• Early as 10,000 BC prehistoric man fashioned tools

to cut human flesh for the purpose of either inflicting

wounds
• The Incas of Peru used razor-sharp flint & sharpened
animal teeth
• The Code of Hammurabi describes a bronze lancet
• Egyptian Ebers papyrus mentions blades made of
Flint, reed & bronze used around 1900 to 1200 BC
• During the pre-Christian era in India, Susruta
made grasping tools designed for extracting
objects such as rrowheads; he described more
than 100 instruments including scalpels,
lancets, saws, bone cutters, trocars and needles
 • In the first century AD, celsus described
the use in Rome of scalpel handles with
blunt dissecting ends, knives, saws,forceps
and clamps with locking handles, probes
and hooks for retraction
• These crude & often heavy instruments
were the armamentrium of medicine through
the Dark and Middle Ages
• Ambroise Pare’ (french surgeon )was the
first to grasp blood vessels with a pinching
instrument
•
• In the United States, amputations were the surgical trademark of the Civil
War wherein it is performed in the kitchen tables with crude heavy knives
and instruments and table forks were used as retractors

• Through the 18th & 19th centuries surgical tools were made by skilled
silversmiths, coppersmiths and woodworkers
 • When sterilization became accepted around the
turn of the 20th century, instruments made entirely
of metals such as carbon steel, silver & brass
replace those with ornate handles
• Craftsmen – primarily in Germany, Sweden,
France, England, Pakistan & the United States
continue to provide the surgical instruments
needed to extend the capabilities of the surgeon’s
hand

• Hippocrates wrote that the size, weight & delicacy of an instrument ought to be
well suited for its purpose.
• Consequently, instrument modifications vary from the strength needed for
bone work, to the length needed to reach the depths of body cavities to the
delicacy needed to handle structures even under the microscopes
 • Stainless steel
• Titanium
• Vitallium
• Other metals: brass, silver or aluminum;tungsten carbide
• Plated instruments: chromium, nickel, cadmium, silver & copper
are used for coating or flash-plating

 surgical instruments are designed to provide the tools the surgeon needs to
control bleeding

 all instruments can be classified by their function only to be used for their
intended purpose and they should not be abused
 A. CUTTING & DISSECTING
 they are used to dissect, incise, separate or excise tissues
 these instruments should be kept separate from other instruments & the
Sharp edges should be protected during cleaning, sterilizing and storing
A1. SCALPELS
 the type of scalpel most commonly used has a reusable handle with a
disposable blade
 the blade is attached to the handle by slipping the slit in the blade into the
grooves on the handle; an instrument never the fingers is used to attach &
detach the blade
• No. 10 blade is used most often
• No. 11 blade has a straight edge that comes to a sharp point
• No. 12 blade is shaped like a hook with the cutting edge on the inside
curvature
• No. 15 blade has smaller & shorter curved cutting edge than a No. 10 blade
• No. 23 blade has a curved cutting edge that comes to more of a point than
Nos. 20, 21 and 22 blades
A2. SCISSORS
 the blades of scissors may be straight, angled or curved as well as either
Pointed or blunt at the tips (Fig 19-2)
 are used only to cut or dissect tissues; others are used to cut other materials
• TISSUE / DISSECTING SCISSORS must have sharp blades
• SUTURE SCISSORS have blunt points to prevent structures close to the
suture from being cut
• WIRE SCISSORS have short, heavy blades that are used to cut stainless
steel sutures;heavy wire cutters are used to cut bone fixation wires
• DRESSING / BANDAGE SCISSORS are used to cut drains & dressings & to
Open items such as plastic packets
A3. BONE CUTTERS & DEBULKING TOOLS
 have cutting edges suitable for cutting into or through bone & cartilage
 these include chisels, osteotomes, gouges, rasps and files (Fig. 19-3)
A4. SHARP DISSECTORS
 to cut tissue apart or to separate tissue layers may be accomplished with
other types of sharp instruments:
• Biopsy forceps & punches
• Curettes
• Snares
A5. BLUNT DISSECTORS
 friable tissues or tissue planes can be separated by blunt dissection
 the scalpel handle, the blunt sides of tissue scissors blades & dissecting
sponges may be used for this purpose
B. GRASPING & HOLDING

