Surgical Instruments and Their

Application for Incisions

 Surgical operation - is a dissection of patient’s
tissue for treatment or diagnose.
Operation is carried out by surgical
team in sterile condition, which
includes:
• Surgeon, which carries out all main
actions and is the chief;
• One or two assistances, who help
the surgeon;
• Scrub nurse, which gives
instruments, solutions, cotton pads;
• Circulation nurse helps to the scrub
nurse and is non sterile.
Any operation can be carried out with
local and general anesthesia. The
surgeon injects the anesthetics for
local anesthesia with himself.
Anesthesiologist gives general
anesthetics to the patient.
Elements of Operation: any operation contains follow
elements: tissue dissection, control of bleeding, connection of
tissue.
1. Tissue dissection is incision of
tissue of patients body which
results in exposure of pathological
locus and different anatomic
formations relevant to the
operative procedure.
2. Control of bleeding is necessary
because any incision results in
damage to blood vessels and
bleeding, which is necessary to
stop.
3. Tissue connection allows to
restore a continuity of structures
destroyed by pathological process
or during operation.
 Elements of Operation
•These elements are carried out in
different volumes and
combinations during various
operations. For example, in
superficial abscess drainage all
operation is reduced to one
incision only.
•To provide good healing of clean
incised wound it is necessary to
connect its margins by sutures.

•In injury of large blood vessel all

actions are directed to control of
bleeding.
 Elements of Operation.
1.Surgical Dissection
•It is possible to separate tissue by
means of sharp or blunt dissection.
•Tissue incision can be carried out by
scalpel or scissors, or other modern
surgical methods.
•Blunt dissection is made by probes,
blades, forceps or graspers, or even
by surgeon’s finger.
•Anatomical identification is an
essential prerequisite of sharp
dissection, and gentle blunt
dissection helps to separate tissue
planes and to define anatomy.
• Commonly combination of these
two techniques is necessary to
enable completion of the operation.
 Tissue Dissection.
Common rules of tissue dissection are as follow:
1. Incise tissue subsequently step by step (layer by layer). It allows to
provide control of every step of surgical intervention; to prognoses
follow actions; to make necessary correction into the operation
according to individual features of patient and pathological
process.
2. Dissection of different layers at the same length. It provides
• minimization of surgical trauma;
• good view of the formation at the floor of the wound.
3. Dissection should be parallel to the main neuro-vascular bundles
to avoid their injury.
4. Length of the incision should be as short as possible and as long as
necessary, because very long wound is good for surgeon’s actions,
but does not provide cosmetics, and the intraoperation trauma
increases in this case;
but rick of complications is higher if incision is very small.
5. Shape of the incision should be linear.
Modern Methods of Tissue Dissection
are the Follows:
Mechanical – by means of various types of
blades;
Electrical (diathermy);
Plasma current;
Ultrasound;
Cryodestruction;
Laser scalpel.
 Electrosurgery
The goals of electrosurgery are to destroy benign and malignant
lesions, control bleeding, and cut or excise tissue. The major
modalities in electrosurgery are electrodesiccation, fulguration,
electrocoagulation, and electrosection. Electrosurgery can be used
for incisional techniques that produce full-thickness excision of
nevi, for shave techniques that produce partial-thickness removal
of superficial lesions, and for removing vascular lesions such as
hemangiomas or pyogenic granulomas. The correct output power
can be determined by starting low and increasing the power until
the desired outcome is obtained (destruction, coagulation, or
cutting). Smaller cherry angiomas can be electrocoagulated lightly.
Larger cherry angiomas may be easier to treat by shaving them
first, then electrocoagulating or desiccating the base. The elevated
portion of pyogenic granulomas can be shaved off with a scalpel or
a loop electrode using a cutting/coagulation current. The base of
the lesion is curetted to remove the remaining tissue and then
electrodesiccated. Complications such as burns, shocks, and
transmission of infection can be prevented by careful use of the
electrosurgical equipment
 Electrodessication and Fulguration
In electrodessication, an active electrode touches or is inserted into the skin to
produce tissue destruction (A). Electrodesiccation can be used to treat fine
telangiectasias and spider angiomas.
In fulguration, the electrode is held away from the skin to produce a sparking at
the skin surface and more shallow tissue destruction (B). Fulguration is especially
useful in treating superficial epidermal lesions, such as a superficial basal cell
carcinoma of the trunk.
 Electrocoagulation
Electrocoagulation is ideal
for clotting small blood vessels (less
than 2 to 3 mm in diameter) in
deep and superficial surgery.
Usually, a 2- to 5-mm
metallic sphere at the end of a
treatment electrode is the optimal
tip for hemostasis of small vessels.
These electrode tips can be directly
applied to the relatively dry surface
of a surgical bed that has been
momentarily compressed or used
indirectly by touching a hemostat or
anatomical forceps which is used to
grasp the small bleeder.
 Electrosection
In electrosection, the electrode is used to cut
tissue. An electrode tip in the shape of a fine
needle, wire loop, diamond, ellipse, or triangle
is advanced slowly through the tissue, causing
a steam envelope to advance around the tip
and producing a smooth cutting effect with
little sense of pressure against the tissue by
the operator.
This minimization of power produces a
specimen with minimal heat damage along its
margins and clinical wound healing the same
as when surgical steel blades are used. The
specimen should be acceptable for pathologic
interpretation compared with specimens
produced with laser techniques. Wound edges
can be approximated with sutures when an
excisional biopsy is performed. Cosmetic
results are similar to those seen with scalpel
and suturing.
Various Types of Surgical Knives(1-5) and Scalpels:
1- amputation knives, 2 – cerebral knife for autopsy, 3 – knife for
cartilages, 4 – knife for plaster casts incisions, 5 – knife for oral
techniques, 6 – scalpels, 7 –handle with blade
 Handle and Blades of Scalpel
Scalpel contains the blade,
Scalpel of various types with sharp
neck and handle.
and oval, big and small blades which
are used commonly in oral and
general surgery.

