SURGICAL INSTRUMENTS

Claudia Gherman, Răzvan Ciocan, Ovidiu Fabian

Learning objectives
What you should know
 The main types of surgical instruments
 The main instruments used for cutting tissues
 The main instruments used for tissue manipulation
 The main instruments used for exposure (retractors)
 The main instruments used for suturing
 The functioning principle of electrocautery devices
 The main laparoscopic instruments

What you should do

 Recognize the main surgical instruments
 Attach a scalpel blade to a handle/remove it from the handle
 Hand a scalpel to another person correctly
 Perform an incision
 Handle scissors (hold them correctly, cut under visual control,
hand scissors to another person)
 Handle a self-retaining forceps (hold it correctly, grip the
tissue, close and open the forceps, hand it to another person)
 Hold a retractor correctly
 Hold, close/open and hand over a needle holder correctly
 Recognize a suturing needle; recognize a sharp needle and an
intestinal needle; find on the needle and suture package the
main information about the needle

Classification
In order to perform surgery, the surgical team needs a
number of surgical instruments. Each of the thousands of
instruments used is designed for a specific function. They can be
classified depending on use as follows:
 Cutting instruments
 Instruments for tissue grasping and manipulation
 Instruments for tissue exposure
 Suturing instruments
 Hybrid instruments
 Endoscopic instruments

Cutting instruments
Scalpels: consist of a handle and a blade; the handle is
made of metal (reusable) or plastic (disposable); blades are
disposable, of various shapes and sizes.
The top of the scalpel handle has a special part, with a
groove that allows its sliding into the blade slot and securing of
the blade in position.
The scalpel blade has a slot - larger at its base and narrower at its
top. The larger part is fitted to the groove of the handle, and the
narrower part secures the blade into the groove.

Figure 1. Handle of a scalpel

Figure 2. Scalpel blades

The attachment of a scalpel blade is illustrated below:

Figure 3. Attachment of a scalpel blade: the larger part of the blade slot is
placed in the handle groove, then the blade is moved so that the narrower part
of the slot slides and snaps into the groove

The removal of a scalpel blade is presented below:

 Figure 4. Removal of a scalpel blade: the blade is lifted over the securing
device and then slided out of the handle groove

A scalpel must be handed from one

person to another so as to completely
eliminate any risk of injury. The scalpel is
held by the upper part of the handle, with
the completely visible blade pointing
upwards; the recipient takes the scalpel by
grasping the lower part of the handle. Figure 5. Handing over
a scalpel
During its use, the scalpel can be
Held as a knife, as a pencil or as a dagger (see the figure below).

Figure 6. Use of scalpels – as a knife, as a pencil, as a dagger

Scissors are used to cut

tissues, suture threads, dressings, as
well as for blunt dissection (the closed
scissors are introduced between the
planes to be separated, and are opened Figure 7. Metzenbaum
scissors
before they are extracted).
Scissors exist in a variety of sizes and shapes. They can be
straight, curved or angular. They can have a sharp or blunt tip.
A. B. C. D.
Figure 8. Different types of scissors: A. Mayo scissors; B. Potts scissors (used
in biliary and vascular surgery); C. Castroviejo scissors (used in microsurgery,
ophthalmology, neurosurgery); D. Scissors for cutting dressings
During usage, scissors are held as follows:
 The fourth finger is inserted through the ring of the lower arm
of the scissors
 The third finger supports the lower arm of the scissors
 The second finger is extended along the arms of the scissors,
ensuring the precision of movement
 The thumb (about half of the first phalanx) is inserted through
the ring of the upper arm of the scissors

Figure 9. The correct way to hold scissors

It is important that cutting with scissors should be

performed under visual control; the tip and the entire length of the
blades must be observed in order to avoid damaging other tissues
than those concerned.
To cut the threads after tying a
knot, the following are performed:
 The open blades are placed around
the threads
 The scissors are lowered to the
proximity of the knot, they are rotated Figure 10. Cutting a
so as to make the knot clearly visible thread under visual
control
 The threads are cut to the desired length
 This allows to avoid
o Leaving too long or too short thread ends
o Cutting the knot
Scissors should be handed
from one person to another as
follows:
 The first person holds the tip of
the scissors
 The second person opens the Figure 11. Handing over scissors
Palm of the hand to receive the instrument
 The first person places the handle of the scissors in the palm
of the recipient
Other cutting instruments are chisels, osteotomes, saws
(used for cutting bones), curettes (used for scraping tissues),
dermatomes (used for collecting free skin).

