MoutreySteve 2017 Chapter5 TheFundamentalsOfSURG

The Fu ndamentals of SURGICAL INSTRUMENTS - A practical guide to their recognition, use and care
Surgery of this type and nature obviously has an associated risk where vascular
clamping is involved, so it becomes vitally important that the whole surgical team has
an understanding of the procedure and instrumentation, to prevent delays or
avoidable complications. This includes the surgical assistant, who may be required to
close or release a clamp slowly, to the scrubbed practitioner who needs to anticipate
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
the needs of the surgeon. The im portance, therefore, of understanding and having a
knowledge of these instruments and procedures can save lives.
Copyright 2017. TFM Publishing.
EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 7/12/2023 9:56 AM via THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH
AN: 1690437 ; Moutrey, Steve.; The Fundamentals of SURGICAL INSTRUMENTS
Account: s3137220.main.ehost
C h a pte r 6
S U CTI O N D EV I C ES
These are devices that when attached to a vacu u m source via appropriate s u ction
tubi n g , are used to remove blood and body fl uids, allowing the s u rgeon to adequately
visualise the s u rg ical fie l d .
They have various designs and 'tips' attached t o a form o f handle t o al low
s u ctioning of eve rything from small wounds to large abdominal wounds. For larger
incisions where an i ncreased blood loss or large amount of fluid is anticipated , for
exam ple, i n a hydrocoele repai r, a wider bore and s uction tip with m u ltiple holes can
be used - as in the Yankauer sucker (. Figure 6 . 1 ) , or fo r abdominal s u rgery a
Figu re 6.1 . Ya nkauer sucker (suction tip): a) disposable; and b) metal reusa ble.
EBSCOhost - printed on 7/12/2023 9:56 AM via THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH. All use subject to https://www.ebsco.com/terms-of-use
The Fundamentals of SURGICAL INSTRUMENTS - A practical guide to their recognition, use and care
Poole (. Figure 6 . 2) or S impson-Smith s u ction device (. Figure 6 . 3) may be

considere d .
� -. . . .. • .
Figure 6.2. Poole suction tip.
Figure 6.3. Sim pson-Sm ith suction tip.
6 SUCTION DEVICES
A s u ction tip with m u ltiple h oles avoids an aspiration i nj u ry where more delicate
tiss u es may be i nadvertently s ucked i nto the tip, as in abdom inal s u rgery where there
is a danger of s uctioning bowel i nto the s ucker tip. If this occurs then either release
the s uction by taking the finger off the control port (for suckers that have this facility)
or bend or occlude the s u ction tubi n g , then gently prise the tissue away from the
s u cker tip. Tissue that has become trapped i n the s u ction tip/h oles s h o u ld n ever be
forcefu l ly p u lled out; gently remove the tiss u e when active s u ction has been t u rned
off.
Good visualisation of the s u rg ical area to be s u ctioned is paramount to provide a

good field of vision fo r the s u rgeon and to avoid trauma. Tiss u e trauma can occur if
overzealous use is employed when s uctio n i n g , especially if a fine-tipped device is
used, as t h is co uld penetrate or tear friable tissue causing both damage and even
more blee d i n g .
S o m e s u ction devices , such a s the F razier s u ction can n u la (. Figure 6 . 4) , have

small removable tips (as in E NT procedures) , and these need to be accou nted fo r
Figure 6.4. Frazier sucker showing the finger control port (fi ne tip).
carefu lly and cou nted with the instrume nts and swabs , as it is easy to lose one of
them . It is also possible that the s u rgeon may find it n ecessary to u ns crew or remove
a s h eath or tip; this m ust be taken by the scrub practitio ner and again accou nted for
appropriately.
The F razier s u ction tube is t h i n n e r than other suckers and is used fo r removi ng
fl uid from smaller and more confined spaces such as the nasal cavity o r, if used with
fine tips , the ear canal. It can also be employed in cranial or spinal s u rgery. It
normally comes with a fine wire stylet which can be used to remove any tiss u e that
blocks the lumen of the s u ction tube. The s u ction is controlled by the finger port in
the handle.
A specially designed s u ction (i rrigation) device is used for laparos copic s u rgery
where the s u rgeon needs p recise s uctioning with i rrigation (. Figure 6 .5) . The
irrigation is com bined within a single instrument with the s u ction facility, where both
the s u ctio n i n g is used for evacuating body fluid and blood , and the i rrigation can be
Figure 6.5. Laparoscopic suction/irrigation system.
6 SUCTION DEVICES
employed using the dual control at the s u rgeon's fi nger tips . I rrigation is dep loyed to
aid the visualisation of tissues and structu res being operated o n , for exam ple, to
irrigate an area that is b leed i n g . In this instan ce, the s u rgeon n eeds to identify the
bleeding point so that he can facilitate s u itable haemostasis; by stream ing the
irrigation fluid over this area, he can see exactly where the bleeding point is -
s u ction is then applied to remove the irrigation flu id . Anoth e r prime use is to irrigate
and s u ction bile from the gallbladder bed i n a laparoscopic cholecystectomy if it
becomes perforated .
T h e control o f laparoscopic s u ction/i rrigation i s i n t h e hands o f t h e operati n g

s u rgeon (. Figure 6 . 6) . Both controls c a n be operated s i n g le-handed, alte rnating
between s uction and i rrigation as req u ire d .
Figu re 6.6. Suction and irrigation controls.
The tip of this device (. Figure 6 . 7) , designed in a sim ilar way to the abdom inal
s u ction tip catheter (Simpson-Sm ith and Poole s u ction d evice) , has m u ltiple holes to
preve nt the i nadvertent 's ucking' i n of s u rrou nding tiss u e .
Many s uction tips are n o w p rovided a s d isposable sing le-use devices (. Figure
6 .8) , as the re usable s uction tips have cleaning and sterilising iss u es d u e to the fin e ,
narrow bore on some - s u ch a s t h e F razier s u ction tip. These need t o b e carefu lly
cleaned with either a specially provided lumen brush (. Figure 6 .9) and/or
processed through an u ltrasonic cleaning bath .
Figure 6.7. Suction tip on a laparoscopic device.
6 SUCTION DEVICES
Figu re 6.8. Disposable Poole sucker.
Figure 6.9. Frazier suction tip showing the lumen brush.
Chapter 7
SEARCHING AND DIAGNOSTIC

INSTRUMENTS
There will be times when the surgeon cannot see or feel specific structures and
will need to seek out areas within these structures. It will be important for him/her to
access, exam ine or periorm a procedure within these areas without disrupting
surrounding tissue that would otherwise be inaccessible without causing excessive
trauma.
To allow access to these parts there are many options open to the surgeon:
• Non-invasive techniques.
• Minimally invasive techniques.
• Surgically invasive techniques.
Many non·invasive techniques using both radiological approaches and non·

radiological approaches are available to the surgeon to aid diagnosis, such as
ultrasound scans, angiograms, echocardiograms and special scans such as
computed tomography (CT) and magnetic resonance imaging (MRI).
Minimally invasive techniques can be accomplished by using instrumentation such