Single action scalpels can be of

different blades in sterile pack.
Instruments for Sharp Dissection

Blades of Scalpels
 Types of Scissors:
by Richter (1), sharp-blunt tips (2), blunt-blunt tips (3), with
curved blunt blades by Cooper (4)

2
4
 Correct Way to Hold the Scissors:
the 1st and 4th fingers are within the rings, the 2d finger is
placed on the distal part of the shanks.
•This position of the 2d finger
stabilizes the instrument. The
cut is made from right to left or
away from the surgeon. When
cutting from the right to left, the
wrist is superextended. The cut is
usually made close to the tips of
the blades.
•Scissors are suitable for blunt
dissection and also for
preparation of tissues. In this
case, the scissors are introduced
into the tissues with their tips
closed, then opened, and
dissection is carried out with the
lateral blunt edges of the blades.
 Types of Probes.
stick probes (1 – 3), gutter probes (4,5), dissecting probe (or blade for
blunt dissection – 6), probe by Kocher (7)

1
Probes are
2
the
3 accessory
instruments
4
for sharp
5
dissection
and used for
blunt
6
dissection
too.
7
 Different types of forceps
• From left to right: surgical,
anatomical, by Ott (Russian
forceps)
Tips of forceps
•The teeth of tissue forceps prevent tissues
from slipping, only a small pressure is
required to grasp tissues firmly. Thus, to
grasp skin and subcutaneus fat, the surgical
forceps is used most frequently, But if the
skin is gripped firmly with this forceps for a
prolonged period it can be necrotize.
•For very strong tissue (walls of the uterus)
or to give the surgeon some instruments or
gauze balls and napkins forceps by Ott is
useful.
•Vessels, hollow viscera most not be grasped
with surgical forceps because of risk of
bleeding or perforation. For these purpose,
or for holding sponges or bandages,
anatomical forceps should be chosen. They
have blunt ends with cross-striations to give
the additional grasping power.
 Correct Position of Forceps: Grasp Like a Pan.

