

C. *Brown-Adson thumb/tissue forceps – each tip has two rows of intermeshed teeth (fit together)

a. Most commonly used!

D. Rat-tooth forceps – used for tougher tissues; much narrower handles; varying amount of teeth that always interlock

a. Example: 1x2 or 2x3

E. Debakey thoracic tissue forceps – the most slender and delicate Two long rows of microscopic teeth on each jaw Most atraumatic; used when you want delicate tissue to stay in tact Used for handling blood vessels

F. Russian thumb forceps – two broad, spoon shaped tips with serrated edges strong gripo Great for extracting tissue you want removed

G. Bayonet thumb forceps – most used in ear and nose procedures Easily grasp objects through the speculum of an otoscope Surgeons fingers are not in the line of anatomical site when using these

2. Tissue Forceps- locking instruments

PARTS: jaws, box lock, shank, finger rings and ratcheted locking device Come in various tooth patterns and sizes

USES: Grip tissue (with more strength than thumb forceps); can be left in place while surgeon continues elsewhere

TYPES:A. *Allis tissue forceps – traumatic; applied to tissue being excised

o Tip has inward facing, interlocking teeth that can vary in number

B. Babcock intestinal forceps – used on bowel, bladder (viscera)o Less traumatic; wide grasping surface; tips are rounded and hollow with

longitudinal striations

C. Doyen intestinal forceps – non-crushing; used to temporarily occlude the lumen of the bowel o Longitudinal striations along entire jawso Jaws are very long and don’t completely close when ratcheted all the way

Example procedure: intestinal resection and anastomosis

D. Hemostatic forceps- these tissue forceps are a category all their own

3. Hemostatic Forceps – also known as hemostats; a type of tissue forceps but there are many of them so they get their own category

USE: to stop bleeding, by crushing tissues and vessels Classified by: size, pattern of jaw striations, and shape of tips

o Size = their length, measured in incheso Shape of tips = straight or curved (all types can come in either)

o Jaw pattern- transverse or longitudinal Most have transverse striations along jaws (NOT ALL)

HOLD: thumb and ring finer are inserted into rings; index and middle fingers are used as a guide

Curve is pointed upwards when in use on the patient Curve is down when tech is handing this instrument to surgeon (that way it will

be pointing up when surgeon applies it to tissue)

TYPES:A. *Halsted mosquito hemostats – crushing small vessels

o 3.5 or 5 inches longo Transverse striations on entire length of inner jaws

B. *Kelly hemostatic forceps – occluding larger vessels and tissues o 5.5 inches longo Transverse striations on jaws that go from tip to half way down

C. Crile hemostatic forceps - occluding larger vessels and tissueso 5.5 inches longo Transverse striations along entire length of inner jaws

D. Rochester-Pean hemostats – grasping larger vessels and hollow organ tissue (pedicles and stumps)o Transverse striations along the entire inner jawso Larger than criles; come in many lengths

E. *Rochester- Carmalt hemostats - grasping larger vessels and hollow organ tissue (pedicles and stumps) before ligating

a. Example: OHEo Opposing longitudinal grooves along entire bladeso Cross hatching at the tip = aggressive crushing power

F. Rochester-Ochsner hemostats – grasping larger vessels and tissues very well; identical to Peans, except these have teetho Transverse striations along entire inner jawso Teeth on the tip- one on one tip and two on the other tip (1x2)

G. Ferguson angiotribe – heavy duty; arresting and preventing hemorrhage o Deep, longitudinal grooves with total cross hatching

4. Towel Clamps- used to secure sterile towels/drapes to the patient; a type of forceps Must actually penetrate skin when securing item to patient!

TYPES: A. *Backhaus towel clamp – tear drop shaped, curved blades; ends in sharp

pointso Ring handles and a ratchet

B. Jones towel clamp – spring action, yet self-retaining due to locking mechanism

o Has a joint at the end of two handles ; ends in sharp points

C. Roeder towel clamp – Backhaus towel clamp + ball stops

5. Miscellaneous forceps

A. Alligator forceps – very long shank which sits at a 45° angle to the ring handles

o Serrated jaws at the end for graspingo No ratchet

USES: grasping small objects; removing items from the body; probing fistulas

B. Forester sponge holding forceps – box lock, shank, ring handles and ratcheto Jaws are oval loops; can be straight or curvedo Blades are narrow/thino Instrument comes in varying lengths

USES: holding gauze/lap pad to swab surgical siteo To dry site; soak up fluids

C. Young tongue holding forceps – box lock, shank, ring handles and ratchet

USES: Manipulating the tongueo Jaws are oval loops with a rubber insert o Blades are slightly shorter and wider than Foresters

6. Retractors- exposing instruments; may be hand held or self-retaining

USES: to atraumatically improve field of vision; give surgeon more room for viewing wounds/incisions