as endoscopes. These can be either rigid or flexible. The endoscope is a generic
name given to all instruments that are used to exam ine a structure or internal organ
through a natural, surgically manufactured opening or orifice. Most areas of the body
are available to the 'surgeon's eye' by using an endoscope through these
approaches. Some of these instruments can be used intra·operatively such as the
choledochoscope (. Figure 7 . 1 ), which can be used to access and see inside the
biliary system to look for blockages, i.e. stones.
Figure 7.1 . Choledochoscope.
Endoscopy is deve loping i nto a h i g h ly tec h n ical specialty that req u i res a range of
external ' h i g h-tec' equ ipment, such as stack systems containing an optical camera,
processor, insufflator, light sou rce and i n many cases a compatible printing device .
There is also consideration made for the provision of specialised s u ction/i rrigation
system s . These are mainly for laparoscopic procedu res but are also req u ired by
s u rgeons utilising oth e r endoscopes - both rigid and flexible - for procedures such
as , fo r example, cystoscopy i n u rology and hysteroscopy in gynaecology. Als o , other
specialties such as orth opaedics use an e n doscopic approach for some of their
proced u res , such as with arthroscopies - looking i nto joints . ENT s u rgeons also use
these systems fo r e n doscopic proce d u res such as sinus s u rgery. For m ost types of
en doscopic s u rgery, practitioners need to be familiar with the tasks and normal
operating functions of this e q u ipment, from wh ich an u n derstanding of the problems
and troubleshooting of the equipment will deve lop. Other instru ment cons iderations
that need to be addressed are the ope rative can n u las and ports that are req u ired to
facil itate p lacem ent of the e n doscopic i nstruments used fo r the procedure - this will
be covered later under laparoscopic instrumentation (see C hapter 1 1 ) .
7 SEARCHING AND DIAGNOSTIC INSTRUMENTS
S u rg ically invasive tec h n iq u es em ploy the use of i nstruments such as probes, for
exam ple, a sinus probe that has a n u mber of d iffering s izes and shapes to enable the
s u rgeon to fo llow a sinus tract; an example of this is the Lockhart- M ummery fistula
probe (. Figure 7 . 2 ) . These are just as important to the armam entarium of the
s u rgeon and are used to search out s i nuses, u n natu ral tracts and cavities for
blockag es , stones and foreign bod ies .
� (rr
Figu re 7.2. Lockhart- M um mery fistula probes.
Oth e r i nstruments can be employed to remove these blockag es , caused by, for
example, stones . Depen ding upon the caus e , these instrume nts may be handled,
g rasping-type fo rceps , such as the Randall stone forceps/graspers (. Figure 7 . 3) or
catheters with an inner device that can be opened within a structu re to g rasplremove
blockages caused by stones or blood clots , for example, a Dorm ia basket (. Figure
7 . 4) .
Figure 7.3. Randall stone-removing forceps.
7 SEARCH I N G A N D D I AG N OSTI C I N STR U M E N TS
F i g u re 7 . 4 . D o r m i a b a s ket s h ow i n g t h e ' b a s ket' o p e n rea d y to ca ptu re a sto n e .
Pro b i n g , w h i c h m a y be fo l l owed b y i r r i g ati o n , i s a p roced u re used t o assess t h e

a n atom y a n d f u n ct i o n of a d u ct , fo r exa m p l e , t h e lacri m a l d rai nage s y stem w i t h t h e
e y e . I t m a y be c a r r i e d o u t to t reat a b l ockage o r obstruction w i t h i n t h e lac r i m a l d u ct
w h i c h m a y be d u e to ste n o s i s from rep eat c h ro n ic i nfect i o n , tra u m a or from a
c o n g e n ital nasolacri m a l d u ct o bstruct i o n . B y p ro b i n g t h e l ac r i m a l d u ct , t h e s u rg e o n
can a s s e s s t h e i nteg rity of t h e d u ct a n d either use t h i s assess m e n t fo r i n itial
treat m e n t b y cleari n g a n y b l o c kage present o r fo r f u rt h e r s u r g i cal treat m e n t . The
s u rg e o n uses a set of lacri m a l p ro bes which c o m e in vari o u s g rad u ated sizes - so
as well as b e i n g u sed as a n explorato ry p ro b e , t h e y can be classed as a d i l ator. A n
exa m p l e i s t h e Bowman lac r i m a l p ro b e ( . F i g u re 7 . 5) .
�
�
�
�
Figure 7.5. Bowma n lacrimal probes.
Rigid endoscopes
For m ost d iag n ostic en doscopic p roce d u res , a flexible endoscope can be used.
These can access and exam ine the i nterior of a hollow orga n , d u ct or cavity. As these
will mainly be d iagnostic, a biopsy specimen can also be taken or injections (for
treatment) g iven t h ro u g h the flexible scope.
Rigid en doscopes , such as , for exam ple, cystoscopes (. Figure 7 . 6) (looking i nto
the u rinary bladder) or hysteroscopes (looking i nto the uterus) are used to perform
specific procedures where a flexible scope would not be sufficient. Where, for
example, a large resection is req u i red , an endoscopic resectoscope would need to
be used and this would be better perfo rmed through a rigid scope. An example is
transu reth ral resection of the prostate (TU RP) . The resectoscope (. Figure 7 . 7) is an
instrument that consists of a s h eath , normally fenestrated , that can accomm odate a
kn ife or electros u rg ical cutti ng loop, as a working element, for s u rgery with i n a body
cavity. The electros u rg ical loop or kn ife may be eith e r monopolar or b ipolar - these
may be single use or reusable and fit into the working element of the resectoscope
(. Figure 7 .8) .
7 SEARCH I N G A N D D I AG N OSTI C I N STR U M E N TS
F i g u re 7 . 6 . R i g i d cystosco p e .
F i g u re 7 . 7 . Resectosco p e s .
C u tt i ng l oop
Coagu lation e l ectrode
C u t t i n g el ectrode
C u tt i ng l oop
Figure 7.8. Bipolar electrosurgical resection instrum ent ends.
Oth e r proce d u res that can be performed through an endoscope include the
removal of renal stones (calculi) t h rough ridged cystoscopy or u reteroscopy. B ladder
stones can be removed i n the same way but oth e r, more specific devices are
available to extract bladder stones . A retrieval system (Oormia-type basket) is passed
into the u reter, opened around the sto n e , then closed to trap the stone, enabling
extraction . • Figure 7 .9 s h ows the p rocess of i nserting the catheter with the basket
Figure 7.9. Removal of a renal stone from the ureter.
7 SEARCHING AND DIAGNOSTIC INSTRUMENTS
withdrawn inside the catheter, the basket device ope n i n g and captu ring the stone,
which is secure ly h e ld prior to its removal . This is facilitated by d i rect vision through a
rigid e ndoscope.
An example of a procedure that co uld be performed through a flexible endoscope

is the removal of biliary stones in the p roximal common bile d u ct . • Figure 7 . 1 0
s h ows the endoscope with i n the lumen of the duodenum and the sto ne retrieval
basket being passed up the common bile d uct (CBO) through a sphincterotomy to
retrieve a biliary gallstone. The basket device is then with d rawn with the gallsto ne
firmly g rasped and held by the bas ket .
Figure 7. 10. Biliary gallstone being removed from the CBO through a sphincterotomy.
Within t h is section it is worth mention ing instruments that are used to 'see' and
'observe' certain anatomical structures , or allow the s u rgeon to access areas he/s he
may need to ope rate through by proceeding through natural o r s u rgically constru cted
orifices. These i nstruments are classed as specu lums and perform a sim ilar role to
that of the retractor - they are d iscussed in more detail in C hapter 3 - " Retractors
and specu l u ms" .
B riefly mentioned al ready is the d i lator (lacrimal probe/dilator) . These instruments

are mentioned late r in C hapter 8 - "Ancil lary i nstru mentation".
C h a pte r 8
A N C I L LA RY I N ST R U M E NTAT I O N
Instruments can not always be categorised into specific design types or g roups as
they vary widely dependent upon the s u rgeon's preference of use , knowledge of
instrume ntation and hospital reg ion. I nstrument sets will d iffer and specific instrume nts
within them will chan ge. Some procedures require specific and u n ique instru mentation
to facilitate with , or help, a specific proced u re . In this chapter is an introduction to other
instrume nts that are u n iversally used but are not easily placed into function g roups, for
example, the Collingwood Stewart hern ia ring (. Figure 8 . 1 ) and the l igature pusher
Figure 8.1 . Co l l ingwood Stewart hernia ring.
Figure 8.2. Negus l igatu re pusher.
(. Figure 8 . 2 ) . This chapter will also cover an overview of i nstruments in certain

