Surgical instrumentation [2nd ed] 9781337517362, 1337517364

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Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202

SURGICAL

INSTRUMENTATION

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

SURGICAL

SECOND EDITION

INSTRUMENTATION

Nancymarie Phillips RN, PhD, BA, BSN, MEd, RNFA, CNOR(E)

Australia

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Brazil

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United States

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Surgical Instrumentation, Second Edition

© 2019, 2010 Cengage Learning, Inc.

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CONTENTS

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii CHAPTER 1  HISTORY OF SURGICAL INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 1 Historic Surgical Instrumentation . . . . . . . . . . . . . . . . 1 Ritual and Magic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

CHAPTER 2  ANATOMY OF SURGICAL INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 5 Evolution of Modern Surgical Instrumentation . . . . . 5 Anatomy of a Surgical Instrument . . . . . . . . . . . . . . . . 6 Handle Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Joint Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Tip and Jaw Styles: Sharp Dissection . . . . . . . . . . . 11 Tip and Jaw Styles: Clamping, Occluding, and Grasping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Tip Styles: Blunt Dissection . . . . . . . . . . . . . . . . . . . 15 Categories of Surgical Instruments . . . . . . . . . . . . . . . 16 How Surgical Instruments Are Named . . . . . . . . . . . 17 Materials Used in the Manufacture of Surgical Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Metallics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Steel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Copper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Silver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Surface Finishes of Metallic Surgical Instruments . . 19 Inspection and Quality Control of Metallic Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . 19 Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Clamps, Needle Holders, and Graspers . . . . . . . . . 20 Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Cleaning and Lubrication . . . . . . . . . . . . . . . . . . . . 21 Ultrasonic Cleansing . . . . . . . . . . . . . . . . . . . . . . . . 21

CHAPTER 3  CATEGORIES OF SURGICAL INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . 23 Clamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Basic Hemostatic Clamps . . . . . . . . . . . . . . . . . . . . 24 Grasping Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ring-Handled Grasping Forceps . . . . . . . . . . . . . . 39 Non-Ring-Handled Grasping Forceps . . . . . . . . . . 41 Dissection Instrumentation . . . . . . . . . . . . . . . . . . . . . 48 Sharp Dissection Instrumentation . . . . . . . . . . . . . 48 Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Manual Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Probes and Dilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Measurement and Expansion . . . . . . . . . . . . . . . . . 62 Evacuation and Instillation Instrumentation . . . . . . 66 Evacuation Instrumentation . . . . . . . . . . . . . . . . . . 66 Injection and Irrigation Devices . . . . . . . . . . . . . . . 68 Retraction and Exposure . . . . . . . . . . . . . . . . . . . . . . . 68 Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Approximation and Closure Instrumentation . . . . . 77 Suturing Instrumentation . . . . . . . . . . . . . . . . . . . . 77 Anesthesia Intubation Instruments . . . . . . . . . . . . . . 83

CHAPTER 4  CONSIDERATIONS FOR INSTRUMENT SET ASSEMBLY . . . . . . . . . . . . 86 Instrument Containers and Trays . . . . . . . . . . . . . . . . Perforated Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . Closed Rigid Containers . . . . . . . . . . . . . . . . . . . . . Specialty Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assembly of Instrument Sets . . . . . . . . . . . . . . . . . . . . Determining Instrument Set Contents . . . . . . . . . Counts and Accountability . . . . . . . . . . . . . . . . . . . Overview of Processing Options . . . . . . . . . . . . . . . . .

89 89 90 91 91 91 92 93

CHAPTER 5  SOFT TISSUE FOUNDATION SETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Short Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . . 96



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vi Contents

Excisional Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Medium Foundation Set . . . . . . . . . . . . . . . . . . . . . . . 109 Soft Tissue Dissection . . . . . . . . . . . . . . . . . . . . . . 109 Long Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Laparotomy Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Extra-Long “Add-On” Set . . . . . . . . . . . . . . . . . . . 135

CHAPTER 6  PLASTIC SURGERY INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 136 Basic Plastic Surgery Instrumentation . . . . . . . . . . . Basic Plastic Surgery P ­ rocedures . . . . . . . . . . . . . . . . Rhytidectomy-Browlift . . . . . . . . . . . . . . . . . . . . . Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surface and Subsurface P ­ rocedures . . . . . . . . . . . . . Debridement and Excisional Procedures . . . . . . Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Breast Augmentation-Reduction Procedures . . .

136 164 164 164 164 164 164 165

CHAPTER 7  GENERAL SURGERY INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 166 General Surgery Major Laparotomy Tray . . . . . . . . 166 Gastrointestinal Instrumentation for Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Cholecystectomy Add-Ons . . . . . . . . . . . . . . . . . . 180 Liver and Stomach Add-Ons . . . . . . . . . . . . . . . . .182 Lower Gastrointestinal Instrumentation for Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 184 Bowel Resection Add-Ons . . . . . . . . . . . . . . . . . . . 184 Rectal-Anal Instruments . . . . . . . . . . . . . . . . . . . . . . 189 Hemorrhoidectomy and Rectal Excision . . . . . . 189

CHAPTER 8  GYNECOLOGIC INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 195 Basic Gynecologic Instrumentation . . . . . . . . . . . . . Basic Gynecologic Procedures . . . . . . . . . . . . . . . . . . Abdominal Hysterectomy . . . . . . . . . . . . . . . . . . . Vaginal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . Vaginal-Perineal Procedures . . . . . . . . . . . . . . . . . . . Dilation and Curettage . . . . . . . . . . . . . . . . . . . . . . Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . .

196 227 227 227 227 227 228

CHAPTER 9  UROLOGIC INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 229 Open Urology Instrumentation . . . . . . . . . . . . . . . . . Nephrectomy, Cystectomy, and Prostatectomy Instrumentation . . . . . . . . . . . . Testicular Instrumentation . . . . . . . . . . . . . . . . . . Uroplasty Instrumentation . . . . . . . . . . . . . . . . . . Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

229 230 238 240 242

CHAPTER 10  BASIC BONE AND JOINT INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 244 Plates and Screws: Fracture Fixation Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Drills and Power Equipment . . . . . . . . . . . . . . . . . . . . . . 250 Bone Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Small Bone Instruments . . . . . . . . . . . . . . . . . . . . .254 Large Bone Instruments . . . . . . . . . . . . . . . . . . . . . 254

CHAPTER 11  HEAD AND NECK

PROCEDURE INSTRUMENTATION . . . . . . . 285 Ear and Mastoid Instrumentation . . . . . . . . . . . . . . . Ear Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . Mastoid Instrumentation . . . . . . . . . . . . . . . . . . . . Nose and Throat Instrumentation . . . . . . . . . . . . . . Intranasal and Pharyngeal Instrumentation . . . . Anterior Neck Instrumentation . . . . . . . . . . . . . . . . . Thyroidectomy and Neck Dissection Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . Tracheostomy-Tracheotomy Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . .

285 286 293 297 298 315 315 317

CHAPTER 12  NEUROSURGERY INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 319 Basic Neurosurgical Instrumentation . . . . . . . . . . . . 319 Cranial Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Spinal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .340

CHAPTER 13  CARDIOTHORACIC AND VASCULAR INSTRUMENTATION . . . . . . . . . 342 Basic Cardiothoracic and Vascular Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Basic Cardiothoracic and Vascular Procedures . . . 375

CHAPTER 14  MICROSURGERY INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 376 Basic Microsurgery Instrumentation . . . . . . . . . . . . 376

CHAPTER 15  ENDOSCOPIC INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 395 Essential Components of Endoscopic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Percutaneous Endoscopy Procedures . . . . . . . . . Nonpuncture Endoscopy . . . . . . . . . . . . . . . . . . . . Access and Creation of the Working Space . . . . . . . Illumination and Viewing within the Working Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

395 396 396 396 397

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.



Contents

Manipulation within the Working Space . . . . . . . . . 397 Irrigation and Evacuation within and from the Working Space . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 ­ orking Space . . . . . . . . . . . . . . 397 Closure within the W Specialty Instrumentation . . . . . . . . . . . . . . . . . . . . . 397 Essential Endoscopic Instrumentation . . . . . . . . . . . 398 Basic Endoscopic Procedures . . . . . . . . . . . . . . . . . . 409 Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Robotic-Assisted Percutaneous Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 Neuroendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412 Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 Upper Airway Endoscopy . . . . . . . . . . . . . . . . . . . 412 Urologic Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . 412

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CHAPTER 16  DECONTAMINATION AND STERILIZATION . . . . . . . . . . . . . . . . . . . 413 Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Instructions for Use (IFUs) . . . . . . . . . . . . . . . . . . 414 Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .414 Inspection/Packaging . . . . . . . . . . . . . . . . . . . . . . . . . 416 Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 Disinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418 Sterile Storage and Packaging . . . . . . . . . . . . . . . . . . 419 Microbiological Concerns . . . . . . . . . . . . . . . . . . . 421 Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . 422

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

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PREFACE

This text, Surgical Instrumentation, Second Edition, is designed for perioperative personnel in all surgical disciplines. Surgeons, nurses, technologists, and technicians will find the design and collections in this book informative and user friendly. Books about surgical instrumentation have been in print for more than 100 years. However, none have offered comprehensive collections of instruments used with foundation sets for multiple specialties. They feature individual instruments without providing guidance for establishing or streamlining the set creation process.

instrumentation and provides background information about the philosophy and contributions of different cultures to the discipline of surgery. ●●

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THE DEVELOPMENT OF THIS TEXT The four foundation sets described in this text are designed to be base units for use during procedures that meet the needed instrument weight, length, gauge, shape, and material necessary for a safe, efficient surgical procedure. The additional instrument groupings, such as those specific to a particular organ or region of the body, can be established as “add-on” sets to be used in combination with the appropriate foundation set. Every perioperative nurse or surgical technologist who scrubs has encountered sets with instruments that have not been used for many years, yet the items continue to be packed into the tray for no apparent reason. This book may serve as a guide for establishing standardized instrument sets that will facilitate the count process and ease the burden of inventory control.

ORGANIZATION OF THE TEXT This text is divided into 16 chapters. Images of the surgical instrumentation are displayed in table form with descriptions and sizes listed. ●●

History of Surgical Instrumentation. The first chapter describes the history of surgical

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Anatomy and Physiology of Surgical Instrumentation. The materials and characteristics of surgical instruments are explored, as well as the design from handle to tip. Categories of Surgical Instrumentation. Surgical instruments are designed for specific functions and are grouped into functional categories that define the purpose for each instrument. Specific groupings make it easier to learn the instruments. Considerations for Instrument Set Assembly. Trays and containers for packaging instruments are described in this chapter. Accountability is a team effort that begins with the construction and assembly of each set. Soft Tissue Foundation Sets. The foundation sets are designed to meet specific needs for a procedure at a basic level by grouping instruments by category and function. Plastic Surgery Instrumentation. Instruments specific to the type of plastic surgery procedure are described in combination with foundation sets. General Surgery Instrumentation. Functional instruments that are added to foundation sets for general surgery are described by organ system and body location. Gynecologic Instrumentation. Specialty instrumentation specific to the needs for surgery of the female reproductive tract is described. Urologic Instrumentation. Instrumentation specific to genitourinary procedures of the urethra and kidney is included in this chapter.

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Preface ●●

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Basic Bone and Joint Instrumentation. Many specialties utilize instrumentation to debulk, dissect, or repair bony tissue throughout the body. The bone instruments are used in combination with soft tissue foundation sets according to the location on the body. Head and Neck Procedure Instrumentation. Upper airway and otorhinolaryngology procedures require specialty instrumentation designed for narrow passages and the soft tissues of the anterior neck and throat. Neurosurgery Instrumentation. Procedures of the brain and spinal cord use a unique blend of soft tissue sets, compact tissue sets, and microsurgical sets. Instrumentation for procedures of the cranium and spine is described. Cardiothoracic and Vascular Instrumentation. Instrumentation used for surgical procedures

ix

of the lungs, heart, and vascular system is ­described. ●●

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Microsurgery Instrumentation. Microsurgery is usually performed on soft tissues. These sets can be used in combination with foundation sets or as stand-alone sets. Endoscopic Instrumentation. The application of endoscopic techniques to multiple specialties is described. Percutaneous and natural orifice endoscopy is described in functional terms. Decontamination and Sterilization. A critical component in a complete understanding of surgical instrumentation is understanding decontamination and sterilization of the instruments. This new chapter includes information on cleaning (manual and mechanical), inspection, disinfection, sterilization, and packaging.

