2. Practice
Introduction of basic surgical instrument and practicing their use
Tissue dissection:
1.Conventional scalpel: handle and blade is together, blade cannot be changed. Handling of scalpel can be performed in two ways. One is the fiddlestick handling used by long straight cuts. Handle is positioned horizontally holding between first and third finger, held form upside by the second finger, fourth and fifth finger are encompassing the remnant part of the
handle. (The other type of handling is the pencil handling used by short cutting, it will be showed during 9th practice.)
2.Scalpel’s handle: it can be re-sterilized; on one end single used scalpel blades can be taken.
3.Scalpel blades: for single use only, blades are sterile packed singly. Blades are numbered 10-24 based on size and shape. On figure sterile opening of package and giving to scrub nurse can be seen.
4.Handle and single use scalpel blade: the blade is put on handle immediately before operation. High attendance must be taken because of danger of injury. Correct way is shown by a riffle. On figure correct handling of scalpel can be seen.
5.Cutting of the skin: after planning of cutting’s length skin must be tensed by left hand (in case of left handed person it is made by right hand), and pressing slightly the scalpel whole depth of skin must be cut through. By this way formation of irregular margins can be avoided (which can cause higher scar formation). It can be seen that cutting with scalpel performs in every case sharp margins. The affected and bleeding vessels must be salved.
6.Apart from scalpel scissors are used most frequently for tissue dissection, preparation and cutting. Threads and bandages are also cut by scissors. There are scissor varying in size, shape can be straight or curved, end can be sharp-sharp, sharp-dull, or dull-dull. First introduced is used by scrub nurse, shape is straight, with dull-dull end, and it is used for cutting thread. Proper handling of scissor: first and fourth finger are introduced in the rings of the scissor, second finger is laid distally on body of the instrument fixing it.
This type of holding is used in every instruments ring at the end!
7.Curved sharp-sharp scissor: can be used for cutting and dissecting tissues. Scissor must be put in the tissue with closed end, and after this scissor must be opened dissecting tissues dull. Assistant is elevating the skin using wound retractor, until operator is dissecting dull on tissue borders or cutting sharp through scared tissues. Bleeding must be salved posterior.
8.Fine, straight, sharp-sharp scissor: can be used for cutting and dissecting.
9.Fine, curved, sharp-sharp scissor: can be used for cutting and dissecting.
10.Fine, angular curved straight, sharp-sharp scissor: can be used for cutting and dissecting.
11.Lister’s bandage scissor: it is angular curved; one of the blades is longer than other, there is no cutting edge on dull end. This is for avoiding damage of patient’s skin during removal of bandage.
91
12.These instruments (Kocher, Péan, Mosquito, and Lumnitzer) are suitable for tissue dissection, grabbing, and haemostasis also. All they have got variant of straight and curved. At first Kocher can be seen, teeth at the end. This is suitable for grabbing strong tissues. It is not good for dissection because the teeth at the end can cause damage. Proper handling: first and fourth finger are introduced in the rings of the scissor, second finger is laid distally on body of the instrument fixing it. For fixation of grabbing it contains a lock system. Opening: one ring must be pressed down by first finger, while the other ring must be elevated by fourth finger. This opening technique must be performed by both hands.
13.Péan hasn’t got any teeth at the end, that’s why it is suitable for dull dissection, atraumatic grabbing of tissues, and haemostasis. For example on the avascular side of mesentery Péan can penetrate through without bleeding. Closing the vessel with two Péans, it can be cut through and the vessels end can be ligated by threads. In order to minimize the amount of left thread, thread must be cut 2-3 mm. distal from the knot. Scissor must be slid by assistant towards the knot, it must turned a bit (leaving back short end), and without endangering knot safety both ends of the thread must be cut.
14.Curved Mosquito: it is smaller and finer instrument as Péan. It can be used for fine preparation, for grabbing smaller particles, and stopping smaller bleeding.
15.Curved abdominal Péan: suitable for grabbing and preparation of thicker parts of tissues.
16.Lumnitzer vary form Kocher in size (it is longer and bigger). Suitable for grabbing big tissues or sponges, and because of the teeth elevation of tissues can be performed using this instrument.