specialties.
8 AN CILLARY INSTRUMENTATION
Collingwood Stewart hernia ring
The Collingwood Stewart hernia ring (_ Figure 8 . 1 ) is an instrument designed to be

placed around the inguinal cord during procedures periormed within the inguinal
canal. The 'ring' is placed around the inguinal cord so it can be manipu lated and
retracted to avoid damage to its vascular contents, as in the repair of an inguinal
hernia where the surgeon defines the type of inguinal hernia present so a repair can
be made.
A ligature pusher (_ Figure 8.2) is designed to aid knot tying and is a useful tool to
aid the tying of ligatures or sutures in deep tissues, or anatomical areas where it
would prove d ifficu� for the surgeon to use his fingers to push the ligature sufficiently
tight when knotting. The ENT surgeon would use this when tying ligatures around the
tonsil vessels deep in the oropharynx during a tonsillectomy for example.
Aneurysm needle
An aneurysm needle (_ Figure 8.3), having a blunt or sharp point, is an instrument

for suturing, puncturing or passing a suture or ligature around a structure such as an
artery or vein to allow it to be tied off. The ligature is passed through the eye of the
needle which is found at the point of the needle end of the instrument, pushed
through and under the vessel and then captured on the other side by forceps
allowing the surgeon to then tie it off.
Instruments for measurements
Surgeons may sometimes need to periorm precisely measured interventions.

These are done using a stainless steel ruler (_ Figure 8.4), or a pair of calipers (_
Figure 8.5). Measurements in surgery are important in many special isms, including
orthopaedic joint relacements, where specific measurements, sized jigs and trial
instruments are used; _ Figure 8.6 shows a femoral head·measuring device. I n
plastic and reconstructive surgery and maxillofacial su rgery, reconstruction may need
specific measurements in order to rebuild facial structures; so suitable and accurate
measurements need to be made. I n the case of ophthalmic procedures, a small pair
of calipers can be used to measure d istances in rectus muscle surgery (_ Figure
8.7), where resection and recession of these muscles need to be made in strabismus
(squint) su rgery.
Figure 8.3. Syme aneurysm need le.
8 ANCILLARY INSTRUMENTATION
Figu re 8.4. Stainless steel ruler.
Figu re 8.5. Orthopaedic cal ipers.
Figure 8.6. Femoral head-measuring device.
Figure 8.7. Castroviejo cal ipers.
The o rthopaedic depth gauge (. Figure 8 .8) is designed to m eas u re the

appropriate screw length to fit a drilled hole in bon e , to secure fractu red bone
fragments together or to al low a plate to be placed to repair a bone fracture or
pu rpose-made bone cut or osteotomy.
Figure 8.8. Orthopaedic depth gauge.
•
Uterine sound
A uterine sound is used to m eas u re the internal depth of the uterus so perforation
of the uterus is avoided when inserting other instru ments , e.g. cu rettes and
en doscopes. Two types to consider are the Sims (_ Figure 8 .9) and Galabin (_
Figure 8 . 1 0) uteri n e mal leable s o u n d .
Figure 8.9. Sims uterine sound.
Figu re 8. lD. Galabin uterine sound.
Vascular instruments
The following s h ow some of the bas ic vascular ancillary i nstruments that are used
in vascu lar procedures to augment the general instrume nts that you would expect to
find i n a typical vascular set (other than the range of vascular clamps described
earlier) : the Cooley vascular m eas u ring clamp (. Figure 8 . 1 1 ) , a vein stripper used in
varicose vein s u rgery (. Figure 8 . 1 2) , a vascular s h u n t clamp ( . Figure 8 . 1 3) and
vascular t u n n elling devices for tunnelling g rafts s ubcutaneo us ly (. Figure 8 . 1 4) .
Figure 8.1 1 . Vascul a r measuring clamp.
Figu re 8. 12. Vein stripper.
Figu re 8. 13. Vascular s hunt clamp.
"
Figure 8. 14. Vascul a r tunnel l ing device.
Phlebectomy hooks
Phlebectomy h ooks (. Figure 8 . 1 5) are instrume nts that are used to treat b ranch
varicosities of the large and small saphenous ve ins. A se ries of small incisions or skin
pu nctu res are made i n the skin over the varicos ities and the hook is used to catch the
ve i n and p u l l it through the incision wh ere it is avu lse d .
Figu re 8. 15. Phl ebectomy hooks.
Tibbs flushing cannula
The Tibbs can n u la ( . Figure 8 . 1 6) comes in various s izes with a 'peanut' or

con ical e n d p roviding a snug fit i n a vesse l which allows insertion i nto the b lood
vessel to flush it through with h epari nised saline solution d u ring vascular procedures .
Figure 8.16. Tibbs ca nnul a .
Biliary instruments
I n biliary s u rg ery, there may also be a req u i rement for M oynihan cholecystectomy
forceps (. Figure 8 . 1 7) or Lahey cholecystectomy d u ct forceps (. Figure 8 . 1 8) ,
Figure 8. 17. M oynihan chol ecystectomy forceps.
Figure 8. 18. Lahey forceps showing the opened tips.
described earl ier in Chapter 5 - "Clamps and cl ips". Lahey forceps may also be
req u ired by the vascular s u rgeon - so, clearly, some i nstru ments have a n u mber of
ro les and uses across a variety of specialties . They present in a n u mber of s izes and
lengths, some havi ng fine tips and others slig htly larger. These are versatile
instrume nts that are used p rimarily for blunt d issection around vessels o r d u cts to
identify them , and to pass ligatu res o r tapes aro u n d to facilitate their l igation or
retraction . The ang led and fi ner jaws make them an ideal instru ment for this type of
d issection . To manipu late or hold the gallbladder, the s u rgeon may use a pair of
gallbladder lifting forceps - examples of which are the M ouat gallbladder l ifting
forceps or J udd Martel gallbladder forceps (. Figure 8 . 1 9) .
a b
Figure 8. 19. a) Mouat gall bladder l ifting forceps. b) Judd Martel gall bladder forceps.
For exp loring the common bile d u ct , a range of stone forceps or d u ctal exploration
forceps are available to rem ove stones. This instrument is used to extract stones from
the com mon bile duct. They can also be used to extract stones from the kidn ey,
kid ney pelvis and u reter. An example in com mon use is the Ran dall sto ne forceps
which come with varying degrees of tip c u rvature (. Figure 8 . 20) .
Figure 8. 20. Randa l l stone forceps.
•
Micro instrumentation
I nstruments that are used to perform m icrosu rgery are usually small and del icate .
They are precise d evices that are normally used with operating m icroscopes or by
s u rgeons using binocular lou pes (. Figure 8 . 2 1 ) to magn ify the ope rative s ite . They
al low the s u rgeon to manipu late and repair very small structu res or tiss u e .
Figure 8.21. Binocular lou pes.
Micro instru me nts , typically made of titanium or stain less steel (titanium being the
prefere n ce as it is lighter in weight and stronger) , mai ntain their edge and delicate
precis ion in their active operati ng 'end' . The i nstrument fi nish is d u l l so light from the
microscope is n ot reflected back into the eyes of the operati ng s u rgeon and his team.
These i nstru ments are designed to be manipu lated with the thumb and forefinger
which al lows m ore s u btle and delicate manoe uvres than would be otherwise ach ieved
with instru m ents havi ng ring finger handles; therefore , scissors and needle holders
are operated with spring action hand les ( . Figure 8 . 2 2) with a s in g le ratchet that
locks and u n locks the jaws of the needle holder t h ro u g h a single 'sq ueeze' of the
instrument handle.
Figu re 8.22. a) Spring scissors. b) Castroviejo need le holder.
Micro-thumb forceps used in ophthalmic s u rgery are small, del icate and have very
fine poi nts , as in a pair of Pierse-Hoskin forceps (. Figure 8 . 23) .
Figure 8.23. Pierse-Hoskin forceps showing the m icro end.
I n n e u rosu rgery, the instruments are normally offset with an angle b u i lt i nto the
handle. The arach noid kn ife (. Figure 8 . 24) is a com monly used kn ife for d issection
with m icro-d issectors and n e rve hooks used fo r blunt d issection. Forceps (. Figure
8 . 25) may have fine teeth or be plain or sm ooth , and may be curved or straig ht; they
are also offset to aid vision when in use.
r
$ :
r ·'
.�.
,
�.·l
:"
'I�·
••
Figure 8.24. Arachnoid knife (showing the offset bend).
Figure 8.25. M icro forceps.
The fine ends and tips of these instrume nts need to be protected carefully
because they are eas i ly bent or th rown out of alignment if handled rou g h ly.
Micro cl ips used with a clip applicator to occl ude small vesse ls are also spring
loade d , as with the Yasarg i l clips (. Figure 8 . 2 6) . This tech nique of 'open s u rg ical
clipping' is performed fo r aneurysms in the vas cu latu re of the brain to treat and
prevent rupture of these aneurysm s , wh ich would cause a subarachnoid
haemorrhage (. Figure 8 . 27) .
Figure 8. 26. Yasargil clips.
Aneurysm
Clip
Figure 8.27. Appl ication o f a clip on a n aneurysm .
Dilators
D i lators are instrume nts used to g radually d ilate an orifice or d uct to allow the
introd uction of a larger instru ment, o r to open a strictu re i n a d uct o r o rifice. These
d ilators take the form and s hape of the anatom ical area in which they are to be used ,
such as u rethral d i lators , with d ifferent designs fo r males and females . The Cl utton
sound is an example of a male u rethral d i lator (_ Figure 8 . 28) , and the Hegar dilator
is an exam ple of a female u reth ral d ilato r (_ Figure 8 . 29) .
The Hegar female d ilato r g radually tapers from a wider proximal e n d to a thinner
d istal end and are fou n d in a range of s izes . Some are sing le-ended whilst oth e rs are
dou ble-en ded with the oppos ite end being one s ize up o r down in its widt h .
S o m e d ilato rs have b e e n designed to d ilate d ucts , s u ch a s the Bakes d ilato r (_