Tissue manipulation instruments

Hemostats are used to grasp, handle and retract tissues. In
certain situations, spaces are too narrow for the surgeon’s hands,
so that hemostats can apply force, pressure or can expose certain
anatomical structures. There are two types of hemostats: self-
retaining and non-self-retaining.
Surgical hemostats are traumatic hemostats (equipped
with teeth allowing to grasp tissue firmly). They are used for
handling hard tissues (skin, fascias).
Anatomical hemostats are atraumatic (without teeth).
They are used for handling sensitive, friable tissues.

A. B.
Figure 12. A. Surgical hemostat. B. Anatomical hemostat

An anatomical or
Surgical hemostat
should be held with
the thumb on one
A.
side and with the B.
second and third Figure 13. Holding an anatomical/surgical hemostat: A.
fingers on the other Correct B. Incorrect
Side, towards the volar part of the hand – similarly to a pencil.
Holding
A hemostat with its handle in the palm
should be avoided; this position is
uncomfortable and does not allow precision.
An anatomical or surgical hemostat should be
passed from one person to another by placing
the instrument with its handle (not its tip) in Figure 14. Handing over an
the recipient’s hand. anatomical/surgical hemostat
Self-retaining forceps
are used for grasping tissues
and they have a locking (rack
and pinion) mechanism that
keeps them closed, allowing
them to hold the tissue Figure 15. Self-retaining forceps
Between their arms. They are similar in shape to scissors, the locking
mechanism being situated near the rings. They can be straight or
curved.
The most widely used self-retaining forceps are:
 P‚an’s forceps – without teeth
 Kocher’s forceps – with teeth

A. B.
Figure 16. A. P‚an’s forceps. B. Kocher’s forceps
Other forceps, similar to the two above, are
 Mosquito forceps – a fine, small size Pean’s forceps
 Overholt forceps – a fine, curved P‚an’s forceps, used for
dissection or hemostasis

A. B.
 Figure 17. A. Mosquito forceps. B. Overholt forceps

To secure drapes that cover the patient during surgery,

special self-retaining forceps are used1:
 Backhaus forceps (with a rack and pinion mechanism)
 Doyen forceps (with a spring mechanism)

A. B.
Figure 18. Forceps for securing surgical drapes: A. Backhaus forceps B.
Doyen forceps

Handling of self-retaining forceps:

 Forceps should be
held similarly to
scissors: the fourth
finger is inserted
through the lower
ring, the middle finger
supports the forceps, Figure 19. Holding a self-retaining forceps
The index finger is extended along the arms of the forceps
to ensure precision of movement, and the thumb (the proximal
half of the first phalanx) is inserted through the upper ring
 A self-retaining forceps is closed by moving its arms so as to
allow engagement of the teeth of the locking mechanism
 The forceps is opened by pushing the rings (arms) apart so as
to disengage the teeth of the rack and pinion mechanism

Figure 20. Opening a self-retaining forceps by pushing apart the teeth of the
locking mechanism

1
Known as “crayfish”, due to their arms similar to the claws of crayfish
 A self-retaining forceps
should be handed from one
person to another similarly
to scissors: the handing
person holds the tip of the
instrument and places the
Figure 21. Handing over a self-
handle (rings) of the forceps retaining forceps
In the recipient’s open palm.