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

ABOUT THE AUTHOR

Nancymarie Phillips, RN, PhD, BA, BSN, MEd, RNFA, CNOR(E). Dr. Phillips is the Professor Emeritus for Perioperative Education at Lakeland Community College in Kirtland, Ohio. Her programs included Periopera­tive Nursing, Registered Nurse First Assisting, and Surgical Technology. She has authored numerous articles and texts about perioperative patient care. She was the 2006 recipient of the AORN Perioperative Clinical Education Award, the 2006 Lakeland Community College Teaching Excellence Award, and was a nominee for the 2006 Ohio Magazine Excellence in Education Award. Dr. Phillips has been a perioperative nurse since 1975. In addition, she has worked as a scrub nurse, circulator, first assistant, consultant, author, and educator. She can be reached at [email protected]. Her RNFA education website is www.nvo.com/delphipro.

x Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

ACKNOWLEDGEMENTS

We thank Denell Lewalk, MLS, and Jennifer Gerres, DPM, for their assistance in this massive undertaking. The author and Cengage Learning wish to extend a deep gratitude to Berkeley College School of Health Studies, Woodland Park, NJ campus for providing their lab and instruments for a photoshoot. Special thanks to Joseph Charleman for his assistance with the arrangements, preparation, and logistics of this photoshoot. We would also like to acknowledge the following individuals for their assistance with the photoshoot: Mike Gallatelli, photographer Metroland Photo www.metrolandphoto.com

Joseph Charleman, CST, CSFA, CRCST, LPN Chapter 7: General Surgery Instrumentation Chapter 10: Basic Bone and Joint Instrumentation Chapter 16: Decontamination and Sterilization

Margaret Rodriguez, CST, CSFA, FAST, BS Chapter 2: Anatomy and Physiology of Surgical Instrumentation Chapter 4: Considerations for Instrument Set Assembly Chapter 5: Soft Tissue Foundation Sets Chapter 9: Urologic Instrumentation Chapter 11: Head and Neck Procedure Instrumentation

Annadelia De La Cruz, AAS, BA Administrative Assistant Surgical Technology & Surgical Processing Department

REVIEWERS

Mayra Y. Cabrera, AAS, CST Clinical Coordinator Surgical Technology & Surgical Processing Department

Rob Blackston CST, CSFA Program Director of Surgical Technology North Idaho College Coeur d’Alene, ID

Robert Torres, BA, CRCST, CHL Clinical Site Monitor Surgical Technology & Surgical Processing Department

David Braun, CST, CRCST Program Director/Instructor School of Surgical Technology Western Suffolk BOCES Northport, NY

CONTRIBUTORS The author and publisher would like to acknowledge the following professionals for contributing to the content of this book:

Julia Hinkle, RN, MHS, CNOR Professor/Program Chair Ivy Tech Community College Evansville, IN



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Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

xii Acknowledgements

Rosemary Nagler Assistant Principal Health Careers/Clinical Education Coordinator of Surgical Technology Western Suffolk BOCES Northport, NY Alisia Pooley, CST Surgical Technology Instructor Mohawk Valley Community College Rome, NY

Mecklin Soules, CST, AAS Surgical Technology Program Director Meridian Community College Meridian, MS Stefanie Vaughn, CST Program Director of Surgical Technology Angelina College Lufkin, TX

Mary Seely, CST, AS Surgical Technology Program Director Monroe Community College Rochester, NY

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

ABOUT THE INSTRUMENTS

The instruments appearing in this book have been graciously provided by the following manufacturers: CareFusion Becton, Dickinson and Company 1 Becton Drive Franklin Lakes, NJ 07417-1880 Phone: 201-847-6800 Cook Medical, Inc. www.cookmedical.com P.O. Box 489, 750 Daniels Way Bloomington, IN 47402-0489, USA 812-339-2235 Integra LifeSciences Corporation www.integralife.com JARIT Surgical Instruments Padgett Surgical Instruments R&B Surgical Instruments Ruggles Surgical Instruments 311 Enterprise Drive Plainsboro, NJ 08536 Phone: 609-275-0500 Intuitive Surgical, Inc. www.intuitivesurgical.com 1020 Kifer Road Sunnyvale, CA 94086-5304 Phone: 408-523-2100

Scanlan International www.scanlaninternational.com One Scanlan Plaza Saint Paul, Minnesota 55107 International: 651-298-0997 U.S. & Canada: 800-328-9458 Fax: 651-298-0018 Email: [email protected] Sklar Instruments www.sklarcorp.com 889 South Matlack Street West Chester, PA 19382 Phone: 610-756-7863 Email: [email protected] Sontec Instruments www.sontecinstruments.com 7428 South Tucson Way Centennial CO 80112 800-821-7496 Teleflex Medical http://www.teleflex.com 3015 Carrington Mill Boulevard Morrisville, NC 27560 919-544-8000



xiii Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

CHAPTER 1

HISTORY OF SURGICAL INSTRUMENTATION OBJECTIVES

CHAPTER OUTLINE

After reading this chapter the learner should be able to: 1. Describe several historic findings that indicate ancient humans used surgical instruments. 2. Discuss the countries that contributed ideas to the surgical armamentarium. 3. List several materials that comprised early surgical instruments.

Historic Surgical Instrumentation Ritual and Magic

INTRODUCTION Since the beginning of time, man has sought to appease the gods and remedy the failings of the human body with the medical and surgical arts. Each culture has historically approached medicine and surgery in a different way and has lent a societal touch to the evolution of surgical practice.