Figure 8 . 30) . The Bakes d i lator has an oval tip of various s izes on a malleable shaft
and can be used i n choledocholithotomy to d i late the com mon bile duct, enabling
stone remova l . It can also be used to check the patency of the oes ophagus i n
paediatric s u rgery and fo r p robing the pancreatic d uct and d ilati ng the ampulla of
Vater in cases of stricture.
Figure 8. 28. Clutton sound - male urethral dilator.
a b
Figu re 8. 29. Hegar d ilator - female d i lator: a) singl e-ended; b) double-ended.
Figure 8.30. Bakes d ilator.
The N ettleship d ilato r (_ Figure 8 .3 1 ) is used to d ilate the lacrimal pu nctum -

usually in conj u n ction with the lacrimal probe to open the d uct in the lacrimal sac, and
to facil itate syringing to remove a blockage . _ Figure 8.32 s h ows the N ettleship
d i lator i n use to d i late the punctum.
Figu re 8.31. N ettleship d il ator.
Figure 8.32. Dilatation of the l ower eyelid punctum with a N ettleship dilator.
•
Cardiac dilators
An example of a specific cardiac d i lato r is the Tubbs transventricular d i lator (_

Figure 8 . 33) fo r m itral valve stenosis . The instru ment is used to open a closed o r
damaged m itral valve caused b y a g e , d isease o r a defect that h a s b e e n i n h e rited .
This still remains a popu lar instrument today even though it has been in use for a
n u mber of decades . When the Tubbs cardiac d ilato r i nstrument is passed i nto the
m itral valve , the handle is closed , ope n i n g the d i lator to 45mm i n width .
Figure 8.33. Tubbs cardiac d il ator.
Sponge holder and towel clip
The sponge holder is another versatile i nstrument that is used p rimarily for holding
swabs and sponges fo r 'prepping' the patient's skin prior to d raping the ope rative
s ite . It may also be used to g rasp and manipu late structu res or tiss ue with out caus ing
trauma or damage. Exam ples of its use in t h is role are i n holding the gallbladder
d u ring an open cholecystectomy, and manipulating cervical tissue and removal of
endometrial tiss u e d u ring gynaecological proced u res . A common use is for it to carry
a fixed swab, known colloqu ially as a 'swab on a stick' to aid both blunt d iss ection
and mopping u p of blood . An example of a common sponge holder is the Rampley
sponge holder (_ Figure 8 . 34) which is sim ilar to the Foerster sponge holder (_
Figure 8 . 35) .
Figu re 8.34. Ram pley sponge holder.
Figure 8.35. Foerster sponge holder.
Towel clips
The towel clip primarily was used to clip together the woven fabric d rapes when
isolating the operative s ite; h oweve r, m ost d rapes in use today are made of
d isposable waterproof, impregnated paper fabric, wh ich have an adhesive edge to
hold them in position provid ing a secure seal around the ope rative s ite. Some
s u rgeons when applying the towel clip to d rapes used to clip them through the
patient's skin, wh ich i n modern practice is thought to be inappropriate caus i n g
u n n ecessary damage. They can also be u s e d t o g rasp tiss u e (and s k i n ) to a i d t h e
s u rgeon's visualisation of woun ds/structu res and indeed they can be u s e d to aid
entry with a laparoscopic port. This use, to aid laparoscopic entry, is largely frowned
upon i n modern practice as it causes u n n ecessary s kin damage. These towel clips or
clamps have s harp, perforating tips as with the Backhaus towel clip or clamp (_
Figure 8 . 36) . There are also towel clamps that have non-perforating tips such as the
Lorna towel clamp ( _ Figure 8.37) and clamps with a ball and socket tip (_ Figure
8 . 38) . These will n ot perforate the towels and d rape they are used to clam p .
Figu re 8.36 . Backhaus towel clip.
Figure 8.37. Lorna towel clamp.
Figure 8.38. Towel clamp with a ball and socket tip.
Curettes
A cu rette or 'spoon' is an instru ment designed to scrape or debride biological

tissue from a n umber of various anatomical areas . They can be used to take tissue
biopsies from the inside of body stru ctu res; fo r example, taking e n dometrial biopsies
from the inside of the uteru s . This is a hand tool that has a tip s haped as a spoo n ,
hook or gouge t o scrape a n d capture tiss u e for rem oval , with eith e r b l u nt , but
normally s harp, edges .
Figure 8.39. Curette loop.
Figu re 8.40. Curette spoon.
They can be used i n a variety of ways and may be used to remove, fo r example,
im pacted ear wax, fo r the excision of adenoids (by scrap ing them out) , fo r debrid ing
abscesses and deroofi ng cysts to rou g h e n the edges to promote healing and to take
tiss u e for investigatio n . These are hand-held instrume nts that may be double-ended
(with d iffering s ized ends) or sing le-ended with a solid handle. _ Figures 8 . 39 , 8 . 40
and 8 . 4 1 s h ow a variety of curettes.
Figure 8.41. Volkmann spoon (cu rette) .
Trocar (and cannula)
This is an instrument consisting of an obturator with a s harp cutti ng point and