Special forceps: gynecological,

auricle, ophthalmic

This position makes possible the

most convenient holding, the finest
handling and free movements. It
doesn’t result in fixation of the
wrist joint.
 Tissue Retractors:
Retractors by Volkmann, • Retractors are need to hold tissues and
with sharp (1) and blunt (2) tips organs aside in order to improve the
exposure and hence the visibility and
accessibility of the surgical field. Hand-held
retractors cause minimal trauma because the
assistant maintain tension on the tissues
only as long as necessary.
1 •To the skin sharp Volkmann retractors are
used. To fatty tissue and fascias blunt
Volkmann’s are used. To retract the muscles,
vessels and internal organs and tissues
Faraboeuf’ retractors are preferable.

Tissue retractors by Faraboeuf

 Self-retraining Tissue Retractors

•Another type of tissue retractors

are self-retraining retractors
(Weilander self-retractor, Gosset
self-retraining retractor, etc.) are
of great help, but care should be
taken not to damage the tissues
when they are placed and
removed.
•These retractors are used to the
small (eye) or large (laparotomic)
wounds and help to make hands
of assistant free to carry out
other manipulations.
 Correct Positions of Tissue Retractors
•The assistant (usually the 2d) holds
these retractors.
•The scrub nurse gives him two
retractors at the same time with
their handles toward the surgeon.
•To take tissue retractors correctly
their handles must be on the palm
of the hand, and toothed part of
Volkmann retractors or working
part of Faraboeuf’ retractor should
be from medial side of the hand
and directed downward.
•No one finger should be within the
rings of the handles. These
openings help to make weight of
these instruments more easy.
 Towel Clamps by Backhaus (1) and Schaedel (2)
are mainly serves to fix the draping towels and napkins
placed on the operative field, as well as for securing the
surgical suction tube etc.

2
Preparation of the Operation Field
•To start any operation it is
necessary to prepare
operation field with
antiseptic twice. After that
the surgeon has to drape
operation field to separate
operation field from other
skin. Different methods can
be used. Application of towel,
napkins, cotton sheets or
plastic sheets is suitable. To
clip the napkin (towel)
different clamps can be used.
 Local Anesthesia
•Start with small syringe (with
volume of 2-3,0 ml) and short
needle. Syringe is held with right
hand of the surgeon from above
or from below. 1st finger is on the
cannula of the needle and the
eye of the needle looks upward.
Piston of the syringe is between
the thenar and hypothenar
Fig.1
eminencies (fig.1).
•Push the needle parallel to the
skin into the derma. The eye of
the needle only should be within
the derma. Then press to the
piston till whitish elevation about
0,5 – 1,0 cm in diameter will be
visible (like a lemon bark)- fig.2. Fig.2
 Local Anesthesia
•Start with small syringe (with
volume of 2-3,0 ml) and short
needle. Syringe is held with right
hand of the surgeon from above
or from below. 1st finger is on the
cannula of the needle and the eye
of the needle looks upward.
Piston of the syringe is between
the thenar and hypothenar Fig.1
eminencies (fig.1).
•Push the needle parallel to the
skin into the derma. The eye of
the needle only should be within
the derma. Then press to the
piston till whitish elevation about
0,5 – 1,0 cm in diameter will be Fig.2
visible (like a lemon bark)- fig.2.
 Rules of Correct Local Anesthesia
•In any direction (toward and backward)
anesthetic solution should follow in front
of the needle. This helps to prevent injury
of the superficial nerves and vessels.
•The weakest place of any needle is at a
distance of 2 – 5,0 mm from the cannula
where the needle can be broken.
•When you reach this distance move the
needle backward together with
anesthetic solution to fill pathway of the
needle with solution, because soft tissue
infiltrate must be tight.
•When the eye of the needle only is
within the subcutaneous fat it is possible
to change direction of the needle to the
right and left side from the line of skin
incision and to continue injections of
anesthetic to lateral sides (A,1).
 Rules of Correct Local Anesthesia
It is possible to repeat the same
manipulations from the opposite side of
skin incision (A, 2). Infiltration of the
subcutaneous tissue usually is carried
out in a shape like a rhomb from two
points: first direction is along a bisector
of the rhomb (line of skin incision) and
then asides.
If skin incision is too long it is possible
to carry out local anesthesia from
several points along the line of skin
incision. Any injection should be done
within the borders of previous
infiltrated area because the patient
should not feel more than one
puncture.
Apply anesthetic into the depth (C)
through the same points and wait 5 -10
min before skin incision.
 Positions of Scalpel depends on the goal of incision and
help to carry out desirable length and depth of incision