 tissues should be grasped & held in position so the surgeon can perform the
desired maneuver such as dissecting or suturing, without injuring the
surrounding tissues
B1. TISSUE FORCEPS
 are used to pick up or hold soft tissues & vessels (Fig. 19-6)
 are used to grasp & hold soft tissues & organs are too numerous to allow
further elaboration
 the configuration of each is designed to securely grasp but prevent injury
to tissues
• SMOOTH FORCEPS also referred to as thumb forceps or pick ups;
resembles tweezers; they will not injure delicate structures
• TOOTHED FORCEPS differ from smooth forceps at the tip;rather than
being serrated, they have single tooth on one side that fits between
two teeth on the opposing side;provide a firm hold on tough tissues
including the skin
• ALLIS has a scissors action; each jaw curves slightly inward & there is a
row of teeth at the end; the teeth hold tissue gently but securely
• BABCOCK FORCEPS the end of each jaw of a Babcock forceps is
rounded to fit structure or to grasp tissue without injury; this rounded
section is circumferentially fenestrated
 B2. STONE FORCEPS
 either curved or straight forceps are used to grasp calculi such as kidney
stones or gallstones; these forceps have blunt loops or cups at the end of
the jaws
B3. TENACULUMS
 curved or angled points on the ends of the jaws of tenaculums penetrate
tissue to grasp firmly such as when a uterine tenaculum is used to manipulate
the uterus
 the cannula or probe, can be used during laparoscopy to raise the uterus
Into the visual field
B4. BONE HOLDERS
 grasping forceps, vice-grip pliers & other types of heavy holding forceps
stabilize bone
 C. CLAMPING & OCCLUDING

 instruments that clamp & occlude are used to apply pressure

C1. HEMOSTATIC FORCEPS
 most clamps used for occluding blood vessels have two opposing serrated
jaws that are stabilized by a box lock & controlled by ringed handles; when
the box locks are closed, the handles remain locked on ratchets
• HEMOSTATS are the most commonly used surgical instruments & are used
primarily to clamp blood vessels; either straight or curved slender jaws
that taper to a fine point
• CRUSHING CLAMPS many variations of hemostatic forceps are used to
crush tissues or clamp blood vessels;the jaws varies in shapes & the
serrations varies in directions; some are named for the surgeon who
designed or it is designed to be used on specific organs
• NONCRUSHING VASCULAR CLAMPS are used to occlude peripheral or
major blood vessels temporarily which minimizes tissue trauma
 D. EXPOSING & RETRACTING
 soft tissues, muscles & other structures should be pulled aside for exposure
of the surgical site
D1. HANDHELD RETRACTORS
 most retractors have a blade on a handle; the blades vary in width & length
to correspond to the size & depth of the incision; it may be solid or pronged
like a rake; others have traction groves for slippery surfaces such as the
tongue; usually used in pairs & they are held by the first or second assistant
• MALLEABLE RETRACTORS is a flat length of low carbon stainless steel,
silver or silver plated copper that may be bent to the desired angle &
depth for retraction
 HOOKS are single, double or multiple very fine hooks with sharp points
are used to retract delicate structures; used to retract skin edges
during a wide flap dissection such as a face lift or mastectomy
D2. SELF-RETAINING RETRACTORS
 holding devices with two or more blades can be inserted to spread the
edges of an incision & hold them apart (Fig. 19-13)
E. SUTURING OR STAPLING