s harp edges at its d istal end and a s h eath o r can n u la (hollow tube) over the trocar
that al lows penetration of the skin or body cavity, leaving the can n ula in p lace once
the trocar has pen etrated the structu re and is removed . This may be for the d rainage
of fl uid within that struct u re or fo r the insertion and placement of an e n doscope . The
trocar and can n u la may be made of m etal (. Figure 8 . 42) or plastic with the trocar
tip-bladed or non-bladed (. Figure 8 . 43) . The hollow can n u la is normally left in place
after tiss u e pen etratio n . The function of this device i n laparoscopic s u rgery is to al low
passage of the ope rative te lescope and instrume nts to facil itate s u rgery. The can n u la
has a seal so the pneumoperitoneum can be maintained. These 'ports' are d iscussed
further i n the laparos copic instrument chapter - see C hapter 1 1 .
Originally, s u rgeons used this device to d rain fluid o r gas from body cavities , as i n
abdom inal ascites . Two exam ples o f a trocar and can n u la are s h own be low.
Figu re 8.42. Trocar and ca nnula.
•
Figure 8.43. Laparoscopic first-entry ca nnula.
Dissectors
These i nstruments al low the s u rgeon to perform various b l u nt d issections of tiss u e

within certain stru ctu res and a r e specifically designed f o r t h is p u rpos e . An example i n
common use is the Watson-Cheyne d issector (. Figure 8 . 44) , w h i c h i s a double
ended instrument that can be used both as a d iss ecto r and a probe; another double
ended instrument com monly used is the McDonald d issector (. Figure 8 . 45) , having
a straight s pade-type e n d and a c u rved end.
Some d issectors are designed to s l ip u nder specific structu res to allow the
s u rgeon to incise tiss u e ove r the i nstrument - the i nstru ment therefore protects the
anatomical stru ctu res and tissues unde rneath or behind the d issector. An example of
this type is the Kocher thyroid d issector (. Figure 8 . 46) . This d issector has chann els
for the s u rgeon to cut d own onto g iving some d i rection and protection to the cut.
Figu re 8.44. Watson-Cheyne dissector.
Figure 8.45. McDonald d issector showing the two different ends.
Figu re 8.46. Kocher thyroid d issector.
C h a pte r 9
I NTEST I N A L I N ST R U M E NTS
I ntesti nal instrume nts are added to gen eral and major laparotomy sets of
instruments to facil itate specific s u rgery on small and large intestine and i n clude
clamps needed to occlude bowel to prevent leakage of bowel content. They include
extra-long forceps , stapling devices and i ntralumi nal devices s uch as the Poole-type
s u ction can n u la/tips (described earlier in Chapte r 6 - "Suction devices") and
intestinal decompress ion i nstrume nts , s u ch as the Savage d ecompresso r (. Figure
9 . 1 ) , based on a trocar and can n u la design - the s harp trocar penetrates and
introd u ces the can n u la into the bowe l that req u i res decompress i n g , and s uction is
applied to the can n u la to evacuate the build-up of air.
Figu re 9.1 . Savage decompressor.
Bowel clamps
A variety of bowel clamps are needed to facilitate both bowel occl usion and bowel
crushing , used for resection and refashioning of bowel. Occlusion clamps s u ch as
the Doyen bowel clamp (. Figure 9 . 2) are non-cru s h i n g and are designed to be used
on bowel n ot to be damaged, whe reas the crus hing type of clamp will crush o n ly
bowel tiss u e that is due to be resected . These i nstru ments hold bowel m ore secure ly
and will, by crus h i n g the bowel held , damage the bowel tiss u e . Examples of cru s h i n g
clamps a r e the Payr and Parker- Kerr clamps (. Figure 9 .3) . The Parker- Kerr clamp
Figure 9.2. Non-crushing Doyen occlusion bowel clamp.
9 INTESTINAL INSTRUMENTS
<D
Figu re 9.3. a) Parker-Kerr clamp with jaw shields. b) Payr clamp.
has a slotted s h ield that fits over the jaws of the clamp; once applied, it secu res the
clamp jaws and protects from bowel seepage getting into the abdomen.
The Lane twi n anastomosis clamp (. Figure 9 . 4) was origi nally designed for
stomach resection and has two s ets of clamps that can be joined together, allowing
resected stomach to be approximated, aiding the reanastomosis. It can be used both
on small and large bowel in the same way. The Lane twin anastomosis clamp is a
non-crushing clam p .
Figure 9.4. Lane twi n anastomosis clamp.
Stapling devices
S u rg ical stapling devices (. Figure 9 .5) have revo lutionised gastro intestinal
s u rgery both fo r open and laparoscopic proced u res . They have made the formation
of anastomoses much q u icker, simpler and m ore secure for eve ry part of the
gastro intestinal tract.
rr
Figure 9.5. Stapling devices.

•
The stap ling device was i n itiated as a m echan ical suturing device that al lows for a
superior res ult in end-to-end anastomoses , in comparison to that of hand s uturi n g . It
causes less trauma than manual suturing and performs an end-to-end i ntestinal
anastomosis (. Figure 9 . 6) that is superior and more anatom ically s o u n d . The
fore runn ers were cylind rical devices that resembled a proctoscope and could be
inserted peranally, so maki n g resection of lowe r co lonic and rectal tumours m ore
anatom ically s o u n d , obviating the need fo r a pe rmanent colostomy, as the
desce nding/transverse colon could be rejoined or anastomosed to the remaining
rectal o r anal stu m p . This proved ideal as the trad itional abdominoperineal resection
was the operation of choice and usually res u lted in clos u re of the anus with a
res u ltant perman ent colostomy. Hand suturing of colon to the rectum or anal stump is
d ifficult or almost im poss ible.
The instrument is cylind rical i n s hape with a cone that can be opened away from
and s u bsequently closed onto the main barrel of the i nstrument. The proximal and
d istal ends of the remaining bowel, after the main resection has taken p lace , are
secured around the 'nose cone' and barre l of the d evice o nto the shaft and then
d rawn together to app roximate them . The device is then 'fired' by squeezing the
handle which inserts a cyl ind rical row of staples i nto both ends of the bowe l and
simu ltaneo us ly cuts two d iscs of bowel from the lumen inside the stapled ends.
Figure 9.6. The principle of the stapling gun in an end-to-end anastomosis.
These resemble 'dou g h n uts' in s hape and al low the s u rgeon to see that two
complete rings of tiss u e have been take n , proving that a sound anastom osis has
been fo rmed.
The circ u lar stapler has also been used successfu l ly to treat haemorrhoids (_
Figure 9 . 7 ) . It provides a q u ick and accu rate solution with a faster recovery fo r
patie nts who present with haemo rrh oids, or p ro laps e , havi ng a u n ique advantage over
that of conve ntional s u rg ical excis ion as it is used above the de ntate line inside the
anal canal . The stapler is applied in the anal canal for transection and resection of
internal tiss u e affecting fewer n e rve endings, therefore provid ing a proce d u re which
is less painfu l .
Figu re 9.7. Disposable haemorrhoidal stapl er.
Anterior resection of the rectum
A stapling g u n inserted via the rectum and used to anastomose rectum to large
bowel after resection is s h own i n • Figure 9.8. The circ u lar stapler has made this
procedure m uch eas ier and produ ces a more secure suture line with a ci rcu lar row of
double staples . This produ ces an e n d-to-end anastomos is (EEA) between the bowel
and rectum .
Figure 9.8. Stapl ing gun inserted through the anus to anastomose distal colon
showing a pu rse-string suture in place.
The d evelopment of stap ling devices has n ow progressed i nto m i n imally invasive
s u rgery and/or laparoscopic p rocedu res (. Figure 9 .9) . I nterest has been generated
as laparoscopic s u rgery has developed and the developm ent of laparoscopic linear
cutters and stap lers has allowed the s u rgeon to perform upper and lowe r
gastro intestinal procedures , colectomies , gastric s u rgery and, more recently, s u rgery
for bariatric cases through this route .
Figure 9.9. Laparoscopic stapling device.
Chapter 10
GYNAECOLOGICAL INSTRUMENTS
A variety of specialised instruments are available to the gynaecolog ist that will
cover open abdominal, vaginal and laparoscopic procedures. The instruments used
will vary between different regional theatres and the surgeon's preferences for
his/her own practice. The following provides information on the more commonly
used instruments and their uses; speculums have been covered in Chapter 3 -
"Retractors and speculums", and d ilators have been covered in Chapter 8 -
"Ancillary instrumentation".
Uterine sound
A uterine sound is a long instrument with some malleability in its shaft, having a
blunt tip to avoid perforation to the uterine wall. It has measurements o n the shaft
to gauge the depth of the uterine cavity and length of the cervix. It can also be
used to feel for any specific pathology within the uterine cavity such as fibroids or
anatomical abnormalities like a uterine septum or a bicornuate uterus. They are
commonly found on d ilatation and c u rettage sets (D&C). An example of a uterine
sound is the Galabin (. Figure 1 0 . 1 ) or Sims (. Figure 1 0.2) uterine so und.
Figure 10. 1. Galabin uterine sound.
Figure 10. 2. Sims uterine sound.
10 GYNAECOLOGICAL INSTRUMENTS
Tenaculum forceps
These i nstruments are used fo r g rasping the cervix, usually at the anterior/superior
lip of the cervix. The vulse llum forceps usually has t h ree to fou r teeth and are very
s harp. The tenacu lum is a straight i nstrument and has o n ly a s i n g le s harp point at the
tip (. Figure 1 0 . 3) . Both instrume nts are employed to hold and steady the cervix
a b
Figure 10.3. a) Tenacul u m forceps. b) Vulsell u m forceps.
when perform ing procedures such as the insertion of a uterine s o u n d , a cervical