Instruments for exposure (retractors)

They are used to hold back tissues/organs in order to
expose only those organs/tissues that are being operated on; they
ensure visibility of the surgical site. Retractors come in different
shapes and sizes, depending on anatomical location. To minimize
trauma to the retracted organs and tissues, the position of
retractors must be frequently changed during surgery. Below are
some examples of retractors:
A. B. C.

Figure 22. Retractors: A. Farabeuf retractor; B. Doyen retractor; C. Self-

retaining (Weitlaner) retractor

Handling retractors
is difficult and fastidious,
but exposure provided by
them is important because it
ensures visibility of the
surgical site. Traction on
retractors is generally Figure 23. Handling the Farabeuf
exerted in two directions: retractor
Laterally and downwards; consequently, the most effective
way to hold a mobile retractor is using the thumb and the third-
fifth fingers (ensuring lateral traction), while the second (index)
finger is extended along the instrument and ensures downward
pressure.
 Suturing instruments
Needle holders are special self-retaining forceps used to
maneuver the needle during suturing (they hold and guide the
suturing needle). X-shaped striations allow a secure grip of the
needle between the arms.
There are 2 main types of needle holders, the others being
variations of these: the Mathieu needle holder and the Hegar
needle holder.

A. B.
Figure 24. A. Mathieu needle holder; B. Hegar needle holder

The Mathieu needle holder is held in the palm of the hand;

it is closed and opened by pushing the rack and pinion mechanism
situated at the end of the arms.

Figure 25. How to correctly hold the Mathieu needle holder

The Mathieu
needle holder is passed
from one person to
another by placing the
handle in the
Figure 26. Handing over the Mathieu needle
recipient’s palm. holder

The Hegar needle holder can be held:

 With the thumb and the second-fourth fingers (like a self-
retaining forceps)
 In the palm (like the Mathieu needle holder)
A. B.
Figure 27. Maneuvering the Hegar needle holder: A. Like a self-retaining
forceps; B. Held in the palm

The Hegar needle holder should be handed over similarly

to a self-retaining forceps; in addition, care should be taken to
correctly orient the needle and keep the thread free (out of the
palm of the hand).

Figure 28. Handing over the Hegar needle holder

Needles are used to pass threads through tissues during

suturing. They should be sharp enough to penetrate the tissue with
minimal resistance, rigid enough not to bend, and flexible enough
to allow the movements desired by the surgeon. The most
frequently used needles are curved (Hagedorn) needles – due to
their maneuverability, but there are also straight needles, as well
as other types2.
Curved needles usually have the shape of a circle segment
(half, two-thirds, three/five-eighths of a circle, etc.); there are also
needles with a special curve (compound curve – hook-shaped or
J-shaped, ski-shaped), but these are rarely used.
Needles are mainly classified depending on their cross-
section shape:
 Sharp needles – they have a triangular (sometimes
trapezoidal3) cross-section; they cut tissues with both their tip
and sharp edges; they are appropriate for hard tissues (skin,
aponeuroses)

2
For example, Reverdin or Deschamp needles
3
Spatulated needles
 Intestinal needles – they have a round cross-section; they cut
tissues only with the tip and are adequate for friable tissues
(digestive tract, blood vessels)

A.
B.
Figure 29. Types of needles: A. Cutting needle; B. Round (smooth) needle

The tip of the needle can be:

 Sharp (cone/pyramid top): penetrating tip
 Round (blunt): round tip

A. B.
Figure 30. The tip of needles can be: A. Penetrating, B. Round

Suture threads can be swaged (the suture thread is attached

to the needle by an industrial method), double swaged (a suture
thread has needles at both ends) or unswaged (the suture thread is
passed through the needle manually, and the needle is reusable,
after sterilization).
Swaged needles have the same
diameter as the thread and are termed
atraumatic. Needles through which the thread
is passed manually have a larger eye
diameter; in addition, tissues are traversed by A.
A double thread;
consequently, these needles
induce tissue trauma not
only with their tip and edges,
but also with their base; B.
these needles are termed Figure 31. A. Traumatic needle; B.
traumatic needles4. Atraumatic needle (swaged suture)
Traumatic needles usually have a closed lower eye (similarly to
usual sewing needles) and a half-open upper eye5 (through which
the thread is inserted by pushing the slot between the lateral

