Introduction to Instrumentation
Daniel Stokoe, CST, A.A.S.
Grades of Instruments
• 3 grades of instruments:
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Surgical – highest possible quality instrument.
• Stainless steel from Germany or U.S.A. only.
• Most made from either 300 or 400 series stainless steel or Electroplated steel
(chrome plated)
• Few made from Vitallium (inert metal and very $$$$)
• Vitallium: Trademark for a cobalt–chromium alloy used for surgical
appliances and implants
• Titanium Alloy (stronger than stainless, used for micro surgical instruments)
• Most important – these instruments go through a process called Passivation: a
process in which a chemical dip removes all debris and creates a layer of
chromium oxide. This makes the instruments more resistant to corrosion and
stains.
– Floor Grade – medium/low level quality surgical instruments.
• Have shiny finish.
• Used to teach.
• Not to be used in surgical set.
– Disposable – low level quality surgical instruments.
• These items are single use only!
• Should NEVER be reprocessed.
• Stamped “single use” on instrument.
Anatomy and Classifying
Instruments
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Jaws
Box lock
Shank
Ratchets
Finger ring
Anatomy
Five Basic Categories
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There are 5 basic categories of surgical instruments:
– Hand-held
• Largest category of instruements.
– Microsurgical
• Most are hand-held but require special handling.
• Ophthalmic, ENT (Ear, Nose and Throat) and Vascular instruments fall under this
category.
• Will not have Tungsten Carbide tips (to small)
– Powered
• Drills, saws, etc.
– Endoscopic
• Includes Ridged and Flexible Endoscopes, fiber optic light cables, cameras and MIS (
Minimally Invasive Surgery) instrumentation.
– Laparoscopic
• This category includes Robotic instruments.
• Insulated and Non-insulated.
• Typically very long, thin and ringed instruments.
Classifications
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Cutting
Grasping and holding
Clamping
Retracting
Probing
Dilating
Suturing
Suctioning
Accessory
Cutting
• Instruments with sharp edges.
• Includes knives, scalpels, scissors, bone
cutting instruments, saws, drills, punches,
adenotomes, and Dermatomes.
• Sometime referred to as “sharps”
Cutting Instruments
Scalpels
• Handles commonly come in #’s 3,4,7,and 9.
Cutting Instruments
Scissors
• There are tissue, suture, wire, and dressing
scissors.
• Can have Tungsten Carbide tips
– Very strong metal that helps tips stay sharper
longer.
• Black handled scissors are referred to as
“Super Sharps”.
– One tip can be serrated.
Basic Cutting/Dissecting
Instruments (continued)
Grasping and Holding
• Designed to manipulate tissues.
• Use to dissect, suturing assistance, reduce,
or stabilize.
Basic Grasping/Holding
Instruments (continued)
Basic Grasping/Holding
Instruments (continued)
Basic Grasping/Holding Instruments
Forceps
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Do not have ratchets.
May have teeth, serrations, or smooth.
Vary in length and type.
Common examples: Adson, DeBakey,
Russian, Gerald, Cushing Bayonet forceps.
Basic Grasping/Holding
Instruments
Ratcheted Grasping and Holding
Instruments
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Allis
Babcock
Kocher
Lahey thyroid tenaculum
Grasping and Holding Instruments
Bone Holding Clamps
• Use to hold bone in place
• Ratcheted and vary in type and size
• Example are Lane, Kern, Lowman, and
Lewin
Clamping/Occluding
• Designed to occlude or constrict tissue
• Vascular clamps are used in vascular and
heart surgery
• Hemostats are use to occlude vessels until
ligated
Basic Clamping/Occluding
Instruments
Basic Clamping/Occluding
Instruments (continued)
Kelly
Basic Clamping/Occluding
Instruments (continued)
Retracting
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Designed for exposure at the operative site
May be hand held or self retaining
Vary in size, length, and type
May be sharp or dull
May be malleable
Basic Retracting/Exposing
Instruments
Large Richardson or
Basic Retracting/Exposing
Instruments (continued)
Basic Retracting/Exposing
Instruments (continued)
Basic Retracting/Exposing
Instruments (continued)
Probing
• Used for exploration of a fissure, fistula or
duct
• Commonly found in gallbladder and rectal
trays
• Wire like instruments with guides
Dilating/Probing Instruments
Dilating
• Used to gradually dilate an orifice to allow
a larger instrument to be introduced or
measurement of lumen diameter
• Used in Endoscopy, GYN, GU (cysto),
Vascular surgery
Dilating Continued…
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Tapered at on end then increase in diameter
Cervical dilators are double ended
Urethral dilators are single ended
Esophageal dilators are the longest and
most flexible
Suturing
• Needle holders are used to hold needles for
suturing
• Vary in shape and size
• Jaws have small serrations to hold needle in
place
• Similar in part structure to the hemostat
• Can have Tungsten Carbide tips.
– These can be replaced!
Needle Holders
Suctioning
• Used in removing blood or body fluids from
operative site to maintain surgeon visibility
to perform surgical procedure
• Disposable or non disposable
• Type of suction based upon surgical site and
procedure
• Common suction tips are Yankauer, Poole,
and Frasier
Basic Visualization Instruments
Visualization
• Laparoscopic procedures require trocars, ports,
cannulas for laparoscopic instrumentation access
• Is it a retractor or a speculum?