biopsy, a vag inal hysterectomy, insertion of a Spackman can n ula (. Figure 1 0 . 4) (for
laparoscopic gynaeco log ical procedures) or any hyste roscopic proce d u re . The
vulsellum forceps being extrem ely s harp are n ot used if there is a potential danger of
teari n g the cervix.
Spackman cannula
The Spackman can n u la ( . Figure 1 0 . 4) is inserted into the open ing of the cervix
and is secured in p lace by either tenacu lum or vulsellum forceps , the handle rings of
Figure 10.4. a) Spackm a n ca nnul a . b) Cannula tip.
the forceps being attached to the manoe uvrable, hooked p late on the shaft. The
Spackman can n u la is used for i njecting methylene blue dye for laparoscopic
hysterosalpingography to check the patency of the Fallopian tubes in s uspected tubal
blockag e . It is also p laced in situ for laparoscopic p rocedu res to enable manipu lation
of the uterus as the s u rgeon looks into the abdom inal pelvis . The uterus can be
retroverted , antiverted, o r m oved lateral ly, so the s u rgeon can see all aspects of the
anatomy.
Episiotomy scissors
Episiotomy scissors are used to perform an epis iotomy prior to a vacu u m or

forceps delive ry. The scissors are s haped so the bottom blade (. Figure 1 0 .5) is
inserted in the vag ina wh ilst the baby's head is protected by the practitioner's fingers ,
a s t h e proce d u re i s perfo rmed when t h e baby's h ead crowns. N o rmally the
epis iotomy is done as a mediolateral cut which can be exte nded to the anus if a
median approach is adopte d .
Figu re 10.5. Episiotomy scissors.
•
Polyp forceps
This instrument may be straight or curved and is used to retrieve intrauterine

polyps . The cervix is normally d i lated sufficiently to al low passage and ope n i n g of the
instrument to g rasp any polyps with i n the uterus (. Figure 1 0 . 6) . It is sim ilar i n
design to the sponge h o l d e r but with smaller jaws . The sponge h o l d e r can sometimes
be the instru ment of choice if th ere are large polyps to retrieve . Its insertion is
depe ndent upon h ow wide the cervix can be d i lated . An example of polyp forceps is
the Bon ney forceps (. Figure 1 0 .7) .
Figure 10.6. Uterine forceps in use, shown grasping an intrauterine polyp.
Figu re 10.7. Polyp forceps ( Bo nney) .
The F u n d a m e nta l s of S U R G I CA L I N STR U M E N TS - A practica l g u i d e to t h e i r recog n i t i o n , use a n d ca re
Vag i n a l wa l l retractors
Both the L a n d o n ( . F i g u re 1 0 .8) and S i m s ( . F i g u re 1 0 . 9) retractors can be used

i n co nj u n cti o n with t h e S i m s o r A u vard s p ec u l u m m a k i n g it eas i e r to v i s u a l i s e the
cervix a n d vag i n a . T h e y a re espec i a l l y u sefu l for a n te r i o r a n d poste r i o r vag i n al re p a i rs
fo r a c y stoco e l e , e nte rocoe l e a n d rectocoe l e .
F i g u re 1 0 . 8 . La n d o n a nt e r i o r va g i n a l wa l l ret ra cto r.
10 GYNAECOLOGICAL I NSTR UMENTS
Figure 10.9. Sims a nteri or vaginal wall retractor.
•
Gynaecological clamps
Kocher forceps (. Figure 1 0 . 1 0) (or clamp) are a commonly used instrument i n

gynaecological s u rgery d u e to t h e i r robust h o l d i n g featu res . They are u s e d t o clamp
and hold the major vascular ped icles i n hysterectomy and both straight and c u rved on
flat instrume nts are used i n tandem. Any pedicle or vascular tiss u e can be held
Figure lD. lD. Kocher (Ochsner) forceps.
secu rely in the jaws which have teeth at the tips - these add secu rity when tissue is
g raspe d . Other specific clamps , s u ch as the Gwilliam hysterectomy clamp (. Figure
1 0 . 1 1 ) , Heaney-Ballentine hysterectomy clamp (. Figure 1 0 . 1 2) and Main got
hysterectomy clamp (. Figure 1 0 . 1 3) are des igned for g rasping the uterine tiss u e
and pedicles to faci litate excision and l igatio n . T h i s i s very t h i c k , muscular tiss u e
containing major vesse ls w h i c h req u i res a firm , secure hold. If this h o l d s l ips th ere
could be a massive haemorrhage wh ich may be d ifficult to control - hence a very
robust, toothed clamp is req u ire d .
Figu re 10. 1 1 . Gwi l l ia m hysterectomy clamp.
Straig ht/S ingle C u rved/Single Straig ht/Double C u rvedlDouble
Figure 10. 12. Hea ney-Bal lentine hysterectomy clamp.
-
l amp ·
ste, e ctO"W c
t hv
!M,ogo
10 .13 .
Fi g" ,e
Yo
Figure 10. 14. Wertheim vaginal and pedicle clamp.
These abdominal hysterectomy clam ps , l ike the Kocher forceps , are designed to
g rasp and hold vascular ped icles firm ly, as i nadvertent 'sl ippage' of the pedicle from
the instrument co uld res u lt in major and catastrophic haemorrhag e . These
instruments are robust and are presented with various designs of jaw
se rrations/ i nserts and teet h , to firmly hold tiss u e in betwee n them. For vag inal
ped icles , the Wertheim pedicle clamp ( . Figure 1 0 . 1 4) is the instru ment of choice .
Elevating forceps
Uterine e levating forceps , such as the Somer forceps (. Figure 1 0 . 1 5) , are