TYPES:Hand held:

A. *Snook hook (ovariohysterectomy hook) – looks like a shepherd’s hooko Specifically for grabbing uterine horns during OHE

B. Volkmann Retractor – looks like a curved forko Number of prongs can vary

C. Army-Navy retractor – flat, blunt blade that is bent on each endo The projection on one end is longer than the other projectiono Hole in the center of bladeo Commonly used to retract muscles from bones

D. Senn retractor – curved 3-prong claw at one end; bent, flat blade on the other end (pointing opposite directions)

E. Malleable retractor – thin metal that is bent to desired shape

Self-retaining:

F. Balfour abdominal retractor – 3 adjustable curved loops, mounted on a baro Middle portion rests on xiphoid; lateral loops open the incision

laterallyo Comes in pediatric size too

USE: Retract abdominal wall for access to peritoneal cavity

G. Finochietto rib spreader – two broad, outward facing blades mounted on a ratcheted bar = 6-12” spread

o Handle to adjust distance by turning

USE: gaining access to thoracic cavity during thoracotomy holds ribs apart

H. Gelpi retractor – points, blades, finger rings, ratcheted hingeo Very sharp points that separate as the hinge is closedo Wide shafto Points face away from each othero Can buy stops to put on the points

USE: opening deep wounds

I. Weitlaner retractor– claws, blades, finger rings, ratcheted hingeo Claws open as hinge is closed (opposite of scissors)o Prongs point away from each othero 3 x 4 interdigitating teeth

7. Stapling Devices – fast and easy application compared to suturing; can be internal OR external depending on which stapler is used

USES: primary wound closure; vessel ligation; anastomosis Good for patients with suture reactions Can be plastic with pre-loaded staples (one patient use) or stainless steel

with clips that you order and re-load (reusable)o But really we reuse everything in veterinary medicine…

TYPES: A. Skin stapler – primarily closing skin incisions; staples are stainless steel;

plastic; “one time use”o Faster than suturing o Few allergic reactionso Also used for securing catheters, nasal cannulas, feeding tubes, etc with

the use of butterfly wings

B. Surgical clip applicator – closing visceral wounds/incisions; ligating vessels (internal)o Example: Ligaclip Stapler – quickly ligating vessels; fires one staple at a

time when handles are squeezed o Example: Hemoclip Applicator – ligate vessels after taking organ biopsieso Staples are permanent o Stapler must be sterilized before/after use

C. Skin staple remover- required to remove skin staples

Dilating Instruments:

1. Speculums- may be plastic or steel

USES: to open up a narrow passageway

TYPES: A. NasalB. VaginalC. Oral

2. Cannulas- hollow tubes

USES: for delivery of fluids, or removing blockages

TYPES:

A. Lacrimal cannula – to flush the lacrimal ducto Aluminum hub; small as 30 gaugeo Curved or straight

Can also be used for anal sac duct flushing

Miscellaneous Surgical Equipment:

1. Suction Tips- tip attached to a long, sterile polyethylene tube, which is attached to a vacuum (suction machine) and plugged in

USES: clearing blood/fluid from surgical site, lavaging wounds, dentals o Ex. GI surgery w/ gastric lavage

TYPES:A. Poole suction tip – plastic; made of two tubes within each other; taken apart

for cleaning Can be curved or straight o Outer tube is like a sleeve with holes throughout it:

Avoids clogging of tip Distributes suctioning power

USES: suctioning large volumes of fluids from surgical field o Commonly in abdominal or thoracic cavities

B. Yankauer suction tip – stainless steel or plastic; hollow tube with a curve and a bulbous head; only one hole for suctioning

USES: removing secretions during oral surgery, suctioning fluid

C. Fraizer suction tip – small and slender; various diameters (measures in Fr)o Small hole on the handle to regulate degree of suction

USES: remove very small amount of fluid (in place of gauze)

2. Mayo Instrument Stand – metal device with two wheels on the same side, and flat projections on the other side

USES: to hold instruments during surgery

o Covered with a sterile huck towel or a drape before instruments are placed

o Adjustable heighto Can also be attached to the surgical table and have a swivel

3. Surgical Table – used for holding the patient during surgeryo Can usually move up and down to fit surgeon’s heighto Can sometimes form a “V” shape by lifting both sideso May or may not be heated (VTI has a heated table!)