HISTORIC SURGICAL INSTRUMENTATION Forms of early surgical practice encompassed tending injuries and wounds associated with animal encounters or battles. Some Neolithic tribes were known to have practiced amputation for serious injury, tumors, or infection. Relics of surgical instruments, such as sharpened flints and natural substances like shells, have been found wherever civilizations have been uncovered. Scientists have speculated dates ranging from 10,000 bc for early incisions to 2500 bc for suturing with horsehair or animal tendons. Hindus developed the earliest known organized practice of surgery (shastrakarma), which is one of the eight branches of Ayurveda (Indian medicine). Shushruta (circa 800 bc), a medical practitioner from Benares, India, wrote the Samhita. In this text he described the need for cleanliness and precision in surgical treatment. His writings were captioned under seven topics: esya (exploration), ahrya (extraction), chedya (excision), lekhya (scarification), vedhya (puncturing), vsraya (evacuation), and sivya (suturing). He based his methods of surgery on his studies of anatomy using dead bodies. Shushruta developed 121 separate surgical instruments of natural materials, such as bone, ivory, mussel shell, and stone. He also advocated the use of hypnosis and wine as anesthetics.

1

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Surgical Instrumentation

the internal anatomy sacred. Archeologists discovered papyri that described medical care during this period. In 1862, American Edwin Smith purchased a 22-page papyrus, dating from 1500 bc that contained many treatments performed during ancient times. It was later deciphered by James Henry Breasted. German Egyptologist George Ebers purchased a similar papyrus in 1872 that consisted of 110 pages that dated back to the First Dynasty in 3000 bc. A later papyrus was written as a guide for midwives and those who cared for female patients. These papyri contained medical and surgical references intermingled with magical spells for protection against supernatural forces. Cataract surgery, known as couching in many ancient lands, was a common procedure between 1345 and 1200 bc. This surgery was performed by using a rodlike tool with a blunt end to tap the eye, causing the lens to shift away from the pupil. This allowed light to enter. Later methods of performing this procedure included inserting a needle into the eye to dislodge the natural lens (Figure 1-2).

RITUAL AND MAGIC

Courtesy of the National Library of Medicine

Prehistoric man performed documented incisional procedures as early as 6000 bc. Scientists speculate that some procedures, such as opening holes into the skull (known as trepanation), were performed for ritualistic or magic reasons. Significant numbers of skulls have been found that indicate the patients lived for many years after the procedure, as new bone growth was identified around the cut edges of the bony holes. Figure 1-1 depicts trepanation instruments used for opening skull bone. The ancient Egyptians did not feature cutting as a primary medical treatment. Egyptian temple and tomb art indicates that most of the anatomic study involved the embalming of bodies for burial. The religious sects were guardians of physical knowledge and held

Figure 1-1  Ancient trepanation instruments.

Courtesy of the National Library of Medicine

2

Figure 1-2  Instruments used historically for cataract surgery.

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Chapter 1 History of Surgical Instrumentation

Mesopotamian society (circa 3500 bc) exercised generalized laws and rules governing conduct. They had a concept of comparative worth concerning human life and believed in medical training before commencing practice. The physicians in Mesopotamia identified specific procedures, named each drug used in medical care, and kept records of medical and surgical activities by carving cuneiform figures into clay tablets. Over 20,000 such tablets have been discovered. Ancient Babylonians (modern-day Iraq) were led by the great King Hammurabi (1795–1750 bc). He established the first known major metropolis and set forth the law that bears his name. The law was clear with regard to medical treatment. A surgeon who successfully treated his nobleman patient would be paid 10 shekels for his labor. If he treated a slave, he was paid 2 shekels, and for treatment of a freeman, he would be paid 5 shekels. If the nobleman or freeman patient died, the surgeon could lose a hand. If a slave died, the surgeon had to repay the cost of the slave to his master. The law was carved in black diorite stone that stood 8 feet tall and was designed like a monument for display in a public location in the city until it was taken by warring tribes as a trophy. It was discovered in Persia in 1901. The entire code of Hammurabi has been translated into English and is available online. Greek civilization gave rise to more organized written texts on medicine and health. The Greeks encouraged a scholarly approach and established formal schools. Most of the surgery performed dealt with war wounds and orthopedic injury. The Greeks used palm bark and wood bound by moist clay and linen strips like splints to stabilize broken bones. Hippocrates (460–377 bc) used instruments of hardened iron, copper, bronze, and brass. His surgical armamentarium consisted of more than 200 types of surgical instruments. Although physicians were trained in medical and surgical treatments, the main focus of healthcare dealt with diet and exercise. The early Romans had knowledge of steel. The ancient ruins of Pompeii (circa 310 bc to 79 ad) revealed an instrument manufacturer’s place of business with preserved bundles of surgical tools made of several metals wrapped in protective fabric. Homes of physicians revealed beautifully carved boxes for instrument storage. Most of the surgical practice was borrowed from other cultures. Couching was performed as a

3

necessity to displace cataracts. Surgery was considered manual labor, and the ancient Roman physicians contributed very little to surgical knowledge. In fact, artists frequently had a greater knowledge of the human body than physicians because they studied corpses during postmortem dissection. Arabian surgeons established a school for brain surgery in Islam in 800 ad. Other surgical procedures were also performed, such as couching. However, little was known of human anatomy because human dissection was banned by the Koran. During this era, Andalusia (Moorish Spain) was part of the Islamic Empire. A famous skilled Moorish surgeon of the time, El Zahrawi (940–1013 ad), wrote an encyclopedia of 30 volumes referred to as the At-Tasrif to record methods of medical and surgical treatment. He taught his students to treat each patient as an individual and to practice within ethical limits. His writings guided the development of most surgical textbooks in European universities between the 12th and 17th centuries ad. Many of the surgical instruments used during that period were designed by El Zahrawi himself, who personally drew the 200 illustrations for his texts. He is also credited with being the first to use ligatures for hemostasis in surgery. The history and images of El Zahrawi and other Muslim physicians are available online at http://www.muslimheritage .com/surgery. The Chinese practiced acupuncture and acupressure for at least 2000 years of recorded history. The central belief of these practices is that there is a mind–body–spirit connection to health and wellness associated with the ch’i, or life force. The main focus of health and wellness was not based in surgical procedures, but in a pharmacopoeia of 1800 medicinal herbs, biologic materials, and chemicals. The ancient Aztec civilization left little written history, but significant evidence of successful surgery has been unearthed in archeological explorations. They had a strong knowledge of human anatomy because their culture practiced human dissection on their enemies. They felt that they captured the essence of the life force if they cut the beating heart from the chest of their captives. Blood sacrifice was a daily event. The main feature of their surgical armamentarium was sharp dissection of bone and soft tissues.