commonly use to extract tumours , tiss u e or polyps from the uterus by elevating the
vag inal wal l . The jaws are se rrated to allow a firm hold when g rasping the tiss u e to
be removed and they are c u rved to allow full visualisation d u ring the p roce d u re . The
uterine e levator is also usefu l i n manoeuvring the uterine wal l , making the removal of
tiss u e eas ier.
Figure 10.15. Somer uterine elevating forceps.
•
Myomectomy screw
To facilitate the removal of a fibroid tumour from within the uterine wal l , it may be
necessary to secu rely hold the fibroid and manipu late it, whilst excising it from the
myometrium , the muscle layer of the uteru s . The myomectomy screw is 'screwed'
into the fibroid which allows a firm hold on the tiss u e as the s u rgeon d issects it out. It
can be used for both ope n , abdominal procedu res and also fo r laparoscopic excis ion,
using a smaller 5mm i nstrument (. Figure 1 0 . 1 6) enabling passage down a 5mm
port.
a b
Figure 10. 16. a) a nd b) Large (open) myo mecto my screw. c) La pa rosco pic
myomectomy screw.
Cervical biopsy
The s u rgeon will sometimes need to remove a small amount of tiss u e from the
cervix if any abn ormal ity is s uspected (usually fou n d o n routi n e exam ination or Pap
smear) .
This tiss u e is removed for h istolog ical exam ination , and the extent of abn ormal
tiss u e to be exam ined and removed will d ictate the instru m ents used for this
procedure. Punch biopsy forceps normally s uffice for this proced u re (. Figure
1 0 . 1 7) , but more extens ive excision may need a cone b iopsy, wh ereby a circu lar,
Figure 10. 17. Cervical biopsy forceps.
cone-shaped piece of tiss u e is taken to include the ope n i n g of the cervix. This is
normally facilitated by scalpel or laser excis ion (. Figure 1 0 . 1 8) .
..."., - - -..
"-
� "
I \
/ \
I I
\ I
\
\
" /
"- ./
- - -
Figure 10. 18. Sca l pel excision for cone biopsy showing the incision route.
Chapter 1 1
LA PAROSCOPIC INSTRUMENTS
One of the most recent developments to have revolutionised su rgery is the

development of minimally invasive, keyhole, laparoscopic surgery. Even though the
framework of laparoscopic s u rgery has been developed from over a century ago,
modern techniques have been a rapidly growing science since the 1 960s and
1 970s, when it became a vital part of gynaecologists' practice. Since that time it
has become fully integrated into the armamentarium of the general surgeon. This
followed the development of the video chip and camera which placed the images
onto the television screen, allowing for magn ification and wider observation of the
operative site.
Modern developments have allowed high definition and 3·D imaging, hand·
assisted laparoscopic surgery (HALS)(_ Figure 1 1 . 1 ) , and the use of 'sing le·port'
laparoscopic s u rgery (SPLS) (_ F i g u re 1 1 . 2).
Single· port laparoscopic surgery, being one of the latest advances, allows the
surgeon to use flexible endoscopes and articulating instruments. The surgeon can
periorm complex procedures through one single, or multiple, small incisions in the
abdomen, into which he/she can place the telescope and the operating instruments.
The main incision is normally made at the umbilicus; as with the normal m u lti·port
technique, the scar can be hidden within this area. The number of operations that can
Figure 11.1 . Single entry port in use showing instrument and camera placements.
Figure 11.2. Single port showing a three-port entry facility and two gas entry ports,
for single-port laparoscopic surgery (SPLS).
l l LAPAROSCOPIC INSTRUMENTS
be periormed laparoscopically are now m u ltiple and have replaced the need for a
large abdominal incision, such as:
• Nephrectomy.
• Prostatectomy.
• Hemicolectomy.
• Cholecystectomy.
• Splenectomy.
• Intussusception red uction.
• Gastrostomy tube placement and appendectomy.
I n gynaecology, SPLS has been used to periorm:
• Oophorectomy.
• Salpingectomy.
• Bilateral tubal ligation.
• Ovarian cystectomy.
• Surgical treatment of ectopic pregnancy.
• Both total and partial hysterectomy.
Laparoscopes
The modern 'telescope' has been adapted to carry light through fibreoptics and to
magnify through a series of lenses, allowing the surgeon to view structures at
different angles to facilitate the procedure within the abdomen. They normally provide
a 0°, 1 2 °, 30° and 70° angle of vision (. Figure 1 1 .3). The image is digitised through
the camera processor where it can undergo some additional processing, such as
filtering, 'noise' red uction, image enhancement and colour adjustment. This image is
then sent to the monitor where it can be viewed not only by the surgeon but by the
rest of the surgical team. Some telescopes have a flexible end that can be
manipulated by the surgeon to obtain a view from a number of angles rather than by
just 'set' angles (. Figure 1 1 .4).
====�
Figure 11.3. Telescope: 10mm laparoscope showing the various angles for viewing.
11 LAPAROSCOPIC INSTRUMENTS
Figu re 11.4. Flexible-ended telescope.
Light cables
There are two main types of light cables available to conn ect the telescope to the
light sou rce on the stack system : flu id-filled cables and fibreoptic cables . F l u id-filled
cables tend to conduct more heat than fibreoptic cables and are usually stiffer in
nature, so they are a little more d ifficult to manipu late and manoeuvre. Some have an
inability to be autoclaved , so sterilisation becomes an iss u e .
Fibreoptic cables (. Figure 1 1 .5) a r e m ore user-friendly and m ore flexible, but are
more fragile, so if rou g h ly hand led are prone to damage. If the fibres break and
become g reate r than 25% damaged, then the cab le s h o u l d be replaced as the
d i m i n ished light transmission will adversely affect the vision of the operative s ite .
Figure 11.5. Typical l ight l ead with m u ltiple connectors.
11 LAPAROSCOPIC INSTRUMENTS
Trocars and ports
There are many types and designs of laparoscopic trocars available - some
reusable (_ Figure 1 1 .6) and most, i n modern practice , are d isposabl e , single use (_
Figure 1 1 .7) . Some have an integral s h ielded blade to aid insertio n , whilst some have
Figu re 11.6. Reusable metal port.
a b
Figu re 1 1.7. Laparoscopic ports : a) 10mm first entry; b) Smm with a reta ining
balloon.
•
a sharp p lastic point or a blunt point. The trocars are referred to as 'in itial' or first
entry ports and secondary-entry ports . The first-entry ports , wh ich are normally
placed to take the telescope , are 1 0mm or 1 2m m d iameter ports . The 5mm port is
inserted as a secondary entry; these will take the operati ng i nstruments . All the ports
have a one-way si licone or rubber seal wh ich h elps to maintain the pneu moperitoneum
when the scope or instrument is removed . Some first-entry ports allow the telescope
to be placed inside as the port trocar as it is being i ntroduced , to al low the s u rgeon to
visualise its entry i nto the abdomen - thus reducing the danger of damag ing
abdominal conte nts . The port hub has a small entry port with a control tap that al lows
the ins ufflation tubing to be attached.
Hand-assisted laparoscopic surgery (HALS)
The s u rgeon uses h is/ h e r n on-d o m i n ant hand to g u id e and man ipu late the
lapa roscopic instrume nts i n t h is variation of laparoscopic s u rg e ry. By u s i n g h is/h e r
han d , it al lows a g reater flexibil ity and sensory fe e l to the p roce d u re w h i c h
u ltimately makes t h e operation safer, g iving a g reater depth of f e e l and t o u c h t o
g u i d e h is/h e r dissectio n . It a l s o al lows retraction of t i s s u e a n d structu res that
would oth e rwise not be feas ible when using instrument retractors . It has a g reater
adva ntage i n some procedures, where larg e r organs a re excised , s u c h as the
splee n , by allowing the organ o r structure to be removed from the abd omen whole
rather than piecem eal. The hand access port, s u ch as the GelPo rt® (. Figure 1 1 .8) ,
Figure 11.8. HALS technique showing port position and colon removal through the
port.
allows the pneumoperitoneum to remain intact whilst the hand is inside the
abdomen.
The HALS technique can be used to perform a number of d ifferent procedures

through smaller incisions, such as:
• Colectomy (hemicolectomy or anterior resection).