4
Simplified: needles with swaged (attached) threads are atraumatic
5
In Anglo-Saxon manuals, it is called “a French eye”
edges).
The package of swaged suture threads provides relevant
information about needles:
 The needle type (sharp/intestinal) and cross-section shape
o Are suggested by a symbol:
 For intestinal needles (round): a circle
 For sharp needles: a triangle with the top pointing
upwards or downwards (depending on the cross-
section shape) or a trapezoid (for spatulated needles)
 The shape of the needle
o Suggested by a symbol and marked by circle divisions
(1/2c, 1/3c, 3/8c, etc.)
 The length of the needle
o Suggested by a symbol at a 1:1 scale and expressed in mm
 The thickness of the needle
o Usually on the USP (United States Pharmacopeia) scale:
 Needles/threads with a thickness 0 = 0.35 mm
 Thinner needles/threads are marked as 2-0, 3-0 ... Up
to 11-06
 Thicker needles/threads are marked with figures from
1 to 67

Instruments for electrosurgery

Electrosurgery is based on the effects of high-frequency
electric current on tissues.
Electrocauters are hybrid instruments, having both a
cutting function (signalled by a yellow led) and a coagulation
function (signalled by a blue led). There are two types of
electrocauters: monopolar and bipolar.
In the case of monopolar electrocauters, the current passes
between a sharp active electrode (handled by the surgeon and
applied to the tissue) and a passive return electrode (a large
surface plate applied to the patient’s skin, outside the surgical
field). The effects of the current occur only in the active electrode.

6
A 2-0 needle/thread corresponds to a 0.3 mm diameter, and an 11-0 needle
corresponds to a 0.01 mm diameter
7
A 1 needle/thread corresponds to a 0.4 mm diameter, and a 6 needle/thread
corresponds to a 0.8 mm diameter
 Figure 32. Information about a swaged needle marked on the package

In the case of bipolar electrocauters, the electric current

passes between two active electrodes – a special hemostat.

A. B.
Figure 33. A. Monopolar electrode; B. Bipolar electrode

A. B.

Figure 34. A. Monopolar cautery; B. Bipolar cautery

 Over the past years, other electrosurgical instruments,
used both for hemostasis and cutting, have been introduced8.

Laparoscopic, thoracoscopic instruments

Laparoscopic/thoracoscopic surgery is performed by
creating a chamber filled with air in the body cavities
(pneumoperitoneum, pneumothorax). With a special needle,
carbon dioxide is introduced into the peritoneal/pleural cavity.
Through the abdominal/thoracic wall, special trocars are inserted,
and through these trocars, a video camera, allowing visualization
of the internal cavity, and surgical instruments are introduced.
Laparoscopic/thoracoscopic instruments are special long
instruments, having metal and plastic components; most of them
also have an electrosurgical function.

A. B.
Figure 35. A. Laparoscopic instruments; B. Trocar for laparoscopy

8
For example, LigaSure or ForceTriad hemostats
Assessment / self-assessment form

Stage / Criterion Correct Incorrect

Recognize cutting instruments
Handle a scalpel correctly
Attach and remove the blade
Perform an incision
Hand over the scalpel
Handle scissors correctly
Hold scissors, cut under visual control
Hand over scissors
Recognize tissue manipulation instruments
Handle an anatomical/surgical hemostat
Grasp tissue with a hemostat
Hand over a hemostat
Handle a self-retaining forceps
Grasp tissue with a forceps
Hand over a forceps
Recognize mobile/self-retaining retractors
Recognize the main types of needle holders
Handle a needle holder
Hold a Mathieu/Hegar needle holder
Hand over a Mathieu/Hegar needle
holder
Recognize the types of needles
Identify information about a swaged needle on
the package
Explain the principle of electrosurgery
Recognize the types of electrodes for
electrosurgery
Recognize laparoscopic instruments