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4

Surgical Instrumentation

SUMMARY Throughout history, physicians have devised and modified available materials for use in surgical procedures. As scientists contributed new knowledge of metals and eventually synthetics, such as plastics, instrumentation became more functional, incorporating the principles of physics. The increasing

REFERENCES Ahmed, M. (2008). Muslim scientists and scholars. Retrieved from www.ummah.net/history/scholars. Haeger, K. (1988). The illustrated history of surgery. New York: Bell.

knowledge base concerning human anatomy and physiology led physicians to create new tools for exploration and treatment of body regions never surgically treated before. With each successive era, the sophistication of surgical instrumentation has improved significantly.

Phillips, N. M. (2016). Berry and Kohn’s operating room technique (13th ed.). St. Louis: Mosby-Elsevier. Rutkow, I. M., & Burns, S. B. (1998). American surgery: An illustrated history. Philadelphia: Norman Publishing.

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CHAPTER 2

ANATOMY OF SURGICAL INSTRUMENTATION OBJECTIVES

CHAPTER OUTLINE

After reading this chapter the learner should be able to: 1. Discuss the evolution of ancient surgical instruments into designs in current use. 2. Describe the ergonomics of instrument design. 3. List the three essential design components of every surgical instrument. 4. List the common metals used in modern surgical instrumentation.

Evolution of Modern Surgical Instrumentation Anatomy of a Surgical Instrument Handle Styles Joint Styles Tip and Jaw Styles: Sharp Dissection Tip and Jaw Styles: Clamping, Occluding, and Grasping Tip Styles: Blunt Dissection Categories of Surgical Instruments How Surgical Instruments Are Named Materials Used in the Manufacture of Surgical Instrumentation Metallics Steel Copper Titanium Silver Surface Finishes of Metallic Surgical Instruments Inspection and Quality Control of Metallic Surgical Instruments Scissors Clamps, Needle Holders, and Graspers Forceps Retractors Maintenance Cleaning and Lubrication Ultrasonic Cleansing

INTRODUCTION Surgical instrumentation is one of the essential elements of a safe and efficient operating room. Even in the most skilled hands of a surgeon, the instruments must be in good condition and function as intended to prevent potential tissue damage. Surgical procedures require the use of a variety of instruments of different sizes, shapes, and chemical compositions in order to achieve a safe and optimal outcome for the patient. This chapter explores the broad range of unique design specifications of surgical instrumentation used to perform invasive procedures on all types of tissues and anatomic structures.

EVOLUTION OF MODERN SURGICAL INSTRUMENTATION As discussed in Chapter 1, civilization has evolved and so, too, have surgical instruments and procedures. Conversely, human anatomy has not changed significantly over the centuries; however, the practice of surgical intervention has become increasingly complex in its goal to treat disease while minimizing tissue trauma, pain, and recovery time for patients.

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6

Surgical Instrumentation

Despite these changes, much of our basic modern instrumentation has been modeled after long-standing styles with modifications for contemporary surgical procedures.

ANATOMY OF A SURGICAL INSTRUMENT Basic design specifications are generally standardized according to the required function of the instrument. Modifications in size, shape, and design are made to accommodate the variety of human anatomic structures. Instruments can be classified by their use and function, which then determine the unique designs and shapes. A simple form of instrument anatomy is depicted by the small mosquito hemostat shown in Figure 2-1. It has all the standard design components, such as jaws, box locks, shanks, and handles. The essential standardized design components include the following: ●●

The handle or other form of hand grip held by the surgical practitioner

●●

●●

The functional or connecting joint mechanism that allows the instrument sides to stay together in order to perform its task The tips and jaws are the working ends that come into contact with the patient’s tissues and may be sharp, blunt, smooth, toothed, serrated, crushing, or noncrushing, also known as atraumatic.

Keeping these components in mind, the design possibilities are nearly limitless. Surgical instruments can be as simple as a flat sheet of metal or a single rod, or as complex as having up to 15 to 20 parts and pieces. Newer energized instrumentation can make contact with the patient’s tissues through electrical current, radio frequencies, or collimated laser light waves.

Handle Styles Handles are designed to optimize the operator’s functional grip and dexterity. The working parts of an

Tip Jaws

Box Lock

Shanks

Finger Rings

© Cengage®.

Ratchet

Figure 2-1  Basic anatomy of a surgical instrument (Halsted mosquito clamp). Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

7



Chapter 2 Anatomy of Surgical Instrumentation

instrument’s jaws determine the style of the handle. Controlled and precise actions such as cutting, dissecting, and clamping require steady and secure manipulation as provided by ring handles and compression grips (Figure 2-2). Compression handles are pressure sensitive for precision closing power on heavy or firm tissues such as bone, cartilage, or fascia. Spring handles are preferred for microsurgery because activation of the jaws requires only minute motion to effect action

on delicate tissues (Figure  2-3). Ratchets are used to lock and keep constant pressure from both sides of the instrument to occlude flow, provide traction, or hold structures together (Figure 2-4). Pistol grip handles provide additional leverage for instruments with longer shafts used in narrow anatomic spaces or small incisions such as in open nasal or spinal procedures and in laparoscopic instruments, which must be inserted through percutaneous trocar cannulas (Figure 2-5).

B. Grooved handle

C. Grooved handle with horn

Figure 2-2  Ring handles and compression handle grips. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

A: Courtesy of Sklar Instruments. B: Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ. C: © 2019 Cengage®.

A. Ring handles

8

Surgical Instrumentation

A. Double-leaf spring

B. D  ouble-leaf locking spring

D. Bar and locking nut

E. Bar ratchet

A–B: © 2019 Cengage®. Photo by Margaret Rodriguez. C–D: Courtesy of Sklar Instruments. E: © 2019 Cengage®.