17.Dissector: stick is long; end is curved in 90°, with rings at the end without lock system. It is suitable for atraumatic dissection.
18.Electrocutes can be monopolar or bipolar. At first monopolar diathermy is introduced which can be used both for cutting tissues and coagulation. Sterile cable’s end must be connected to the central unit. The other sterile part must be clamped to the isolation. Negative pole is directly in connection with patient’s skin, the hand port of the device must be grazed to the tissues or holding instrument. Pressing blue button on hand port coagulation, pressing yellow button cutting can be performed. There are also instruments working with foot pedal.
19.Bipolar diathermy can be used for finer and precise coagulation. There is no need for negative electrode, because circuit is circulating between the two parts of forceps.
20.Amputation knife: this type is sharp on both sides of blade. It is suitable for quick cutting of soft tissues (muscles, fascia, and vessels) during amputation.
21.Bone gauges.
22.Straight surgical raspatory: on side is flat, other side is rounded, half circular end is slightly sharp. It is used for dull removal of tissues from the bone.
23.Hammer.
92
24.Charriére’s amputation saw.
25.Straight saw.
Grabbing instruments:
26.For grabbing something the easiest way is to use a forceps. Forcipes are varying in size; there are straight, curved and angular curved (dental forceps) types. End can be dull (anatomical forceps), hooked (surgical forceps), sharp (splint forceps, ophthalmologic forceps), or ring shaped (tumour forceps). Forceps is used to hold tissues while cutting, suturing, or during exploration, also used to grab vessels while coagulation, or to take into sponges, gauze when bleeding appears, even to evacuate blood, or to remove foreign bodies. At first a hooked forceps is introduced. Forceps has to be held as a pencil, while grabbing the shafts must be pressed by first and second finger (to ensure comfortable holding, finest movements, and widest size of movements). Forceps is like to the lengthening of the fingers. No way is to hold forceps in palm! The teeth of the hooked forceps avoid loosening of tissues, that’s why there is no need to expand big pressure for safe tissue holding. For that reason for holding skin and subcutaneous tissues surgical forceps is mostly used, but vessels, parenchymal and luminal organs (e.g. bowels) mustn1t be grabbed because of the danger of bleeding and perforation.
27.Anatomical forceps: end is fluted; ensuring atraumatic grabbing for vessels, luminal organs can be grabbed. On this picture a small sponge (10×15 cm.) can be also seen, suitable for evacuation of fluids (blood, tissue fluid, pus); it is multiple sheet gauze. Big abdominal sponge is also multiple sheet gauze, 30×40 cm. in size. Both sponges’ margins are seamed.
28.Dressing forceps: Long instrument with ring at the end, with or without locking system. Most frequently used during washing of operation area, including a tupfer. Hospital orderly is taking disinfective agent into a sterile container (mug), which contains also tupfers. Using these tupfers washing can be performed. Dressing forceps and tupfer are used during operation for removal of bleeding, only pressing tupfer on bleeding area a slice, not scrubbing it. Dressing forceps is also suitable for making tunnels in the tissues.
29.First introduced organ holder is the bowel clamp. It can be straight or curved. The inner side of the shaft is fine, contains corrugations lengthways (it doesn’t damage bowel wall while grabbing it). It is a ringed instrument with lock system.
30.Gallbladder holder: mostly used during open cholecystectomy for grabbing and elevating the fundus of the gallbladder. It is a ringed instrument with lock system.
31.Duval’s organ holder: end is slightly toothed. Triangular shaped, used as vascular clamp in the past. Nowadays it is used to grab skin or tongue while inserting piercing.
32.Allis’ organ holder: end is slightly toothed. Used for grabbing organs (e.g. lung).
33.Lung holder: use is nowadays decreased.
34.Backhaus towel clamp: used for fixing isolation to the skin.
35.Schaedel’s towel clamp: used for fixing isolation to each other.
93
Haemostasis:
Kocher, Péan, Mosquito and Lumnitzer belong also to this group.
36.Guiding probe (Payr): end is narrowing, slightly curved, including a riffle.
37.Deschamp’s ligation needle: 90° curved, dull ended needle.
38.Deschamp’s ligation needle must be guided into the riffle of the Payr probe.