• Hepatectomy.
• Splenectomy.
• Nephrectomy.
• Gastrectomy.
Insufflation of the abdomen
Entry into the abdomen with a port is a blind technique and does present problems
with a number of possible complications, for exam ple, the surgeon may periorate the
bowel, liver or a major blood vessel. To help overcome this, there are two main
recognised entry methods. The classic technique, still used today by many
gynaecologists, is by using a Veress needle to insufflate the abdomen before entering
with a port. The other is the classic open technique, or Hasson technique, where the
surgeon makes an incisional opening, identifying structures through their layers down
to the peritoneum before inserting the port, before inflating the abdomen. In both
techniques, the abdomen is then inflated with carbon dioxide gas.
The Veress needle has an external d iameter of 2mm with an external, sharp
hypodermic·like point. Internally there is a spring·loaded inner cannula that has a
blunt point which when the resistance of the abdominal wall is overcome on entering
the abdominal cavity, springs forward so just the inner blunt atraumatic cannula is
exposed. This blunt tip is designed to prevent entry into abdominal contents.
The Veress needles in use now are mainly single use (. Figure 1 1 .9); however,
mu ltiple use ones are still available (. Figure 1 1 . 1 0) . The normal entry point for the
Veress needle is through the umbilicus.
The Fundamentals of SURGICAL INSTRUMENTS - A practical gUide to their recognition, use and care
Figure 1 1 .9. Veress needle - disposable.
Figu re 11 . 10. Veress n eedle - the reusable length (A) is norm a l ly 12-1Scm .
Laparoscopic instruments
The instruments used are often miniature variations of the normal general surgical
instruments used in open surgery. The tips of the instruments are smaller versions of
their larger cou nterparts, and as such they are able to do the following:
• Aspirate.
• Dissect.
• G rasp.
• Retract.
• Cut, clip and staple.
• Suture.
• Cauterise using mono polar and bipolar electrosurgery.
The instrument design requirements are based upon the procedure being
performed through a small incision, and with a lack of d irect open vision. They are
designed to provide the ergonomic conditions for the surgeon to manipu late them
single-handed, operating all the functions of the instrument with one hand. The
instruments must be light, but robust and comfortable in the surgeon's hand to allow
repetitive movement over prolonged periods of time; some of which requires a
delicate touch, especially in long dissection.
The instruments have rounded edges and have darkened su rfaces to reduce
reflected light. Most instruments need to be covered in an insulating coating so
electrocautery may be used at the tip of the instrument without causing thermal
damage to surrounding organs or tissue.
Each 'hand' instrument is usually around 30-33cm long and their main parts are:
• Handles - with and without a ratchet device, some with an electrode connector
(_ Figure 1 1 . 1 1 ) .
• Rotator device, usually attached to the handle, to allow a full 360' rotation of the
working instrument tip.
• The shaft which should be insulated.
• Inner operative/working part.
The instruments should be easy to assemble and disassemble with the parts being
interchangeable between similar instruments. They should have a simple design with
minimal hinges/bolts and should be easy to clean and sterilise.

MoutreySteve 2017 Chapter5 TheFundamentalsOfSURG

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MoutreySteve 2017 Chapter5 TheFundamentalsOfSURG

Uploaded by

Copyright:

Available Formats

The Fu ndamentals of SURGICAL INSTRUMENTS - A practical guide to their recognition, use and care

Poole (. Figure 6 . 2) or S impson-Smith s u ction device (. Figure 6 . 3) may be

Figure 6.2. Poole suction tip.

Figure 6.3. Sim pson-Sm ith suction tip.

Good visualisation of the s u rg ical area to be s u ctioned is paramount to provide a

S o m e s u ction devices , such a s the F razier s u ction can n u la (. Figure 6 . 4) , have

Figure 6.5. Laparoscopic suction/irrigation system.

T h e control o f laparoscopic s u ction/i rrigation i s i n t h e hands o f t h e operati n g

Figu re 6.6. Suction and irrigation controls.

Figure 6.7. Suction tip on a laparoscopic device.

Figu re 6.8. Disposable Poole sucker.

Figure 6.9. Frazier suction tip showing the lumen brush.

SEARCHING AND DIAGNOSTIC

Many non·invasive techniques using both radiological approaches and non·

Minimally invasive techniques can be accomplished by using instrumentation such

Figure 7.1 . Choledochoscope.

Figu re 7.2. Lockhart- M um mery fistula probes.

Figure 7.3. Randall stone-removing forceps.

F i g u re 7 . 4 . D o r m i a b a s ket s h ow i n g t h e ' b a s ket' o p e n rea d y to ca ptu re a sto n e .

Pro b i n g , w h i c h m a y be fo l l owed b y i r r i g ati o n , i s a p roced u re used t o assess t h e

Figure 7.5. Bowma n lacrimal probes.

Coagu lation e l ectrode

Figure 7.8. Bipolar electrosurgical resection instrum ent ends.

Figure 7.9. Removal of a renal stone from the ureter.

An example of a procedure that co uld be performed through a flexible endoscope

B riefly mentioned al ready is the d i lator (lacrimal probe/dilator) . These instruments

Figure 8.1 . Co l l ingwood Stewart hernia ring.

Figure 8.2. Negus l igatu re pusher.

(. Figure 8 . 2 ) . This chapter will also cover an overview of i nstruments in certain

Collingwood Stewart hernia ring

The Collingwood Stewart hernia ring (_ Figure 8 . 1 ) is an instrument designed to be

An aneurysm needle (_ Figure 8.3), having a blunt or sharp point, is an instrument

Instruments for measurements

Surgeons may sometimes need to periorm precisely measured interventions.

Figure 8.3. Syme aneurysm need le.

Figu re 8.4. Stainless steel ruler.

Figu re 8.5. Orthopaedic cal ipers.

Figure 8.6. Femoral head-measuring device.

Figure 8.7. Castroviejo cal ipers.

The o rthopaedic depth gauge (. Figure 8 .8) is designed to m eas u re the

Figure 8.8. Orthopaedic depth gauge.

Figure 8.9. Sims uterine sound.

Figu re 8. lD. Galabin uterine sound.

Figure 8.1 1 . Vascul a r measuring clamp.

Figu re 8. 12. Vein stripper.

Figu re 8. 13. Vascular s hunt clamp.

Figure 8. 14. Vascul a r tunnel l ing device.

Figu re 8. 15. Phl ebectomy hooks.

Tibbs flushing cannula

The Tibbs can n u la ( . Figure 8 . 1 6) comes in various s izes with a 'peanut' or

Figure 8.16. Tibbs ca nnul a .

Figure 8. 17. M oynihan chol ecystectomy forceps.

Figure 8. 18. Lahey forceps showing the opened tips.

Figure 8. 20. Randa l l stone forceps.

Figure 8.21. Binocular lou pes.

Figu re 8.22. a) Spring scissors. b) Castroviejo need le holder.

Figure 8.23. Pierse-Hoskin forceps showing the m icro end.

Figure 8.24. Arachnoid knife (showing the offset bend).

Figure 8.25. M icro forceps.

Figure 8. 26. Yasargil clips.

Figure 8.27. Appl ication o f a clip on a n aneurysm .

S o m e d ilato rs have b e e n designed to d ilate d ucts , s u ch a s the Bakes d ilato r (_

Figure 8. 28. Clutton sound - male urethral dilator.

Figu re 8. 29. Hegar d ilator - female d i lator: a) singl e-ended; b) double-ended.