C. Cam ratchet

Figure 2-3  Spring handles and locking handle grips. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Chapter 2 Anatomy of Surgical Instrumentation

A. Ratchet lock

D. Single spring

B. Thumb screw

E. Double spring

C. Twist screw

F. Double spring with ball and socket joint

Figure 2-4  Locking and opposition handle system.

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9

A, C: Courtesy of Sklar Instruments. B, D–E: © 2019 Cengage®. F: Courtesy of CareFusion, a divison of Becton, Dickinson and Co.



10

Surgical Instrumentation

A. S  tyle 1 pituitary or Takahashi

B. Style 2 Kerrison

D. Style 4 Kerrison

A, C–D: Courtesy of CareFusion, a divison of Becton, Dickinson and Co. B: © 2019 Cengage®.

C. Style 3 Kerrison

Figure 2-5  Rongeurs handles. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Chapter 2 Anatomy of Surgical Instrumentation

Joint Styles

tissue or other materials placed between the open jaws of the scissors. Double-action joints use the principles of pivots and levers to increase the closing pressure and enable the jaws to grasp, cut, and debulk firm tissues.

The type and style of a joint facilitate the closing precision of the jaws and tips of an instrument. Three styles are most commonly used (Figure 2-6). Grasping and clamping instruments with finger rings usually have box lock joints. Hemostats and ringed tissue forceps have a unique design of one side passing through the hollowedout center of the opposing side to create a box lock between the jaw portion and the shanks. Overlapping joint styles are common in sharp dissection instruments such as scissors. The two sharp, flat blades are held together with a screw, and the scissoring action slices

Tip and Jaw Styles: Sharp Dissection Sharp dissection is used to precisely cut and separate tissue planes and divide tissue attachments. The distal end or instrument tip styles of scissors may be sharp or dull, curved, straight, or angled. Cutting graspers known as rongeurs or biters have two sides

A. Box lock

C. Double-action joint

Figure 2-6  Joint types. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

A–B: Courtesy of Sklar Instruments. C: © 2019 Cengage®. Photo by Margaret Rodriguez.

B. Scissor or lap joint

Surgical Instrumentation

that close, entrapping tissue in between hollowed depressions referred to as cups or in linear channeled grooves. Examples of these instruments may be found in upcoming specialty chapters. Incisions are sharply made with a variety of scalpel handles and varying shapes of disposable blades or other types of nondisposable knives (Figures 2-7, 2-8, and 2-9).

Tip and Jaw Styles: Clamping, Occluding, and Grasping Clamping jaws and grasping tips are used to hold tissue or items such as sutures or retraction material (e.g., umbilical tapes, Silastic vessel loops, Penrose drains) (Figure 2-10). The jaws of clamping instruments

A. Straight

B. Slightly curved

C. Strongly curved

D. Forward angle

E. Lateral angle

F. C  urved microsurgical spring handled

G. Angled with tip guard

A, G: Courtesy of Sklar Instruments. B: Courtesy of Scanlan International. C–F: © 2019 Cengage®. Photo by Margaret Rodriguez.

12

Figure 2-7  Sharp dissection tip styles: curvatures and angles. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.



Chapter 2 Anatomy of Surgical Instrumentation

13

A. Blunt–blunt

B. Blunt–tenotomy

C. Sharp–blunt angled

E. Sharp–tenotomy

Figure 2-8  Sharp dissection tip styles. Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

A, C–E: © 2019 Cengage®. Photo by Margaret Rodriguez. B: © 2019 Cengage®.

D. Sharp–sharp

Surgical Instrumentation

© 2019 Cengage®. Photo by Margaret Rodriguez.

14

Figure 2-9  Variations of scissors.

A. Kocher clamp

are designed to mechanically occlude the lumens of vessels, ducts, intestinal tracts, and other structures. Clamps, commonly called hemostats, are primarily used to provide hemostasis, or the stoppage of blood flow. Noncrushing styles of clamps are used to temporarily occlude structures with lumens, such as the bowel for surgical repair or excision. Grasping tips are used to hold tissue for manipulation, traction, or excision. Some grasping tips have teeth for a more secure attachment to the tissue. Most of these have serrations over the surface of the instrument’s jaws. There are styles of jaw serrations designed for specific use with soft tissue, bone, metal needles, and blades and include horizontal, longitudinal, atraumatic, and cross-hatched patterns (Figure 2-11).

D. Lahey/Gemini/right angle longitudinal

B. Right angle/Mixter and Adson/Schnidt F. Kelly hemostat

C. Rochester Pean

G. Doyen noncrushing intestinal clamp

Figure 2-10  Hemostatic clamps: jaw and tip variations.

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E. Crile hemostat



Chapter 2 Anatomy of Surgical Instrumentation

15

C. Cross-hatched (diamond jaw) needle holder with tungsten carbide insert

D. Micro “alligator” grasping forceps

A. Curved Allis and straight Judd-Allis

B. Allis-Adair and straight Allis

F. Regular and large Babcock tissue forceps

Figure 2-11  Grasping: tip variations

Tip Styles: Blunt Dissection Blunt dissection is used to separate tissue planes without creating an incision (Figure 2-12). Examples include the scraping or peeling back of periosteum from bones in the specialties of neurosurgery, orthopedics, and

plastics. Other forms of blunt dissection include separating tissue layers such as peritoneal attachments of the bladder flap to the anterior surface of the uterus, separating adhesions, and freeing up nerves from the thyroid or in the axillary region to name a few.

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A–B, D–F: © 2019 Cengage®. Photo by Margaret Rodriguez. C: Courtesy of Sklar Instruments.

E. Foerster straight and curved sponge forceps

16

Surgical Instrumentation

A. Pillar retractor/dissector B. Freer elevator C. Micro-ring curette D. Boies nasal fracture elevator

E. #5 Penfield elevator A–B: © 2019 Cengage®. C: Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ. D–E: © 2019 Cengage®. Photo by Margaret Rodriguez.