Scalpel is held in a pen grasp Scalpel is held like a knife

Position like an amputation knife

Position of a fiddle
bow
 Position of Scalpel Like a Pen
To carry out a long deep and
precise incision surgeon can
hold scalpel like a pen
between the tips of the 1st
and 2d fingers. The handle is
within the interdigital space.
 Position of Scalpel Like a Violin Bow

• For long superficial

incision position of a
fiddle bow is useful.
• It means that the handle is
held with four fingers from
one side, and the 1st finger
is from the opposite one.
 Position of Scalpel Like a Kitchen Knife
•To carry out long incision of
moderate depth the 2d finger of
the surgeon should press to the
blade of scalpel which handle is
between thenar and
hypothenar compartments of
the hand.
•It is said a position of the
kitchen knife
 Skin Incision
•To start skin incision put the
1st and 2d fingers of the left
hand aside the line of follow
incision to retract the skin and
provide its fixation.
•Surgeon holds the scalpel in
the right hand in position of
kitchen knife and pushes the
tip of its blade through the skin
and some subcutaneous fat at
an angle of 900.
 Skin Incision
•After that operator
incises the skin and some
fatty tissue parallel to the
skin, and blade of scalpel
should be at a straight
angle to the surface of the
skin.
•Cutting is usually made
from left to right or
toward the surgeon.
 Skin Incision
•Any time the operator
retracts the skin with his left
hand to provide its fixation
and thus to avoid
movements of the skin. So
his left hand follows the right
one along the line of incision.
•To continue the incision the
surgeon has to cut through
the skin and some
subcutaneous fatty tissue
parallel to the skin at a
straight angle to the surface
of the skin.
 Skin Incision

To finish skin
incision blade should be
at an angle of 900
because all layers must be
cut at the same length.
 Application of Tissue Retractors
•Second assistant should move edges
of the wound aside with sharp
retractors by Volkmann.
•Teeth of retractors should be at the
same level of the opposite sides of
the wound. First assistant has to dry
operation field with forceps and
gauze ball.
•Then surgeon incises subcutaneous
fat and superficial fascia till the deep
fascia is visible. The 1st assistant dries
operation field and the 2d one has to
change sharp Volkmann retractors
into blunt retractors to prevent injury
of superficial vessels.
 Incision through the Deep Fascia
•To incise deep fascia special
methods should be used to prevent
injury of underlying anatomical
structures.
•Surgeon with 1st assistant has to
lift this deep fascia with two
forceps across the line of skin
incision at a distance of 1 – 2 mm in
between. Forceps can be
anatomical for friable fascias and
surgical for strong fascias. Position
of forceps within the hands of the
surgeons is like a pen.
•
 Incision through the Deep Fascia
•Surgeon incises
fascial plane on 1 – 2
mm and pushes the
gutter probe through
this hole below the
fascia.
•Operator pushes to
the handle of probe
from above to make
its tips visible.
 Incision through the Deep Fascia
•1st assistant provides some
tension to the fascia, and
surgeon incises the deep
fascia with scalpel in position
of violin bow.
•But the back of the blade
follows along the gutter and
sharp part of the blade is
upward and cuts the fascia at
the length of skin incision.
•The 2d assistant has to apply
blunt Volkmann retractors to
the deep fascia.
 Dissection through the Muscle
•Any muscle is well supplied
with blood. Therefore
muscular incision across the
muscle can result in severe
bleeding development.
•Sharp and blunt dissection
can be used for muscles. But
scarring after operation can
result in disturbance of
muscular function and bad
cosmetic view. So for
muscular dissection blunt
method along fibers is
preferable if it its possible.
 Dissection through the Muscle
•To split the muscle surgeon
pushes the probe by Kocher
through all thickness of the
muscle between its fibers.
•From this hole operator moves
probe to one side of the
incision, and tip of the closed
forceps (or artery forceps) is
directed to the opposite one.
• This method helps to separate
the muscle along its fibers and
results in good healing and
function after recovery.
 Dissection through the Muscle