4. Groove directors – used to guide scalpel blade Stab incision made in skin, inserted in (above the muscle), keeps surgeon

from accidentally cutting deeper layers Most surgeons just use thumb forceps to hold the superficial

layers up and out of the way

5. Thoracic positioner – “V-trough”; used to stabilize patient/position for surgery Can be plastic or foam Not needed if your surgical table forms a V

6. Instrument tip protectors – to protect tips of instruments when not in use (in the drawers or sterilized in the pack)

7. Instrument tape – used to label instruments by color coding (expensive) Can be sterilized with this tape on

8. Light handle- plastic handle that attaches to a surgical lamp in order for the sterile surgeon to direct the light source as they see fit

Can usually be autoclaved

Ophthalmic Instruments: Used for procedures involving the eye

1. Iris scissors – small, delicate scissors; usually sharp/sharp

2. Ophthalmic needle holders

TYPES:A. Castroviejo needle holders – delicate needle holders; with or without lock;

straight or curvedo Long handles, spring action, delicate jawso Catch and release in the middle

USE: corneal surgeries (laceration, cataract), third eyelid prolapse repair

B. Derf needle holders – smaller version of Mayo-hegar needle holders (4-5 inches) Can have carbide jaws

USE: suturing eyelid lacerations, tarsorrhaphy, entropion, extropion, enucleations, etc

3. Ophthalmic retractors – retracting the eye lid open; come in multiple sizes

TYPES:

A. Cook eye speculum – two curved, outward facing blades attached to a baro Screw for adjusting the size self-retaining o Each blade gently retracts one eyelid away from the other eyelid

B. Barraquer speculum (eye lid speculum) – wire; no screw adjustment Self-retaining

C. Desmarres Lid Retractor- retracting EITHER the upper or lower eyelid; must be held while in use

Orthopedic Instruments: Used for procedures involving the prevention and correction of muscles, bones, joints, tendons, and ligaments

Ex. FHO, amputations, fx repair, cruciate ligament repair, etc…

1. Periosteal elevators – has a blade like structure at one or both ends

USES: to pry off periosteum or muscle from bone surface

TYPE:A. Freer elevator

2. Bone holding forceps

USES: to hold bone fragments in line while positioning orthopedic implants are applied; available in various sizes

TYPES:A. Kern bone holding forceps- four pointed prongs on the jaws; may or may not

have a locking mechanism

B. Clam shell bone holding forceps- jaws look like a clamshell

3. Ruskin Rongeurs – hand held; sharp, heavy, cupped jaws with rounded tips

USES: to cut/remove small pieces of dense tissue (bone, cartilage, or fibrous tissue) Double-action mechanism; can be straight or curved; various jaw sizes

4. Liston bone cutting forceps- used to cut bone; single action w/ angled blades Heavy duty, sturdy box lock With or without a spring locking mechanism

5. Bone curette – look like an ice cream scoop, but with a sharp cutting edge Available in many sizes

USES: to scrape hard tissue (bone, cartilage, or fibrous tissue)

6. Osteotome/Chisel – difference is osteotome has a double beveled sharp edge; chisel has a single beveled edge

USES: to cut through or shape bone; must be used in conjunction with a mallet

7. Mallet- drives cutting tip of instrument into the bone; provides the force

8. Bone rasps – used to cut/file bone smooth rough edges

9. Gigli wire – comes in various gauges

USES: to cut bone; must be used in conjunction with T-shaped handles

Wraps around bone and used in a saw like fashion o Ex: at the zoo we used gigli wire to trim elephant tusks and goat horns

10. Hohmann retractor – single blade and handle; sometimes has holes on bottom of handle Flat blade with a small, sharp beak at the tip

USE: mostly used in joint surgeries; can be used to retract tissue away from bone

11. Michele trephine—heavy duty, T-shaped boring tool with graduated diameter shafts that end in circular, sharp edges

The top of the “T” is the handle Available in various sizes from 5-8 mm

USE: obtain samples of cortical or cancellous bone (biopsy)

Orthopedic Implants and Tools:

1. Steinmann pins – also called intramedullary pins (IM pins) Vary in length, diameter, type of point Stainless steel pin inserted into IM cavity Can be smooth or threaded Usually come in large packs with multiple widths and lengths

USES: fracture fixation

2. Jacob’s Hand Chuck – required to insert IM pin into bone Tightens down around the IM pin with the use of a key Must have the key to be operational! Don’t forget to sterilize this too!

3. Pin cutter – necessary to cut IM pins to the proper length

4. Orthopedic wire – stainless steel wire on a spool Comes in many gauges (18-22 most common) Applied with a wire twister

USE: to secure orthopedic implants in place; sometimes to oppose rotational forces

5. Wire twister – has two holes in which wire is inserted Once wire is circling the bone, it is twisted like a twist tie

USES: bone stabilization in conjunction with plates and pins

6. Bone screws – come in many lengths and diameters Required to be drilled in place into the bone

7. Bone plates- named by the number of screw holes and the screw diameter size Example= 4 hole 3.0 mm plate Requires- drill, bits, guides, depth gauges, screws, plate benders

8. Plate benders – bend bone plates to fit patient’s anatomy