E1. NEEDLE HOLDERS

 are used to grasp & hold curved surgical needles; resembles hemostatic
forceps the basic difference is the jaws; has a short, sturdy jaws for
grasping a needle without damaging it or the suture material; handles are
long to facilitate needle placement in deeper surgical sites
• TUNGSTEN CARBIDE JAWS is a hard metal; to eliminate the twisting &
turning of the needle in the needle holder; these can be identified by
the gold plating on the handles
• CROSSHATCHED SERRATIONS provides a smoother surface & prevents
damage to the needle
• SMOOTH JAWS have jaws without serrations; these are used with small
needles
E2. STAPLERS
 reusable or disposable are bulky heavy instruments; disassembled for
cleaning & assembled in the sterile field before use; the staples are usually
made of titanium, stainless steel or absorbable material (Fig. 19-18)
• CLIP APPLIERS are used to mark tissue & to occlude vessels or small
lumens of tubes
• TERMINAL END STAPLERS are designed fro closing the end of a hollow
organ with a double staggered line of staples
• INTERNAL ANASTOMOSIS STAPLERS are designed to connect hollow
organ segments to fashion a larger pouch or reservoir
• END TO END CIRCULAR STAPLERS are designed to staple two hollow,
tubelike organs end to end to create a continuous circuit; usually use
in bowel anastomosis after resection
F. VIEWING

 use by surgeons to examine the interior of body cavities, hollow organs or

structures with viewing instruments & can perform many procedures through
them
F1. SPECULUMS
 the hinged, blunt blades of a speculum enlarge & hold open canal or a
cavity
F2. ENDOSCOPES
 the round or oval sheath of an endoscope is inserted into a body orifice or
through a small skin incision
 each type is designed for viewing in a specific anatomic location
• HOLLOW ENDOSCOPES the rigid hollow sheath permits viewing in a
forward direction through the endoscope
• LENSED ENDOSCOPES have either rigid or flexible sheaths & they have
an eyepiece with a telescopic lens system for viewing in several direction
G. SUCTIONING & ASPIRATING
 blood , body fluids, tissue & irrigating solution may be removed by mechnaical
suction or manual aspiration; many of these items are available in disposable
models
G1. SUCTION
 involves the application of pressure to withdraw blood or fluids usually for
visibility at the surgical site
 appropriate style tip is attached to sterile tubing depending on the surgeon’s
preference (Fig. 19-21)
• POOLE ABDOMINAL TIP is a straight hollow tube with a perforated outer
filter shield; used during abdominal laparotomy or within any cavity in
which copious amounts of fluid or pus are encountered
• FRAZIER TIP is a right angle tube with a small diameter;used when
encountering little or no fluid except capillary bleeding & irrigating fluid
such as in brain, spinal, plastic or orthopedic procedures;keeps the field
dry without the need for sponge
• YANKAUER TIP is a hollow tip that has an angle for use in the mouth or
throat; large quantities of blood & fluid can be suctioned quickly with this
tip & useful for visualization during ruptured aneurysm
• AUTOTRANSFUSION a double lumen suction tip is used to remove blood
for autotransfusion
G2. ASPIRATION
 blood, body fluid or tissue maybe aspirated manually to obtain a specimen
for laboratory examination or to obtain bone marrow fro transplantation;often
performed with a needle & syringe
• TROCAR may be needed to cut through tissues for access to fluid or a
body cavity; has a sharp cutting edges at the end of a hollow tube;
has sharp cutting edges at the end of the hollow tube
• CANNULA with a blunt end & perforations around the tip maybe used to
aspirate fluid without cutting into tissue;are used to open blocked
vessels or ducts fro drainage or to shunt blood flow from the surgical
site
H. DILATING & PROBING
 is used to enlarge orifices & ducts; a probe is used to explore a structure or
to locate an obstruction
 probes are used to explore the depth of a wound or to trace the path of a
fistula
 tunneling devices can be used to make a passage for a vascular graft or
shunt
 I. MEASURING

 rulers, depth gauges & trial sizers are used to measure parts of the patient’s
body; some of these devices are used to determine the precise size needed
for an implant such as a joint or breast prosthesis
J. ACCESSORY INSTRUMENTS
MALLET needed to drive a cutting instrument into bone
SCREWDRIVERS are used to affix screws into bone
K. MICROINSTRUMENTATION
 used in microsurgical techniques that result to miniaturized precision
instrumentation
 intruments are extremely fine, delicate &miniature enough to handle in the
very small working area;designed to conform to hand movements under the
microscopes
 KEY POINTS IN HANDLING INSTRUMENTS
BEFORE THE SURGICAL PROCEDURE