39.Under the vessel of the mesentery Payr’s probe must be led. Deschamp’s ligation needle (containing thread in its hole) must be guided into the riffle of the Payr probe. Thread must be grabbed by forceps on the other side, Deschamp’s needle drawn back. Threads should be knotted and cut. Finally between two ligations vessel can be cut through.
40.Vascular clamps make reversible closing of vessels possible. One of them is Satinsky’s vascular clamp, its end is curved. Particular closing of big vessels make possible, under the closing the circulation is continuous.
41.Blalock’s tourniquet: it can be closed using a twist; two ends are mostly covered with rubber (atraumatic closing).
42.Bulldog: small, short atraumatic tourniquet, spring at the end.
Tissue retraction:
43.Wound hook: hanging into the wound corners and drawing the edges suturing can be performed easier.
44.Wound retractor: it is varying in size very much. It is used to elevate wound edges, establishing better visibility for operator.
45.French retractor: end is dull. Advantage is the less tissue damage; disadvantage is the easy slide out from the operating area when it is not held correctly.
46.Abdominal retractor for elevation of parts of the abdominal wall.
47.Organ retractor.
48.Self retractor (Weitlander): end is similar to wound retractor. Opening lock system ends are diverging making retraction without manual holding.
49.Self retractor (Balfour): two dull ends are inserted under abdominal wall. After making sure there is no bowel or other organ between abdominal wall and self retractor, it can be opened. Tension is ensuring retraction.
Tissue rejoining:
50. Mathieu’s needle holder: it is held in palm. It has got 3 teeth. At first pressing needle is closed into the instrument, at second needle is held tight; at third pressing needle holder is opened.
94
51.Inserting needle into needle holder: needle should held in left hand, needle holder in right hand. Needle have to be kept in needle holder in ⅓ - ⅔ ratio, needle have to be positioned perpendicular to needle holder.
52.Inserting thread into French needle: 1. taking thread into the complete hole, after it drawing it into the half hole at the end of the needle; 2. holding needle holder (containing needle) in right hand also holding one end of the thread together with it; other end of the thread should be guided at the back of the needle; thread must be positioned at the end of the needle and drawn into the hole.
53.Sterile opening and taking of the atraumatic needle-thread combination: the outer bandage must be opened without touching inner bandage. Scrub nurse takes the inner bandage. Opening the inner bandage needle can be caught by needle holder, and needle-thread combination can be pulled out.
54.Hegar’s needle holder: ringed end, it must be held using first and fourth finger. At first pressing needle is closed into the instrument, at second needle is held tight; at third pressing needle holder is opened. It is suitable for fine suturing (vascular, bowel, lung suture).
55.Michel’s clip applier/clip remover, and skin clips are strung on a U-shaped wire.
56.Skin clip must be grabbed by clip applier and drawn away from the wire. Assistant is grabbing and elevating both wound edges using surgical forcipes (proper adaptation is very important to avoid irregular margins). Clip must be positioned between the forcipes. Clips must be taken 1 cm. distal from each other.
57.Clip removal: clip remover must be positioned under the clip in the midline, than pressed. By this way the U-shaped clip becomes straight, releasing the skin.
58.Skin can be closed also using automatic clip applier machine.
59.Skin can be closed also using adhesive sticks. These sticks (Steri-Strip®, Proxi-Strip®) are suitable for closing short superficial wound without need for suturing, and for securing intracutaneous suture.
60.Tissue glues are mostly made from fibrin bases, causing consistent fibrin mesh (using last steps of the haemostatic cascade) (Beriplast® P Combi-Set).
Special devices:
61.Volkman’s bone curette: this spoon-shaped instrument is sharp, it is used for removing tissue particles, and to refresh infected wounds base.
62.Probe: end is dull, that’s why extent of fistulas can be revealed without making tissue damage.
63.Payr’s stomach and bowel crushing forceps: inner side is finely fluted, atraumatic. It is suitable for crushing wall of the bowel, avoiding rupturing the serosa during ligation of the bowel. Bowel must be laid on the instrument, than closed and open. After opening the layer of the crushing can be seen, in this line the ligation must be performed.
95