• Also for viewing called a speculum or specula
(plural)
• Think ear speculum when you visit physician and
he/she does an ear exam
• Ladies think GYN visit (it’s a Graves speculum
they use)
Basic Visualization Instruments
(continued)
Accessory Instruments
• Sponge sticks
• Towel clips
• Not really a clear use for it that is related to tissue
handling
• Also multi-use instrument
Endoscopes
1. Diagnostic
2. Operative
(channeled)
• Rigid
Visualization:
Direct (0°)
Angled (30, 70, 120°)
• Semi-rigid
• Flexible
Visualization:
Panoramic
Two Types of Flexible:
1. Fiberoptic
Visualization through
eyepiece
Connect to light source
2. Videoscope
Visualization on monitor
Connect to light source
and camera
Diagnostic Endoscopes
• For observation
• No operating channels
Operative Endoscopes
• Channeled: irrigation, suction, insertion of
biopsy forcep or needle, connection of
accessory instruments such as cautery or
laser
Tools Required to Perform MinimallyInvasive Surgery With an Endoscope
Robotics
pages 103-105, 132
• Robotic instruments
– Similar to laparoscopic instruments
• Jaw design and length similar
– Differences arise in handling and cleaning
procedures
• Da Vinci
– Endo-Wrist instrumentation.
• Multi-use instruments
Endo-Wrist
turn to page 104
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Have 5 main components:
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4.
5.
Release levers (A)
Instrument shaft (B)
The wrist (C)
The tip or end reflector (D)
Instrument housing (E)
Summary
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3 grades of instruments
Anatomy and Classifying Instruments
5 basic categories of surgical instruments
Classifications of surgical instruments
– Cutting, Grasping and holding, Clamping,
Retracting, Probing, Dilating, Suturing,
Suctioning, Accessory
• Scopes and Robotics
Instrument Care and Handling
Minor and Major Trays
Micro Instrumentation
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Small and delicate instruments
Used with a microscope
Made of Titanium instead of stainless steel (Much lighter yet strong)
Held with thumb and forefinger
Beaver blades are used for knife blade
Scissors and needle holders are spring loaded
Usually hand washed after case
Gas sterilized due to the delicate nature of instrumentation (may steam
sterilize in separate load)
• Tips can be bent very easy
• Be very careful when handling and cleaning these instruments
Care and Handling
• Must be handled with care
• Very expensive
• Inspection for function before and after
surgery in essential
• Do not place delicate instruments under
heavier instruments
• Micro instruments should be hand washed
Types of Instrument Trays
• Varies from institution to institution
• Some procedures require smaller special trays
• These would have to be opened in addition to the
primary instrument tray
• Types of sets include:
Laparotomy,OB/GYN,Ophthalmic, ENT, Plastics,
Genitourinary, Orthopedics, Cardiac, Thoracic,
Peripheral Vascular, and Neuro.
Laparotomy Sets
• General abdominal procedures
• May use major or minor tray
• May also need:
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Long Instrument tray
Balfour or Bookwalter retractor
Gastrointestinal tray
Gall Bladder tray
OB/GYN Instrumentation
• Include D&C, Abd. Hysterectomy, Vag.
Hysterectomy, Laparoscopic procedures,
LAVH, and C-Sections.
• Need:
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Abd. Hysterectomy tray
Vag. Hysterectomy tray
C-Section tray
LAVH tray
Misc. Lap instruments
Ophthalmic Instrumentation
• Eye procedures
• Need:
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Conjunctival tray
Muscle tray
Cataract tray
Cornea tray
Globe and Orbit tray
Ophthalmoscope
Retinal Instruments
ENT Instruments
• Use in Ears, Nose, and Throat surgery
• Trays for:
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Myringotomy
Tympanoplasty
Nasal procedures
Tracheotomy
All other head and neck type procedures
Plastic Instrumentation
• Covers cosmetic and reconstruction
procedures
• Need delicate as well as larger
instrumentation
• May include Reattachments
• Some small bone instruments may be
needed
• Liposuction
Genitourinary Instrumentation
• Includes kidney and prostate procedures
• Need:
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Major tray.
Kidney or flank tray.
Vascular and a thorocotomy tray.
Long Instrument tray.
Prostatectomy:
Major tray.
Prostatectomy tray.
Long instrument tray
Special trays for:
Pyeloplasty, ureteroplasty, tuboplasty, and vasectomy.
Orthopedic Instrumentation
• Used for all bone and total joint procedures
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Universal bone
Basic total joint tray
Total tray
Fracture systems
Misc. bone holding instruments
Cardiac Instrumentation
• Cardiac procedures
• Need instruments for:
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Heart
Great vessels
Cardiopulmonary bypass
Saphenous vein harvest or internal mammary artery
dissection
Coronary anastamosis
Sternal saw and Sternal retractors
Internal mammary artery retractor
Valve sizers
Valve instruments
Thoracic Instrumentation
• Chest/Thoracic procedures.
• Need:
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Major tray or cardiovascular tray
Chest instrument tray
Sternal saw available
Self retaining chest retractors (Burford, Finochietto, or
Tuffier)
– Thoracoscopy set if thoracoscopy
• Still need open instruments in case converts just like with
laparoscopic cases
Peripheral Vascular Instrumentation
• Vascular repairs and shunts
– AAA trays
• Major tray or Cardiovascular tray
• Self Retaining Retractor (Bookwalter or Omni-tract)
– Carotid tray
– AV fistula tray
– Specialty surgeon trays
Neurosurgical Instrumentation
• Brain and Spine
• Need:
• Brain:
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Craniotomy tray
Rhoton Instruments
Micro scissors
Farley or greenburg retractor
• Spine:
– Spine trays
– Self retaining retractors
– Spine fixation trays
Instrument Check List
• An inventory sheet with all instruments in
that tray
• Used for counting
• Locate missing instruments or incomplete
trays
• Tracking instruments out for repair