1. Always adhere to the sterile principles at all times

2. The scrub person counts all
instruments, sponges & sharps with
the circulator before setting up the
Mayo stand & instrument table

3. Handle loose instruments separately to prevent interlocking or crushing

4. Inspect instruments such as scissors & forceps for alignment, imperfections,
cleanliness & working condition
5. Sort instruments neatly by classifications
6. Leave retractors & other heavy instruments in a tray or container or lay them
out on a flat surface of the table
7. Protect sharp blades, edges & tips. They should not touch anything. Take
care not to perforate the sterile table cover
OVERVIEW OF SAH –OR INSTRUMENT SET UP
 KEY POINTS IN HANDLING INSTRUMENTS
BEFORE THE SURGICAL PROCEDURE
 Efficient instrument handling throughout the surgical procedure is the
hallmark of an efficient scrub person
1. Know the name & appropriate use of each instrument. Using fine instruments
for heavy tissue damages the instrument
2. Handle instruments individually. Tangled instruments are hard to separate in
an emergency
 3. Hand the surgeon or assistant the correct instrument for each particular task.
Remember the following principle: Use for the intended purpose only
• Avoid placing fingers in the instrument rings as the instrument is passed
• Many surgeons use hand signals to indicate the type of instrument needed
• Select instruments appropriate to the location of the surgical site
• Many instruments are used in pairs or in sequence
• Hand instruments around the incisional area, not directly over it, to prevent
possible injury
• A knowledge of anatomy is useful for determining which instrument is
needed
4. Pass instruments decisively & firmly
• If the surgeon is on the opposite side of the operating bed, pass across
right hand to right hand
• If the surgeon or assistant is on the same side of the operating bed & to
the right, pass with your left hand;if the surgeon or assistant is to your left
pass with your right hand
• Hemostatic forceps are held near the box lock by the scrub person &
passed by rotating the wrist clockwise to place the handle directly into the
surgeon’s waiting hand
 • Clip appliers are held between the fingers by the hinged joint during
loading and passing
• Sharp and delicate instruments may be placed on flat surface for the
surgeon to pick up

5. Watch the sterile field for loose instruments. After use, remove them promptly
to the Mayo stand or instrument table
6. With a moist sponge, wipe blood and organic debris from instruments
promptly after each use
7. Flush the suction tip and tubing with sterile distilled water periodically to
keep the lumen patent; keep a tally of the amount used to clear the suction line
& deduct this amount from the total used to irrigate the surgical site
8. Remove debris from electrosurgical tips to ensure electrical contact
9. Place used instruments that will not be needed again into a tray or basin
during or at the end of the surgical procedure
Including :
Army navy # 2
Richardson # 2
Towel clips # 5
Bowl # 2
Enamel #1
 Whether used or unused, all instruments on the instrument table are
considered contaminated and must be promptly & properly decontaminated/
cleaned, inspected, terminally sterilized and prepared for subsequent use
KEY POINTS IN HANDLING INSTRUMENTS
WHEN DISMANTLING THE INSTRUMENT TABLE

1. Check drapes, towels and table covers to be sure that instruments do not go
to the laundry or into the trash. A final quick count is a safeguard
2. Collect instruments from the Mayo stand and any other small tables & collect
those that may have been dropped or passed off the sterile field
3. Separate delicate, small instruments and those with sharp or semisharp
edges for special handling
4. Disassemble all instruments with removable parts to expose all surfaces for
cleaning
5. Open all hinged instruments to expose box locks & serrations

6. Separate instruments of dissimilar metals to prevent electrolytic deposition of

other metals
 7. Flush cold, distilled water through hollow instruments or channels such as
suction tips or endoscopes to prevent organic debris from drying
8. Rinse off blood and debris with demineralized distilled water or an enzymatic
detergent solution
9. Follow the procedures for preparing each instrument for decontamination
or terminal sterilization
10. Wrap the instrument for sterilization

11. Sterilize the instrument in steam unless contraindicated by the manufacturer

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