Figure 2-12  Blunt dissection: tip variations

tenaculum. Graspers can have locking or spring compression handles. The tips can have single or multiple teeth or be fine or blunt. The jaws can be smooth or serrated for firm holding of tissue.

CATEGORIES OF SURGICAL INSTRUMENTS Surgical instrumentation consists of many materials, styles, weights, sizes, and shapes. All categories of instruments can be found in sets for open or minimally invasive surgery (MIS), also known as endoscopic procedures. The common element is that each instrument has a specific function and should be used only for that purpose. Failure to use the instrument for its intended purpose can cause injury to tissue secondary to damage to the instrument’s function. Instrumentation categories as arranged for this text are described as follows: ●●

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Clamps: Used for closing circumferentially around an anatomic part either in a crushing or noncrushing manner for hemostasis or occlusion. Standard clamps usually have locking handles, but some forms of micro-­ instrumentation require the operator to maintain grasping pressure to hold tissue. The jaws can be smooth or have serrations (teeth). Grasping and holding forceps: Used to temporarily secure an anatomic part while it is manipulated as appropriate. Grasping and holding instruments may be of a tweezer-type, which requires manual compression of both sides, or they may be ringed and ratcheted instruments such as Allis, Babcock, or sponge forceps, which are often mistakenly referred to as clamps, however, are not designed to provide hemostasis or occlude the flow of tubular structures. Graspers are also used to extract stones as with Randall stone forceps or provide traction such as the Schroeder-Braun uterine

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Dissection instrumentation: Used to bluntly separate or sharply incise soft tissues, cartilage, or bone. Handles can be ring, spring, or pistol style. Scalpels and tissue elevation tools have sharply pointed or rounded tips on a flattened, rodlike single hand grip. The sharpened jaws of scissors can be straight, curved, or angled. The tips of scissors may come to a sharp point or be relatively blunt and rounded. Unique shapes may be seen in microsurgical, vascular, or rhinoplasty instrumentation. Dissecting instruments designed to excise soft tissue or bone have a variety of handle shapes, including ring, spring, or pistol grip as with pituitary and Kerrison rongeurs. Scraping instruments include periosteal elevators such as Cobb or Key, as well as Penfield and freer elevators. Malleable looped endometrial curettes are also used to scrape and remove fibroids from the inner lining of the uterus. Probes, cannulas, and dilators: Used to sharply or bluntly expand, tunnel, examine, or create an anatomic passage through which injection, tissue sampling, or decompression can take place. Templates and measuring instrumentation: Used to mark, calculate, and assess anatomic tissues and landmarks for removal, positioning, implantation, or excision. Depth gauges, rulers,

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Chapter 2 Anatomy of Surgical Instrumentation

calipers, trials, and sizers are included in this category. ●●

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Retraction and exposure instruments: Used to provide a clear visual field at the surgical site by displacing and securing tissues and organs. Retractors may be handheld single- or doubleended instruments. Self-retaining retractors may be simple ratcheted designs or be extremely complex with interchangeable parts that may require separate sterile table setup and careful accounting to prevent retained items. All retractors must be placed carefully to prevent tissue damage or potential practitioner injury. Approximation and closure instrumentation: Used to align and secure edges of soft and compact tissues for healing. Some approximation devices employ fixation implants such as sutures, staples, clips, wires, screws, and plates. Miscellaneous instrumentation: Instruments typically not used directly on a patient’s tissues; however, they are used in conjunction with other instruments. Examples include mallets, plate benders, tamps, and impactors.

HOW SURGICAL INSTRUMENTS ARE NAMED A surgical instrument is commonly named for a person, its appearance, its function, or even by a nickname. Names of many instruments can be associated with specific surgical specialties and may be named after pioneers in that field. Examples include: ●●

Heaney—gynecological

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DeBakey and Cooley—cardiovascular

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Cushing—neurosurgical

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Kocher—gastrointestinal

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Lahey—thyroid

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Castroviejo—ophthalmological

There is a degree of geographic or regional preference for the types and even names of surgical instruments used. Surgeons may call an instrument by its correct name or use a nickname that was used in the area where he or she trained, but then find the same instrument is called by a different name in other parts of the country.

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MATERIALS USED IN THE MANUFACTURE OF SURGICAL INSTRUMENTATION Materials used in the manufacture of surgical instruments include metals, metal alloys, plastics, silicone, natural latex rubber, and other synthetics. These materials can be used alone or in combination. Care is taken when working with a patient who may be allergic to one or more of these materials. Implantable devices represent a higher risk of potential serious immune response than the surgical instruments used to perform a specific procedure. These factors should be addressed in the operative care plan by the patient’s physician. The metals that present a risk of sensitivity include the following: ●●

Nickel (most commonly associated with sensitivity)

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Beryllium

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Cobalt

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Chromium

And rarely: ●●

Tantalum

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Titanium

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Vanadium

Metallics The most common types of modern metals used in the manufacture of surgical instruments in the 20th and 21st centuries include steel, copper, nickel, titanium, and silver. Combination alloy metals, such as Vitallium (combined cobalt, chromium, and molybdenum), have been used in dental and orthopedic implants since the 1930s. Occasionally, items such as patient positioning devices are sometimes made of malleable lead or aluminum. With the exception of titanium, all metals have some magnetic properties and cannot be used in the presence of magnetic resonance imaging (MRI). The most common types of metals used for surgical instrumentation in surgery are described in the following sections.

Steel Alloy composition of steel may be iron or carbon based. Most of the instrumentation used in surgery

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18

Surgical Instrumentation

is stainless steel, which is a carbon-based material. Additional components include carbon, silicon, manganese, phosphorus, sulfur, and chromium. Stainless steel was given its name for resisting stains when placed in a vinegar solution. This “stainless” property is caused by passivation of the chromium that forms the surface layer. It is not actually totally stainless; however, it is resistant to corrosion and rust formation. Stainless steel is sold in bar stock lots referred to as “forgings” graded by its composition. The forgings are exposed to heat and placed into molds for casting. A large weight is pounded on the mold to cause the metal to take the desired shape and hardness. Several grades are manufactured throughout the world. German-made surgical instruments are commonly preferred, although many other countries produce forgings suitable for surgical instruments. Steel is further refined into the chemical constituents of austenite and martensite by exposure to heat.