•Retraction of the
superficial muscular layer
can be done with blunt
tissue retractors by
Volkmann.
•Muscular layer at the
floor of the wound can be
split with same method.
 Dissection through the Muscle
•Faraboeuf’s tissue
retractors are used for
deeper wounds and delicate
tissues.
•Position of Faraboeuf’s
tissue retractors is from
opposite margines of the
wound parallel to each one.
• 2d assistant has to hold
these tissue retractors on
the palm of his hands.
•Any time tissue retractors
should follow movements of
scalpel to open the wound.
 My e-mail
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• 8921-348-64-95
• Kovshova Marina Vasilievna
Select the best continuation:

1. First department of topographical anatomy was opened in

a) Woman Medical Institute
b) Medico – Surgical Academy
c) Sankt- Petersburg University
d) Moscow University\
e) In all these universities at the same time
Select all correct continuations:
2. To describe information of an object follow characteristics
are used:
a) Sintopy
b) Holotopy
c) Sceletotopy
d) Norm
e) Anomaly
Select the best continuation:
3. Holotopy is said
a) definition of an object’s position according to the bone landmarks
b) definition of the relations between adjacent anatomic formations
c) definition of a position of an object in relation to a human body
as a single whole
d) definition of layers in strictly defined region
e) definition of correct direction of dissection

4. For description of the relationships between adjacent anatomic

formations human body is considered in follow position:
a) standing erect, facing downwards, the arms by the sides, and the palms of the
hands facing forwards
b) standing erect, facing ahead, the arms by the sides, and the palms of the hands
facing forwards
c) standing erect, facing ahead, the arms by the sides and the palms of the hands
facing backwards
d) standing erect, facing backwards, the arms by the sides and the palms of the
hands facing forwards
e) standing erect, facing ahead, the arms upwards and the palms of the hands facing
forwards
Select the best continuation:

5. For sintopy definition of an organ are used the follow

well known concepts:
a) Medial – median - lateral
b) Superior – inferior
c) Anterior – posterior
d) Proximal – distal
e) All previous answers are correct

6. There are follow constitutional types:

a) Dolichomorphic
b) Brachymorphic
c) Mesomorphic
d) All previous answers are correct
e) No one answer is correct
Select all correct continuations:
7. According to their function instruments of general set
divide into follow groups:
a) General instruments
b) Auxiliary instruments
c) Special instruments
d) Dissecting instruments
e) Suturing instruments

8. General instruments contain follow groups:

a) Instruments for sharp dissection
b) Instruments for blunt dissection
c) Tissue grasping forceps
d) Hemostats
e) Tissue retractors
Select the best continuation:
9. Special instruments contain follow group:
a) Needleholders
b) Surgical needles
c) Suture materials
d) Instruments for control of bleeding
e) All these groups of instruments

10. Instruments for grasping and clamping other tissues and

textile belong to follow group:
a) Special instruments
b) General instruments
c) Hemostats
d) Instruments for tissue retraction
e) They belong to no one group