400 Series Stainless Steel Heat treating and passivation are processes used for the manufacture of instruments requiring a dissection or debulking edge to maintain the necessary sharpness to cut both soft and compact or bony tissues. Passivation is the terminal process of submerging instruments in a nitric acid bath, which removes any traces of foreign particles and creates a coating of chromium oxide to resist corrosion. Instruments made of this grade of steel do not readily bend or flex while in use. Other instruments that require this level of hardness are used for secure grasping and holding. Examples of instruments made of 400 series stainless steel include: ●●

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Scissors: Used to dissect fine and heavy soft tissues and suture materials Chisels, osteotomes, and rongeurs: Used for debulking and dissecting bone or other compact tissue Curettes and rasps: Used to remove, shape, or smooth dense tissue Clamps and hemostats: Crushing and noncrushing for mechanical hemostasis, occlusion of lumens, and stabilizing tissue Needle holders: Used for tissue approximation by grasping suture needles attached to strands of suture material to allow for passage through tissue layers

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Forceps: Used to grasp and hold various types of tissues Dilators: Used to sequentially expand a lumen or opening

300 Series Stainless Steel Instruments that require slight to moderate malleability are composed of 300 series stainless steel. This type of steel is also corrosion resistant. Instruments that are made of 300 series stainless steel include: ●●

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Suction cannulas: Used for removal of fluids and substances from the surgical field Probes: Used for exploration of depth or direction of anatomic areas and blunt dissection or separation of tissue planes Retractors: Malleable (bendable or shapeable) for displacement or repositioning of tissues to enhance visualization at the surgical site Surgical wire: Used for stabilization of fractures Surgical steel suture: Used for tissue approximation and wound closure

Copper Few surgical instruments are made of copper. Those copper instruments in use today are plated with nickel to minimize staining and corrosion. Copper is sometimes preferred for malleable uterine curettes and vascular suction cannulas. Newer styles of instrumentation are made of malleable 300 grade stainless steel to avoid the use of plated instruments in surgery. The plating wears off with time, exposing the bare copper surface.

Titanium Certain specialty surgical instruments and implants may be made of lightweight, nonmagnetizing titanium. These instruments are corrosion resistant and very strong. However, purchase of and repairs to these instruments are costly. Microsurgical instruments, vessel occluding clips, staples, replacement joints, screws, and bone plates are commonly made of titanium because it is inert and lightweight. This metal has been known to science since 1791, but received more scrutiny after 1910 as a specialty metal for surgical application. Titanium is named for the Titans from Greek mythology, known for their strength.

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Chapter 2 Anatomy of Surgical Instrumentation

Silver

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The malleability, stability, and strength of silver make it a good material for metallic tracheostomy tubes and delicate probes, such as those used in the lacrimal ducts of the eye. ●●

SURFACE FINISHES OF METALLIC SURGICAL INSTRUMENTS

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Polished: Shiny, high gloss, highly reflective like a mirror. This finish resists corrosion due to its density; however, it may be marred or damaged by poor instrument care. The reflectivity may also allow for light to bounce off the instrument and obscure the surgeon’s visualization of the field. Matte or satin: Dull finish, low reflectivity; however, it is slightly less resistant to corrosion due to the sand-blasting technique used during the manufacturing process. Ebonized: Blackened or dull surface. Not reflective at all, so appropriate for use in laser cases, especially in narrow, deep passages such as the vagina or nasal passages (Figure 2-13).

© 2019 Cengage®. Photo by Margaret Rodriguez.

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Figure 2-13  Ebonized nasal specula.

Chrome plating: Chrome electrically bonded over brass or carbon steel; used in floor-grade instrumentation; not suitable for surgery as the plating can chip off. Do not place these types of instruments in an ultrasonic cleaner. Ceramic or plastic coating: Provides insulation during procedures that utilize electrosurgery.

INSPECTION AND QUALITY CONTROL OF METALLIC SURGICAL INSTRUMENTS

Consideration is given to the surface finish of a surgical instrument as part of its overall selection criteria. The surface finish selection is based on several factors. Basic surface finishes available in surgical instruments are as follows: ●●

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Care of the metallic instrument used in surgery consists of proper handling and usage, cleaning and processing, and packaging and storage. All newly purchased instrumentation should be cleaned, lubricated, and processed before sterilization and patient use. Stainless steel instrumentation will pit and stain over time when combined with certain elements. Table 2-1 shows the types of stains and their probable sources. Chloride ions found in iodine, blood, and saline cause corrosion and pitting. A pencil eraser can be used to determine whether the mark is rust or a surface stain. If the mark rubs off with the eraser, it is a stain. If the discoloration is removed, revealing a different color mark beneath, it is rust. Rusty instruments pose a hazard to patients and should be removed from service and replaced. Each pitted and roughened area represents a weakened area that can harbor and shield microorganisms from effective decontamination and sterilization. Common points of pitting are near the box locks and other hinge points. Pits can lead to fractures in the joints, causing instrument breakage during use. Misuse of instrumentation includes using an instrument for an unintended purpose, such as using a fine needle holder for a heavy needle or bone cutters to cut wire. Each instrument should be inspected for stress cracks at the joints, gaps along closed jaws, tight opening and closing action, sharpness of cutting surfaces, and generalized appearance prior to placement in processed trays and again prior to use in the operating room (Figure 2-14).

Scissors Most manufacturers have recommended test materials such as latex sheets or gauze pads for use in testing the cutting edges of scissors during tray assembly. The scissors should work smoothly, without snagging

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20

Surgical Instrumentation

Causative Agent

Rust color or dark orange

Dried blood is autoclaved on the instrument. Discoloration appears like rust. It can also be from soaking in tap water.

Brown

High pH (>7.0: alkaline) detergent or chlorhexidine solution can cause this type of stain. It can also be from soaking in tap water. Chromium deposits can be a cause. Polyphosphate detergent can cause copper components in the sterilizer to deposit on the instruments in an electrolytic action.

Dark brown

This can be caused by an improperly functioning sterilizer. Low pH (